BM LIBRARY UNIVERSITY OP CALIFORNIA SAN DiEeO A '"^^ IJ1015 7071 vjB iOO 6A1 A TEXT-BOOK OK THE THEORY AND PRACTICE MEDICINE. BY AMERICAN TEACHERS. EDITED BY WILLIAM PEPPER, M. D., LL.D., Provost and Professor of the Theory and Practice of Medicine and of Clinical Medicine in the University of Pennsylvania. in two volumes- illustrated. Vol. L I' 11 I \.\ 1) K L 1' IN A: w. H. s A u N I ) i: us, 913 Walntit Sthket. 1893. Copyright, 1893, by W. B. SAUNDERS. ELEOTnOTYPED BY PRINTED BY WESTCOTT & THOMSON, PllILADA. EDWARD STERN & CO., PHILADA. LIST OF AUTHORS. J. S. BILLINGS, M. D., Professor of Hygiene, University of Pennsylvania; Cnrator Aimy Medical Museum and Library, Washington, D. C. FRANCIS DELAFIELD, M. D., Profesor of Pathology and Practice of Medicine, College of Physicians and Surgeons, New York City. R. H. FITZ, M. D., Shattuck Professor of Pathological Anatomy, Harvard Medical School. JAMES W. HOLLAND, M. D., Professor of Medical Chemistry and Toxicology, Jetferson Medical College, Philadelphia. E. G. JANEWAY, M. D., Professor of Principles and Practice of Medicine, Bellevue Hospital Medical College, New York City. HENRY M. LYMAN, M. D., Professor of Principles and Practice of Medicine, Rush Medical College, Chicago, 111. WILLIAM OSLER, M. D., Professor of Practice of Medicine, Johns Hopkins University, Physician in Chief to the Johns Hopkins Hospital, Baltimore, Md. WILLIAM PEPPER, M. D., Provost and Professor of the Theory ami Practice of Medicine and of Clinical Medicine, University of Pennsylvania. W. GILMAN THOMPSON, M. D., Professor of Piiysiology in the Mi-dical Department of tin University of the City of New York. W. il. \\'EL(;iI, M. D., Professor of Pathology, .Irilms il(i|ikiiis Uiiivt^rsity, Haltinjort^, .Mil. iv LIST OF AUTHORS. JAMES T. WHITTAKER, M. D., Professor of tlie Theory and Practice of Medicine, Medical College of Ohio, Cincinnati ; Lecturer ou Clinical Medicine, Good Samaritan Hospital, Cincinnati, Ohio. JAMES C. WILSON, M. 1)., Professor of Practice of Medicine and Clinical Medicine, Jefferson Medical College, Pliil- adc^lphia. HORATIO C. WOOD, M. D., Professor of Therapeutics and Clinical Professor of Nervous Diseases, University of Penn- sylvania. PREFACE In the preparation of this work some of the teachers of Pi'aotical IVFedi- eine in leading schools of America have associated themselves, in order that each snbject should be discussed by an expert of special authority. It may, then, be said to represent truly the best teaching of the science and art of Medicine at the present time in this country. As such it is oifered to the medical profession and to the large body of our medical students, with the earnest hope that it will be found to meet their needs and to })rove a safe guide. Especial care has been taken to provide a strong article on Hygiene, including the full discussion of disinfection, isolation, and other principles of preventive medicine. Bacteriology is treated at length by an eminent author- ity, while in connection with each of the infectious diseases full consideration is given to the nature and cause of the morbid process. The important subject of Intestinal Parasites is presented with unusual fulness. Here, as well as in connection with bacteriology, no pains have been spared to provide the best illustrations ; so, too, wherever the text lias seemed to require it, charts and diagrams have been freely used. The object of the work is essentially a practical one. The subjects are treated in an autiioritative manner. It has been impossible to give space for bibliographical lists or for many references. Any apparent absence of recog- nition of the views of other writers must be attributed to this cause. The sections on Symi)tomatol()gy, Diagnosis, and Treatment are especially full, and many formuhe are admitted. Important assistance has been rendered in the preparation of this work by Dr. F. A. Packard, who has been associated with the Editor in the revision of MSS. and the correction ol' the proof-sheets. WILLIAM I'KPPER. 1811 Spruce St., Philauici.phia, ) January 30, 1893. i" CONTENTS. PAGE HYGIENE 1 By John S. Billings. EPHEMERAL FEVER AND SIMPLE CONTINUED FEVER 40 By William Pepper. TYPHOID FEVER 52 By William Pepper. TYPHUS FEVER 134 By William Pepper. RELAPSING FEVER 150 By William Pei'PER. CEREBROSPINAL FEVER IGli By William Pepper. INFLIENZ.V 184 P>Y WiLMA.M Pepper. DEN<;UK 197 By Willia.m Pepper. MILIARY FEVER 201 By William Pepper. MILK SICKNESS 2'^4 I>Y William Pkppkk. M(JUNTAIN FEVP:R 207 By William Prpprf;. SCARLATINA 20.S By Jamks T. Wiiittaker. MEASLES • 2:50 15 Y Jamks T. Willi taker. RUBELLA 254 By .Jame-s T. Wiiittaker. SMALL-POX 201 P>Y .Jamics T. Willi taker. vii viii CONTENTS. PAGE VACCINATION 283 By James T. Whittakkr. VARICELLA . 297 By James T. Whittaker. MUMPS 304 By James T Whittaker. WHOOPING COUGH 311 By James T. Whittaker. SEPTICEMIA AND PYAEMIA 324 By William Pepper. ACUTE MILIARY TUBERCULOSIS 329 By W. Oilman Thompson. SCROFULA 336 By W. Oilman Thompson. SYPHILIS 345 By W. Oilman Thompson. LEPROSY 369 By W^illiam Pepper. DIPHTHERIA 373 By W. Oilman Thompson. ERYSIPELAS 397 By W. Oilman Thompson. MALARIAL FEVERS 405 By' W. Gilman Thompson. CHOLERA 434 By W. Oilman Thompson. YELLOW FEVER 451 By W. Oilman Thompson. TETANUS 462 By James T. Whittaker. ACTINOMYCOSIS 473 By James T. Whittaker. ANTHRAX 478 By James T. Whittakkr. HYDROPHOBIA 485 By James T. Whittaker. TRICHINOSIS 499 By James T. Whittaker. GLANDERS 512 By James T. Whittaker. coxTJcyrs. i\ PACK FOOT-AND-MOUTH DISEASE ,jl!> By James T. Whittaker. GENERAL SYMPTOMATOLOGY OF DISEASES OK THE NERVOUS SYSTEM . 523 By Horatio C. Wood. MENTAL DISEASES ryld By Horatio C. Wood. FUNCTIONAL NERVOUS DISEASES 587 By Horatio ('. Wood. ORGANIC DISEASES OF THE BRAIN 669 By Wii.i.iam O.-^lek. SY Bin LIS OF THE NERVOUS SYSTEM 726 By Horatio C. Wood. 0R(;ANIC diseases of the spinal cord and ITS MEMBRANES . ■ . 737 By Horatio C. Wood. DISEASES OF THE NERVES , .- . . . . 80o By William Osler. DISEASES OF THE MUSCLES 850 By Willlxm Osler. VASO-MOTOR AND TROPHIC DISORDERS . . ■ 855» I5y William Oslkh. LIST OF ILLUSTRATIONS. FIGURES. FIGVRK PAGK 1. Diagram showing Relative Freqiiency of Sniall-pox Belore and After Compulsory Vaccination 14 2. Diagram showing Deaths from Scarlatina in Providence 15 3. Typical Temperature-chart of Typhoid Fever 73 4. Temperature-chart of Case of Typhoid Fever, showing prolonged hyperpyrexia . . 77 o. Teniperature-cliart of Case of Typhoid Fever, showing effect of intestinal hrpmor- rhage 86 6. Temperature-chart of Case of Typhoid Fever, showing pseudo-relapse 94 7. Temperature-chart of Case of Typlioid Fever, showing effects of complications ... 96 8. Temperature-chart of C;isc of Abortive Typhoid Fever 86 9. Temperature-chart of Case of Typhoid Fever, showing results of Brand method of treatment 121 10. Temperature-chart of Case of Typhus Fever 139 11. Spirilla of Kelajjsing Fever 151 12. Chart showing Deatii-rate of Pneumonia din-ing E|)idemic of Infliicn/.a 191 13. Temperature-chart of Mild Case of Scarlatina 215 14. Temperature-chart of Case of Measles, showing defervescence by crisis 238 15. Temperature-chart of Ordinary Ca.se of Measles 238 16. Temperature-chart of Four Cases of Measles up t(» Appearance of Eruption .... 240 17. Temperature-chart of Ca.se of Measles following Scarlatina 242 IS. Capillary of Skin in Small-pox 264 19. Section of Variolous Lesion of Skin 271 20. Temj)erature-chart of Case of Small-pox 272 21. Diagram sliowing Mortality from Small-pox in Prussia and .Vustria 290 22. Temperature-chart of Case of Acute Miliary Tuberculosis 333 23. Central Incisor Teeth of Hereditary Syphilis 3(54 24. Forms of Plasmodium Malaria? 407 25. Temperature-<-hart of Ca.se of (Quotidian IiitcriniUciit i"«ver 415 26. Temperatnre-chait of Cjise f)f Tertian Intermittent Fever 116 27. Temperature-chart of Case of Hemittent i''ever 424 28. Comma-bacillus of Cholera 437 29. Actinomyces 474 30. Actinomyces Stained by Gram's Method 475 31. Anthrax-bacilli 479 zi xii LmT OF ILLUSTRATIONS. FIGURE PAGE 32. .Section of Hypoglossal Nucleus of Case of Hydrophobia 492 33. Section showing Miliary Aliscess in Fibres of Origin of Hypoglossal Nucleus of Case of Hydrophobia 492 34. Meischner's Sac 501 35. End of Meischner's Sac, with kidney -shaped bodies free and enclosed 501 30. Uninipregnated Female Trichina 502 37. Male anil Female Trichinae, female discharging young 502 38. Trichiuic in Muscle near Tendinous Insertion 503 39. Living Embryos of Trichina 504 40. Encapsulated Trichina 504 41. Calcified Trichina 505 ■12. Calcified Trichina' (natural size) 505 43. Case of Glanders with Tubercles upon Ahc Nasi 514 44. Temperature-chart of a Case of Puerperal Insanity 573 45. Latei-al Surface of Brain of Monkey, showing motor area 096 46. Median Surface of Brain of Monkey, sliowing motor area 697 47. Diagram showing Arrangement of Motor Fibres in Internal Capsule 698 48. Lichtheim's Schema 701 49. Diagraiimiatic Section of Spinal ('(inl 737 50. Diagram of (Jroups of Cells in Anterior Cornu 738 51. Diagram of Levels of Nerve-roots and Vertebrne 739 52. Tabetic Feet 783 53. Impression of Tabetic Feet 783 54. Tabetic Hand 783 55. Multijile .Mcoholic Neuritis 808 56. Diagram of Visual Paths 817 57. Diagram of Mot(U- Tract 829 58. Pseudo-jiypertrophic Muscular Paralysis 853 PLATES. PLATE Opposite page I. Ihrmatozoon of Malaria 407 II. .Vreas involved in \'arious Forms of Aphasia 705 III. Acromegaly 863 HYGIENE. By JOHN S. BILLINGS. Instruction in hygiene for the medical student has, until recently, been considered as theoretically desirable, but practically unessential. To the stu- dent entering on his course of medical study the question may arise, "Why should a physician be compelled to learn how to prevent disease?" From the business point of view he is to support himself and his family by treating the sick : why, then, should he try to prevent the occurrence of sickness and thus lessen the chances for his employment? The answers to this are as follows : First : From the business point of view the man who has studied modern hygiene is more apt to obtain and retain employment as a practitioner than one who has not. The laws of several States already require a knowledge of hygiene by those to whom license to practise medicine is given ; the medical examining boards of the army, navy, and marine-hospital service lay special stress on the knowledge of hygiene possessed by the candidates who come before them ; and the same may be said for the civil-service examinations for filling various offices in which medical knowledge is essential. Tliere is, in fact, a rapidly-growing demand on the part of the public tiiat physicians shall receive special instruction as to the causes of disease and the means of prevent- ing or destroying those causes, as well as in the treatment of the diseases pro- duced by them ; and this demand exists not only with examiin'ng boards, but with tlie men and women who employ physicians in private life. The people who pay medical bills want to know the cause of their sickness ; whether their houses are in good sanitary condition, and if not, why not, and what should be done about it ; whether the water is safe to drink ; and many other things for which they consult their physicians. Moreover, hygiene is not only the art of preserving health, but of improving it, and is a most important part of the therapeutics of many forms of disease. 8(;cond : It is the duty of the physician (o prevent disease whenever and wherever he can, without reference to any considerations as to whether iiis Vol. I.— 1 1 2 HYGIENE. doing so will be of any pecuniary benefit to himself or not, and to be fully informed as to the best methods of doing this. It is true that the health interests of the people among whom he lives and works ai'e his own interests, because if they suffer he and his family must also suffer; but, without refer- ence to this, or to his obligations as a husband or father, it is his special duty as an educated medical man to consider and advise upon sanitary problems for the benefit of those who have not this expert knowledge. It is the most direct and certain way in which he can serve God and his fellow-man. Questions of public hygiene are becoming more and more prominent in the social and political world : all efforts to make the mass of the people more contented and comfortable are connected with health questions, and there is great need of scientifically educated men who will not be induced through ignorant enthusiasm to endorse the numerous quack reform schemes which are being continually proposed and thrust upon the public. There has been, and still is, a vast amount of charlatanry, humbug, and advertising in so-called sanitary literature, especially in that part of it devoted to attempts to scare people into buying some patent contrivance or article of food or drink ; and it is a part of the business of the physician to know when there is real danger and what is best to be done under the circumstances. Half-knowledge in these matters produces much unnecessary anxiety and fear. Health is a means, not an end. In every-day life many men deliberately choose an occupation and a place of residence which they know involve a cer- tain extra risk to health and life ; in fact, the physician does this himself. In insuring health and life, as well as property, the question occasionally comes up, " What is the greatest amount of premium that it is worth while to pay for such insurance?" There Js both an upper and a lower limit. Some cannot afford to insure at all. Compulsory legislation for securing the health of a community must be framed with reference to economic consequences as well as to health. The public hygiene of to-day dates from about fifty years ago, the time when a really useful system of vital statistics was established for England by Dr. William Farr. Prior to that time the causes and mode of preventing scurvy had been discovered, vaccination had been introduced, and much was known about personal hygiene ; but very little was known about the health of communities or particular cities, or whether it was becoming better or worse. The cholera epidemic of 1849 in England gave a powerful stimulus to investigation, which was made by the Health of Towns Commissions ; but the Crimean War, with its positive demonstration of the effects of sanitation elab- orated and insisted on by Dr. Parkes, was what finally convinced the govern- mental authorities of its inijiortance and necessity. Next came the stage of y tlie first we eompan; indivin^land lienedictine Monks, Paris Males . . . Males . . . Persons . . Persons . . Males . . . Males . . . Persons . . Males . . . 39.7 33.3 40.8 33 3 21.0 43.7 45.3 52.7 47.2 51.1 48.0 41.8 51.8 53.8 50.6 38.5 44.9 49.9 49.3 47.5 48.3 44.9 40.0 48.8 50.5 . . 45.6 37.2 43.1 46.6 45.1 44.7 44.2 40.6 36.8 44.6 46.4 40.6 33.4 39.5 39.5 38.2 37.1 37.5 33.2 31.0 37.5 39.9 34.6 34.0 27.0 32.0 28.5 28.2 28.5 27.7 23.9 21.7 28.5 29.2 24.0 24.5 19.8 22.0 14.5 15.3 16.7 15.0 13.0 11.3 15.6 14.4 11 7 Knglish Life Insurance . . 126 Dublin, 1841 Berlin Males . . . Males . . . 23.8 17.2 11.0 10.0 From this table it will be .seen that at the age of twenty-five the mean expectation of life of that class of American males who insure their lives is -1 PREDLSPOSIXG CAUSES OF DISEASE 7 tliirty-iiine and a half years, while for eolored males in Jxiltiniore it is only thirty-one years. The expeetation of life is the mean after-lifetime ; the probable duration of life is the age at whieh the population at a given age will be redueed one-half. If of 100 children born, 30 live just one year, 20 just five years, 30 live 40 years, and 20 live 60 years, then the probable duration of life of any one of these children at birth is five years, because at the end of that time one-half of them will be dead, but the expectation of life of any one of these children is 25.3 vears, because the 100 altogether live 25,300 vears of life. If we have the results of a registration of deaths, but no information about the population, the best we can do is to compare the number of deaths under one or under five years of age with the whole number of deaths, or the number of deaths from one particular cause with the number of deaths from all causes; but the results are unsatisfactory and may be very misleading. Suppose, for instance, that in a city 1000 deaths occur in a year, and that 250 of them are due to consumption, and that in another city there are 2000 deaths in a year, of which 500 deaths are due to consumption, then the proportion of the number of deaths from phthisis to total number of deaths would be the same in the two cities. But if the two cities were of the same size, the liability to s m:iy be dirase with which they may be stained with different substances, in the tenacity witli which (hey ret^iin these 10 HYGIENE, stains, in the decompositions and decomposition-products which they produce, and in the effects which follow their entrance into the living human body. These differences are constant and each kind breeds true, so that we may say that there are many distinct species. The great majority of the species are not only harmless so far as man is concerned, but beneficial. They feed upon dead, insoluble organic matters, the products of higher animal and vegetable life, and convert them into soluble forms of simpler composition which may be utilized by living plants. They are present in the lower layers of air over the land except in the Polar regions, in the upper layers of soil, and in almost all water, and there is very little dead organic matter which escapes them. Almost all forms of putrefaction and fermentation are produced by them. They multiply by simple division with great rapidity under favorable circumstances, some of them dividing once every half hour, so that a single cell may produce ten mil- lions or more in twenty-four hours. They are about one-twenty-five-thousandth of an inch in diameter, and from one-fifteen-thousandth to one-five-thousandth of an inch in length. It would require about twelve million micrococci placed side by side to cover an ordinary pin's head. All of them require the presence of moisture, nitrogen compounds, usually in the form of dead organic matter, and of a suitable temperature to enable them to grow and develop. A few of them produce disease in man, either directly or through their products. The proof that a particular form of disease is due to a particular micro-organism is as follows : 1. The disease must be one that can be identified — that is, that jiresents a tolerably distinct series of symptoms or of pathological results — so that it can be distinguished from other diseases either in the living or the dead subject, or in both. 2. In all cases of the disease the specific form of the micro-organism must be found in the fluids or tissues of the body. 3. This micro-organism must be separated from the fluids or tissues of the body, and from other micro-organisms, and cultivated in suitable media outside the animal body until a series of pure cultures is thus obtained. 4. The pure culture thus obtained must produce the specific disease in a healthy animal when introduced into its body by inoculation or through the alimentary canal or air-passages. 5. In the animal in which the disease has thus been produced the same micro-organism must be found. Since many different micro-organisms may be found at different times in the human body, including all the varieties found in water and air, the mere occa- sional coincidence of the presence of some one form in a ])articular disease is not sufficient to prove a causal connection. It must also be remembered that the specific micro-organisms may be present in or on the skin or mucous mem- branes of the body without producing disease, for in many cases they require special conditions of injury or lowered vitality of the tissues with which they come in contact to enable them to develop, and in some persons they produce no effects, as will be explained hereafter in speaking of immunity. As inoculations Midi O- O R a A XISMS. 1 1 of disease-producing organisms, or of those supposed to be such, cannot, as a rule, be tried on man, the chain of positive experimental proof can usually only be completed for those diseases which can be produced in other animals ; neverthe- less, a high degree of probability may be obtained when a i)articular form of micro-organism is always found j)rcsent in a person atfccted with a disease hav- ing well-marhed characteristics, and is seldom or never found in the living body when such disease is not, or has not recently been, present. No satisfactory classification of the bacteria has yet been made. For the purposes of this article it is sufficient to say that the spherical forms, or micro- cocci, include Streptococcus, in which the individual cocci after subdivision remain united together in little chains or strings ; Staphylococcus, in whi(;h they are clustered together like a bunch of grapes ; and Micrococcus, in which the granules are usually seen singly or in pairs or in short chains. When they are usually in pairs they are called diplococci. Some authors use the term micrococcus as the generic name of all forms ; thus, the Micrococcus pyogenes aureus is the same as the Staphylococcus pyogenes (uireus. Of the rotl-shaped forms, some authors refer to a separate genus, Bacterium, all those in which spore-formation is absent or unknown, but most writers include them all under th^ term Bacillus ; thus the Bacterium prodigiosum is the same as the Bacillus prodigiosus. The student should bear in mind that there is no sharp dividing-line between the coccus forms and the rod-shaped forms; that very short rods with rounded ends or shaped like an ellipse are called micrococcus by one observer and bacil- lus or bacteriimi by another; and that the same organisms in different stages of growth and development may show single cocci, chains, and rods. The spirally- twisted forms of bacteria are classed as Spirillum, but the sj)irillum of Asiatic cholera is commonly called the cholera bacillus. The following is a list of the principal diseases of man which are due to bacteria, with t\\o usual names of the species of bacteria which cause them : 1. Inflammation of tissues, producing suj>puratiou ami its cohscquenccs, as in abscesses, boils, pyaemia, osteomyelitis, ])uerpcral fever, etc. These are pro- duced by the Staphylococcus pyogenes aureus, the Staphylococcus pyogenes dtreus, the Staphylococcus pyogenes albus, the Streptococcus pyogenes, and by a few other forms, the whole forming a group known as the pyogenic micrococci. Two or more kinds of these are often found together in pus. The specific cause of erysipelas also belongs to this group. 2. Gonorrho-a, pn)du(;cd by the Merisniopedia gonorrhoea or gonococcus. 3. Anthrax, caused by the Bacillus aufhrads. 4. Tuberculosis, caused by the Bacillus tuberculosis. 5. Leprosy, caused by the Bacillus lejtr(v. G. Glanders, caused by the Ilacillux vudlri. 7. Typhoid fi;vcr, caused by the fiacillus typhosus. 8. I)ij)lithcria, caused by the liacillux diphtheria:. 9. Tetanus, cause <^ § 5<5i"5>« S ^ .^ S '5^ ? S^3 s t 0P81 OM! — :::::::::::" . d \ ~^ ' ; i 2 ~» X --J£ \\ _ .. ._ \nVi = t T _ \VA'', ~ X ll 5 J :;::;_+ t s & 0€8I 0881 OfSf t . _. _.. i^ _. ^_i 2 :±±::|i:±::±±j::::: ;::::;::::::::::::::::::: ::::::.: i « - i "": — "z"""'.".y.'.".'Z'.Ui\\ 2 1 -^ ' 1 " 1 £^ _ _ 1 ^ %i [K o ' '■ M '"^ _ _ - ^^ ^ V S '^ _ _ - --- -._ ft; ^ ■""t m^\ ^ ^ Y^llimh g z^ .| . ^ :::::::::: : ::::_::_::::::::::::::::::::: :Eii2|s^S C ::::::::::::::::::::::::" ::::::::::::":::::::::::::::: ::::::::t:::::::::;| 5^1 i -_.3^ 5 ^- .^^ .^^ 1 k 1 1 1 0091 1 1 1 1 1 1 1 1 I^^^^H If 11 IH^^^^' ^ ^^^^^H oe^i. ■ 1 1 ^^^^^^^^^^^^^^^^^^^^1 094.1 ^^^^^^^^^^^^^1 ^^^^n^^^^^^^l "^ iiiiiiiiiiiiiiiii iiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiii^^^^^^^^^^H '^ II mil iiiiiiiiiiiiiii^^^^^H o TT^^^^I ■■^^^1 5 1 1 0U[ m^^^^^^^^^^^H iiiiiiiiiiiiiiiiiiiiiii i^^^^^^^^^^^^^^^^^^^B l^^^^^^^^^^^^^^^^^' j^^^^^^^^^^H ^^^^^^^^^^^^^^^^^^^^^^^m '"''''''' IrnrnflflnTTrffr'^'^^^^^^^^^^^ 09ZI ^T n^^^^^^^^^^^^^^^B 1 1 H^^^^^^^^^^^l VHiVVfViVVVViVfl^^^^^^^^^^^^^^^^^^H 1 1 1 1 1 1 1 iTTtt^^^^^^^^^^^^^^^^^ 1 ^^^^^^^1^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^ ■mii^^^^^^^^^^^^^^^^^^^^^^B - M T ^^^^^^^^^^^^^^^^^^^^^1 OSII T ItTtttttti^^^^^^^^^^^^^^^^I t >" '< N > §i5i 7000 6000 5000 4000 3000 2000 1000 500 sliowing 11 niSIXFECTTON. 15 inhabitant of those quarters has had the disease; and in like manner after an epidemic of typhoid has swept through a village a large number of the sur- vivors will be immune against that disease. Immunity thus produced is the cause of the ajipearance of certain contagious diseases in epidemics at tolerably regular intervals, as small-pox before vaccination was introduced used to be epidemic at intervals of five or six years, and scarlet fever now appears in somewhat similar waves. It requires about that length of time for a new generation of children who are epinosic — that is, susceptible to the specific germ — to be developed in order to furnish sufficient material for an epidemic. This is shown diagrammatically in Figs. 1 and 2. Fig. 2. 14%^ ^ 1 1 S" "^ i 1 5 % ^ S§ 5 ^ ^ ^ 14% 13.. 12. 11. 10. ■ 9. 8- 7. 6. 5. 4. 3. 2. 1. 12.. 11 - 10 - 9 . |_ ■ h 1 _ ■ L ■ 1 ■ 8 . 1 ■ ■ 7 . ■ H ^1 1 ■ M -1 ^1 1. ■ t "■ ^■1 F 1 1 J ^ 1 ■ 4. 3. 2. 1- mi ^■1 ■ ■ ! i^i r ! 1 ■ I ! ! ! ■ I ■ "■ Liiagram showing 'percentage of deaths from Scarlet Fever in total deaths in Providence, K. 1., lor forty-nine years. Disinfection. Sterilization of a substance, or of a flask or other vessel, consists in the kill- ing of all living organisms containal in it. It may be partial or total, relative or absolute, permanent or temporary. In experiments in cultivating bacteria the culture media and the vessels which contain them are usually totally and absolutely sterilized, but it is not desired that this sterilization shall be perma- nent under all conditions. It is to be temporary, and to endure only until we inoculate the media with some particular form of organism which wc wish to grow there. Total perrtianent sterilization is rarely used unless wc wish to entirely decompose and destroy the substance, as by fire. The :i])plication of sterilization to the destruction of those micro-organisms wliich cause s|)ccifi(! infectious or contagious diseases is called ^eof the word, for in the inajoiity of cases in which we use disinfeetanls \\^^ do not know |.ositively (hat s|»eei(i<; disease- producing germs are present, Iml ninciy think it proI)able that tiny 16 HYGIENE. mav be there. Disinfection may often be obtained without complete steril- ization. This is due to the fact that most micro-organisms which are rapidly growing and multiplying in moist media, including most of the micrococci and the bacilli of cholera, typhoid, and dysentery, are much more easy to kill than are the spores of certain forms, especially of the hay bacillus and of the bacillus of anthrax. In comi)aring the effects and efficiency of various disinfectants time is a most important element, for a degree of heat or a chemical solution which will have no eifect in five minutes and very little in half an hour may effectually destroy the vitality of the organisms in twenty-four hours. Antiseptics are substances which prevent the growth and development of micro-organisms, and especially of those which cause fermentation or putrefac- tion or which produce suppuration. They may or may not be disinfectants or germicides. A universal germicide — that is, an agent which effects complete sterilization — is necessarily an antiseptic for the time being, but if meat broth be heated until it is sterilized and is then left in an open vessel, it is not thereby made antiseptic. An antiseptic is something which remains, and pre- vents the development not only of the bacteria present, but of those which may be added afterward, although it does not necessarily kill them. A deodorant is an agent which destroys or mitigates foul and unpleasant odors, but many of these agents have little or no disinfectant powers. There is no definite relation between foul odors and specific disease-producing organisms : either may be present without the other, and it is improper to speak of the process of mask- ing or destroying the odor produced by a uterine cancer in the last stages as being a process of disinfection. The principal agents now used for disinfection are heat, carbolic acid, bichloride of mercury, chloride of lime, quicklime, alcohol, and sulphurous acid. These are the cheapest, the most generally applicable, and the least likely to damage clothing, furniture, etc. The strong mineral acids, chloride of zinc, chlorine, hypochlorite of soda, and certain coal-tar products are also good disinfectants, but are only used in special cases. What may be called the natural process of disinfection is accomplished in the course of time by light, fresh air, and the action of the common bacteria. All of these are of the greatest practical importance in' preventing the undue increase of pathogenic organisms and in aiding in their destruction in water, soil, and air, and should be constantly employed as auxiliaries; but for prompt and certain disinfection we must resort to other agents. The practical utility of these depends not only on their germicidal powers, but on the ease with which they can be applied, their cost, and the danger of injury to persons or property from their use. The most important of these special disinfecting agents is heat, and the simplest method of applying it in many cases is to burn the infected article. Sometimes it is best to do this for the moral effect, to reassure the community, as, for example, to burn up an old small-pox hospital instead of tearing it down. The cremation of garbage, of dead animals, or of human bodies is a disinfecting process, though not usually performed for that purpose. Dry heat — that is, a sort of baking in a closed chamber or oven — has been used to DISIXFECTIOX. 1 7 a considerable extent in many places for the disinfection of clothing, bedding, and small movable articles, bnt is now being abandoned except for laboratory purposes and for the sterilization of some surgical instruments. It penetrates very slowly into non-conducting articles, such as bedlins, and other patients may be mingled and go through the boiling-vats without risk to the subsequent wearers. It should be borne in mind that infected clothing and bedding is chiefly dangerous when it is dry. When it is soaked with water it does not give oif germs to the air. It would often be best, in collecting clothing and bedding supposed to be infected, to place the articles at once in a cask or tub or other vessel containing cold water, partly to soak out any stains and partly to prevent the giving oif of any dangerous dust. It is usually advised tiiat the clothing of the sick, and especially of those in hos- pitals for infectious diseases, should be washed in a place entirely separated from that in which other clothing, such as that of nurses and attendants, is washed ; but while this may be desirable as a matter of sentiment and imagina- tion, it is not necessary, for half an hour's boiling makes all the stuffs harm- less. Boilino- is also an effectual means of destroving choleraic, tvi)hoid, or dysentery germs in water which must be used for drinking, and it is a good method of sterilizing sin-gical instruments that arc properly constructed with reference to this mode of treatment. Moist heat may also be applied by means of steam in boxes or chambers s|)ecially constructed for the purpose. To obtain satisfactorv results, all air should be driven out, and the steam should be moist or saturated at a temperature of about 220° F. If the pressure is less than that ])ertaining to the temperatures as given by Regnault's law, the steam is superheated, and is little better th:m hot air f.r (lisinfc(;ting piu'poses, while if the pressure is greater than that pertaining to the temperature, there is aduiix- ture of air, and the clothing, etc. are not properly i)cnetratcd. Tlic pressin-e should only be great enough to secure that there shall be no condensation of moisture in the chamber. Many forms of steam di-iiiCceting apparatus, butli Vol.. I.— 2 18 HYGIENE. fixed and movable and of various sizes, are now constructed by English, French, and German manufacturers. In judging of the merits of any par- ticular form or in devising a new one the following points should be borne in mind : A constant and uniform temperature should be secured throughout the chamber and in the interior of the naattresses, rolls of bedding, etc. to be dis- infected. To ensure this, a metallic thermometer with electric connections with a small gong should be placed free in the chamber, so arranged that Avhen the temperature reaches 221° F. (105° C.) the gong will sound; and a similar thermometer, similarly connected and adjusted, should be placed in the <;entre of the most bulky article to be disinfected, such as a mattress or pillow. Mercurial thermometers are not as serviceable for this purpose as those made of a coiled strip of metal which make the electric connection by expansion and contact. The steam should flow through the chamber freely at first, until the greater part of the air is expelled ; and this seems to be best eifected in those forms of apparatus in which the steam is admitted to the top of the chamber, the outlet being at the bottom and so controlled by a valve as to secure the amount of pressure required. After the greater part of the air of the chamber has been expelled, the valve may be closed and the pressure and temperature allowed to rise until the gong indicates that the temperature of 105° C. has been reached in the chamber. The valve should then be opened again, and the pressure be made to vary, for the purpose of expelling the air from the interior of the mattresses, etc., until the enclosed thermometer rises to 105° C, as indicated by its gong. When this has been secured the valve should be so set as to maintain this temperature and pressure for about forty minutes, which will be sufficient to secure complete disinfection. The chamber itself is usually made of boiler iron with double walls, and, if it is a fixture in a central disin- fecting establishment, it has a door at each end, and is set in a partition wall in such a way that the articles to be disinfected are introduced at one door and removed from the other, so that thev do not come out into a room which has contained infected articles. The central disinfecting stations of Berlin and of Paris may be taken as types of the arrangement which is desirable. Where the apparatus is in constant daily use it may have its own boiler ; where it is only used occasionally it will be better to obtain the steam from some plant which is in daily use, for the articles to be disinfected should not be allowed to accunudate, but should be promptly treated. It must be borne in mind in operating a public disinfecting station that the results will be judged by house- keepers with reference to the effects upon color, size, and texture of the articles submitted to the process. As Dr. Russell remarks, it is of no use to quote sci(!ntific authorities to the woman who finds that her blankets come back a sliade yellower than they were when she sent them to the station. " Dynamo- metric experiments on the breaking-point of hair-fibres will be of little use against a claim for damages which is supported by the fact that the upholsterer has charged so nuich for the wool or hair necessary to make up the original weight of the mattress or pillow. The result is, that there is constant friction in carrying out disinfection on a large scale. There is a temptation to the J)J>SJA'FJ'J('TIOX. 19 officials to scamp the work to avoid censure, and tliere are constant private efforts to escape interference by concealment or appeal to domestic processes." The chemical disinfectants jnay be divided into those which are used in gaseous and those which are used in liquid forms. Of the gaseous disinfectants, sulphurous acid is the one chiefly employed, and next to this comes chlorine. Nitrous-acid fumes and hydrochloric-acid fumes have also considerable disin- fecting powers, but ar'fe very rarely used. Attempts to disinfect the air sur- rounding a patient are useless. It may to a certain extent be deodorized or be given some special odor, as by the use of saucers containing chloride of lime placed about the room, or of strips of cloth soaked in carbolic acid, or by burn- ing pastilles of various kinds; but all these things, so far as disinfection is con- cerned, are what Simon calls "a futile ceremony of vague chemical libations »»r powderings, savoring rather of superstitious observance than of science." Theo- retically, it is possible to disinfect air by passing it over highly-heated surfaces or by drawing it through cotton filters, but these processes are only used on a small scale in the laboratorv. "We cannot conveniently apply heat to the walls, floors, and surfaces of rooms, to certain kinds of furniture, etc., and for this purpose it has been usual to employ the fumes of burning sul})hur — a very old process, for Homer tells in the Odyssey that Ulysses purified his house in this way. The advantages of sulphurous acid are that it is extremely diffusible, so that it will readily pene- trate into the interior of a mattress or pillow or the upholstery of a chair ; it has little or no injurious effects on the ordinary furniture of ai>artraents ; it is easy to use and is cheap. It will not destroy spores, and is therefore useless in disinfecting for anthrax and tuberculosis, and it escapes so rapidly from ordi- nary rooms that it is very difficult to keep a sufficient strength of it in the air for a sufficient length of time to produce certain germicidal results. It should not be relied upon as the exclusive means of disinfecting an aj)artment, but may be applied after the application of liquid and cleansing disinfectants to all surfaces as far as possible. In most cases it is applied by burning sulj)hur in an iron vessel placed on sand in the room Avhich it is desired to disinfect. The quantity necessary is about sixty grammes per cubic metre, and it is difficult to secure complete combustion of this amount if the room be sufficiently air-tight to secure useful results. It is used in France and in New York, but has been abandoned in Germany. Its efficacy is increased by the presence of moisture in the air. For cleansing walls, woodwork, floors, etc, in a room presumed to be infected rubbing with bread-crumb, as recommended by Esmarch, is a good method. The crumbs should be ke])t moist, carefully collected, and |>i(uiiptly l)urncd. Ilnbbino; with old (•l(»tlis wet with an acid sohilinii of corrosive sub- liraate is also a good methotl. All mere rubbing and scrul)i)ing nicfliods, how- ever, can effect only j)artial disinfection in the habitations of (lie pdor, Itccause of the niunber of fissures and cnicks in the walls, ceilings, and floors, i\u- interior of which cannot be reached in this way. Of liquid disinfectants one of the most useful is a solution of corrosive sub- limate acidified with hvdn.rhloric or tartaric acid. That used in the Paris dis- 20 HYGIENE. infection service is composed of corrosive sublimate 2 grammes, tartaric acid 24 grammes, water 1 litre, with 5 drops of a 5 per cent, solution of carrainate of indigo. That most used in England is corrosive sublimate | ounce, hydro- chloric acid 1 ounce, water 3 gallons, tinted with 5 grains of aniline blue. That recommended by the Committee on Disinfectants of the American Public Health Association consists of 2 drachms each of corrosive sublimate and per- manganate of potash to the gallon of water. Of thes/e the first is the least likely to stain or injure the articles to which it is applied, which should be those that cannot be subjected to dry or moist heat, including articles made wholly or in part of leather, rubber, fur, or pasteboard. It is also used for moistening cloths for wiping floors or woodwork of rooms. Corrosive sublimate is not a good disinfectant for sputa or faeces, as it forms an insoluble compound with albumins. For these matters a solution of chloride of lime, 4 ounces to the gallon of water, is the best, provided the chloride of lime contains at least 25 per cent, of available chlorine. An infectious stool from a typhoid, cholera, or dysentery patient cannot be disinfected by pouring a little strong disinfecting solution on it, shaking it around a little, and then emptying the vessel. About a quart of the solution employed should be placed in the vessel in which the stool is discharged, and the mixture should remain in the vessel at least three hours before it is emptied. E(|ual parts of pure sulphuric or hydrochloric acid and water will disinfect a stool in two hours. The acid corrosive sublimate solution, 1 : 500, will do it in six hours, and a 5 per cent, solution of carbolic acid (about 8 ounces to the gallon) will do it in twenty-four hours. If solid faeces be present, they must be broken up and thoroughly mixed with the solu- tion. Strong milk of lime, made by slacking fresh-burned quicklime and stir- ring up the fresh powder in twice its bulk of water, will kill typhoid bacilli in equal parts of a fresh liquid stool in about half an hour. If the problem is to deal with large masses of excreta, as in an old privy-vault, the chloride of lime or 5 per cent, carbolic-acid solutions are the best. Sulphate of iron is a deodor- ant for masses of excreta or sewage, but it is not a disinfectant, and is but slightly antiseptic. Its use is not to be recommended. A 5 per cent, solution of sulphate of copper, a 10 per cent, solution of chlo- ride of zinc, and a 15 per cent, solution of chlorinated soda will kill the ordi- nary bacteria, but not spores. Such solutions are more costly than the substances previously mentioned and present no special advantages. Most of the patent and proprietary disinfectants on the market are useless, and those that are not cost from ten to one hundred times as much as the satisfactory solutions above given. The physician has no guarantee that their composition remains constant, and had better confine his prescriptions to fresh-made articles of known com- position and efficiency. For certain special and limited purposes, as in dealing with the micrococci of suppuration and occasionally to sterilize the hands of the obstetrician or surgeon, the solution of peroxide of hydrogen is convenient and useful. The hands of the surgeon and his assistants, as well as the skin of the patient, may be disinfected by washing first in a warm saturated aqueous solu- tion of permanganate of potash, then in warm saturated aqueous solution of ISOLA TJOX. — FOOD. 21 oxalic acid, and finally in corrosive sublimate, 1 : 500. The body of a person dying of infectious disease should be \vrapi>e(l in a slieet thoroughly saturated with the strong corrosive-sublimate or chloride-of-lime solution. Isolation. That it is desirable to prevent communication between healthv persons and persons suffering from communicable disease is generally admitted ; but how this is to be done without causing additional suffering and danger to the sick, or great inconvenience and cost to others, is sometimes a diftirult question. Bv the laws of Moses the leper was to be driven out of tiie communitv and liis house, clothing, etc. destroyed by fire, but at present it is required that the leper shall be cared for as well as the community. As regards individual cases, when the family occupies a separate house, one room of which can be given up to the sick person and his attendant, it is always theoretically pos- sible to provide such isolation as, combined with projier disinfection, is suffici- ent to secure protection for the rest of the family and of the community ; but it is difficult, especially in mild cases of scarlatina, diphtheria, measles, etc., to make sure that such isolation and disinfection are properly carried out, and in tenement-houses and where the family occupies but one room it is practically impossible to do this, and therefore it is highly desirable that special hospitals be provided for the care of such cases. One of the most important questions which the physician is called on to answer in scattered or so-called sporadic cases of the acute contagious diseases of children is as to the time during which the child should lie kept isolated. This varies for each specific disease, and varies somewhat in individual cases, but the following may be considered as the minimum time, after the apjiearance of the eruption or other specific symptom, which should elapse before the child is permitted to be with other children : Scarhitina, 40 days ; measles, 25 days ; whooping cough, 40 days; mumps, 28 days; rcHlicln, 14 days. As regards dij)htheria, the time is usually given as 40 days, but the fact is that it should date from the com])lete destruction of the specific bacilli, as shown by bac- teriological examination, and the time required to demonstrate that such destruction has l)cen effected mav varv from ten davs to eiy-ht weeks. The isolation of a mniibcr of people — as, for instance, the crew and pas- sengers of a vessel in what is known as maritime quarantine, or of a town in which an epidemic is raging — is occasionally useful for a short time to allow disinfection, vaccination, etc. to be carried out. Food. The force expended in a licallhy man doing an average day's work is equal to about 8400 fi)ot tons, of which 2H40 l"<'rings, with cotton sheets and woollen blankets. Feather beds are not desirable. It is best that each person should have a separate bed. Clothing may be the means of transmission of infection, either from the homes of those who manufacture it or from those who have worn it, as by so-called second-hand clothing. The virus of small-pox, of scarlatina, and of yellow fever has been transmitted through clothing and beddino;, and the disinfection of such articles in cases of contagious disease is of much practical importance. Occupation. Almost every occupation produces special liability to certain forms, and a certain amount of immunity from other forms, of disease or injury on the part of those engaged in it, but the net result of a particular trade or profession on the health and life of men is often very difficult to determine. Only men of considerable strength and vigor can luidergo the muscular exertion required in certain forms of labor, hence weak and sickly men either do not engage in these occupations or leave them for lighter work. AVhat are called easy, light occupations attract weak lives ; hence the difference in the death-rate of black- smiths and of clerks cannot be taken as the measure of the difference in hcallh- fulness of the two occupations. The average age of those engaged in a jiar- ticular occupation is also of great influence on the death-rate, which for this reason tends to be lower for medical students than for practising physicians. The influence of i)lace of residence and of social status and habits, especially as to use of alcohol, is also very great in certain kinds of occui)ations. The most extensive and reliable series of data as to the relative death-rates in dif- ferent occupations yet i)ubllshed is given by Dr. Ogle in the supplement to the forty-fifth annual report of the Registrar-General of England, and in a |)ap(>r read before the Hygienic Congress in London in 18ill. The following (A) is his table of com])arative mortalities of men between twenty-five anil sixty-five years of ag(! in different occupations, the death-rate <»f clergymen, the lowest of all, being taken as the standard of comparison and represented by 100. The si)ecial causes of disease and injury dindly coiuiecled with particular occu))ations may be classed as follows: viz. 1, accidents; 2, poisonous materials; 3, dust; 4, gases and vapors; 5, excessive temperature ; (i. abnor- mal atmospheric ])ressure ; 7, excessive use or strain of nrlain parts of the body ; 8, special exposure to contagious or i)arasitic diseases. Of I lie poison- ous'materials, lead is the most important, as pro.hicing the greatest amount of 26 HYGIENE. A. — Coinparative Mortality of Men {twenty-jive to sixty-five years of age) in Different Occupations, 1881-8S. Occupation. Clergymen, priests, ministers . Lawyers Medical men Gardeners Farmers Agricultural laborers .... Fishermen Commercial clerks Commercial travellers . . . Inn-keepers, liquor-dealers Inn, hotel service Brewers Butchers Bakers Corn-millers Grocers Drapers Shopkeepers generally . . . Tailors kShoemakers Hatters Bookbinders Compar. Mortal. 100 152 202 108 114 126 143 179 171 274 397 245 211 172 172 139 159 158 189 166 192 210 Occupation. Carpenters, joiners Cabinet-makers, upholsterers . . . Plumbers, painters, glaziers .... Blacksmiths Engine, machine, boiler-makers . . Silk manufacture ....... Wool, worsted manufacture .... Cotton manufacture Cutlers, scissor-makers Gunsmiths File-makers Paper-makers Glass-workers Earthenware-makei's Coal-miners Cornish miners Stone, slate-quarriers Cab, omnibus service Railway, road, clay, etc. laborers . . Costermongers, hawkers, street-sellers Printers Builders, masons, bricklayers . . . Compar. Mortal. 148 173 216 175 155 152 186 196 229 186 300 129 214 314 160 331 202 267 185 338 193 174 disease. Manufacturers of white lead, painters and glaziers, plumbers, work- ers in rubber factories, and file-makers are specially liable to be affected from this cause with colic, local paralysis, and various obscure forms of disease of tiie nervous system and of the urinary organs. Tailors and seamstresses sometimes suffer from lead-poisoning from the use of sewing silk treated with sugar of lead, especially if they have the habit of biting off such thread. Chronic mercurial poisoning occurs in gilders, looking-glass makers, and hat- ters ; necrosis of. the jaws in Nvorkers in phosphorus, especially in match- makers ; arsenical poisoning in zinc- and brass-founders and in workers in papers, feathers, etc. tinted with arsenical colors. Irritating dusts produce diseases of the lungs and air-passages which predispose to phthisis, as will be seen by the following table (B) of Dr. Ogle : B. — Comparative Mortality of Males in certain Dust-inhaling OccujMtions from Phthisis and Diseases of the Respiratory Organs. Occupation. Coal-miners Carpenters, joiners Bakers . Masons, bricklayers, builders Wool,- worsted-workers . . C'otton-workers Quarrymen Cutlers File-makers Earthenware-makers . . . . Cornish miners Fishermen Comparative Mortality from- Diseases of Phthisis and Dis- Phthisis. Respiratory eases of Respir- Organs. atory Organs. 64 102 166 103 67 170 107 94 201 127 102 229 1.30 204 234 137 137 274 156 138 294 187 197 384 219 177 396 239 326 565 349 231 580 55 45 100 HABITATIONS. 27 Alcoliol is also to be reckoned among the poisonous materials, as is shown by the following table : Mortality of Dealers in Liquor {twenty-jive to sixty-jive years of ar^e) from Various Di^^eases, compared ivith that of Men generally of the same Ages. Diseases. Alcoholism Liver disease (iout Diseases of nervous system . Suicide Diseases of urinary system . Diseases of circulating system Other diseases All causes Mortality of— Liquor- Mi-n dealers. gfiiurally. 55 . 10 240 39 13 3 200 119 26 14 83 41 140 I'JO 764 653 1521 1000 Dangerous gases and vapors are evolved in chemical and color works, in the manufacture of sulphate of ammonia from the refuse of gas-works, in India- rubber works, etc. Excessive temperature and rapid changes of temperature affect glass-blowers, puddlers, and firemen in steamships and workers in certain mines, producing diseases of the respiratory organs and rheuniatic affections. Abnormities of atmospheric pressure, and especially rapid changes in the pres- sure, affect workmen in compressed air, producing rupture of the membraiui tvmpani and paralytic aflFections of the nervous system known collectively as the " caisson disease." The chief danger occurs in the rapid passage from a denser to a thinner air, producing tendencies to congestion and hemorrhages in internal organs. For the same reason persons having tuberculous cavities in the lungs are liable to attacks of pnlmonary hemorrhage in passing rapidly by rail to high altitudes. For most of the special causes of disease in factories and workshops the specially important precautions are personal cleanliness and abundant ventilation. In many cases dust or vapors can be at once removed by fans or blowers, and in most cases dangerous and offensive gases connected with waste products can be avoided or converted into materials of value by projjcr methods of dealing with these products. Habitations. Physicians are rarely consulted in the selection of a site for a dwelling, and oven more rarely in the ])rej>aration of plans. Occasionally, however, they are called upon for an opinion as to whether a particular house is unhealthy, and, if so, what should l)e done to improve if, or whether a cliangc of residence is necessary to secure satisfactory resnlts in the treatment of a |)arlictilar ease. In cities most men select their dwelling-i)laces with special reference to cost, vicinity to their plaee of business, kind <»(' neighbors, etc., rather than to sani- tary conditi(jns, with regard to wliicii (li(y have little choice. The sanitary character of a building-site is determined maiidy by its clcvalion aiid exposure to i)revailing winds and the dryness and kind of soil in the iinincdiate vicinity. 28 HYGIENE. An elevated site is desirable as securing abundance of fresh a-ir and facilities for good drainage; but in the rural districts convenience of access and of water-supply must often be the first points to be considered. In some locali- ties shelter from cold northerly winds, and in others from winds coming from over low marshy grounds, is very important. Rock, gravel, and pure sands are healthier sites than clay and alluvial soils, because they are dryer if suffi- cieutlv elevated. Damp sites are unhealthy, having a special tendency to pro- duce or to aggravate diseases of the air-passages and rheumatic alFections. The inhabitants of such sites are especially liable to pulmonary phthisis and to diphtheria, possibly because the specific bacilli and spores of these affections retain their vitality better in such localities, possibly because the slight colds and catarrhs which such sites tend to produce modify the respiratory tract so as to make it easier for the specific germs to effect a lodgment and to multiply and develop. Under the same general conditions of climate diseases of the respiratory organs are more fatal on damp soils than on dry ones. Soil moisture or dampness refers to the water in soils that also contain air. When there is no air in the soil interstices and the water is continuous, it is called ground water. All soil contains a large proportion of interstices filled with either air or water : in coarse dry sand or gravel or in coarse sandstone this amounts to one-third of the bulk. When filled with air this air is always iii motion, and enters buildings freely through the floors and sides of the cel- lars or basements, especially in cold weather, when the air in the house is warmer than that outside. Soil air always contains a greater proportion of carbonic acid than the atmosphere, and this proportion increases with the depth. Tiius, while the atmosphere contains about 0.4 parts per 1000 of COg, the upper layers of the soil contain from 1 to 3 parts, and at a depth of fifteen feet it may contain from 50 to 70 parts. In cities the soil of streets is liable to contain illuminating gas from leaky mains, and this may be drawn into the cellar of a house from a distance of from thirty to fifty feet. The excess of carbonic acid in soil air is greater in soils containing much organic matter, and is therefore, to a certain extent, a measure of the organic contamination of the soil ; but it does not always depend on local oxidation processes, nor is it in itself a matter of much sani- tary iraj)ortance. It is, however, necessary to bear in mind this excess of COj in cellars, due to soil air, in testing the air of rooms with reference to ventila- tion, for otherwise very erroneous conclusions may be drawn. Like the soil air, the soil or ground water is continually in motion. It varies in height at different places and at the same place at different times. Where the ground water is always below fifteen feet from the surface, it is healthy so far as this is concerned. When the level of the ground water is above this, it is healthier when it remains at about the same level than when it fluctuates. In some places, as in Munich, typhoid fever increases as the ground water falls, but this is by no means always the case, and it probably dei)ends to a considerable extent on the condition and amount of use of shallow wells. M 'A TER-SUPPL Y. 29 As the soil water is constantly in motion, and for each locality this motion is tolerably nniform in direction and velocity, it follows that in })rivy-well and cesspool villages and towns it may be much more contaminated in one part of the town than in another. Nearly every form of micro-organism may be found in the soil at different places and times, and their number and character de])cnd on the moisture and temperature and on the presence of suitable food material. From the sanitary point of view the most important of these are the Plasmodium malarife, the bacillus of typhoid, of tetanus, of anthrax, of tuberculosis, of diphtheria, and of cholera, and the nitrifying organisms. The pathogenic micro-organisms or their j^roducts may pass into the soil water, being washed down by rainfall, or into the air with particles of the surface soil blown about as dust. They cannot be drawn far through soil by air-currents, especially if the soil is slightly moist. To prevent ground air and dam])ness from entering the cellars of dwelling- houses, the floor, and the sides of the cellar up to ground level, should be laid with bricks soaked in asphalt. A cement floor is quite pervious to air when it becomes dry. In low sites, and especially in malarious regions in warm climates, it is better to have no cellar beneath the house, which should be raised on piers, posts, or arches. The natural processes for the purification of soil containing nuich organic matter of animal origin, such as the made ground in the suburbs of cities or the ground in the vicinity of leaky cesspools or of graves, is a slow one, requiring from three to eight or more years, according to the porosity of the soil and the accessibility of fresh air to the interstices. Hence, when a system of sewerage is introduced in a city which has previously been storing up its filth in cesspools, it requires some time for the nitrifying organisms to complete the work of purifying the polluted soil. Water- Supply. Water is sometimes considercnl as a food, because it is taken into the body through the alimentary canal, but it supplies no force for the production of either heat or motion. It is, however, the universal medium in and through which the processes of life occur and the products of vital action are removed and excreted. 58 per cent, of a man's body is composed of water ; he must liave from 60 to 90 ounces a day in his food and drink to maintain his weight and strengtli, and he needs a nuich larger quantity externally (o \irv\\ his skin and his morals in good condition. In a fairlv clcanlv household the avera;re necessary consumption of water per head ])er day is from 10 to 15 gallons. Vuv all pur])Oses the water-supply of a town should not be less than IS gallons per head per day ; if it is used freely and ntmc is wasted, it will r((|iiirc about 25 gallons per head per day. The average sn])ply in (lie larger American cities is mon; than three times (his, the greater |i:n( lieiiig wa>(ed (hroiigh leaky fixtures. This constant use of water by (^very living being makes the quality of (he water used of great importance, as it is very liable to contain matters injuri- ous to health. The most important of these are the micro-organisms which 30 HYdTEXE. cause disease, and especially those which produce diarrha?al and dysenteric affections, cholera, typhoid fever, and, sometimes, malaria. Water may also contain poisonous salts, as of lead, or excessive amounts of magnesia and lime, giving rise to goitre or to calculus. No water in ordinary use is chemically pure : rain-water, snow, and hailstones contain organic mat- ter and living micro-organisms. A good drinking water should have a bluish tint when in a layer of three feet thick; it should be limpid, cool, without odor when cold or when heated, and it is most palatable when it has a very faint taste of acid and of salt. A good water should not contain more than 20 parts of lime per 100,000, or it will be " hard," so that it will not easily form a lather with soap and is not well suited for laundry and cleansing purposes. There is no simple, easy means by which any one can assure himself that a water contains nothing harmful, but in bad cases the sense of smell, taste, and sig-ht will assure him that it is not fit to drink. Bv chemical analvsis w^e can discover the amount and, to some extent, the source of the foreign matters pres- ent, and can usually tell whether it is contaminated with sewage or not. This last is indicated by the presence of an excess of chloride of sodium and by the long-continued production of free and albuminoid ammonia in distillation with an alkaline permanganate, indicating the presence of urea. Much care is neces- sary in obtaining the samples to be examined. Chemical analysis tells nothing about the living organisms in the water. vSomething may be learned about these by mixing a drop of the water with a little melted peptone gelatin, spreading the mixture in a tube or on the bottom of a thin, shallow glass dish, and cultivating the mixture. In this way it is possible to determine approximately the number of bacteria in a given quantity (as a cubic centi- metre) of the water, and the nature of some of these bacteria can be discovered by subsequent pure culture methods ; but it is rarely possible, by either chem- ical or bacteriological analysis, or by both combined, to make sure that a water is free from disease-germs, although it is otiten possible to be positive that it is polluted. If it is suspected that a Avell or spring is being polluted from a neighbor- ing leal^y cesspool or privy- vault, the question can sometimes be settled by throwing a large quantity of crude carbolic acid or of common salt into the cesspool or vault. If there is communication, the peculiar odor and smell of the acid or a considerably increased proportion of the salt will be found in the well water. The most reliable sources of what is ordinarily called a j)ure water-sup])ly are springs and deep wells in the open country and streams coming from uncul- tivated and uninhabited uplands. Surface water from cultivated land is dubi- ous ; streams or ponds into which sewage is discharged, and springs and shal- low wells in cities, furnish dangerous waters. The danger is mainly due to the possible ])resence of disease-producing bacteria which have passed from the bodies of sick j)eople into the water through sewage contamination or as air- blown dust, but it may also be due to an excess of the products of organisms which in small quantity are harmless. / u'ATijn-.srrrLV. 31 In a gpneral way, it may be saitl tliat a well drains a fnnnol-.shaped area, the radius of tlie tc.p of which is equal to its depth, and this whetlier its diameter is two inches or three feet. The shape and area of tlie o;round which it drains depend on the nature of the water-bearing strata or the velocity of the ground-water current, and on the amount that is drawn from it. A general water-supply is desirable, because it usually gives a purer and more wholesome water than the wells or eisterns of a town, because it saves much labor, ])romotes cleanliness, lessens the danger from fires, ])ermits of watering the streets, and increases comfort and hapj)iness in niauv ways. On the other hand, when a general water-suj)p]y does become dangerously contaminated, its effects are widespread, and it necessitates the provision of means whereby the large amount of water brought in and made foul bv use can be taken out again without producing nuisance or danger to the town itself or to its neighbors. A general water-sujiply may become polluted at its source, or while it is in an open stream or pond, or while stored in reservoirs, or while in the distribution-pipes. The pollution which occurs in reservoirs is due to the growth and decay of various species of algje or of fresh-water sponges, pnxlucing unpleasai*t odors. Uncovered reservoirs more frequently become affected in this way than covered ones, light being necessary for the development of the algaj which jjroduce them. While in the distributing pipes the water may become contaminated by sewage if the pipes are leaky, and especially if the supj)Iy is intermittent. Such contamination may be sus- pected when a sudden outbreak of typhoid fever occurs, confined to the houses supplied by a ])articular water-main, and there is no other circumstance com- mon to these houses, such, for instance, as a common milk-supply. The tyi^hoid bacillus has been known to pass many hundred feet beneath a mountain and infect a spring at its base, and to preserve its vitality for several weeks in excreta thrown out on snow, and then, through the melting of the snow, pass into a stream and produce an extensive epidemic. When a running stream has been pc^lluted by sewage, a j)rucess of self- purification occurs by sedimentation, by the action of bacteria, and of microzoa which feed upon the organic matters. The rapidity and completeness with which this natural purifying process goes on depend on the nnioimt of dilution of the sewage, the presence or absence of fine ])articles of clay, which proiluce sedimentation, and especially on the amount of oxygen present in the water, which determines the character of the bacteria which fioini-li in it. If there is abundance of oxygen, those bacteria which rc(|uire It lor growth will mul- tiply and consume the organic mattei- to the exclusion (»f other forms. Such l>acteria are called aerobic — that is, air-loving — bacteria, and among these are the nitrifying organisms, which will be referred to liereafter in speaking of the filtration of sciwage. When it is necessarv to u.>(; water which lia> heeu polluted by >e\vage, it may Ix; rendered harndess by bi»iling, and thus sterilizing it, or by certain methods of filtration and aeration, 'i'lie only >iiiall hoiixhold filters which can be relied on t(j remove bacteria are tho-e made of uuglazed pr»rcelain, and 32 HYGIENE. these will only do so for two or three days, at the end of which time they must be thoroughly cleansed and sterilized. On the large scale the cheapest and most satisfactory filters are constructed of sand, but their action must be intermittent, as will be explained in speaking of sewage filtration. Spongy iron also makes a g-ood filter, and a combination svstem bv which iron is showered through the water in a revolving cylinder, with subsequent aeration and sand filtration, gives good results. The freezing; of water does not destrov the vitalitv of the micro-organ- isms contained in it. It kills some of the soft microcopci and bacteria, but only a portion, and has little or no effect on spores. The bacillus in ty- phoid will preserve its vitality and powers of development in ice for sev- eral months ; hence, ice cut from a sewage-contaminated pond may be very dangerous. The jurisprudence of water-sup])lies is in an unsatisfactory condition in the United States. The common law of the subject rests on contradictory decis- ions of different courts, and where there is not clear and definite statute law upon the subject it is very uncertain in any given case as to how far manu- facturing or other interests of more or less public importance will be allowed to override the health interests of individuals or of small communities. The gen- eral principle is, that a person living on the banks of a stream has the right to demand that the water of this stream shall continue to come to him in its natural purity and volume, but that, if pollution has been going on for twenty years without complaint or attempt at interference, what is called a prescriptive right to continue such pollution is established. The fact that a person or corporation owning property on the banks of a stream does not use the water does not prevent them from bringing an action to protect themselves against the acquirement by others of a prescriptive right to pollute the stream, thereby depriving them of their rights in future. It has also been decided in one case that the ])rinciple applies to subsoil water while on its passage to springs or wells, and that therefore the placing a cesspool or drainage from gas-works in such a position as to pollute a well is good ground for action for damages. When it is possible to prove to the satisfaction of a court that actual dis- ease and death have been caused by the pollution of a water-suppl}^ bv sew- age, no doubt the nuisance can be stopped and damages collected in many cases ; but it is rarely possible to prove this. In some cases it is a question whether it is not best for the public to abandon a stream to ])ollution, so long as it does not injure the public health. It is generally admitted that the dis- charge of excreta into a stream the water of which may be used lower down for driidving purposes is unlawful, but, practically, it is not possible to pre- vent a small amount of this contamination in most cases. What amount of contamination is excessive and unnecessary is a question to be decided sep- arately for each particular case. So far as statute law is concerned, the best form is probably that of the SEWAGE-DISPOSAL. 33 State of New York, wliicli authorizes the State Board of Ileahli " to make rules and reguhitions for protectnig from contamination any and all public sup- plies of potable waters and their sources within the State." Sewage-Disposal. AVater-supply, and its pollution and purification, are closely connected with the subject of sewage-disposal. \\\ "sewage" in this connection is meant water made foul by nse in habitations and manufactories or by street-wash- ings. It is a complex liquid, containing a large amount of organic inattcr and innumerable micro-organisms, but varying much in composition in different places, or in the same sewer at different hours of the day. Chemically, and as regards the amount of organic matter, the sewage from towns where it is not allowed to connect water-closets with the sewers does not differ greatlv from that from water-closet towns. Ordinary sewage has been drunk with impu- nity ; diluted sewage, as found in the shallow wells of most small towns and villages is constantly imbibed with onlv occasional bad results. The sewage from a single house rarely contains the specific bacteria of cholera, typhoid, or dysentery, but that from a large city will rarely be free from those of tyjihoid, and never from those capable of producing intestinal irritation. In considering the question of the disposal of the sewage of a particular locality there must be taken into account the probability of its containing spe- cific causes of disease, and the communication of these to water-supplies ; its liability to produce offensive odors ; its effects on fish or on the iitness of a stream for manufacturing purposes ; and its value as a fertilizer. When there is no general water-supply the amount of sewage jiroduced is comparatively small, and it is usually disposed of on the premises by iiuans of a cesspool or privy-vault or by being thrown on the surface of the ground or into the gutter. To remove it entirely from a town some system of water-carriage is necessary, and this requires a general water-sujiply ; while, as mentioned above, a general water-supply requires some kind of system of sewers to remove the fouled water. 1000 adults excrete each day about 250 })ounds of faeces and 375 gallons of urine. Practically, the amount of sewage from a community maybe taken as equal to the amount of its water-su|)ply. In considering the merits of different systems of residential sewage-disposal the chief points to be borne in mind are as follows: 1. Fresh sewage conlains a large amount of dead organic matter in complex forms of coinl»ination. '1. These complex forms are to be decomposed and rerond)inc(l in(o siinpler forms, such as nitrates, ammonia salts, etc., in which the combined nitrogen is in a form suital)le to nourish plants. 3. The nafiiral pr by the action of bacteria. -1. Tlie l);icteria wlii.'li gr<»\v nnd multiply be>( wlicii there is little f)r no free oxygen j)resent — /. r. tlic :iMierol)ie bacteria — do not effect this decom])osition into sim])!*- salts, but pnuhice substances which are more complex, more dangerous to health, and more ofVcnsiyc to the sens<' of smell tlian are the ])ro(lucts of tliose which grow be^t in nbundance of iVee oxygen — the arobic bacteria. 5. In moipes leading from them, of cisterns or tanks lor ll„.-lung them of traps, of special ventilating pipes, and of the soil pipes as lar as fl.eir 36 HYGIENE. connection with a sewer or cesspool outside the house. The essential feature of a satisfactory system is that no air from the interior of the waste or soil pipes or from the sewer shall escape into the house or into any part of its water-supply ; that all foul matters turned into the system shall be washed rapidly away without stagnation at any point ; that the liability to obstruction of any of the pipes shall be as small as possible; and that if it does occur it can be easily located and removed. It is moreover desirable that the waste and soil pipes shall have a constant gentle current of fresh air passing through all parts of them as far as possible, in order to favor the growth of the aerobic bacteria in the slime which lines them, and thus to prevent the development of those organisms which produce foul odors as well as of those which cause disease, as explained in the section on Sewage-disposal. All this requires a proper plan of arrangement and connections, good materials and good work- manship, and care in use, with occasional skilled inspection to make sure that all the parts remain in good order. From such a system there is no special danger to health. As regards plan and arrangements, the plumbing regula- tions of most of our large cities are now fairly in accord and are satisfactory, the main points being as follows : 1. Soil pipes must be extra heavy cast-iron or standard wrought-iron pipe, not less than four inches in diameter and free from cracks, holes, and other defects ; they must have a continuous fall toward the sewer and must be so put together as to be air- and water-tight at all joints. 2. Soil pipes must be extended fidl size up to and through the roof, and be freely open to the outer air at the top. 3. It is not desirable that the sewers should be ventilated through the soil pipes or through rain-water pipes in any case where the air escaping at the top of the pipe is liable to enter a window of the same or of an adjacent house. In most cases it is better to cut off the sewer air from the soil pipe by a trap between the house and the sewer, and to provide a fresh-air inlet to the soil pipe just inside of this trap. 4. Every fixture should have a trap on its waste pipe fixed as close to it as possible, and from the top of this trap there should be a ventilating pipe of a size not less than that of the waste pipe to which the trap is attached, which ventilating pipe should continuously incline upward and open above the roof. A mechanical trap which merely prevents siphonage is not a satisfactory sub- stitute for the ventilation of the trap and. waste pipe. 5. All water-closets or slop-sinks should be flushed from a special tank or cistern, and never directly from a water-supply pipe. 6. Waste pipes from refrigerators, from safes placed beneath fixtures, or from tanks or cisterns except flushing tanks, should not be connected with soil pipes, but should discharge in the open air. 7. The arrangement of the waste, ventilating, and soil pipes should be such that they can readily be inspected at all points. About half of the houses having a sewerage system have one with defects in it of some kind which permit of the occasional discharge of soil-pipe air into VEXTILA riOX. 37 the house ; lience the discovery of such a defect in a house in \vliicli there is sickness is no proof tliat the latter is caused by the former. In a well-sewered house the chief danj^er to health connected with the system occurs when the fixtures have been unused for two or three months, and the traps and interior of the pipes have become dry, so as to give oil' dust-particles which are carried into the rooms. The best-water closet is one of the all-porcelain wash-out forms, of which several varieties are in the market. The worst form is the pan closet. Trapless closets should be avoided. Ventilation. Most persons of average cleanly habits in this country would object to being compelled to wear under-clothing that had just been removed from the body of another man, or to use another person's toothbrush, or to cat food that had been partially masticated by another. They do not, however, often object to drawing into their noses, mouths, and lungs air that has very recently been inside anotlicr man's body ; and upon the whole it is fortunate that they do not, for they cannot very well help doing so under the ordinary conditions of civilized life. The evil results of the continuous inhalation of impure air are not, in most cases, such as to attract notice unless the impurity is very considerable or the conditions of moisture and temperature connected with it are such as to produce evident discomfort. The injury inflicted on the bodv by breathing air deficient in oxygen and contaminated with animal exhalations is usually not perceptible until after a considerable period of time, and is then often attributed to other causes. The proof that this injury occurs has been obtained by comparison of the statistics of disease for a series of years among men living in unventilated with those of men living in well-ven- tilated barracks, ])risons, etc., and also among cavalry horses kept in well- and ill-ventilated stables. The diseases which are especially produced or aggra- vated by defective ventilation are chronic inflammatory affections of the throat and lungs and certain forms of contagious disease, more especially typhus fever and phthisis. With regard to phthisis, this is due in part to the fact that the probabilities of inhaling the specific bacillus or its spores are greater where a number of men or animals are repeatedly breathing air cotitaining the dried sputa and other excretions of their companions, and partly because the inhaling of air loaded with dead or dying organic matters tends to accinnulate in the air-passages materials well suited Wn- the nonrishnu'ut of the specific germs, which in the absence of such food-material would be killed by the liv- iniit of cold air h'aking in throu thirty degrees warmer tliaii the air of his room in winter, ami therefore acts as a little stove, causing an ascending current of air. The ;iir which 1 xliales is also warnur than the siin-oiuiding air, :iiid rises. It is frne that it contains more carbonic acid than the surrounding air, and tliat carbonic a.id is Iieavier than air of the same temperature, but as dihite.l and warni<'{' ;m inhabited room. V<'ntilation dibit<'s (he gases and va|)ors in a n.oin, but it has not nnich eflec^t on the suspended |)articles, incluIeen does not eidarge so decidedly; the Ehrlich renetion is likely to be absent ; episfaxis and loose- ness of the bowels are more rare; aii'l no cliaracferisfie ernjilioii makes ils appearance, while, on the other hand, herpes is of far more fn^pient occurrence. It must be remend)erehoid fever is wholly con- trolled by the fiict that a special micro-organism, observed and described by El)erth and bv Klebs, and after ihcm by K..cli, CJaffky, Arlhaud, Pfcill'cr, Friedlandcr, and many others, has been sh..wn to be constantly ass(.ciated with the disease. The organism is a small bacillus, of alxMit onc-thir.l llu- diameter of a red blood-corpuscle in length, oiw-lhinl as thick as long, rounded at the extremities, and sometimes exhibiting at one or both cuds, or, according 56 TYPHOID FEVER. to Arthaiid, in the centre, a shining rounded body, possibly a spore, but pos- sibly also only a degenerative alteration of the protoplasm. It occurs singly or in filaments composed of a number of bacilli joined end to end. The descriptions of it vary considerably, owing to the fact that the bacillus itself varies with the culture medium. All observers, however, agree on its motility as a characteristic feature. Loffler was able to demonstrate that this motion was due to the presence of a vibratile cilium. The bacilli are found chiefly in the spleen, intestinal and mesenteric glands, and liver. Pfeiffer was the first to discover them in the stools. They are, however, rarely detected before the period of actual ulceration, when they become much more numerous. According to Chantemesse and Widal, they exist in great numbers in the pas- sages from the tenth to the sixteenth or seventeenth day, but disappear, as a rule, after the twenty-second day. They have been observed in the kidney, and Neumann and Karlinski found them in the urine. They have been dis- covered in the expectoration in certain cases, and also, though rarely, in the blood. Riitimeyer reports their presence in blood taken from the rose-colored S})ots. They have also been reported as occurring occasionally in many other parts of the body, as in the meninges of the brain and of the spinal cord, the substance of the cord, the heart-muscle, lungs, and testicle. They have been found, further, in pus from an encapsulated peritonitic abscess, in periosteal abscesses, in empyema, and in serous pleural effusion. Perhaps in this connection it can be best recorded that Widal and Chante- messe found bacilli in the placenta from a woman who aborted at the fourth month on the twelfth day of an attack of typhoid fever ; Neuhaus in the liver and spleen of the foetus ; Eberth in the foetal blood from various parts of the body ; and P. Ernst in the spleen and the blood from the heart in the case of a child prematurely born of a mother with typhoid fever, which died suddenly on the fourth day of life. The mother had received an injury some days before labor which had probably produced a lesion of the placenta. The experiments of Frilnkel upon guinea-pigs led him to believe that the bacilli could not be transmitted from mother to foetus unless there had been an injury to the placenta ; and Eberth holds much the same view. The bacilli of Eberth will produce pure cultures on potato, gelatin, agar, and in blood-serum and bouillon. They grow rapidly in sterilized milk, and become quite large. They have been found to live in milk for thirty-five days, and in butter for twenty-one days. In fact, as Heini has shown, there is scarcely any article of diet which does not form an excellent culture medium for this bacillus. Very few of the cultures are characteristic, that on the potato being the most so. Even this, however, is so like that of the colon bacillus that much confusion has arisen and still exists, especially as this bacillus, like that of Eberth, penetrates at times into different tissues of the body. There is no doubt that the (;olon bacillus has re])eatedly been mistaken by able observers for the typhoid bacillus. The uncertainty has indeed gone so far that Vaughn concludes, from an elaborate series of experiments, that the Eberth germ is not ETIOLOGY. 57 a specific Diicro-organism, but a modified form of any one of a number of other closely-related germs. In this opinion, wiiich seems improbable in the light of what we know of other infectious diseases, he is upheld by some other investigators. It lias been claimed that successful inoculation experiments have been made, but this matter does not appear to be positively determined as yet. The typhoid bacilli unfortunately possess tenacious vitality. They have been known to remain active and virulent in parts of the organism for as long as fifteen months after the convalescence of the patient. Outside of the body it seems undoubted that they may retain their vitality for weeks in water, and may even increase in number, while in illy-drained soil they are capable of multiplication and growth, and thus continue to live indefinitely. Although they are killed by exposure for twenty minutes to moist heat, they are not killed by heavy frost. Prudden has shown that they may retain their vitality in ice for months, and Seitz that they will grow at a temperature of 37.4° F. They develop rapidly in milk, without altering its appearance in any res]iect. It would appear that they will continue to live in fseces for extraordinarily long periods. Magnant reports a small epidemic of fourteen cases which he could ascribe only to the careless emptying of a privy-well into which the stools of a typhoid-fever ])atient had been emptied a year before. Utfelmann says that in one instance under his observation the bacilli had certainly remained alive and virulent for over a year. He made some interesting experiments bv adding pure cultures to faeces under different conditions, and found the bacilli still living after four months. Karlinski's experiments, while indicating a shorter duration of life than this for the bacilli, still prove their great hold upon it. It has been found, too, by Grancher and Deschamps that typhoid germs, placed upon the surface of frequently moistened ground, will penetrate to the depth of fifty centimetres, and there retain their life for five and a half months. Just how long the bacilli may live in ordinary water is not positively known. Under favorable circumstances they may persist twenty to thirty days. Hochstetter even found them live twelve days in a syphon of selt/A'r- water. It is certain that they will live a shorter time in running water than in cisterns or reservoirs. Sunlight i^roves quite destructive to the germs. Janowsky found that cultures ceased to develop after f..ur to eight hours' exposure to light. The bacilli enter the system by the way of the intestinal mucous membrane. This is certainly true in the vast majority of cases. That they may occasion- ally enter by way of the resjjiratory tract has been asserted, but never proved. That they may be transmitted by way of the placenta from mother t.. fo'tus has already been stated. Astotiie exact mode of action oC the ha.-illi alter th.-ir admission to the intestine, further investigations are neeply that many virulent epidemics in boarding-schools, hotels, and public institutions are to be explained. Infected milk is also a frequent mode of conveyance of the ])oison. The milk may become polluted by the water with which it has been diluted or which has been used to cleanse the cans, or the gern)S may be introduced directly into the milk from the hands of the milker, soiled with the discharges of a typhoid-fever patient whom he or she is engaged in nursing. The latter is evidently a less common method of infection. Instru(;tive instances of epidemics due to infected milk have been reported by Murchison, Cameron, and Ballard. More recently Almquist reported an epidemic in Sweden where 104 cases with 11 deaths occurred among jicrsons all of whom received milk which was in all probability contaminated. Another milk-epidemic is recorded by H. E. Smith as occurring at Waterbury, Conn., and Littlcjohu published the account of an epidemic of 63 cases traceable only to the milk sup- plied from one dairy. Numerous other instances of infection from this source })ave been recently reported. Dr. L. II. Taylor of Wilkes- Barrc, I'm., has favored me with the notes, as yet uniMiblislied, of such an epidemic occurring under his observation. Quite a number of cases occurred in this epidemic, but only in a limited portion of the tr.wn. A careful inv.'sligation showed that the disease could not be traced to the water-supply, which was excej)- tionally pure. Further study revealed the fact that the greater uunibcr of the patients had received milk regularly from a certniii fanii, that a uiimlter of retailers of milk in the neighborhood had i)rocnreil milk from this soun-c, and th;il .1 )H. pillar druirgist, who dispcMised milk-shakes to the inhabitants ol that part of the borough, also bought his milk from the farm. It was discovered also that a number of persons living upon the farm had been sick with ty|)hoi(l fever, and it seemed beyond (luestiou that this arose from using the wallace, the cellular elements becoming fatty and granu- lar, and being absorbed. The plaques may gradually become less swollen, preserving meanwhile their even surface; but as the retrogression takes place more rapidly in tlie fi)llicles than in the celhdar infiltration of the interfi)llicular tissue, the former are very apt to seem dej>ressed and a retic- ular appearance is given to the plaques. It is |)('rhaj)s still more probable that this appearance is due to a necrosis of the follicles, l(>aving little i)its. The "shaven-beard" appearance also may be |troduced by the deposit of pig- ment, the result of hffimorrhagie extravasation, in the depressions in the ful- licles. The plaques may exhibit this pigment even years after recovery from the disease. (2) Should resolution not occur the staf/c of /)re/o.s/.s- develop-. The blood- vessels become compressed by the surroiuiding eellidar inliltratioii, and in eon- sequence of lack of nourishment the follielr'< die ;ind Innn sloughs. This process may occur in all or in only some of the glands of the |)atches, and 62 TYPHOID FEVER. may be superficial or extend even to the serous layer of the intestine, finally producing perforation of the bowel. The solitary glands undergo the same change to some extent. The process is most marked at the lower part of the ileum, and in bad cases the greater part of the mucous membrane in this region may be in a sloughing condition. The necrotic tissue is sharply demar- cated from the surrounding parts, has a yellowish, greenish, or brownish color, and becomes softer. Tiie neighboring tissue is often decidedly hypersemic. The second stage rarely begins before the middle of the second week, and reaches its height toward the end of this week. (3) Following the necrosis and directly dependent upon it is the stage of ulceration. The sloughs loosen and gradually separate, beginning at the per- iphery, and finally, at about the end of the third week, become completely detached, leaving ulcers of varying sizes and shapes. Sometimes a whole Peyer's plaque is involved, producing an oval ulcer of corresponding form. More frequently several irregularly-shaped ulcers, separated by bands of mucous membrane, may be seen in one plaque. At the lower part of the ileum the ulcers often run together to a great extent, and occupy almost the entire circumference of this portion of the bowel. The solitary glands likewise undergo ulceration, producing ulcers of a rounded form. The walls of the ulcers are hypersemic, swollen, and often overhanging. The floor varies in character according to the depth to which the necrosis has pen- etrated, being smooth and usually of a gray color if the ulceration be super- ficial, showing the parallel lines of the muscular fibres if the mucosa has been entirely penetrated, and being smooth and transparent if the serous layer be reached. The ulceration of the solitary follicles is apt to be well marked in tiie colon, and especially in the caecum, where the ulcers are often very numerous. Eichhorst has observed a case in which the only ulcer discoverable anywhere was at the tip of the vermiform appendix. The ulceration may extend so deeply that perfi)rati()n may take place into the peritoneal cavity. This was found to have occurred in 5.7 per cent, of the 2000 autopsies on cases of typhoid fever made at the Munich Pathological Institute, and in 21.2 per cent, of the 64 autopsies made at the Montreal General Hospital. (4) The stage of cicatrization follows immediately upon that of ulceration. It usually begins at about the commencement of the fourth week and continues for two or more weeks. The walls of the ulcers become less swollen, and attach themselves to the subjacent tissue. Delicate gray granulations cover the floor of tlie ulcers, and sometimes secrete pus. Later the granulations are replaced by connective tissue. The cicatrices thus formed remain as smooth thin spots for years, often exhibiting pigmentation. Epithelium cov'ers the cicatrices, and villi may even grow upon them, but the true adenoid tissue is y)robably never replaced. Any one of the stages described docs not exist at one time in the intestine to the exclusion of other stages. Different glands may be found illustrating two or more stages. The neighborhood of the ileo-csecal valve is the portion MORBID ANATOMY. 0;] of the bowel usually oxhibitiug the uiost advanml !?tages of the glandular lesions. Again, the same Pever's patch may be undergoing cicatrization in one part, while sloughing is still proceeding or ulceration actually spreading in anotlier part. Such a condition of course prolongs the stage of healing very greatly, and may lead to perforation after convalescence is seeminolv well under way. B. Contemporaneously witii the early changes in the intestine, alteration takes place in the mesenteric glands, especially in those in the vicinity of the part of the bowel most affected, and usually, though not always, in proportion to the degree of involvement of the intestinal glands. Intense hypertemia is followed by swelling due to cellular infiltration. The soft, swollen glands, of a bluish-red color, may vary from the size of a bean even to that of a small hen's c%^. On section the central portion is often of a lighter shade than the perij^hery. At about the time of ulceration in the intestine resolution begins to take place in the mesenteric glands, the histological process being identical with that seen in the intestinal follicles. The color then becomes paler and yellower, and the swelling diminishes, although the glands arc apt to continue hyperremic and firmer in consistence. Where the swelling has been very great spots of necrosis with softening occur, especially in the central jiortion, but the puriform fluid thus formed becomes absorbed if the process has been limited to a small area. When, however, it is extensive, a large part of a gland breaks down and later is transformed into a cheesy and, finally, calcareous mass. Sometimes a liquefied gland bursts into the peritoneal cavity. Glands in other parts of the body also sometimes become congested and enlarged. Particularly is this true of the retroperitoneal and bronchial glands and those in the fissure of the liver. In fact, any of the lymphatic glands mav occasionallv undero;o this chano-e to some extent. According to I^ieber- meister, the lymphatic follicles at the root of the tongue and in the tonsils are often affected in the same way early in the disease, but almost always undergo resolution. C. The sj)leen nearly always becomes enlarged in typhoid fever. l>irch- Hirschfeld, however, states that this enlargement not uncommonly fails to occur in elderly persons. It may also be absent when the capsule has been thickened by previous inflammation and the organ has heconie firmly adherent to sur- rounding parts. The increase in size begins in tlic middle of (lie WxA week, and reaches its height toward the end of the second week, the organ being tin n Iwo or three times its normal dimensions. In the fourth week toins is rare. It is more a])t to occur in children than in later life, excc|)t in cases of a very malignant tvpe. Oftener the invasion is so gradual that it is difficult to determine the day from which the actual begiiniing of the disease shoidd be dated. The premonitory symptoms — sonic of which, at least, are commonly exhibited — consist of increasing sense of weakness and fatigue on exertion, light and disturbed sleep, confusion of ideas, fiiilure oC :ippe(il<\ occasional colicky pains in the abdomen, a tendcMKy to slight looseness of (he bowels, nausea, coated tongue, epistaxis, bronchial cough, severe headache (which is frequently occii)Ital), a sense of weary aching in the limbs, and not rarely a decided degree of dulness of hearing, especially toward the close of the stage of invasion. When these .symptoms are present in any marked degree it is 68 TYPHOID FEVER. evident that they possess a certain diagnostic importance, as in no other dis- ease are there sucii varied prodromes extending over so many days. I have repeatedly been led to anticipate the approach of typhoid fever by the unusual dulness of hearing and by the persistent occipital headache coming on after a few days of general malaise. The pulse may not be disturbed during this stage, but if the temperature be taken it will usually be found that there is slight evening elevation. The actual onset of the disease is rarely abrupt, but more frequently so in children than in adults. It may be marked by some chilliness and evidence of fever, but rarely by an outspoken rigoi*. The occurrence of decided fever is usually the evidence of the beginning of this stage, but as the prodromic symptoms very often merge gradually and imperceptibly into those of the actually developed disease, it is a common custom to date the beginning of this stage from the time when the increasing sense of weakness leads the patient to take to bed. As this, too, is a variable date, depending upon the severity of the attack and the will-power of the patient, it often hajipeus that the, case must be regarded as already in the third or fourth day before the confinement to bed begins or before medical aid is first sought. The fever gradually increases day by day, usually presenting an evening exacerbation, with a remission in the early morning hours, until by the end of the first week it reaches 103° or 104° F. It must be borne in mind, however, that the temperature not at all infrequently rises with miKih greater rapidity. The appearance dui'ing the first week is listless and apathetic ; the hearing is dull ; headache is often intense; and the patient lies, much of the time, with the eyes closed as though in sleep. Delirium is apt to occur, especially at night. In severe cases more marked nervous symptoms present themselves. The respirations are but moderately accelerated ; the pulse is increased in fre- quency, but not always in proportion to the increase of temperature. It is full, of low tension, and often dicrotic. The tongue is coated, appetite is lost, thirst is moderate; the abdomen is moderately distended, and pressure in the right iliac fosssa will usually disclose some gurgling sounds and tenderness. Constipation is present in perhaps the majority of cases at first, but during the first week, if not indeed from the outset, diarrhoea sets in, with yellowish and liquid stools. The spleen is distinctly enlarged toward the end of the first week. At about the seventh day or later a characteristic eruption of rose- colored spots appears, usually first upon the upper part of the abdomen. There is occasionally cough, sometimes quite severe, and auscultation shows a few scattered rales. The urine presents a febrile character and is diminished in amount, es])ecially if diarrhoea be present, and sometimes contains a small amount of albumin. In the second week the sym])toras become aggravated. Headache is apt to be replaced by an increased tendency to torpor and sonmolence. Delirium is present, usually of a mild, wandering type, though it may be violent. The tem- perature remains high and presents a more uniform course, though still marked by daily remissions. The pulse is now more rapid, less full, and less dicrotic. CONSIDERATION OF SPECIAL SYMPTOMS. 69 The tongue is apt to lose its coating and to beounie ml and more or less dry. It is protruded with difficulty, and often exhibits tremor. Tremor is also seen in the limbs. The spleen increases in size. Kfdes in the lungs are more abun- dant. The abdomen grows more distended. In the third week the temperature becomes of a distinctly remittent type, the morning fall growing more marked, and the height of the evening eleva- tion gradually lessening. The other symptoms of the ])revious stage persist. In some cases all the symptoms become worse toward the end of the second week and in the third week. The stupor grows more extreme ; the patient can scarcely be roused at all ; the tongue is very dry and is covered with a brown crust ; the teeth are coated with sordes ; the pulse is rapid and feeble ; subsultus tendinum is marked ; the urine and faecas are often passed uncon- sciously or there may be retention of urine. Weakness is progressive and great ; muscular relaxatiears ; diarrhrca lessens and tlie stools become darker in color, and constipation is finally apt to supervene ; the hvpertrophy of the spleen diminishes; the pulse improves in strength and lessens in frequency ; the eruption, which had developed in successive crops, ceases to appear. Convalescence begins with the entire disajij^ea ranee of fever, often marked by a subnormal morning temperature. It is gradual and often tedious, lasting into the fifth and sixth week, and sometimes not beginning until then. Vari- ous sequelffi may now occur, just as diilerent com})lications may develop during the course of the disease. During convalescence, too, the patient is subject to sudden temporary elevations of temperature, produced by excitement, over- exertion, or indiscretions in diet. These recrudescences last a day or two only, and are to be distinguished from true relapses, wlildi <'xhibit other symptoms of the ])rimary attack besides the mere febrile reaction. Consideration of Special Symptoms.— Tr'nir/Yr/ CondUion and Appear- ance. The expression of the face in tyjilioid f<'ver is characteristic. Kven from the beginning there is a drowsy, listless appearance with heavy eyes. If, however, headache be severe or fever high at the ousel, the expression at that time may be excited and anxious, the eyes bright, and liie pu|)ils ay be but little al(<'red at any time. When the disease is fully develo|)e(l, if of the ordinary type, the patient lies quietlv, more commoidy upon the back, with the eyes often closed, and 70 TYPHOID FEVER. witli a peculiar placid, sleepy, and heavy expression, unless there be active delirium, when jactitation may be marked. The face is often pallid or there may be a circumscribed flush on one or both cheeks. If confined to one side, this may indicate a higher degree of congestion of the corresponding lung. The flush comes and goes, and is often brought out or made worse by the administration of food or stimulant. Tlie general strength of the patient is usually prostrated from the begin- nino-. In crrave cases weakness becomes so extreme as the disease advances that the patient lies utterly helpless on his back or slides down in bed. In very mild cases, on the other hand, tliere may be but very little prostration. The patient may be about or may rebel against confinement to bed. Cases are met with in wliich the patient has kept about until very sliortly before death. Emaciation frequently becomes great, or even extreme in cases which have lasted several weeks. According to the studies of Cohin, there takes place at first a systematic loss of weight, varying with individuals, the loss bearing a unifi)rra relation to the course of the temperature. Later the patient begins to gain weight, the constant increase being an evidence of convalescence. Zieniec found as a result of the study of 384 cases that there was an average daily loss of weight of 0.6 per cent, which continued while the fever lasted and even longer. In the event of delirium or other threatening symptoms, or of the development of complications, the daily loss became 1 to 1| per cent. If the increase in weight during convalescence suddenly ceased, a relapse was probal)ly indicated. In fatal cases the total loss was 22 per cent, of the body weight. Skin, Muscles, etc. — The skin is often persistently hot and dry throughout the whole course of the disease, but more frequently more or less sweating occurs. There may be sudden flushings or sudden outbursts of perspiration. Sweating is more common in typhoid fever than in almost any other of the acute diseases except malaria, relapsing fever, and rheumatism. It is usually slight, occurring at night or on awakening in the morning or after the employ- ment of the bath, but it may develop at other times, may be limited to the '■ face and head, or may aflect also the trunk or extend to the entire surface. In severe cases, marked by a high degree of nervous ataxia and exhaustion, the body may be bathed in sweat continuously for many hours or even for several days. A special sudoral form of typhoid fever has even been, though unn'3(!essarily, described by some observers. The characteristic eruption of typhoid fever demands close study, as upon it the diagnosis dejiends in many cases. It consists of isolated round or len- ticular, rose-colored, slightly elevated spots, which first appear usually on the seventii or eighth, but occasionally not until the tenth or twelfth, day of the disease, and then continue to make themselves visible in successive crops. They are rarely to be discovered after the middle of the third week. They are, as a rule, first found upon the upper jiart of the abdomen and lower part of the chest, and may be limited to that region. Occasionally these parts do not exhibit any rash, while other portions of the body do. The CONSIDERATION OF SPECIAL SYMPTOMS. 71 spots often also ajipear on the sides of the trnnk and on tlie back, and sometimes upon the extremities. In very rare instances they are spread over the entire snrface, and I have seen face, trunk, and extremities ehisely dotted over with them. When tluis copious the spots may, to a sH;j:ht extent, be confluent by twos and threes by the edges. They are soft and very slightly elevated papules of a pale, rose-red color, varying in diameter from 1| to 2 or 3 lines, disappearing rapidly on pressure and returning ])romptIy when the pressure is removed. Each spot lasts three to five days, and then gradually fades, leaving sometimes a brownish stain. Fresh crops appear at intervals of three to five days. There is no uniformity in the amount of eruption nor in the number of successive crops, nor does the extent of eruption or the number of crops or of individual spots bear any relation to the gravity of the case. Murchison has counted as many as one thousand spots in a single case. Generally, however, the number is quite limited, and careful search may sometimes fail to detect more than two or three spots during the whole course of the disease. The eruption is sometimes entirely absent throughout the case. This hap- pens oftener in children than in adults. Mm-chison reports its presence in 4606 of tlie 5988 cases of typhoid fever which occurred in the liondon Fever Hospital during twenty-three years, and probably careful search would have shown it present in still more of them. Eichhorst failed to miss it entirely in over one thousand cases under his own observation. Although I admit that the observation is doubtfid, owing to possible want of sufficiently frequent and careful search, it is my opinion that in diircrent outbreaks and in different seasons there may be great difference in the amount of the eruption, and that in some of our epidemics it has not been extremely rare for the typical typhoid spots to be almost or entirely absent, and this especially in young children. We should never conclude that no rash is i)resent until after repeated and carefid examination, not only of the abdomen and chest, but of the back and thighs as well. The importance of this critical examination cannot be over- estimated. Occasionally some of the rose-colored spots may be capped by a small vesicle with tiu'bid contents. Certain accidental eruptions may be seen in typiioid fever, and it is import- ant not to confound these with the true rash. Sudamina, or minute pearly vesicles, occur more frequently in thi-^ tliiin in any other of the infectious diseases. They arc, ho\v O O 1 O O ' o ^ ) CO i5 i 01 o • ^ 3 (| Q q ■'^ -.^ h^ — »^ T 2 .m '*■■. i>- g s 1^ :_::? r m ^f z ■■"> m 4k _±:: 4_ i:::::::::::""2^:: 2 \ ::r m ^A 01 z ,^^ ^ -:• s> X j~ '^ 3 '-3 m /"" ___ I" s '-e ^ I e'' " i '^ '■'■hi .. ' = ', 4- ^ ■'6: ;?• m 'i ^c.. \ «s "='. s r 5a m ^? © ___ 'cll i 2 T:*» m ^ t - S^T s Ir^ai n S IC -^-f --- 2 T>' i^ ■if'-.-i. w '*i ^ ^*-.. '^ T'l? ^ i «. lt"t'T 2 -LLIC""'' ^ ^^ ^. c< l"-P^ n ■i a> * * it ^ i^i m x--. -?*-, *i ajH 2 TTlc ; * ' (^ ^ ce («; tTJi s Thbp ri ■■.'J. S: « ■ ;qd TJ" s T n^zp f^ ^ ^ g «T _L ^ 1 1 T TI^ " ^ ^^ i« "•" T ■:: i 1 T i 1 5 Jj"^*1-^ 1^ ^ ■ ST"! 5 I -5" 1^ € ■0 3-=:;: — "■ " ac __ . _ - - T^r ±:» m # l« 4> s I-.- :=■• fn •^ ■*«• ■6 "t ;;' T z i -■ ^*' PT ':^ ■i IC '■s; i 1 S rt=-S"' m ■*5, •%. IC *" -i' ' i 2' i»- i*#- T 1 1 i*"t' m 16 '< "n" m _ __ ^ n rTTZ s ■ ■ ' : s n.-'^. Xe "' III r ni 1. I'v--- O ,,-- ■" "^ _ - ---5 X* "3 * "~ ' m M ~*^' X z \">' ' " " PI s 'C -1- :::::: ^ ^ m .^^ n ! -^z.' "X -- ---- 'S. T:= rn T^ "t-"?: ":+::::: m '* ■Ji. '3 — 1 — i 1 ^ •4. __.. , ^ + T =^ 1. _i.:::l- ^x- I I I I 1111 1 111 1 1 1 I H[I I II M II |I III I III [IIIIIIM |MMIMI| I M 1 1 1 1 r CO e % ■tk O Ik ra 74 TYPHOID FEVER. represents diagrammatically what may be called the typical pyrexia. In the early stages of the disease the curve exhibits a gradual ascent, occupying about one week, during which each successive daily maximum and minimum is from one and a half to two degrees higher than the corresponding points of the pre- vious day. By this step-like ascent, with a daily variation likewise of fully one and a half to two degrees, a temperature of 103° to 104° F. is reached by the close of the first week or sometimes earlier. Following this initial period there is present, for about two weeks, a febrile movement of a more uniform severity, often spoken of as the fastigium. The maximum daily temperature now oscillates about the maximum temperature of the preceding period. The morning remissions are much less marked, although the daily range is still one to two degrees. The course of the fever during this period is marked by occasional fluctuations in which the temperature drops considerably below the average or else rises to the point of hyperpyrexia. During the third week the fever begins to fall gradually, but by more irregular steps than it showed in the initial rise. In a typical case the evening exacerbations are, for a time, as great as before, but the morning remissions become daily more marked. Very soon the evening maximtmis also begin to grow less by about half a degree every day, while the morning remissions are still more decided. There may be a difference of as much as two to four degrees between the daily maximum and minimum, and by the close of the third week or in the fourth week the morning temperature is nearly or quite normal, or even sometimes subnormal, though an evening exacei'bation is still present. The pyrexia thus often has a somewhat intermittent character. The evening temperature continues to fall gradually, and with considerable regularity in typical cases the normal is attained about the twenty-eighth day of the disease. It is not unusual during the period of defervescence to have an evening maximum higher than that of the previous day, but followed by a more abrupt fall on the following day. While a temperature curve possessing these features may be regarded as the type, it must be understood that there are many variations, and that a typical temperature chart is not often seen. This will be understood when the com- plex character of the pyrexia in typhoid fever is considered. Not only is there the general infectious process, with the morbid chemical changes in the blood and tissues and the disordered nervous action affecting the production and dis- sipation of caloric, these acting as the exciting causes of the primary fever, but there are often, even from an early period in the disease, widespread lesions which develop with irregular rapidity and influence powerfully the febrile movement, producing what may be called the secondary fever. In addition to these is the operation of numerous and varied accidental factors influencing the temperature curve, such as indiscretions in diet, the occurrence of intestinal haemorrhage, temporary nervous excitement, profuse diarrhoea, free epislaxis, and the development of complications. I know of no disease in which it is more difficult to appreciate the origin and meaning of the pyrexia. In certain rare cases a high temperature, even 105° F., may prevail almost continuously, day after day, for two weeks, and yet be unassociated with any CONSIDERATIOX OF SPECIAL SYMPTOMS. 75 grave nervous symptoms or evidences of heart failure. I have observed this most frequently in young and sensitive women, in whom it was ajiparently thie to a peculiar disturbance of the nervous system, since there were no marked pulmonary or intestinal symptoms to explain any considerable portion of the elevation. On the other hand, it is not exceptional to meet with cases, espe- cially of patients of phlegmatic disposition, where all the symptoms are fairly well marked, and yet the temperature does not exhibit a corresponding rise. Undoubtedly, there is, however, a general correspondence between the gravity of the case and the height of the fever ; and this is true whether the attack owes its severity to a high degree of infection or to a marked development of local lesions. Cases where the temperature is throughout little above the nor- mal are generally of mild type, although, as will be seen later, there is danger in them, as in others, of grave complications arising. The most characteristic feature of the temperature curve of typhoid fever is the gradual initial rise. This is im|)ortant in its bearing on prognosis, l)ut especially in relation to diagnosis. There are many cases of influenza and other affections in which, about the close of the first week, the symptoms closely resemble those of typhoid fever, but in which the fact of a more abrupt onset is a guide to the avoidance of a serious error. It must not be forgotten, however, that a rapid initial rise in temperature to 103° or 104° F., with or without preceding chill, may occur in typhoid fever also. This is, at times, met with in very grave cases, but it may also be noticed in those of ordinary severity, especially in children or when there is an unusual degree of pulmonary or gastro-intestinal irritation at the beginning of the attack. An implicit dependence upon the typical mode of ascent during the first week may readily lead to mistakes. As an illustration of the caution requisite I may mention two cases of typhoid seen in consultation as these pages go through the press. Of four children — two girls aged nineteen and eight, respectively, and two boys aged seventeen and fifteen, respectively — the older girl was taken suddenly ill in the night with vomiting, and the next morning had a fever of 105° F. ; the younger boy was taken ill 'the following morning, and before night his temperature reached 104.6° F. The girl, on subsequent inquiry, stated that she had not felt bright and strong for a week, l)nt twenty- four hours before the onset she had been to a large dinm i-p;irty. The boy had continued to bathe in the ocean :mn the mininnim and maximun). The shorter the tim.; that the temperature re- 76 TYPHOID FEVER. mains high in each twenty-four hours, the better is the fever borne as a rule. The indication is unfavorable when a high temperature is maintained almost continuously. On the other hand, extreme variations, as from three and a half to five degrees, are usually associated with nervous atony and with marked sepsis from the intestinal ulceration. The most extreme daily variations of temperature I have noted in this disease amounted to seven degrees for several days in succession in a fatal relapse complicated by exten- sive catarrhal pneumonia. In some cases the appearance of successive crops of eruption and the variation in the intensity of the abdominal symptoms cor- respond with exacerbations of fever, and suggest a relation between the latter and the varying intensity of the intestinal lesion. Hyperpyrexia, or fever above 105° F., is much less common in typhoid fever than in typhus, scarlet, or relapsing fever. When present it usually indicates a high degree of danger, and the cases in which it occurs more than a few times exhibit a large percentage of mortality. Nevertheless, it is not infrequent to have recovery follow where a temperature of 106° F. has been reached several times during an attack, provided that the fever has not remained too continuously so high. Very high initial temperatures indi- cate intense infection or violent nervous disturbance, or an early complication, such as marked gastric or pulmonary catarrh. During the second or third week hyperpyrexia is more common than at any other time. When the tem- perature rises with less decided remissions toward the close of the second week, or remains high during the third and fourth weeks, it indicates continuance of grave lesions or the occurrence of reinfection ; and such cases are very unfa- vorable. As death approaches it is not unusual to note a progressive rise of temj)erature (see Fig. 4.), which may reach 107° or even above 110° F., as in a case reported by Wunderlich. In such cases the body remains warm for a long time after death. On the other hand, when death is about to take place by collapse the temperature sinks to normal or even below it. It is important to observe the time when the daily maxima occur. The study made by Ampugnani of hourly charts from 200 cases of typhoid fever shows that the maximum temperature occurred between three and six o'clock in the afternoon. The maximum is followed by a gradual fall during the night, so that the minimum is reached between four and eight o'clock in the morning. The tolerance of the fever by the patient de})ends much upon the length of the remission. There is often a marked difference between successive days in this respect. Some cases present two maxima in each twenty-four hours, the tempera- ture pursuing a very rapid and irregular up-and-down course. The tempera- ture is said to be inverted when the daily maximum occurs in the morning and the minimum in the evening. This is not unusual in cases occurring under the age of twelve years. It may, however, be present at any period of life, and has no special significance. There is no crisis or abrupt fall of temperature in the normal curve of «» ''^ — £■ ? "_ CIC t? =- 2 8" Ci< — SI s; 3 p O X =• '^ o •'; fo re T3 S* ir '^ P i. -1 5 re ■< B 'jv re n> X X < ^ p " 3 '^ ^■g £ E = S 2 a 5 » p & on v; 3 2. 3 re g 2 p ?r -■ "—Ay. c C re s - 3 5-^ S -1 2 3 re re _. fs 3 re 9 7 » C re o „ 3 C rt § y- - E 5 re = 5 a, 5 3 o -> -. s H =? &^ 5 re X ^ re s 3 o re 2 D- -. 1 re re re C. » re S re » , g 1 1 S S 2i8 8iS^ 'o ^c ■- = . » 1 I - ■ " V, ■^'' I s . i C f. 1 n >b_% T "r t^ ^----r. ^i. 'i _r ci^"-^ M X """' ^<:- 1 ■ '••: ' n 'e>: .X ■ " 2 -z ^— ^ " '^, % X %, ■ 1 ; ; ; _ j 1 5 1 1 ^ -l-» 1 n i\ ' n -■,•?> e> ' . ..<^.. 5 '-■-. ■i- '■'/ ,>• 2 i^"^ - - . ]..->• ^ ^ 5 lir-^ ^ v.. ^ tf ..:. > 2 t + iT "':::::::::::::::::::: [4^ J> s Ml^ ■ d •4. , --^^J-:»!L_ 2 « p» n J r' ^ i \-'^ O ^ 2 ^'"'^ ill ; " 1 II j,^' , lil 2 1 'c' "i" T^ ^___jj_>« , T 5 T r^"" J- " V v_ 2 ^-\ . " r< r-i -U -i~ V ^ ^ n i 1 ' S 1, n V = '4^' !": ^ TTsi j n ■fe " :; ■ M ■ 2 ~-«. n ^z- :::::::: 14 > ^ i^ < , n -t j » 2 , , -* ' " n k. ''» _ _._ ,._^^ ^ — ~*~'"~- :» - A H n ■^ ^~ T : 4 .:.. < ^ ! ■ > , " T ^ -> 1 .'^^■^ ■ ._4_S ■. ■"^ L_. j't'T 2 Xi^--^;; *«=: rr 1 '^ ' _»-?T= "r* . . . ; 1 ! * ♦«=: "" ' , , " T _^__^:=»* 2 ^"ST' "^ '^ i ; ! . ■ i;^r=" ■ . . . . ■ ^- ' ♦ie :r^ '*^ ^ li--— ^^=^ n , ^ :....I.ii^-iii..-;:;::;:| "« t. l^^^ji xilJilJii-:::;:;:::::! ^ 't. ■"^ >, 1 -G-e5^^"— --5 '^ — "•+ ■ ..1 [ njl--^- ' "i T-"- '""""t ^ iiiii ^ 5 — -) 1" 1 M^ T X 1 -J. ....:" I m TTTTTT 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 r 1 1 1 II 1 r ti iiTi II 1 1 -rill III! iiiiiiM^ k k -. k n 78 TYPHOID FEVEB. typhoid fever. Any sudden drop must therefore be viewed with suspicion. It may indicate the approaching development of a serious complication, as when, owing to some carelessness in nursing, the patient has been allowed to become chilled and there is to be an attack of ])neumonia. It may mark the occurrence of severe intestinal hsemorrhage, and the temperature may fall sud- denly as much as five, seven, or, in rare cases, even nine or ten degrees, with marked evidences of shock, before the bloody discharges occur to furnish the positive explanation. It may attend the occurrence of a perforation of the intestine. Occasionally a fully-developed case which is pursuing apparently the usual course will culminate early in the third week in a rather rapid fall in temperatiu-e to the normal, and this be followed by uninterrupted convales- cence. These abortive cases may owe their short duration to the slight degree of intestinal lesion and to the early stoppage of infection from that source, as well as to the absence of the secondary fever which extensive ulcerative pro- cesses would naturally produce. It is never safe to consider the disease ended until the temperature has been at or a little below normal both morning and evening for several days in suc- cession. If the temperature continue to rise even to 99f ° or 99f ° F., though the morning temperature be normal or somewhat subnormal, it must be under- stood that some lingering trace of the disease is still in the system or that some complication is present. Occasionally a post-typhoid anaemia may account for this daily slight evening rise, or the evening fever is purely nervous in origin, and will be cured by allowing the patient to abandon the bed. It often haj)pens that after the temperature has fallen to the normal there will be an irregular rise, which on close examination will be found due to the occurrence of phlebitis, periostitis, a latent pleurisy, or some other sequel. In other instances, after convalescence has been established for two or three days, the temperature will rise again rather suddenly, and remain elevated for a day or two without any severe constitutional disturbance being present and without the action of any complication or sequel. These recrudescences are due to various slight causes, as fatigue, excitement, indiscretions in diet, etc. In the event of a true relajise of the disease the temperature, after being strictly normal for several days, will begin for a second time a gradual, step-like ascent, reaching 103° or 104° F. by the sixth or seventh day, and then pur- sue, for a week or ten days, a fluctuating course similar to that in the original attack ; this being followed by a gradual decline to the normal again. Lastly, there are certain cases of tyjihoid fever, to which reference will be made again, in which the temperature never rises above normal. The Nervous Symptoms deserve minute study. It occasionally hajipens that throughout the course of a case the mind will remain clear and the special senses almost normal, but such instances are excejitional. Usually there ap- ])ears at an early stage of the disease a mild degree of drowsy dulness, styled hebetude. The patient looks and seems sleepy, and will lie quietly, with the eyes closed, paying little or no attention to his surroundings and rarely making any remark. If addressed he opens his eyes leisurely, and in a slow and COXSIDERATIOX OF SPECIAL SYMPTOMS. 79 deliberate voice returns an api)ru])riate answer. He seemingly relishes liqnids when given, yet would go a long time without asking for nourishment or drink. Wlien roused he soon falls back again into the same somnolent state, so that it is ]K)ssible to administer food and remedies at regular intervals without inter- fering with his rest. Headache is one of the most frequent of the symptoms of tvphoid fever, and is often complained of bitterly at the onset. It is, as a rule, most severe in the occipital and cervical region, but at times extends anteriorlv. It may be so violent as to arouse fears of meningitis, especially when combined, as it sometimes is, with retraction of the head, twitching of the nuiscles, and allied symptoms. In some cases it persists throughout the greater part of the attack and constitutes the most troublesome symptom. More connnotdy it subsides as hebetude develops, which after the first week renders the patient too dull to notice it clearly even if it exists. Headache appears to be as fre(|uent in chil- dren as in adults. Its presence does not seem to be any indication of the severity of the attack. Vertigo often accompanies headache, but usually disappears with it. AVakefulness at night, with restlessness, is usually com|)lained of during the early portion of the attack. It may appear again later in the disease, asso- ciated with wandering or more violent delirium. It is at times a troublesome svmptom, and, though the patient may seem dull, there may be little or no actual sleep. If this condition persist exhaustion is apt to ensue. It is most important to bear this fact in mind, because the dull ai)pearance of the patient \ may mislead the attendants into the belief that he is getting sufficient sleep. The symptom is one which should receive early and efficient treatment. Delirium of some sort may be observed at times in the majority of cases. It mav be present from the start, but it oftener does not appear until toward the close of the second week, following headache and somnolence and preceding stupor. Its mildest form is simjily a slight confusion of ideas, particularly noticeable toward evening or during the night or on awakening from sleep, the patient being at other times perfectly rational. The most characteristic form is that of the wandering type. The patient talks to himself ra])idly, softly, and unintelligibly, and often appears to be hdhling a conversation with imaginary persons; and this delirium may last nninterruj)tedly for hours. The wandering delirium may alternate with periods of somnolence, or, on the other liand, there may be outbreaks of active, noisy delirium, which are peculiarly liable to be attended by such effiyrts to leave the bed fhat forcible restraint becomes necessarv. Occasionally maniacal delirium ••(•( iirs early in the disease. It has sometimes been the first symjitom noticed. A case is reported by Motet in which a ])atient was sent to an insane asylum before the true nature of the febrile disease was discovered. Even when the patient has seemed almost rational (hiring \\\r dny, it is necessary that a close watch be kept during the night, as then he ofteri dn-ams of being awav from home and that he is summoned to return, or he awakens with the notion that he \^ not in his own rocm), and rises (juickly to go thither. 80 TYPHOID FEVER. This is a very common delusion, and in this confused state serious accidents may happen to the patient from stepping out of windows or falling down stairs while trying to follow some imaginary summons or to escape from some a])parently strange and uncomfortable place. It is necessary to impress this fact very clearly upon the attendants, not only in private practice, but in hos- pitals, since fatal results from this source are not infrequent. In children or in young and sensitive women a violent form of delirium is sometimes met with which must be regarded as partly hysteroidal in type. There is extreme restlessness and agitation of the whole body ; the patient talks rapidly and with utter and wild incoherence; at the same time there is a ])eculiar quality of voice and of expression, conjoined with a less degree of violence of the associated symptoms than would seem naturally to accompany such excessive delirium ; which indicates the presence of a large emotional ele- ment. Such cases, although very alarming in appearance, recover habitually. In the second or third week of the disease in severe cases somnolence, which preceded delirium to some extent and then alternated with it, may deepen so as to replace it to a great degree. The active delirium entirely ceases, and only a low, muttering form remains. Finally the patient settles into a state of more or less deep coma. It is only in grave cases that such stupor ensues or that intelligence is so wholly lost that it becomes impossible to rouse the patient so that he will pro- trude the tongue when requested. Profound stupor may, however, exist for fully two or even three weeks, and then gradually clear up as the fever declines and the case approaches convalescence. Coma vigil, a state in which the patient, although in deep stupor, lies with the eyes open, fixed, and staring, is much more rare in typhoid than in typhus fever. It indicates intense nervous irritation combined with exhaustion, and is of grave omen. When it occurs it is usually toward the close of fatal cases which have been marked by violent nervous symptoms. The organs of special sense present few disorders. Ringing and buzzing in the ears are frequent in the early stages, and allusion has already been made to the dulness of hearing frequently observed in the early days, and which is apt to continue as a marked symptom. This deafness usually occurs in both ears, and is due partly to a catarrhal condition of the Eustachian tubes and partly to the blunted mental sense-perception. Deafness in one ear is apt to be a more serious sympton. Vision is rarely affected. Sometimes there is slight haziness, or there may even be double vision. There is at times decided photophobia. Injection of the conjunctivse is rare. The pupils are usually dilated, in contradistinction to the contracted pupils of typhus fever. The dilatation develops in the latter part of the second week, and very often accompanies delirium, though it may occur without it. Occasionally the pupils are unequal, and after stupor comes on they may become much con- tracted. Strabismus is sometimes seen. Epistaxis is a common symptom, and Is often one of the earliest ones, though it may occur at any period in the disease. It may vary in amount COXSIDEIiATIOX OF SPECIAL .SYMPTOMS. 81 froai a few drops only, just sufficient to stain the liandkcrcliief or the pillow, to a haeniorrluiiro of a profuse nature. There is evidently a morbid condition of the nasal mucous membrane which disposes to it, and which is aided by the altered crasis of the blood. Even when no blood has escaped, the nails of the patient may show traces of it. It thus has considerable diagnostic value. Although epistaxis occurs occasionally in other infectious diseases, and is absent in some cases of tvphoid fever, it is incomparably more frequent in the latter affection than in any other acute disease. It does not, as a rule, afford any relief to the symptom's of the disease, and is, indeed, rarely free enough to affect the system, although I have occasionally seen apparent temporary relief to severe headache and rest- lessness from a free epistaxis in tlie early stages of the disease. On the other hand, when there is already decided debility any considerable loss of blood is to be dreaded. In hsemorrhagic cases epistaxis is one of the commonest forms of bleeding, and even where there is no blood lost from any other surface epistaxis may be so profuse and obstinate as to induce dangerous or fatal exhaustion. The sense of taste is often greatly impaired, owing both to the blunted perception of taste and to the thick coating of the toiTgue. Cutaneous hyperaesthesia sometimes occurs, jnirticularly in women and children, but it is not seen as often as in typhus fever or cerebro-spinal fever. It may be so severe that the slightest touch causes great suffering. It can occur at any time during the attack. Its principal seat is the superficies of the alxlomen and the lower extremities. Cutaneous anaesthesia has been reported in rare instances. With the headache already mentioned there is at times violent ])ain extend- ing down the spine. Tenderness over the spinous processes may be associated with this. Pain in the extremities, particularly the legs, is of quite common occurrence, especially at the commencement of the disease. Toward the close of the first week, however, it subsides, and it is only in exceptional cases that much pain is complained of in the later periods. As a ride, patients looking back uj)on their attacks of typhoid fever do not speak of them as painful. Trenndousness and weakness of the muscles, as seen in the hands, Iij)s, and tongue, are very often present. Most marked in the severer cas(>s, they may occur even in those patients whose mental faculties are entirely preserved. They are commonest in the old and feeble and in the intemperate. Clonic spasmodic movements are present only in (he later periods of (he graver cases. Subsultus tendinum is one of the syiii|ii>iiii^ df this class, as is also twitching of the face. The condition becomes iikkI ni.iikeil iind nearly mw- stant when the low muttering delirium of I he l.itter stages develops. ("ar|>lio- logia is also on(! of the severer symj)toms. In it the p.-itienl gropes in the air after imaginary objects (jr picks at the bed-<.' lot lies as though to remove something from them. Obstinate hiccough may be seen toward the last stages of grave cases, or sometimes, indeed, as an (>arly symptom, it is usually a sign (}f evil omen. General convidsions are unusual, being chielly met with Vol. I.— 6 82 TYPHOID FEVER. toward tlie end of grave cases, and oftener in children than in adults. Recovery, however, may take place after them. Rigidity of various groups of muscles is frequently seen in severe cases. In some there are marked retraction and stiifness of the muscles of the neck, and even of those of the spine. This may be as marked as in cerebro-spinal fevei-. but does not, nevertheless, call for a description of a special cerebro- spinal type of tvphoid fever. Sometimes spasmodic constriction of the muscles of the pharynx prevents swallowing. Trismus, spasm of the glottis, and riinditv of the extremities have also been reported. I have noted in some cases an extreme degree of general muscular rigidity, with a fixed ecstatic expression of fiice. Tiiis may be met with in cases of hysterical type, when it bodes no special danger ; or, on the other hand, it may be seen toward the close of fatal cases where tliere has been great nervous irritation in the earlier stages. According to Hughlings-Jackson and Money, the knee-jerk is never absent in typhoid fever. The Digestive Symptoms are numerous and of the greatest importance. There is no other disease in which anorexia is more marked or persistent. It is complained of during the initial stage, and lasts until convalescence begins. Usually it is only an indiiference to food and not an actual aversion, and it is generally possible to administer a fair amount of nourishment, especially in the form of milk or light broth which has no decided taste. In mild cases, where there is an unusual retention of intelligence throughout the disease, I have frequently observed continuance of more or less decided appetite. Thirst is generally marked in the early stages, but later, when the mental faculties are greatly obtunded, water is no longer asked for. The tongue, as oftenest seen in typhoid fever, is enlarged and flabby, not rarely tooth-marked around the edges, and with a whitish or yellowish coat. The papillae are not especially prominent. The edges are generally unnaturally red, and there often is a red triangular area near the tip. At about the middle or end of the second week it may lose its coating entirely or in spots, and become bright-red, dry, clean, glazed, and sometimes fissured ; but more frequently it grows brownish, especially in the centre, and may finally become coated all over with a thick, cracked, brownish crust which renders its protrusion very difficult. Toward the beginning of convalescence it becomes gradually more moist and the crust is slowly gotten rid of. It is not at all unusual, however, in cases of moderate severity for the tongue to remain moist and only slightly coated throughout tlie wdiole course of the disease. The viscidity of the secretion of the mouth causes it to dry and be depos- ited as sordes upon the teeth and lips. This is particularly liable to occur M-hon the typhoid state is well developed, but is not at all characteristic of typhoid fever alone. The lips are generally dry, and often crack and bleed if picked. The gums rarely bleed. The pharynx is commonly the seat of marked catarrhal irritation, and the mucous membrane is swollen and con- gested and secretes a thick mucus. The tonsils may be enlarged at the same time. CONSIDEliATION OF SPECIAL SYMPTOMS. 83 Nausea and vomiting- sometimes occur, especially at liie be^nmiing, but arc not common, in my experience, unless excited by injudicious fmliuo; or medi- cation. Late in the disease vomiting is even more rare, except as the result of peritonitis or of ulcer of the stomach. The morbid irritability of the stomaeli is at times marked, and I have seen violent nervous symptoms, even convul- sions, produced by minute amounts of solid food. Rarely vomiting is so per- sistent that death may follow from exhaustion. Tympanites is a very frequent symptom. Generally it does not develop before the second week, but sometimes is seen earlier than this. It varies in degree from slight meteorism to extreme distension, suflieient to interfere with breathing and heart-action and to cause extreme distres.s. It is generally most marked in severe cases, especially if diarrha^a be a j>romineut symptom, but it may develop independently of this. It is due to the influence of the intestinal ulceration paralyzing the peristaltic movements of the bowel, to tiie degenera- tion of the muscular coat of the bowel, and to the ])roduction of gas from decomposition of food and of the intestinal discharges. Tympanites once developed is apt to persist, though often varying in degree upon ditlerent days. Abdominal pain and tenderness are very commonly observetl. The ])ain may be due, as stated, to abdominal distension (»r may be directly produced by the ulceration of the bowel. Fugitive griping pains often occur among the earliest symptoms. Tenderness on pressure is chiefly found in the right iliac fossa, and is caused by the intestinal ulceration in this region. Xevertheless, severe ulcer*ation may sometimes be present without producing tenderness. Gurgling is often elicited by jiressure in the right iliac fossa, and is due to the presence of gas and liquid in the lower part of the ileum. It may oceur in any disease accompanied by diari'hcea. Diarrhoea must be considered one of the cardinal symptoms of typhoid fever. It may be one of the early manifestations of the disease, perhaps present even upon the first day of the onset, or possibly among the prodromes, but it more frequently develops toward the end of the first week, and some- times not until late in the disease. It may last for a few days or may persist throughout the whole attack. Its severity varies greatly, the movements numbering two to four daily as an average number, but in many cases reai-h- ing ten or twelve or even more in the twcnty-fi)ur hoiu-s. 'V\\v evaeuati(»ns are rarely accompanied by pain, and tencsnms does not occur. ()ceasi(.nally, brief griping pains will precede each movement of the bowels, and I have known the occurrence of frequent painful contractions p.vial uneasiness, provided thev be small and unattended with any sympt.mis of .xhanstion. Even in' cases of decide.ry strength of the patient can often thus be best determined by eonstantly watch- ing the nature and alterations of the first sound. l»al|.il:ilion of the heart may result from the disturbance of (he nervous system. In a <".se re.vnily ui..ler ray observation there were daily paroxysms at almost the same hour, att.'uiled Fig. 5. H. B , male, set. 3-1, case of moderate severity, without marked diarrhoea, began Dec. 6th. Tem- perature range moderate until Dec. 24th, when it began to rise, reaching 105° on Dec. '26th. Hsem- orrhago on the 27th, and five otliers during next thirty-six hours, with fall of temperature to 97°. Admini.stration of large doses of oil of turpentine, one ounce during the thirty-six hours of haem- orrhage. Delirium and unconsciousness for nine days. Final recovery. Discharged March 20th. Fig. 8. F ^ IMEMEMEN dEIMEMEf ^€^: ^e:h -IEMEWEMEME: MEMEMjEMiEMEMEME — • 1 1 1 107° 1 —^ 106° 105° — — 104° -x-^-¥ "f" T- T :— S-)!: ^-^■^ r\ iiEp=E====E====EEEEEE 102°-- TO#F d Ml/1 j 101° -- 4m !_^___. ||e=eeeee^eeeeee| 100° -t — J — TfttTrf ' A M 3- 99°-: 98° z; 97° -- ^V — Oatm/Du 1 i 8 4 6 6 7 8 10 II 12 13 14 IS 16 V>¥'V; !?««; '^^: ^,i '>\i '^\-. *''^' *\. f4 ly' y y^^ y^ y \^y%'2£. >5^^ x^^ H- ^v\o ^\. ^*., Hv y^y^^T^y -43° -41° -40" — 39» -38° -370 -se' ■38' 86 Temperature-chart of Case of .Vborlive Typhoid Fever. CONSIDERATIOX OF SPECIAL SYMI'TOMS. S7 by pallor of the face and followed quickly by intense determination of blood to the head and by orthopnoea. The pulse is increased in frequency, and often in proportion to the elevation of temperature. It rises in the evening with the temperature and fall- in the morning, but besides this it is subject to many variations iVom time to time, and is readilv modified bv slight influences. Its rate is trenerallv somewhere between 100 and 120 per minute. A velocity above 120 indicates a deciiUil condition of cardiac weakness. It is not infrequent, however, to find the pulse but little accelerated even when the temperature is high. This occurs more often in typhoid fever than in any other of the inl'ectious febrile diseases. On the other hand, the pidse may be unduly frecpient in mild cases when the temperature is but little elevated. It is at first full in volume and very ulten markedly dicrotic. This existence of dicrotism is particularly characteristic of typhoid fever. As the disease advances and weakness grows greater the frecpiency of the pulse increases. In severe cases it may often reacii 140 or 150 a minute, and recovery yet ensue, though a rate as high as this renders the prognosis very grave. At the same time it loses in force and becomes compressible and small. If exhaustion progresses, it becomes yet faster, run- ning and almost imperceptible. At the same time duskiness of the skin and coldness of the extremities indicate the great weakness of the circidation. This local coldness may exist even when the general temperature is high, and constitutes a decided danger signal. Collapse may rapidly develop fn)m this condition. A sudden slowing and weakening of the pulse may also indicate a tendencv to collapse. In a case to which reference Mill be made more par- ticularly the pulse fell in a lad of seventeen years to 28 for a period of three or four hours, attended with subnormal temperature, 95° to 97° F., and with respiration of from 6 to 8 per minute. As the patient approaches convalescence the pulse diminishes in rapidity, and after convalescence is established not infrequently becomes abnormally slow. This post-tvphoid bradycardia need excite no anxiety, even wIk'u. a- I have frequently observed, it continues during several weeks at a rate of 50 or 45. Cases are met with where the pidse falls as low as 35. I have seen this con- dition especially in hospital practice and in the cases ol" men of strong, muscu- lar frame and phlegmatic temperament. Exertion will usually cause a marktHl rise in the pulse-rate. Indeed, it is not rare to find persistent rapidity of pulse continuing as the temperature falls, and even for some time alter coiivalrs.vncv is otherwrse complete. This may be the result of mere cardiar irritability, or may be caused bv the slow disappearance of serious lesions of the cardiac nms- cle. It occasionallv happens that wlwi. these latt.-r hav b.vn severe the lieart's action becomes so rapid an alteration in the early stages ..f typhoid Irvr, l.u( in the thinl week a decided diminution in (ii. number of retom and demands catheterization. As soon as marked hebetude apjx'ars the region t)f the bladder should be percussed daily, as ])artial retention may occur even when there is occasional discharge from overflow. Complications and Sequelae. — Many of the conditions already descrilxHl as symptoms or as pathological lesions might with efpial propriety be considered among the very numerous and varied complications and sequels (tf the disease. Of the complications involving the dermal, nuiscular, and osseous systems, bed-sores deserve first mention, as they arc frc(|ucnt and troublesome in severe cases. They depend u])<)n the im|)erfect niMriti(»ii of fhc skin, (he emaciation, the constant pressure over bony prominences, ami. in (he case of the nates, the great diflicidty in keeping the |)arfs perfectly clean and dry. Patients may die from the exhaustion caiiseerved, as in a case reported bv Weiss. I)o.d,tless in this ease the haMuorrhage wa< caused by gastric ulcer. Care must be taken not to ..onhmnd with tln^ the vomiting of blood which has flowed down IVnin the pu.frior naiv>. On several occasions I have been greatly alarmed until the sou.v. ..I the haMuo,- rhatre was discovered. 92 TYPHOID FEVER. Dysentery, sometimes diphtheritic, occasionally exists as a complication or sequel. Gangrene of the intestinal mucous membrane may even take place. Jaundice only rarely complicates typhoid fever. It may result from a catarrhal process or from parenchymatous changes in the liver which can attain such a degree that the characteristic symptoms of acute yellow atrophy api)ear. The liver is occasionally enlarged. Hepatic abscess is a rare sequel. Diphtlieritic or ulcerative processes may occur in the gall-bladder. Perforation of the intestine by an ulceivis the most dangerous complication which can arise. It occurs in about 2 to 3 per cent, of all cases. The 4680 cases tabulated bv Fitz give a mortality from perforation somewhat higher than this — viz, 6.58 per cent. The accident forms, according to Murchison, about 11 per cent, of the causes of death in typhoid fever. In the 2000 Munich autopsies perforation constituted 5.7 per cent, of the causes of death. It is very frequently preceded by haemorrhage. It takes place most often in the severer cases, especially in those in which other abdominal symptoms, as diarrhoea and tympanites, have been marked. At the same time, must ever be borne in mind the important fact that it sometimes occurs in the mildest of cases which have exhibited no abdominal symptoms. Fitz found it much more frequent in men than in women, and rarer in children than in adult life. It is commonest toward the end of the second week and in the third and fourth weeks, but it may occur later than this, and it has been met with as early as the eio-hth day. There are numerous instances on record in which perforation has taken place some weeks after convalescence had commenced, the patients being out of bed and even at work. Among the immediate causes of the accident may be mentioned the presence of hardened fsecal masses, undigested food, excessive tympanites, severe vomiting, the increased peristalsis caused by purgative medicines or by an enema, ascarides, straining at stool, sudden changes in position. A perforation which occurs early in the attack is probabl}^ due to the separation of a slough, while that which comes later is probably the result of an extension of the ulcerative process to the visceral peritoneum. The opening through the intestine is generally small, with clean-cut edges, and the slough may still be present and cover it, or may have entirely disappeared. The symjitoms attending perforation come on abruptly. They consist of very severe abdominal pain, which develops in the right iliac fossa and rapidly spreads over the whole abdomen, and of profound colla})se, the latter evidenced by feeble running pulse, cold sweat, subnormal temperature, feeble respiration, great thirst, suppression of urine, and frequent vomiting. Death may take place in a few hours. If it does not, the symptoms of acute diffuse peritonitis soon set in, the abdomen becoming more tympanitic and the liver dulness being obliterated. The latter symptom constitutes a valuable diagnostic sign. The abdomen grows excessively tender, the face wears an expression of intense suf- fering, the legs are drawn up, and the temperature rises again. Death takes place in two to four days, or sometimes after a longer time. The opinion was formerly held that perforation was inevitably fatal, but there is abundant evidence that recovery mav occur in rare instances. Thus COMPLICATIOXS AXD .SEQl'EL.H:. 93 the perforation may at times produce only a looalizwl peritonitis, terminating in abscess, which may be discliarged by tlie bowel or externallv, ami recovery follow; or the bowel at the seat of a minute perforation may be so tirmlv glued by an adhesive inflammation to the wall of the abdomen (.r to another loop of intestine that little or no escape of intestinal contents can take place Peritonitis, local or diffuse, resulting from ciuises other than perforation, may complicate typhoid fever. This may bo produced by the spreading of inflammation from the ulcerating mucous lining to the serous laver of the intestine, without perforation existing ; or it may be the result of the rnj>tin-o of a softened mesenteric gland or of the bursting into the peritoneum of an abscess of the spleen, liver, gall-bladder, urinary bladder, or abdominal wall ; or it may follow causes entirely independent of the febrile disease. I have known death to occur from general peritonitis, with abundant ])urulent and plastic exudation, as early as the tenth day, without perforation and without any evidence to connect its origin with any particular ulcer in the intestine. Venous thrombosis is the most frequent ct)mplication from the side of the circulatory system. It is oftenest met with in the femoral vein, where it is of very common occurrence, producing cedema and ]>ain. Tt happens nuich oftener in the left leg than in the right, possibly due to the tact that the left iliac vein is crossed and pressed upon by the right iliac artery ; not rarely the other leg is subsequently affected. It may be a complication, but is oftener a sequel, coming on after convalescence seems established. Its onset is marked by pain in the groin or thigh or calf. There is tenderness on pressure along the femoral vein, which can soon be felt to be swollen or hard. Pain is also complained of if pressure be made upon the calf The swelling of the log which follows is often considerable, and is more elastic and pits loss readily than in ordinary oedema. It indicates that the lymph-channels, as well as the vein, are involved. The leg is heavy and entirely powerless. Irregular fever of moderate grade is kept up for some days, and may at fn-st cause appreluMi- sion of a relapse. Recovery nearly always takes i)laee, owing to the late ])eriod in the case when this sequel occurs. Convalescence is, however, pro- tracted ; the swelling subsides gradually as the collateral circidation is estab- lished, but some slight enlargement (»f the afl'eeted leg may remain pcr- manentlv. In very rare instances the thrombus may become dislodgetl and be carried to the heart with fatal result, or septicaemia may ensue upon suppu- rative softening of the clot. Obliteration of the larger or smaller arteries by embolism or throiubosis is an infrequent complication. Gangrene of the part from wliieh the blood is cut off naturally follows. Arteries sui)plying any of ilw skclrtnl or vis<-eral pcn-tions of the' body may be involved, but the femoral artery i> the ..ne in which the condition most frequently develops. Pericarditis and endocarditis arc unusual eomplicalions, while myoeardiiis, with consequent dilatation of the cavities, is more frecpient. Valvular dis<.ase is a rare sequel. Graves' disease; has also Ixrn known to develop. A post- tvphoid anaemia is occasionally observed, and tl..' di.uinnlion ofthe pereeuiage 6 t; IT TFTTT A S- * 'S'o . (■.... r * . y... . I ... »- ..•:,.. l; ■'" ,' a |5 ::;,;: ^<« - - -- ^ ^3 '■^fc -* >?" "" i? !{ - - 3 •^ _ ^'^ * <, .(- - -.3 •i" . ..;i: cf - - -- § €^ s. t"-': 3!) ^ •, *; r- .?* •o ■^ tf •^^ — ±IE •c >* C"* 1 J -0 ! *!• ^ . ■* u^ fg ^^ ■ " "^ ■■ -- , lo . « ^o 4- " ^" ^4i So , ^ ---P^ -^ » ^•» ■ ^ --- -_ .^ lO ■31 ^ '" ® toN T ' 99 ^„ H T " ^-^ — S, ^-ti '' '^ J 3Cl ew — "^T* "i * ■?.,""" .-. - - — "T ^ k<» "■ ^ — - ! "^ V» -L -- ^ w lil ' ■■ ■ ■ j » ■ . §" -4- -1- 1; ;| - -^ X --.1 i __ . » i~ ' ^ ^ S"- • ►5- ■"" ■■ "**» J l» .■* « ^s--- + '■ ; S^ r- *** 1 '--^:! ^ ■ -■ (« "■ « >. ' tfi ^» ■ -- - - 1 V^..^. . - -i J't 3= rf "=C-, -c J^ ..__. •« ^11 -f ■■--- --__ Bl % ---'T' « ^ ■o ' """*- i - . *' > ._ 1 , _ -p--r -^^ *l <^\ T*"*" --t TT ei cr. - - - - - — r -i-^'^ "^^ ' 1 -* "■'"*- -^-^il|. . .,jj_ j "p Si'o,. .. ' ]-•*• "^"^ ' 1 1 1 rf^ -^-u-i_ > _. X ill" -**"'' S-o '^^"~**'^ -f-ta *♦ .i^-rrtr^"" i5m ^T^j-i, N. J". 5 ' "-I- - XXL 1 snI -fr "^ « ■N — LL ,^ ^^ ii . ---■* k '^"7 '" _i T J.II ' .1 L... l-ill 2 2 ^2 1 'sill 6 b -1 t> h <£ 0) 01 Oi a, ^ 3 o .0) 3 0) a 03 I— I 0) 3 03 o CD .3 a o u o M .^3 3 O 03 SO a c a 'So neumonia occiwred from expo- sure in early convalescence, the temperature gradually rose I'or several days, and then assumed a paroxysmal type, with morning fall to 9il° and evening rise to 106° for three days before death. Pulmonary oedema and hypostatic congestion of the lung\s an- ol very Irc- (pient occurrence in the later stages of the disease. They rcsidt from lailure of the circulation and the constant reciunbent position of the j)a(ient. \hvu\- orrhagic infarct sometimes develops, and gangrene or abscess may result from this or from lobular or lobar ])neumonia. Pleurisy with effusion is a serious but rather rar vurrence. When it arises acutelv during the course of (he disease it may !.<■ sero-pla>ti<- and ter- minate in gra d o > a a; 0) .2 >. > - o o o ,o OS a SB 0) 3 r" a o > 'o o i a COMPLICATIONS AND SEQUEL.^. 97 Acute railiarv tuborcnlosis niav bo developed during or after tvphoid fever. This, however, must be of extremely rare occurrence, and it is not improbable that some of the reported cases were errors of diaijnosis by which tuberculosis was regarded as typhoid. The general opinion that persons recovering from typhoid are particularly liable to develop phthisis tlucs not seem sui)p()rttHl by adequate evidence. Febrile albuminuria without casts is common in typhoid, as already stated, and does not materially add to the gravity of the case. Acute nephritis may develop, however, at the beginning or during the course of the disease, when the urine becomes scanty and contains albumin, casts, epithelium, or bl(K)d. The affection is a severe one, and the i)atient may die of uraemia, l^ndoubt- edly, the typical typhoid state is often induced in part by this renal com- plication. The nephritis which comes on as a sequel after convalescence has commenced is attended by oedema and the usual symptoms of acute Bright's disease. It is often followed by recovery. Sugar in minute amount is occasionally found in the urine during the course of the fever, and diabetes apparently occurs as a rare sequel. Hanuaturia is a rare complication, and indicates a dangerous hsemorrhao-ic tendencv. Vesical catarrh is not infre<]uent, especially after cases where retention of urine was present and required catheterization. It may be slight or severe, transitory or obstinate and troublesome. More rarely pyelitis follows tyj)hoid fever, and may even be attended with ulceration and membranous exudation. Among other rare sequels may be mentioned orchitis, inflaniiiKitioii of the ovaries, and gangrene of the genitals, which latter may occur in both sexes. Menstruation is often irregular during the attack. It may occtu- prema- turely and be profuse, or it may fail to appear. Amenorrhoea, lasting several months, is a frequent sequel. Pregnancy may possibly give some degree of immunity from typhoid fever, but does not protect absolutely, as was formerly supjiosed. Abortion is very apt to take place, especially if the disease be contracted in the first half of pregnancy. It occurs oftenest during the later periods of the disease. The existence of typhoid fever does not protect the system fi-om possible invasion by other infections. Erysipelas may develop during the height of the disease, or more frequently as a sequel, but its occurrence is rare. Scar- latina has been repeatedly observed in those suffering with tyjihoid fever, and there are other reported instances in which the reverse has oeeurrehlegmatic temperament. I have, however, seen not a few instances among women en- gaged in domestic service. There is an almost total absence of nervous symj)- toms, and this, joined with the fact that such persons are rarely accustomed to note carefully or to attend promptly to slight distiu'banees of health, may help to explain the marked peculiarity of these^cascs. They are more gen- erally met with in hospital practice; and it is a familiar thing in every large dispensary service to find ])atients ap])]ying with complaints of diarrluea or cramps or dyspepsia who on examination are fi)und to have a temjieratiire of 102° or 103° F,, with characteristic eruption, enlarged si)leen, and bronchial catarrh. These patients, when put to bed, often develop symptoms of a more severe tyjie, especially if they have travelled far. Sudden delirium, ])ro- *fuse intestinal haemorrhage, or even perforation of the intestine, may be the first indication of the serious nature of the illness. T have known several cases in which the first complaint made by the patient was only after intestinal perforation had occurred, and when, after death in the course of twenty-four or fi)rty-eight hours, examination showed advanced lesions corresponding to at least the condition at the close of the second week. The evil results which follow mental or bodily effort during the early days (.f typhoid fi-vi-r are often conspicuously seen in these cases. It is probable that w(>re rest and suitable care secured at the onset they wouM habitually nui a mild cours(>. The grave forms of the disease may ix- eliaract(>rized by the severity of (he symptoms in general, dependent upon the intensity of ihr |)nion the disease, while jaundice is more liable to occur, with i)ain in the upper portion of the abdomen. Bemittent malarial fever may simulate tyjihoid fever very closely. Diar- rhoea, vomiting, epistaxis, splenic enlargement, and cerebral symptom-^ may exist alike in botii. The locality and the history of the case should b(> con- sidered. An absence of i)rodromes ; a sudden onset ; marked gastro-hcpati(r disturbance with bilious symptoms and even jaundice; the occurrence of hei-pcs, but no rose-colored spots; and fever of markedly and regularly remittent type, attended with ])rofuse sweating, — point to the malarial nature of the iliseasc The decided effect of a full dose of a. cinchona salt, given as a therapeutic test, is an important help in diagnosis ; and linally an examination may be made for malarial organisms in the blood. It is necessary to bear in mind that arKfc miU'irii fiihrrciiloxitt, which is happily of rare occurrence, may readily be mistaken lor typhoid fever. In both affections there is a prodromal stage, with anniv\i:i, progress! vly in.ivas- ing fever, cough and bronchitis, headache, and .tipMli.wj with retracted belly and cerebral vomiting. The temperature curve in tnb.T- 108 TYPHOID FEVER. culosis is hio-hlv irregular ; the pulse presents important variations at successive stao-es ; respirations are hurried out of "proportion to any demonstrable pulnio- narv lesion ; strabismus, double vision, and local palsies may appear; eruption is wanting ; epistaxis is rare ; ^nd splenic enlargement is less constant and marked than in typhoid. Hughlings-Jackson states that an important diagnostic sign between typhoid fever and tubercular meningitis consists in the fact that the knee-jerk is never absent in the former, while in the latter it is variable — present one day, absent another, increased another. In this view he is sustained by Money. The diazo- reaction (jf the urine, once supposed to be characteristic of typhoid fever, occurs in tuberculosis as well. Leucocytosis is present in acute miliary tuberculosis, whereas in typhoid fever the number of leucocytes is often diminished. In all doubtful cases an ophthalmoscopic examination should be made. Although the failure to discover choroidal tubercles affords only negative evidence in favor of typhoid, their detection is of course proof positive of the tuberculous nature of the case. Primary peritoneal tuberculosis, especially in children without j)recedent pulmonary lesion, may occasionally cause temporary hesitation in diagnosis, but the irregular fever, the absence of cerebral and bronchial symptoms, as well as of eruption, and the widely diiferent course of the case will soon clear up the doubt. Influenza may resemble typhoid fever in exhibiting great prostration with early bronchitis, and sometimes epistaxis, combined with sleeplessness, fever, and perhaps delirium. Diarrhoea also often occurs in it, and the typhoid state may develop. The disease is distinguished, however, by the shorter duration, absence of rose-colored spots, of abdominal symptoms other than diarrhoea, and of the characteristic temperature curve. Scarlatina could only be confounded with typhoid fever in those cases of the latter disease in which the development of the characteristic eruption is preceded for several days by a scarlatinal efflorescence. Even in such there is little chance for error if the mode of onset and the symptoms in general be carefully studied. Trichiniasis resembles typhoid fever in exhibiting vomiting, diarrhoea, fever, and, later, symptoms of the typhoid state. In no other respect are the two diseases alike. The muscular pain and oedema of trichiniasis are not seen in typhoid fever. Those cases of typhoid fever which begin with marked mental symptoms may sometimes be mistaken for insanity. The same is true of cases first seen at the height of the disease, and of which no previous clinical history can be obtained. A systematic employment of the clinical thermometer and a care- ful observation of the symptoms will ensure the avoidance of any such error in diagnosis. G astro-intestinal catarrh at times produces a group of symptoms highly suggestive of ty])hoid fever. Either as the result of a profound im})ression made by unfavorable atmospheric influences upon a morbidly sensitive ali- DUBATiox, pno(rX()s/\\ MoirrMJTV. i(n» mentary tract, or ot'tlie ingestion of^onie non-spoc-itio toxic agent, an obstinate subacute catarrhal i)rocess is started which may for several weeks keep up irregular fever of moderate degree, coated tongue, anorexia, inital)iiity of stomach and bowels, abdominal distress, marked debility, and mild lu'rvous symptoms, such as headache and restlessness. In children the nervous symp- toms may be more marked. Epistaxis is, however, uncommon ; the sj)leen is not enlarged ; bronchial symptoms are wanting ; there is no characteristic eruption; and the course of the disease is wholly irregular. \\'hen the wide irregularities of a tyjiical typhoid are recalled, it must be admitted that it mav occasionally be impossible to arrive at a positive diagnosis ; under which cir- cumstances the patient should have the bencht of the doubt, and be treated as though in a mild typhoid fever. Uvoemia may develop gradually and pass into a typical typhoid state. I have met with this condition most frequently at or after middle life and in connection with chronic interstitial nephritis. The facial expression and men- tal state are curiously like those of typhoid fever; a low grade of fever with bronchial and gastro-intestinal catarrh is not unusual, so that I have repeat- edly been asked to see such cases as instances of anomalous and j)rotract(Hl typhoid. The detection of arterio-sclerosis and cardiac hypertrophy and albu- minuria with casts, the odor of the breath, the absence of eruptit)n, epis- taxis, and splenic enlargement, and the history and course of the case, will serve to establish a diagnosis. Duration, Prognosis, Mortality. — The onset of typhoid lever is usually slow and insidious, so that it is diiiicult to determine the exact date of com- mencement or the total length of the attack. In many instances the duration can be only approximately estimated. More rarely the suddenness or severity of the early symptoms permits of a positive decision. The average duration of the attack is three to four weeks. IJartlett estimated it at 22 days in 255 cases, and Murchison at 24.3 days in 200 cases which reec.vered, and at 27.67 days in 112 cases which did not. Wh(>n fever continues alter the twenty-eighth day some complication may be susi)ected, yet the last stage of the di.sease is occasionally prolonged for several days bey(»nd this date without discoverable cause. So slight a local irritation will th(Mi suirice, however, to maintain or to revive fever that such a cause may be strongly suspected. The extremelv prolonged course pursued by cases where one or more relai)s(>s oe( ur has already been fully alluded to. Typhoid fever may, on the other hand, end considerably within the average period. In abortive cases it lasts no more than fioiu ten d:iys t<. two weeks. Indeed, some of the abortive mild cases run so >liort a e.Muve that the alVee- tion is recognized with difficidty. The date of death in fatal cases is no less variable. In very grave cases the disease mav i)rove fotal as early as the fifth ..r sixth day. an-i in the malig- nant form .leaili mav occur ..n the third, seeond. or even on the very fn-st day. On tl,.' other hand, "it may result from exhaustion or from some sequel or pro- tracted complication long after the specific disease has itsell" en.led. 'i'h.' (ever 110 TYPHOID FEVER. which may attend such cases is manifestly irritative or septic, and not due to specific typhoid infection. It has already been stated that death may occur in a relaj)se although the original attack has been a mild one. In o-eneral it may be stated that the third week is the period of greatest mortality in tvphoid fever. Death is comparatively rare before the fourteenth day, and, although less rare after the twenty- first day, is still not so frequent then as in the third week. The immediate causes of death are numerous and varied. Toxsemia and cerebral exhaustion, associated with coma, with or without hyperpyrexia, cause death in many cases, especially from the beginning of the third week onward. In some instances ura?mia, owing to a high grade of nephritis, plays a part in causing this condition. Hyperpyrexia, at whatever date it may develop, is often fatal unless promptly subdued. It speedily induces nervous exhaustion and cardiac failure, partly of nervous and partly of muscular origin. Intense asthenia is, as woidd be expected, a fruitful source of death in this disease. It may come on rather gradually and late in the disease as the result of continued high fever, of sleeplessness, of vomiting, of diarrhoea, or of re- peated nasal or intestinal haemorrhages. Or sudden collapse may occur from a single large haemorrhage, from profuse diarrhcea, from the shock of perfora- tion, or from direct cardiac failure. There are various ways in which cardiac failure may be induced. The mechanical effect of extreme tympanites, causing great upward displacement of the diaphragm, may co-operate. Advanced de- generation of the cardiac fibre, due to intense toxsemia and high fever, and possibly also acute changes in the cardiac or pneumogastric ganglia, serve to explain the extreme loss of contractile power or the violent disturbance of innervation (delirium cordis) which often precedes and hastens death. Sud- den death may occur from cardiac or pulmonary embolism ; from the entrance of gas into an intestinal vein ; from convulsion, whether ursemic or not ; from cardiac paresis, due to imprudent effort; from enormous haemorrhage. Severe bronchitis, pneumonia, pleurisy, or other complication may turn the scale against the patient. It is evident, therefore, that from the earliest day to the completion of convalescence there is ground for constant uncertainty and anxiety. The exhausting effects of bed-sores, or of large centres of sup])uration, as in the parotids, may prove fatal even after all the ordinary dangers of the dis- ease have apparently been esca])ed. The mortality of tyj^hoid fever has been calculated almost exclusively from hospital statistics. It is evident that these are to some extent misleading, since many cases are admitted too late to be amenable to any treatment what- ever, and the rest are only too apt to have undergone such exertion or expo- sure in the early days of the disease as to materially increase its dangers. It must be remembered also that the mortality of typhoid fever varies much in different epidemics and apparently in different localities. Study of the most extensive statistics available indicates that before the introduction of the Brand method of treatment by systematic cool baths the mortality of typhoid fever in DUBATIOX, PROaXOSIS, MO Ji TALI TV. Ill liospitals varied from 10 to 30 per cent., but most commonly rangetl between 15 and 25 per cent. It i.s impossible to avoid drawini; the conclusion, from recent statistics, that in those institutions where the Brand method has been used the mortality has been reduced abruptly, and without other ascertainable cause, to from 5 to 8 per cent. Undoubtedly, the modern antipyretic methods, even without the use of full baths, have been of vast service in the treatment of ty})hoid, especially in private practice, where as yet the Brand system has been used but rarely. Xo accurate figures are available on any large scale, but from numerous inquiries I incline to believe that the mortality of typhoid fever in private practice is not less than 10 per cent. It happens occasionally that a large series of cases will occur without a single death. I have myself treated 100 consecutive cases in private practice without a fatality, and I know of several series of 100 cases with a mortality of only 1 to 2 i)er cent. The prognosis of typhoid fever is very difficult to estimate, and is iullii- enced bv general considerations and by special symptoms. The disease is decidedly less fatal in children from infancy u{> to puberty. I have observed that in young persons who have been growing very rapidly the nervous svmptoms and the asthenia are apt to be marked and the disease dangerous. The mortality increases rapidly after forty-five years of age. Sex exerts no definite influence. Most of the statistics show an excess of deaths among females of about 1 per cent. Season does not appear to liave any effect on the mortality. The varying reports are probably due to the different gravity of the outbreaks. Cases occurring during protracted spells of intense heat are undoubtedly more apt tt) be fatal. The station in life is without influence on the prognosis. Quite as large a percentage of rich as of poor die. The personal constitution and habits are of some importance. I have repeatedly been impressed with the unhappy effect upon the course and result of typhoid fever produced by exertit.n or exposure during the early days of the Mtack. The curious fa(rt that those who are in delicate health from i)revious disease or other causes do not suffer more in attacks of typhoid fever than those in vigorous health may be partly explained by the fact that the former yield to the early symp- toms and place themselves promptly under treatment, while the latter are too apt to persist in their usual occupation until utterly exhausted. Mur- chison and others maintain that the strong and n.bust and those of large muscular development more readily succumb. It is well known (hat the corpulent are particularlv liable to die from it. This is due to the fact that the fever runs unusually high in them, and that the high f.MMp.-ra- ture induces degenerative changes in their tissues with unusual .-asc. in persons of intemperate habits or in those with gouty or rmal alVcctums the disease is more apt to terminate fi.tally. In th<.se ..f a nervous tcn,p,.ra.n.nt manv of the svmptoms are liable to be worse. Thr s.isccptd.d.ty ol I ,.- system and the intcusitv of the virus have mor.. to do with th- gravity ol ih. case than any other infl"uences. It is a n.attcr of general agreenu-nt that young 112 TYPHOID FEVER. persons who have recently moved into large towns where more or less typhoid is always i)resent are specially liable to the disease and in an aggravated form. On the other hand, most fatal outbreaks occur in isolated and healthy families or communities, owing to accidental infection of the locality. When typhoid fever attacks pregnant women abortion nearly always follows, and the danger of a fatal result is considerable. The existence of organic heart disease, em- physema, cirrhosis of the liver, or Bright's disease greatly increases the gravity of typhoid fever. The prominence of certain symptoms has an important bearing upon the proo-nosis. The higher the temperature goes and the more persistently it remains elevated, the greater the danger to life becomes. This is, however, onlv a general rule. High temperature may often be borne well for a con- siderable time, provided severe nervous symptoms do not attend it. When the morning remissions are slight and brief the prognosis is worse. An inverted temperature curve, with the morning temperature higher than that of the evening, is also unfavorable. On the other hand, the earlier in the attack the morning fall begins to become steadily more marked, the more favorable is the prognosis. A sudden fall of temperature, if accompanied with a corresponding fall in pulse-rate and improvement in general symp- toms, may denote the crisis of an abortive attack and be followed by convalescence. If, however, the sudden fall be attended with marked depression of strength, it may denote the approach of collapse, especially from copious hsemorrhage. A temporary descent in the temperature curve and improvement in general condition during the second or third week, followed by a return of the fever and other symptoms in aggravated form, is an unfavorable occurrence, and the attack is apt to end fatally. I have repeatedly seen bitter disappointment result from this delusive lull in the symptoms. I am inclined to agree with Lacaze that the appearance of sudamina in the third week in severe cases is apt to be a favorable sign, and that the temperature often falls within a few days subse- quently. Most writers, however, do not believe that sudamina possess any prognostic value. A pulse of over 120 — except in children or under excitement — is always a sign of cardiac weakness. This is particularly true if the pulse be at the same time feeble. Liebermeister's statistics show that the more rapid the pulse-rate the greater the mortality becomes. Of 12 patients in whom it attained a rapidity of over 150, 11 died. The character of the first sound of the heart is also of great prognostic importance. The more valvular its quality and the more feeble the cardiac impulse, the graver the prognosis. Naturally, the earlier the pulse and the heart-sounds show signs of weakness, the more unfavorable is it. Dicrotism is so characteristic of the pulse in typhoid fever that unless associated with great softness and weakness it is not especially significant of danger. The early developuient of nervous symptoms is unfavorable. The presence of coma or of wild delirium is a grave indication. Low muttering delirium. TREA TMEXT. 1 1 ?, with tremor, occurring early in the attack, also is an indication that the case is a very severe one. According to Zonner, the degree of delirium is to some extent a measure of the gravity of the infection, thougli care must be taken to recognize those cases where the excitcxl delirium is hysteroidal in nature and unattended by other symptoms of special danger. Coma vigil, carphologia, subsultus, rigidity, general convulsions, ])rotracted hiccough, early inconti- nence or retention of urine, early incontinence of fjeces, insomnia, great pros- tration early in the disease, great tymiwnitcs and abdominal pain, a dry brown tongue, severe diarrhoea, severe intestinal hremorrhagc, vomiting late in the attack, and the occurrence of peritonitis from any source or the development of any other complication, of course add to the seriousness of the disease to a greater or less extent. Eegarding the influence on prognosis caused by the association of other infectious fevers with typhoid fever, it is sufficient to say that the coexistence of malarial poison does not seem to add to the danger, but that most cases of the malarial form of typhoid are of favorable type. Treatment. — Prophylaxis. — Typhoid fever is certainly to a large extent a preventable disease. Produced as it is by a specific germ, it is self-evident that the objects of prophylaxis are to destroy the germ wherever known to exist, and to adopt every precaution against its admission to the svstcm. In the care of each case of typhoid fever the frecal discharges, which con- tain the virus in abundance, must be thoroughly disinfected and properly dis- posed of. Special reference is here made to the careful directions given for this purpose in the section on Disinfection in the article HvcaENK. The disinfected discharges should be emptied into ])rivies or water-closets, but never upon the open ground. In rural districts they may be buried in the earth at points remote from the supply of drinking-water. Equal attention must be given to the disinfection of the body-linen of the sick, the bed-clothing, the mat- tresses, and the furniture of the sick-room. While thus endeavoring to prevent extension of the disease, it is essential to make careful search for the source of infecti(m in each individual case. The remarks under the head of Etiology in this article, as well as the article on Hygiene, may be consulted with advantage. The driidving- water and the milk-supply offer themselves as the most probable sources of infection. In large cities it is for the most part impossible to follow uj) the investigation. In localized outbreaks, in small towns, or in rural districts, on the other Jiand, we know with what admirable results such examinations have been pin-sued. Grave defects, leadins: to contamination of these necessarv articles (»f universal consumption, are detected whose correction will avert fntiu-e trouble. If in any large community typhoid fever is habitually |)revalent to a greater i^v less degree, it may be accepted as highly damaging evidence against the drainage, sewerage, water-supply, or milk-supj)ly. During the existeii.e of an attack of typhoid fever it is desirable that both the water and milk should be I)(.ile some other Ibrm of nourishment. Again, the repugnance of ihe i)atient to milU may necessitate a change of diet. In such cases buttermilk, whey, or kumnyss may be ..f value. Broths or soups of mutton, beef, chicken, veal, oysters, or ropcr antipyretic measures are the rational treatment, it is neces- TRKA TMEXT. 1 ] 7 sary to use alcohol for immediate effect. The heart suffers so seriously in typhoid from failure of innervation, from changes in the muscuhu- tissue, and from protracted reflex irritation that a weak, small, compressible, rapid pulse, M-itli impaired cardiac impulse and systolic sound, is a frequent indication for alcohol. Other remedies may be, as we shall see, recpiiral, but alcohol^ can- not be dispensed with safely. The development of the typical tyj)hoid state, with profound dulness, tremor, dry, brown tongue and sordes, weaU jMdse, and shallow, rapid breathing, whether associated with very high temperature or not, expresses so much nervous exhaustion that stimulation is called for. It is necessary to give alcohol in the serious complications of tvpjioid, such as pneumonia, pleurisy, hiemorrhage, and severe bronchitis or diarrluoa. Patients over forty years of age, even of previously temperate habits, and younger ones who have been intemperate, had better receive small quantities of alcohol early ; and the dose should be increased more or less rapidly as rcfjuired. It will be seen, therefore, from the above indications, that although alcohol is not to be ordered as a mere matter of routine, it is called ibr in most cases, and we must be ready to give it as soon as, and in such amounts as, recpiired. The amount to be administered will vary with the needs of the case. Unless the symptoms are urgent it is well to begin with small and well- diluted doses. As the case advances, from 2 to 6 ounces of whiskey daily may be called a moderate amount ; 8 to 12 ounces daily is not too nuich for severe adynamic or complicated cases ; and even more than this, up to an ounce hourly, may be absolutely required for days in succession to tide a patient over a critical period. When alcohol is ordered or when the amount given is increased, it must be considered a tentative measure, as in the case of any other remedy. I am con- vinced that under the routine practice of excessive stinuilation in vogue until recently the symptoms of alcoholic over-action were often mistaken for advancing debility and regarded as an indication for still more free stinuila- tion. If delirium grows less, the pulse stronger, and the tongue less dry under the use of alcohol, the remedy is doing good ; but if these symptoms become aggravated, the question should be entertained whether too uiuch alcohol is not being given. Probably the most convenient and reliable form of stiuuilaut is wliisk(y or brandy, its greater strength making the dt)se smaller and more manageable. It may be given in milk or, when this is not borne well, iu water. Some- times it is well to change for a time to clKUupagne, sherry, claret, or otlier wine. Undoubtedly, one of the most important indications, wliich nmst be met in the great majority of cases of typhoid fever, is (hat for reduction of Icuipera- ture. It is "true there are cases which run so iiiil'l a course, llir Hv( r not rising at any time above 102° F., that this (|uestioM Anrs not liav to be <-on- sidered. There are other and more rare cases where liigl. t.m|MiMtun- is carricHl without apparent inconvenience. I have seen th.Mlaily maxinuMu at lOo" F. for ten davs in succession in (he case of a young woman who had at n.> time .-ither 118 TYPHOID FEVER. delirium or cardiac weakness, and who made a rapid and complete recovery though no antipyretic treatment was used. This only shows that the pyrexia of typhoid fever is a highly complex condition, and that high temperature may occasionally persist, owing to some peculiar nervous disturbance, without the serious results usually consequent. Even when a temperature of 103° or 104° F. is apparently unattended with damage to the brain or heart, it must be watched with incessant anxiety, because alarming symptoms may appear most unexpectedly. To what point may fever be allowed to go safely in typhoid without interference, and have we any means at our disposal by which it can be surely and safely reduced if it threaten to overstep this limit ? Our knowledge of the natural history of typhoid shows it to be a self-limited disease which tends to recovery in the great majority of cases, though the temperature reaches 102.5° or 103.5° F. more or less frequently in the course of average cases. But the normal mortality of the disease, if allowed to run its course simply with proper food and good care, is altogether too high to be satisfactory ; and it is being more and more clearly made out that a large proportion of this mortality comes directly or indirectly from the baleful influence of the pyrexia. This statement has been confirmed con- clusively by the remarkable results obtained in a large series of cases by reso- lutely kee{)ing the temperature down below the lowest degree above mentioned (102.5° F.). The only way in which this can be done safely and effectually is by the external use of cold water, and hence to-day hydrotherapy is an almost constant feature in our treatment of typhoid. There are various modes of a])plying it, which vary in their efficiency and value, including repeated spongings of the surface ; the ice-cap to the head; the cold-water pack ; cold afiPusion ; Leiter's tubes ; the graduated bath ; the strict Brand method of cold-water bathing. In mild and even in ordinary cases sponging the entire surface of the body with cool water as often as the temperature in the mouth reaches 102° F., is distinctly valuable. A little vinegar or alcohol may be added to the water, which may be cold (50°-70° F.) or cool (70°-80° F.) according to the less or greater degree of fever ; and the sponging may be kept up for ten minutes or more, and be repeated as often as every two hours. Friction and gentle kneading of the surface should be com- bined with it. The temperature may be temporarily reduced from 1° to 1.5° F. in this way. As a rule, it promptly rises again, but the process is agreeable and not fatiguing to the patient. A thin rubber bag or bladder filled with cracked ice may be applied to the head at the same time, and kej)t in place much longer. Even when the fever is not high, but nervous excitement is marked, this may be used with good effect. The cold pack is a much more powerful antipyretic, and is applicable even when the temperature is 104° or 105° F. The bed should be protected by a riibi)er cloth, and the patient, with his body-clothing removed, wrapped in a sheet wet with cold water. The surface is then rubbed briskly through the sheet, and from time to time cold water is sprinkled freely over the sheet so that it shall be kept wet and cold. By using ice-water, even hyperpyrexia, TREATMEXT. IIU 104.5° F. or above, may be dealt with etfectively in this way ; but the process is tedious and troublesome. The recommendation to use friction durino; the pack must not be overlooked. Cold affusion possesses no advantage over the cold pack, and is rather more troublesome to cai ly out etFectivclv. Both of these methods are inferior to the cold bath in certainty of action and durabil- ity of effect. Leiter's tubes were originally made of flexible metal, but now mucli more conveniently of rubber. The most valuable forms are those for application to the abdomen and trunk and to the head. A vessel containing icc-watcr is placed at a slight elevation above the bed : one end of the tube is introduced, and, the 'flow having been started by syphon action, the water runs contirui- ously through the coil, and escapes by the other end of the tube into a receptacle below the bed. One great merit of this simple api)aratus is that it may be kept in operation for hours at a time with no attention save the occasional filling and emptying of fhe respective vessels. In my own experi- ence I have not found these tubes adequate to cojie with very high fever, but they are valuable adjuvants and are sufficient for many ordinary cases. In the graduated bath the patient is placed in water of about 90° F., which is then cooled down to 70° or even lower. This form of bath must be con- tinued longer and its results are less reliable than when the water is cold from the start. It has the advantage that the shock to the patient is not so great : it is therefore especially suited to children, to old persons, and to greatly debili- tated cases. All of these modes of supplying cold externally are useful and have their respective places, but from none of them can sncli results be obtained as from the svstematic use of cold baths in precise accordance with the method advo- cated by Brand. His original publication in 1861 led Ziemssen, Liebermeisfer, and others to take up the subject, and gradually hydrotherapy in typhoiil fever became generally recognized. Currie in the last century was the pioneer in this field. Hiram Carson in this country has for many years bravely advocated its claims, but the medical mind was not ready and the recommendations lacked strict scientific method. Herein is the immense credit of I'raud, and it must be admitted that no such results have ever been achieved as ar(> now reported by many observers who have followed his directions implicitly. The Brand method consists in the systematic employment of general cold baths with frictions whenever the temperatiu-e of the patient reaches a certain elevation. A large bath-tub, nun-able on rollers, is kept half lull of water of 65° to 70° F., and is rolled to the edge of tlie bed when needed. As often a-^ th<- temperature, taken every three hours in the mouth or nclmn, is over 1()2.'2° F., the i)atient receives a bath lasting fifteen to twenty minutes. His clothes are removed, and he is covered with a sheet or arrayed in a ihin iini>Iiu or linen garment specially adapted for the puri)ose. lb' is then careluily assiste CD ■ £- ;' 3*^ H?- : <^ ^ X ''' T ' ' : '^' :: s. r ? Ot 5" c" 3- ^ 2 cr ^ ._ T ,. t ^ £^ 2 I ^:: 2 ?; w 1 1= 1 2"^ ?= = S^ ?^-' C 3 £ P « ■ ■ '«. != ^ 5- ( •■ ■ B" r* s" rt- ^ 4— f. 4- r ■ ■ ' ' T § 8 ^S- ::::::::: :::::::::::::::,:s!;:::::::::::::: -, 35 s •-> 3 r" - _, i :: 1 T ■ :::'"" ;S j> D* a ""■=:5ffl::'t ::::::::::::::: S- ^ ^ 5 •^ 3- cr 3. ::::::-!=::iEJ:±:; ::::::::::::: ::::::: r- 71 <^ = ";=::nt'TiT.. :? 8 § S S » yiy^rn tt±t^^ Q § "■' " 2. 3 e; -4 c "_^ ;::: ■ (£, d, ro M OT ' ■ ::" ■ 1 S ?■« T :::::::■ :::::::::: (^ 3 ft p a p p 1 r^i;::: i:: :.: S "S (? " o< I....= -±:='? ■ s '-^ ■= ==-^T-. 1 X £ s 2> r 1 :±*:=:: 3 S. n. p- P P ^ :" ■ ■ ' T C 12, ' ( " "■ ■ -i B* _ "s S —-^X i::r::: ::::: C. 3 " it --g 5? S. 5 '«;■ :'• 3* '^ c:.i: ►* 3 3 T ..'• --- g 3 5 ■ mim ^t ■ ffcH m] ■■< — 3 IC f -H 1 1 1 1 1 H 1 It iTr ttU S S.S' D P &': i ,c' p S-? ,, :'' o- :? ' : " f* £ - , 1 • ' » r. =^ ■*" i 'S iB- , ^ s - ^ ~ ■" ■ . . ... T p- n p 1 ,,::::! 1 '■ ' a g ■:; ^ '-^ =■ ,,:i '. " 3 B: IC ,,1 H S 's ■^-i:'-"-- « _ -^ ::::::::.;:!:::::::: &^l s--: 3 ::;;::::::ii ring hen sec- M|lii"'iii|iiiiiilii| |rTTTriTM[riMiiiir]- 2 j! a 8 5 i 121 122 TYPHOID FEVER. and childhood. Not only are such complications as pneumonia and bronchitis not induced by cold baths, but it has been shown that their existence does not contraindicate this mode of treatment. Pregnancy likewise is no contra- indication. Enough has been said to show that there has been placed in our hands by Brand a mode of treating typhoid fever of great simplicity and value. The question remains as to its limitations and as to when it should be insisted upon. In the first place, it is as yet a very difficult, and often an impossible, thing to secure its adoption in private practice. If it is to be employed, it should be with the rigid observance of every detail as above described. This certainly seems to many a harsh course of treatment to pursue, and the patients often complain bitterly of it. Not rarely, however, the relief obtained after a few baths is so great that the repugnance to it disappears. The difficulty of securing a suitable movable bath-tub at short notice and on reasonable terms has been a serious obstacle. It will be found, however, that any leading druggist will cheerfully co-operate, so that a tub with proper attendants may be available at all hours and at reasonable rent. Dr. Wilmer R. Batt of Philadelphia has recently devised a portable tub which is all that can be desired in point of compactness and convenience. It is obvious that no community can with propriety be without this invaluable resource in the treatment of the numerous acute infectious diseases. In cases which do not come under our treatment until a comparatively late period, as happens frequently in hospitals and less commonly in private prac- tice, this method is less successful, as is urgently represented by Brand him- self, than when adopted before the fifth day of the disease. In mild cases the fever may not rise sufficiently high at any time to sug- gest any more powerful mode of applying cold water than by repeated spong- ing. If, however, the temperature rises to 102° in the axilla or 102,2° in the mouth or rectum, the Brand method should be adopted if practicable, or the use of Leiter's tubes, with the ice-cap, repeated sponging, and, if neces- sary, the cold pack, should be instituted. This is the more urgent in propor- tion as the temperature remains at or about the maximum for a greater num- ber of hours. Let it be remembered that under such circumstances, even though serious cerebral or cardiac symptoms may not be present, they are liable to appear abruptly and unexpectedly, so that the case will speedily assume a highly dangerous position. In extremely nervous cases or in elderly or much debilitated subjects the milder forms of hydrotherapy are preferable. The actual existence of intes- tinal haemorrhage or of peritonitis precludes cold-water bathing. In addition to the external use of cold water we have other antipyretic remedies that may be used in conjunction with hydrotherapy, or even, in cer- tain cases, to its exclusion, A warning word must be spoken as to many of them, for serious harm is often done by the excessive use of drugs which pos- sess the power of reducing temperature, under the mistaken notion that this result alone is sufficient proof of their value in the case. It must never be TREA TMENT. 1 23 forgotten that the mere lowering of temperature by such means is not neces- sarily an improvement in the febrile process, and that the drugs which are pow- erful enough to effect it are sure to possess other activities which may be harm- ful. In short, it is to be borne in mind that it is the patient, and not the fever alone, we are called on to treat. Happily, a reaction has set in against the practice, which grew out of the recognition of the dangers of pyrexia and the possession of drugs of great antipyretic power, of hammering down, and of trying to keep down, the temperature by large, and if necessary by larger, doses of such remedies. Antipyrine, phenacetin, and acctanilid are the most powerful and reliable drugs of this class. Not only do they reduce fever temperature remarkal>ly, but they are usually w'ell borne by the stomach and they often exert a decid- edly tranquillizing action. Upon their first introduction the natural mistake was made of giving them in doses far too large and frequent, so that serious depression of strength, and even fatal collapse, followed in many instance.s. Patients with typhoid fever are often peculiarly susceptible to the action of these substances. This is true throughout the course of the disease, but ]iar- ticnlarly so in the later stages, when great variations in temperature nat- urally occur. It is not so much that these drugs are directly depressing to the heart, for thev rarely cause cardiac symptoms when given in afebrile condi- tions. Even here, however, I have observed not a few cases of extreme sus- ceptibility to their depressing action. But it appears that in fever they aflt'ect the nerve-centres, so that an artificial crisis is produced, and, as in all crises, danger of severe depression, and even of collapse, arises. With this danger clearly in mind the proper cautious use of these remedies is of great service in certain cases. They are nol required in the mild form with moderate fever : the question as to their use arises when the temperature reaches or passes 103° F. If hydrotherapy is to be used systematically, only occasional doses, if any, of these powerful antipyretics will be required. The amount given should always be small. Five grains of antipyrine and less of phenacetin or acctanilid is as large a dose as should be given. If no effect is produced it may i)c rcpeatctl in the course of an hour. The object should not be to cause a great ii.Il in temperature: it is enough if a reduction of one or one and a half degrees is secured. It sometimes happens that this reduction lasts a considerabk^ time, 80 that only a few doses at long intervals are required ; and it is in such instances that the happy effects of the remedy are conspicuous, if the tem- perature promptlv rises again to the former jx.int, T am totally opposed to pushing the use of anv remedy of this class. Ehrlieh and others have f.sted the plan of keeping the fever constantly low by the continuous administration of small doses of these drugs, but the results were not satisfactory eitluM- a> to the duration or the mortalitv of the cases so treated. ^ The use of quinine in tvphoid fever has been excessive, and yet it is of service in many cases as a tonic rather than as an antipyret.e. 1 lien- are so many more powerful and reliable means of redn.ing ten.p.ratnre than by colossal doses of quinine (20 to 40 grains in the evemng, as udv.se.1 by L.eb.T- 124 TYPHOID FEVER. meister, so that the full efFect of the drug may be exerted at the time of the usual morning remission) that it is now rarely used for this purpose. If in any case with high fever hydrotherapy cannot be used, if antipyrine or its analogues would be too depressing, and if the stomach be not irritable, antipyretic doses of quinine could be given. It is, however, in moderate doses, 4 to 8 grains in the twenty-four hours, that it is of most general utility. It may be given in soft, freshly-made pills, in capsules, or in solution with mineral acids. If there l)e tlie least reason to suspect that it irritates the stomach or favors diar- i-lioea, its administration in larger amount by suppository or enema should at once be substituted. In ordinary cases which are pursuing a normal course it need not be given until marked debility begins to show itself. The preparations of salicylic acid will often exert a powerful antipyretic action, but in adequate doses they affect the head as unpleasantly as does (piinine, are apt to disorder the stomach, and are probably depressing to the heart. In the moderate fever of mild or ordinary cases aconite in small doses may be given safely and with pleasant effect. One drop of the tincture of the root, with or without a small amount of citrate of potassium, solution of acetate of ammonium, or spirit of nitrous ether, may be given every hour or two for five or six doses from noon onward. Digitalis is a drug about whose value in fever I have much doubt. I am clear it should not be given in large doses for its antipyretic effect. The onlv indications for its use are to be found in the state of the heart's action and the pulse. Having considered the general care of the patient, the diet, and the indica- tions for the use of stimulants and for the control of the fever, we have met the questions which arise in every case of typhoid fever. We have seen that it is only in the mild cases that an expectant plan of treatment can be pursued, because the scientific use of antipyretic measures constitutes a definite treat- ment, and we have now learned that by this method far better results are secured than by allowing the disease to run its normal course. It constantly haj)pens, however, that special indications present themselves which call for additional medication. It cannot be too strongly urged, however, that no single dose of medicine should be ordered unless with a definite and well-recognized purpose. Tiie symptoms are numerous and complex, so that many suggestions for medicati(m offer themselves : the patient is dull and acquiescent, so that remedies are taken for the most part without opposition ; care must be con- stantly observed lest by degrees drug is added to drug until opportunities for rest are curtailed and the digestive power of the stomach is damaged. The catarrlial and ulcerative lesions of the gastro-intestinal mucous mem- brane are constant in greater or less degree. It is true they are part of a specific process, and therefore much less amenable to treatment than if idio- pathic. There is much evidence, however, that these lesions can be favorably affected by suitable remedies if administered from a very early period of the disease. It is obvious that if this can be done the secretions will be improved, TREA TME^T. 1 _>;-) digestion will be assisted, and intestinal asepsis promoted indirootlv. It is doubtful, indeed, whether any of the so-called antise})ties which have been recommended in typhoid fever can be given in sufficient amount to disinfect the whole mass of intestinal contents ; and it is not improbable that their sur- face action may account for a considerable part of whatever good tiiey do. But, upon the whole, it seems desirable that a remedy of this class shall be given in all cases of the disease, due care being taken to select one which is adapted to the condition of the stomach and bowels. The large nnnd)er of such remedies recommended is of itself sufficient to prove that no one is the most available in all instances. The list from which choice may be matle is a large one, so that the special indication of each may be met. Among them may be mentioned calomel, nitrate of silver, the mineral acids, turpentine, naphthalin, iodine and carbolic acid, chlorine-water, thymol, salol, iodoform. It is of course understood that only one remedy of this class should be used at one time. My own decided preference has for years been for nitrate of silver, which I give in every case from the first hour that the nature of the disease is sus- pected. It is given purely for its surface action, just as it would be used in a case of idiopathic gastro-intestinal catarrh. It is administered in conjunction with appropriate antipyretic treatment, and it is usually comjiatible with any other remedy required for special indications. Its use is contimied through- out the entire course of the case, and as much as twenty-five grains may be given to an adult without the least fear of causing discoloration of the skin. In case symptoms arise which suggest another remedy of this class, the change should be made promptly. If the stomach is irritable, the following solution may be used : I^. Argenti nitratis, gr. i.j ; Aquae destillat., f.^iij vcl iv. M. Ft. sol. Sig. A teaspoonful on an empty stomach every four or six hours.. One op two drops of deodorized tincture of opium may be added to each dose. Usually silver is best given in pill form, according to this formula : 'Sf. Argenti nitratis, g'"- vj ; Ext. opii, Ext. belladonnas, aa. gr. ij ; Mannse, 4- •"'• Misce et div. in pil. xxiv. Sig. A pill tiiree times daily soon after food. If diarrhoea develop, the belladonna may be omKtcd ant vane.l localities, but they are most frequent, as alrea.ly stated, in s(>aboard t..wns and during the winter, when the ventilation and eleanbness of hous.s an^ apt to be most defective. The exeiting came of tvphus is exclusively the sp.rific virus. I !.<• extreme contagiousness of this disease is so fully establishcl that the ..vi.len.v nee.i no, be recited. Murchison formulates the con.-lusions as fbllows : W hen Ivplius appears in a house or a loeality il usually sp.vads will, grrat rapidity; the 136 TYPHUS FEVER. imuiber of cases in llie house or in the circumscribed locality is in direct pro- portion to the relation between the well and the sick ; individuals living in localities where the disease is unknown acquire it on visiting typhus patients in a distant hx-ality ; the disease is often imported by infected persons into previously healthy* localities ; and, finally, the contagiousness of typhus is established by the success of prophylactic measures, and especially by the iso- lation or removal of the earliest cases. The virus may acquire intense energy. It is not necessary that there should be actual contact with the sick, and yet the distance through which the ])oison can exert its influence is limited. Brief visits to a single case may be made with impunity, but if several cases are confined in one room the air be- comes so infected that those who enter are apt to contract the disease though they may not go within several feet of the sick. A large proportion of per- sons unprotected by a previous attack contract the disease when first exposed to it. As would be expected, therefore, many physicians and nurses lose their lives during large epidemics. There is, however, great difference in the susceptibility of different individuals and of the same individual at different times. Thus, one of my nurses, who had passed unscathed tlirough previous epidemics of typhus, and in the severe outbreak here in the winter of 1864-65 had been most faithful and devoted in his care of many cases in the fever ward, escaped until May 1, when he suddenly developed a malignant attack, and died in four days. The disease is contagious throughout its entire course, and it is difficult to say if it be more so at one period than another. Although it is evidently difficult in such cases to exclude other sources of infection, it seems that typhus may be contracted from the corpses of those who have died of that disease. I shall never forget the sudden impression made upon me as I dissected the body of a subject dead of malignant typhus in 1866. It seemed as though a thick, strong vapor rose from the open surfaces and struck me in the face. Within ten minutes I was too giddy and weak to walk ; a chill occurred within an hour, a high fever followed immediately, and an attack of moderate severity ensued. I had, however, been in almost daily contact with typhus patients for a year previously. Tlie avenue by which the infection gains access to the system is not def- initely known. There is no evidence to show that it is by contamination of drinking-water or other ingesta. Analogy is opposed to the view that it is through the skin. It seems probable that it is by way of the inspired air that the disease is contracted. The poison attaches itself tenaciously to cloth- ing and bedding, and the fever may be thus communicated by fomites at con- siderable intervals of time and space. An attack of typhus protects strongly and usually permanently against subsequent attack. Both relapses and recur- rences are extremely rare. No typhus microbe has as yet been discovered. Hlava in 1888, at Prague, fijund a streptococcus which he was dis})osed to believe peculiar to the dis- ease. But he found it only in 20 out of 33 cases, and Cornil, Thoinot, and others are not disposed to regard it as specific. Thoinot gives fresh experi- MORBID AXATOMY. 137 meuts to confirm tlie view that theblood of typhus patients will not convey the disease to animals by inoculation. The effect of overcrowding, defective ventilation, and filth in increasing the virulence of the poison is so decided that the question has naturally arisen if under such influences it may not arise dc novo. This view has been espoused by some high authorities, but if the ])oison is, as is probable, asso- ciated with a microbe, all analogy is opposed to its spontaneous generation. A moi-e plausible suggestion seems to be that the microbe, which may be widelv distributed, and under ordinary circumstances possessed of but moderate path- ogenic properties, acquires, when cultivated in contact with the foul effluvia of human beings overcrowded, filthy, and degraded in vitality, such virulent ])roi)erties as make it the effective cause of tyi)hus fever. Morbid Anatomy. — There are no lesions of the solids peculiar to ty|)hus fever. As a rule, rigor mortis is not marked. Putrefaction occurs rai)idly after death. The petechial eru])tiou persists after death, and large purple patches are present on the dependent portions of the body. The blood is profoundly altered. It is dark and fluid ; the lining of the aorta is deeply stained by imbibition; such clots as are present are soft and dark like currant jelly. Eccliymoses may be seen on all the serous membranes, and especially on the pericardium. The muscles are dark and, notably in the case of the heart, have undergone granular degeneration. Plxtravasations of blood are occasionally noted in the substance of the n)uscles, more fre(|uently in the recti than elsewhere. The liver is softened and somewhat swollen. The spleen is enlarged, though usually not so much so as in typhoid : its pulp is greatly softened, even to diffluence in many cases. In some of the cases I observed it was from three to five times its normal size and extremely soft. The kidneys are swollen and enlarged, and may show the changes of infectious nephritis. Congestion and catarrh of the larynx and bronchial tubes are com- mon. Hvpostatic congestion of the lungs is very frequently, and pneumonia not rarely, met with : the latter may be either croupous or catarrhal. Pleu- risy, either sero-plastic or purulent, is an occasional (•()m])lication. On the whole, the lesions of the respiratory organs arc nuicli less constant and pronounced than in typhoid fever. The gastro-intestinal tract presents no characteristic lesions. Congestion and occasionally ccchymoses of the nmcous menibrane of the stomach may be noted. Peyer's patches may be slightly swollen and present the shaven-beard appearance, but not in a degree greater than is occasionally Ibuiid in all violent infections. The solitary glands also are sometimes unduly i)r()minent. The Breslau epidemic, in which Lebert reports the occiinvncc of small ulcers of the solitary and agminated glands, was certainly e.\ee|)tional. In iIh' I'hda- delphia epidemic of 1864-05, where diarrluea oeeiinvd in Inlly (.iie-(liinl the cases, some enlargement of Peyer's patches and .if tlie solitary glands was found repeatedly, i)ut no ulceration was rejHtrted. A teiideiicy to g.neial l.v|.erplasia of the lymphoid tissue is present, but in a inueli jess marked degree t inn in relapsing or tvphoid fever. The eerebra! meninges are n-^nally .■ongr-sfe.j and 138 TYPHUS FEVER. the sinuses filled with dark blood. A moderate amount of subarachnoid and ventricular effusion of serum may exist, but not to a greater degree than in acute diseases unattended with the intense nervous disturbances of typhus. Oro-anic lesions of the nervous centres are conspicuously absent as a rule. General Clinical Description. — The incubation of typhus fever varies from a few hours to two weeks or even longer, according to the virulence of the infection and the susceptibility of the individual. Twelve days may be retT-arded as a safe average. Prodromes are more often absent than present. There may be a feeling of general indisposition, with weakness, vertigo, and loss of appetite, for two or three days. The invasion of the disease is as a rule abrupt, with sudden vertigo, rigor or actual chill, extreme weakness, and rapid rise of temperature. The patient is forced to take to bed at once in most cases. Headache, pains in the back and limbs, and soreness of the flesh appear speedily. Nausea and vomiting are not rare. The tongue is moist at first, with but slight coating. The abdomen is not distended, and constipation is usual. Epistaxis is rare. The expression is heavy and like that of one in- toxicated. Tlie face is flushed uniformly, and the eyes are congested. Delir- ium may occur almost at once, and serious nervous symptoms speedily ensue. Prostration may appear early, and is so marked as to be highly characteristic. The fever rises so rapidly that a temperature of 104° or 105° may occur on the second or third day, and this may be the highest point attained during the attack. The daily variations are not marked. The sense of heat imparted to the hand even exceeds the degree actually present. (See Fig. 10.) The pulse is rapid from the first. Not rarely it reaches 110 or 120 by the third day, and this rapidity increases as the disease advances. Even if full and strong for a day or two, the pulse speedily grows small, soft, and compressible, and the heart's action is found to fail rapidly in force. The respirations are hurried, in accordance with the height of fever and the acceleration of the pulse. If any pulmonary complication develops, the disturbance of pulse and breathing may become extreme. On the third or fourth day the typhus eruption makes its appearance in the form of numerous irregularly-rounded spots, of a dull-red color, barely ele- vated above the skin. These disappear on pressure at first, but soon it is found that the centre persists on pressure, and later the entire spot is con- verted into a petechia. It is preceded or accompanied by an irregular conges- tion of the derm which causes a subcuticular mottling. By the end of the first week the disease has reached its height. The stupor from which the disease takes its name is pronounced. The decubitus is dorsal, and the patient must from time to time be turned on either side. There is a deep dusky flush of the face, and the expression is profoundly dull. It is often impossible to rouse the patient to answer. Deliriimi may be low and muttering or wild, excited, and noisy. Despite the stupor, sleep may be almost absent. The prostration and muscular weakness are extreme. Tremor, difficulty in protruding the tongue, retention of urine, slipping down in the bed, and inability to turn are often present. The severe headache of the earlier SPECIA L S } WP TOMS. l.">9 days has subsided, or, if it continues, may be associated with innscuhu' rigidity and retraction of the head. Tlie fever continues uniforndv hiuh, with a drv Fig. 10. F 106^ 104<^ 103^ 102° lOi^ 100" 99 ° 98'= Days oj Di) PuUt. Hetp. ME m'e ME ME ME ME m'e ME ME m'e ME m!e m'e M'El ME ME M'El 1 1 - - — ~ ■ X A /v A /) ;r A / A / / L ^ /\ A / /^ f A \ i r P / , A \i A Y f I . w X 7 \ Y -VL J 1 ' , / \/ v \ / f . / v/ \ / Vi i V U V 1 1 ' J ~^ Y 1 j V -- - -f- -- L- -. j i i 1 ! J — 1 — — 1 ' L 4_ h- — 1 j ! I 1 i 1 ^ -- -- -- — r - 1 -- V 1 i — 1 1 — — 1 1 -n 1 ' 1 1 ' i ; 1 ! J_ ^ 1 ' ~ 1 7 1 1 l/^ 1 ,-il r 1 ]/ s, • \ > 1 ^1^ ^ 1 "^ V ' 1 1 1 1 1 1 1 J o 3 1 & c 7 » a 10 11 12 13 u 15 IG i; -•Vo 8^0° ,"^.^ ,0?.- ''•>' "^ '^^e "■:^' 'l^oV :?^^ ?^pf' .^^93 9-, es,-' '^,8 ^.V 2''a3' .^'ai ii,, << 2°.^ 23.; '!.^ '"i' 5^^.^ :V' |9,0 I8.-9 '%o '\s la--' -40< 41 39° — 38° 37° -36< Temperature-chart of I'alicnt, at. I'.i, siilleriii!,' tr^e and first •sound of the heart are almost effaced. The tongue is dry and brown, tremu- lous, and protruded with great difficulty if at all. Liquid may .still be taken freely, and digestive disturbances are for the mo.^^t pait wanting. Some enlargement of the liver and spleen is present. The urine is scanty, con- centrated, highly colored, and often albuminous. No second croj) of erup- tion has appeared ; the spots have become to a large extent petechial, and after the ninth or tenth day begin to change color and fade. The alarming or even desperate condition of the patient grows aggravated as the limit of the dis- ease approaches. A sudden critical improvement occurring about the end of the .second week, with a rapid fall in fever and abatement of all symptoms, ushers in a .speedy and uninterrupted convalescence. Or, on the other hand, complication.s arise and may determine a fatal issue to the ca.se, or the symj)- toms of infection and of cerebral or cardiac failure progress, and death occurs from the middle to the end of the .second week. Special Symptoms.— The appearance of th<" patient is highly charactcr- i.stic. It is true that in some cases of typhoid fever and in sical typhoid state develops in some cases, with mcteorism and looseness of the bowels, but even then neither ochre-colored stools nor intestinal luemorrhages occur. In some epidemics, as at Philadelphia in 1S64-65, tiiarrhiea maybe present in fully one-third the cases. The liver is occasionally soniewhat swollen, the sj)lccn much more fVc- (picntly so, but to a less degree and with less constancy than in typhoid fever. Tenderness on pressure is apt to cxi^l over the liver or spleen if enlarged. A rapid pulse is nearly always ])rcscut. Its rate corrcspiMids with the height of fever and with the degree of disturbance of the cardiac ganglia and muscle. In mild cases with moderate fever it may at no time exceed 96 or 100. Occasionally a disproportionate slowness may be noted, and if this be unaccompanied by alarming uraemie or cerebral symptoms, it is lavoiablc, as indicating a large reserve of cardiac power. \\n\ nsnally th.' pnlsc-rate rises rapidly from the onset and varies between n<» nnd 120 in eases of ordinary severity. In children, in sensitive females, and in grave cases a pulse of i;{(> to 160 is iKjt uncommon. SufMen slowing of the pidse withont fall in tempera- ture or improvement in nervous symptoms is of serions siguificanc.'. Wlieu the ci-itical fall of tcnii.cnilin-e (.ccui'<, aliont the clox' of the .second wceU, the 142 TYPHUS FEVER. pulse-rate should fall (leeidedly, though not so rapidly. Abnormal slowness to 60, or even to 48, is not rare during convalescenee. In one case in the Blackwood epidemic the pulse on the twentieth day was 24, with respirations 16 and temjiorature 98° ; recovery followed, and by the thirty-second day the pulse had attained its normal rate. Excitement or exertion will rapidly send the pulse-rate up again, however, and this undue mobility of the heart may last for wrecks. When the muscular substance or nervous ganglia of the heart are seriously involved the pulse may be so rapid, small, and irregular as to be uncoimtable; the pulse taken at the wrist may diifer widely from the count of the cardiac impulses at the prsecordia, and, if life be spared, pro- nounced weakness and irritability of the heart may persist long after recov- ery is otherwise complete. The character of the heart's action and pulse is even more important than the rate. In mild cases and in the young and strong the pulse may retain fulness and force ; but there is pronounced tendency to failure of cardiac ]iower, and as a rule the pulse grows soft, small, and compressible in two or three days, and from that onward its weakness increases. For some time before the crisis, in very grave cases which nevertheless recovered, I have been unable to detect the pulse at the wrist. Dicrotism is less common than in typhoid. The cardiac impulse soon grows weak and diffuse ; it becomes impossible to count the apex-beats by palpation ; the first sound is altered in character, becoming short, clear, and valvular, and ultimately almost inaudible, owing to increasing impairment of the ventricular contractions. A blurred or murmur- ish character of the first sound is also often present, but actual endocarditis is rare. These changes indicate, and to some extent measure, the dyscrasia of the blood, the degeneration of the cardiac muscle, and the failure of innervation. The pulse-respiration ratio is fairly preserved, so that the breathing is usually 30 to 40 in the minute. I have, however, observed the respiration at 50 and at 40, with a pulse of 104 and of 88, respectively, and without demon- strable pulmonary lesion in either case. Respiration becomes much more rapid in case of pulmonary complications, not rarely reaching 50, or even 60. As the development of such complications is often insidious, cautious explorations of the chest should be made daily. Weak respiratory murmur, with fine ex- pansion crepitus on deep breathing heard over the lower lobe behind, may often be found as evidence merely of hypostatic congestion and imperfect expansion. But even when pneumonia exists the percussion-dulness may be only relative and bronchial respiration be imperfectly developed. Cough may lack force, and the muco-sanguinolent expectoration be scanty and raised with difficulty. The increased lividity and cyanosis, elevated temperature, and car- diac failure confirm the susi)icion aroused by the physical signs. Bronchitis in any serious degree is greatly less frequent than in typhoid. Sonorous and sibilant rales scattered over the chest are common, and indicate congestion and slight catarrh. The character of respiration varies greatly. SPECIAL .SYMPTOMS. 143 If there be much pulmonary congestion, it is shallow anil superior costal in type. If the cerebral symptoms and the toxaemia are profound, it is irregu- lar, jerking, or even stertorous. Under these circumstances its frequency may fall below the normal. An inverted type of respiration, due to pneumogastric paresis, is a fatal symptom. The expired air is heavy and offensive. Little is known of its composition save that it often contains an excess of ammonia. Hiccough is not rare in grave cases. It is im])ortant to be aware that epistaxis is of quite frequent occurrence in some epidemics. It was noteil in twelve out of one series of thirty cases under ray observation. The urine is scanty and highly febrile. It is highly colored, of strong, offensive odor, and apt to become ammoniacal. The urea aixl uric acitl are increased, while the chlorides are greatly diminished or absent. Albu- min is usually present in all but mild cases. The amount is not great, nor does it it add materially to the gravity of the case unless infectious nephritis be present, Avhen albumin is more abundant, with granular or epithelial tube-casts. The proportion of cases in which nei)hritis occurs varies much in different e]ii- demics ; its existence adds decidedly to the gravity of the case. If the patient survives the fever, the nephritis rarely persists. At the time of the crisis copious discharges of urine, at first loaded with urates and then very light colored and of low specific gravity, sometimes occur. As already stated, retention of urine is of frequent occurrence. The urine may be passed if the ]>atient's attention is drawn to it ; but the region of the bladder must be exam- ined regularly, and the catheter be used if required. The cutaneous symptoms demand careful study. The skin imi)arts a peculiar sense of pungent heat, aptly styled calor mordax. It exhales an odor which, combined with that of the breath, may be recognized as charac- teristic after a few experiences. There is but little tendency to moisture, so that sudamina are of rare occurrence in typhus as contrasted with tyi>hoid fever. A copious sweat may attend the critical fall in the temperature. Cold, clammy sweats of the head and extremities, with continued high central temperature, often presage fatal cardiac failure. Herpetic eruptions are of rare occurrence. The eruption of typhus consists of a combination of subcuticular mottling with the characteristic macules. The mottling is not essential or constant, tiiough of common occurrence. It may ai)pear as cai-ly as the fii-st day. The spots or macules appear, as a rule, on the third or fourth day ; ihcy may be postponed for several days later, as to (he seventh or even (cnth day. They come out in a single crop, ai)pcaring first on (he trunk, then on' the extremities, and less constantly or copiously on the face. 'V\w spots are irregularlv rounded in form, barely if at all el.'VMthritis rarely persists as a sequel unless the patient is allowed to expose or exert himself at too early a period of convalescence. Epistaxis is occasionally met with, even when no pronoiuiced hjemorrhagic tendency exists. Ha-matemesis is nnich more rare. In certain iiffimorrhagic cases blood escapes from almost all surflices, in addition to numerous subcuta- neous ecchymoses. Parotitis is both more frequent and more dangerous than in tvj)h()id. Both glands may be affected simultaneously, though more cominoidv but one, or first one and then the other. Suppuration usually ensues, and the gland breaks down and is discharged in small necrosed fragments. 1 have seen death result from parotitis arising after all danger from the original attack of fever seemed over, extensive infiltration and burrowing having caused fatal exhaustion. If the pus be not evacuated promptly, it is apt to discharge by the ear, the cartilaginous meatus being separated from the bone. I have rarely known deafness to jwrsist. There may be inflammatory swell- ing of other glands, analogous to the buboes of the plague. Meningitic or other intracranial lesions are, as already stated, rare. Palsies of a single member, or even paraplegia, may occur among the sequels. Nein'itis is in most instances the cause. Jaundice, erysipelas, cancrum oris, and abscesses in the subcutaneous tissues or in the joints are occasional complications. The muscular tissue of the heart is affected in typhus with gramdar degen- eration whenever high fever is present, but in some cases this lesion is so extreme as to be the chief cause of fatal heart failure and collaj)se, Endo- and peri- carditis are rare. The hair falls out after typhus, though probably not so frequently as alter typhoid. Permanent baldness is not to be feared. The nails j)r('sent transverse ridges, as after other severe acute affections. Prognosis. — The duration of tyj)hus fever i>, im an averag(\ about two weeks. Short, abortive cases are occasionally met will", in which the crisis occurs as early as the eighth or tenth day. On the other hand, the lever may be prolonged to tiie eighteenth or twenty-first day, and if serious se(|uche have developed the sickness may be greatly i)rotracte(i. The mortality varies in dilferent epidemics between 10 and .'>") \>iv cciit. Tiie type of the disease nnist be considered in estiniating the pidgiiosis, as well as the symptoms of the individual case, ('hihh-cii rarely die; ymiiig adults have many chances in their favnr; beyond the age oftlilrly ilie pni-im- sis grows more grave, and after middle life the nmrlality may icaeli •">( • |»<'r Vol.. I.— 10 146 TYPHUS 'FEVER. cent. Sex exerts no influence. The previous condition and habits of the patient, and especially as regards privation and intemperance, are of great impoi-tance : the disease is terribly fatal among drunkards. The negro race seems to succumb readily to typhus as well as to relapsing fever. Intensity of the nervous symptoms ; persistent hyperpyrexia ; extreme pros- tration and rapid, feeble pulse, with threatened heart failure ; scanty, highly albuminous urine; vomiting or diarrhcea ; copious dark-colored eruption, soon becoming petechial ; pulmonary complications, — these are most unfavor- able elements in prognosis. Typhus is noted, however, for the almost miracu- lous recoveries which take place when patients seem moribund, so that our efforts must nev'er be relaxed as long as a spark of life remains. By far the larger proportion of deaths occur from the ninth to the twelfth tion be more or less uniformly converted into petechipe and acconijumicd with subcu- ticular mottling. On the other hand, in typhus the symptoms may be mild, the eruption postponed till the sixth day, and then be scanty, light-colonvl, and disappear wholly on pressure; the bowels disposed to be loose and the symptoms of prostration be largely wanting. In short, there are few out- breaks of typhus in which some cases are not met which demand cautious and critical study before the diagnosis can be established. The eruption of typhus comes out at about the same time as does that of measles, and at first may resemble it considerably. But in measles the erup- tive stage is preceded and attended by marked catarrhal symjitoms; the rash comes out first on the face ; the spots form groups with crescentic borders, and rarely become petechial. The bubo plague is so strictly limited to certain Oriental coimtries by modern quarantine that the question of its differential diagnosis from typhus can rarely arise. The symptoms of the onset are not dissimilar, but the very rapid development in the j)lague of profound typhoid symptoms ; the early ai)pearance of buboes, carbuncles, and extensive petechiie ; the pronounced tendency to collapse, with sudden fall of temperature ; the absence of the characteristic eruption, — serve to distinguish this frightfully fatal disease from typhus. It is unnecessary to repeat here, with reference to the possibility ol' mis- taking typhus for uraemia, wliat has been elsewhere said on this point in regard to typhoid. Treatment. — The highly contagious nature of typhus fever renders imper- ative the prompt isolation of each case. The infected house should be vacated and thoroughlv cleansed and disinfected. If a case has occurred in a large conununity, the public health authorities are to be summoned to take charge of the locality, with a view to the adoption of sucii radical sanitMry measures as mav prevent any spread of the disease. Patients sulTering with typhus fever should not be admitted to general hospitals if it can be avoided, but should be accommodated in special hosi)itals for infections diseases, if the climatic conditions are favorable and the cases are numerous, they aiv best treated in isolated tents. The hygiene of the sick-room as regards nursing, rigid cleanliness, venti- lation, disinfecti(m of all clothing, demands specially close altenli..i.. Allimugh 148 TYPHUS FEVER. there arc no grave lesions of the alimentary tract, and though there may be some maintenance of appetite, it is on the whole safer that the diet should be li(piid throughout the course of the disease. Milk is the best basis, and to it mav be added strong animal broths. Junket, thin arrowroot, light custard, and raw egg may be cautiously tried, and continued if found to agree. Tea or coffee, either black or with hot milk, may be taken with relish, and may be very nsel'ul, especially where there is a tendency to ataxic symj)toms or to stupor. Nourishment should be given in comjiaratively small quantities at short intervals : four to six ounces of milk or its equivalent every two hours may be taken as a fair standard. Water should be offered frequently, and the patient may be encouraged to drink it freely. Alcohol is indicated in nearly all cases bv the prostration and the tendency to heart failure. It is specially well borne in childhood and in advanced life. Cases of moderate severity in vigorous young adults often do well without it. The same rules are to be observed as to administration and as to deciding for or against its beneficial action as were laid down in the article on Typhoid Fever. Upon the whole, it is needed in ty}>hus earlier, more constantly, and more freely than in tvphoid. It is usually well to begin with small amounts much diluted, but the remedy mu!?t be unhesitatingly pushed if the symptoms call for it. I find among my notes the records of two cases where one and a lialf ounces of strong brandy were given every hour, day and night, for ninety-two and ninety-six hours respectively, with the manifest effect of saving life. The presence of marked ataxic or adynamic nervous symptoms, a copious and dark eruption with abundant petechise, a small, weak, and rapid pulse with failing cardiac impulse and first sound, are the positive indications for stimula- tion : the effect of the stimulus upon the symptoms is the guide as to the proper amount to administer, and the fact that the disease runs a short, self- limited course justifies the freest use of stimuli to carry the patient along till the critical hour is reached. The management of the fever should be upon the same general lines as in typhoid. The use of cold baths, systematically employed after the Brand method, should be insisted upon in all cases where the fever rises to 103° in the axilla or 103|° in the rectum. While the temperature remains below that point dependence may be placed upon repeated sponging with cold water or an occasional pack. Should the surroundings of the case render bathing imprac- ticable, it will of course be necessary to rely on repeated, thorough cold-water packs or affusion as originally used by Currie. It will, however, soon be pos- sible to secure portable bath-tubs by means of which hydrotherapy can be carried out in private houses of every class. It is of the utmost importance that the temperature should be controlled from the very first day. If this be judiciously and firmly done, the development of the gravest nervous symp- toms and of alarming heart failure may often be averted. The most fre- quent cause of failure of hydrotherapy is its postponement until heart, brain, and blood have been too seriously damaged by the continuance of high tem- perature. TREATMENT. 149 Antipyrine and analogous antipyretics must be used with extreme caution. A sudden rise of temperature may be met and modifieil by one or two medium doses, but in typluis, even more tlian in typhoid, there is a tendency to contin- uous high temperature, and anything lilvc the continuous use of these antipy- retics is absolutely forbidden. The mineral acids, especially nitro-muriatic and phosphoric, may be used freely with advantage. There is no good ground for believing that they exert any specific effect on the virus of the disease, but their general and local action is tonic. Besides, when properly diluted they make a pleasant acidulated drink, so that the ]nitient is encouraged to take water freely. Dilute cidorine- water may be used in the same wav. Headache may often be relieved by applications of cold to the head, but if intense and persistent it may require the use of sedatives. Small doses of mor])hine and atrojiine may be given safely by hypodermic injection, or opium may be used by the rectum or by the mouth. ^yhen active delirium is present, with sleeplessness and severe headache, an opiate combined with cannabis Indica or with hyoscine hydrobromate is to be tried; under these circumstances Graves advised tartar emetic in conjunction with opium. Chloral hydrate, in doses of 12 to 15 grains by the mouth or of 20 grains by enema, has given good results. If insomnia, with or without headache, is associated with marked prostration and ataxia, remedies such as camphor, valerian, or asafoetida are of use' and may have a small amount of o])ium associated with them. Full doses of quinine and asafoetida, 10 gi'ains each, in the form of suppository, given morning and evening, exert a support- ing and quieting effect. If irritability of the stomach and \niniting are present, they must be relieved by simple sedative remedies and restriction of food, with substitution, if necessary, of nutritious enemata. Constipation may call for the use of gly- cerin suppositories or of simple enemata, or for the internal administration of fractional doses of calomel or mild saline aperients. A careful watch must be maintained against comj)lications. I^dmonary congestit)n or catarrh, if moderate in degree, may be relieved by dry cups or by counter-irritation applied to the back of the chest. If nmre severe, or if ])neumonia has developed, increased stimulation, annnonium car- bonate, and strychnine should be directed. I have used turpentine with much aj)|)arent advantage when the typhoid state became fully developed, with great nervous prostration, feeble circulation, and marked ]»ulmc)nary congcvtion. Strychnine should be used in the same manner and to meet the same indica- tions as in typhoid fever. More reliance is to be placed on it and alcohol than on digitalis in the treatment of threatened heart failure. Convalescence is retarded by few sequels, and iclapses do not occur. Care should, however, be observed both as to tli«t mid exercise. The amount of stimulant should be reduced as nipidly as possible, and a bitter tonic with iron may be substituted with advantage. RELAPSING FEVER. By WILLIAM PEPPER. Definition. — Relapsing fever is an acute infectious and contagious epi- demic disease, characterized by its division into successive stages of exacer- bation and intermission, by various uniform alterations in the viscera, and by the constant presence in the blood of a specific micro-organism — the spirillum of Oberme}'er. Synonyms. — It has many synonyms, the chief of which are — Riickfalls typhus, Febris recidiva vel recurrens, Fievre a rechutes. Bilious typhoid fever, Hunger-pest, and Spirillum fever. History. — While it is certainly a fact that the disease existed prior to that date, the first clear account of it was written in 1739. Since then numerous outbreaks have from time to time occurred in various parts of the world. Its first appearance in America of which we have any certain knowledge occurred in 1844, when it was imported by the passengers on an emigrant-ship. After this a few cases were observed in this country, and in 1869 an epidemic of the disease prevailed in Philadelphia. I had the opportunity, in conjunction with my colleague, the late Edward Rlioads, to study several hundred cases which were admitted to our wards at the Philadelphia Hospital. Since that time other epidemics have occurred, the last of any considerable size having been located in Russia during the years 1885 and 1886. Etiology. — The etiology of relapsing fever is not as yet entirely clear, but for reasons that will be more fully stated below it is certain that the spirilhun of Obermeyer plays an important, if not the chief, part. Aside from this immediate cause, we have numerous factors important in their influence upon the existence and spread of the disease. Chief among the predisposing causes, although not essential, is the presence of the combination of filth and starvation. The former of these is usually associated with overcrowding, itself a powerful predisjiosing cause aside from its importance in effecting the spread of the disease and widening the limits of the affected area; while all three factors — filth, famine, and overcrowding — make a combination pro-eminontly calculated to reduce the vital foi'ce of both individual and community, thereby offering favorable conditions for the onset and S])read of this as of any other general disease. That filth, overcrowding, and starvation are not necessary factors is shown by the fiict that those in the entirely oj>posite condition may be, and often are, attacked. A still more essential and ever-necessary factor is contagion. Tliis may take place either by direct contact of the well with the sick, or the contagious 150 ETIOLOGY. 151 ])rinciple may be carried by foniites, as is well evidenced by the frequent occurrence of the disease among laundresses. The infecting material may be transported from the ill without the bearer contracting the disease, although communicating it to others. Neither age nor sex has any manifest bearing upon the etiology of this dis- ease, although, as would be expected from the greater exposure to infection, the male sex and the active or middle ]HM-iod of life furnish the greater num- ber of cases. Race would seem to have no predisposing or protective iuHuence, save only in so far as the hygienic surroundings and j)I\ysical condition of ditfcrcnt nations may alter the relative resistance to contagion. The negro shows, pos- sibly, somewhat greater susceptibility to the poison than do other races. Tiiis liability is not strongly marked — not more so than we M'ould expect when we remember the susceptibility of this class to various other diseases of a some- what similar character. Season has no evident etiological relation to the onset of the disease, nor do climatic conditions favor or limit its power, save for the wide variation in habits of life and surroundiny-s amon"; the dwellers in different climates. By far the most important etiological factor is, however, the minute sjiiral organism discovered by Obermeyer in 1873 — the spirillum Obermeicri. This has been found so constantly in the blood of patients suffering from this dis- ease that suspicion pointed strongly toward it as the cause before its successful cultivation on artificial media and inoculation into anituals. The micro- organisms are long, extremely delicate, fibre-like bodies of spiral shape, in length measuring about six or seven times the diameter of a red blood-cell. (See Fig. 11.) They move freely about in the field of the microscope, causing oo; Fig. 11. c8o?)Og# o o ^ Recurrent Spirals in the Blood fafler .laksch). disturbance of the blood-cells. This spiral motion takes place in the dircH-ti..n of the length of the organism. Dried preparations ..f tlic Mh.hI ...ay be read- ily stained bv the ordinary a.iilinc coloi-s in o.-dcr to sl...\v the i)arasilc. Net only has it been found in "the blood ol.tainc.1 dirc.-tly, but ih<- organis... is also present in the menstrual l,loo;lands of the intestine presenting less swelling and congestion than is usually found in other infectious diseases. The abdominal lynq)hatic glands show no pronounced morbid changes. The spleen is constantly and characteristically altered, with more definite and specific changes than any other organ exhibits. It is always large, usually adherent to the diaphragm, and almost always partly covered by fresh fibrinous exudation. The size of the spleen is quite variable, the limits in the series of cases observed by me being 10 and 44J ounces. The capsule often presents a mottled appearance, or may actually have in its substance large ]>uri)le ecchvmotic areas. In a few cases rupture of the capsule has been found. The splenic pulp is usually more or less softened and swollen, and shows enlarged Malpighian bodies. The latter may vary somewhat in character with the stage of the disease at which death occurs. \n the early stages they are enlarged and of a greenish-yellow color, giving to the cut surface very much the appearance of shad-roe. Later in the disease this enlargement still further increases, until, by coalescence or aggregation of neighboring cor]>nscles, laro-e masses raav be formed. Iliemorrhagic infarction of the spleen is very frequent, the infarcts being, as a rule, venous, and freciuently breaking down into purulent, softened areas. These enlarged Mali)ighiau corpuscles are fouinl, upon microscopical examination, to be composed of large nundx'rs of small lymphoid cells which have undergone cloudy swelling, or. l;itressure. The areas of hepatic and splenic dulness are invariably increased during this pyrexial stage, the latter being more markedly enlarged than the former. There is usually some annoying cough, and epistaxis may be (piitc t.bsti- nate. Examination of the chest during this stage may be negative, but there are .usually present the signs of acute bronchitis or even of pulmonary conges- tion, with'some impairment of resonance at the bases. There is frequently to be heard a hsmic murmur over the cardiac region, but no other nnn-nuirs arc developed as a result of the disease. The urine is concentrated and iiigh-colorcd, bile-stained in the cases with icterus, and may contain blood. As before stated, wh.iv liaMuatuiia is present the spirilla mav be found in the urine. The condition above described persists, the temperature varying but bttle from dav to dav, until the crisis, wbi.-ii usually .M-eiirs in ab<.iit six cr seven days. Just preceding this event there is fre(iuently a mark.^l v^^v „, tlw body- temperature to a point even higher than (hal ,.nvinnsly attained. I h,- ens.s 156 RELAPSING FEVER. is sio-nalized by a rapid fall in the temperature, a less-marked fall in the pulse- rate a cessation of many of the most distressing symptoms, and, as a rule, the occurrence of some critical discharge — a profuse outpouring of sweat, a free flow of urine, a copious stool or a series of bowel movements, epistaxis, or, more rarelv, metrorrhagia. During the occurrence of the crisis the face becomes pale unless icterus mask all pallor. The crisis may extend over as much as several hours, the temperature in that time falling 6°, 8°, or even 14° F. The patient then enters upon a period of apyrexia, the intermission. During this stao-e most of the more distressing symptoms are absent : the temperature remains subnormal for a day or two before regaining the level of health ; the pulse-rate diminishes, but not to an extent commensurate with the fall in tem- perature ; the pulse loses its bounding character, but becomes easily excited ; the cephalalgia becomes less intense, although the muscular pain and soreness continue to be severe. During this time, it is to be remembered, but few or no spirilla are to be found in the blood. The disease in some cases ceases after one attack, the patient's condition merging from that of the post-critical period into that of convalescence ; but usually after an apyretic interval of six or seven days (the extreme limits beino- two and twenty) a relapse occurs resembling in its onset the first attack described above. The relapse diifers from the primary pyretic period in but few ]iarticulars. The patient's general condition is not so favorable, owing to the fiict that the attack occurs in a system already weakened by fever; but, fortunately, the second attack is not, as a rule, aceom])anied by such high fever and such intense cephalalgia, nor is it of such long duration as was that with which the illness began. The first relapse (second pyrexial period) continues, on an average for from three to four days, tiie extremes being a few hours and seven days. With the beginning of this second pyrexial attack the spirilla reappear in the blood, to again disappear with the second crisis. In the great majority of cases the morbid process terminates after the first relapse, but two, three, four, or even so many as eight, relapses may occur. The duration of the disease may thus extend to eighteen or twenty days, all told, where a single relapse has occurred, up to ninety or even more days in cases with multiple relapses. During an attack such as has been described certain other symptoms. and conditions, more or less deserving of the name of complications, may occur. These demand a more detailed examination. Delirium, that at times, though infrequently, occurs, may be of different kinds. Although the temperature may remain at a great height, the mental condition is much clearer than is usually observed in cases of either typhus or typhoid fever, in which the thermometer indicates so high a degree. There may, however, appear in alcoholic subjects a delirium that is active and almost maniacal. On the other hand, there may be present a low, muttering delirium in the cases that assume the so-called typhoid character. Sometimes in the first intermission — or, more rarely, at other times — there COMPLICATIONS AXD SEQCIJL.E. 157 occurs a sudden rise of temperature without any appreciable cause. This uiav in some cases be due to the influence of embolism of some important organ. During the period succeeding crisis, when the temperature should maintain a normal or even subnormal course, we may have a continuance of febrile mt)ve- ment. This is usually due not to the continuance of the influence of the specific poison, but to the continuing irritation of some organ or tissue secondarily involved. The local peritonitis in the splenic region may well be suflRcient to maintain a considerable elevation of temperature. Complications and Sequelae, — Of complications, lobar pnciunonia stands well to the front as being the most frequent cause of death. In the St. Peters- burg epidemic of 1885-86, Puschkareif found this lesion present in 18 out of 47 cases examined. A\'hile, however, this complication is one of the most fre- quent immediate causes of death, its presence does not necessitate a fatal i)rog- nosis. With hepatization of the lung-tissue there is usually associated plas- tic pleurisy, and at times pericarditis. Gangrene of the lung may terminate the course of a complicating lobar pneumonia. So numerous arc the exam- ples of pulmonary congestion that that condition scarce merits the nanie of a complication, as it seems to be a part of the ensemble of a severe case of relapsing fever, just as it is in typhoid fever and other diseases of asthenic type. In some epidemics grave catarrhal laryngitis has been a frequent complica- tion, while cases with a diphtheritic deposit in the ujiper air-passages have been recorded. ICpistaxis may be sufficiently severe to require ]>lugging of the nares, and may vastly increase the anasmia so prone to occur in the ordinary course of the disease. Pericarditis is not a frequent com])lication, but is met with occasionally, being usually an accompaniment of lobar ])neiunonia. Cardiac thrombosis is frequently the immediate cause of death, being due, in ])art at least, to the extreme weakness of the degenerated heart-muscles. Sudden cardiac failure is quite often seen, cases dying after some ai)]iarently trivial exertion necessitated by change of posture. While cardiac thrombosis is frequently seen, the same ])rocess in the veins is observed niuch less fre- quentlv in this disease than in typhoid fever. P>rief allusion has been made to the tendency to the oeeiirrence of embolism in various organs. Whatever may be the cause of this liability, its fre(|iieney is remarkable. Almost all of the c-hief organs of the body may be alVectcd, giving rise to the symptoms peculiar to that condition when occurring in other morbid conditions. 8uj)erfi('ial gangrene, prol)ably a result of embolism, has been seen in the extremities and alfecting the tip oI'iIk' mxc and ears. The digestive tract is not especially prone to offer a field lor cninplications in this disease. Supjuu-ative jianttitis is a condition tlial may oc<-nr. as in one of the cases occurring in the e|)i(lcniic olxcrvcd by llic anther. It occurs in a varying number of cases in different cpidcrni<-s. I liccniinli is a (Vc(|ncnt and unfavorable syni|)tom, being not only productive of inneli discomfort, but also. exhaustin<'- strength and preventing natural rot. I laMiiali'iiicsis is imi a v<'ry 158 RELAPSING FEVER. rare complication, and is of very unfavorable import, three out of four cases in which it occurred in our series of cases being fatal. Altlipugh diarrhoea is not so frequent as in typhoid fever, it occurs in a con- siderable proportion of cases, and may be sufficiently profuse to bring about a fatal result. Melfena may occur to a varying extent, and dysentery was, as might be expected, a notable complication in some of the epidemics occurring in India. General peritonitis is rarely present save as a result of splenic rup- ture : when present a fatal result may be predicted with certainty. Splenic abscess occurs with sufficient frequency to cause us to be on our guard lest it may be the lesion present in those cases where the temjierature of what would naturally be the period of apyrexia remains above normal. Rup- ture of a sj)leuic abscess may be the cause of a generalized purulent perito- nitis. The occurrence and significance of perisplenitis has already been men- tioned. The urinary system is the seat of varying morbid conditions, some of which are of great importance in determining the result. Albuminuria is present in a very large number of cases, and is not necessarily a cause of very serious alarm. When, however, the excretion of albumin is accompanied by the pres- ence of tube-casts, the prognosis is very grave. The affection of the kidneys may vary from simple congestion to the lighting up of an old chronic process or tlie production of an actual acute nephritis, which may be hseraorrhagic in character. Complete suppression of urine is at times present. Hsematuria may be profuse and exhausting : it is a grave complication, and is often fol- lowed by a fatal issue. Glycosuria has been observed during the course of some cases. Profuse haemorrhage from the uterus may occur, and it is recorded that in one case observed by Wolberg the menstrual accession seemed to be brought on by the general disease. Abortion usually happens when the disease attacks pregnant females. Purulent otitis media or purulent rhinitis may present itself during some part of the course of the disease. Various local palsies occur with peculiar frequency during or after attacks of relapsing fever. The lower extremities, shoulders, arms, or forearms may be affected. Precisely what condition is the underlying cause of these palsies it is sometimes difficult to determine; but in most cases, and more certainly in those with coincident anaesthesia, a perineuritis may be assumed as the pathological lesion. An extremely frequent complication is collapse. This may be due to car- diac weakness from degeneration of the heart-muscle, to cardiac thrombosis, to rupture of the spleen, or to internal or external haemorrhage. All of these conditions have been more particularly mentioned above. Following an attack we may have a variety of more or less important pathological conditions. A frequent sequel is intense and persistent cephalal- gia, or severe rheumatoid pains with or without swelling of the joints may persist. In some cases imbecility has been known to follow upon an attack BIAGXOSIS. 159 of this disease. Intense anseniia is by no moans a rare seciuel, while dia- betes mellitus and aeute miliary tuberculosis are aniono- the rarer results. A frequent sequel is a peculiar ophthalmia that is subdued with difHculty and is of long duration. Tiiis is most frequently seen in indivitluals whose nutrition was impaired before their attack of rela})sing fever. Optic neuritis and atrophy are among the rarer sequelae. Diagnosis. — It would seem at first sight that the existence of the specific spirillum in the blood would be sufficient to prevent all chance of confounding this with any other disease. This would be true were it possible or customary to examine the blood of every patient, and were it always an easy matter to discover this organism when such an examination was made. In the earlier cases of an epidemic that is so rare a visitant to any one locality as is the one now under consideration it is not probable that a correct diagnosis will be made until either a case has been observed that has gone through a relapse or a clear case of contagion has been remarked. To enumerate again the prominent symptoms : a sudden onset with cliill, preceded by few or no prodromes; enlargement of liver and spleen ; a flushed face ; rapid, bounding pulse ; rapid rise of temperature without marked ner- vous disturbance; intense rheumatoid pains; cephalalgia and obstinate insom- nia; tingling of the extremities ; tenderness and pain in the epigastric and livpochondriac regions ; nausea and vomiting ; haemorrhages from various sur- faces ; frequent jaundice ; crisis, followed by a period of normal or subnor- mal temperature. These go to make up a picture too characteristic to be mis- taken where we are induced to bear in mind the existence of this affection. The diseases with which it is most apt to be confounded are ty])hus fever, typhoid fever, malaria, and rheumatic fever. In tvphus the onset, although quite abrupt, is usually much less so than in relapsing fever. The temperature rises less suddenly, but, instead of the insomnia, persistent headache, rheumatoid jiains, and freedom from the cere- bral svmptoms of liyperpyrexia which mark relai)sing fever, there appear delirium, deepening stupor, subsultus, and rapid loss of cardiac power. To these must be added the appearance of the characteristic eruption on the fourth day and the absence of the spirillum from the blood. In typhoid fever we have gradual and progressive rise of temperature, with early epistaxis, diarrhcea, increasing muscular weakness, tendency to hebetude, tympanv, local tenderness in the right iliac fossa, and u|)()n the seventh or eighth day the characteristic erui)tion. To distinguish relapsing fever from malarial i)ois(.niug is less dilVK nil if we bear in mind the place of residence or l)nsiness, and note the iircscnce or absence of periodicity, the j)resence in the blood ol' pccidiar organisms in each disease, and, finally, the ready control of (he malarial manifi-stations by quinine. From yellow lever the history of the case as to residence would !.<•, as a rule, sufficient to prevent error. In rheumatic fever without arthritis we may have r:ipi( be met as they arise, bnt during (lie whole ee oC treatment the need for support of the vital forces nni.st ever be kejW in mind. Vol. L— II CEREBRO-SPmAL FEVER. By WILLIAM PEPPER. Definition. — Cerebro-spinal fever is a specific, infectious, pandemic disease, slightly if at all contagious, probably niicrobic in origin, occurring sporadi- cally or in epidemics, characterized anatomically by inflammation of the meninges of the brain and spinal cord, and clinically by irregular nervous symptoms pointing to profound disturbance of the cerebro-spinal functions, the most prominent of which are intense pain in the head and often in the trunk and extremities, hyperaesthesia, contraction of the muscles of the nucha and back, vomiting, irregular fever, delirium, and, in severe cases, coma. Name and Synonynas. — No satisfactory title has yet been suggested for this disease. Upon the whole, cerebro-spinal fever seems preferable. It is open to the objection of implying that the fever is dependent upon the menin- geal lesions, whereas it is an infectious disorder of the general system, and the meningitis is only one of its manifestations. For the same reason we refuse to accept the name " enteric fever " in place of typhoid fever. But, in the lirst place, although the intestinal lesions in typhoid fever are of great importance, they do not dominate the symptomatology of that disease nearly to the same extent as does the cerebro-spinal meningitis the symptoms and course of the disease we are now considering. Further, it cannot be said that any of the clinical conditions in cerebro-spinal fever suggest for it a descriptive name so characteristic as, for instance, typhoid is of the fever which is almost univer- sally known by this term. Again, there are weighty objections against all other names suggested. The disease is so often sporadic that I fear the term " epidemic cerebro-spinal meningitis" has not rarely led to a failure to recognize the nature of isolated cases. " Infectious cerebro-spinal meningitis " is a name I have thought of proposing, and it may have some advantages, but it does not mention the acute febrile nature of the disease, and it must be remembered that there are other forms of acute infectious meningitis. Other names which have been more or less widely used, such as spotted fever, petechial fever, malignant purpuric fever, have become wholly obsolete. Pending the sugges- tion of a better name, it seems desirable to unite in the use of the title " cerebro- spinal fever," since the possession of a simple, clear, generally-accepted name certainly favors the clinical recognition of a disease and an appreciation of its nature. History. — There .seems to be no reason to believe that the disease was clear- ly recrognized before the early part of the present century. Whether or not it 162 .J I HISTORY 163 existed before cannot now be dcterminecl, altliough some autliors claim that there is evidence of its having occurred even in ancient times. It seems difficult to doubt its occasional occurrence, as the specific cause has probably not come into existence of recent years only. Yiesseux in 1805 appears to have been the first to give a clear description of an epidemic which occurred in Geneva, and in which 33 persons died. In the following year the disease made its appearance at Medfield, Mass. From this date up to 1816 local epidemics were observed in various countries of Europe and in several parts of the United States. It then disappeared entirely until 1822-23, when cases were reported from Vesoul, France, and from ]Middletown, Conn., and after this, up to 1837, from a few other localities. From 1837 the disease began to si)read throughout France, and for years prevailed extensively there. Since that date, also, epidemics have appeared suddenly, and often simultaneously, in different parts of the world widely separated from each other, and where there has not been the slightest possibility of transportation. They lasted a variable time and were more or less widely spread. Sometimes the disease was for years unheard of in one country while prevailing in another. From 1850 to 1854 it was unheard of anywhere. Since 1860 epidemics have occurred in nearly every civilized country. In the United States it has at times been very prevalent and very fatal. In 1864, 400 persons, out of a population of 6000, died of it at Carbondale, Pa. It affected both the Uni(m and .Confederate armies during the Civil War, and was at times very malignant. Although 782 deaths from cerebro- spinal fever were reported in New York City in 1872, the disease appears on the whole to have been more limited there, both in extent and duration, than in Philadelphia, where it has been endemic since 1863, and at times severe. The tabular statement of the number of deaths in Philadelphia yearly from 1863 to 1883, published by Stille, I have completed up to the year 1892 : Deaths in Philadelphia from Cerebrospinal 3Icniiigitis from I860 to 1891, inclusive. 18fi3 1864 1865 1866 1867 1868 1869 1870 1871 1872 49 384 192 92 109 55 37 36 49 133 1873 1874 1875 1876 1877 1878 1879 1880 1881 1882 246 82 83 85 56 90 62 78 90 51 1883 1884 1885 1886 1887 1888 1889 1890 1891 Total, 50 124 87 75 45 50 37 25 23 ^575 I had the opportunity of studying the severe lMiiladel|.lii:i epidemie d" 1863-65 under my father, the late Dr. William Pepper, and the late Dr. William (k-rhard. ^ I made a iniml)er of autopsies und<'i- their dire<-ti.in and verified the nature of the cases. Having been Cainiliar thus .Mrly with the disease, I can confirm from subsequent experience the truth of Dr. S(illC''s stati*- 164 CEBEBRO-SPIXAL FEVER. ment, that it has lingered in this locality longer than has been reported of any other place in this conntry from which information has been obtained. Etiologry. — Of the predisposing causes, climate seems to have a decided influence, for, although cerebro-spinal fever has occurred in all portions of the temperate zone, it is unknown in the tropics. It is most prevalent in the northern regions of the temperate zone. Season, too, is an important factor, as the prevalence of the affection is much greater in cold weather. Not only do by far the greater number of epidemics occur in the winter-time, but those developing then are more severe and extended. The nature of the locality with regard to moisture, elevation, sea, mountain, city or country, is generally con- sidered to be without predisposing influence. With regard to moisture, however, this opinion is not undisputed. Wollf, who carefully analyzed 132 cases which had been treated in the Hamburg hospital, came to the conclusion that moisture of the earth and air is a decidedly predisposing factor. Very few of his cases occurred during July and August, the dry months of the year. As in regard to all infectious diseases, it may be said that bad hygienic conditions, as exposure, overcrowding, excessive bodily or mental exertion, insufficient food, and the like, exercise a predisposing influence. But it appears that the effect of these conditions is much less marked as regards the occurrence of cerebro-spinal fever than of other diseases of this class. I must state, however, that in the majority of the cases I have seen there has been some marked defect in the sanitary condition of the dwelling or in the physi- cal condition of the individual. In the other cases iiealthy subjects under admirable sanitary conditions were attacked violently. It has often been noticed that soldiers crowded in barracks and the occupants of tenement- houses suffer most severely. On the other hand, in some epidemics large cities, which apparently afforded the most favorable conditions for severe attacks, escaped entirely, and tiie disease has devastated cleanly villages or occurred in isolated outbreaks. Race is not a predisposing factor. Sex is also probably without influence, and that more males than females are attacked is doubtless due to the fact that the former are more exposed to privation, crowding, and other predisposing causes. Age is a very important factor. Statisticians agree that the disease is far more prevalent among children, and is also more fatal among them. J. L. Smith found, from the reports of the New York Board of Health, that infants under one year of age furnished the largest proportion of fatal cases. Different epidemics have, however, differed widely as to the relative proportion of adults and children attacked. The question whether cerebro-spinal fever can be acfjuired by direct contact with or proximity to a patient suffering with this disease is an important one. It is, however, almost universally admitted -that it is either not directly con- tagious at all or so to a very slight extent. Not only do the first cases of epi- demics develop without there existing the slightest possibility of the disease having been accpiired by contact with other cases, but the majority of cases occur singly in fiimilies, and where several cases do occur in a household it is never possible to trace any fixed period of incubation between them which ETTOLOdY. 165 might indicate tliat they had ae(iuiml the disease the one tVoni the other. Nurses and physicians in attenchuiee are attacked with the greatest rarity. Nor does the evidence justify the oi)inion that it can he transmitted by the secretions. On the otlier hand, there is abundant ])roof of the existence of a specific poison which may attach to certain liouses or localities so as to render them infectious. An imi)ressive instance is rccorded l)y Ilirsch, in which a woman who had nursed a j)atient with cerebro-spinal fever leturned to her home in another village, and there sickened and died. Mourners at the funeral came from another township, and three of these died from the disease soon after. ^Moreover, there are cases on record which indicate verv strongly that the disease may be contracted by contact with infected garments, if n()t by direct contagion in rare cases. In one instance, reported by J. L. Smitii, a mother was attacked by cerebro-sjiinal fever two days after washing the clothes worn by her son, wlio had died with it, and a few days later her infant also sickened and both died. One of the most remarkable published cases with which I am acquainted is that reported by Kohlmann. A servant-girl died with typical symptoms of cerebro-spinal fever. Her clothes were lent bv her family to different neighbors. A man in one house, who had received a coat, was attacked by the disease some montiis later, and several weeks afterward his son was stricken down, and in one week more his daui-hter. A woman who had visited the last ease for not more than ten minutes, and wlio had held the head of the ])atient while the throat was being examined by the physician, suffered from the disease in a mild form eight days later. Another coat was lent to a young boy in another house in a different part of the citv. He took the disease and died, while his mother also died, })rol)ably of the same affec- tion, although it began in her case as a croupous pneumonia. Instances such as these, together with other j)eculiarities of the affection, warn us not to be dogmatic as to the possibilities of the transmission i>f the disease when the poison is virulent and the system unusually suscej)tible. Recognizing, then, the existence of a specific virus as the true cause of this disease, it must be stated that its exact nature is as yet unknown. It is generally believed to be microbic. A micro-organism identical with or indistinguishable from the pneumococcus has repeatedly been found in the meningeal exudation. Manv investitrators claim that this is the onlv microbe which occiu's in the men- inges in this disease. It certainly is the one oftenest discovered, i)ut in many cases other oi'ganisms as well have been described, so that it wouhl seem |>os- sible that the disorder may be capable of being j)roduced l)y dillerent species of microi)es. Foa and Uffreduzzi made some interesting studies of the pneu- mococcus found in the meninges of several cases, and ol)scrved that it re(aiueli:i|»ed coccus, similar to or identical with the pneumococcus, is tlie mo>t coniiiiun ; luit I do not consider that the bacteriological studies .if thi- «|iieain and stiffness of the muscles of the back of the neck develop, and consti- tute one of the most characteristic symptoms. The headache grows worse and there is sensitiveness to light and noise, and often irritability and restlessness. The ])ain and stiffness extend along the muscles of the sj)ine, and even into the limbs as well, where the suffering may be very intense. In severe cases retrac- tion of the head and orthotonos, or even opisthotonos, soon develop. As a result of the tonic spasm in the muscles of the extremities, the forearms are flexed upon the arms and the legs upon the thighs. There may be tremor or clonic spasm in the muscles of the arms, legs, eyelids, or face. Strabismus is frequent. The pupils are dilated, contracted, or unequal, or do not react well to light. General epileptiform convulsions with unconsciousness are sometimes observed, but more often in children than in adults. Local paralyses occa- sionally occur in various })arts, as in the muscles of the face, of the eye, or in a single group of muscles of an extremity or of the trunk. With these motor symptoms are seen also disturbances of sensation. The intense pain has already been mentioned. There may be great sensitiveness over the spine, and a remarkable hyperaesthesia of the entire surface of the body and of the joints. Vertigo sometimes persists, and is distressing even when the patient is lying quietly in bed. Ringing in the ears, with great sen- sitiveness to sound, is succeeded by deafness. Photophobia is almost constantly present, and there may be double vision and even temporary blindness. Delir- ium occurs very early, varying from a simple wandering to a true maniacal form, and often alternating with stupor. The tongue is coated and often remains moist, though in severe cases it may become dry and brown. Vomiting usually subsides as the disease advances, but may ])ersist and be distressing. Taste and appetite are lost. The bowels are usually constipated, and the abdomen may be decidedly retracted. SYMPTOMA TOLOG V. 1 69 The amount of uriue passed is variable, but is apt to be increased, and all)u- jnin is occasionally present. The spleen is often somewhat enlarged, as already stated. Even during the first few days of the disease the skin is liable to exhibit eruptions. Herpes facialis is a very common form, and a petechial rash is quite frequent. Other eruptions likewise occur in some cases. The fever is irregular and presents no typical curve. It is generally moderate in degree, though occasionally it is high. The pulse is likewise variable; sometimes slow, and again very rapid. Respiration, too, varies, but is not often much accelerated. Cheyne-Stokes or sighing breathing is sometimes encountered. The disease exhibits a variable course, but generally reaches its height between the third and the sixth day. It has been claimed by Frey and others that a remission in the symptoms sometimes occurs about the third day, althou";h it lasts but a short time. I have on several occasions noted this in such marked degree as to rouse hope that error in diagnosis had been made, but the characteristic symptoms quickly resumed their course of development. The duration of the disease may be from a few hcMirs to several months. If the case tends toward recovery, the symptoms become less marked alter five or six days, the spasms grow less, the mind becomes clearer, and the depression, headache, and general pain ameliorate. Convalescence is fairly established in one or two weeks, although often not until after a much longer time, and it is verv apt to be interfered with by complications and setiuclse. If, on the contrary, the case is destined to cud fatally, the symptoms of nervous excitement pass into those of exhaustion ; delirium changes into a state of coma ; prostration grows extreme, the jiulse rajiid, the temperature hiirh, and there is paralysis of the sphincters with involuntary discharge of urine and fteces. Sometimes the course of fatal as of non-fatal cases is greatly prolonged, lasting weeks or even months. •2. The Malignant Form. — This form has also gone under the title of ful- n)inant {meningife foudroyante, meningitis siderans), a])oplectic, rapid, explo- sive, etc. It may occur sporadically in rare instances, and with variable fre- quen(;v in all epidemics, but especially at their commencement. The patient, previouslv in perfect health, is stricken by the disease with the greatest sudden- ness, and rapidly passes into a condition of collapse. There is nsnally a vio- lent chill, intense headache or drowsiness, great prostration, and a iivbic pulse, which mav be slow at first, but which soon grows rai)id. 'lUvro is little or no iever— the temperature may, indeed, be subnormal— and there may be coldness and clamminess of the skin, with cyanosis. Respiration is slow and labored. The urine is scanty and full of albumin. Th.-rc is .•ontractioi. of the muscles <.f the back of the neck, spasm in other muscles, or cases it only occurs when attempts are made to move the patient. The intensity of the pain is not always proportionate to the degree of retraction, provided no effort is made to overcome the latter. Pain in th(> extremities, especially in the legs, is also a common symptom. Movement of the body often brings it .m or intensifies it. It shifts 'from place to i)lace, and is of a darting charaetcr. Severe darting pain frequently attacks other parts. In the abdomen it is often situated in the epigastric and umbilical regions or is acvompanicl by nbstiimtc vomiting, and in the chest it is attended by .iiifwully in breathing. In a recent sporadic case in a boy aged thirteen years, already r.'l'.'rn.l f:.. ih.' atlaek began with intense pain. The chihl, who was out playing ball, endently of that in the muscles which is produced by this action. The introduction of the thermometer into the rectum sometimes evokes an outcry. Hypersesthesia is one of the early syuiptoms, apjiearing by the second or third day. It is often associated with great sensitiveness to light, sound, and odors. Partial aneesthesia sometimes occurs, but is not frequent. Vertigo is often j>resent, and may develop early with the headache. It may be one of the prodromes, and be so severe that walking is nearly impos- sible, and patients may fall and be unjjble to rise. It is sometimes present even when the patient is reclining. The mental state vari^. Many patients seem simply apathetic. Restless- ness is of common occurrence except in mild cases or in those in coma. The severity of the pain causes constant tossing, so that the patient may move all over the bed. Sleeplessness, too, is often present, and is sometimes one of the prodromes. But little genuine sleep is obtained, although a drowsiness which borders on coma is common. Delirium is a very frequent symptom, and exhibits the greatest variety both in degree and in kind. One form may rap- idly change into another. Though sometimes one of the earliest symptoms, it nsually does not develop until the second or the third day. Not infrequently it is so violent that restraint is demanded. It may also show itself as a simple delusion, or it may resemble intoxication or hysteria. It is seldom continuous throughout the whole attack, but is liable to alternate with lucid intervals or with somnolence. Coma eventually follows delirium in nearly all fatal cases, but usually only a short time before death. Patients may, how- ever, exhibit pronounced coma and yet recover. Of motor symptoms the most characteristic, and one rarely absent, is con- traction of the muscles of the nucha, causing retraction of the head. It may appear by the close of the first day, but far more often not until the end of the second day. When once developed it may be persistent, lasting even into convalescence. It varies in intensity from a slight stiifness to a retraction so great that swallowing is difficult. Hart reports a case in which a slough in the tissues of the back was ]iroduced by the occn'put jiressing between the scapulae. In a large number of cases there also exists a tonic contraction of DESCRIPTIOX OF jyDIVIDlAL SYMr'nUfS. 173 the erector spinse imiseles, producing gnulations from mere stiifness to com- plete opisthotonos, though the hitter is unusual. It renders the raising of the patient in bed both difficult and painful. The stiti'ness lasts several weeks, even sometimes well into convalescence. Rarely the muscles upon only one side of the spine have Uecn contracted. Less common than the spasm of the muscles of the neck and back, though still quite frequent, is that of those of the abdomen and extremities. The thighs are flexed upon the abdomen, the legs uj)on the thighs, and tlu- fore- arms upon the arms. Both active and ])assive movements are painful and dif- ficult of execution. Trismus is occasit)nally seen, and is a most unfavorable symptom. Clonic spasm of the muscles is less freciucnt than the tonic contraction. It is oftenest seen in voiuig children. It mav varv in dee-ree from twitchinu: of certain muscles to general epileptiform convulsions. In children general eon- vulsi(ins sometimes take the place of the chill in ushering in the disease, but thev may exceptionally constitute the first symptom in adults as well. Vio- lent convulsions may occur repeatedly during several days, or even throughout the disease, and yet the case may recover. Or, again, they do not occiu- until late in the disease, and are then, as a rule, accompanied Ity a decided increase in the severity of all the symptoms. Clonic spasm may be associated with paralvsis of other muscles or may alternate with tonic contraction. Chorei- form movements have been sometimes observed. Paralysis is one of the less common symptoms. It has been noticed even among the initial synqitoms, but this is very rare, and it is generally one of the later ones. It affects most often associated groups of muscles, as those of deglutition or articulation, or of some one of the limbs, or it may develop in the region supplied by some one of the cranial nerves. Hcmijilegia and even general |»aralysis have been reported, but are rare. Recovery from paralysis usually takes place as con- valescence advances, but the condition may be more or or less iiermanent. Of the special senses, that of smell is not often affected, as far as can be deter- mined. Patients are sometimes sensitive to odors, and J. L. Smith reports an instance in which the sense was tnitirely lost in one nostril. Taste appears to be no more affected than would naturally result from the inllueiice of the fi'brile state upon the tongue and mouth. The eye is often involved. Intol- erance to light is a very frequent symptom. The condition of the |»u|>ds varies greatly. Tliev may be normal or dilated or contracted cither early or late, or one may be dilatcd'and the other contracted. Dilation is perhaps more com- mon than contraction. They very usually «lo not react well to light. Stra- bismus, generally convergent, is frequent, and may develop at any time, an. 1 last from hours to weeks or even be permanent, or mav occur s<-veral tunes during the attack. Nystagmus is inicomnion. 1 nllanitnatory hvpcra'mia of the conjunctivfe often occurs ;n id may pass into intense conjiniclivitis with great tumefaction of th<. liyrexial. Wundcr- lich has recorded it in one instance as 107.5° F., and as still somewhat higher .shortly after the death of the patient. The curve exhibits variations which are great, sudden, and raj)id. It fluctuates remarkably from day to day, and even from hour to hour, and there is no regularity in the difl'erences between morning and evening temperature. Sometimes accessions of pain are accom- panied by increase of fever. In the intermittent form, as already stated, there occur dailv or every second day exacerbations of fever with alternating periods of apyrexia, but without the regularity characteristic of malarial infection. The variations are apt to be so marked in all forms of this disease that when it does not too greatly annoy the patient it is well to take both the axillary and the rectal temperature. The pulse is likewise very variable. It is generally full and strong at first, but becomes feeble and small in states of general depression. It may occa- sionally be abnormally slow at the outset, but soon increases in fVc(iuency, in fatal cases becoming too rapid to permit of being counted. Its rate is not at all in proportion to the elevation of temperature, and it is nearly always rapid in children. The pulse may change from slow to fast, and vice vcr,sd, even within a few minutes, this varial)ility forming a very constant and characteris- tic symptom of the affection. Not infrequently the pulse is irregular. Palpitation of the heart is sometimes a very annoying featuie. Blood taken from patients by venesection usually shows an increase in tiie amount of fibrin— an observation which is explained by the lixt that it is only in cases of infiammatory type that any one would thiid< nf bhrding. ' in cases of grave, infectious type the blood becomes (piickly daik and dilliucnt. Respiration mav be unaffected, but in severe cases is liable t<. Uvmuw sigh- ing, labored, intermittent, or slow. In fatal .ms.s it may assume the ( 'hcyuc- Stokes tvpe. Vom'iting, the most prominent of t lie .iigeslive disturbances, is lu reality dependent purely upon nervous influences. It is an initial symptom verv c.m- stantlv present. It may last a few liours to one or two days, and the,, ,lisap- 176 ■ CEREBROSPINAL FEVER. pear, perhaps to recur later in the course of the attack. It is often accom- panied by vertigo, and usually by faintness. Sometimes it is a troublesome symptom throughout the whole sickness, and may become a most dangerous one, on account of the exhaustion Avhich ensues from lack of sufficient nour- ishment. Appetite may persist in full force in spite of the vomiting, but in other cases is lost. Taste is im])aired. The tongue may be but slightly coated, and continue moist throughout the disease, even though there may be decided hebetude and delirium. This has seemed to me to be in part due to the fact that the mouth is less apt to be kept open than in typhus or typhoid fever. In cases which run into the ty])hoid state the tongue becomes brown and dry, and sordes form freely. The throat is sometimes inflamed. A])hthous sto- matitis has been reported. Thirst is generally very great. Inflammation of the parotid gland has been occasionally met with. Jaundice has been seen in a few instances. The abdomen may be as strongly retracted as in tubercular meningitis. I have frequently seen this continue for weeks during the whole duration of prolonged cases, occasionally becoming so extreme toward the close of those fatal cases which run a very long course with great marasmus that the spinal column and the various abdominal organs might be felt with extra- ordinary distinctness through the wasted abdominal walls. On the other hand, in cases of the ty])hoid tyjie distension of the abdomen, partly, at least, of paretic nature, with uncontrollable looseness of the bowels, may develop. Con- stipation rather than diarrhoea is, however, the rule in cerebro-spinal fever. The secretion of urine is sometimes greatly increased, even when the tem- perature is high. The amount passed is, in fact, oftener increased than nor- mal, but is sometimes diminished. Albumin or sugar has been occasionally observed, and casts and blood are more rarely found. Retention of urine may occur in coma and necessitate catheterization. On the other hand, there may be incontinence. The spleen is generally not sufficiently enlarged to produce an increase of percussion dulness. Complications and Sequelae. — The complications have already been out- lined to some extent in the description given of the symptoms. Certain others in addition to these may be passed in review. Broncho-pneumonia, croujious pneumonia, pleurisy, atelectasis, bronchitis, endocarditis, and pericarditis are not uncommon. The frequent combination of croupous pneumonia with men- ingitis often renders it doubtful which is to be considered the primary disease in any individual case. It is certain, at least, that pneumonia frequently develops during the prevalence of epidemics of cerebro-s]>inal fever, and that the two affections are often closelv associated. Various other infectious dis- eases, as malaria, measles, typhoid fever, scarlatina, and cholera, have occurred in connection with cerebro-spinal fever. Intestinal catarrh is also seen, and parenchymatous changes of the liver and kidneys are occasional complications. Of the sequelse, permanent blindness and deafness are among the most important. Cer(>bro-spinal fever has been a very frequent cause of deaf- mutism, and careful inquiry will elicit the fact that a considerable pro- portion of all cases in institutions for the deaf and dumb are traceable RELAPSE AyD EECURREXCE.— DIAGNOSIS. 177 to meningitis. The deafness is probably ottenest tlue to an intiamniatoiy involvement of the labyrinth. Aphasia and imperfect artienlation may, like the deafness, be prodnced by the disease. Headache is often the most tronble- some seqnel, persisting for months or even years. Mental feebleness is often observed. Ziemssen regards chronic hydro(.'cphalns as a seqnel by no means rare. The symptoms of this condition consist of " paroxysms of severe head- ache, pains in the neck and extremities, with vomiting, loss of conscionsness, convulsions, and involuntary discharges of faeces and urine." He regards the prognosis of this condition as nearly alwavs hopeless. Paralyses of single extremities or of the parts supplied by the cranial nerves are not very uncommon. They depend on lesions of the brain or cord or of the nerves themselves. ]Most of the cases recover after a few months ; which suggests that they have been due to lesions of the nerve- trunks, and is confirmatory of the view that perineuritis and neuritis are of common occurrence in this disease. Relapse and Recurrence. — Relapses are common. They sometimes occur so frequently, and prolong the case to such an extent, that a " chronic form " of cerebro-spinal fever has been made a distinct type by some writers. I have, however, already expressed the opinion that more frequently the jirotracted course of the case is due to a persistent or progressive lesion, such as chronic meningitis, chronic hydrocephalus, or even abscess of the brain. The occur- rence of the disease does not afford a complete immunity from a recurrence of a second attack. Miner found several instances of a second attack of the aifection in which the patients had suffered from it the year previous. Diagnosis. — Ordinarily the diagnosis of cerebro-spinal fever is a matter of no great difficulty. Sometimes, however, it is alm(jst impossible in the early stage, as Avhen the disease occurs sporadically or at the beginning of an epidemic. In young children also, or when in combination with other dis- ea.ses, the aifection may be very difficult to recognize. The most characteristic features are the sudden onset and rapid advance; prostration; intense pain in the head, neck, back, and limbs; vomiting; faint- ness; vertigo; tonic contraction of the muscles of the neck, and, later, of the back; clonic local or general convulsive movements ; hyperiesthesia ; delirium alternating with somnolence; very irregular pulse and temperature; and the cutaneous eruptions. The diagnosis of mild sporadic cases is rendered addi- tionally difficult by the fact that in these the crnption, the liypera\>^thcsia,. pain in the back and extremities, and stilfncss of the spine may be mostly wanting, while the pain and spasm at the back ol" the neck may not be as well marked as in the epidemic form. Several affections are likely to be confounded with cerebro-spinal fever. Tubercular menivi/ifis very closely resembles il il" tlie case is seen att<'r ihc development of partial or com|)lete unconsciousness, with stilfness of tlie iieek, cerebral erv, irregular fever and piil-e. Uiil If tlieiv Iims Ikcii an opportunity to observe the case from the start, it will be readily reeogni/.ed as one of tuber- cular nature by the longer prodromes and m(»re gradual (»nset, with lieadaelie, Vol.. I.— 12 178 CEREBROSPINAL FEVER. vomitin"-, and constipation ; the characteristic stages of alteration of the pnlse ; the earlier appearance of retraction of the abdomen ; the less degree of retrac- tion of the head, of hypersesthesia, and of pains in the extremities ; the rarity of petechial or herpetic eruptions ; the greater frequency of Cheyne-Stokes respiration ; the detection of choroidal tubercles by the aid of the ophthal- moscope ; and the longer course and invariably fatal ending. The cerebral form of typhoid fever may occasionally simulate cerebro-spinal fever very closely. Cases of it may exhibit high fever, headache, delirium, stiffness of the neck, tremor, and spasm of the muscles. Ordinarily, however, typhoid fever differs widely in the slow onset, absence of vomiting and of inuscular spasm, and presence of continuous hebetude, typical temperature curve, characteristic cutaneous eruption, epistaxis, abdominal tenderness with diarrhtiea, and greater enlargement of the spleen. Typhus fever has been repeatedly confounded with cerebro-spinal fever, and it is true that in certain epidemics cases present themselves which are difficult to discriminate. This is, of course, pre-eminently the case when outl)reaks of the latter occur in localities or under conditions which render the occurrence of typhus plausible or where it already exists. Between cases of the cerebro- spinal type of typhus fever and of cerebro-spinal fever the points of resem- blance are the sudden onset with rapid development of delirium and stupor, the extreme hypersesthesia and muscular soreness, the headache, rigidity of the cer- vical muscles and occasional retraction of the head, and the occurrence of a petechial eruption. On the other hand, typhus fever is a highly contagious disease, which does not occur sporadically in this country nor in epidemic form unless in seaports, where it occasionally spreads from imported cases. High initial fever is almost constant in typhus, and the temperature curve is charac- teristic ; the facies is distinct ; the eruption is constant, and appears about the fourth day as a roseolous rash, becoming gradually petechial instead of occur- ring as it does, when present in cerebro-spinal fever, almost at the very onset of the attack; herpes does not occur in typhus; vomiting is rare; convul- sions are much less frequently seen ; there is much less pain, and muscular rigidity is less marked. Influenza may not seem likely to be confounded with cerebro-spinal fever, yet there are points of striking analogy which demand attention. These two affections are distinguished from other infectious diseases by their remarkable pandemic character. In the various epidemics of influenza the utmost variety in its manifestations has been exhibited. Although catarrhal irritation of the mucous membranes, with fever of irregular type, is the usual expression, there is a proportion of cases, varying in different epidemics, where the force of the disease falls on the nervous centres, and cerebro-spinal meningitis is developed with severe pains of perineuritis, muscular soreness, rigidity of the cervical muscles, and retraction of the head, convulsions, delirium, and stupor. Death is frequent in these cases, but when they recover lesions of the organs of special sense, of the peripheral nerves, or of the nervous centres may remain. It is well known now that even in ordinary cases of influenza peri- DURATION, MORTALITY, PROGNOSIS. 179 neuritis is of frequent occurrence. During the. recent severe epidemic many cases of meningitis, as above sketched, have occurred. It is altogether prob- able that in some instances these were sporadic cases of cerebro-spinal fever, but it is also clear that there was a sudden development of meningitis in other cases which were unmistakably influenza. Eheumatic fever, with little or no joint iuvolvement, but with muscular soreness and rigidity, retraction of the head or trismus, aud with marked cerebro-spinal symptoms, either connected with hyperpyrexia or with actual meningeal irritation, may occasionally closely simulate cerebro-spinal fever. It undoubtedly ha})pens that at times cerebro-spiual rheumatism is regarded as cerebro-spinal fever, and the reverse. Pernicious malarial fever may resemble malignant cerebro-spinal fever in the rapid development of collapse and coma. It can be distinguished from it by the consideration of the etiological circumstances and by the fact that the first malarial paroxysm rarely exhibits the malignant character. Tiie detection of the malarial organism in the blood, the greater enlargement of the spleen, and the specific effect of quinine properly administered will establish the diagnosis. Malignant scarlet fever may occasionally resemble cerebro-spinal fever in the sudden onset with high temperature, vomiting, convulsions, and stupor. Its presence, however, may be suspected from the early redness of the fauces. The appearance of the scarlatinal rash settles the ditliculty unless death takes place before this occurs. Small-pox may also be mistaken for it, the resemblance being in the severe pain in the back and head, in the vomiting, and in the development of a pur})uric rash in some cases. The papular character of the eruption and the general course of the disease aid in distinguishing it. During epidemics of cerebro-spinal fever occasional cases are noted where death occurs in a few hours, when there has been little or no rise of tempera- ture, but such extensive appearance of petechite and ecchymoses as to raise the question of the fulgurant type of purpura. Meningitis secondanj to croupous pneumonia and other acute diseases is with difficulty distinguished from cerebro-spinal fever. In the cerebral form of pneumonia, whether a true meningitis or a jiseudo-meningitis be present, there are often considerable tremor and muscular spasm, but tlie stilfness of the nuiscles of the neck and back and the hyperesthesia are not so marked. In some cases, however, it may be very difficult to determine whether wc have to do with pneumonia complicated by meningitis or with (vrcbro-spinal fever complicated by pneumonia. Mild cases of cerebro-spinal fever have sometimes hrvu mistaken for hi/s- teria, but the severe pain, the muscular rigidity, and the occurrence of fever should prevent the mistake. Duration, Mortality, Prognosis.— The <-ourse of tlie diseas." is v.>ry variable. Jn the mikler forms and in tlie ,„ost malignant variety tl..' duration varies from a few hours to five days. The moderately severe 180 CEREBROSPINAL FEVER. cases begin to recover after one or two weeks, but may be prolonged fur months. Convalescence is comparatively slow and subject to many inter- ruptions from complications and sequelse. The first week of the disease is usually the time of greatest danger, and patients who live until the close of the second week will probably recover. At the same time, the prognosis in any individual case is a matter of the greatest uncertainty, both as regards life itself and as regards the persistence of permanent danger of some part. In moderately severe cases no prognosis at all can be made for some days, and even then it must be most guarded. Malignant cases nearly always die, but even to this there are exceptions. Mild and abortive cases generally recover, but here, too, a guarded prognosis must be given. Under five years and over thirty years of age the prognosis is less favorable than between these periods. In children under two years of age the rate of mortality and the danger of grave sequels reach the highest point. Symptoms generally unfavorable are abrupt and violent onset, evidences of great excitement, hyperpyrexia, coma, convulsions, great prostration of strength early in the affection, irregular respiration, unusually intense head- ache, persistent vomiting, evidences of extensive disorganization of the blood. The occurrence of complications, especially those connected with the lungs, increases the gravity of the prognosis. The mortality of cerebro-spinal fever is very great, varying much in differ- ent epidemics. Ziemssen places it at 30 per cent, for mild epidemics and over 70 per cent, for the most severe ones, the general mortality averaging 40 per cent. Treatment. — Prophylaxis. — Little can be done in the line of prophylaxis, inasmuch as we know so little regarding the cause of the affection. The avoid- ance of unsanitary conditions in streets and houses is of course an important matter. It is also advisable that the inmates pf a house in which the disease has broken out should leave it until after the epidemic is over, since there sometimes seems to be a tendency for the affection to spread in families. Linen used about the patient should be disinfected or destroyed. As in the case of other serious infectious disease, it is important during an epidemic of cerebro-spinal fever to avoid fatigue of any sort, to lead as quiet a life as pos- sible, and to preserve the general health in the best possible condition. Indeed, it is to be recommended that persons in poor health leave the locality while the epidemic lasts. Treabaent of the Attack. — The great variety of type in different epidemics and in different cases in the same epidemic, and the highly complex grouj) of symptoms presented, explain the impossibility of formulating any uniform plan of treatment. It is necessary in each individual case to adapt our rem- edies to the grade and to the special localization of the morbid process. The room should be kept dark and quiet. The diet should consist of easily assimilable liquid substances, given freely and often, since the disease is one in which exhaustion so readily supervenes, and in which there is rarely any lesion of the gastro-intestinal tract. As soon as the fever has abated solid TREA TMEXT. 1 8 1 food should be administered. Watei' is to be ffiven freelv at all times. In many cases the obstinate cerebral vomiting interferes with the administration of food at first, and in such nutrient enemata may be employed. It is often difficult to secure the ingestion of enough food, but I have never found it necessary to resort to forced feeding by means of a stomach-tube. Even when prostration is apj^arently not great, the patient should not assume the erect position in bed, as dangerous syncope may follow. Until convalescence is complete all exertion and excitement nuist be shunned, and a return to the ordinary methods of life is well deferred for some time. A'enesection was early advocated, and the sym])toms of acute, intense cere- bro-spinal irritation often suggest it forcibly. It must be remembered that when fever is high the blood becomes rai)idly disintegrated, and such pro- found debility soon develops as to render depletion dangerous. In young chil- dren, also, it is nearly always inadmissible, and even local bleeding has been followed by alarming depressi(m. On the other hand, in the onset of cases of sthenic type, where the pyrexia was moderate and the pain and cerebro-sjiinal irritation were extreme, I have bled healthy adults with great advantage, liiid- ing the blood highly coagulable. The prompt relief afforded to the pain and central congestions has been followed by improvement in the force and volume of the pulse. In carefully selected cases I would therefore advise moderate venesection soon after the onset. AVhen the propriety of this is doubtful, as in delicate or voung persons, when the fever is high, or when the first day or two has passed, wet cups or leeches, or even dry cups alone, may be applied to the temples, the mastoid regions, the nape of the neck, or along the spinal colunni. Cold to the head and spine is a valuable therapeutic measure. It should be applied for hours continuously in the form of ice-bags or in Leiter's tubes. Cold aifusions or cold sponging may be substituted sometimes. Cold is par- ticularly useful in the early stages when pain in the head is at its worst. It often decidedly relieves the suffering and ])roduces quiet sleej). Tiie applica- tion should be renewed as often as pain returns. Cold baths to reduce tem- perature may be given systematically if the fever be high. As, however, the temperature is rarely either high or ai)parently ]u-ov(i<':itive of dangerous symptoms, this measure is not often indicated. Moist or drv heat locally applied is of value botli in mitigating violent symptoms and in anticipating or removing the colla])se which is so apt to come on in this disease. Hot mustard foot-l)aths, hot bottles, bricks, or sand- bags, hot moist flannels and the like are all useful ior this purjx.se. It is well to apply heat to the rest of the body wliile cold is being used about the head and spine. In this way any depressing effect of the cold is prevented. Blisters have long been employed to reliev*' pniii :ind to lessen congestion. It is true that sometimes they seem to 1 it was common to have patients come to physicians' offices or to And |)atients walking abont their houses with a temperature of from 102i° to 104°. A widespread fcl)rile tendency exhibited itself; the most trivial ailments were attended with high fever; the entire poj)ulation seemed to be infected. 'IMiere was danger of a sudden development of grave or rapidly fatal com|)lieati(.iis even in the mildest cases if exertion and ex])osnre were <'ontiniie and White have suggested that in some cases the Ijronchial glands may be acutely enlarged, and the nervous tract about the root of the lung may !•(• involved. Children and aged and infirm sid>jects are especially liable to this com|.licatioii of pneu- monia. The readiness with which violent pnciniiunia may be induced by slight exposure, even in mild cases of inlliicn/a in viirun.iis adults, was remarkably shown dmiii- the l;i(e epidemic. A single instance will illustrate what was of freqiicnt occurrence, though usually with less violence: A yoiing 1 90 INFL UENZA . man of thirtv years returned from a hunting-trip in fine physical condition to his home, where members of his family had influenza. He promptly con- tracted the disease in so mild a form that he did not consult a physician nor even remain in his chamber. By the fourth day he felt so much better that he insisted on walking about two hundred yards in the raw evening air. Within one hour he was taken with severe chill ; the temperature was 105° F. bv the time he was conveyed home ; he vomited blood ; pneumonia began in the left lower lobe, involved the entire left lung, then spread to the base of the right lung, was complicated with nephritis, jaundice, and delirium ; and the autopsy showed that finally there was but a small area at the right apex which was not consolidated. I secured statistics of 35,413 cases of influenza occurring in the practice of 272 physicians in Philadelphia : pneumonia occurred in 1485, or about 4 per cent., with a mortality of 173, or 11.65 per cent. Dr. Latta, chief medical exauiiner of the Pennsylvania R. R. Voluntary Relief Department, kindly gave me the statistics of influenza as affecting its members, who may be regarded as a carefully selected body of men. In 1890 and 1891 there were 6680 cases of influenza, showing that over 14 per cent, of the entire member- ship were so severely affected with influenza as to confine them to the house ; pneumonia occurred in 138 cases, or in 2 per cent., with a mortality of 29, or 20 per cent. The accompanying chart (Fig. 12) exhibits the extraordinary prevalence and fatality of pneumonia during this epidemic. Undoubtedly in very many cases of death reported as from pneumonia the disease was grippal in nature. Many cases of pneumonia presented an extraordinary feebleness of respira- tory murmur, both before and after the appearance of consolidation. Typhoid delirium and a tendency to heart failure were common. Intense abdominal engorgement with jaundice, and slight intestinal haemorrhage, were not rare. Both hings were often involved and the mortality was high. Alison of Bac- carat describes a focus of contagion which gave rise to eight cases of pneu- monia in closely related families, and in every case a fatal result followed. Plastic pleurisy is almost universally associated, and empyema may occur, as may also purulent pericarditis, either with or without pneumonia. Abscess and gangrene of the lungs are rare sequels. Pulmonary phthisis must be noted among the sequels also, and when influenza attacks those already affected with plithisis, the mortality is high and the course of the organic disease is greatly hastened in those who survive. The same statement must be made, in identical terms, in regard to Bright's disease. The occurrence of severe gastro-intestinal catarrh as a complication, with vomiting and purging, has already been mentioned, together with the much, more rare haemorrhage from the stomach or bowel. After the subsidence of tiie acute symptoms a chronic gastro-intestinal catarrh is apt to persist, with grave impairment of nutrition, and to prove rebellious to treatment. Cerebro-spinal meningitis undoubtedly occurs as an occasional complication. In some instances the onset is indistinguishable from cerebro-spinal fever save a- a- o 5" a c 3 s TO c B o a ■5* 00 CO Hi 3 C c «> B ts) P & 3S-8881 tJiuoiuiiDaj; "- • 1 11/. 11 1^ 11 yiu UO"U«Sl »:1>.I*JIUUJU^ 1= '•n ^ 2 ; ft- •* k" ^ =■ ^ ■" ^ 5 ? a- ; Ok -5 55 5? ft 1 g ? 3. r 1 1 1 1 5 > a- — S— \ %' \ I f -ni- \ /'i T 1 1 s- y 1 1 ^ K s.^ f s/- \ \ y V T / \ ^ / -Off- nf 1 \ ■\ 7 ■\ ^•^ ■i .1 K / \ / A -\ / / r \ \ \ '' '\ \ • f 1/ r -ss- \ J \ > \ 1 ji " it' nc ; J \ \ 1 K' I \ T "^ 1 CO- • -CO- -nft- ■001- 501- OLL^ 00/ SOi- oa- s// o?x- set- 0*-* nci- 911- ozi- ■ osi- ■9Sl- Ot'l- 9PL- - ■091- 5SJ- 991- 091 S9i SZ/- 091- ■901- Oll- 081- u 1 > s a = » » >■ S '3 » 'i ■n la •< o > o *< o > o > e T a. o a 5 ir O i 1 u 5 s I'Jl 192 INFL UENZA . by the absence of petechial eruption ; and it is important to bear in mind that not a few epidemics of influenza have been regarded as of that nature by ex- perienced observers. The cases either run an acute course with intense head- ache, delirium, stupor, general convulsions, extreme retraction of the head, and terminate fatally, or the symptoms are less violent and the case goes on to gradual recovery or to the development of all the symptoms of exudation with fatal pressure. Several cases of abscess of the brain were reported in the late epidemic by Bristowe, and one case occurred in the P. R. R. series. Persistent headache, insomnia, and neuralgia are common sequels. Otitis media was reported in a number of cases, and affection of the optic nerve like- wise. Melancholia, impairment of mental power, and even mania are among the sequels. In no less than 18 cases in the P. R. R. series did it become necessary to confine the patients to insane asylums: 5 of these cases have proved fatal. The dejection of spirits which often attends convalescence is remarkable, and has not failed to attract attention in many epidemics. Perineuritis is one of the most frequent complications and sequels. Much of the suffering in the disease may be referred to this cause. The nerves of special sense may be involved, and it is not impossible that implication of branches of the pneumogastric may explain some of the grave pulmonary and gastric conditions which arise. Persistent peripheral neuritis, muscular atrophy, and partial palsies have been exceptionally frequent since the last widespread outbreak of influenza. Enlargement of the lymph-glands, and especially those of the cervical chains, is not infrequent in some epidemics as a sequel. It may prove per- sistent and troublesome, and occasionally ends in suppuration. As already stated, an attack of influenza affords but little protection against subsequent attacks. Several well-marked attacks have been suffered by many individuals during the past two years. Relapses also are not infrequent. In the 6680 cases of the P. R. R. series they occurred in 762 instances, or in over 11 per cent. Diagnosis. — During an epidemic of influenza the entire mortality of the community is greatly increased. At the height of the recent epidemic the num- ber of deaths in many cities was quite double that of the corresponding period of i)receding years. In Philadelphia the total mortality for the month of Jan- uary, 1889, was 1862, and for December, 1889, was 1488; in January, 1890, the epidemic of influenza Avas at its height, and the mortality rose at a bound to 3044, of which number only 116 were reported as influenza. It is evident that this sudden increase in the number of deaths is due in large part to the serious mortality of influenza itself when complicated, as with bronchitis or pneumonia. But, in addition, many chronic affections, such as Bright's dis- ease, phthisis, heart disease, are awakened to rapidly fatal activity by tiie influence of the grippal poison. While, therefore, there is a tendency dur- ing the prevalence of all e])idemic diseases to err in regarding almost every case of illness as belonging to the prevailing malady, it is doubtful whether. PROGXOSIS; MORTALITY. 193 in severe outbreaks of influenza, the extraordinary ditTiision of the infection is even suflKciently appreciated. On the other hand, it is no less true that sporadic cases of influenza are liable to have their true nature overlooked, and to be regarded as idiopathic catarrhal fever or to be confounded with other infectious diseases. Not until the bacterioloo;ical diagnosis of influenza conies to be widely practisetl will the protean manifestations of this disease be fully determined. Cases of the ordinary thoracic type should be readily recognized by the sudden onset, the absence of the usual causes of bronchitis, the ciiaracter of the cough, the pains in the head, back, and limbs, the prostration and sense of ill- ness out of seeming proportion with the degree of fever or the physical signs of pulmonary trouble. The gastro-intestinal type is more apt to be mistaken either for acute catar- rhal gastritis, for simple continued fever, or even for typhoid fever. The absence of the usual causes, the greater degree of prostration, and the charac- teristic pains distinguish it from the first, while typhoid fever is known by the more slow onset and gradual development, by the greater enlargement <»f the spleen, the appearence of the stools, and the characteristic eruption, although in influenza abdominal distension, diarrha?a, epistaxis, bronchial catarrh, fever, headache, and delirium may occur. During an epidemic of influenza many cases which are regarded as ephemeral or simple continued fever are doubtless grip])al in nature. Cases complicated with the early development of pneumonia are peculiarly liable to have their true character overlooked. Allusion has been made in the article on Cerebro-spinal Fever to the resemblance between that disease and the cerebro-spinal type of influenza. It appears that from the earliest period these two diseases have often jirevaikxi coincidently or in close sequence. When the meningitic symptoms ensue in a case which has begun as of the catarrhal type, there is less danger of over- looking their grippal nature. But when, as happens with considerable fre- quencv during certain epidemics, patients are seized with intense pain in the head, back, and limbs, slight fever, rapidl}* developing delirium and stupor, muscular rigidity, and possibly retraction of the head, or even general convul- sions, herpetic and possibly petechial eru|)ti<)n, and when at the autopsy the lesions of cerebro-spinal meningitis are discovered, it is evident that careful bacteriolotive of special symptoms. The name dengue, equivalent to "coquettish " in Spanish, seems to have been given on account of the stiff, affected gait of those recover- ing from the disease. Etiolog-y. — Dengue is essentially a disease of warm latitudes. It was first recognized in 1779 in Java by David Brylon, who called it articular fever. The earliest accurate accounts are of epidemics in India in 1824 and later. According to Matas, the conclusion of epidemiologists is that it was originally an Asiatic tropical infection, starting perhaps in India. It is known to prevail sporadically there, and also in Africa, and ])rol)ably also in our Gulf States. Of European countries Spain alone has suffered. Frequent epidemics have occurred in South American countries, in the West Indies, and in the Southern United States. Rare outbreaks have been noted in Philadeljihia, New York, and even in Boston. The usual limits of its epidemics are 32° N. and 22° S. lat. The summer seasons appear to favor its occurrence. Neither race, age, sex, nor social condition exerts any influence. There can be little doubt as to its contagiousness. Its epidemics spread with extreme rapidity along the routes of travel. It is probable the poison may be carried by fomites. McLaughlin of Texas has found in the blood of patients with dengue a micrococcus which he believes to be characteristic of (he disease, but Osier holds it to be still sub jiuJicc. The susceptibility to the infection of dengue is almost uuivcr<:il. In the great Texas epidemic of 1885, McLaughlin estimates that in the city of Austin alone, out of a population of 22,000, no less than 10,000 j)ersons were attacked in the course of a few months. The occurrence of an analogous disease among domestic animals simultaneously with (he prevalence of dengue has been noted several times. The frequency with which relapses and recurrent attacks occur wouM swni 187 198 DENGUE. to diiFer in different epidemics ; but on the whole they are much more frequent than in most infectious diseases. In some epidemics relapses have occurred as often as in 15 per cent, of all cases. It has even been claimed by a few that an attack of the disease predisposes to a subsequent attack. Morbid Anatomy. — There are no lesions known to pertain to the disease itself. Death scarcely ever occurs, except from complications, and even then is of extreme rarity. Symptomatology. — The onset of dengue is usually abrupt, after a period of incubation of about four days' duration, and without prodromes. There is a chill, which in young children may be replaced by a convulsion. The tem- perature rises quite rapidly, and at the close of the first or second day usually reaches its height, from 102° to 106° F., according to the severity of the attack. Intense headache, backache, and pain in the joints ensue quickly. The muscles also are painful and sore. There is a sense of extreme depression and prostration. Delirium and hebetude are slight, if at all present, and the patients are usually keenly conscious of their intolerable sufferings. The pulse and respiration are rapid. The tongue is moist and yellow-coated ; appetite is lost ; nausea is moderate ; the bowels are quiet. The urine is febrile, but scarcely ever albuminous. A transitory erythematous rash appears in a varying proportion of cases in different epidemics. The joints are often painful, stiffened, and even red and swollen. In some cases the symptoms assume a marked gastro-intestinal type and severe vomiting and purging occur. More rarely cerebral symptoms may be prominent, and increasing stupor and evidences of meningitis ensue. Doubt- less these nervous symptoms are often due to hyperpyrexia : Holliday reports a fatal case in which the temperature rose to 109|° F. Epistaxis may occur, and so may haemorrhage from the stomach or bowels. The primary febrile paroxysm lasts from three to five days, and is termi- nated by a critical fall with sweating or diarrhoea. The temperature may become subnormal and the pulse abnormally sIoav, but more commonly it is only a remission. The symptoms are greatly relieved, but the patient still feels stiff' and Aveak. At this time or with the return of fever, which occurs after an interval of two or three days, a second eruption appears, with vary- ing frequency in different epidemics. It is not characteristic, but may resem- ble urticaria, herpes, lichen, or erythema. The second paroxysm of fever is usually mild and short. The pains, restlessness, and anorexia return. Defer- vescence occurs again after two or three days, and subnormal temperature and pulse are noted not rarely. The eruptions fade rapidly, and desquamation commonly follows. The entire duration of an ordinary case is from seven to nine days. Con- valescence may be prompt, but is apt to be slow and protracted, and to be attended with a singular degree of mental depression and loss of energy or actual debility. As already stated, the disease terminates habitually in recovery in spite of the painful or alarming symptoms. COMPLICA TIOXS A ND SEQ UEL.E.— TREA TMEST. 1 1»9 Complications and Sequelae. — The oc-easional occurrence of severe nervous syniptoms has been mentioned. The character and favorable coui*se of these indicate their dependence on the high fever as a rule. Any lesion, such as meningitis, which is mentioned by some observer's, must be extremely rare. Insomnia may persist for some time after the disease, but more com- monly the only nervous sequels are neuralgic pains and markeil prostration and depression of spirits, Avhich may last for weeks, especially among the weak and infirm. Rush states in his report of an epidemic of dengue in Philadelphia in 1780 that a young lady remarked it might be called brearts of the body is not rare, and may prove obstinate : in some epidemics crops of furuncles and superficial abscesses have been noted. Diag-nosis. — Sporadic cases of dengue may readily be mistaken for mild rheumatic fever, but the presence of eruptions, the absence of acid sweats, the peculiar course of the fever, and the absence of cardiac complication serve to distinguish it. The disease to which it presents most resemblance, both in its sporadic and epidemic forms, would seem to be influenza. The accounts of some epidemics of dengue leave doubt as to whether they may not have been outbreaks of mild influenza in a warm latitude. The diseases rescrnl)lc each other in the rapidity of development in great communities and over large areas ; in the large proportion of the population afl'ectcd ; in the frequency of relapses and the liability to successive attacks; in the disproportion between the apparent gravity of the symptoms and the very small mortality of the uncomplicated disease ; in the sudden onset, the peculiar severity and charac- ter of the pains, the great mental and bodily prostration. But in influenza the only eruption frequently present is herpes; there is no afl'cction of the joints (although :Matas states that in dengue also true evidences of arthritis, such as redness and swelling, are exceptional); the remission and recurrence in the course of the fever are not present ; there is a far greater liability to seri- ous complications ; and the disease is wholly indei>endcnt of geographical re- strictions. Bacteriological research must, however, complete the separation of the two diseases. When yellow fever and dengue prevail simultaneously, care is recjuired to avoid confounding the latter with mild and imi)er('(rt cases of the more grave malady. The initial eruption may lead dengue to be mistuken also for some one of the eruptive fevers. The prognosis is, as already stated, almost invariably favorable. In American epidemics it has been rare for even a single death to oeeiir. Mafas quotes a statement that in Madras dengue was sometimes fatal in adults from pericarditis and in children from wmvulsions, 20 deaths occurring out of .'1017 cases collected by one observer. Treatment.— The nniformlv lavorable and selC-liniited course of .l.ngue 200 DENG UE. calls for merely symptomatic treatment. Strict rest in bed should be insisted upon, and rigid attention should be paid to all details of nursing and hygiene till convalescence is established. A mild laxative may be administered at the outset. The fever may be high enough to call for small doses of phenacetin or antipyrine, which should also be very useful in allaying the peculiar arthritic and myalgic pains. Quinine or salicylate of sodium may also be used. Hydro- therapy is rarely indicated, but should be used if the pyrexia is high and accompanied with severe nervous symptoms. The bromides and codeine or morphine are often required to secure sleep and relieve suffering. Convalescence demands a continuance of careful regulation of diet and hygiene. Tonics and nutrients should be given to improve appetite and over- come the persistent debility. If myalgic or arthritic pains continue, potassium iodide or sodium salicylate will be found useful. A change of residence may be required to promote complete restoration of health. MILIARY FEVER. By WILLIAM PEPPER. Definition. — An acute, infectious, and at times epidemic disease, character- ized by a sudden onset, with i)rofuse sweating, sense of oppression in the epi- gastric region, and the appearance of a papulo-vesicular exanthem. Synonyms. — Sweating sickness ; Schweissfriesel ; Suette miliare ; Suette des Picards; Sudor anglicus. History. — In August, 1486, there broke out in the army of Henry VII., after its return from the battle of Bosworth Field, an acute, virulent, infectious, and hio-hlv dangerous malady that soon spread throuirhout Eny;land and ratred until November of the same year. In 1507 the disease again became epidemic, but was confined to England. In May, 1529, London was again attacked, but on this occasion the continent of Europe was also affected. In 1551 another epidemic occurred in England, being confined by the boundaries of that country. In 1718 a disease resembling in most of its essential features these earlier epidemics appeared in l^icardy, and from that point spread to other parts of France. Hirsch has tabulated 194 epidemics of this '* miliary fever" that occurred between the years 1718 and 1874. In various parts of Italy and Germany also small epidemics have been described. In 1887 there was quite a severe epidemic in France. Tiie disease is practically never seen now save in the north-eastern provinces of France and in a small portion of Italy. Etiology. — Regarding the auxiliary causes of the earlier epidemics of "sweating sickness" but little is known. There are, however, a few facts in relation to the later outbreaks of what has been most generally called "miliary fever" that show, at least in the majority of epidemics, some uniformity. Most of the epidemics have occurred in spring and summer; the disease usually is most prevalent in low-lying and (lam|) areas, but has been observed at higher elevations witii a porous, dry soil ; women are more subject to attack than are men, and the middle period of life liirnishes the greatest number of cases ; social condition as to habits of life inHuciice the liability to the disease to no appreciiible extent. The disease is not c(.ntagious, and is not particularly prevalent in institutions, barracks, etc., when- people are congregated in large numbers. No iinincdiatc exciting cause has ever been discovered. A curious relation between epidemics of this disease and of A^i.ili.- chdera JOl 202 MILIARY FEVER. has been noted, the diseases interchangeably following each other or the two diseases occurring at the same time. Symptomatolog-y. — After a brief prodromal period of malaise, weakness, and iieadache the patient is attacked, usually in the night, with profuse sweat- ing, fever, and a sense of oppression referred to the epigastric region. The pulse is rapid, there is elevation of temperature that is rarely excessive, and there is found to be marked tenderness over the upper portion of the abdo- men. After a period of three or four days, in some cases later, there appears a characteristic eruption, with temporary increase in all of the symptoms pre- viously observed. The exanthem consists of small reddish spots of irregular contour, but of a generally round form, varying in diameter from -^^ to y^ of an inch. The lesions are either closely aggregated or confluent. In the centre of each spot there appears, after a few hours, a small vesicle, which graduallv enlarges to the size of a millet-seed or pea. The clear contents of the vesicles soon become opaque, owing to a purulent transformation, and then after two or three days dry into crusts which are cast off as scales. While the skin is the usual site of the eruption, it may also be found upon the nasal, oral, and conjunctival mucous membrane. The first appearance of the eruption is generally upon the neck and chest ; after which it is seen upon the back and extremities. More rarely the scalp and abdomen may be the seat of the exanthem. From mild cases, wherein almost the only prominent symptom is the occur- rence of frequent and profuse sweatings, the disease varies in severity to fatal cases with most severe symptoms and intense anguish. In addition to the symptoms that have been mentioned there may be insomnia, vertigo, cephalal- gia, complete anorexia, thirst, nausea, and marked constipation. The sense of oppression at the epigastrium may in grave cases become so intense that the patient tosses from side to side, clutching at the bed-clothes in order to obtain relief; indeed, death from apnoea has been stated to occur. During the sweat- ing stage convulsions may occur, sudden and fatal collapse may end the scene abruptly, or the patient may fall into a typhoid condition. Convalescence is prolonged. Morbid Anatomy. — No characteristic lesions are found. Decomposition is said to occur rapidly, and the blood is thin and dark in color. In some cases oedema of the meninges of the brain has been found. In most cases the linigs are found to be congested and the heart soft; the pericardium the seat of ecchyraoses ; the mucous membrane of the alimentary tract congested ; the liver full of blood ; the spleen enlarged, soft, and friable. Some observers claim that they have found upon the mucous membrane of the intestine vesi- cles similar to those upon the skin. Diagnosis. — In time of e|)idemics this should present no special difficulty. The only diseases with which miliary fever would be apt to be confounded are acute rheumatic fever, measles, and malarial infection. The absence of local- ized articular pains, the peculiar sense of oppression in the epigastric region, and the appearance of the eruption distinguish it from the first of these. In PROOyOSIS.—TREA TMEXT. 203 ^ measles the prodromal catarrhal symptoms, the absence of vesiculation in the centre of the eruption, and the distribution of the latter would prevent a mis- take in diagnosis, even without the absence of profuse sweating, From inter- mittent fever this disease would be distintruished bv the absence of marked rigor, the lack of periodicity, and the failure to respond to specific antimala- rial treatment, while the discovery of Laveran's micro-organisms in the blood would positively announce the presence of malaria. Prognosis. — Different epidemics vary so much in their extent and severity, and individual cases in an epidemic present such wide variations in the intensity of their symptoms, that the outlook in each case must be judged upon its own merits. In some epidemics of considerable extent the mortality has been nil, while in others it has reached as high as 50 per cent., or even 80 per cent., of those attacked. The greatest mortality occurs during the sweating stage. Epidemics vary much in their duration, the usual time of prevalence being from one to four weeks. Treatment. — At one time attempts were made to abort or stay the severity of the disease by covering the patient Avarmly and administering diaphoretic remedies. This practice was very justly abandoned, and it would seem that the expectant plan of treatment is the best. The diet should be light, easily digestible, and nutritious. The patient should be lightly covered, and cool acidulated drinks may be permitted. Quinine in moderate doses has seemed to have some beneficial influence. Stimulants should be given in accordance with the condition of the patient; they are not required in the milder cases. After recovery tonics are needed to restore the patient to his former condition. MILK-SICKNESS By WILLIAM PEPPER. Definition. — An acute disease occun-ing in the sparsely-settled and uncul- tivated regions of the United States, primarily affecting cattle, but also attack- ing human beings as the result of eating the flesh or drinking the milk of ani- mals so affected ; characterized by great weakness, marked constipation, vom- iting, foetor of breath, and twitching of muscles. Synonyms. — Trembles ; Slows ; Puking fever ; Sick stomach. During the early settlement of various portions of the central region of the United States this disease Avas very prevalent and of great virulence. As civ- ilization advanced and the land became more highly cultivated, it gradually disappeared from regions where it formerly abounded, until at the present time it is limited to a few localities of small area in but a few of the States lying west of the Alleghany Mountains. Etiology. — Several theories have been advanced in the attempt to arrive at the cau.se of this affection, but as yet none has been found that furnishes a satisfactory explanation of its mode of production. It most commonly occurs in summer and autumn, and is more prevalent in years of drought and in hot and dry weather. The three theories that have been most strenuously advocated as explaining its causation are — (1) that the poisonous principle is furnished by some variety of rhus ; (2) that it is due to a mineral poison con- tained in the drinking-water of cattle in the area affected ; and (3) that it is produced by a miasm. Regarding the first of these theories, which is much more rational than the others, it may be said that the point has not been proven, and that the history of its propagation and transmission from animals to man and from diseased animals to healthy animals through the ingestion of the flesh or milk of the former would point toward some poison capable of increase in the animal body, rather than toward one that attained its highest development while existing in itJs natural condition as a plant. The second theory is untenable from the well-established fact that laborers who have drunk of the same water as animals that became diseased failed to be affected, although the consuming of the flesh or milk from such animals produced the disease in man. Against the third theory all that need be said is that the fencing in of limited areas of a farm may cause the total cessation of the appear- ance of the disease — a measure that would have no effect were the disease projxigated by a miasm. Symptomatology. — -The symptoms in animals occur at times with great 204 MORBID AX ATOM V. 205 abruptness ; at other times the onset of the disease is shjw. The former man- ner of attack is most frequently observed after the animal has nnderu;one, or while it is undergoing, some unusual amount of physical exertion. The chief and characteristic symptoms are — marked muscular weakness with tremor upon motion, inability to stand, at times vomiting, and a j)eculiar fcetor of the breath. The tremor may amount to a positive convulsion ; tiic inability to stand may develop so suddenly that the animal drops during or alter exertion, and lies trembling in every muscle and tossing the head from side to side. In man the disease is ushered in by chilly feelings with hot flushes, by pain in the head and limbs, with great muscular debility. With this weakness there is marked unsteadiness in performing muscular acts or even tremor of the muscles at rest. There are also developed various disorders of the digestive tract. There is marked foetor of the breath, the odor being described as cha- racteristic and being likened to various odors or combinations of odors of familiar objects, being most frequently said to resemble that of chloroform and the odor produced by mercurial salivation! The tongue is coated and marked by the teeth ; later, dry, fissured, and swollen. Vomiting is a frcfjucnt symptom, the vomited matters consisting first of the food last ingested, later of a peculiar "soapy" material of a yellowish or greenish hue, or it may con- sist of mucus stained with blood or of a material resembling coffee-grounds. With these symptoms there is associated marked tenderness in the epigastric region, with a sense of oppression. The bowels are obstinately constipated. The pulse is at first full, but later becomes small and rapid. The temperature is, as a rule, elevated somewhat, save in the cases of sudden and violent onset, when it may be subnormal. The skin of the trunk may feel hot to the touch, while the extremities are cool. Respiration is frequently much embarrassed in the severe cases. Prior to death the patient may pass into a typhoidal condition, while delirium, hiccough, and coma frequently appear. The patient may be vio- lently attacked and die within a few hours ; usually, however, the disease continues for from three to five days before either death comes or convalescence begins. The latter is usually announced by a copious cvacuntidn of the bow- els, and is apt to be very protracted. Morbid Anatomy. — P>ut few opportunities for necropsies have been afforded, but in those made the appearances fi)imd coincide closely with those noted by Graff in animals killed experimentally by the ingestion of flesh from diseased cattle. These pathological findings .arc, in brief, as follows: Cerebral sinuses much distended with blood ; marked congestion of cerebral and spinal meningeal vessels; pia mater opaciue and (•overeeing enlarged to, in many cases, twice its normal size; liver, spleen, lungs, and kidiievs fnll of I)lood ; blood fluid. The above conditions point dearly to an infcetious jjrocess. The occurrence of meningitis is of special importance, and sugg(>sts possible analogies with irregular cercbnt-spinid fears. The spleen is usually enlarged. Pulmonary complications occasionally occur. Curtin refers to four cases called mountain lever in which croupous pneumonia existed as a comjilication, if it did not constitute the entire disease. Few cases have died, and but two j)ost-mortem examinations are recorded. In both the typical lesions of typhoid fever were present, and |)er- foration of the ileum hadocciu'red in one case. There woukl seem td \)v little doubt that such is the true nature of nearly all cases of this form of inoinitain fever. It is fair to assume that the effect of the high altitude would modily somewhat the sym))toms of the disease. I( may be admitted that sometimes a malarial element is associated, and that in rare instances the alTeetion may be simply a malarial remittent fever. It is clear, therefore, that uo atle(|uate rea- son exists to longer continue a separate description of a disease wlii
  • ntagi<»ns in llic strict sense of the term. Every case owes its origin (o a previous case. Tlic dis- ease never originates de novo ; but it is not yet dctermincil in wlmt \\:iy the poison is disseminated. It is believed (hat it circidates in the blood to con- taminate and infect the various exhalations and excretions. It is pi-ob:ible that the disease is conveyed by exhalations, or nither excretions, iVoin the throat, which are received by inhalation (eontagium h.-ilitno^um) into the throat, where it shows its first signs. Children have been born, as staid, in every stage of 21 2 SCARLA TINA . the disease from incubation to desqnamation. Infection in these last cases conld have occnrred only through the blood. More importance is to be attached to this fact than to any inoculations of lower animals, as in the well- known experiments of Coze and Feltz, because the symptoms which resulted were not typical or under comparison with so-called *' control observations." Thev miolit have occurred with other inoculations. The attempts of Williams, Rostan, and Miquel at inoculation with a view of inducing a milder Init pro- tective attack for the most part failed, and contradictory testimony is fur- nished (Radel, Stoll) as to the propagation of the disease by means of the skin. It is assumed, rather than proven, that the poison of scarlatina exists in the skin. The claim is more definitely made of small-pox. It may be con- sidered, in fact, established of this disease by inoculation. There are eminent clinicians ( Volz) who deny all infection to the skin, or (notably Leyden) who maintain that the eruption of scarlatina is to be looked upon as only a reflex phenomenon, like that of erythema from gastric catarrh or like a toxic (drug) eruption, in which case it would be useless to look for the poison in the skin. At the present time, for the sake of safety, it is wise to believe in dissemina- tion from the skin, and to act accordingly. It is singularly tenacious, adhering to clothing; after months of disuse and to rooms after months of vacation and seemingly thorough disinfection and ventilation. Thus, Von Hildebrandt's coat retained its contagiousness for a year and a half. Adams reports that he found the disease to have been communicated by a convalescent who showed no signs of ill-health as late as the forty-third day. In the experience of the writer the opening of a closet in a house vacated for three months after the death of a child, and the handling of garments suspended in it, coili muni cat ed the disease to another child of the same family. Surgeon Brooke, U. S. A., detailed an instance of apparently spontaneous scarlatina in a child that had been subject to no discernible exposure. It was subsequently ascertained that one of the domestics had nursed a case of scarlet fever in a distant city a year before. Some of the clothing which she had worn at the time was packed away in a trunk, and this trunk had been opened, the contents removed and handled by the child a short time before the attack. The poison of scarlatina literally lurks in long-discarded clothes. An illustrative case is also reported by Richardson of London. A family consisting of a man, his wife, and four children lived in a small thatched cot- tage. One of the children was attacked Avith scarlet fever and died. The remaining children were removed four or five miles. After several weeks one of them was allowed to return. This one took sick within twenty-four hours and quickly died. The cottage was now thoroughly cleansed and white- washed, the floors scoured, and the wearing apjiarel destroyed. Four months later another of the children returned, to be stricken down with the disease in malignant type on the following day. The author believed that the poison had become fixed in the thatched roof, whence it could not be dis- lodged. This tenacity of life is counteracted in great degree by limitation- of range. SCAIILATIXA. 213 The poison of scarlatina is not witlely disseminated. On the contrary, its area of distribution is confined to very narrow limits. The field of infection is pretty closely circumscribed about the body. The poison is entangled as a particulate body in the texture, or is fixed upon the surface of fomites. It is therefore nnich easier to sequestrate cases of scarlatina than measles, and thus to protect other members of a family or house. Confinement to a ditl'erent storv of a house or to a room absolutely isolated in its ins and outs — that is, in its exits as well as entrances of attendants and things — will generally suf- fice. Stay in an adjoining room with separate entrances, though with an unopened door between, has proven protective. The tenacity of the poison — that is, the maintenance of the disease — is helped also by its intensity. But very short contact with a case suffices for infection. Thomas quotes from Palante the casi' of a mother in contact with a patient " but a moment," who returned immediately to her home at a dis- tance of six miles, but whose contact had been long enough to collect and carry the disease to her children, in whom it showed itself in the coui*se of a few days ; and from Hennig the case of a child attacked four days after asso- ciation " but for a short time" with another child which had had the disease six weeks before. The mere handling of woollen goods, clothes, shawls, blankets, curtains, furniture covers, etc. has repeatedly conveyed the disease. Cold does not affect it. It is destroyed, however, by heat, by boiling water, especiallv by steam, and quickly by steam in motion, so-called "live* steam." Henry, after subjecting the flannel garments of scarlatinous patients to a dry heat of 212° F., felt safe in having had them worn by unaflected children from six t(j thirteen years of age, and no infection followed. Therefore the cause of scarlatina must be a micro-organism, though it has not yet been definitely isolated and determined. It has been described as a Plasmodium, and even as a pilz (mould-fnngus). Klebs (1880) pictured and described a structure found in the blood as the 3Ionas scarlatuiosum. Eklund (Stockholm, 1881), found constantly in the urine as well as in the soil an(l ground-water an immense number of discoid corpuscles without further i>roof of pathogenesis than presence. Power, Cameron, and Klein ^188^-86) described coincidently with an outbreak of scarlatina a disease of cows in the Hendon (England) dairy, an acute general infiannnation attended with the formation of pustules and ulcers on the bag, communicable to other animals, and from the pustules as well as from internal organs could be isolated and developed micrococci (streptococci) whicii when intnxluced int.. Ii< l.l-ii.i t.. isolate from the blood and from desquamations of the skin no h-ss than eiudit dilVerenf baetena, one ol whieh, designated the baciUns scarlatiuic, introdi.ee.l into g.i a-pigs and 214 SCARLATINA. rabbits, produced temporary fever and erythema. An inoculated calf died with fever on the following day, showing the same bacilli in the blood. The bacteria of mouse- septicaemia, rabbit-erysipelas, and the swine-plague will, however, all produce erythema, and often even desquamation. These various micro-organisms are now believed to be varieties of the ordi- nary pyogenic bacteria. It cannot as yet be maintained of any of them that thev are found uniformly or only in scarlatina, nor that the disease produced by them is really scarlatina. It is not yet established that any of the lower animals are susceptible to the disease. It would be more natural to look for the poison in the tiiroat and in the blood in the earliest stage of the disease than in the secretions from the kidneys or in the substance or exfoliations of the skin. The kidney affection is doubtless the result of a chemical poison in its escape from the body, and the exanthem must also be regarded as toxic, like that produced by certain drugs. Luff has succeeded in eliminatiug a hitherto uuknown alkaloid from the urine of scarlatina, and Leyden declares it to be useless to look for the poison of scarlatina in the skin. Regarding the relationship of diphtheria, it is admitted that one affection may follow the other, or that they may even coincide, but in all cases only as exceptions. The rule is that the diseases prevail in communities and exist in individuals independently of each other. Experimental evidence at the hands of the most competent and conservative observers multiplies to support this view, which was first clinically established by Henoch and Huebner. It is cer- tain that most of the cases of so-called scarlatinal diphtheritis distinguish them- selves by the absence of the Klebs-Loffler bacillus, and by the presence only of the streptococcus, which stands in some, though not specific, genetic rela- tion to the development of the membrane. When inoculation is made early — i. e. so soon as the membrane is visible — on the very first day of its appearance, and when the matter is taken only from typical cases of scarlatina, as in the .studies of Tangl, the culture shows in no cases the bacillus of diphtheria. Course of the Disease. — TJie period of incubation is short, ranging from four to seven days. Ziemssen declares that the few unimpeachable observa- tions that we possess put it at seven days, English writers make it generally less, and declare that from the second day after exposure liability of attack grows progressively less. In all the twenty-four cases mentioned in this article as having been caused by milk the symptoms showed themselves within twenty-four hours after the drinking of the milk. On the other hand, Pons extends the incubation to four, Moore to seven, and Veit to fourteen days. The most critical observers (Gerhardt, Thomas) admit these periods as exceptions, but place the general average at four to seven days. The invasion is usually sudden and violent, grave, dangerous, sometimes fatal illness developing within a few hours. An initial chill or series of shiverings is attended by a quick and high rise of tem]ierature. It is more frequently the case that the disease is ushered in without anv chill at all. COVRSK OF rilE DISEASE. 215 A child presents evidence of attack in a shock nuinilcstcd l.v extreme pallor and prostration. A highly snsceptible, sensitive ehil.l mav be seized with a convulsion. Usually the scene opens with vomiting. Karly vomiting belongs to all the grave, acute infections, but it occurs with especial frcquencv in scar- latina, because of the gravity of the disease. Alter th.- vomiting it'is noticed that the patient has fever. Inspection thus early iwi als angina or the child complains at once of sore throat. Vomiting, sore throat, and 1'ever at the start should excite the suspicion of scarlatina, or, in the presence of an epidenn'(! or proximity of another ca.se, establish the existence of the disease. The temperature distinguishes itself by the ra|>i(lity ,.f its ascent (See Fig. 1,3). loa* 102* 101 100* 99 Fio. l.S. 3 4 5 Ikll ■■■■gi ■■■■■I wammmmA\i ■■■■■■■■ravHaiBHHi ■iinnSBB&BSSSSS ■■■■■■■■■■■■■mSiBh ■[■■■■■■■■■■■ichBh mi HI Temperature-charl of a Mild Case ol' Sturluliiiu. The ascent of the temperature in scarlet fever is more rapid than in alnidst any other disease, reaching often within twenty-four to forty-eight hours 104° to 107° F. Calor mordax was the term applied by the older pic- thermometric writers to express the biting heat of the skin. If there is no question of complications, the fever reaches its height w ith the appearance of the eruption, or at least with its fidl efflorescence, to gradually subside in the course of one or two wrecks in a mild or sharp average case respectivclv. In cases in which the eruption "siid^s in " or disa|)j)ears in the face of, or is a residt of, a grave complication, the coldness of the surface is onlv apparent. The thermometer in the rectum or vagina i-egisters high grailes (1().")° to 1()S° F.), to fall, often rapidly, under a hot bath, which may bring the lilood, aiitl with it the eruption, to the surface. The persistence of (he complicalioii, meningitis, pneumonia, etc., re])ro(hices the surface coldness after (lie ba(h. In correspondence with the height of this fever, especially in yoimg chil- dren, nervous signs, as stated, show themselves — viz. deliriinii .iml coii\iil sions. The delirium may deepen rapidly iiid* coma. 'fherc i< in evciy marked case profound jirostration. It is seen on the most superficial inspec- tion that the child is seriously ill. This stage of invasion lasts from one lo two days. Comment has been made upon the irrcgnl:iii(y or varic(y in sever- ity of epidemics of scarlatina. The same varic(y is noticed in individual caivcne^s is regarded as a sign of much value. It is unfortunately not always present, but when pres- ent it should excite at once suspicion of the existeu d' this disease. Scarlet fever shows predilection lor three <.i<::nis besides flic skin and tJiroat — namely, the ear, tin; joints, an, 13 times in 84 cases, and in other epidemics not once in 100 cases. The severity of the individual case or of the epidemic does not necessarily indicate the probability of nephritis. It cannot be saitl that early ex))osure as to cold predisposes to it. It may not be ascribed to the atlection of the skin, as no such sequel follows small-pt)X with its much more destructive lesions. Kverv case marked by high temperature shows, as stated, some albuminuria, but the albuminuria which excites apprehension is that which appears not at tin- height, but in the later course of the disease — at the end of the third week, after the disease proper and during convalescence. Strictly speaking, the process, is therefore, a post-scarlatinal ne|>hritis. It sets in on the tenth to the thirty-first, on the average in twenty days, after the first show of the rash. It is an acute parenchymatous process, from which the jxitient recovers or succumbs quickly, very rarely developing into chronic Bright's disease. It is announced often by nervous symptoms, headache, neuralgia, vertigo, insom- nia, restlessness, blindness, convulsion, or coma. Puftiness of the eyes, any local oedema, or dropsy should excite suspicion of its presence. Sweeting showed by statistics that albuminuria stood in direct relation to crowd-poisoning, so that the percentage of cases was in direct ratio to their number. Thus, in 1882, when the hospital ward contained but 64 patients, the percentage of albuminuria was 14, while in 1887, when it contained 104(1, the percentage increased to 34.9. It is questionable, however, whether this albuminuria may be regarded as evidence of the true scarlatinal nephritis, which depends more, as stated, upon the character of individual cpiilcmics. Thus, Barthez found 80 per cent., Friedreich but 4 per cent., of cases. It must, however, be admitted that the albuminuria which attends cases of high fever is often the origin of a later nephritis. The typical nephritis ]>resents, as a rule, a picture very different from that of ordinary albuminuria. It dis- tinguishes itself by the gravity of the nervous symptoms, by the extent oft lie dropsies, as well as by the marked changes — presence of blood, reduction in quantity, even to anuria, etc. — in the urine. It distinguishes itself further by the fact that even the gravest symptoms do not jiredude recovery. A not infrequent sign to announce the advent of tlir true nephritis is vomiting. Vomiting without cause, especially ii" rciM'aicd several times, should excite suspicion. The patient is fi)und pallid or there is a du>ky line about the face. On inspection of the body it is seen that there is cedeiiKi. It may be observed first about the loins, but is, as a ml.', noiieed first under the eyelids. It appears soon about the ll'ct and in the sidx'utaneous coimeetivc tissue generally. The redema becomes an anasarea extending over the body, and shows such degree of distension as is hardly e.|iialled in any other (IJmmm'. The hvdrops invades also the serous cavities, the |.l(nr:e, perilniieimi. ;iihI j.. ri- cardium. Effusions here may be fiital l-y mere meeh:ini.;il pre<-Mre. There may be superadded new or mixed inCeetious elements to e.,ni:iniiii:it.- the elear serum with pn- or blood. Severe cases begin with te,np,.tii.ms signs— ehill with rapidly rising temperature, vomiting, hnnbnr pMiii, headaehe, aMiaurosis, 220 SCARLATINA. convulsion, delirium, stupor, coma — and such cases may terminate in a few hours. Usually, however, the outlook is not so bad, and even in the presence of grave ursemic symptoms the prognosis is not necessarily fatal. It is upon the condition of the urine that the recognition of nephritis really rests. The disease is an acute parenchymatous nephritis. It begins, as stated, insidiously or suddenly, and, as also stated, late in the course of the disease. This late beginning is, however, really only apparent. The fact is, the nephritis begins early and develops itself insidiously until it has attained an extent sufficient to show signs. Scarlatinal nephritis may be divided into two periods, in the first of which there is a diminution in the quantity of urine, albuminuria, and some of the general symptoms mentioned. The second period is distinguished by hsema- turia, with the discharge of formed elements, granular and epithelial casts, also with an increase in the quantity of urine and diminution of the general signs, so that should the urine become more abundant, contain more blood, and exhibit formed elements, though grave symptoms may still shoM' them- selves for a time, the worst is over, and, as S5rensen puts it, " the kidneys are beginning to free themselves of the disease." Perhaps the most grave single symptom of nephritis is anuria, but even long-continued anuria is not incom- patible with recovery. While it may be said that the gravity of the case cor- responds in a general way with the degree of oliguria or the duration of anuria, there need never be despair as to the possibility of recovery, as Whitelaw re- ported a recovery after a total absence of urine for twenty-five days. As a rule, it may be said that the blood and albumin disappear in mild cases, and the patient entirely recovers from the nephritis in two to three weeks. Varieties of Scarlatina. — Besides the typical form described, scarlatina fallows itself in variation as follows : 1st. Abortive, in which the eruption dis- appears after a short duration without, or with very mild, throat symptoms, but usually with lamellar desquamation and sometimes with subsequent nephritis. 2il. Fulminant, in which the patient is killed by the poison of the disease before the period of eruption. 3d. Anginose, in which throat symj)toms predominate. 4th. Malignant, with the datua typhosus, in which all symptoms are intense, and haemorrhage may occur su])erficially from the various mucosse or into the skin, or with rapid collapse after signs of a cholera morbus. In some very exceptional instances of undoubted scarlatina the erup- tion is entirely wanting, throat symptoms only being present. In these cases careful inspection will usually disclose some eruption on covered parts, espe- cially on the posterior aspect of the bod}-. It may be seen at times on or over any part of the body immediately after death in fulminant forms. True diphtheria may coincide with or follow scarlatina ; much more fre- quently, as a rule, the membrane which forms in the throat is sid generis. The membranous angina or pseudo-diphtheria of scarlatina is much less amenable to treatment than true diphtheria. Relapse must l)e distinguished from second attack or recurrence. Such cases only should be considered as relapses where the fever and the eruption DJAOyO^SIS. ' 221 more or less immediately follow the first attack, as in the course oi' typhoiil fever. Recurrence or second attack is, as stated, vei-y vmw One attack gives immunity, as a rule, for life. A relapse occurs before there can he any (|Uos- tion or consideration of immunity as a result of reabsorj)tion of toxic matter from the throat or wherever lodged. Thomas, who studied this suliject most thoroughly, admits a relapse not later than four or five weeks after the first attack. The disease repeats itself in relapse in all its details, and for the most part in equal severity. Shoidd they vary in severity, the second attack is apt to be the less than the more severe. At times it is only rudimentai-y. Notwithstanding the renewed infection, relapses have, as a ride, a more i'avor- able prognosis. Diagnosis. — The diagnosis rests upon — 1st, the absence of previous attack; 2d, the existence of other cases; 3d, the short period of iiicui)ation, one to seven days as a rule; 4th, the violence of the invasion, csjiecially the occurrence of unprovoked vomiting (80 per cent, of cases) and the nci-vous symptoms; 5th, the early appearance (second day) of the eruption, which shows itself first usually about the clavicles, is scarlet-colored, diifusc, but punctate upon close inspection — in its disposition about the face, connnonly sparing the mouth, showing in vivid contrast the blanched lips and the blazing cheeks ; 6th, the strawberry tongue ; 7th, the early ajijicarancc of throat symp- toms, Avith glandular enlargements in the neck ; 8th, the lamellar desquama- tion ; 9th, the ear complications; 10th, nephritis. In very mild, sjioradic, or anomalous cases the diagnosis may be deter- mined only by desquamation, conq)licati()ns, or sequelfc. Scarlatina is differentiated from measles by knowledge of previous attacks of either, of the existence of other cases of either, especially in the same family, neighborhood, or school ; by the longer incubation of measles when the p.riod of exposure may be (exceptionally) known ; by the coryza wJiicii pi-eccdes the eruption of measles, and the angina that of scarlatina ; by the shorter or more intense invasion of scarlatina with vomiting and sharp nervous symptoms not so common in measles; by the time of appearance of the crui>tion, twcnty-fi)ur to fortv-eight hours after initial chill or vomiting in scarlatina, four days in measle<; by the color, character, disposition, and duration of the orui.tion, dark red, aggregated in patches, and disappearing in two to four days in measles, scarlet-colored, punctate, diffuse over the chest and face, sparing the month, disa])pearing in eight days or more in scarlatina ; by the eonqilications or sequela?— bronchitis, catarrhal pnemncmia in measles, joint and ear alfcc- tions, nephritis in scarlatina; by the desquamnti..n, usiially branny in measles, mend)ranous in scarlatina. Scarlatina is differentiated from rubella (rolheln) by the h.nger incubation or shorter or absent stage <.r invasion; bv the ore sev.-n- faue.al ndlam- mation and gland implieation in scarlatina; by Hir inn<4. nulder ehara..(er and shorter diu'atiou oi' rubella. 222 SCARLATINA. Septicaemia and pyaemia show, with the history of a cause, successive chills, irrecrular temperature, efflorescences in appearance and in order of distribution quite different from the eruption of scarlatina, more marked enlargement of tiie liver and spleen, more common general affections, metastatic processes, and a lono-er duration. Ervthema shows a diffuse rather dark redness without points or desquamation, though sometimes with a light furfuraceous desqua- mation, with absent or but very slight fever (up to 100° F.), has neither the throat symptoms nor com})lications of scarlatina, and disappears in a few days. Drug eruptions, copaiba, cubebs, and antipyretics, have a history of administra- tion, no fever, and no complications. Scarlatina differs from diphtheria in its cause. At least it may be said that the cause of diphtheria has been now quite definitely determined, and that, while the same cause is not to be found in unmistakable cases of scarlatina, it must be held in mind that the diseases, as stated, may coincide, and that either mav be a sequel to the other. These things, however, are exceptional, the rule being that the diseases exist alone, and that, as stated, the exudation of scarlatina is not that of diphtheria, but is sui generis. Clinically, the affections differ as follows: The false membrane appears at once in diphtheria, later in the course (three to five days) of scarlatina. It shows itself in nearly all cases of diphtheria, but in only severe cases of scar- latina — namely, such as are marked by high fever, delirium, etc. at the start. It shows a preference after the pharynx for the lar^aix in diphtheria, and for tiie upper respiratory passages in scarlatina. In connection with it suppura- tion of the cervical glands and affections of the ear are frequent in scarlatina, rarer in diphtheria. The interglandular connective tissue is indurated in scarlatina and only cedematous in diphtheria. Paralysis, which is frequent in or after diphtheria, is almost unknown in scarlatina. On the other hand, ne- phritis, a frequent sequel of scarlatina, is very rare after dijihtheria. Lastly, as stated, treatment has much less effect on the membrane of scarlatina. For all these reasons it is proposed by good clinicians to abandon the use of the term "diphtheritic" in scarlet fever, and to designate such cases as mem- branous scarlatinal anginas. Coin])lications. — Scarlatina distinguishes itself by the intensity of its j)oison. It is therefore natural to expect to find frequent and various compli- cations. Perhaps there is no disease in which complications are so many and manifold. The gravest are those which affect the brain. The disease sets in with symptoms of shock, with profound prostration, with delirium, convul- sions, and coma, and these accidents may occur at any time in the course of the disease. They may be due, in the first place, to direct effect of the poison upon the nervous system. They may be the effects of septicaemia or of sup- ])urative processes about the throat and neck. They may be due to mechan- ical ])rcssure of the swollen tissues upon the great vessels in the neck, thus interfering with the circulation in the brain. They may be due to meningitis, or, finally, they may be due to kidney disease. The nervous symptoms which are due to direct intoxication are, as a rule, COMPLICATIOXS. 223 the most intense. They most diroetly and frequently threaten and take life. They inspire the dread of the disease. These severe nervous symptoms, inclie- ative of fresh influx or inundation of the poison, not infrequently precede the eruption, or, occurring after the eruption, even in its full ettloreseeuee, cause it to quickly fade away. These are the eibtor— not at the door, window, or fire, but at the head of the bed. An open fire in winter is preferable to any other method of heating. The })atient shoidd wear a lon^r muslin nidit-dress without other clothing. Tlie bed-covering must be as light as is consistent with comfort. Milk and meat soups make the best diet, AVatcr, carbcunted water, seltzer, apollinaris, lemonade, toast-water, barley-water, should be given freely to relieve thirst and to keep the kidneys flushed. Prink should be protfered once an hour in high fever during the day. The utmost cleanliness is to be maintained by frequent sponging and bath- ing of the surface. Daily tepid baths (full length) give the greatest comf.)rt throu.rhout the disease. ' Fev<-r ab..ve 1<»;;^ F, is best <-ombated with cold 228 SCA RLA TINA . sj3onges, cold packs, or cold baths. Cold baths are most effective, but are seldom practicable as yet. It is not essential that the temperature be brought down to the nornjal degree. A reduction of a few degrees suffices to give the patient comfort, and relieves all danger attendant upon high temperatures. A warm or tepid bath will reduce the temperature one or two degrees, and patients solicit such bathing when the cold bath may excite terror. While it is true that the temperature reaches the highest grades in scarlatina, and the patient suffers corresponding discomfort and danger, it is not true that the dan- ger is caused by the fever. The danger, the discomfort, and the fever are produced by a common cause — namely, the poisoning of the blood ; and there can be no question of radical therapy until after the discovery of some agent, some antitoxine, which will neutralize the chemical poison circulating in the blood. It is indeed a question if some fever be not salutary. We combat the fever in our day more especially with regard to the cocpfort of the patient. A difference of two degrees makes great difference in the feelings of the patient. The reduction of high temperatures by cold bathing is attended, as a rule, with diminution of discomforts and dangers. The bath addresses the cause indirectly through its effects. Frequent bathing is the best therapy in the treatment of scarlatina as of any other infection. There may be reasons which render a bath impossible. In these cases resort must be had to frequent ablutions. It may become necessary to substitute a bath by drugs, especially in the presence of other indications. Resort may then be had to the antipy- retics. Phenacetin is the least injurious. It may be given to a child in a dose of 2^ to 5 grains — to an adult in double this dose once or twice in the course of a day. It is of especial value in headache or other nervous distress. It is best administered in capsule or in powder, taken directly upon the tongue or stirred — that is, suspended — in milk, or, in case of high fever with dry tongue, floated upon the surface of a teaspoonful of water. Only in case of failure with phenacetin should resort be had to antipyrine or antifebrin, either of which must be given in half the dose of phenacetin. Burning and itching of the skin are best allayed by application, after tepid baths, of vaseline, cocoa butter, lanoline, goose-grease, bacon, or fresh lard. Quiet, peaceful, and more or less restorative sleep is wont to occur after a bath and inunction in this way. Nervous distress, jactitation, convulsions, insomnia, headache are best com- bated by bromide of sodium in doses of from 5 to 10 grains to a child, 30 to 40 to an adult, largely diluted, or if more obstinate by chloral, 5 grains to a child, 15 grains to an adult. No other single remedy gives the comforts of chloral in repeated doses of 2 or 3 grains. Broken doses of Dover's powder in grain doses to a child, 3 to 6 grains to an adult, may substitute it in a suit- able case. Ice-bags should be applied to the head for meningeal symptoms. The vomiting which occurs in the inception of the disease is often suf- ficiently relieved by carbonated drinks, the best of which is the German seltzer water, with milk equal parts, or by lime-water and milk 1 : 3, by small doses of bismuth (5 to 10 grains), by the bicarbonate of sodium in equal dose, or by sips of excessively hot water. The most powerful drug we possess is TREA TMENT. 229 chloral. The most refractory vomiting, of whatever cause, will yield to the administration of a few doses of from 2 to 5 grains of chloral diluted in a dessert- to a tahlespoonful of pei)permint-water. Should the remedy be rejected before it can be absorbed, it may be introduced into the bowel in double dose. It must be a remarkable case to resist chloral in one or other of the modes of use or to justify resort at last to a subcutaneous injection of morphine. Throat symptoms call for inhalations of steam, best from the steam vapor- izer, simple or medicated with bicarbonate of sodium, saturated solution of boric acid 3 drachms to 4 ounces, or carbolic acid J- a drachm to 4 ounces, or thymol 5 grains to 1 ounce alcohol or 3 ounces of water, or gargles of hot water, of carbolic acid 15 to 30 drops to 4 ounces, perchloride of ir(»n 1 drachm to 4 ounces, or direct applications of carbolic acid, with glycerin equal parts, bichloride solutions from 1 : 1000 to 1 : 100, or intraparenchymatous injec- tions (tonsillar) of a few drops of the carbolic-acid solution Ity means of a hvpodermic syringe with a fine long aspirator needle. Cloths wrung out of boiling water, applied about the throat and covered in by thick dry cloth, relieve the pains of extreme distension. Affections of the ear are best treated by a douche of hot water and a Polit- zer inflation with air. Tension in the membrane of the tympanum may require puncture, and suppuration of the mastoid cells trcj^hining. Earache is best relieved by instillation of hot water or solutions of atro])ine, 1 grain to the ounce. Otorrhcea is best treated by filling the external canal with powdered boric acid after thorough cleansing with a cotton-wrapped sound, or direct application to accessible granulations of chromic acid, London paste, or the galvanic cautery. Nephritis calls imperatively for hot baths, under which all the symptoms of this complication, including vomiting, are wont to speedily subside. The bath must be hot (100° to 110° F.) ; the patient must be rolled in a blaidvct after it, and be allowed to sweat for an hour. Rheumatism calls for the sali- cylates in saturating dose. Alcohol, digitalis, and nitro-glycerin may become necessities in the later course of all grave cases, and may be urged in over- dosao-e. together with other analeptics— camphor, ether, musk — in the way of a "forlorn hope" in fulminant forms. MEASLES. By JAMES T. WHITTAKER. Synonyms and Definition. — Measles (Sanscrit), masiira, masern (Ger- man, spots), rubeola (Sauvages), ruber, rougeole (French, red), morbilli (Italian, diminutive of morbus), — an intensely contagious, acute infection, characterized by coryza and bronchitis, a red spotted eruption with branny desquamation, fever of typical course, subsiding at efflorescence, with liability, mostly as sequel, to catarrhal pneumonia, sometimes to tuberculosis. Ahrun (Aaron), a Christian priest and physician of Alexandria (a. d. 610- 641), is celebrated as having been, by universal acknowledgment, the first writer to have mentioned small-pox and measles. Though existent from time immemorial, measles was first described by Rhazes (900 A. D.) in an attempt to separate it from small-pox. Rhazes noticed among the symptoms of measles " redness of the eyes, with a great flow of tears, nausea, and anxiety," remarking also that the measles " that are green or violet-colored are of a bad kind, especially if they sink in suddenly, for then a swooning will come on and the patient will soon die." The disease was described under the name hhasbah. Nearly all subsequent writers adopted the Italian term morbilli up to the middle of the eighteenth century, when Sauvages substituted for it or re-established the term, said to have been first used by Haly Abbas, rubeola, which the French accepted in their own equivalent of rougeole. Fagge laments the substitution of rubeola and its adoption by later English writers, but surely without cause, for mor- billi refers simply to the mildness of the malady — a fact to which there are many exceptions. Morbilli is, anyhow, too indefinite to be the name of any disease. It liolds its place only under the sanction of antiquity and authority. Rubeola means something definite. It expresses a characteristic feature of the disease — in fact, the most characteristic feature — the redness of the eruption. It is unfortunate that this term, rubeola, has been adopted by certain German writers to express that particular subv^ariety, special, or hybrid form of dis- ease known as German or French measles or popularly in Germany as rotheln. As scarlatina would seem by universal acce})tance to be the most appropriate name for scarlet fever, rubeola must be the most appropriate for measles. Foreest, the Dutch Hippocrates, in 1565 first pointed out certain dis- tinctions between measles and scarlet fever, though the separation of the affec- tions is usually credited to Sydenham (1665), the English Hippocrates. Sydenham described the rigors which constitute the chill in the inception 2;in SYX0NY3fS Ay I) DEFiyiTKJX. 231 of the disease, and furnished an account close and succinct enough to cutitlr him to the position of pioneer. Thus : " It generally attacks infants, and, with them, runs through the whole family. It begins with shivcrings anil shakings, and with an inequality of heat and cold which, during the first day, mutually succeed each other. By the second day this has terminated in a genuine fever, accompanied with general disorder, thirst, want oi" appetite, white (but not dry) tongue, slight cough, heaviness of the head and eyes, and continued drowsiness. Generally there is a wee})ing from the eyes and nos- trils ; and this epijihora passes for one of the surest signs of the accession (tf the complaint. But to this may be added another sign equally sure — viz. tlu' character of the eruption. The patient sricezes as if from cold, his eyelids (a little before the eruption) become pnffy ; sometimes he vomits; oftener lie has a looseness, the stools being greenish. This last symptom is common- est with infants teething, who {ilso are more cross than usual. The symptoms increase till the fourth day. At that period (although sometimes a day later) little red spots, just like flea-bites, begin to come out on the forehead and the rest of the face. These increase both in size and nund)cr, grouj) themselves in clusters, and mark the face with largish red spots of ditt'erent tigures. These red spots are formed by small red papula-, thick set, and just raised above the level of the skin. The fact that they really protrude can scarcely be determined by the eye. It can, however, be ascertained by feeling the sur- face with the fingers. From the face— where they first appear— the spots spread downward to the breast and belly, afterward to the thighs and li>gs. Upon all these parts, however, they appear as red marks (uily. T.y the eighth day the spots have disappeared from the face and show but faintly elsewhere. On the ninth day there are no spots anywhere. In place thereof, the face, trunk, and limbs are all covered with particles of loosened cuticle, so that they look as if they had been ])owdcred over with Wowv, since the particles of broken cuticle are slightly raised, scarcely Ik.UI together, and, as the disease goes off, peel off in small particles and fall from the whole of the b..dy in (he form of scales." The primeval home of measles is unknown. From its earliest reiM.gnitinn it has prevailed in epidemic form in Asia, Furope, and South America. It was imported to the United States with the first settlers, to gradually spread over it with -the march of the pioneers. It reached Oregon in 182!), Cali- fornia and Hudson's Bav in 1846, the Sandwich Islands in 1848, when.c .t was carried to Australia in 18o4, Grcenlans arc ol .ontumal occurrence in large cities, measles usually prevails as an («pian.c way and will, 232 MEASLES. the same signs, course, complication, and duration from its earliest recognition. It has in it much less of the irregular, capricious, and unexpected than has scarlet fever. It does not show the sudden changes, storms, and strokes of lightning in the midst of comparative fair weather that may occur in scarla- tina. Consequently the disease is by no means so much feared. As the name indicates, it is considered a comparatively mild disease, a diminutive disease. It is the nature of measles, aside from complications and surroundings, to be mild in its course, but it may assume, especially under bad hygiene, a malignancy and mortality which associate it with the plague and the worst forms of infection. The fact is, the mildness of measles is over- rated, or, at least, is to a great extent counterbalanced by the frequency of the disease and the quality of its complications. Thus the statistics from the whole of Austria and Saxony from 1873-87 show that there died in every 10,000 people in Austria of measles 27, of scarlet fever 67 ; in Saxony of measles 25, and of scarlet fever 48. Henoch quotes the mortality of measles in Berlin in 1887 at 0.74, scarlet fever at 0.85 per cent. To get some idea of the respect which is due to measles as a malign disease, as one of the veritable plagues of mankind, we must study the record (Hirsch) of its ravages in sav- age and semicivilized lands. As late as 1749 measles carried off among the aborigines about the Amazon 30,000 people, whole tribes at a time ; in As- toria one-half of all the inhabitants fell victims to measles in 1829; and the same proportion was observed among the Indians at Hudson's Bay in 1846, the Hottentots in 1854, the Tasmanians in 1861, and the Mauritians in 1874. Squire relates that a frightful epidemic of measles in the Fiji Islands car- ried off 20,000 — that is, nearly one-ft)urth of the whole population. Cruik- shank reports of this attack that later in the epidemic, when it was said to be like the plague, the people with fear abandoned the sick. The excessive mortalitv resulted from terror at the mysterious seizure and the want of the commonest aids, thousands being carried off by want of care, as well as by dvsentery and congestion of the lungs, which set in as complications. The effect of crowd-poisoning in measles was well illustrated in the mortality of measles among: the Confederates in the War of the Rebellion, where 1900 of the 38,000 cases terminated fatally. In two of the larger hospitals the mor- tality (still according to Hirsch) amounted to 20 per cent,, and in some of the improvised hospitals about Paris in the Franco-Prussian War (1871) it reached 40 per cent. Mastorman says that at the beginning of the Brazilio-Paraguayan War measles swept off nearly one-fifth of the national army in three months, not from the severity of the disease, for he treated about fifty cases in private ])i-actice without losing one, but from want of shelter and proper food. Etiology. — Measles knows no consideration of geography, climate, sex, race, or caste — resjwcts nothing but sanitation, which puts a muzzle on it and makes it mild. If, therefore, the disease seemed to prevail more extensively and severely among the colored race, it was not because of physiological pref- erence, but of unfavorable hygiene. Susceptibility to the disease is almost universal, so that it has been said that ETIOLOGY. 233 if measles had the mortality of scarlet fever the human race would have long .since become extinct. The eminent contagiousness of the disease is shown in the attack of whole communities previously entirely or for a long time exempt, as in the Faroe Islands, where 6000 people were seized at once, and in the cases of extensive prevalence just mentioned. In 1886 the disease overran nearly the whole of Russia. The universal susceptii)ility is best observed in the cases of isolated islands. Up to the present time the disease has visited the Faroe Islands four times (1781, 1846, 1862, 1875), and Iceland four times (1644, 1694, 1846, 1868). In some of these cases the intervals between epi- demics have been so great as to have furnished a large amount of material for attack, so that upon some occasions only a few old people, tiicy who had the disease in infancy, were left to attend upon tiie sick. Measles has in these cases suspended all business operations and inflicted upon a community as much distress as the gravest infections. Measles, therefore, makes up for its mildness by its range. Universal susceptibility implies exquisite contagiousness. The poison of measles is eminentlv diffusible. It must be verv lio-lit. It floats in the atmo- sphere about a patient and does not stick long to things. The first experimental proof of the contagiousness of the disease was fur- nished by Home of Edinburgh in 1758, at the instigation of Mnnro. Home soaked rags in blood from cuts made througii the spots of measles and applied them for three days upon fresh cuts in the arms of healtiiy persons, inducing thereby veritable but much milder attacks than the prevalent form. The sat- urated rags retained their infectiousness but ten days. There seems to be no doubt as to the infectiousness of the blood. Katona in 1842 failed to inoculate the disease in but 7 per cent, of 1222 cases. He used bhtod mixed with other fluids, sometimes with the fluid of vesicles, sometimes tears. A red areola formed about the point of inoculation, to be followed in seven days by fever and the ordinary prodromata. The eruption appeared in nine or ten <]ays, and the disease ran a regular but milder course. Joerg and Wendt made the same experiments, produced measles, but failed to find any mitigation of type, so tiiat any hope of protection by inoculation proved futile. Mayr claimed to be able to inoculate measles with the nasal nuicus apj)lied directly to the mucous membrane of children ; and Berndt asserts that Monroe and Lock succeeded in producing the disease with desquamations of skin, with tears, and with saliva. There is, however, uniformity of opinion only as regards the blood, "^riie fact is, there is need of more modern investigation with modern methods of control. The disease is certainly contagious throughout its entire course, most intensely so at the period of fullest efflorcsencc — /. e. at its acme — less during the stage of incubation, least, if at all, during and after desquamation. Measles prevails more distinctly in the colder months. Of the epidemics tabulated by Plirsch, 3390 occurred in the nAAw mid l!)l in ihc wanner months. The frequency of epidemics in w Iiiiy Pamim, who vacci- nated a child in the incubative stage of the disease, both vaccinia nnd measles running typical courses. With the excepti(Mi ol" pertussis, the existence of :ui acute disease as a ride postpones an attack of measles until alter its subsidence. Coincidence is therefore an exception to the rule. An inlt majority of cases wholly fnrof .symptoms. Very exceptional cases show malaise or ephemeral fever, whicli 238 MEASLES. may, but often does not, arise from the poison of the disease. The stage of invasion may be marked by a distinct chill or more commonly by a series of shiverings, to be attended or followed by a rise in temperature to 100°-104° F., with gastric irritation and nervous symptoms in correspondence with the temperature. The fever is in many cases so slight as to be overlooked, when the disease may announce itself with more distinctive signs. After the first re- mission the temperature again rises with the appearance of the eruption (Fig. 14), to reach its acme at the period of full efflorescence, and to decline as it fades Fio. 14. Day of DiseoM 7 3 S 'C // /^ 106' m' JC}' lOZ- 10 1' 100- 99' 9S 97' \ \ \ \ , ] Lfc- -t - I t :t -X - -A - U- t ^ A N I f \ ^ ^ / "C - 1- 3 T ^ Fk; . 15. Day of Disease. i 2 3 4 5 6 7 8 102° 101^ 100° 99° 98° 97° A : A — ■ ^ —\ — ' — " f- / A n / \ ' \ M \/ \ / \ A V / \ / / w / V — ; __ U- 1 1— ^^ -f "^ ■\- \- ~~ I \ / \ 1 k / V I V --, A, N. , /' V _ , _, _^ , Temperature-Chart of Ordinary Case of Measles. Measles — Defervescence by Crisis. away. In an average case the fever falls by crisis — that is, within thirty-six hours after the first decisive fall (Fig. 15). During the stage of invasion charac- teristic catarrhal symptoms show themselves in the mucous membrane of the nose, eyes, throat, and bronchial tubes. These symptoms are summed up under the term "coryza." The eyes grow intolerant to light, the conjunctiva is hypersemic, the nose "runs," the eyes, nose, and throat itch and burn — sensations but partially relieved by more or less sneezing and cough. The uvula and soft palate now show dark-red spots, and later diffuse redness, the so-called enanthem, the first appearance of the eruption. Bronchitis, the result of direct invasion of the bronchial tubes, belongs to measles as def- initely as the eruption. In an average case the first evidence of affection may be a disturbance of disposition. The child, usually cheerful and animated, becomes listless, indif- ferent, fretfid, feverish ; or attention may be first attracted to the (ihild by a sudden fit of sneezing not to be accounted for by any perceptible exposure. Irritation about the nose is further manifested by itching and burning, which the patient may attempt to relieve by manipulation. It is observed also that COURSE OF THE DISEASE. 239 the eyes arc reddened and tears flow over upon the face. The dryness of the nose felt at first is soon relieved by a discharge of watery fluid, which may accumulate to trickle down upon the upper lip. There often is complaint of dryness and soreness in the throat, inspection of which frequently at once dis- closes dark-red spots about the uvula and soft palate, some of which may coalesce to present more or less extensive erythematous discolorations of the surface. There is the same evidence of irritation in the bronchial tubes. The cough is more or less frequent and distressing, and auscidtation may reveal an abundance of drv rales thus early in the disease. So Ions: as the bronchitis is confined to the larger tubes all physical signs may be absent. As a rule, these catarrhal signs are obtrusive. They mark the onset of the disease unmistakably as regards the diiferential diagnosis between this affection and scarlet fever or small-pox. These signs may, however, be very slight (morbilli sine catarrho), wiien the nature of the disturbance may be revealed only by careful study of the tem- perature. It is seen that the temperature rises to 100°-102° F. in the evening, and that it does not entirely subside on the next day. It is, however, as a rule, very irregular during the period of invasion. It may fall to the nor- mal on the second day, to rise slightly on the third, and maintain itself at this elevation or fall again on the fourth or even the fifth dav, to meet its characteristic elevation with the appearance of- the eruption. The irregularity of the temperature during the period of prodromata speaks thus more definitely for measles, as the temjierature of scarlet fever, as a rule, is a continuous eleva- tion up to the period of the eruption. An association of catarrhal symptoms, more especially the presence of an enanthem, with a light rise or irregular course of the temperature during the first few days, ainiounces the advent of measles. The stage of invasion lasts, as a rule, three full days, exceptionally four, still more exceptionally five or six. The four temperature-charts here reproduced (see Fig. IG), adapted from Henoch (translated into Fahrenheit), illustrate varieties of invasion in per- fectly normal measles. The affection of the upper respiratory tract is a feature of measles so con- .stant as to have been always recognized from the beginning of time. This feature assumes especial value in the colored race, where the discolorations of the eruption proper may be but indistinctly or not at all observed. It is rather the rule tlian the exception that even as early as the end of the first day, certainly by the end of the second, the hypcMwmia which marks the catarrhal process in the throat, more especially the palate, is so intense as to produce the appearance of an eruption. Dark-red spots, varying in size from that of a pin's head to that of a ])ea, are phiinly visibh- upon the palalc and uvula, presenting at times a distinctly spotted appearance. The nuicous mem- brane of the lii)s, of the cheeks less frequently, occasionally (he conjunctiva itself, may show the same spots, the so-called enanthem, which disapjicars as a rule entirely before the true eruption shows itsclldn the skin. The enanthem extends also to the deeper mucosae. Steiner saw it in lit;' in the hrynx and Fig . 16. Day TEMPERATURE. 9T 98 99 100 101 lOa 103 104 105 .106 107 1 -_^ L, 2 •=z — ^ f Cc-Lcefhy E 3 ' v. '" i. 4 T^JL '^^~- — • E> Ajl/pdAX^- E 1^ B IS/I E Day TE^MPEttATURE. 97 98 99 100 101 loa 103 104 105 106 107 1 Ts^ _^ fu>T*-i a- E 4 •il._ 3vi: — ;3:r^ C<.-cca. [-— ^^ fc. i}.4xp{Zo\v E Day TEMPERATURE. 97 98 99 100 101 loa 103 104 105 106 107 1 3^<£ — _-• \ E 2 ^ Cc CuA^-ij, E 3 > IvI J Co niurvcy Ci/i/iti4 E3 4 1»I ~ — -^ E 5 I^ ^ E 6 •• J^ z4:/i^ei. us E 3 1 lyt a-* E 4 IvI -% E 5 ^ Ivs, none assumes such prominence as disease of the resi)iratory tract. The |)oison — micro-organism — falls upon the upper respiratory passages and is inhaled into the bronc-hial tui)cs, to lodge in its course upon the larynx and trachea. Affections of the larvnx and trachea, as stated already, sometimes assume 246 MEASLES. prominence. Even during the period of invasion the cough may assume a ringing character. The epiglottis and the surface of the glottis may show deposits of enanthem. Hoarseness, pain, and dysphagia occur in certain cases. Cough is sometimes so continuous as to harass the patient during the day and exhaust the strength from want of sleep at night. It has at times an exquisitely croupous clang, wholly of nervous or muscular origin, and totally independent of the slightest deposit in the way of false membrane. These symptoms usually disappear with the outbreak of the exanthem : tlie cough ceases and the voice clears up. In exceptional cases, however, the catarrh of the larynx assumes a more formidable character. Exudation takes place ; the epithelial cells undergo transformation ; genuine false membrane — that is, croup — develops in the throat, fortunately however, only as a great excep- tion. It must be remembered also that diphtheria itself may coincide with or follow measles. In fact, measles rather predisposes to, or prepares the soil for, the development of diphtheria. In all cases of laryngeal complications the condition of the larynx should be definitely ascertained, when possible, by the use of the laryngoscope. Bronchitis belongs to measles as an integral factor in the history of the disease. So long as it remains confined to the largest and medium-sized tubes it is unattended with special danger. There is, however, the constant tendency to the extension of the disease, and capillary bronchitis and catarrhal pneu- monia are the most frequent and the most grave com])lications. The mortality of measles is really due to this cause. Catarrhal pneumonia may set in at any stage of the course of measles. Where it begins early it usually delays or disturbs the eruption and leads to its irregular development or disposition. Where it begins late it may actually, though it does not usually, cause the eruption to suddenly disappear. Catarrhal pneumonia is commonly announced by a more or less rai>i(l rise of temperature, increase in the frequency of the pulse, and rapidity of respi- ration. Dyspnoea is at times intense. There is pallor of the face, which soon shows signs of cyanosis about the lips. There is rapid play of the alse nasi. Respiration seems often almost too quick to count — the " breath flies." The pulse cannot keep up with it. Its relation to the pulse must be men- tioned later on. The supra- and infraclavicular spaces, the jugulum, the inter- costal spaces, the epigastrium, are deeply drawn in with each act of ins])iration as if by some powerful internal suction force. The vesicular murmur is drowned under the abundant, diffuse, dry, and moist rales. Bronchial respi- ration may be sometimes detected, along with dulness to percussion in the lower, occasionally also in the middle, lobes, especially at the posterior inferior aspect of the chest. Any elevation of temperature after the entire disappearance of the eruption should at once excite the suspicion of broncho-pneumonia. This is the time at which this complication most frequently occurs — that is, during the period of resolution — and \\\q complication assumes gravity in direct correspondence with the age of the patient. In sucklings it is almost universally fatal. The AByOIUIITIES, COMPLKWriOXS, AXD SfJQUEL.E. 247 heart is rarely affected either in the course or se(][iience of measles, yet cases have been rejiorted of endocarditis, myocarditis, and pericarditis — the last sometimes with suppuration — by Rilliet, Barthez, J5ouillaud, and Thomas. Com])lications on the part of the digestive system are very frequent. Sometimes stomatitis develops, or various mycoses may occur in the mouth, chiefly in neglected cases. The tongue presents, as a rule, only the furred appearance that belongs to all intense or febrile processes. It very rarely displays that enlargement of the fungiform papillte so commonly observed in scarlet fever. As. in all infections, the invasion may open with vomiting. Distress on the part of the stomach is, however, much uiore infrequent in measles than in scar- let fever, from the fact that the toxaemia of measles is so much less. A much more frequent complication is that form of intestinal catarrh which shows itself in diarrhoea. Certain epidemics are characterized by the frequency, and at times the severity, of diarrhoea. The discharges may become so profuse as to lead to rapid prostration, or in some cases tormina and tenesmus with dis- charge of blood impart a dysenteric character and may lead to raj)id collapse. As a rule, however, the intestinal catarrah is light and vields readilv to treat- 7 7 ~ • ». meut and to time. Nephritis is rare : Kassowitz reported a number of cases. The urine showed albumin, blood, and casts, and there was dropsy in the clini- cal history. Nephritis is, however, as rai'c in measles as it is common in scar- let fever. Loeb called attention to the fiict that propeptone may be found in the urine of measles. Propei)tone (hemi-albuminose) is a mixture, according to KUhne and Chittenden, of four different albuminoid bodies like serum, albumin, and globulin. It is deposited by heat and nitric acid, but, unlike them, only after the process of cooling. Propeptone occurs, however, in so many and such varied diseases as to have, at present at least, no diagnostic value. Complications on the part of the nervous system are fortunately very rare. In very young or very sensitive children the disease is not infrequently announced by epileptiform convulsions. Headache belongs to the fever as well as to the catarrh. Somnolence, sopor, stupor, light delirium, occur in the height of fever without exciting any especial apprehension. Yet graver symp- toms have been recorded. Strabismus, tetanic contractions, cataleptic states, maniacal attacks, have been observed in exceptional cases. It is essential here to bear in mind the relation between measles and tuberculosis. JSIany of tliese cases of grave cerebral complication are expressions of basilar meningitis. With its intense hyperocmias, especially in the lungs, measles often awakens quiescent bacilli, and liberates them from the bronchial glands to be distrib- uted over the body. Measles is, in fact, the most frequent exciting cause of tubercular meningitis. Comi)lications on the part of the organs of the special senses concern more particularly the eye and ear. Measles is often announced by conjunctivitis. Photophobia and pain in the eyes belong among the earliest signs of llic dis- ease. Extension of this process t(t the deeper structures may lead to danger- ous lesions: ulcerative keratitis, kera(o-malacia, irido-cyclitis, and plithisis 248 MEASLES. buibi have been recorded, Tobeitz calls attention to the evil influence exerted by measles upon previous — /. e. old chronic or subacute — affections of the eye. The ear is by no means so frequently affected as in scarlet fever. In many cases, however, aural disease assumes prominence. Cordies considers the affec- tion as a simple catarrh of the cavity of the drum, which is the result, accord- ing to Tobeitz, of direct extension of the rubeolar process from the throat through the Eustachian tubes. Otitis media may ensue, with perforations of the membrane of the drum. The aural affections, when they occur, are usually milder and less destructive than those of scarlatina. In his latest report Blau calls attention to the necessity of the early recognition of aural disease in measles. Measles is, he declares, the cause of 2 to 10 per cent, of all dis- eases of the ear, and of 8 to 10 per cent, of all cases of suppurative otitis media. Affections of the labyrinth, due to the invasion of pathogenic micro- organisms in the course of measles, have been studied and reported by Moos. Particulars here belong to the domain of aural pathology. Any of the various complications of measles may become sequels. They may survive the natural duration of the disease, be ])rotracted into conva- lescence, or may develop after convalescence has been established. The various affections of the eye and ear, ulcerative processes of the skin, caries of carti- lages and bones, as of the nose and alveolar processes of the jaw, set in in cer- tain cases, or the hgemorrhagic diathesis may be imprinted upon a case in the course or convalescence of the disease. Pertussis is very wont to supervene. The coincidence of whooping cough and measles has long been noticed, and the relation of these diseases to each other is rather intimate. The occurrence of whooping cough in the course of measles or the development of measles in the course of whooping cough intensely aggravates a prognosis which might be, and is, as a rule, naturally mild for either disease alone. These cases are exceedingly prone to the develojmient of more persistent diseases of the lungs. Not infrequently they more directly and quickly take life by exhaustion and collapse. The sequels at all times most to be feared are broncho-pneumonia and tuberculosis. In a very delicate or debilitated child, esjiecially in ev^ery case brouglit up in the atmosphere of infection, the danger of these diseases is immi- nent, and the symptoms which announce the advent of either are awaited with apprehension. At any time during the course of the ordinary bronchitis of measles the infection may extend to involve the minuter bronchi and air-cells, and the complication announces itself at times so insidiously as to escape rec- ognition. The increase in the frequency of respiration is, as stated, a most frequent ])recursor. The respirations increase to 40, 50, 60, or even 80, in tlie minute — an increase out of all proportion to the rapidity of the pulse. The ])ulse-res])i ration ratio becomes 1 to 2 instead of 1 to 4 — a much more significant factor in the development of pneumonia than mere increase of frequency alone. The respiration becomes as shallow as short. A child is incapable of sustained effort. The child at the breast must frequently release its hold to breathe. It loses the ability to make a continuous crv. Children niA GXOSIS. 249 that may continue to nurse uninterruptedly or may utter a prolonged cry have no catarrhal pneumonia. Henoch makes a fine critical comment in saying that " it is a good sign when the child makes the physician wait to hear its respirations in an auscultation of the chest." The physician may become reconciled to the loss of time in this investigation. Attention must be paid to these factors, because the physical signs of this complication or sequel are so delective. They may often not be dissociated from the signs of finer bronchitis, at least not until retraction of the inter- costal spaces and the sinking in of the spaces about the clavicle and the epigastrium indicate occlusion of the lungs. Signs or absence of signs in the islets and tracts of condensation of catarrhal ]>ncumonia are alike drowned under the universal moist and dry rales of diftuse bronchitis. So much more important become the studies of the temperature. Any sustained elevation of temperature after the eruption, or any evening exacerbation of temperature in the course of convalescence, should excite the suspicion of broncho-pneu- monia or tuberculosis. The skin often feels hot in these cases. The mother calls attention to the heat of the skin, or the physician is struck by it on application of the hands or more especially of the side of the face in auscultation. Elevations of temperature not so marked, noticed more espe- ciallv or perhaps exclusively in the evening, indicate the insidious develop- ment of tuberculosis ; and this indication assumes all the more value in the presence of anorexia and progressive emaciation. The child does not gain strength ; it becomes peevish and fretful ; toward evening is excitable, difficult to put to sleep, seems disturbed in its dreams, continues to cough, always of course without expectoration, sweats at night, shows later perha])s some diarrluea and marasmus : this is the history of a developing tuberculosis. Above all other diseases, as stated already, measles liberates tubercle bacilli from bronchial glands. This is probably the true relation of these diseases. The primary infection is a thing of the past. Penetration to the bronchial glands has been favored by coddling, by the house climate, by various medi- cations, by the administration of cough-mixtures or opiates, under the cover of which the disease has secreted itself in the recesses of the lungs — to wit, the bronchial glands. Measles, with its hyperaemia and its bronchial and pulmonary congestions, irrigates the soil, swells the glands, and arouses dormant or quiescent seed into active life. Ziemssen long ago called attention to the revelations of the laboratory with reference to cervical glands, in that they so often contain tubercle bacilli hitherto quiescent ; and the same con- dition has been revealed of the bronchial glands, which may be called nurture .soils of the tubercle bacillus. Diag-nosis. — The diagnosis is easy as a rule. The prevalence of an epidemic or existence of other cases, escape from attack hitherto, are points in circumstantial evidence. Measles is din'crentiated fruni a simple catarrh or a corvza bv its higher temperature, by the eiiMuthem on llic secdud or third day, and by the exanthem on the loiiith day ; iVoin hay fever by the period of occurrence and the history of repeated attacks of liay fever, as well as by 250 MEASLES. the eruptions of measles; from simulating drug eruptions, as from copaiba, quinine, and the various antipyretics, by the history of the case and the imme- diate supervention of these eruptions without })revious coryza ; from roseola by the more uniform redness, of lighter color, more limited range, but shorter duration, with the absence of fever characteristic of this affection, if this affec- tion may indeed be specialized. Papular erythema, which may coarsely resemble measles in the face, is distinguished by its localizations elsewhere, upon the forearms and backs of the hands and feet, as well as by the absence of fever, catarrh, and bronchitis. Measles must be separated from typhus fever. The distinction seldom comes in question, because typhus occurs only in certain places, and is, in general, on the road to extinction. Typhus fever in itself closely resembles a bad case of measles, in that the disease is so contagious, the liability so uni- versal, and in that the eruptions may be, at first at least, much alike. Typhus fever, like measles, begins suddenly, often in the midst of perfect health. There is from the start more profound prostration in typhus, and, with the very inception of the disease, overshadowing symptoms of mental dulness, drowsiness, sopor deepening into stupor, which readily passes over into coma. This is the cloud about the brain which has given the name to the disease. It is present in only the worst cases of measles. Typhus has no exanthem and no catarrh. The eruption of typhus appears on the third day, first upon the chest, to extend thence over the entire body, but to spare always or nearly always the face. A peculiarity in the eruption of typhus fever is the fact that by the third day the spots, which may have hitherto resembled mea- sles, aggregate themselves into points of pin-head size, filled with black blood, the so-called petechise. Another very distinctive peculiarity is the fact that the temperature does not fall with the full appearance of the eruption. Disregarding diurnal variations and accidental complications, the temperature of typhus maintains itself at about the level at which it began up to the twelfth or fifteenth day — a duration which is never seen in measles except as the result of obvious complications. Morbid Anatomy. — The morbid anatomy of measles does not differ much from that of the other exanthematous diseases. What studies have been made concern chiefly the changes found in the skin and the condition of the lungs in pulmonary complications. Neumann found the vessels of the skin dilated and hypersemic, crowded in the upper portions of the cutis with round cells. Sweat-glands, which were also dilated, were invested in the same way, their coils and ducts packed with thickly-crowded round cells. Round cells accu- mulated also about the sebaceous glands and insinuated themselves between the muscle-cells in the skin. This inflammatory process distinguishes itself in measles by its more superficial character. The upper layers of the skin were affected rather than the deeper layers, as in scarlatina. Gerhardt and Coyne studied the changes observed in the larynx. They could still discover evi- dences of catarrhal affection, swelling and thickening, and desquamation of the epithelium, and in some cases suppuration, as in the conjunctiva. Coyne PROGNOSIS.— TREA TMEXT. 251 distinguished the affection of tile larynx as an erytliematous laryngitis. He found it in connection with capillary hypcrffimia and with accuniulation of white blood-corpuscles about the glands and vessels. The epithelium had been often more or less denuded, and the interglandular spaces filled with numerous lymph-corpuscles. Tobeitz, as the result of his investigations of the pneumonic process, observed the disease to start always from the finest bronchi in invasion of the air-cells. The affection differed in no way from the broncho-pneumonia or ciitarrhal pneumonia originating in the course of any descending bronchitis. The cellular elements exuded are excessively prone to decay. Bartels had made all these observations before. The hypersemia, with caseous degenera- tion of the bronchial glands and liberation of their contents, more especially of tubercle bacilli, has already been sufficiently described. Black measles showed the changes in the blood and parenchyma of organs to be seen in all cases of grave infection, more especially in true typhus. Prognosis. — The prognosis in general is favorable. The mortality of measles, •per se, is almost nil. Death seldom or never occurs directly from the disease, but from complications, previous debility, and bad surroundings. Thus, Pott found as the cause of death pneumonia and capillary bronchitis in 21, and croup in 3, of 24 cases. The mortality of the disease in hospital and tenement-house practice is quite different from that of private practice. It is not uncommon to observe a mortality of 30 per cent, under bad surroundings, and the range would be still higher if it included the subsequent cases of tuber- culosis which have come to light in consequence of measles. The mortality stands also in quite direct relationship to the age of a child, and diminishes from 50 per cent, under two to 15 above this period. The ravages of the disease among savages, as among our own Indians, were due wholly to lack of sanitation. Treatment. — Prophylaxis is almost impossible. Sickly, debilitated, more especially tuberculous, children should be removed from infected houses. The liability of infection by third persons and things is by no means so great as in scarlatina ; hence the necessity of withholding other members of the family such a length of time from attendance at school and association with others is not so imperative. The treatment is purely expectant and symptomatic. Full and free ven- tilation at a temperature of 70° F., a night-gown without under-wear, light but sufficient bed-covers, absolute cleanliness, water and milk ad libitum, sup- ply the requisites of treatment for an average case. Fever above 103° F. is best controlled by warm baths, which may be gradually cooled, or by the occasional administration of phenacetin in doses of from 3 to 5 grains, more especially in relief of associated nervous distnvss. Burning or itching of the skin is best relieved by warm baths, with subsequent anointment with vaseline or cocoa butter. Photophobia calls for smoked glasses or shading of the eyes in the disposition of ihf ifcd or screens, rather than for darkening of the room, an (.lijcctioMablc j)rocedure. A drop or two 252 MEASLES. of a solution of morphine containing 4 grains to the half oance or of atropine (1 grain to the ounce) allays any extreme irritation of the eyes ; smearing the edges of the lids with an ointment of hydrargyrum oxiduni flavum (gr. v. to ^ss of ungueutum petrolei) will usually prevent or cure blepharitis marginalis and keratitis. Simple pure vaseline or boric-acid ointment (gr. xv to §ss), snuifed into the nose, will generally relieve the sense of dryness and irritation in the nose and throat. The instillation of hot water or of a drop or two of the solution of atropine (gr. j to 5J) will often quiet earache. Evaporation from a piece of cotton saturated with chloroform held close to the meatus is often equally effective. Gastric distress and vomiting may require cracked ice, sips of hot water, lime-water, and milk (in proportion of one-third), bismuth (.^ss to sj), or chloral (2 to 5 grains), rectal injections of sodium bromide (gr. x— xxx to f ^ij of water), or of chloral (gr. v-x to 5J of water). Few cases of vomiting from any cause will resist chloral if its absorption can be secured. Nervous symptoms may call for sodium bromide in doses of 10 to 30 grains largely diluted, or from 5 to 10 grains of chloral or phenacetin suffice for a lighter case. Haemorrhage and prostration demand alcohol, best given in the form of brandy; black coifee; turpentine, in doses of 5 to 15 drops, briskly stirred in a wineglass of milk ; or nitro-glycerin, in doses of 1 drop of a 1 per cent, solution, in whiskey and water ; possibly opium (best in the form of the camphorated tincture, in doses of 5 to 40 drops), or codeine, in doses of |- to ^^ of a grain, may substitute morphine for more continued use; carbonate of ammonium, in doses of 5 to 10 grains, in milk ; ergotin or preferably sclerotinic acid, in doses of from ^ to |- a syringeful, may be required. The syrup or wine of ipecac, to which may be added, if necessary, a small quantity of Dover's powder, preferably in the form of a syrup, suffices to restrain any excess of cough. The following is a good prescription for a child in relief of cough : I|ij. Apomorphin. hydrochlorat., gr. ss ; Acid, hydrochlor. dil., gtt. x ; Syrup., |ss ; Aquse menthse piper., ^jss. — M. Sig. Teaspoonful every two or three hours. Diarrhoea requires at first no control. I^ater, as the discharges become more abundant or colliquative, it may be restrained by bismuth, to which may be added if necessary a drop or two of tincture of opium. An improvement on a time-honored remedy may be written as follows : ^,. Tinct. opii, gtt. xl-3;j ; Acid, hydrochlor. dilut., gtt. xl ; Aquse camphorse, ad siv. — M. Sig. A tea- to a dessertspoonful every two to four hours. TREA TMEXT. 25^ Broncho-pneumonia calls for stimulation of tlie respiratory centres as well as of the heart. These centres are best reached by warm baths with cold ati'usions to the head. A rapid respiration, a quick pulse, cold surface, somno- lence, and delirium call for baths and baths, repeated baths with cold affusions, together with the use of the analeptics — camphor, benzoic acid, ether, musk, nitro-glycerin, caHeine, and brandy. Gangrene of the skin, noma, ulcerative processes, caries of bone, are best treated with caustics, carbolic acid, solutions of corrosive sublimate, the actual cauterv, or applications of iodoform. In all these cases alcohol must be ad- ministered abundantly. Cod-liver oil, ]Mire or with malt extract, iron, arsenic, out-(K»or air, fresh air, for the inlander especially sea-side and mountain air, with good food, pleasure, and peace of mind, are the best reconstruct ives during and after convalescence. RUBELLA. By JAMES T. WHITTAKER. Definition. — A specific, feebly contagious, acute infection of short dura- tion, characterized by the absence of prodromata, the presence of an eru})tion simulating that of true measles, faucial catarrh, and enlargement of the lym- phatic glands. Synonyms. — Rubella, diminutive of rubeola, from ruber, red ; R5thelu, diminutive of roth, red ; German measles, French measles, because described by German and French observers, really first isolated by an English physi- cian ; Hybrid measles ; False measles, etc. The word " rubella," which seems to have been first recommended by Veale (1866), soon met with general acceptance. The Germans still call the disease rubeola, our term for measles, which they still call raorbilli. The French distinguish it as rubeole, in distinction from rougeole, true measles. The popular designation in Germany is rotheln, a term recognized by scholars everywhere, and as commonly used by writers in Germany as is measles in our country. Rotheln can never be adopted among English-speaking people. The sound of o with the umlaut cannot be translated. The name is therefore too distinctly racial for universal acceptance. Rubella means exactly the same thing. No valid objection can be urged against the name rubella as indicating a diminutive of rubeola, and as permitting, however akin to rubeola, the recognition of an independent malady. The universal acceptance of the term varicella, which has a similar relation to variola, establishes a perfect precedent for rubella and rubeola. Bergen, who described it among the roseolse in 1752, first maintained the view that it should be separated from measles and scarlet fever, but it was reserved for an English physician, Maton, in 1815 to establish the individu- ality of the disease as based chiefly upon the observation that, though self- protective, in that one attack confers future immunity, it does not protect against either measles or scarlatina. Nor do these diseases protect against rubella. There was almost up to the present time — in fact, there is yet — much lack of harmony regarding the true nature of this affection. K5stlein in 1865 still considered rubella a variety of measles. Striimpell, on the other hand, declares that only they who have never seen it deny the existence of the dis- ease as an independent malady. Heim looked upon it as an anomalous scar- latina. Hildebrandt regarded it as an intermediate or hybrid form of measles 264 ETIOLOGY. 255 and scarlatina — a view whicli lnul singular fascination for many authors, including such close observers as Gintrac and Hebra. Barthez and Rilliet, Eniiuinghaus, Gerhardt, Griffith, Hardaway, Murchison, Roger, Steiner, Thomas, Thierfeldcr, Trousseau, AVilson, all acknowledge the individuality of rubella, while Faggc, Henoch, and Stewart still deny it. It is certain that epidemics of rubella may prevail apart from epidemics of measles and scar- latina. It is also established, as stated, that an attack of either scarlatina or measles gives no immunity from rubella. Again, an attack of rubella does not exempt the individual from attacks of measles and scarlet fever. AVhile more closely allied to measles than to any other disease, it is not hence to be regarded as a subvariety of measles, but as a distinct and separate affection whose cause is sui generis. Rubella stands in relation to rubeola not as vari- oloid, but as varicella, to variola. It certainly differs from both measles and scarlet fever in its contagiousness, mode of invasion, symptomatology, dura- tion, and decline. Etiology. — Though much less contagious than measles, and hence much less frequent, the disease is decidedly more prevalent than commonly believed. IVIany cases are mistaken for measles, and most of the so-called successive or repeated attacks of measles are really rubellse. Rubella is certainly distinctly contagious, and the contagium increases in virulence with the number of cases and with defective hvgiene. As to the intensitv of its contagion, authorities differ. Nymann, Picot, and Arnold think it but feebly contagious ; Thomas and Bonrneville regard it as less contagious than measles ; Jacobi and Squire consider it eminently contagious, and maintain that the contagiousness is man- ifest before the appearance of the eruption and persists for several weeks after its disappearance ; Atkinson claimed that it is less contagious than measles, and Edwards concludes that it is one of the most contagious of all the erup- tive fevers; Griffith states that 37 of 100 children in a "home" which he attended contracted the disease, notwithstanding the most prom))t and careful isolation; and Edwards quotes from Hatfield that 110 of 196 inmates of an asylum suffered from the disease. The disease is propagated also by third persons and by things. The bedding of steerage passengers has been known to conceal and convey contagion for a long time. From the nature of the disease the cause of rubella must be a micro-organ- ism, but the specific structure has not yet been isolated. Micrococci have been observed in the blood, but without any other evidence of positive rela- tionship. Rubella occurs at all ages, rarely in inliuicy ; 75 per cent, of cases occur before the age of fifteen. Childhood is thus the period of greatest liai)ility, but susceptibility to it is so much less than to measles that the majority of people escape it throughout life. Sholl saw the enq)ti(m in a newborn child ; Steiner and Roth report cases in infants under six mouths. These cases arc regarded as exceptions. Attacks in adtdt life are ihikIi more frequent than attacks of measles — first, because the susceptibility is not so universal, so that childhood often escapes it ; and sccoudly, because epidemics prevail :i( much 256 RUBELLA. longer intervals. Adnlts have, however, immunity in high degree. Kasso- witz observed but five cases in adult life. The range of liability in regard tO' age is illustrated by the possibility of attack in advanced life. Seitz recorded a case in a woman aged seventy-three. Symptoms and Course. — The period' of incubation, two to three weeks, is uncommonly long, while the stage of invasion or prodromal stage, half a day to one day, is uncommonly short. An initial chill is exceptional ; malaise, pain in the head, back, or joints ; anorexia, rarely vertigo ; very rarely more pronounced distress on the part of the nervous system, — more or less immediately usher in the eruption and affection of the mucosae and glands. Not infrequently the appearance of the eruption, totally unprefaced by any fever, is the first sign of disease. The eruption appears as minute rose-red maculae, discrete or confluent, " like dark red ink pen-points in white blotting- paper," on the forehead and temples, spreading quickly over the rest of the face, neck, and trunk, to reach its full efflorescence and begin to fade in twenty-four or thirty-six hours. By the third day, as a rule, all signs of eruption disappear without desquamation. Coincident with the eruption is a rise of temperature to 99°-101° F., very exceptionally to 102°-103° F. Hypersemia of the conjunctiva, with photophobia and epiphora, of the nasal mucous membrane, with a sense of dryness and irritation, with sneezlno^ or with increased discharge, more especially hyperaemia or visible enanthem of the fauces and pharynx, may precede the eruption during the stage of inva- sion when it occurs, to coexist with the eruption and remain after it as late as the fourth day of the disease. Affection of the glands constitutes a much more distinctive feature of rubella. The cervical submaxillary and occipital glands, more rarely also the glands of the axilla, elbow, and groins, become swollen and tender, limiting the movements of the head at times in the swelling and stiffness of the neck. These adenopathies, Avhich exist in 50 to 75 per cent, of cases, disaj^pear entirely in two or three days. Abnormal cases show only an eruption or only affection of the glands. The reviewer of the literature of rubella is struck with the variety of opinions encountered regarding every feature of the disease. In this regard rubella differs radically from rubeola. True measles has a distinct history and a singular uniformity of symptoms. All competent observers agree in the main regarding the period of incubation, the stage of invasion, the character of the eruption, etc. The occasional abnormalities and irregularities are to be accounted for by the condition of the patient and the character of his surround- ings, rather than by any difference in the nature of the disease, expression, order, or sequence of its symptoms. In rubella, on the other hand, scarcely two observers agree, and the differ- ence at times is so marked as to lead to the belief ^hat different affections are being observed or described. It is questionable if the disease commonly described as rubella be a distinct or single affection. Competent observers, as stated, still maintain it to be a subvariety or hybrid form of scarlet fever,, SYMPTOMS AND CO UBS E. 257 or more especially of measles. It certainly most dearly simulates measles. The admission of the disease as an entity depends almost wholly upon its independence of measles or scarlet fever. This fact does not exclude the exist- ence of more than one malady. Thus the period of iucuhation has been fixed in its descrii)tiou at two or three weeks. Griffith, Glaistor, Sholl put it at five to ten days, Steiner at ten to fourteen days, Jacobi at fourteen to twenty-one days, Cotting at three weeks. Edwards fixes it at certainly between ten and twelve davs : the short- est period recorded in his experience was six days, the longest twenty-one. In the observation of the author the stage of invasion has been always free of symptoms. Grave symptoms have, however, been remarked by others. Smith saw convulsions ; Hardaway, delirium ; Priolcau, haemorrhage from the eyes and ears ; Nymann, vertigo ; and various eruptions have been noticed by others. The disease is announced generally by the eruption, which appears so quietly at times as to be noticed for the first time in the morning on awakening from sleep. It shows itself first upon the fiicc, and spreads, as a rule, so rapidly over the body and extremities as to seem to show itself everywhere at the same time. Patterson indeed declares that it comes out universally. Occasionally it is very sparse and circumscribed. Edwards says that he has seen it confined to a small part of the brow, face, and neck, and so scanty as to have made a diag- nosis impossible had it not been for the presence of other cases. It is usually entirely discrete, but becomes confluent at times on the face or upon surfaces kept warm by apposition, as in the flexures of the joints, about the groin, etc. As with all the eruptions, it is more pronounced under hot applications, poul- tices, embrocations, etc. Griffith says that he saw it once in circular bands about the leg above the knee, in the line of the garter. Klatsch made a similar remark. The character of the eruption diffin-s in every particidar in the description of diffi^rent authors. Hcim gives it the color of red ink on white paper. Tiiomas declares that it is not so red as that of scarlet fever, nor so blue as that of measles. It is usually entirely macular. Aitkin dcelares that it is more elevated than measles. Griffith felt induration like shot under the skin. Cases have been described as so closely simulating measles or scarlet fever as to have justified the designations rubella morbilliforme and rubella scarlatini- forme. Harrison, Copeland, and Goodhardt claim that it may resemble either measles or scarlatina. Byers, Picot, and Henderson saw cases where the erup- tion was morbilhTorm in one part and scarlatinifi>rm in aiiotlicr part (if the same patient. Dukes and Kassowitz declare that it may resemble measles, and Murchison and Tonge-Smith declare that it simulates scarlet fever. These statements are from Edwards, who made an exhaustive study of the authorities, and adds: "This list could be almost iudcfiiiitc^ly prolonged, but to no ))ur- pose. Sufficient has been cited to show that the eruption of rubella is iudi'cd multiform in character." The eruption disappears, as a ride, iu twenty-four to thirty -six hours: Vol. I.— 17 258 RUBELLA. Emminghaus savs in from two to four days ; Klaatash, in from one to five da3'S ; Liveing, in from five to seven days. Tlie eruption disappears, as stated as a rule, without, or with but very sh'glit, desquamation. When present, desquamation is always furfuraceous. Sometimes it is best marked in the throat. Slight fever to 100°-101° F. is the rule. Exceptional cases show high temperatures. Haig-Brown recorded 105° F. ; Davis, 106°, with a hseraor- rhagic eruption and convulsions ; Wunderlich declared that many cases show no fever at all; and GriiBth reported a case of extensive eruption marked by the complete absence of fever. Sore throat, faucial catarrh, is observed in the majority of cases. There is perhaps, more unannimity of opinion upon this symptom than upon any other. Hypersemia of the throat shows itself sometimes in an enanthem like that of measles. The infection may also involve the larynx, and occasionally the bronchial tubes. The most characteristic symptom is affection of the lymphatic glands. Few writers — among the most noted Kassowitz — failed to mention its frequency. The distinguishing feature of the adenopathy is the universal involvement of the glands. The cervical, occipital, submaxillary, and sublingual glands are often all involved. Park found distinct adenopathy in the neck and under the tongue in 50 per cent, of his cases. The affection may extend so as to involve, as stated, the axillary and even the inguinal glands. The diagnosis is made to rest largely upon this extensive implication of the lymphatic glands, measles rarely showing any such affection. Scarlatina shows it as a rule, but the swelling is confined almost exclusively to the glands and interglandular tissues below the jaws. Scarlatina never, or almost never, affects the cervical and post-cervical glands. Few observers w^ould, however, be prepared to go so far as Osborn, who claims as a pathognomonic feature of rubella — one so constant in its occurrence, he says, that when observed there can be no longer doubt — " an enlargement of the small glands just about the edge of the hair on the postero-lateral sides of the neck." This feature was never absent in any case which he saw. Gastro-intestinal disturbance corresponds in severity rather with the fever than with the eruption. It is usually absent or, if present, but trivial and transitory. It is a rare case which shows the intensity of disturbance not infrequently seen in measles and observed as a rule in the inception of scarla- tina. The "strawberry tongue" of scarlet fever is never seen. It is commonly said that rubella has neither complications nor sequelae. This is true, however, only of the average or milder case, especially as observed in j^rivate practice under favorable hygienic conditions. In hos- j)ital and tenement-house practice complications are not so rare, though they are by no means so common as in measles. Bronchitis may become excessive. Edwards saw pneumonia three times, Griffith twice in 1 50 cases. Stomatitis, intestinal catarrh, icterus, rheumatism, various eruptions, including pemphigus, have been remarked in individual DIA GNOSIS.— MORTALITY. 259 cases. Sequels of diphtheria, mumps, blepliaritis, keratitis, aud otitis, to be fouud in the records, must be looked upon as accidental. The light distm-b- ance produced in the lungs is evidenced by the rarity of subsequent tubercu- losis as compared with the history of measles. Re]a])ses and recurrences are very rare. Diagnosis. — As a rule, the physician is summoned to distinguish the erup- tion from that of measles. The eruption of this disease, as stated, appears earlier, often without any previous disorder; is lighter in color — a rose not a raspberry red ; is more frequently discrete, or M'hen confluent more diiFuse, not aggregated into patches; disappears completely without or with but slight desquamation in one to three days. These features, in connection with the more pronounced implication of the throat and the glandular affections, suf- ficiently distinguish the disease. Rubella is distinguished from measles, the only affection with which it is likely to be confounded, by the history or absence of a previous attack of measles, bv the existence of other cases, bv its feebler contagiousness, long-er incubation, shorter invasion, hence earlier appearance of the eruption, absent or but light or limited affection of the mucosae, more frequent and extensive adenopathies, more trivial fever, and shorter duration. Rubella is distinguished from scarlatina by the history of the individual, as stated above; by the longer incubation — two to three weeks in rubella, one day to one week in scarlet fever; by the characteristic intense sore throat of scarlet fever in contrast with the trivial catarrh of rubella ; by the violence of the invasion of scarlatina — vomiting, hyperpyrexia, often delirium and convulsions, in scarlet fever, all absent in rubella ; by the more universal affection of glands in rubella, more intense inflammation and tumefaction of the submaxillary glands only in scarlet fever; by the appearance of the erup- tion, first upon the face or iniiversally in rubella, first on the chest and neck with slower spread in scarlet fever ; by the disajjpearance of the eruption in one to four days in rubella, in four to six days in scarlet fever; by the disap- j)earance of symptoms with the appearance of the eruption in rubella, by the j)ersistence of symptoms during the eruption of scarlet fever ; by the straw- berry tongue of scarlet fever, absent in rubella; by the albuminuria and affections of the kidney in scarlet fever, absent in rubella ; by the desquama- tion, membranous in scarlet fever, absent or furfuraceous in rubella. The roseola, adenojiathies, and sore throat of syphilis could not, on account of their persistence, be long mistaken for rubella, even in the absence of all history of primaiy infection. The diff"use crvthemata of drug eruptions — antipyretics, coj)aiba, chloral, etc. — liave the history of their use, and are unattended by fever, sore thi-oat or affections of the glands. Prophylaxis. — Inasmuch as most people escape riilielia, isolation of eases ill a separate room or story of the house is, when |)ractieal)le, advisable. The mortality is almost nil. In this regard the disease has, however, the same historv as measles. Bad surroundings may impart great gravity. JI<.s- 260 RUBELLA. pital and tenement-house practice furnishes a mortality of 3 to 10 per cent., due almost wholly to complications, chief among which are capillary bron- chitis and bn^ncho-pneuraonia. Treatment, which is for the most part superfluous, does not diifer, when necessary, from that of measles. SMALL-POX. By JAMES T. WHITTAKER. Synonyms and Definition. — Siiiall-pox or pocks (pock, a bag or sac — i. e. small sacs); Variola, from varus, a pimple, a term applied in ancient times to many eruptions, first limited to small-pox in the epidemics of France and Italy, 570 a. d. (Hirsch), first used by Constantinus Africanus, 1080 A. D. (Curschfeld) ; German, Pocken, Blatter (blister) ; French, Petit v6role, — is a highly contagious, extremely dangerous, literally dreaded disease, characterized by violent onset with severe chill, excruciating pain in the back and head, by an eruption of papules, subsequently converted into vesicles and pustules, wliich leave in drying disfiguring pits or scars, and by a fever which remits at the period of papular efflorescence to increase in the stage of suppuration. Small-pox has existed from time immemorial in India, where temples were built and a goddess worshipped, and where, more to the purpose, the Brah- mins practised inoculation in protection against it. Accounts of it in Africa date also from the most remote antiquity, and the great susceptibility of the negro race lends color to the view that the disease mav have oriy-inated in these lands. It was imported into China probably about 200 a. d. Galen speaks of the prevalence of it in Rome, 160 A. D. ; Marius, of its invasion of France and Italy, 570 A. d. ; Gregory of Tours, of its epidemic occurrence in a large part of the south of Europe, 580 A. D, ; and Rhazcs wrote his famous work concernino; it in 900 A. d. Riiazes declared that while the disease had received frequent mention in antiquity, up to his time " there liad not appeared either among the ancients or the moderns an accurate and satisfactory account of it," and therefore he composed his discourse. Rhazes certainly saw small- pox and described its most striking features, especially in distinction from measles. Small-pox entered England in 1241, Iceland in 1306, but did not reach Germany and Sweden until toward the close of the fifteenth century. It was imported to America first in the West Indies in 1507, exterminating whole races of natives ; next by Spanish troops into Mexico in 1520, where it carried off three and a half millicms of j)e()ple. In the United States it reached Boston from Europe in 1649, and, though decimating the Indians in every direction, made l)ut slow progress and limited ravage aiiiung Ihc white races because of the introduction of vaccination in 1799, the period of coinmcncing Western migration. Thus it did not reach Kansas until 18.'}7:uhI California until 1850. Epidemics in South America, first in 1554, corresponded with the intro- 201 262 SMALL-POX. duction of slaves from Africa. Certain islands of Polynesia remain as yet exempt. Small-pox has now only historic interest. It is on the road to extinction, and may occur in our day in epidemic proportion only in uncivilized lands. The most modern text-books of medicine, if they describe it at all, dispose of it, as of the pest and other plagues of ancient times, in but few words. Small- pox, as we see it, occurs in the modified form known as varioloid. Cases of true variola become rarer and rarer every year. Since the general introduction of vaccination small-pox has lost all its terrors for those who recognize its abso- lute protection. In many parts of Europe small-pox patients are no longer isolated in pest-houses, but are received into the general wards of hospitals, other inmates being protected by, if necessary, fresh vaccination. The dread- ful character of the disease in former times is evidenced in our dav in no way better than by the fear inspired, the panic created, by the knowledge of the existence of a case in a community. Watson said of it — the disease may not be studied without reference to the old masters — " The horrible asj^ect, disfig- uring consequences, and fatal tendency are so strongly marked that its appear- ance has always been watched with affright by mankind in general, and with intense interest by the philosophic physician," The havoc which the disease has made in the past is apparent in the holo- caust effected in Mexico and in the veritable slaughters in India. In the two years as late as 1874-75 half a million })eople in the presidencies of Bombay and Calcutta alone fell victims to small-pox. In 1865, 7000 natives died in less than two months. It constituted 7 to 9 ])er cent, of the total mortality in England in the seventeenth and eighteenth centuries, and nearly 9 per cent, of that of the citv of Berlin in 1783-87. In France during; tiie whole of the eighteenth century 3000 people died annually of small-pox. Whole races of men were carried off in Brazil, one-third of the population in Iceland in 1707, two-thirds of that in Greenland in 1734. It is computed of the century pre- ceding vaccination that fifty millions of people died in Europe of small-pox. The human race was beaten down until men became resigned to the disease. Macaulay called it the most terrible of all the ministers of death. The dan- ger to life and disfiguration of the living, especially loss of sight, made it, to a degree of which we can have now no coneej^tion, the most dreaded of all diseases. "There is no contagion so strong and sure as that of small-pox," Watson writes, " and none that operates at so great a distance." Etiology. — Susceptibility to small-pox is almost, though not quite, uni- versal. The extent of immunity is difficult to establish in our day because of the protection of vaccination, but it was recognized in ancient times that certain individuals who came in close or repeated contact with the disease remained exempt from attack. Three distinguished physicians, Morgagni, Boerhaave, and Diemerbroeck, were said to have enjoyed this immunity, and Dicmerbroeck Avas so struck by it in his own person as to have been led to believe that the disease was but feebly contatjious. The common Eno;lish name is said by one writer to have been derived from the fact that it attacks the ETTOLOav. 2n3 small. This is true, but it is rathor oviJeiu'c of universal sustx'ptibility. Though it spares no age, siuall-pox is essentially a disease of ehiklhootl, " interrupted and postponed by vaeeination." Of the newborn, one-third died before their first, one-half before their fifth year of lite (Werner). Old synonyms of the disease (Kinderpoeken, Barnkoppen) attest this tact. Of 622 persons who died of small-pox in Kilmarnoek in 1728-64, 508 — i. €. 92.2 })er cent. — were five years of age and under ; 7 only were over ten years of age, and the oldest was but twenty-six. This exemption of maturity and age was, however, due, in some degree at least, to innnunity seeured by former attack. Accurate statistics disclose the fact that the disease occurs at all periods of life, even uj) to the advanced age of sixty and seventy, and in proportions at these times which nearly correspond to. the number of people alive at this period of life. Sucklings enjoy some immunity. Liability grows intense at the end of the first year and continues up to forty, when it becomes less marked. Pregnancy and the puerperium rather invite than repel the disease. It may certainly attack the foetus in utero after the fourth month, and children have been born in every stage of the disease. The greater liability of these periods is counter- balanced in man by his more frequent exposure, so that sex shows no real difference. Allusion has been made to the frequency and severity of the disease in ne<>;roes. This fact has been noticed not onlv in their own countrv, but in all lands to which they have been carried. The more frequent disfiguration among the colored race, which may be seen upon the streets, is due jiartly to this cause, but chiefly to neglect of vaccination. One attack confers immunity for the future, with occasional rare excc[)tions, as does also one successful vaccination, with more frequent exceptions. The lightest attack protects, as a rule, for life. This fact was proven by the results of inoculation, "the mother-])rogenitor of the beneficent vaccination." A second attack, if it occur, is usually, but not always, milder. Louis X V. of France survived an attack at the age of fourteen, but died of one at sixty-fi)ur. Aitken quotes a case reported by Ron})el of three attacks, a lady of M. Guin- net, wdio had it five times, a case by Matson of seven attacks, and one by Raring, a surgeon attacked on every attendance upon a case. The existence of other infections gives comj)arative inunnnity only during their course. The chronic diseases of the heart, lungs, kidneys, etc. do not diminish liabilitv. It has been fitund to coexist with other iidections — scarla- tina, measles, and j)ertussis. Kpidemics occur more fre(|ncn(ly in the colder seasons, partly because of the closer contact of people at this time, j)artly because of the concentration of the contagiuni in less-ventilated rooms. Boerhaave, who himself never contracted the disease, first established it^s development by contagion. The contagious principle of small-j)ox certainly exists in (lie skin, whence it is disseminated about th<' bodv of'the patient. In(»cidatiou was formerly practised wlioliv bv the nialtei- r,|' die disease in the skin. It was the eiistom 264 S3IALL-P0X. in China in the most ancient times to introduce the crusts of small-pox matter into the nose in the process of inoculation, and in India to rub the matter on an abraded skin. The fact of infection of the foetus, which is undeniable, proves that the poison exists in the blood. There is, however, no proof of the existence of the poison in any of the various secretions or excretions of the bodv. Experiments made upon man date altogether from ancient times. These exj^eriments with the secretions gave negative results. Doubt even had been thrown upon the infectiousness of the blood until Ziilzer succeeded in communicating the disease to a monkey with the blood of a variolous patient. The contagious principle has singular tenacity of life. It sticks especially to bedding and clothing, which, if kept secluded at a warm temperature, may remain infectious for months and even years. The body and bedding of a patient affected with small-pox is surrounded by the infectious matter as by a cloud or halo. In a large, Avell-ventilated apartment the danger of infection on account of dilution and diffusion of the poison is much reduced. It is certain that the disease has been contracted by an individual who has approached a patient no nearer than three feet, and it is well established that the disease may be con- veyed by third persons and by things. The contagion is given off from the body at all periods of the disease, and also for some time after death, at least up to decomposition, but not so long as to account for the cases recorded by Dr. Franklin, when he relates that ''several medical men who assisted in London at the dissection of a mummy died of a malignant fever, which it was supposed they caught from the dried and spiced Egyptian." The contagious principle or cause of the disease has not yet been isolated, the micro-organisms discovered being only those of pus. AVe have to remem- ber in this connection that the same statements were made for a long time regarding erysipelas and influenza, whose micro-organisms turned out to be quite different or to have different properties from those of pus. To speak only of the latest studies, Weigert found in the pustules (see Fig. 18) the streptococcus pyogenes, which Garr6 ascribed to mixed infection, and Guttmann found in cult- ures from pustules the staphylococcus pyogenes aureus and the staphylococcus albus. V. LoefF claims to have devel- oped in sterilized tubes from fresh mat- ter amoeboid proteids, and Pfeiffer claims to have discovered as constantly pres- ent in the exanthem of variola a parasite of the species protozoa, which runs its whole course of development in the body of man or other mammal. This parasite is a cell of round or oval form, 33 fi long by 24 fx broad, with- FiG. 18. Capillary of Skin, stuffed with Micrococci (Zuelzer). COURSE OF THE DISEASE. 265 out cilia or meaus of attachment or opening, and enveloped in a smooth mem- brane. Motion is present only in its early amwha-like stage, and reproduction occurs in the budding of" spores resembling microcowi. Pfeiffer found this ])arasite in the small-pox of man as well as in genuine cow-pox, also in that of the hog, cow, horse, pig, and goat. Vaccine matter, especially animal matter, contains fully-developed protozoa as well as spores. Judgment is reserved as to the relation to the disease of this parasite, which is studied best in hanging drops. Smaller structures, proteids and amoebse, were found by V. der Locff, in great number and much variety of form, in matter from pustules as well as from fresh animal matter examined in hanging drops. Colored with fuchsin, thev may be studied also in cover-glass })reparations. Garre thinks he discovered the cause of failure of detection of characteristic micro-organisms in the blood in the fact that investigations had been made at too late a period of the disease. Bowen states that he discovered nodules of reticular structure, with subse- quent surface pits like those of the skin, in the internal organs — liver, kidneys, lungs, and testes — but without a trace of any organisms. Weigert made the same observations, and Chiari found similar forms in the testes. Berard long ago pointed out an orchitis, and more rarely an oophoritis, as complications of small-pox. Piotopopoff examined tiiis lesion microscopically, and discovered in it three zones — a central total necrosis, a middle zone with small-cell infil- tration, and a peripheric zone with exudation. He hoped to be able to isolate the variolous principle in these studies. He examined 6 cases in boys and made cultures in glycerin agar, finding in all 6 cases a streptococcus whose macroscojMc and microscopic ajipearance resembled that of the streptococcus pyogenes. Bowen, Garr6, and Hlava reached the same conclusion. Inocula- tion of this streptococcus in animals showed in the case of rabbits that it ]>ossessed no pathogenic properties — an additional confirmation of the view of Koch and Schultze that our present methods will not suffice to discover the virus of variola. The contagious principle or cause of the disease is disseminated, as stated, from the surface, not from the secretions, throughout its whole course, includ- ing the period of incubation, also for some time after death, in greatest inten- sity with the maturation of the vesicles, so that infection is brought about both by direct and indirect contact, and the contagion may remain active, more especially in clothing, bedding, etc., as stated, for a long time. Proof of the transference of the disease during incubation was offered by Schaper in the ease (jf an individual who had ])articles of skin engrafted upon an ulcer. Tiie ]>articles were taken from the amputated arm of a man during an unsuspected period of incubaticm of small-pox. The patient who received the grafts was attacked by variola <»n the sixth day after the operation. Course of the Disease. — The period of iiicubntloii varies from ten to fourteen days. The fact that the disease oecurs at such intervals iiiid announces itself with such marked sym|)tt)ms renders observation of tliis period easier in small-pox than in nlinosf miiv other disease. It is usually 266 SMALL-POX. easy to fix the exact period of incubation of a case by recall of the exact moment of exposure. To be of value in fixing this period the exposure must have occurred, of course, but once and for a very short time. Exact results acquired in this way fix the period of incubation for ordinary exposure at from ten to fourteen days. Thus, Bjirensprung saw seven cases all infected from the same source on the same day. In every one of them the outbreak occurred between the thirteenth and fourteenth day : some of them had been vaccinated and some had not. The introduction of the poison directly into the blood is followed by symptoms sooner, as the period of incubation after inoculation is but six to seven days. There is during this period, as a rule, no disturbance in the general health. The individual is unconscious of the fact that he has become the victim of a loathsome disease. In very exceptional cases there has been noticed malaise, a sense of languor, and sometimes pharyngeal catarrh. But Curschmann, with the most pains- taking investigations, could discover these signs in but 11 of 1000 cases — i. e. less than 1 per cent. The character of the symptoms which may show them- selves in the incubation has no prognostic value. Invasion is ushered in by a chill, which is, as a rule, violent, with rise of temperature to 103°-104°- F. on the first day. Prostration may be pronounced from the start. The patient is put to bed, or if on his feet staggers as if drunk. Anorexia, vomiting, jactitation, insomnia, and severe headache set in at once. Above all other signs, pain in the loins assumes prominence. It accompanies the fever from the start, and subsides only with its fall at the apjiearance of the eruption on the third day. Persistent pain in the back (sacrum), peculiar in its intensity, constitutes the most characteristic symjjtom of this stage ; unfortunately, it is present in but little more than one-half of all cases. The initial stage of invasion — i. e. the period from the chill to the outbreak of the eruption — lasts, as stated, three days. If there be any variation from this duration, the stage is rather shorter than longer. It may be very much longer in the most grave form, known as variola hsemorrhagica or jiurjmra variolosa. The chill which announces the invasion has been characterized as violent. In this regard small-pox associates itself with malaria, pneumonia, and meningitis (epidemic). There may be, however, every variety of inten- sity of rigor, or the single severe shock, wdiich is marked by a chill, may dis- tribute itself over a longer time in several or a succession of chills of liarhter intensity. The temperature, which reaches, as a rule, 103°-104° F. on the evening of the first day, may continue to rise to reach !106° or even 107° F. by the time of the appearance of the eruption. The pulse, which runs uji to 100-120, in women 130-140, and in children 150-160, usually corresponds pretty closely with the temperature. Respiration increases in ratio more fre- quently than the pulse — to such degree in some cases as to constitute dys])noea, probably from direct action upon the respiratory centres. Gastric distress is usually a prominent feature in the onset of small-pox. Vomiting may be so severe, especially in grave or hseniorrhagic forms, as to constitute a very COURSE OF THE DISEASE. 267 serious symptom. Constipation is the rule, though diarrhiea is not iutVequeut in childhood. All these symptoms indicate the onset of a irrave infectious disease. There is, however, in no one of them anything especially or absolutely characteristic. Stress must be laid now upon the two symptoms which early assume promi- nence, and which more distinctly bespeak the character of the disease. The most frequent, if not the most distinctive, of these signs is hea may be sometimes seen spots upon the fauces, especially unoii the soil |)alale. Coryza with ])hotophol>ia and epipliora may be so marked as t(» siniiihile measles. Bronchitis is not so frcfjucnt. Inasmuch as the eruption proper does not appear until the thiid day, especial value is attached to two rashes of earlier occurr.nee in certain cases or in certain epidemics. One is petechial, the other erythematous. 268 ^SMALL-POX. Petechise may appear on the second day in the form of a fine macular or spotted eruption in the space known as " Simon's triangle," whose base is at the umbilicus, apex at the knees. It may occur elsewhere, especially in the space under the axillae. The erythematous eruption has its favorite spot on the sides and inner surfaces of the legs from the ankles up, sometimes in women about the nipples. This eruption indicates a mild case of the disease, whereas petechiae have no such prognostic value. Petechise should never be mistaken for the true hseraorrhagic eruption, which may stamp the disease from the start or occur at any period later. Both these eruptions disappear, as a rule, in twelve to twenty-four hours. They may last longer, and they may, especially the petechise, leave behind them slight brownish discolorations. The older writers, more familiar with the symptomatology of small-pox, admitted the possibility of termination of the disease at this stage. These are the cases of lightest possible infection, either by reason of natural insuscepti- bility or acquired immunity, as by inoculation or vaccination. These are the cases of so-called " variola sine eruptione." Absolute proof of the cha- racter of the infection is offered in the universally quoted cases — one is enough for proof — of the birth of a foetus in any stage of eruption from a mother who showed signs only of the stage of invasion. Additional evidence is offered in the fatal haemorrhagic form which steps in to shut out the true eruption. Subsequent eruption is final proof. The distinctive feature of small-pox is the true eruption. The symptoms hitherto described, the severity of the chill, the rapid and profound prostration, the vomiting, the pain in the head and back, should excite the suspicion of the development of the disease ; and these symptoms present themselves in the nature of almost absolute evidence in the presence of an epidemic. They may, however, any or all of them, be present in many of the grave acute affections. Occurring in an isolated and individual case, they could not in their ensemble be relied upon to declare the diagnosis of small-pox. The initial rashes fur- nish more convincing proof. This fact is not so true of the erythematous as of the petechial form. Erythema is too often an index of mere reflex disturb- ance. Petechial eruption, or that particular petechial eruption which early in the history of disease shows itself in, and is confined to, the base of the abdo- men and the inner aspects of the thighs (Simon's triangle), is surer testimony. Diagnoses have been made upon these symptoms alone, and cases have been recorded where the disease, as stated, cut itself short at this j^eriod, and sub- sequent exemption was secured. Petechise elsewhere furnish no necessary evi- dence of small-pox. These eruptions, both the erythematous and the petechial, are often entirely absent. They occur only in certain individuals and in certain epidemics. When present they are often overlooked. The nature of the dis- ease is therefore only finally and fully declared by the true eruption which shows itself on the third day of the disease. The eruption of small-pox is peculiar. It differs from that of all the acute infections. While it may show resemblance at first to the eruption of other COURSE OF THE DISEASE. 269 diseases, it soon assumes changes which distintrnish it. The eruption of small- pox runs through successive phases of development. It is at first jnipidar, then vesicular, then pustular. The pustules dry to form crusts, whicli fall to leave most characteristic scars. These phases of development mav be simu- lated to some extent bv varicella or bv svphilis, but there is ahvavs somethinor in the character, conduct, or course of the eruption over the body which enables even the superficial observer to separate them as a rule. In its very first appearance the eruption is purely mac'idar — that is, not ele- vated above the surface. In the course of the very first dav, however, so intense is the inflammation, the macule is thickened to become a papule, so that, as a rule, with its first recognition it seems lifted above the general surface. It shows itself first on the face and scalp, where it is unfortunately alwavs worst ; over the forehead and temples, then upon the sides of the nose, about the lips, over the chin, and s|)rca(]s thence downward in quite regular progression over the body. Surfaces rendered hypersemic, as by poultices or mustard plastei-s, show more profuse eruption. The hands and fingers furnish the next most favored surfaces. The eruption disappears upon pressnre, yielding to palpation a sense of hardness as of shot under the skin. By the end of the first day, as stated, it becomes elevated, and by the third day is distinctly papular. It is always discrete at first. By the sixth day the papules contain fluid ; tliey become vesicles and protrude like half peas. These vesicles are peculiar in showing later a central depression or umbilicus, which is most marked just before the vesicles change into pustules. The depression is explained in tiiis way : The vesicle is not a single sac. It is reticulated — i. e. many-celled — in structure, so that puncture evacuates only part of its contents, and the bands which form the reticula hold down the surface more firmly at one point, perhaps the site of a hair-follicle, sweat-gland, or firmer strip of connective tissue. Effusion takes place between the upper and lower layers of the ej)idcr- mis with the dissolution of these bands. In three days more the umbilicus disappears, the vesicle becomes a pustule, which is full, round, and large ; the half becomes a whole jiea. With the coalescence of pustules dividing walls are broken down, dissolved, and eroded. The eruption becomes confluent. The contents of the pustules now escape, and, becoming inspissated and decom- posed, cause the pecidiarly re|iulsive appearance and odor of a small-pox patient. Desiccation of uidiberated pus to form crusts begins in three days more. In this ))rocess the more fluid central portions evaporate first, to repro- duce the umbilicus. The crusts fall in about fifteen days, leaving scars or pits the result of necrosis of epidermic cells. Hyperremic at first, the scars grow graduallv lighter in color and more contracted in circumference than the sur- rounding skin, until finally thoy remain as disfiguring white spots with radiat- ing lines for years in childhood or fi)r life in adults. A pectdiar deformity ensues at times about the ala; of the nose, with notching of the free borders, and distortions as from extensive biu-ns are ocensioually seen about the face. Every possible lesion of the eve up to cotn|)lete blindness and destruc- tion of the globe is also seen. A stroll ni.uu the streets in {jre-vaecination,. 270 SMALL-POX. clays, when these accidents were to be observed at every step, would, were it possible, do more to dissipate the folly of the opponents of vaccination than mortnarv statistics. These " anti-vaccinationists " are not as wise as the pirates who knew that dead men tell no tales. The greater or less abundance of the eruption distinguishes certain forms of small-pox. Where the pustules stand apart the attack is known as discrete, where they coalesce, as confluent. There is in no case coalescence at the start. The confluent form is the result of such abundant eruption as in the growth of vesicles to more than cover the skin. Vesicles break into each other as their surfaces extend. The disease distinguishes itself in modified form by show- ino- the eruption always discrete — /. e. less abundant. It may be so much fur- ther modified as to disturb the regular course of other features of the disease. This modification is observed more especially in cases of partial immunity secured by previous attack or vaccination, and this much-modified form is known as varioloid. In the very gravest form of the disease, a form which is fatal from the start, the eruption distinguishes itself by its absolute absence. The peculiar eruption of small-pox is substituted by haemorrhage, to constitute the variety known as purpura variolosa. Quantitative varieties exist, therefore, in modi- fied (varioloid), discrete, and confluent forms, and qualitative in hsemorrhagic forms. Returning now to the more detailed study of the eruption, it is observed that it appears first on the uppermost part of the body, on the scalp, about the roots of the hair, on the forehead. The hair conceals it, so that, as a rule, the eruption is seen first on the forehead. It passes down thence over the face in regular progression, invades next the neck and upper extremities, then the chest and trunk, and lastly the lower extremities. Aitken declares that it appears in these different parts of the body in successive crops, the first upon the face, the second upon the neck and upper extremities, the third upon the trunk and lower extremities, and that there is something of an interval in the outbreak of these eruptions. A distinctive feature of the disease is the reg- ularity of its march, so that while it is pustular u{)on the face it may be only vesicular on the trunk, and at the end of the papular stage on the lower extremities. There is observed also regular progress in the stage of the erup- tion, so that papules, vesicles, and pustules are not to be found intermingled on the same parts of the body. The eruption, of whatever form, is always less marked upon the body than the face. As the papules develop they become more and more conical, to finally show at their extreme apices a clear opaline fluid, which gradually invades the substance of the papule to convert it into a vesicle. The reticulated structure of the vesicle accounts for the fact that when punctured it does not collapse, but allows to exude from its interior only a small quantity of its contents. The vesicle is, as stated, many-celled. (See Fig. 19.) The walls of these cells are composed in part of sweat- glands or hair-follicles — structures which resist the erosive action of pus or of the poison of the disease, so that, while the vesicle expands in every COURSE OF THE DISEASE. 271 direction, it is held down bv these tirnicr tissues. This fact accounts, as stated, for the central or eccentric depression which is regarded as such a cliaracteristic feature of small-pox. It must be said, however, that many vesicles and pustules which show no umbilication or depression may always be encountered. It must be further admitted tiiat this same central depres- Section of Variolous Lesion of the Skin : a, outer layer of epidermis; ft, midille layer; c, cylindrical cells of the rete Malpighii resting immediately upon the papilUe ; d, reticulated cavity of the pock, con- taining pus-corpuscles, with the epithelial framework ; e, purulent infiltration of the middle layer of the epidermis (Curschmann). sion is also occasionally, but by no means so commoidy, .seen in the vesi- cles of varicella and syphilis. So soon as the vesicle has become thor- oughly distended it loses its clarity, to become more and more turbid and opaque — that is, the number of pus-corpuscles increases. The inflamma- tion has become now ,so extensive as to have affected subjacent structures, so that the base of the ])ustulc becomes dark and the pustule itself seems surrounded by a halo. The whole skin is now infiltrated and thickened, and where the eruption is abundant, as upon the face, the eyes and ears are swollen to closure, the face bloated to distortion. The distension may be so great, esjiecially in unyielding structures, as to give ri.se to extreme pain. Pain is felt more especially in the fingers, where tlie eruption is always so abundant, even in pronounced di.screte forms of the disease, as to show .some degree of confluence. The pain of this distension about the fingers may be so great as to overshadow all other subjective sensations :iii(l reipiire es|)ecial treatment in its relief. One may only realize the severity ol" the pain in tin- fingers by recalling the amount of suffering which is occasioncil by :i single |»ar(»nychia. In small-j)ox there ai'e paronychia' n|)()n every finger. 'I'lie old wi'iters speak of the cedemato-phlegmonous inflammation of" the e.\( icniities. A few pustules 272 SMALL-POX. in the eye may destroy the sight. Van Swieten records a case where a single pustule on the prepuce produced a painful phimosis and dysuria. Curschmann claims that the more abundant eruption observed under heat or moisture, under poultices, plasters, etc., shows itself only when these a]ij)li- catious are made before infection or in the stage of incubation. When he produced hyperemia later, as in the initial stage, with mustard plasters, iodine, etc., the eruption was not thicker here than elsewhere. In one case in his experience an individual presented himself with long lines of eczema, the result of numerous scratchings of the skin for relief of the irritation of pediculi. The eruption when it occurred showed itself in these lines and seemed studded with pustules like strings of pearls. The eruption of small-pox does not confine itself to the outside skin, but appears also on the inside skin, the mucous membrane of the mouth, pharynx, and sometimes deeper structures. It may be nearly always discovered in the fauces, over the palate and tonsils, and sometimes on the inner surfaces of the lips and cheeks. Occasionally it invades the larynx, to alter or abolish the voice. It may show also deeper lesion than hypersemia and swelling of the mucous membrane. Ulcers may form in the larynx, with affection of the cartilage, perichondritis, and oedema of the glottis. In a bad case the tongue, which seldom shows any sign of eruption, is swollen to such extent as to pro- trude from the mouth, and in confluent cases salivation may be profuse. The aifection may also extend from the throat to the nose, which it may block from behind, and subsequently involve the Eustachian tubes and middle ear. Mu- cosae of other parts of the body are rarely invaded. Fig. 20. FaK* 104. 102 2 too * 9H 6 C a 18 9 10 11 It 13 li 15 16 n 18 19 70 2/ 22 23 W 25 26 27 2a 29 30 JI 5 K . .._.:: . . zt -I -- - t^ - .... A - ^^ - .. ^. iq ^^ _- . _ J L. ^ ^ - - - f^ r.t- X.^ J I . .. i yV r~\/""\ a'1/\ 4 t ^5 ' t „^^ 5 tziA ,~ / ' ■ a'\ t "V "'\ / ^ \ ^ 1 \l \ -^'\ / h K - X^„^ 1- y r^-^ y 3 P 7 -- - - V^ X.'^ v.--^ J v\- V- y V- ^ ■ \l \ \ \ , \ _. ._ _..._. % ^ X-Z %l ^ ii J v " \ , — -■ ~ — ^-.-- _-^" __- ^ i"±._l: Temperature-ohart of Case of Variola (Wunderlich). The course of the temperature in variola is characteristic. (See Fig. 20.) The fever reaches its height, as stated, with the period of eruption. As soon as the eruption has covered the body the temperature begins to subside, and falls often nearly to the normal grade within thirty-six hours. With the subsidence of the temperature the pain in the back, the nausea, and vomiting disappear, and the patient seems on the road to recovery. As soon, however, as the vesi- cles become converted into pustules, about the sixth or ninth day of the disease, the fever is renewed, sometimes with shivering fits, always with a ri.se of tem- perature to 102° or 103° F., but rarely to the elevations reached during the stage of invasion. This is the .secondary fever, the fever of suppuration, caused COURSE OF THE DISEASE. 273 entirely by the micro-organisms of pns. Strictly speaking, it does not belong to the small-pox process. It is only a secondary effect, but is none the less cha- racteristic of the course of the disease. AVith the stae-e of desiccation the fever again gradually subsides, to terminate by lysis in the course of the subsequent week. This subsidence, however, may be at any time interrupted and the fever aggravated by complications. In confluent small-pox the eruption is more abundant from the start. It shows itself, instead of in distinct maculae or papules, as a more profuse red- ness from coalescence. Sometimes the sense of hardness or unevenness of the surface may not be recognized on account of the more uniform elevation of the whole surface. The individual papules are always smaller than in the discrete form, but they are much more abundant. The stage of vesiculation is repre- sented by an accumulation of a more or less milky fluid over flat surfaces, often in irregular or zigzag shapes. The swelling is greater, as is also the corresponding deformity at the period of suppuration. The eyes and the ears are swollen, the face is enormously bloated. The scalp is lifted from the head, and the face has the appearance as if covered with a mask or heavily coated with coarse sand [pergamence speciem visu horrendam (cutis faciei) exhibet) (Morton). With the rupture of this parchment-like coat masses of decom- posing fluid ooze out to stream down over the face and make of the patient an object so loathsome as to be repulsive even to intimate relatives. Chief among the varieties of small-pox are the abortive and haemorrhagic forms. The abortive is that varietv in which the course of the disease is altered from the start. The period of incubation is sometimes shortened, the invasion may be brief, the eruption changed in various ways, the duration cut short. This form is best described under the rather unfortunate denomination of " varioloid." Haemorrhage may occur in the course of small-pox in no less than four dis- tinct varieties. Blood is not unfrequently effused in the vesicles or pustules of patients who do not remain recumbent, mIio leave the bed and get up too soon in the period of convalescence. In these cases the h.iemorrhage is con- fined almost exclusively to the lower extremities, and shows itself as petechiie or purpura, not unlike the common form of this aflection. Such hremorrhage is purely local, due to escape of blood through paretic vessels. It s|)eedily subsides by absorption with rest in bed ; it has no prognostic gravity. Reference has already been made to that petechial cruj)tion which occurs as an initial rash on the lower surfaces of the abdomen and inner aspect of the thighs. This eruption has also a haemorrhagic foiuidalion. It is of diagnos- tic value, but, as stated, has no ])rognostic significance. Aside from these eruptions, blood may be poured out into (he Inic erup- tions of small-pox at any part of the course of the disease. This accident occurs most frerpientlv in cases debilitated by j)revious disease oi- bad sur- roundings, but sometimes, fortiniately exceptionally. \\\u\ry lotnlly uiiaeeoinit- able circumstances. The blood is effused ;i( limes iiilo thi' papules, more fre- quently into vesicles, at the period of lull niatnration — /. c. at the height of Vol.. I.— 18 274 SMALL-POX. the disease. The clear serum becomes turbid, sero-sanguinolent, and finally the vesicle is filled with blood. Sheets of blood, diifuse and black, fill the interior of confluent vesicles and pustules, and blood appears under the skin as livid patches, vibices, and ecchymoses in various parts of the body, to con- stitute what is called hsemorrhagic small-pox, black small-pox, " variola nigra." With this effusion of blood there is a corresponding collapse. Free haemorrhages — metrorrhagia, hsematuria, enterorrhagia, least frequently hsema- temesis — may occur also from the various mucous surfaces, under which the patient rapidly succumbs. Should he survive the prostration caused by the l)£emorrhage itself, he may have to face other and worse dangers. Diphther- itic deposits form in the pharynx, a scorbutic condition of the gums develops, or nephritis ensues and the patient may perish from ursemia. Recovery from this condition is rare ; convalescence is slow and tedious. Last among the hsemorrhagic eruptions remains to be described that par- ticular variety in which the haemorrhage assumes prominence over all other signs. This variety presents such distinctive features, so different from all other forms of small-pox, as to have led competent observers to consider it a special malady. The fact that the disease, in any of its forms, may be com- municated from this form, and that the body remains infectious also after death, establishes its true nature. That this hsemorrhagic form may be dis- tinguished from those just described, esjiecially from the variola hsemorrhagica pustulosa, it has been given the se})arate name of "purpura variolosa" — a term which fixes in the foreground the hsemorrhagic character which literally dominates the disease. In this variety of small-pox the initial rash and the true eruption are alike wanting. Although this is the fulminant form of small-pox, it does not necessarily commence with violent signs. It attacks, by preference, the young, healthy, and strong, but does not spare the weak and debilitated. Drinkers and pregnant and parturient women are among its preferred victims. The disease begins in the ordinary way — with chill, vomiting, and rapid prostration. The stage of invasion (if it differ in any way from the ordinary oases of small-pox) is distinguished by the severity of pain in the back. In the experience of the author patients have complained of excruciating pain in the back when there was no other symptom, not even fever. Another dis- tinctive feature is the rapidity of appearance of hsemorrhage. Should the dis- ease occur during menstruation, metrorrhagia ensues, and the nature of the disease may be thus overlooked, as the jiain and the hfemorrhage may be both connected with menstruation. Hsemorrhage now shows itself under the skin — first u})on the trunk, later upon the extremities, but never upon the face. The surface assumes a blood-red hue, like that of scarlet fever, and in this redness points and patches of blood appear. The eruption is usually petechial upon the extremities and confluent as irregular ecchymotic patches on the chest and trunk. The face is swollen, the eyes suffused and sunken and surrounded with black rings. The tongue is thick and heavily coated. The breath is exceedingly foetid. There may be elevation of temperature ; sometimes there COURSE OF THE DISEASE. 275 is no fever, and often the temperature is subnormal. Tiic tendency is steadily downward, and death occurs by the end of the first week. Fortunately, this form occurs in but 5 per cent, of cases. A peculiar snbvariety.or disposition of eruption is that described by Mar- son as "corymbose." In these cases the eruption shows itself in patches or clusters the size of the hand, as thickly set as possible, while the surrounding skin remains often entirely free. The patches are often symmetrically distrib- uted upon the extremities. The variety is very rare, but, contrary to what might be expected, is very dangerous. Marson found that the appearance of but a single cluster gave gravity to the attack, and rendered it much more liable to complications and greatly protracted convalescence. The mortality was over 40 per cent. Other singnlarities are verrucose, pemphigose, or mil- iary eruptions. They are, however, more commonly met with in varioloid. Varioloid is a misnomer, for the affection is not like variola ; it is variola itself. Varioloid does not stand in the same relation to variola as typhoid to typhus fever; varioloid is variola in modified form — is, in fact, the lightest form of small-pox. The disease occurs in this form on account of natural insusceptibility, on account of ])revious attack, formerly on account of inocu- lation ; but the great majority of cases seen in our day are due to incomplete ])rotection from vaccination. The immunity secured by vaccination has run (»nt, and the severity of the attack Avill, to a certain extent, depend npon the remaining degree of protection. A case of unmodified variola in our day is a rarity ; that modified or jnitigated variola known as varioloid is still fre- quently seen. A knowledge of the nature of varioloid and its differences from other simulating affections is necessary, that the disease be recognized at once in protection of others. From what has been stated it is needless to add that varioloid, mild as it may be in itself, may transmit true variola in anv, even its most fulminant, form. Most of the cases encountered in our day are so mild that the question of diagnosis concerns differentiation of varioloid from varicella as much as the recognition of variola itself As already stated, small-pox is a very uniform disease. In modified form, however, it presents many irregularities. Varioloid distinguishes itself by abnormalities in every stage of the disease. As most of the cases are due to incomplete protection by vaccination, the various irregularities are mentioned by Morrow when he says that " vaccination denaturalizes small-pox, deranges the original order of the disease, and effaces its most distinctive features." It is generally assumed that the modification of .symptoms is apparent in the initial stage of the disease. This view, however, is by no means correct. The disease begins with its nsual train of symj)toms, and a- a rule with its orii'inal violence. The diflfcrenee concerns duration rather than degree. The initial stage is often cut short a day or two, so that the eruption may ai)i)ear by the end of the first or second day. 'i1ie various initial eruptions occur also in varioloid — the petechial as an exccjition, th<' ervthematous as a rule. It is a common observation that a prouotuiced erytlieuiatous eruption or scarlatiui- form rash betokens varioloid rather than variola. Curschniann declares that 276 SMALL-POX. we may predict, in spite of the severe depression of the general system, that the form of the disease, if erythematous, will be mild, while petechise will nearly always be followed by variola vera, which is not infrequently conflu- ent. For what comfort it may bring, the author may state that the three cases of petechial eruptions in Simon's triangle which have occurred iu his expe- rience have preceded, without exception, mild, abortive attacks of the disease. With regard to the real eruption, varioloid presents the greatest variations. It may begin on the scalp, forehead, and temples, as in an ordinary case, and progress in regular or irregular course. It may, on the other hand, show itself first on the neck and chest or elsewhere over the trunk, to appear later on the extremities or face. As a rule it is much less abundant, so that it is nearly always discrete. There are, however, exceptions to this rule, and marked cases may show isolated patches of confluence on the face and hands. On its first appearance the eruption differs in no way from that of the more pronounced form of the disease. It comes out in spots, which are elevated into papules in the course of the first day. The papules slowly show fluid at their accuminated apices, and become thus entirely converted into vesicles as before. Here, now, the change is usually observed : the eruption usually stops at this stage, and the vesicles, which may have become umbilicated, begin to dry up and disappear. They may fill out as in the course of severer forms ; their contents may become turbid and opaque, and the vesicle may be transformed into a pustule, but it is plain to see that the force of the disease is spent. Certain pustules may rupture, but the process is limited, and the secondary fever of suppuration is reduced or is entirely absent. In conse- quence of the fact that pustulation does occur in places with erosion and destruction of tissue, pits may be left, but they are few and far between as compared with the lesions of ordinary small-pox. The disturbance of the general progress of the disease is marked also by irregularity. It is more common to find pustules and vesicles or vesicles and papules in a closer proximity in varioloid than in variola. Moreover, the eruption does not last so long. Desiccation begins on the fifth or seventh day, and most of the papules dry up into crusts without rupture. These crusts, as a rule, leave only pigmented traces without scars. There is often also dispro- portion between the severity of the fever and the eruption. There may be high fever in the presence of but ten or twenty vesicles or pustules over the body, or, per contra, the eruption may be almost, or in places entirely, con- fluent, with but little elevation of temperature. It is plain to see that vac- cination has at every point put a muzzle upon the disease. The various transfi)rmations of vesicles and papules which may occur dur- ing the process of modification or abortion may convert vesicles or pustules into warty masses or bullse, or ruptured vesicles may fill with air to constitute varieties known as variola verrucosa, pemphigosa, miliaris, ventosa, or cellulosa, etc. So of the various affections of the mucous membrane. While they may be present, or in individual cases more or less pronounced, in initial stages they rarely assume prominence or give rise to serious complications. COMPLICA TIOXS.—DIA GNOSIS. 277 Complications which occur in the course of small-pox do not differ much from those of equally grave acute infections. Sufficient mention has already been made of the lighter affections of the pharynx and larynx. It remains to be said that gangrenous processes, oedema of the glottis, and perichondritis occur in exceptional cases. Stenosis from either of these causes may necessi- tate intubation or tracheotomy. Bronchitis belongs to variola as to most of the exanthemata. It is very liable to extend in childhood, to infect the finer bronchial tubes, and to result in broncho-pneumonia. Pleurisy is by no means so common, but is by no means rare. Pericarditis, endocarditis, endometritis, meningitis, are not uncom- mon complications in grave cases. Affections of the joints, arthritis, pyaemia, septicaemia are much more frequent. Small-pox occasionally affects the eye. Conjunctivitis, keratitis, affections of the lids, are the most common lesions. Disease of the choroid and retina occurs in exceptional cases. Panophthalmitis, with destruction of the globe, was not uncommon in ancient times. Ocular complications in our day are neither frequent nor severe. In all his remarkable experience Hebra saw them in only 1 per cent, of 5000 cases of small-pox. By extension of the inflammation of the fauces and pharynx the middle ear may be attacked, to result in otitis or otorrhoea, with subsequent ankylosis of bones and deafness. Phlegmonous inflammations, gangrene of the skin, and furunculosis occur frequently in confluent cases ; and local and diff'uscd inflammation of the brain and cord, paralysis, and bed-sores may nearly com- plete the possible complications. Diagnosis. — The diagnosis of the disease rests upon the following points : the possible existence of other cases, the history of sufficiently recent protec- tion by vaccination. The mere existence of a scar is no evidence of protec- tion. The worst case of purpura variola encountered in the experience of the author had three well-marked cicatrices upon the arm as evidence of previous vaccination. Then it is observed that the illness sets in suddenly, and is usually severe from the start. Strong men stagger as if drunk. The tem- perature rises rapidly. Pain in the back is peculiar in its intensity ; initial eruptions may be characteristic. The true eruption appears upon the third day after the initial chill. It is maculated, not punctate like that of scarla- tina, but darker than the scarlet of scarlatina and lighter than the dusky hue of measles. It is seen first upon the scalp and upper part of the face, spread- ing downward regularly and rapidly ; it does not sjiare the nose or region of the mouth. It yields a peculiar feeling of hardness as of shot under the skin. Elevation into papules occurs during the first day. The diagnosis becomes nearly certain when the pai)ides by the third day change into vesicles, some of which subsequently bccotnc umbilicated. Small-pox is one of the most grave of the acute infi-ctions which survives from the pre-sanitary period of civilization. We see it, fi)r the most i)art, as a mere relic or rudiment of its former self. There is lacking with us that ele- ment of tiHiltitiidinous infection which gives voliiiiic and virulence to the 278 SMALL-POX. disease. Nevertheless, even in its modified form, it preserves its character as a grave infection, and it may hence be confounded with any of the infections of equal gravity, especially any of those that are attended with an eruption. Disregarding the eruption for the present, because not present at the start, mistakes have thus arisen in connection with meningitis, pneumonia, and typhus fever. Meningitis, especially the cerebro-spinal form, pneumonia, and typhus fever begin, like small-pox, in the midst of health, with violent chill, rise of temperature, and rapid prostration. Gastric symptoms, vomiting or nervous shock, especially in children, and convulsions, may announce the onset of any of these infections. In the absence of an epidemic or the history of exposure, in the absence also of adequate protection by vaccination, the diagnosis must sometimes be held in abeyance for twenty-four or forty-eight hours until distinctive signs of one or the other of these diseases are manifest. Meningitis distinguishes itself by hypersesthesia, opisthotonos, and herpes, as well as by its irregular temperature curve. Pneumonia is early characterized by pain in the side, cough with glutinous and rusty sputum, and increase of respiration out of proportion to the pulse. The diseases which are, however, most frequently confounded with small-pox are those which are attended with an eruption, and chief among these is typhus fever. Typhus fever has, how- ever, a history of importation which may be traced or prevalence which may be known. It begins often, like small-pox, suddenly, with a severe chill in the midst of health, and shows an eruption on the third day. The eruption of typhus, however, appears first upon the body, chest, and abdomen in the form of maculas which soon become petechial. The eruption of small-pox appears first upon the scalp and forehead, and progresses over the face before it appears upon the body. It shows itself in the form of maculae, which soon become papular, vesicular, etc. ^The petechiae which may occur in small- pox occur on the legs or thighs or in the course of a lisemorrhagic form. Vesicles, especially umbilicated vesicles, are never seen in typhus fever. There is also characteristic difference in temperature, whi(;h subsides with the appearance of the eruption in small-pox, but persists unaffected for sev- eral days or as long as a week in typhus fever. Confusion with typhoid fever is less pardonable. Typhoid fever begins insidiously, requiring the time of a week to reach the temperature attained by small-pox in a day or two. The cloud about the brain which belongs both to typhoid and typhus fever from the start is not present in small-})ox until the last stages of the disease. Typhoid fever shows abdominal symptoms, roseola on the seventh to tenth day, meteorism, gurgling, diarrhoea, etc., absent in small-pox. A light case of small-pox may be regarded as measles, and a bad case of measles as small-pox. Consequently, the separation of small-pox from measles is the most frequent problem submitted to the practitioner. The future of the case, the safety of the community, the reputation of the physician, depend upon the proper solution of this problem. Here, too, help may be had by a know- ledge of the history of the case as to the existence or absence of an attack of DIAG.XOSIS. 279 measles or sniall-pox, the period of the ki.->t successful vaccination, the prev- alence of either disease in the couimuuity. As for measles, it is always present in cities, and, thanks to the popular iear of suiall-pox, knowledge of its exist- ence is early promulgated by the health authorities. Nevertheless, sporadic cases steal in at times unannounced. In the experience of the author with the management of a large dispensary practice small-pox was twice introduced into Cincinnati by pei'ipatetic philosophers commonly called "tramps." These cases formed centres of infection. Knowledge of the period of exposure — /. e. the period of incubation — is of little value. The stage of invasion is much milder in measles than in even modified forms of small-pox, for, as has been stated, varioloid may be announced with symptoms as severe as those which dis- tinguish the onset of variola vera. The chill is less severe, the fever is less high, the prostration is less profound, in measles as a rule. There are, of course, excep- tions on both sides. The eruption ap})ears on the third day of small-pox, on the fourth day of measles. The maculse of measles are bigger than those of small-pox. They appear also upon the back almost at the same time as upon the face, whereas the eruption of small-pox much more uniformly apj)ears upon the face, and reaches the back only later in its advance over the body. The maculse of measles are softer than those of small-pox. Rhazes said nearly a thousand years ago : " The diiference between the two he found to be that measles are red and appear oidy on the surface of the skin without rising above it, while the small-pox consists of round eminences. When these eminences appear fix your attention on them, and if you are in doubt as to the disease, do not express any opinion about it for a day or two ; but when there arc no eminences you must not give as your opinion that the disease is small-pox." Collie declares: ''A case of small-pox severe enough to simulate measles imparts to the hand in passing it over the surface a hardness and furrowed roughness, as that produced in passing the hand over a piece of corduroy ; whereas in raised, confluent measles it is that of passing the hand over a piece of velvet." Moore gives the " grisoUe sign " as a certain means of diagnosis : "If upon stretching an affected portion of the skin the papule becomes im- palpable to the touch, the eruption is caused by measles ; if, on the contrary, the pai)ule is still felt when the skin is drawn out, the erui)ti<)n is the result of small-pox." The catarrhal symptoms, more especially the cory/.a, which may exist in both affections, are wont to be more prominent in measles at the start, but persist longer in small-i)ox. The course of the temperature is cha- racteristic in the two diseases. The fever falls in small- pox with the ai)pear- ance of the eruption, whereas in measles it remains unalVected or may rise higher. The appearance of papidcs or vesicles soon dissipates all idea (.1' measles. The sevoritv of the sore throat, the backache, aud the s.-aHd (-..lor of (he rash, whicli appears as minute points as early as the second day alter the ini- tial chill, distinguish scarlet fever. Th<' grave h.-.-inonhagie f.-rm, " purpura variolosa," is recognized by the extreme severity of pain in the back, as well as by the petechial character ol" tii<- eruption, free hfem..rrhages, etc. 280 SMALL- POX. Papular eczema is irregular in its distribution, unattended with fever or involvement of the mucous membranes. The same exceptions apply to ery- thema, acne, and herpes. Only the most superficial observer could consider these eruptions variolous. Syphilis may show pustules to closely resemble discrete variola, including even the process of umbilication, but the absence of the initial signs, chill, fever, pain in the back, etc., the history of syphilis or associated evidence else- where, render the diagnosis easy as a rule. All cases concerning which there is any doubt should at least be isolated for a time until sufficient protection can be offered to others by vaccination. Marson says of his experience in the London Small-pox Hospital : " Upward of twenty diseases have been mistaken within the last few years, in the early stage of the disease, for small-pox, and the patients have been sent, as having small-pox, to the small-pox hospital." The separation of variola and varicella will be discussed under Varicella. The progTiosis is largely determined by the last successful vaccination. The next most important factor is the determination of the form of the dis- ease. The third is the age of the patient. Small-pox in infancy has a mor- tality which is put at 90 per cent. Almost equally grave are the cases which occur in pregnancy and the puerperium. The greater danger which is thus imparted to the female sex is counterbalanced in the male sex by the mortality of the disease among drinkers. The percentage runs high again in advanced age : nearly 75 per cent, of old people unprotected by vaccination or previous attack succumb to the disease. Severe symptoms on the part of the nervous system are of evil omen, but to a less degree in children than adults. Trousseau laid great stress upon tumefaction of the extremities — what he called *' red oedema " — which should set in at the end of the ninth day with acute pain ; with Sydenham, Morton, Van Swieten, Borsieri, he attached great importance to it in a prognostic way. He says : " Swelling of the hands and feet is such a necessary phenomenon in confluent small-pox that patients almost invariably succumb where it is absent unless there be a great critical discharge by the kidneys or bowels." Profuse suppuration in the skin is a sign of danger. Hemorrhagic small-pox is very serious ; less than one-half the cases recover. The prognosis is not, however, unfavorable because of initial petechise, which may show later upon the legs of patients who try to get about too soon. Purpura variolosa is always fatal. The mortality of the unvaccinated ranges, even in our day, at 20-40 per cent. Prophylaxis. — Vaccination, if it could be enforced, would render super- fluous all other prophylaxis, including isolation. Inoculation, which it substi- tutes, has only historic interest. Vaccination and revaccination, if they could be made compulsory, would eventually eradicate {\\e disease ; thus but a single fatal case of small-pox has occurred in the German army during the past fifteen years. Unfortunately, however, vaccination cannot be made com- pulsory in our country, "where the cry of infringement of personal liberty is the shibboleth of the demagogue" (Foster), so that patients must still be TREATMENT. 281 isolated aud sick-rooms disinfected. A temperature of 400° F. is fatal to small-pox. The organisms of the disease are destroyed by sulphur in suffi- cient concentration. That this process may be properly brought about, it must be done by health authorities. All combustible material should be consumed if it may not be subjected to the antimycotic action of live steam ; walls should be rubbed down with bread, and floors scrubbed with a solution of corrosive sublimate, 1 : 1000 ; doors and windows should be closed, and sulphur, 4 pounds to every 1000 cubic feet of air, should be burnt to bring about perfect fumigation : at the end of two days the cham- ber may be thrown open and thoroughly ventilated for two weeks. Bedding, clothing, curtains, etc., after subjection to superheated steam, should be sus- pended in the air day and night for a week. The dead body should be sub- jected to immediate interment, as infection is disseminated from its surface up to the period of decomposition. In the interval between death and burial the body should be enveloped in a sheet saturated in the solution of corrosive sublimate, 1:1000. Transportation should be permitted only when a body is put in an air-tight metal case. In the experience of the author an endemic was once developed at a distance in a country town by neglect of this precaution. Treatment. — If seen early the patient should be vaccinated at once. Vac- cination in the early stage of the disease modifies variola. After the fourth day vaccination is useless. Marson puts it positively : " Suppose an unvacci- nated person be exposed to small-pox on Monday ; if he be vaccinated as late as Wednesday, the vaccination will be in time to prevent small-pox being developed; if it be ])nt oif until Thursday, small-pox will apj)ear, but will be modified ; if the vaccination be deferred until Friday, it will be useless : it will not have had time to reach the stage of areola, the index of safety, before the illness of small-[)ox begins." Curschmann does not subscribe to these views. He declares that he has seen in cases in which vaccination was prac- tised that infection with vaccinia and small-pox pustides developed side by .side. He doubts whether vaccination can render the disease even milder in its course. Nevertheless, so long as there is doubt the patient should have the possible benefit of early vaccination. Treatment in the absence of a specific is wholly symptomatic: rest in bed in a thoroughly ventilated room at a temperature of 65° F., as determined l)y a thermometer at the head of the bed; light but sufficient covering; cool drinks, water, lemonade, seltzer- water, in sufiicient (|nMntities ; fever diet, milk, sou[)s, gruels. This nuich we owe to Sydenham. \\'hat it must have effected may be learned by the results from that which it substituted. The contrast is shown in a chapter from the ])ractice of Diemerbroek. " Keep the patient," says Diemerbroeck, "in a chamber close shut ; if it be winter \v\ the air be corrected by large fires; take care that no cold air gets to the patient's bed; cover him ovev with blaidIe niiu of the patient. Far better it is to let the palieiil lie.ir with the stench than 282 SMALL-BOX. thus be the cause of his own death." Trousseau is right when he says : " If the second epoch in small-pox was introduced with inoculation, and the third with vaccination, the first was introduced with the treatment of Sydenham." Fever above 103° F. can best be combated by frequent baths or by phenacetin, gr, X, or antifebrin or antipyrine, gr, v, or in half of these doses in childhood. For throat complications steam from an atomizer, simple or medicated with boric acid, gr. xv to fsiv; thymol, gr. xv, alcohol and water, cid. f 5ij ; or carbolic acid or creasote, 3ss, glycerin, f sj, water, §iij, or with less efficacy gargles of the same strength. Inhalations may substitute all local applications in very young or refractory children. Chloral, gr. ij-x, becomes a necessity in periods of unrest, nervousness, insomnia. It has no equal in the relief of nausea and vomiting. For jactitation or extreme nervous distress it may have to be sub- stituted by Dover's powder, gr. ij-v. Frequent ablutions of tepid water, ointments, diachylon ointment, plasters, mercurial plaster, or opening pustules after the manner of the Arabs and touching them with nitrate of silver, or better carbolic acid and glycerin da., or touching the tops of beginnwg pus- tules — i. e. mature vesicles — with a camel's-hair brush dipped in carbolic acid, best prevents or limits pitting. Xylol internally is said by Ziilzer to have the power of coagulating the contents of pustules, but the claim was not at all substantiated by subsequent trial. Where tissue is destroyed, cicatriza- tion must result, and, in consequence of it, pits and scars. Means to prevent deformity to be effectual must therefore be brought into use before the stage of suppuration is complete. Nothing can prevent ])itting in an established confluent small-pox. The best clinicians are content with frequently renewed water-dressings made antiseptic as much as may be with sublimate solutions, 1 : 5000 or 1 : 10,000. The whole question, with all the other horrible evils of small-pox, sinks into insignificance and slinks away like the devil at sight of the cross when brought face to face with vaccination. VACCINATION. By JAMES T. WHITTAKER. Vaccination (from vacca, a cow ; vaccinia, cow-pox) is a terra introduced from France to express the inoculation of man willi cow-pox in prevention of small-pox, and to substitute the awkward word "cow-poxing," Tiie promul- gation of vaccination by ?]dward Jenner in 1798 constitutes one of the great epochs in the history of maidvind, in that from this period the terrible tropical plague variola, which overran and literally ruined Europe and the rest of the world, was reduced to the trivial malady varioloid, which is, uncomplicated, never fatal. Jenner was a medical apprentice at Sodbury when he became acquainted with the popular belief in the protective influence of cow-pox; and, though he was unable to interest his preceptor, the celebrated John Huntei", in whose house he subsequently lived for two years, or to convince any of his medical brethren of any relation or antagonism between the affections, he could not dismiss the subject from his mind. He visited dairies in Gloucestershire and made observations and prosecuted investigations for himself. Pie found that there existed a widespread belief among the dairymen that certain indi- viduals, who had contracted sores upon their hands from contact with sores on the udders of cows, were never attacked with small-pox. Much contradictory testimony presented itself at first, and many disheartening exceptions were found. If genius be patience, it found in Jenner an example, for Joiner worked with this subject for more than twenty years before all the mighty truth of it was clear to his mind. May 14, 1796, was the memorable day when Edward Jenner transferred cow-pox from vesicles on the hands of Sarah Nelmes, a dairymaid, by means of two superficial incisions, into the arms of James Phip]>s, a hc:iltliy boy eight years of age. The cow-pox ran its ordinary course, and a subse<(uent inocula- tion with small-pox on the first of the following July failed to produce tlu' disease. In the same month Jenner wrf)te to his intimate frienvciiien(, anurdeil to all mankind protection fVoni the ravages of small-pox. .leniier was led to make this experiment by tlic observation that individuals accidentally infected with 28;} 284 VACCINATION. cow-pox, to use his own words, " resisted every effort to give them small-pox." A number of children, subsequently vaccinated in succession, " one from the other," were after several months exposed to the infection of small-pox, " some by inoculation, others by variolous effluvia, and some in both ways, but they all resisted it." Though Jenner was himself now thoroughly convinced, he determined to withhold his conclusions from publication until, by frequent repetition and fortification in every direction against any possible error, he might establish them without doubt. He repeated his inoculations with every precaution, and finally prepared his pamphlet. Hereupon he visited London to obtain the assent and support of his medical friends, but was unable for nearly three months to find any person in London who would submit to the operation. Finally, on his return home, the distinguished surgeon Cline introduced vaccine matter over the diseased hip-joint of a child as a means of securing counter-irritation. When he found later that this child had thus secured immunity against small-pox, he became an earnest advocate of the operation, and a supporter of Jenner at a time when the latter stood in need of one. There is evidence that Jenner worked with this subject, encounter- ing and overcoming obstacles and opposition on every hand, for over twenty vears before he announced his results to the world, and it is known that fully two years elapsed — a delay which might be considered culpable in our day — between the first vaccination and the publication of his paper. The paper was modestly entitled an " Inquiry into the Causes and Effects of the Varioloe Vac- cince, a Disease discovered in some of the Westerii Counties of England, par- ticularly Gloucestershire, and known by the name of Cow-Pox, London, 1798, 4; 1800, 8; 1801, 8." Jenner lived to see all opposition overcome and the procedure adopted all over the world, and to receive, with universal honors and emoluments, from Parliament in 1802 an award of ten thousand pounds (nearly all of which Mas lost in fees), and later, in 1807, a second allowance of twenty thousand pounds. In 1857 a statue was erected to him in Trafalgar Square in London. The most consummate cynic must admit that up to the present time Edward Jenner has been the greatest benefactor that the world has known. Intimations of the protective influence of cow-pox had been made here and there in variou.s parts of the world, especially in connection with dairies. People in different places had believed in the influence of this protection, and certain individuals had actually practised it upon themselves and in their families. Such statements have been handed down from Persia, Scotland, and Holstein, but they made no impression of the virtue and secured no adop- tion of the practice of vaccination up to the time when a country milkmaid said to Jenner during his student-life at Sodbury, " I cannot have the small- pox, for I have had cow-pox." This statement repeated itself and rang in his ears for over twenty years. It left him no rest until it resulted in the discov- ery of the protection of mankind, and but for the stupidity of men would have long since led to the exter^iination of the disease. Vaccine matter was soon carried all over the world. The Spanish govern- VACdXAriOX. 28-3 ment sent ships atul surgeons to all its possessions in the Okl and Xew Worlds. The expedition made circuit of the entire globe in the course of three years. The operation was first performed in this country by Prof. Waterliouse of Cambridge, and in the same year (1801) was practised in his own family by Jetferson, then President of the United States. The Empress baptized the first child vaccinated in Russia with the name " Yaccinotf," and gave it govern- ernment endowment. The nations of the earth vied with each other in tributes to Jenner and demonstrations of joy. Napoleon Bonaparte took his signature as a passport. The anniversaries of the first operation and that of the first vaccination were celebrated in Germany — in a special temple at Brunn, Moravia — as the Churcii celebrates its saints, with holidays, and our own Indians sent with belt and wampum a declaration that ''we shall not fail to teach our children to speak the name of Jenner and to thank the Great Spirit for bestowing upon him so much wisdom and benevolence." Jenner spent the rest of his life in the perfection of his discovery. His practical conclusions remain impregnable. In theory, however, he fell into two slight errors : one, the belief that cow-pox would protect for life — a belief that led later to some doubt regarding its protection in general; the other, that the disease was conveyed to the cow from the horse bv individuals eno-atred in the double duty of hostlers and milkmen. A disease of the horse's hoofs, commonly known as "the grease," when conveyed to the bag of a cow pro- duces an eruption which simulates, but which subsequent investigation has shown to be not identical with, the true cow-pox. The belief that cow-pox is modified human small-pox found much wider acceptance, and has few opponents in the present day. These opponents maintain, however, that the doctrine is dangerous, and that it has been the cause of insufficient protection, and therefore injury to vaccination, as well as directly of death by the propa- gation of small-pox itself. Cow-pox is an infectious disease which appears in dairies from time to time, often at wide intervals of both time and space, and shows itself first in some particular cow, usually a young cow, a heifer in her first milk. It never appears first in other cattle than milk cows, and never shows itself elsewhere than on the teats or at adjoining parts of the bag, as they may be infected by direct pressure or contact. It appears in the foriu of scattered papules, which in the course of a few days show fluid at their ai)ices, to become transformed into distinct vesicles. These vesicles are broken by the hands of the milkers, and the disease is thus disseminated in the coiu'se of a few weeks, sometimes months, throughout the entire dairy. After rupture the fluid of the vesicle thickens to form a cnisl, under which the eroded tissue or ulcer cicatrizes, produ(!ing a sear with indurated margins and puckered surface. Uncleanly dairymen often infect other parts of their own bodies with their hands. Jenner, Ceely, and Pearson described such eases of infection of the lij>s, side of tlie nose, (em|)le, etc. In January, 1799, Woodville of the Fiondon Small-pox Hospital succeeded in storing a supply of pure material, from which source Jemier, with several 286 VA CCINA TION. hundred practitioners, got their vaccine matter. This Woodville stock was then used all over the world up to 1836. At about this time matter began to be introduced from other sources : first, from the Passy cow in 1836, and here, again, from the accidental infection of the hands of a milker. Material from these vesicles started a new stock, which was subsequently used in France. By 1838 the new disease, vaccinia, was so far forgotten in Jenner's own parish, Berkeley, Gloucestershire, that the milkers were ignorant of the cause of the appearance of vesicles upon their own hands. From these vesicles Estlin of Bristol established a new geniture. Next Ceely of Aylesbury (1838-41) dis- covered half a dozen cases of cow-pox in dairy-farms of his district, and cul- tivated lymph from them. In 1866 the disease was discovered in Beaugency, and this source furnished lymph for the inoculation of calves, which was now practised as a regular business in Dutch, Belgian, and other vaccine farms. Genuine cow-pox has since been discovered and described in Holland, Italy, Bengal, South America, Mexico, New England, Pennsylvania, and California; and there can be no doubt, as Seaton says, that " much more would be found than really is found if only looked for." The first case of kine-pox in the United States was reported by Dr. John Yale of Ware, Mass., as observed at Torringford, Conn. (1844), and at Ware, Mass. (1855), the true nature of the pox having been established at Ware by inoculation of man as well as by propagation in calves. Martin of Massa- chusetts established the first well-equipped vaccine farm in the United States in 1870, with the inoculation of a constant succession of heifers. He was followed by Foster of New York and Griffin of Fond du Lac in Wisconsin. Vaccinifers from these farms furnish nearly all the lymph used in this country. A disease attended with eruption of vesicles and pustules occurs in many animals besides the cow, as in the horse, sheep, goat, dog, etc. Sometimes the eruption is general, sometimes local. In some cases the disease is marked by ulcers, in others by glandular enlargements, etc. In some animals the disease is trivial, in others dangerous and often fatal. Cow-pox differs from all other kinds of pox in that the disease, as stated, is confined almost exclusively to female animals at the time of lactation, and the eruption is confined to the bag. After a period of incubation of three or four days the eruption appears as red spots, which speedily swell to assume the form of pa])ules, become converted into vesicles by the fifth or sixth day, to be transformed into pustules by the tenth day. The pustules in full development ai'e present to the number of twenty or thirty as fully-rounded bodies, slightly depressed in the centre, and often urabilicated. Sometimes they remain flat, with no central depression, their presence being then easily overlooked. A vesicle or pustule is not a single sac, but a set of chambers, puncture of which does not permit the escape of all the contents, and the full discharge of which can be secured only by pres- sure. The })ustules dry to form crusts, which fall on the twelfth to the fif- teenth day, to leave oval or rounded scars which persist for years. It is characteristic of cow-pox to appear also in successive eruptions. Not VACCIXATIOX. 287 infrequently vesicles and pustules appear side by side with dry crusts. Indi- vidual vesicles run their course in five or six days, but the whole disease is a subacute and chronic process, lasting often for several months. The disease causes in the cow, as a rule, no sign of general distress, but sometimes there are fever and loss of appetite ; occasionally there are quantitative and qualita- tive alterations in the milk. The discovery of the origin of genuine cow-])ox has always been a fasci- nating study. The characteristic course of the disease unmistakably gives it place among the infections, so that there can be no question whatever of sj)on- taneous origin or generation. Inasmuch as the disease occurs only at intervals, it cannot be sustained by continuous succession, so far as the cow alone is con- cerned. It must therefore arise from some otiier animal or from man. Jenner considered it to be derived, as stated, from the horse, but this origin is now no longer considered tenable, as it breaks out in dairies where there are no horses, and occurs in places where horse-pox, as in Germany, is almost unknown. The accumulated observations of a century reveal the fact that there are but two chief forms of small-pox — to wit, human pox and sheep-pox. They both attack the multitude, they both assume pandemic range : one is a genuine epidemic, the other a genuine epizootic. All other varieties of pox — that of the horse, cattle (including cow-pox), of swine, goats, and dogs — constitute, as Bollinger proves, no distinct individual disease. They are to be regarded onlv as irregular forms of the primary human or sheep-pox modified in dif- ferent animals. Whether man got the pox from sheep or sheej) from man is a question that may never be determined, but the best authorities (Bohn and Bollinger) unreservedly maintain that the virus is identical in the two cases — identical and interchangeable. The corollary of this fact determines the origin of cow-pox. Cow-pox is in its essence variola vera. It is variola modified in the body of the cow. If vaccinia be but an attenuated or modified variola, its protective action ceases to be a mystery. It protects by the immunity of pre- vious attack. It protects by the immunity of inoculation — i. e. variolation ; for vaccination is variolation with virus robbed only of its virulence. On the other hand, it is alleged that, first, the processes are not similar — vaccinia remains always a local, variola a general disease ; second, one process never produces the other — vaccinia always produces vaccinia, as variola always produces variola. Fatal cases have ensued in man after the use of matter from the cow inoculated with the small-pox of man (Chauveau). According to Bohn, Gassner of Gun/.burg (1807) was the first to inoculate the cow with the small-pox of man. He iiitroduced small-pox matter from the vesicles of children in a number of cattle. The o|)eration succeeded eleven times. With the contents of vesicles so fin-med he vaccinal.d fmir children. They developed, without excejjtion, ])erfect vacractise(! on a hirge scale by Thiclc of Kasan and Ceely of England (18.".8). They inocidated cows on the bag :iii;ins on the fourth dav after the introduction of the virus, and is perfect on the ninth day. The degree of protection, indej>endent of revaccination, is determined to a consilaces vaccinatctl. Thus, according to Marsoii, the aver.-ige mor- tality of small-pox among all vaccinated persons is 5.24 per cent., while that of individuals showing j)erfect cicatrices is about .5 per cent. In 6000 cases of small-pox after vaccination observed by Simon in twenty-five years the per- Voi,. r.— 1« ei ■-t ■■ nig n"il 99 Mlf f'61 as i- •fat 19 It J II 1 .1.1.11. 1 1 1 i i ff. asai [ill i i ii 1 t i "H"" Mill oazs 99 *' i""i' 1 1 1 S 1 tm ^9 ■■ iiii i i 1 ■ i rCai, €9 --|- 1 ■ 1 1 i i o»'ec Z9 1 1 1 1 i i soiZ 1991 "f 1 1 M 1 •■'OS 09 J i i i i i "gi S9 1 1 1 i 1 ta'ei 99 1 1 1 i i -Sj It 1 i 1 i i •Tin 9!m i i 1 Wi -ti'^ .!!!!! ^•■e CZ2 "-. li iiig ifgC OQ a 1 1 1 i 1 ««S; Q (S»i 1 f i 1 n>tt OiH "' 1 1 1 i 1 ■»■« P-i **' 1 # i •I'iM »» 1 i ai «»e» M i i 1 Cf6 9^Si T 1 ' ' I ! KVl fi it TT C» i j .11 (Cm 10 1 i i i 1 •ctZ l'«/ u 1 1 Ma 1 ^TJ mat 1 1 1 # . (^■ uw u|m USI mmli "'a OL iiiiiim hi:::::::::::::: B^m 69 iiiiiiiii c:::::::::::::::: "St »9 lllllllll C" — ■ "-« 19 "*«i 9991 aye 99 iiiin iii|i|K:::::::::: aiZ 19 ■III LaaB^aaMMaBBBMasaS »'jr E9 II Itoaaaaaaaaaaaaaaaw «W E9 •I'ee /sm II iiiiii[::::::::::: «a 99m -* "-■as Ph " nil iiiimiiiii::::::::::: i»te H " 1.4 I !! '! I »a 03 I5SI 1 t !! '! . "-W P 0? 1 !!!! '! .«* 8* iiiiiiiiiiiiiiic:::::::::;::. . »fe iiiiiiiiiiiiiiiiiii:::::::::: .•»-«: t* T I 1 -4- w i««, 919/ T 1 ?1 J - - n CI M (181 01 Sf llllll 8E '" iC 9(81 9C 1C .. Cf xr irsi . OC ■""TT ' T 1 ez 1 ,5 ■^i''-t:ti^::.:'.i ' BZ It - + - 9181 9Z i 12 cz T zz ---- ^ IZBi OZ 1 " 6/ SI LI 91 Si 1 Q » « ^ Q 4 % % 9 s o o o > Hi 13 a a a o 00 00 cd . *^ >> 03 fl O) J2 > 01 la(('il that inoculators were most successful when they practised the operation at periods exempt from the prevalence of the disease. The history of inoculation in Boston relates the disadvantage of inoculation during the period of picva- loncy, for it proved fatal in six cases. Several deaths of prominent ju-rsons in England occurred at about the same time, to check pre<'i|)italely the spread of the new practice. A quarter of a century now elapsed belbrc llu' (.juration was practised in any systematic way in pul)lie institutions where tlic poor as well as the ricji might reeeive its benefits. The LonddU Small-pox aixl Inocu- lation Hospital was not founded until 17-40. During the following half cen- 292 VA CCINA TION. tury it was the fashion to be inoculated. People made engagements with the inoculators as they now do with the dentists. The wife of General Washing- ton during a visit to Philadelphia took advantage of her visit to undergo inoculation, in which process she had "a very favorable time" (Plant). There was no doubt of the protection of the individual by inoculation. The proportion of deaths was reduced from 20 or 40 per cent, to 3 in 1000. There was, however, another side. The disease which was introduced was the true small-pox, and each inoculated person was a centre for infection. By the end of the eighteenth century, when the practice of inoculation had become general, the proportion of deaths from small-pox to deaths from all causes had increased from one-fourteenth to one-tenth. With the recognition of this fact the process was interdicted by law both in England and France. This was in 1841, but inoculation was still secretly practised, with the continued produc- tion of new centres of small-pox, until the government affixed to it as late as 1860 a penalty of fifty pounds. Something of the nature of vaccinia-lymph may be learned by study of this '^ history of inoculation. As has been stated already, it was the custom in China and India three thousand years ago to directly produce the disease by inoculation of small-pox matter itself, and secure protection by immunity thus conferred by previous attack. It was the custom in Europe, as also in the early history of our own country, to isolate people in a period of health in pest-houses, and directly inoculate or engraft them with the disease itself, in the hope that the introduction of the poison at a period free from the presence of an epidemic would produce a milder form of the disease. Some of the older variolators became exceedingly expert in this operation. Gatti, the ** Jenner of inoculation," brought it to a grade of perfection worthy of being called a science. He was certainly able in a large percentage of his cases to bring about a variola so modified as to be distinguished at times by the absence of any general eruption, and sometimes by the 'absence of all eruption. He selected his subjects and season of the year as well as his stock of matter. He learned to make the the smallest possible wound with- out drawing blood, and to introduce his matter in minimum quantity. He selected it also from the oMest case, convinced of the fact that the poison was mitigated by continuous generation. This mitigation of the intensity of the poison is the clue and the key of the whole process of securing immunity against the various infections in modern times, the results of which promise to soon eradicate or modify the forms of these diseases. It was learnt by acci- dent that the mitigation of small-pox virus was precipitated by passing it througli the body of a cow. At the present time there is no doubt that the original cow-pox is human pox modified in this way. It is Avell known also that variola virus may be attenuated in other ways. Thiele of Kasan in the systematic desiccation of genuine small-pox matter, dilution with milk, inocu- lation, propagation, redilution, etc., through several generations, succeeded in producing a virus whose properties Avere absolutely identical in every way with the vaccinia-lymph in common use. In fact, the process of generation VA CCINA TION. 293 can be continued so far as to destroy all infectious properties. This fact was observed long ago in bovine virus, which, when continuously transmitted from calf to calf, finally loses its protective property. To sustain the virtue of bovine lymph occasional resort to inoculation of the animal with human matter became a necessity. The antiseptic fluids, carbolic acid, salicylates, solutions of boric acid, thymol, etc., added to vaccine virus for preservation, gradually reduce its active properties; so too chemically pure glycerin, which is added for dilution, has the same eifect of weakening and finally destroying the active principle. The best lymph from the cow is that which exudes from perfect vesicles before they begin to point. The presence of slight incrustation in the centre of the vesicle indicates the period of greatest virtue. The puncture should be made with a sharp lancet as near the centre of the vesicle as possible, and the fluid collected, as it exudes spcmtaneously or under slight pressure, in capillary tubes or upon the surface of bone points. Puncture of the margin of the vesicle secures only blood, which is worthless. " Vesicles on which the central crust has begun to form are the most productive, particidarly if the crust be small and the margin of the vesicle tender, hot, and tumid : the small super- ficial vesicles are often more yielding than contiguous larger vesicles, which are more deeply seated or confluent" (Aitken). Supply is now so abundant and is furnished from so many sources as to secure mankind against any accident by extinction of the natural disease. No place is so distant from a vaccine farm that it may not be sujiplied in the course of a few days or a week with effective material. In emergency, where a i)ure lymph cannot be secnn-cd, that which has undergone some degree of incrustation, as aggregated lymph found in the immediate vicinity of broken vesicles, may be used as a substitute. It should be clear and colorless like crystals of white sugar candy, or, if colored, but lightly tinged with amber. Central crusts which represent a mass or mould of vesicles, dark brown, but nearly translucent, may also be used. The crust should be pulverized in a clean mortar and preserved in glycerin. Where human lymph is used vaccination is best practised from arm to arm. The vesicle is punctured at the period of full maturity on the eighth dav, never later, and the clear fluid which exudes is collected and utilized as before. Before the general use of bovine virus the material mostly employed was the crust which fell spontaneously from a healthy child. This crust was treated in the same way as that from bovine lymph. Protected from the air, enveloped in rubber cloth and absorbent cotton, and enclosed in well-stoi)i)ed vials, it retains its efficacy for almost indetinite periods. Thus, Miiller of Berlin (1869) made use of cow's lymph which had been originally sent fnmi Holland for the purpose of experimentation, and had been kept oints) and freedom from any possible taint of syphilis soon secured for it general adop- tion. Revaccination at stated intervals — at puberty, maturity, or at any time during an epidemic — robs the question of the vahic of the kind of virus ov the number of simultaneous vaccinations of practical interest. Points of selection for the operation are about the insertion of the deltoid or the junction of the heads of the gastrocnemii muscles. As a protection against future carelessness regarding revaccination the matter may be intro- duced in three places, at the angles of a triangk — horizontal insertions at the shoulders permit concealment by a narrow sleeve — at least half an inch distant from each other. Six or eight parallel trafings or strokes, with as many cross- strokes, with the point of a knife so light as to expose the superficial lymphatics and draw little or no blood, afford the best wound, upon which the moistened bone surfaces may be gently rubbed. Susceptibility is universal. There is no such thing as insusceptibility to vaccination. Seaton never saw it in nioiv than nine thousand cases at the Black Friars National Vaccine Station. Cory confirms this statement with reference later to bovine lynqyh, and I{oi)crtson declares that so-called cnnsti- 296 VACCINATION. tutiunal insusceptibility is usually a confession on the part of the operator that he lias not ascertained the cause of his failures. This fact proves also that there is no real insusceptibility to true variola : escape is due to accident. The true lesion of vaccination shows all the characteristics of a single typical small-pox pustule. At the end of forty-eight hours the surface of insertion is marked by slight redness and swelling to the size of a large papule, upon the summit of which develops by the third or fourth day a small vesicle filled with a clear fluid. This vesicle is a reticulated sac, the puncture of which — as for the collection of lymph — discharges its fluid contents by slow oozing. It reaches its maximum size by the seventh or eighth day, at which time it is'umbilicated and surrounded by a ring of inflamed tissue — the areola — which continues to enlarge for two days, to attain in full development a diameter of one to three inches. The contents of the vesicle now begin to grow somewhat opaque (pus) — to present the appearance on its inflamed base quaintly described by Jenner as " the pearl on the rose." The areola is the evidence of a successful vac- cination. By the tenth day the serum is changed into pus, the vesicle has become opaque, and its centre shows yellow inspissation in the form of a crust, which by the fourteenth day extends to convert the whole pustule into a hard, dry mass. The crust falls spontaneously by the twentieth to twenty -fifth day, to leave as a result of the destruction of tissue a characteristic scar. The cicatrix of vaccinia is a more or less circular depression marked by minute pits and radiating lines. It should measure in its diameter fully one-third of an inch. Red or pink at first, its color gradually fades to the bleached appearance of cicatricial tissue, to remain as a mark for life or to gradually disappear in the course of adolescence to the faintest trace. However pronounced, a cicatrix, it is needless to state, is evidence only of destruction of tissue, not of permanent protection against small-pox. The writer recalls a malignant case of purpura variolosa in a young woman whose arms were marked by two typical cica- trices, relics of successful vaccination in early childhood. Slight fever, fret- fulness, headache, insomnia, restlessness, disturbance of digestion, lymphangitis as evidenced by swelling of the axillary glands, may be present for a few days at about the time of maturation of the vesicle, to subside rapidly during the period of incrustation. More extensive inflammation, dermatitis, or destruc- tion indicates mixed infection. The constitutional signs are mildest in infancy and increase in severity with advancing years. Delay in the appearance of the vesicle even to the end of a week does not ])reclude success, provided the subsequent phenomena ap})ear in course. Ac- celerated, abortive, so-called "spurious" v'accinations differ in various ways, and furnish only partial, limited, or no protection. It is estimated that at the present time twenty -two million people are vac- cinated every year. VARICELLA. By JAMES T. WHITTAKER. Varicella or varicellsc — diminutive of varus, pimple, pock ; chicken- (French, chiehe ; Latin, cicer, insignificant) pocks or pox ; watcr-pock, wind- pox ; variola notha, spuria ; false pox — is a trivial acute infection of childhood, distinguished by a long period of incubation, absence of prodromata, slight fever, a vesicular eruption varied in size and short in duration ; as a rule, without complications or sequelae. Chicken-pox was first described under the term crystalli by the Italian anatomists — Igrassias in 1575, Guido Guidi in 1585 — and received its pres- ent unfortunate name from Vogel in 1764, History. — Fuller (1730) and Heberden (1767) made the first attempts to separate this affection from variola (varioloid), with which it had been for- merly confounded, and has been so since by many authors (Hebra, Thompson) "with inconceivable persistence " (Thomas) — a mistake which resulted in com- plete confusion regarding the nature of both affections, and in reproach and disrepute of vaccination in the early years of its jiractice. As early as 1690, Morton, who introduced later the term ''chicken-pox," is said to have described a case of varicella under the title " variola maxime benigna/' and Jennings declares tiiat at this time the disease was distinguished by the people from small-pox. Opposition to inoculation toward the close of the last century concentrated attention upon the milder forms of small-pox, and the practice of inoculation — which was, by the way, a very lucrative pro- cedure — depended upon the separation of varioloid and simulating affections. Willan (1798) discussed the eruption in detail, describing the vesicles as acumi- nate, conoidal, and globate. With the introduction of vaccination it again be- c^me necessary in its defence to separate cases of varicella, but, notwithstand- ing all the study that has been put upon these infections, the difference between varicella and varioloid has been at times so little marked as to have led cer- tain eminent authorities to regard them as identical, or to look upon chicken- pox, as Morton put it, as the most benign variola. Kaposi and JJruyelle still support this view. Nature and Etiology.— Gee declares that there is not u|)on record a single authentic instance where varicella resulted from variohi, or rice versa. So, too, epidemics prevail entirely independently of each other. Mohl emi)hasized this fact by the statement that small-pox was entirely absent in CopcMihagcn from 1809 to 182.3, while chicken-i)ox was frniucnt every year. Successive ej)i- demics are very rare in varicelhi, but very frecineut in small-pox. Tiiocnlnfed 298 VARICELLA. small-pox produces at times a very light form of variola, but the form is never so light but that it may be distinguished from varicella. Both variola and vaccinia protect against variola, but not against varicella. It is impossible to conceive of the occurrence of a case of varioloid, however benign, immedi- ately or shortly after an attack of small-pox of any kind or shortly after a successful vaccination, but infinite are the cases in which chicken-pox has fol- lowed upon the heels of variola or has occurred in the course of or soon after vaccinia. Varicella is a disease of childhood almost absolutely. Variola is a disease of chilhood by preference, but does not spare the adult unprotected by previous attack or by vaccination. If varicella is but a modified variola, there should be upon record at least one authentic case of communication of this disease to some adult member of a family. Hochsinger thought that he had seen such a case when a boy, set. 10, affected with varicella (together with fourteen of his school-mates), communi- cated chicken-pox to his brother, ?et. 14, who had not been at school, and small-pox to his mother, set. 40, who had not been away from her home. The small-pox case ran a typical course, and the author concluded from this observation that the old Hebra-Kaposi doctrine of identity was thus re-estab- lished. Close study of these cases convinced Thomas, however, that they were all of them mild cases of varioloid. Varicella very rarely attacks a whole family, and still more rarely those of the ages mentioned. Henoch says that he never saw an undoubted case in an adult. It is known, moreover, that individuals who have been vaccinated, or even revaccinated, may, after a cer- tain indefinite period, suffer attack of the lightest possible true variola, which may run its course without or with almost no fever, and be marked by an eruption of papules or vesicles, but no pustules at all. Thomas looked upon these cases, therefore, as the very mildest possible forms of true small-pox, the so-called " variola vesiculosa." Inoculation of varicella, when it succeeds, invariably produces varicella, never varioloid, while inoculation of varioloid invariably reproduces itself or variola, and never varicella. The study of the points of resemblance and difference of these two affec- tions is very interesting, not only from the standpoint of differential diagnosis, but also because it tiirows a side light upon the all-important relation of vac- cinia to variola. Bollinger says " the small-pox which has been described in dogs has a much stronger resemblance to varicella than variola." Dogs do not contract small-pox. The recognition of the fact that an attack of one disease secures future immunity from itself, but does not protect against the other, finally led to a distinct separation of the two affections. Confirmation of this view was also obtained in the fact, as stated, that vaccinia does not prevent varicella, nor varicella vaccinia. Czakert, after three failures in the ordinary way, suc- ceeded in vaccinating a boy set. 4 by introducing lymph into the interior of vesicles during an attack of varicella. Varicella appears in sporadic and endemic (rarely epidemic) form, and epi- SYMPTOMS. 299 demi(s never assume the range nor show the intervals of measles and small- pox. The disease does not die out entirely in large cities, but assumes some- what of epidemic proportion once or twice a year on the opening of schools and kindergarten. It is confined exclusively to childhood (exceptions having been noted by Heberden, Gregory, and Seitz) up to the age of twelve, and is rare after ten. The short-lived contagious principle, probably from the vesi- cles, is believed to be inhaled (contagium halituosum). Infants are never born with it. Inoculation experiments fail oftener than they succeed. Thus, Hesse failed in 87 cases, succcetled in causing a local ernj)tion in 17, and a general eruption in 9. Steiner claims to have succeeded eight times in ten trials, but was unable to propagate the disease from any case. Tenholdt found in the con- tents of vesicles a micrococcus which, inoculated in man, produced light red- ness and swelling like that of spurious vaccinia, and in one case a vesicle smaller than a sudamen, the affection remaining local. Pfeiffer found in fresh vesicles of thirty cases, without exception, a parasite showing an anueboid stage, a cystic stage with spore-formation, and, after the development of numerous spores, a return to the amoeboid stage. Inoculation with the contents of vesicles showed three times in five days a localized, circumscribed varicellar exanthem, recurring in a scattered manner up to the eighth day. The parasite could not be cultivated upon any cidture soil. Symptoms. — The incubation period varies from eight to seventeen days. Prodromata, in some form of light malaise, occur only very exceptionally. In rare cases they may assume prominence, and tliere may be headache, vom- itino-. and hi^h fever. Henoch once saw a case begin with convulsions. The disease is announced, as a rule, by the eruj)tion, which shows itself in the form of spots of hyperremia, in the centre of which appear, in the course of a few hours, distinct but slightly elevated vesicles, which attain their great- est circumference in the course of from three to twenty-four hours. The vesicles contain a clear, sticky serum of neutral or alkaline (never acid, as in sudamina) reaction, which fully distends the vesicle, anarracks, etc., or, again, extends over or is cir- cumscribed to a certain quarter of a city, or ranges over the entire city and surrounding country. Epidemics may be extinguished in the course of a few weeks or prevail throughout the greater part of a year. The disease shows some predilection for soldiers, probably on account of close association in bar- rack-life. Some of the best reports are furnished by the military surgeons (Bruns). It attacks males always more frequently than females, and is at times limited to children, or, again, spares no individual unprotected by previous attack except sucklings and old people, who almost universally escape. The age of preference is from two to ten. In a house full of chil- dren mumps usually begins with the youngest first, successively seizes the older children, and may afterward attack adults. Ijiability of males is nearly universal. The disease has often been known to attack 90 per cent, of the residents or inhabitants of public institutions, schools, barracks, etc. Mumps is undoubtedly contagious, and probably, as no other explanation seems possible, through matter expectorated from the mouth to contaminate the atmosphere in the vicinity of the patient. It may attack animals (ueh a case deformity is most pro- nounced. The cheeks, the jaws, tlie neck form a vast, tumefied, (edematous, 308 MUMPS. indurated mass, and the suffering from distension becomes correspondingly great. A peculiar, characteristic, and not the less striking because somewhat comical, picture is thus presented by an individual affected by mumps. The inflammation or infection of the testicle is the most interesting com- plication of mumps. The organ is usually affected after the process in the parotid has subsided, sometimes coincidently, still more rarely alone as the sole sign of the infection. It is the testicle itself which is invaded (orchitis), very rarely the epididymis or the cord, and then only after puberty. In double mumps the right testicle, in single the organ on the side of the affected parotid, is most frequently affected. Double orchitis is rare. Affection of the testicle is revealed by a sensation of weight and pain in the gland and along the cord, by fever, and sometimes by vomiting. The testicle soon becomes swollen and tender, and the scrotum is often reddened and oedematous. Strange to relate, the existence of a gonorrhoea during an attack of mumps rather repels than invites attack. Liability is not increased by the severity of the mumps. Orchitis may occur in the lighest case. Frequency of attack varies greatly. Granier saw orchitis develop 115 times — i. e. 23 per cent. — in 495 cases from military life, while Luehe saw it but once in 116 cases, and then in a youth of sixteen in a school of young cadets. Brown records orchitis 10 times after 20 cases of raumj)S in a military school, 9 times on the side affected, and once on the opposite side, with subse- quent affection of the same side. Homen speaks of cases of orchitis at the early age of twelve and fourteen, followed by atrophy. The process usually subsides without damage, though it sometimes results in atrophy, a catastrophe that may be prevented at times by faradization of the testicle on the subsidence of acute inflammation. Urethritis with blennor- rhoea has been also noticed with oedema of the scrotum, and in women, very exceptionally, oophoritis with leucorrhoea and swelling of the external labia and the mammary glands. Mumps, though considered a light infection, is liable to certain very grave complications. Sadden deafness may set in from labyrinthine disease, and serious affection of the brain ensue from interference with the circulation or poisoning by toxines. The disease may announce itself with deafness, due usually to catarrh of the middle ear. The catheter may in these cases reveal the presence of fluid in the cavity of the drum, and inspection disclose hyperaemia of the membrana tym]iani. Meniere and Moure reported cases of permanent deafness after mumps, and Kosegarten claimed to have prevented grave lesion by the admin- istration of the infusion of the leaves of jaborandi. Deafness may also occur in the course of mumj^s from transmission of infectious matter to the labyrinth through the fissura Glaseri (Roosa). Musgrove (Austinvillc, Texas) reported in a very old lady, aged 84, a case of parotitis acuta duplex which ran a regular course up to the sixth day, when she suddenly fell into stupor, with jactitation and stertorous respiration. She roused from the stupor sufficiently to swallow fluids, but died on the following METASTATIC PA li OTITIS. 309 day. Percy Smith (London) reported two cases of mental alienation, one in a yonng merchant, and one in a medical stndent, who suffered also with orchitis. In the first case there set in after the eighth day insomnia, which developed into acnte mania that lasted for four months ; the second ease develo]>ed melancholia and suicidal mania, which, however, also entirely disa])peared. Botii cases ex- perienced extreme prostration during the mental malady. Otiier complications recorded are hypersemia of the brain from ]>ressure on the jugulars, meningitis, aml)lyo{)ia and color-blindness, conjunctivitis, laryn- geal stenosis, albuminuria, hsematuria, nephritis. Klichhorst quotes wit'.i an interrogation })oint a case of endocarditis reported by Isham, and from (John a case of ursemia and death, Michaelski saw a death in convulsions. Palsy of accommodation was seen once in an extensive epidemic (Boas), and ])aral- ysis of the limbs was reported once by Joffroy. Gowers thinks that diphtheria may have been the disease in both cases, and mixed infection migiit account for many other complications mentioned. With all this list it must not be inferred that mumps is a grave disease. The author, in the })ractice of a quarter of a century, has never seen any complication other than a trivial and transitory orchitis. The diagnosis is usually easy, and is helped in any doubt by the existence of the disease elsewhere. The extreme swelling and pain, with closure of the mouth, lifting of the lobe of the ear, and torsion of the head, distinguish the affection. Lesser swelling with less pain may necessitate inspection of the throat in elimination of scarlet fever, diphtheria, or quinsy. Digital exam- ination would detect a retropharyngeal abscess, which might extend to involve the connective tissue about the jaw. A lymphangitis or simple adenopathy from infection of the throat, a very common affection, may be nearly as exten- sive and painfvd as mumps. It is usually seated or arises lower on the neck, has no definite duration, and is much more prone to suppuration. Metastatic Parotitis. Metastatic parotitis occurs, as stated, in connection with, or in the course of, the more grave infections, such as typhus, typhoid, and relapsing fever, yellow fever, pygemia, measles, scarlet fever and small-pox, pneumonia and dvsentery. The disease has hitherto been regarded strictly as a metastatic process due to transfer of diseased products from a distant seat. Recent inves- tigations, however, go to prove that the affection begins in all cases in the mouth. Hanau made a special study of the genesis of five cases of su|)purative ])arotitis which occurred as a secondary process in consequence of sei)ti<^ infection. These studies were made esi)ecially to determine the question whether the disease was due to the migration of the micro-organisms irom the mouth or as a result of metastasis from the blood. The micro-organisms encountered wore in all cases micrococci, which in their arrangement were clearly stapliy- lococci. They Avere always found in th.' . As it was also foiuid in the lungs and bronchi of chihlrcn who had died of the dis- ease, the author considers it the true cause of whoo])ing cough, and names it the "ba(;illus tussis convulsivjc." These investigations were subsequently con- firmed bv Schwenker and Wenat. Ssemtchenko after considerable experimen- tation reached the following conclusions : I"'irs(, the l)acillus of Afanassicff is specific. It may be found in the s|)n(Mni a< r:irly as the fourth day of the 314 WHOOPING COUGH. disease. It multiplies in the body, and as it increases the disease diminishes in severity. It disappears with the resolution of the disease or when the par- oxysms are reduced to two to four daily. In the presence of complications, especially catarrhal pneumonia, it increases in the sputum. Thus the bacillus is of value not only in etiology and diagnosis, but also in prognosis. These conclusions have, however, not yet met with universal acceptance, as the obser- vations have not been sufficiently verified. Renewed interest attaches to this bacillus of Afanassieff with the discovery by Griffiths of a ptomaine or tox- ine in the urine of whooi)ing-cougli patients. Griffiths claims to have estab- lished the fact experimentally that an absolutely identical toxine is developed by this- bacillus. The toxine is not found in the urine of any normal indi- vidual nor in that of one suffi3ring from any disease other than pertussis. There is, therefore, scarcely room for doubt that pertussis is a mycosis whose toxines have a special action upon that part of the nervous system which presides over cough — to wit, the centres of the superior laryngeal and vagus nerves. Thus in our day the mycotic has displaced the neurotic theory, and the views of Canstatt and Lebert are substantially re-established. Be this as it may, there is no doubt as to the exquisite hypersesthesia of the larynx in these cases. Any active movement of the larynx as in coughing or cry- ing, the ingestion of food and drink, any irritation as by exposure to cold air as in a draft or a cloud of dust, or to contaminated air as in a close, hot room or crowded apartment, any external pressure or irritation as by inhalation of tobacco smoke or the drinking of any form of alcohol, may produce an explo- sion of the disease. The contagious principle is not often disseminated without direct exposure to the disease. Thus very slight isolation secures exemption from attack. The bacillus has no great tenacity of life. Cases in which the disease has been conveyed after weeks or months by clothing, curtains, or other fomites, so common in measles, and more especially in scarlet fever, are very rare in whooping cough. The disease is spread by direct contact in families, and more especially in kindergarten and schools, to assume endemic proportions and to cease only when the material is exhausted. Whooping cough occurs with special frequency, as stated, during convales- cence from measles. The disease shows itself also in close relation to tuber- culosis. It has long been noticed that tuberculosis often follows close upon the heels of whooping cough. It is impossible to say in a given case whether the whooping cough made the soil fertile or merely aroused the latent disease. Symptomatology. — The disease begins with the signs of an ordinary catarrh of the exposed mucous membranes. There are sometimes conjuncti- vitis with photophobia, and such catarrh of the nose as to lead to the suspicion of the development of measles. Very shortly, if not simultaneously, there is bronchial catarrh, which raav distinguish itself in no way from an ordinary cold. The nature of the disease may, however, be anticipated, especially in the presence or vicinity of other cases, on account of its severity and obstinacy, especially on account of the undue prostration in association with it. Some- SYMPTOJfA TOLOG Y. ,315 times, even at this early period, there is a peouliar rintr or intonation in the congh which excites suspicion. Often, again, the paroxysmal nature of the outbreak thus early defines the disease. The statement of the mother or attendant that the child coughs worse at night is not in accord with an ordi- nary catarrh. A simple catarrh of the larynx or bronchial tubes may dis- tinguish itself by restlessness and exaggerated cough in the early part of the night; but it usually becomes quieter, and the child sleeps more or less con- tinuously after midnight. Whooping cough intrudes itself at any hour of the night, and rouses the child usually to a sitting posture, with a more or le&s violent paroxysm. Tlie statement also that the cough is attended with flush- ing of the face and vomiting lends confirmation to suspicions. If, on inspec- tion, the face, especially the lower eyelids, be swollen and dusky, the disease is probably whooping cough. Throughout the whole period of the catarrhal stage, which lasts from ten to twelve days, there is commonly more or less fever. It is most marked, as a rule, in the evening, and is observed only in those cases where the temperature is taken at bed-time. Fever is often abscMit throughout the whole course of the disease. Whooping cough occurs, as stated, in paroxysms or explosions. It would appear as if the nerve-centres suddenly discharged themselves of accumulated force or irritation, as in a case of epilepsy. Close observation of a case gives rise to the impression that the poison accumulates gradually up to a certain point, when it may be no longer stored, and is discharged with the explosion that characterizes a paroxysm of the disease. Whooping cough is usually divided into three stages — the stages of catarrh, of spasm, and of resolution. The first stage lasts about one week. Sometimes this catarrhal stage is very short, and the spasmodic element manifests itself at the end of the second or third day. A pseudo-crou]> may j>recipitate an attack at once, so that the disease may supervene on the day following the night of its occurrence. A premonitory catarrh of five or six weeks' duration is usually a preceding complication, and not a distinct prodrome or stage of whooping cough. The neurotic element now assumes prominence. The cough becomes more frecjuent, severe, and harassing. The intervals between the paroxysms are, however, more distinct. Very soon the cough assumes the convulsive charac- ter mentioned, and sooner or later occurs the typical stacciito cough, with the long-drawn, audible inspiration. The second stage has now set in. In these attacks the seizure is sudden. Sometimes, though not as a ride, there is a kind of premonition or aura wh.ich previous experience has taught the child to recognize. It is usually a sense <»f impending distress or dang<'r, which leads the child to leave its play and run to its parents or grasp a cliair for suj)port. A water-closet, a slop-jar, or a cuspidor is a fre(|uent goal. The aura may be in the form of dyspnnea, prnecordial distress, nausea, sometim(>s actual vomiting. Thereupon ensiies the scries of expiratory lonnhs which distinus. Upon micro- scopic examination of various organs there may be found islets of coagula- tion-necrosis. The diagnosis is, as a rule, easy, the only difficulty being the discovery of the source of blood-contamination. By careful ex.lmination into the his- tory of the case this can usually be discovered even in the cases that do not restdt from some recent injury or ojx'ration. One point should, however, l>c borne in mind: the frequent dependence of this nmdition upon the attempt to i)roduce criminal abortion or upon the |.rescncc in the uterus of placental renjains after an unrecx)gni7X'd miscarriage. 326 SEPTICEMIA AND PYE3IIA. The prognosis is in all cases to be guarded. Death may occur within the first twentv-tbur hours if the amount of poison absorbed be very large. In reo-ard to treatment but little can be said. Removal of the cause is of the greatest importance. In addition to the adoption of appropriate surgical measures the patient's strength must be supported by appropriate diet and the judicious use of stimulants. In the lighter forms quinine may be of value in small tonic doses ; in the more severe forms its value is very slight. The diet should consist of liquid, easily digestible and nourishing articles, such as milk, raw or lightly boiled eggs, beef- or clam-juice, and liquid peptonoids. Alcoholic stimulants in some form are required in all severe cases. Careful attention must be directed to the condition of the skin, and the urinary blad- der must be carefully protected from over-distension. Should danger arise from hyperpyrexia, suitable hydrotherapeutic measures should be adopted. Pyemia. Definition. — A condition arising from the diffusion of the micro-organisms of suppuration throughout the body, characterized clinically by frequently recur- ring chills, remittent or intermittent fever, profuse sweatings, and various symptoms depending upon the involvement of different organs ; pathologically, by the presence in various tissues of multiple metastatic purulent foci, pro- duced by the transference of the pyogenic micro-organisms from a primary- focus of suppuration. As will be seen by the definition given, this condition is dependent upon the presence in the various organs of single or multiple abscesses that have been produced by the transportation of pyogenic bacteria from some primary focus, thereby differing from septicaemia, wherein no such metastasis is present. Among the more frequent sites for these primary abscesses, when not traumatic, may be mentioned the subcutaneous cellular tissue ; the pelvic cellular tissue and organs; the subperitoneal connective tissue; the marrow of the long bones; the parts surrounding the middle-ear cavity ; and the joints. It frequently hapi^ens that wide dissemination of purulent emboli occurs from an ulcerat- ing lesion of the cardiac valves. This form of endocarditis is usually itself secondary to some other lesion, the valves merely offering a good breeding- ])lace from which the bacterial masses may be swept off by the blood-stream and scattered throughout the body. " Idiopathic pyaemia " is the name applied to those examples where no primary purulent focus can be demonstrated. The essential cause of the condition is one of the forms of pyogenic micrococci. The streptococcus pyogenes is the most frequent form found, but the staphylococcus pyogenes aureus or albus is present in many instances. These micro-organisms," either by their own a(!tivity or by means of the mate- rials they produce, cause coagulation-necrosis of the surrounding tissue-cells ; by their continued action this area of coagulation-necrosis extends; inflammation of the veins of the part follows, with a similar process in the wall of the ves- sel ; the endothelium of the vein so affected is loosened from its dee]) attach- ment, and with its contained micrococci is swept off by the blood-stream. PV.EMIA. 327 Arriving at some portion ot" the eireulatory system where the ealibre ot" tlie vessel diminishes to such an extent as to preehule the passage of the embohis, stasis occurs, and, if the soil be suitable, the transp<»rte(l micrococci repeat tiie process of pus-formation in their new quarters. In this way are tbrmed nimi- erous abscesses in various parts of an organ or in various ami frequently widelv-separatetl regions of the boily. If the original foi-us were in the superficial portions of the body or in the long bones, the secondaiy abscess will be found in the lungs, or if they pass through these organs without Uxlg- raent the heart and kidneys will offer a favorable site for their development. If the primary focus be in the area drained by the portal system, purulent pylephlebitis and secondary abscesses in the liver will result. When malig- nant endocarditis has been the starting-point of the emboli, the secondary foci may be found in the spleen, kidneys, brain, skin, or intestines. The symptoms of pyaemia vary greatly in different cases, depending upon the or^an or organs that are the seat of the secondarv abscesses. There are, however, certain syiuptoms that are present in all forms, and that characterize the condition. The onset of pysemia is usually announced by the occurrence of a rapid rise in the bodily temi)erature. With this rise of temperature, or following shortly thereafter, there is a chill that at times merely amoimts to a sensation of coldness, at times to a severe rigor. The temperature may shortly sink to near the normal, but soon again rises to a point higher than that pre- viously attained. The fall of temperature may not occur until the following morning, the second elevated point being usually observed upon the evening of the dav after the onset. From this time the temperature assumes a peculiar type, with high elevations toward evening, and a fall of oftentimes three, four, or more degrees toward the early morning hours. The rigors are repeated at varvino- intervals, but they may not be a marked feature of the case. A\ ith this peculiar temjierature range and the occurrence of rigors there is found to be a marked tendency to profuse sweating. The sweating may be almost con- tinuous, or it may occur in paroxysms that are apparently causeless, but that are more apt to occur toward night-time. The patient rai)idly loses strength, and emaciation progresses with constantly increasing celerity. With the symp- toms enumerated there are loss of appetite, thirst, a peculiar sweetish, nauseat- ing odor, and usually the signs of involvement of one or more of the internal viscera. The patient sinks into a condition of profoimd jjrostration ; bed-sores form on parts exposed to pressure ; and the patient dies from exhaustion or from involvement of some vital part in the supi)urative process. When the liver is the seat of secondary foci <»f su|)|)urati(»n, a more or less intense yellow discoloration of the conjunctivie and skin will !.<• dcveloi)ed, with in manv cases a varying amount of diarrh(ea, and <.n percussion there is shown to be'eidargcment of the organ with tenderness over its site. Involve- ment of the kidneys may give no sign ; more rre(|.i.iitlv, h..wever, there is :,I1)U- minuria with granular casts, and at times bl.-o'l. Splenie inrmviin,, is shown by pain in the left hypochondriac region, will, j.rogressive enlargeinent ul il„. area of dulness. Metastasis to thr Inngs usually is p.H..luctive of but f.-w changes 328 SEPTICEMIA AND PYEMIA. in the physical signs, save those of the accompanying inflammatory conditions. Intestinal involvement is accompanied by marked diarrhoea, cansing errors to be freqnently made by its simnlating the diarrhoea of typhoid fever. Metas- tatic infarctions of the derm prodnce multiple superficial abscesses. Secondary abscesses may also occur in the parotid gland and in the pancreas, giving rise in the latter to deep-seated pain in the epigastric and umbilical regions. Abscess of the brain may give rise to various forms of paralysis, but the lesions are, as a rule, multiple, and hence give rise to no trustworthy local- izing symptoms. One other form must be mentioned, wherein the joints are attacked, giving rise to what is known as pyajmic rheumatism. The pathology of the condition has been already indicated. Upon post- mortem examination it may be difficult to determine the primary source of infection. The abscesses that form in the various organs are multiple, and usually do not attain to large dimensions before death occurs. In some cases, however, owing to the fusion of smaller abscesses or owing to the embolus obstructing a large arterial branch, one large abscess may be present. In the secondary deposits there can be found the pyogenic micro-organisms that are accountable for their production. The diagnosis is usually readily made by observing the peculiar irregu- larly intermittent fever. Tlie two diseases with which this condition is most apt to be confounded are typhoid fever and malaria. A careful review of the iiistory of the case, due attention to the course of the temperature, the appearance of the countenance, the absence of marked sweating and of rigors, with the presence of the typical eruption, the characteristic stools, the tym- pany, and splenic enlargement, will usually indicate typhoid fever. Malaria can be readily distinguished by the greater regularity of the fever, the periodic occurrence of the rigors and sweating, the completeness of the intermission, the specific action of quinine, and finally the presence of the plasraodium malariae in a patient suffering from the malarial infection. The diagnosis is not suf- ficiently accurate until not only the condition of pysemia is determined, but the lesion that gave birth to it is discovered. The prognosis is in all but the mildest cases extremely grave. Where the disease is well marked, and where surgery cannot be called to our aid to evacuate the secondary depots of pus, recovery is rare. Unfavorable signs are those indicating involvement of the deeply-seated organs. Unfortunately, but little can be done in the way of treatment, save where the secondary abscesses are amenable to surgical interference. All our measures must be directed to keeping up the patient's strength. A nutritious diet, moderate doses of quinine, with suitable amounts of alcohol, are our chief mainstay. Digitalis, caifeine, or strychnine may at times be of use. For the sweating, atropine, aromatic sulphuric acid, or agaririn internally, with sponging of the body with alcohol and alum, may be resorted to. Pain is rarely severe, but may require the use of morphine. The chief indication is to support the patient until surgical interference for the evacuation of second- ary foci may become possible. ACUTE MILIARY TUBERCULOSIS. By \V. oilman THOMPSON. Definition. — Acute miliary tuberculosis is a form of tubercular infection characterized by the general dissemination of minute tubercles throughout the various organs of the body, by pyrexia, constitutional .symptoms, and a rapidly- fatal ending. Etiology. — Acute miliary tuberculosis may occur at any period from infancy to sixty years of age, but it is most common between the age of puberty and middle life. Acute miliary tuberculosis may follow upon a tubercular pleurisy or vari- ous bone and joint diseases of tubercular origin witii caries and necroses, or tubercular lymph-glands with cheesy degeneration. It not infrequently occurs in connection with a tubercular psoas abscess or with the scrofulous diathesis ; hence it is very often a secondary disease. Reich reports a remarkable occur- rence in Neuenburg, a town of 1300 people. The midwifery practice of the town was divided between two women. One of these midwives acquired pulmonarv tuberculosis. She was in the habit of resuscitating stillborn infants by applying her mouth to theirs and breathing into their lungs. In the course of two years ten of these infants died of miliary tuberculosis, which aflected chiefly the meninges, while in the practice of the healthy midwife no such fatality resulted, and the parents of these children were not tubercular. Similar infection has occurred among Jewish children after the rite of cir- cumcision when the operator, having pulmonary tuberculosis, has applied his lips to the incision. Occasionally operation upon tul)ercular joints or upon tubercular bones with incomplete removal has been followed by miliary tuberculosis. None of these various conditions, however, are necessary forerunners of miliary tuberculosis, and the disease occurs sometimes in persons who are in good health — at least in whom no caseous or tulx-rcular foci or tubercle bacilli have been discoverable. The cause of this sudden inftn-tion by miliary tuber- culosis of the entire body in persons previously in ap|)arent health is undecided. It is not directly due to the entrance of any virus through the lungs, and it does not follow acute pulmonary inflammations. It was long ago suggested bv Buhl that it was owing to the sudden liberation of caseous material from a circumscril)ed focus by ulceration into a blood-vessel or lymphatic vessel. In snp])ort of this theory is the fact that l»oiili<'k discovered caseous iuliitration of the walls of the thoracic duct in children who had died of miliary tuber- :j2u 330 ACUTE MfLTARY rUBERCULOSLS. culosis. A few years later Weigert found similar appearances in the walls of the pulmonary veins. Under similar circumstanees it would be easy for a lymphatic gland to adhere to the wall of a vein, ulcerate into it, and pour its products into the circulating blood. On the contrary, miliary tuberculosis is a very unusual complication of advanced pulmonary phthisis, and, indeed, of many other conditions in which there are large caseous deposits of long standing. Since the discovery of the bacillus of tuberculosis by Koch in 1881 the theory has been advanced that miliary tuberculosis is not occasioned by caseous or other infections material present in the circulation, but by the bacilli themselves, which, having escaped into the blood, find lodgment in the different viscera and serve as foci for the development of countless tubercles. In support of this recent theory is the fact that the injection of Koch's tuber- culin into tuberculous subjects occasionally excites acute miliary tuberculosis. Koch's tuberculin is a glycerin extract prepared from a culture medium in which tubercle bacilli have been growing. It is diluted with distilled water at the moment of use, and one milligram, gradually increased to five or more, constitutes the dose, given by hypodermic injection. According to Koch, the glycerin extract contains pejitone, albumose, and other undefined proteids and salts : it is a viscid, thin, syrupy fluid with a neutral reaction, faintly aromatic odor, and the color resembles diluted iodine. When diluted with water it is opalescent and greenish. The action of tuberculin upon tubercular subjects is both local and constitu- tional. In from four to five hours after the first inoculation it produces febrile symptoms. There is a chill with nausea and vomiting, headache, malaise, aching of the limbs, and a sharp rise of temperature to 103° or 105° F. A few hours later the local symptoms appear. If there be a tubei'cular joint or skin or gland lesion, there is local swelling, redness, and pain, accompanied by exudation and infiltration of the tuberculous tissue with leucocytes. Similar changes occur at the site of tubercular processes in the lungs and elsewhere. The tuberculin does not kill the tubercle bacilli, but modifies the nutrition of the tissues that surround them, and it has no influence on necrosed bone or old cheesy material. Living bacilli and caseous detritus have been found in the sputum after tuberculin inoculation. In other instances the bacilli become encapsulated, and are thereby rendered innocuous. In still other cases, how- ever, patients have been found to suddenly develop acute miliary tuberculosis. This is due to the local inflammatory process excited by the tuberculin, result- ing in a communication between a tubercular lymph-gland, or other focus of tubercular material, and a vein or lymphatic trunk. In this manner the bacilli pass into the circulation, and are borne to all parts of the body to excite the formation of fresh tubercles. This occurrence is not very frequent, but well-marked cases have been described by Virchow and others. The use of tuberculin, although so disajipoiuting in its benefits, has proved of excep- tional interest by adding to the knowledge of this mode of exciting acute miliary tuberculosis. MORIiTD AX ATOM v. 3-^1 Morbid Anatomy. — After doadi the hodv j)ros(Mits tin- iippcaiaiu-e cuiiinu)ii to acute febrile disease. Tlie l)loud is dark and fluid, the sj)leen is softer than normal, and there may be more or less visceral congestion. The muscles are refl and rigor mortis is well marked. For the detailed structure of tubercles the reader is referred to the article upon Pulmonary Plitlnsia. They present no anatomical peculiarities in miliary tuberculosis, excepting in regard to their extension and uuitbrm distribution through many organs and tissues of the body. The tubercles vary in size from 3^^^ to 2-jo ^^^ '^" '"^'^* '" ulsp, and there is no abdominal eruption or splenic enlargement. The dis- ease advances much more raj>idly than does typhoid fever. When there are chills at the onset the disease has been sometimes mistaken for malarial fever; but the typical paroxysms, the enlarged spleen of the latter disease, and the influence of quinine will establish the diagnosis. If there be much cough and expectoration, miliary tuberculosis may be mis- taken for a .severe acute general bronchitis, especially in advanced life ; but the mor(> rapid prostration, extremely rapid breathing, and rapid pulse of miliary tuberculosis soon resolve the doubt. Prognosis. — The prognosis is always bad. It is generally believed that recovcrv is impossible, and that reported recoveries were instances of errors in diagnosis. Death will occur sooner in proportion to the number of different organs involveil and the suddenness and severity of the invasion. Death occurs early in cases with meningeal tubercles. Treatment. — The treatment is purely symptomatic, and remedies given with anv other view are useless. Th.e only indications which can be met are to stimulate the heart and to relieve the dyspnoea or other suflering l)y morphine. If the temperature be very high, cold alcohol sponge-baths may be given ; cardiac stimulants and alcohol must be administered to sustain the heart. The diet must consist of milk, broths, eggs, beef-juice, egg-nog, milk-punch, etc. If there be meningeal complication, to relieve headache and delirium leeches mav be applied behind the temples and an ice-bag ])laced upon the luuid. Severe cough should be controlled by sedatives and narcotics. Small hypo- ossibly wandering leucocytes. Sometimes parts of a gland undergo annemic necrosis and form caseous matter without active inflammation, although such a mass really acts as a for- eign body, and is liable to originate inflammation. (6) Inflammation, when it affects the glands, causes an increase in the number of lymphoid cells in the sinuses and follicles. The cells are swollen and have large nuclei. The white blood-cells in the vicinity are swollen by imbibition of albumin (Lynch), and they degenerate. In the glands there are at first hyperemia and an exudation which is either diffuse or localized, forming nodular masses, which may resolve or sup])urate and re- sult in abscesses, or which more often are converted into a dry, friable, caseous material. In the mediastinum and mesentery the glands are apt to become cretaceous. The cut surface of the gland shows irregular yellowish or white spots of cheesy or calcareous material. The spots may be few and isolated, or all the normal gland-structiire be replaced by cheesy matter enclosed by a thick- ened capsule. These ])rocesses may be acute, but they are usually very pro- tracted, and the glands quite lose their vascularity and often become nodular. When the cellular elements undergo fatty degeneration and caseation, it is be- cause the scanty blood-supj)ly, still further reduced by tiie i)ressure of the swollen gland, does not furnish enough alkaline blood-plasma to liquefy the mass, and what is supplied is carried off too rapidly in the relatively large lymph-channels (Cornil and Ranvier). There is periglandidar innaiiuuati..u in the surrounding areolar tissue, and the caj)sule of the gland becomes thick- ened and is permeated with round cells. The overlying skin becomes adherent, bluish, and thin. Giant cells and tubercles are very often found in the glands, and sometimes there are tubercle bacilli. The enlarged bronchial glands n>ay produce pressure symptoms, or may supi)urate and ulcerate through the bronchial mucous mem- brane and occasion bn^ncho-pncmnonia. The cnhugcl mesenteric glands occa- sion chronic; enteritis and dlarrlio'a. (2) The Lesions oe the Mucous Memhuamos may arise by extension 340 SCROFULA. from the skin, or they may spread from the mucous membranes to the skin. Hypersecretion prevails, and it is excited by the slightest irritation. There may be conjunctivitis, catarrhal ophthalmia, or suppurative inflammation of the middle ear, resulting in perforation of the membrana tympani and a muco- purulent, offensive discharge. Opacities of the cornea may be produced which last throuo-h life. There is a marked tendency to catarrhs of the nose and pharynx, which are very chronic, and the mucous membrane is covered with thick exudation which encrusts it, forming scabs. Coryza, laryngitis, and bronchitis occur, and are very persistent. Inflammations of other mucous membranes are less frequent. Scrofulous ulcers are indolent, with anaemic overhanging edges ; they heal very slowly, and often a cicatrix closes in one part of an ulcer while it breaks down again and opens at another. (3) The Lesions of the Skin are of considerable variety. When the diathesis exists, apy skin disorder is affected by it and assumes the scrofulous type. Impetiginous eczema is the commonest of the scrofulodermata, and the face, hairy scalp, or extremities are affected by it. Lupus, prurigo, and lichen also occur. (4) The Bones which are most frequently the seat of scrofulous changes are those about the ankle, the femur, and the vertebrae. The character of the inflammation is a " fungous " osteitis or periostitis, and the joints may be affected by synovitis, white swelling, or general arthritis. There may be caries, necrosis, and extensive suppuration, ending in total destruction of a joint. Tubercle bacilli may be found in most of the fungous bone-lesions. The bones and joints may be diseased without glandular enlargement, and conversely. Symptomatolog-y. — Different scrofulous patients rarely present identical pictures of disease, but most of them may be classed under two general types. These subdivisions are not very exact, and there are many scrofulous children who present the features of neither or of both in -combination ; still, from a clinical standpoint it is convenient to select distinctive types for description, and the following is the classification which has long been in use. The two types are — I. The Eretkitie, and II. The Phlegniatic. I. The Erethitic or Sanguine Variety. — In this form, which is usu- ally hereditary, the child looks delicate and often pretty. The skin is fair and transparent, showing the blue veins distinctly, and blushing easily occurs. The eyelashes are long, the features are small, the weight is light, the nuiscles are soft, and the bones are slender. The hair is fine and the teeth appear early. The nervous system is apt to be irritable, with unnatural activity, but the mental development is good. This type is more frequent in females than males, and more apt to furnish severe and even fatal cases. IL The Phlegmatic Type. — The phlegmatic or torpid variety is more apt to be acquired than inherited. The child is stout, clumsy, and thick-set. The expression is dull and heavy. The head is large. The upper lip and nose are full and the eyebrows thick. The chin is prominent. The skin is coarse and spongy. The nervous system is far less acutely irritable than in TERMIXATIONS AND COMPLICATIONS. 341 the erethitic variety. The abdomen is kirge. The cervical glands are increased in size, and there is nsually a naso-pharyngeal catarrh. C'liiidreu with this type of scrofula have eczema and chilblains, and their wounds heal poorly. The muscles are soft, and there is over-production of subcutaneous fat. The pulse is feeble, and the temperature at times is subnormal. In bad cases the glandular enlargement becomes extreme, and a number of glands in the neck, thorax, or mesenterv are involved. If a uhuid becomes acutelv inflamed, there may be local pain and moderate fever, which disappear after extirpation of the gland or incision of the abscess. In addition, any of the anatomical lesions above described may give rise to special symptoms. If the mesenteric glands are involved, they can sometimes be felt through the boat-shaped abdo- men, and there is exhausting diarrhoia. The child becomes pale, thin, and hollow-eyed, the hair falls out, and the skin is dry and thin. There is often retarded mental develoj)ment. Females frequently have leucorrhoea. In many cases the evidences of scrofula remain latent until evoked by some trivial excitation, as a slight bruise on a joint, which results in inflammation, swelling, hydrarthrosis, and final disintegration of the entire structure; or a spot of facial eczema may spread to the conjunctiva, and finally excite ojihthal- niia, with permanent im])airment of vision; or a simple bronchitis ends in catarrhal pneumonia, with various accompanying symptoms of scrofula. Course and Duration. — The duration of the affection depends largely on the ability of the parents to secure proper surroundings and treatment for the child. Advanced cases yield very slowly to treatment even under the best conditions. There is often periodic improvement, followed by exacerba- tion of the syni|itoms. The same symptoms may recur again and again, and new lesions will develop while old ones disappear. After puberty the scrofu- lous diathesis tends to disappear. Terminations and Complications. — The majority of scrofulous cases recover completely, and the catarrhs and cutaneous eruptions are amenable to treatment. When the bones and joints are extensively involved, with necroses, abscesses, and fistulas, the prolonged sup])uration is apt to engender amyloid visceral disease, which eventually proves fatal. This occurs in the kidney, liver, or spleen. Enlarged bronchial glands may sui>purate and ulcerate into the bronchi, and death may result from pneumonia. luflauimation of the mesenteric glands, accomj)anied by chronic intestinal catarrh and diarrlirea, <-auses death in vonug children more frequently than any other scrofu- lous condition. A less frcfpient but often fiital termination is catarrh of the middle ear, when it involves the m.astoid cells and the inflammation extends to the meninges of the brain. The various scrofidous diseases «»i' the bones and joints may result in pcriiiMucul ankylosis or other disfigurement. Scrofula so weakens the system that sev(>re iuterciirniit diseases arc nnich more fatal when thev occur in connection with it than they are in a previously liealthv person, aixl all accomj)anying morbid processes retrograde very slowly. Scrofulous children niavdie Croni croiq», hydrocephalus, intestinal tiii.ercidosis, or acute miliarv tidxTi'idosis. 342 SCROFULA. Diagnosis. — In typical cases scrofula is easily identified. Separate lesions of the skin or bones, etc. may give rise to some doubt as to whether they are of scrofulous origin or are due to some other cause. In such instances the diagnosis of scrofula can usually be made from a careful study of the history of the patient and from the extremely chronic character of the inflammation and its slow development, the tendency to cell-proliferation and to caseation of lymphatic glands. Congenital or acquired syphilis may be confounded with scrofula. In hereditary syphilis the lesions appear either at birth or much earlier than they do in scrofula, and, moreover, a history of syphilis is usually obtainable, and the disease yields promptly to mercury and potassium iodide. Prog-nosis. — The prognosis is favorable when the patient is seen early, and when he can at once be placed under projier hygienic regimen and dietetic treat- ment. The })rognosis is less favorable when the hereditary factors are strongly marked, and when the bones and joints or the bronchial and mesenteric glands are severely involved. In bad cases there is present a liability to miliary tuberculosis. Treatment. — The treatment comprises (1) prophylaxis; (2) hygiene; (3) dietetic and (4) tonic measures ; (5) the control of the local inflammations. (1) Prophylaxis. — The ideal prophylaxis would include the prevention of marriage among all persons who are tubercular, scrofulous, or actively syph- ilitic, who are suffering from wasting cachexias or malignant disease, and among those whose age or consanguinity makes them unlikely to beget healthy offspring. Such extreme measures are obviously unattainable. It is possible, however, to do much for the children of these parents. An infant born with such heritage, whether appearing scrofulous or not, should not be nursed by its feeble, anaemic mother, but should have a visrorous, wet-nurse. Failino- this, it must be fed on the best of cow's milk, avoiding artificial foods. Unusual care must be taken at all times to secure an abundant supply of pure fresh air, with proper personal cleanliness and warm clothing. A child with enlarged lymphatic glands should be protected with great care from taking cold and from irritation which may establish chronic catarrhs. Enlarged ton- sils should be excised. By giving careful attention to the details which follow many weak infants may be successfully carried through the period of greatest liability to scrofulous manifestations — namely, that which lies between the second and fom-teenth years. (2) Hyr/ienu- Treatment. — Scrofulous children should be kept in the open air as nnich as ])()sslble, and hence country life is best for them. They improve either among the mountains or at the seashore. Children having glandular enlargement are said to do better at the seaside than those who are eczematous (Bergeron), Sea-bathing is particularly beneficial in the former cases. It has been found in asylums and hospitals that children may become scrofulous even with proper diet and cleanliness, provided the air be damp, close, and impure. Special pains should be taken to keep the bowels in reg- ular action, and to maintain the functions of the skin by clothing of proper TRI'JATMENT. 343 warmth and nnirritating toxturo, and by cold baths for tho stronger children or tepid sponge-baths for the feeble ones. Older children shoidd not be allowed to overtax their enerov in stndv or confining work of any kind, and plenty of sleep is important. AVell-reg- nlated exercise in tho open air should be taken daily ; in very feeble cases massase is of service. (3) Dietetic Treatment. — The diet should bo simple and nutritions, and must contain a large proportion of nitrogenous food. It is common for tlie poor to feed their scrofulous children on bulky, starchy food — {potatoes, etc. — which is not in itself injurious, but, by reason of its large voliniie in jiro))or- tion to its nutritive value, overtaxes the enteebled digestive powers. This error should be corrected, when possible, by substituting a portion of milk, eggs, or meat in the diet. (4) Tonic Treatment. — The use of cod-liver oil for scrofulous affections has long proved so benefieial that it has been regarded by some as a specific. It is, however, simply a readily assimilable form of fatty food, and as such it proves of great value when pro])erly administered. It is far more useful, as a rule, in the erethitic than in the tori)i(l type. From 1 to 2 drachms should he given to children two or three times daily, an hour after meals; and because it must be continued for a long period, it is well to suspend its exhibition once a month for ten days, in order to prevent it from disgusting the patient. When it j)rovokes decided distaste, the dose will often be taken with the promise of a pep])ermint lozenge to follow. The oil should be omitted in very hot weather. In simple eases, when possible, it is best to give the pure oil : otherwise, a carefully prepared emulsion with })hosphates may be sub- stituted. Iron, arsenic, and iodide of potassium are the other tonics whicli prove of most value, and the latter is particularly beneficial when glandular liyperplasia is prominent. The syrup of the iodide of iron is a very usi'tul tonic for voung scrofulous children, in doses of from 10 to 30 minims two or three times a dav, well diluted. Pure beechwood creasote in doses of one- (piarter or one-half of a drop three times daily, given in milk, is favorably recommended by Forchheimer, presumably upon the theory of the tubercular origin of the scrofulous condition, which is strongly advocateil by him. Sul- phide of calcium is believed by some to exert a beneficial influence upon the patient's general contiilc contain blood), or kissing with cliap|)cauying enlargement of neighboring lymphatic glands. This ])eriod lasts for about six weeks on the average. It is also some- times designated as the " incubation stage " of the secondary period. All acquired sy))hilis is believed to originate with a chancre. When none is found, it has either eluded observation or it has been slight and has healed before examination was made for it. Occasionally it cscai)es detection by occurring within tlie urethra. The secondary period is characterized by the development of general (M- constitutional svmptoms, particularly a diffuse roseola and the " nuicous})atch." It lasts for a varying length of time, from two months \\\) to two or three years. As a general rule, the secondary syin]»t()ms and lesions have disap- peared at tlie end of the second year. This period embraces the mild and earlier lesions of the mucous membranes and skin, and some of those of the viscera and nerves. It is often verv difficult to draw a strict line of (Icmarcatioii between the lesions of the second and third stages, and, moreover, the secondary eruption frequently appears before the primary sore is cicatrized. There may be a latent period of several months or many years l)etweeii the (lisa|)i)earanei' of the secondary and the beginning of the tertiary le-ioiis, or the two periods may overlap. The tertiary period commonly commences between the third and .-ixth years, although there are wide dei)artures on both sides of these limits. It is characterized by the development of inflammatory growths called "gum- mata," and by a great variety of visceral, cutaneous, mucous, and nerve lesions. Its duration is influenced by treatment, i)ut it may ia>t fr- ne ..r tw.. to twenty years or more, and the lesions, once formed, may outla>t th.' activity of the disease. The lesions of the second stage are often syiiunefrically disposed on both sides of the bc.dy, but the tertiary lesiims are noted for their asynnuetry. While syphilis is inoculable during the first an. deeply than the skin lesions of the secondary stage, and ulcerate, leaving ugly depressed scars. They are usually fewer in number than the secondary svphilides, but are more apt to coalesce. When scaly the scales are seldom lustrous or verv abundant. For a detailed account of the great variety of tertiary syphilodermata the nadcr is referred to special works upon sypliilis.) Partial loss of hair and teeth is of coiunion occurrcuce. Visceral Lesions. — The subjects ol" vixcral or internal sy|)liilis of llic vari-.us or.raus, such as the brain, cranial nerves and spinal con), the liver, kidneys, spleen, and aneiirisnw; .,1" syphiliti<- origin, will Ix" treated in piuper detail" in this work under tin- i—peetive titles of the diseases of the varimis organs. These lesions are <-onii)aratively rare. in a series of 21.757 cases 352 SYPHILIS. of syphilis they were observed in 88. They consist principally of visceral gummata and cirrhoses, which result in more or less profound disturbance of function, give rise to pressui'e symptoms, and beget various secondary changes. Of the deep-seated organs most frequently affected by severe tertiary lesions, the brain and its membranes rank first. Of the abdominal viscera, the liver is oftenest involved, while the kidneys are included with rarity. The syphilitic process may go on to lardaceous or amyloid degeneration of these viscera. Other tertiary lesions are destruction of the nasal cartilages and bones, and sinking in of the bridge of the nose, associated with intractable and very offen- sive ozsena. Serpiginous ulcers of the skin and raucous surfaces, arterial sclerosis, inflammations of the cornea, iris, and retina, periostitis, and cariea or necrosis of the bones of the skull or of the extremities, — all occur from time to time. Periosteal thickening in the form of nodes along the tibial crests is quite fre- quently noted. The tongue occasionally becomes infiltrated, hypertrophied, and deeply fissured upon the dorsum, or it is the site of gummy growth and ulceration. Locomotor ataxia is very frequently though not always associated with a syphilitic history. Individual muscles may exhibit infiltration of the inter- stitial connective tissue and fatty degeneration of fibres. Symptomatology. — Primary Period. — Three weeks is the ordinary period of incubation of a chancre. At the end of this time a more or less typical local lesion appears, which is almost immediately followed by swelling of the nearest lymphatic glands. Secondary Period. — At the end of six weeks the active secondary period is announced by the development of moderate fever — 102° or 104° F. — head- ache, malaise, lassitude, and possibly pains in the back and legs. A chill may precede the fever. At times these symptoms are so severe as to lead one to suspect the commencement of a zymotic disease. The temperature may rise to 105° F., and run an irregular course for a week or two, but the fever is usually of little moment, the temperature remaining at 101° or 103° F. There is angina with diffuse redness of the fauces and hard palate. Some- times isolated small white spots are to be seen in connection with the hyper- aemia. The tonsils may be swollen. A modified rash or roseola develops pro- fusely upon the buttocks, trunks, and thighs, and there are frequently one or two papules upon the dorsum of the tongue. Similar papules may appear upon the scalp. They are small, hard, do not tend to ulcerate, and they are pathognomonic. Other forms of eruption may appear, but in general early cutaneous syphilides are characterized by symmetrical distribution, lack of pain or itching, rounded outline, and of a muscle-red or "coppery" hue. The early eru])tions are usually erythematous and papular, extensively dis- tributed. The later-appearing varieties include vesicles, pustules, tubentles, condylomata, and squamous eruptions, psoriasis, lichen, etc., which are less diffuse, and which tend to become grouped together in localized areas. A roseola sometimes has been observed in the mouth. Several varieties of svMPTOMATOi.oav. ;jr>:j sy]>liili(l<'s may he siiuiiltaiiO(.iisly pivM-ni. In wmhumi and, oix^cially, in children the i-DseoIa may l.e very evaiiesct'iit. It is not tnimd possible to ]>rovent tlie a|)pearaiHv of the secondary rash In any alx.rtivc treatment. At the same time wiili the cruptiun a typical miifuiis patch appears sunie- where within the mouth or at its aiiirles, on the unno, ton-ne. or buccal mucous membrane, or on tli<' skin. A eommnn site tbr it i- opposite the second molar tooth. There may be one or -eveial of the.-e pat<-hes, and thev develop in succession at irreixidar and increa>in(; intervals until the tertiary period. Other common symptoms of this sta-ic are larvno;itis. with a re> become brittle. The hairs of the eyelids and eyebrows may fall off". The ulcers, intlannuations, and cutaner)us syphilides are characteri/ed bv lack of pain and discomfort. The symptom- and lesions oj" the secondarv period niav last liir two or three or more months, and l)e f()Ilow(Kl by an interval ol" ^ood iM-alth. which continues for several months or for many years before anv tertiarv lesions arise. In other cases the secondary symptoms oi- lesions eontimie for two years, or until those of the tertiary period succeed them. In man\ eases thev last about a year. Tt should be observed that not all eases present the svm|)toms ai)ove described with e(pial distinctness. In many instances the entire secondarv stage is ntild, or, while certain of the svmptoms are |)roniinent and -evere, others are unnoticeable. In a certain proportion of cases a .syphilitic cachexia develops diirinii, the .secondary period. It is characterized by the followinii: features: The skin is nuiddy or sallow, the bowels are costive, the touijue is coated with a white tur, the breath is oft'ensive, and there is more or less aniemia, with headache, palj)i- tation, and la.ssitude. The o(!Currence of tertiary .symj)toins and lesions is favonnl by lack ol" proper antisyphilitic treatment in the secondary ]ieriotc. ; by chronic aleoludism ; and bv conditions of want and luisery which lower the ucneral vitality ami resisting; power of the .sy.stem. T<'rtiarv svmptoms show a j^reat predisposition to relajtsc. \\ hen the lesions occasion pain, a- fre<|Ueutlv is the <'a.sc with periostit i.-. the pain is markediv wor-e at nii:lit. If there are cerel.'ral lesions, the pain is frcfpientlv localized and confined to a circumscribed area on one side of the skull, which is sore and painful to the touch. The encephalopathies ma\- result in pressure -yniploms, such as paralyses or convulsions, or in mental apathy "r disturbances of the s|Hi*ial s<'nM's. Various sxinptonis will ariility of syphilis. Gowers, who has especially studied the later manifestations of syphilis in the nervous system, is, contrary to the general belief, inclined to doubt the proofs of absolute cure. Others argue that the possibility of reinfection long after the development of active symptoms is in favor of the positive cure of the original disease, and, further, that syphilis is a self-limited disease, running its course untreated in about four years. Some syphilographers even claim that the lesions of the tertiary stage outlast the disease itself; that is, the activity of the disease is entirely expended, while the new growths which it occasioned are more permanent. On the other hand, treatment may remove all traces of local lesions, and yet the disease breaks out anew. For example, a syphilitic woman has been known to give birth, in turn, first to a stillborn syphilitic infant, secondly, while under treatn)ent, to a healthy viable child, and finally to herself relapse when the treatment was withheld (Gowers). The great majority of cases terminate favorably under proper treatment, and death is comparatively rare from syphilitic lesions. The most fatal forms are the advanced cases of o-ummata or other lesions of the nervous svstem, abscess of \\\q liver in connection with bone lesions, and alterations in the arteries, resulting in the production of aneurism or occlusion. Diagnosis. — In many cases the diagnosis of syphilis is sufficiently obvious from the distinctness of the lesions. In other instances, especially in obscure cases of the tertiary ])eriod, a very careful cross-examination of the patient fails to elicit any history of early infection, and a correct diagnosis is largely aided by the res})onse to treatment. Caution should be observed in questioning some patients, esj)ecially married women, as great care should be exercised in avoid- ing interrogations which might occasion suspicion or extensive family discord. In such cases a diagnosis can often be obtained through indirect queries in re- gard to the existence of eruptions, alopecia, angina, swollen glands, etc. LKSIOmS OF THE TFMTIAUY I'FL'IOD. \\hr^ The diagnosis of an extra-genital dianciv is lurnicHl uiK»n tiic uciioral aspect of the sore, the induration at its base, with a teiideney to form a scab, espe- cially where a liairv surface retains the viscid secretion, and the cnlaro-cinent of the nearest lymphatic glands, although the indolent course of the latter is not as pronounced as it is in genital syphilis. In extra-genital chancres, while the induration is commonly distinct, it is frequently absent when the site of the oliancre is on the finger or tongue. Sometimes the induration is obscured bv csuisties or irritation. The early diagnosis is often rendered difficult by the syn»ptoms ])assing un- noticet^l by the patient, who stoutly denies their occurrence. The true syphilitic chancre nnist be distinguished from the soft non-infec- tious chancre or " chancroid." The latter develops as a i)ustule which ulcerates in two or three days, forming a dei)ressed irregidar sore with undermined j>eripherv. The base is not indurated, and there is a seeretioii of pus from the surface. The chancroid appears earlier than the true eh;un re : it bleeds more easily, and is somewhat painful on ])ressure. The ulcer eaii be iiKKulated upon healthy persons, and reinoculated on the same person, so that several such sores may appear together and coalesce. Finally, it is followed by n<> secondary symptoms. In these several resj>ects it differs from the true syphi- litic chancre, yet the two may occur simultaneously by a double infection and at the same point of inoculation. When there is grave doubt a> to the real nature of the sore, the apj)earance of symmetrical, painless enlaigemeiit of the Ivmphatic glands in the groin confirn)s the diagnosis of sy|)hilis. A syphilitic roseola, accom])anied by rise of temperature and ]>i-ostration. is sometimes mistaken for measles. The presence of nnicous patches, the- his- tory of inoculation, and a careful examination of the apju-arance and distribu- tion of the rash, together with the absence of the catarrhal symptoms belong- ing to measles, will establish the diagnosis of syphilis. AMien potassium iodide is prescribed in doses of a draehni in twenty- four hours without producing iotlism, the chances are very strongly in favor of the .syphilitic character of a lesion, yet personal idiosyncracy in regard t(. toleration of iodine occasionally |)revents this test from being absolute. When repeated abortions occur without other assignable cause, and especiallv if the foetuses are macerated, syjihilis may be strongly -iie recog- nized bv symmetrical cic^atriees on the extremities or fiiee oi' in the niontli. periosteal nodes on the tibial crests, a suide, absent teeth and hair. corneal cicatrices from oland adhesions, ])erforations of the hard or s(»ft palate, i comiiig early under treatment. It is made wor>e by ehroiii.- alcolK.livm, mihI is worse if the disease develo|> vcMy rajtidly and s( vcrely at tlicoii-.t. wjiicli is raivly the case; and it is worse the further the se its infectious quality completely in the third stage, but not until then. Treatment. — The treatment of syphilis is conveniently divided under the following headings : J. Local; II. Specific; TIT. Tonic; IV. Hygienic. Sy|)hilis is a ])articularly satisfactory disease to treat, because a large mnjority of cases, even of those already presenting extensive lesions, respond ]M(>m])tly to the measures employed. A certain ]»roportion of cases never develop symptoms of sufficient severity to lead the j)atient to seek counsel, and time alone is the healing agent. Not infrequently the general health of syphilitic subjects is very good, and it may be so good as to lead them to neglect obtaining treatment for really grave lesions. Other ])atients are always suffering from one ailment or another. I. The Loral Trcatmeni. — The local treatment of the initial lesion is of little avail if it has gained decided headway. Aseptic or antiseptic applications arc mainly \aluablc Ibi' purjmscs of cleanliness, and not for any abortive action. If the chancre is seen very early and if it is very small, it may be thoroughly cauterized with nitric acid or completely excised, but this eradication offers only an indefinite hope of preventing the development of secondary symptoms, and of late years it has been very generally abandoned. If imperfectiv done it makes the original soi'c worse. It is important to keej) the chancre clean and free from irritation. Sonu' authorities claim good results from the local a]ij)licati(»n of a mercu- rial ointment to the chancre. The hx'al ti'catment of the mucous ])atchcs conijM'ises cautei'ization bv nitrate of mercury oi- othei- caustic, and cleanliness, secured by ap))licntion of 1 : 100(1 (•orrosive-std)limate solution. Condylomata may be washed with salt- solution and then on the dis- <'ases of the organs involved and to woi'ks on surgerv. II. Specific Treahiient. — '^Piie two drugs, ])otassium iodide and mercurv in it- vaiious pr<'])arations, are sj)ecific agents against syphilis, and are j)rac- LKsioys or rni: TERTiMiv pkiuoik wiu tically the diily roincHlios whirli (•uiitrol it. 'riicii- ii>c in >\ phili^ is tluTrlnrc roforred to :is"s|KviH(^ treatment," and their employment in combination is often described as " mixed treatment."' Ifemedial mea>nres are capable ot" diminishing the intensity and of shortening the (hn-ation of manv lesions ot' .syphilis, and of greatly redneinj^ the chances of the intlction of healthv p»"ople by th(> syphilitic. Merenry has been (>m])loyefl for this pnrpose for nearlv Ibnr hnndnnl vears. Its niixle of action is nidortant viscera or of the TREA TMF:NT. 359 x'entral nervous .sysUMu, or when any serious romplieiitious supervene, sueh iis convulsions or paralyses, it is of vital iuiportauee t4> saturate the system with the reniedv as ranidlv as possible: and it luav be necessarv to admin- ister half an ounce, or excej)tioually au ounce, of the iodide in the course of twenty-foiu" hours. As a rule, syphilitic patients show great tolerance of the drug, ami in au urgent cas(> one is justitied in giving very large doses inunediately, in order to save life. When the drug is pushed to its full extent i-are should be exercised to keep the bowels ctU'r results than contimied doses, to whi.^h the system luromcs munnl. The specific treatment of syphilis should be continued u. the above nmn- u<;r for at least a year afW all symptoms hav i,n>ne. 360 SYPJIILIS. 111. and IV. Tonk and Hygitnu- Trcainwnt — The specific treatment of KVpliilis is of little avail witlioiit tlie use of tonics and proper hygienic regu- lations. The tonic treatment consists in the administration of phosphates, cinchona, arsenic, strvchnine, or cod-liver oil, and iron should be given in con- nection with one or other of tiiese remedies. The Hygienic Treahnent includes the careful supervision of the patient's daily habits of life. Abundant fresh air, frequent bathing, warm clothing, (hdy-regulated exercise and rest, and a nourishing diet are of great importance. It is almost useless to attempt the specific treatment of .syphilis without accom- panying it with an appropriate hygienic regimen. Under the latter conditions a patient who has been upon a })rotracted course of the iodide witiiout benefit will often show very rapid improvement. Of course indulgence in sexual intercourse should be forbidden, at least until the third .stage of the disease is reached, not only on the patient's own account, but to prevent inoculation of others, and the use of alcohol should be greatly i-estricted, and, if possible, interdicted entirely. The patient should be rea.ssured as to the probable favorable termination of his symptoms, and made to appreciate the importance of a strict compliance with the rules laid down for him. Special directions in regard to diet should be given in order to keep diges- tion at its best. The dietary need not be greatly restricted, but it should be plain and wholesome. Fr]iits and the coarser cereals are u.seful on account of their laxative effect, for patients are much less apt to suffer from iodisni if the digestion be normal and the bowels freely opened. Summartj of Treatment. — As soon as the secondary sym})toms appear the patient should be put upon a daily mercurial treatment, to be continued for a year and a half The dose should be moderate, to avoid salivation. It must be at once discontinued should salivation appear. On the other hand, if any new symptoms develop it may be temporarily increased. The iodide of potas- sium may be added at the end of the first year, and it should be continued for eighteen months longer. The tonic and hygienic treatment nnist be begun early, and persisted in while any symptoms reinain. After two and a half, or better, three, years of such treatment, and if no .symptoms return within six months or a year after its discontinuance, the patient may be regarded as cured, and he may marry Avithout endangering either mother or offspring. HEREDITARY SYPHILIS. Definition. — Hereditary or congenital syphilis is that variety of the dis- ease which is transmitted from one or both parents to their offspring. It exhibits great variety in its manifestations, but the only essential difference in symptoms or course from acquired syphilis is the absence of the stage of chancre. It is usually " conceptional " — i. e. it is transmitted from either one 11 ERE I) IT A R Y SYPHIL IS. 3(;i or both parents at the tiiiu- of cniuvptioii, the virus liavin*r attW-ttil tlio ovmn or the spermatozoon. It may, however, be traiismittiHl to the embryo from the bh)od of the motlier at any period of phieental eireiilation, and in this ciise the disease is apt to be less severe. Synonyms. — Erbsyphilis ((Jer.) ; Syphilis hereditaria. Etiolog-y. — The following; statements in rei:;ard to hereditarv svphilis have been attested by numerous reportcnl eases, and are wortliv of note. When the Father On/i/ is Si/phi/ltir. — If aetively syphilitic — /. «. with ])rimary or secondary lesions — the father usually transmits the disease to the ehild, but no definite relation exists between the severity ttf the disease in father and ehild. This form of infection is the least injurious t(» the ehild. The father mav infect the mother throuiih the circulation of the c-hild //( atcid. This latter statement has been denied by some syphilographers ; Itiit whether the mother .shows active syphilitic symptoms or not, it is believed by manv observers that a .syphilitic infant cannot infect its own mother after birth, even though it virulently inoculates a healthy wet-nurse. This is known as "Colles's law;"' and even if the mother does not develop extensive lesiitns herself, it indicates that she has been rendered immune to any external inoculati<»n lioni her oH- snring, Eichhorst strenuouslv denies the validitv of this hiw, and savs that he has seen mothers infected by their syphilitic iidants after birth throuu,h abrasions of the nipple, etc. Such a mother becomes antemic, and i> a|)t to Imve more or less glandular enlargement and periosteal iuHamniation. Manv more children are inlected bv fathers than bv mothers, because more males have syphilis, andiiot because the disease is more readily transmitted by males. If the mother should have the disease, she is »|uite as apt to trans- mit it as is the father. When the Mother Oii/t/ is Si/j)hi/iti<\ — If the mother be syphilitic prior t«» conception, she iidects the ovide, or she may infect the embryo at a later period. In such cases the disease is often more vii-nlcnt in the iidluit than when inherited ironi the father alone. The infant has the best chance of escape when both parents were healthy at the date of conception, but the mother subsequently accpiires syphilis a W'w months before giving birth to the child. Tiider these cireums(anc<'s it is rare for the child to be affected, and the later the mother cdiitract- the disease the better chance the child has of escaping. It is possible for syphilis in the mother to be ><> niodilied by treatment that the chihi escapes entirely. A child is nest itd'ectehic. Among such children are some- times found cases of chorea, epilepsy, hydrocephalus, and idiocy. Curious anomalies are sometimes observed among the children of actively syphilitic parents. Thus Hutchinson has reported a case of birth of twins, one of whom was syphilitic and the other not. Morbid Proces.se)i in General. — Hereditary syphilis may develop during embryonic life, or it may remain latent for a varying ])eriod after birth, even u|) to twenty years. In the great majority of cases it a|)j)ears before the child is three months old. In the embryo and itifant it occasions cachexia, dys- trophies, malformations, and predisposition to various morbid changes (Fournier). Considerable doubt exists as to whether these malconditions can be trans- mitted to the third generation without fresh infection. Among the dystrophies are slow general growth and retarded puberty and virility, so that the subject still appears like a child when eighteen or twenty years old, with a pasty complexion, scanty hair, irregidar thickenings of the c HEU EDIT A n Y S Y Pill LIS. 36:{ skull, periosteal iioiles on the tibiiv and olsewlierc, keratitis, and serratetl ineisor teeth. Among the rnaltorniations which are found to aceoujpany conticnital syph- ilis are hare-lip, spina bifida, hydroeophalns, clnb-tbot, and vari<.us hernia\ Among the morbid predispositions there is a tendency to a variety of neu- rotic affections and to readily acquired convidsions. Hereditary syphilis, although not at all identical with them, is often asso- ciated with scrofula, rachitis, croujt, or tuberculosis. Morbid Anatomy. — The morbid anatomy of hereditary syphilis does not also ulcci-s of various sizes, moist or encrusted, and condylomata with flattened encrusted surfaces and a fcietid discharge. The oidy characteristic syphiloderm of infan- tile or hereditary syphilis is pemphigus, which in its specific form has a pap- ular base, such as occurs in other eru])tions of the secondary stage. Tlic blebs are either trans])arent or oftener are distended by brownish or even bloody fluid. Thev cover an area of inflamed reerii>hery (»f the anus and mouth, and on the scalp. The papules and <'ondylomata are a))t to occur in the deeper flexures of the skin of the neck and joints, where there is more or less irritation from opposing surfaces. Within a few weeks after birth a simple roseola, with irregidar round or oval macides, may ai)pear, commencing on the abdomen, and later .>|>reading over the bod v and lind)s. It is dry at first, and fades on jiressurc ; lat<'r it acfpiires a |)ermancnt darker, c».ppery hue. It may become moist, or scaly where the skin is thick, and it forms papides with eeilidar inliltrati(»n. The liver is permeated with nbro-|)iastic material anressure the new cells occasion degeneration and necrosis. Osteo-chondritis and osteo-myelitis ensue. Pus may burrow out- ward beneath the periosteum. There may be an excessive deposit of lime salts, which encrusts the cartilage and projects into its substance. Granulation tissue intervenes between this deposit and the shaft of the bone, and the shaft itself may be thickened by a growth of new bone on the outer surface. The epij)hyses and diaj)hyses of the long bones may become separated, giving crep- itus, and spontaneous fracture of the shaft has been known to ensue. Periostitis occurs over many bones, especially where they have the thinnest .V YMPTOMA TOLOa V. :J«)5 oovering of soft parts, and arc foiisoijiu'iitly ii>.>r»' lial)lo to injiuN , like tlic sternum and tibia. The more cxtcnsivo lesions of tlio hones and Joints cause deformities and loss of ahility to move the lind)s. S('\(>re hone thsetise will eanse the death of the infant through septic infection or exhaustion. The gnmniata of infantile syphilis are not often developed at hirth, and they may not aj>pear before the child is eight or ten vears of age. Thcv an- frequently found in the livei- in conneetion with an interstitial he|)atitis, wliich <'anses eidargement of that organ, and sometimes ascites. A few gummv nodules may invade the walls of the jiulmonarv vessels or bronchioles even in the foetus. The disease shows but two periods, the chancre of the first stage of the aequired affection being, of course absent in the hereditary foi-m. In conse- (juence of this we do not find the local eidargement of the lymphatic glands, although a universal adenopathy is often to be discovered later. Tiie secondary period lasts for about a year or a year and a half, either com- mencing with birth or. more frequently, Mithin four or six weeks aftei birth. The tertiary period nuiy, in bad cases, overlaj) the secondary, and develop very early in the history of the disease as compared with acquirehilis. The gurnmata in .such instances aj)])c-ar with the se<'ondary eruptions. In other eases there is an interinediat<' period of freedom from all symptoms, lasting from the termination of the secondary stage until the second dentition or ]iul)erty. Symptomatology. — A large number of infants with hereditary syphilis appear healthy when born, and do not develop any symptoms for several weeks. Even when .symptoms or lesions appear, they are not alway> recog- nized as l)elonirino: to svi)hilitie disease. The chancre being absent, the ilis- ease commences its manifestations with the symptoms which correspond with the se<'ondary stage of the acquired form. There is an crythemato-|)apular eruption or a simple roseola on the buttocks and about the g li'd by a spoon. The nreas of s|)lenie and hepatic dulness may be somewhat enlarge^!. The skill is po(.rl\ nourishe may iil. crate ; .ind the r:i.'i:il e\pre<-ioii i< ein'iously old and wriidmii^. Tlie child is dnil aii|K-arance. The alimentary canal i^ irrimble, and then' i- imp.iireil secretion and aUsorption. There are oceasional vomiting and diarrhoea. More or less bronchial catarrh is commonly present. On inspection of the cavities of the mouth, ]>harynx, and nose mucous patches may be found. Groups of lymphatic glands, es})ecially those about the elbow joint, may be found enlarged. Later in the tertiary period tlie lesions of the bones and joints appear. There are inflammation and opacity of the cornea, interstitial keratitis, and photophobia, and, souievviiat rarely, iritis. There may be optic neuritis or retinitis. Middle-ear cratarrh occurs in some (^ases, which may lead to per- foration of the tym])anum or purulent inflammation of the mastoid cells. Sequelae. — Hereditary syphilis often leaves permanent marks upon the adult in the form of notched teeth, scanty hair, coarse skin, and radiating cicatrices at the corners of the mouth and elsewhere. There may be perma- nent deformities produced by bone and joint lesions, impairment of vision^ deafness, and neuroses or paralyses. Diag-nosis. — The diagnosis will depend upon an accurate history of parental syphilis and upon the appearance of the child. When the infant is born with well-d(!veIoped syphilitic lesions of the skin, joints, bones, etc., the diagnosis is readily made ; but many children present obscure or slight symptoms and lesions which may be confounded with other affections. Others, again, show no sym])toms of any kind until two or three months after birth, and such children appear healthy and normal in every respect. The diagnosis must often be based on the conjunction of several symptoms rather than upon any one. Such symptoms are the coryza, hoarse voice and cry, a prematurely old expression, flabby- skin and muscles, and the presence of papules, pustules, or bullae about the mouth, scalp, anus and genitalia, or on the body. The mucous jiatche.s may l)e confounded, with stomatitis. In simple stomatitis the mucous ])atches cover a larger surface and occur more often in the sulcus between gum and buccal mucous membrane. The exudate is serous, and vesicles form which are not present in the syphilitic patch. In parasitic stomatitis there are far more inflammatory action and swelling than in syphilis. The syphilitic affections of the bones are to be distinguished from rhachitis by the fact that in the latter there are symmetrical enlargement of the epiph- yses, slow closure of the fontanelles, bending of the shafts of long bones, and a lack of involvement of other structures. Rhachitic changes in the bones are rare in the first half year, and in sy])hi]is there are usually cuta- neous and other sym})toms. Besides, there is the history of the case, which will throw much light upon it if thoroughly investigated. Prog-nosis. — About one-third of all syphilitic infants are stillborn. For the remainder the prognosis depends largely upon the time of appearance of the early lesions. Children born with syphilitic eruptions seldom survive the first year. r///-; TIIREE J'KRlOJhS. aG7 Those ill whom the disease develops shortly atter birtii may live for a few years with enl"eeblekiii Ih I..(. tender, the immctions are not desiral)le, and ..n.' of the milder preparations ol' men-my must be selected fi.r int.rnal w-v. Sli..uld any indication of stomatitis appear, the child's mouth slionM be cleanM-runswick are also aflectcHl. On the Pacific coast the disease is frequently seen aniong the Chinese. Etiolog-y. — T^eprosy is jK-culiarly a disease of young ju-rsoiis, the great majority of cases occurring from the fifteenth to the thirfiefh ynir. It is slightly more common among men. Social conditi»»n |»]:iys a i»:ut in liic etiology in so far as squalor and overcrowding expose to contagi Iml all classes of society are susceptible. Heredity certaiidy has some inlluence. as several well-authenticated congenital ca.ses deliniti-ly i)n.ve. 'i'hr theory of Vo... i.-:!i ■•|»i« 370 LEPROSY. Galen, lately advocated by Hutchinson, that a diet of decayed fish leads to the disease, is not substantiated by recent experience. The specific cause is the bacillus leprce, discovered by Hansen in 1874. This organism resembles very closely the tubercle bacillus, but may be dis- tinguished by its staining properties, its shape, growth, and distribution. It occurs abundantly in the leprous tubercles, and has been found in the blood. It has been successfully cultivated, but inoculation of animals has failed to produce the disease. It has, however, been established that inoculation of man with parts of the growths will cause the disease. The contagiousness of leprosy cannot be doubted, though this always re- quires direct inoculation, as in the case of syphilis. Sexual congress has been indicated as the method of transmission in the majority of cases (Morrow). Instances of inoculation through vaccination are also recorded. Morbid Anatomy. — The bacillus finds .two favorite seats — the skin and the nerves. In the former it gives rise to the characteristic leprous tuber- cles, in every respect similar to the other granulomata. Microscopically, these tubercles contain lymphoid, epithelioid, and giant cells, and numerous bacilli between or within the cells. Eventually these tubercles soften and dis- charge thick puriform material, or in rare cases more or less complete organi- zation occurs and limits the further progress of the disease. In the nerves extensive neuritis marks the invasion of the bacilli. In the late stages of the disease leprous new growths may be found in the internal organs, espe- cially the spleen and liver. Clinical History. — Two distinct types are recognized : the tubercular and the anaesthetic or nerve leprosy, and in some cases a combination of the two occurs. Tubercular Leprosy. — The period of incubation is indefinite, some cases having followed infection by a few months, others by as much as twenty years. A prodromal stage of excessive sweating, mild, irregular fever, and lassitude has been described, but is rarely prominent. The onset of the dis- ease is marked by the appearance of erythematous patches, slightly elevated and hyperaesthetic. These, after a time, disappear, but return with greater distinctness, and may then persist for a long time. The color of the patches may be a livid red, or there may be only a diffuse mottling. In all cases, when persistent, they become darker from deposition of pigment. The tubercles occur in the skin and mucous membranes. They are partic- ularly common about the face, to which they give the heavy features desig- nated by the name leontiasis. Other localities are the ears, extremities, mam- mary glands, and scrotum, but all parts, excepting the seal}), may be involved. The palms and soles, however, are rarely involved. Of mucous surfaces the mouth, throat, larynx, and Conjurictivse are most frequently affected. The nodules vary in size from a pea to a large nut, or they may run together, pro- ducing extensive new growths. The skin over the tubercle is tense and glis- tening, especially at certain times when the redness, heat, and tenderness indi- cate inflammatory reaction. The hairs of the affected areas drop out, and in DIAGNOSIS. 371 leprous countries disappearance of the eyebrows is regarded a significant syni])- toni. Subsequently tlie tubercles soften and ulcerate, discharging tiiick yel- lowish or brownish puriform matter, which forms thick crusts and contributes to the repulsive api)earance of the terminal stages. The ulceration may extend deeply, even involving the bone. This is often seen in the nose, where the sep- tum becomes destroyed, with a falling in of the bridge of the nose. In the eye the tuberculous and ulcerating processes cause extensive destruction, until the globe becomes a shapeless mass. la certain cases, on the other hand, ulceration does not occur, but by organization of connective tissue destruction is checked, and possibly the whole progress of the disease is arrested. Anaesthetic or Nerve Leprosy. — In this form the characteristic symp- toms are the spots, the anaesthesia, bullas, trophic alterations, and mutilation. No definite order of occurrence can be assigned to the different symptoms. The spots appear insidiously or sometimes acutely with fever. They affect particularly the back, buttocks, knees, arms, and face, and vary in size from that of a small coin to extensive areas. At first they are often erythematous, slightly elevated, and hyperaesthetic ; later they become pigmented or pigment- less. Usually the centre is light-colored, the periphery dark, but the whole area may be white. The characteristic feature of the spots is the altered sensibility. At first hypersesthetic, they soon become anaesthetic, and retain this as a pathognomo- nic feature. In addition to anaesthesia, absolute suppression of sweat from the surface of the spots has been pointed out by Manson as a symptom of great significance. The bullae of nerve leprosy occur at any stage of the case, and may con- tinue to appear for a long period. They come out suddenly, last a few hours, and then break, leaving a red spot, which may persist as a chronic ulcer or heal kindly. In size they vary from that of a nut to a hen's egg, and are filled with a vellowish-green liquid. The bullae occur in any part of the body excepting the scalp ; they are frequent on the palms and soles. As the process of neuritis advances there is widespread hyperaesthesia, then anesthesia and pains radiating along the nerves. When large superficial trunks are involved, these may be felt as thickened cords under the surface. Later on, atrophy of muscles, partial palsies, and various trt»phic disttn-bances occur. In the hands may be seen the claw hand, which also occurs in other forms of neuritis ; and the phalanges, as also those of the foot, may infiame, .swell, and be removed bv ulceration. In the foot a perforating ulcer of the sole is quite common. Diagnosis. — Tubercular lci)r<)sy must Ik- distinguished from tubercular syphilis. The distinction is easily made; by the altered sensation, by the history, and by the distribution of the lesions. Kalindcra advocates the application of a blister and the examination of the scrum for bacilli. Nerve leprosy is distinguished from vitiligo and similar alVections by the altered sen- sation, and from syringomyelia, or Morvan's disease, by carefid examination of sensation, by the partial palsies, and by the distinct spots. 372 LEPROSY. Prognosis. — The prognosis is always bad, but, as there are at least 155 cures recorded in the literature of this disease, the outlook is not hopeless. The tubercular cases usually live from eight to ten years, the anaesthetic fifteen to twenty years. Acute cases witb rapid death have been described by Leloir. The course of the disease may sometimes be arrested or partial restoration may occur, but this is rare. The causes of death are mainly exhaustion, colliquative diarrhoea, obstruc- tion to the air-passages, and inspiration pneumonia. Treatment. — Prophylaxis is of the greatest importance. The good effects of isolation and hygiene were seen conclusively in the subsidence of the disease in Eiu'ope during the Middle Ages. Of the many remedies successively praised and condemned, iodide of potas- sium, arsenic, chaulmoogra, and gurjun oil seem most worthy of trial. Dan- ielssen after forty years' experience regarded the iodide as of distinct service. It should be pushed as freely as is possible without producing iodism. Chaul- moogra oil in doses of 2 drachms and gurjun oil in 10-minim doses may be of use. The latter has received special attention of late. It may be used by inunction when the stomach is sensitive. Palliative and supporting measures will be needed at the end. DIPHTHERIA. By \V. oilman THOMPSON. Definition.— DiPHTHEPaA is an acute, infectious, and inoculahle disease, oeeurring sporadically and epidemically. It is characterized anatomically by a croupous inflammation of the mucous membrane and abraded surfaces. This atlects chiefly the pharynx and upper air-passages, and has a marked tendency to spread to adjacent parts. It is attended with eidargement of the associated lymphatic glands. Clinicallv the disease is marked bv irre<>-ular fever, great debility, and frequent albuminuria; by a tendency to death from toxsemia, from membranous croup, or from heart-failure; by slow, uncertain convalescence and by peculiar paralytic sequelae. Synoxyms, — Diphtheritis ; Cynanche contagiosa; Angina maligna; Diph- therite (Fr.) ; Diphtherie (Ger.).' Etiolog-y. — The Bac'iUm. — Diphtheria is undoubtedly a germ disease, caused by the activity of the bacillus. There has been much disjmte as to the identity of the bacillus, but the clinical history of the disease and all that is known in regard to its propagation afford conclusive proof of its bacillarv origin. A variety of microbes are found in the mouth and throat in connec- tion with diphtheria, such as staphylococci and streptococci, which render dif- ficult the isolation of a specific diphtheritic germ. Harmless germs may even accumulate in the lymph-vessels leading from the inflamed surface. It is an important question, especially in regard to any theoiy of treatment, whether diphtheria is a- general disease with a local lesion or whether it is ])rimarily a local disease. In other words, is there a y-eneral svstemic infection which mav give rise to constitutional symptoms prior to the appearance of any local lcsi(»n produced by action of bacteria, or are the constitutional symptoms, lever, albuminuria, paralyses, etc., caused by absorjition of ])tomaVues generated by the agencv of the bacteria ? The majority of authors are still agreed in calling dijihtheria a general or constitutional disease which develo])s a local lesion at somt^ period of its course, though many are inclined to advance the opinion thai in exceptional cases the local lesion may first appear. Further researches in icgaid ti> ihe bacterial origin and mode of infeeliou l>v the disease niav alter llieir views. The ba fill II. H (lijiJif/irri(r was discovered by Klebs in ISS.'^and by LiWlIei- of Greifswald in 1.S84. It is found in the exudate or false membrane on the surface of the nnicons menil)rane, and is often coughed ont with shred.s of pseudo-inenibrane. The causative relation of this germ to diphtheria has been disputed l)V some bacteriologists, bnt there is accumulaling e\ii|eiice iu favor of its being the originator ol" the disease. I'^-um the fact that both ;i7a 374 DIPHTHERIA. observers deserve credit for the discovery of the germ it is often called the " Klebs-Loffler bacillus." Among those who have confirmed the observa- tions and exjieriments of Klebs and Loffler are Babes, Ortmann, V. Hoff- mann, Welch, Abbott, and other experienced observers. Tiie Klebs-Loffler bacillus has been passed through a series of twenty-five rabbits by inoculation of the false membrane, and still retained its virulence. The bacilli are more numerous and appear better nourished in the pseudo- membrane than in prepared culture media. The diphtheria bacillus is a little shorter than the tubercle bacillus, but is much broader and has thickened or clubbed extremities. It is sometimes curved, sometimes spindle-shaped. It is 2.5-3/i long and non-motile. It is capable of deep staining, and then presents a segmented granular appearance. The bacilli often occur in groups. On the outer surface of the false membrane several varieties of bacilli, includ- ing the Klebs-Loffler germ, are found. Immediately below is a layer contain- ing many cells and but little fibrin, and here, again, the bacilli in groups are apparent. Finally, in the deepest fibrin layer which rests upon the mucous membrane no Klebs-Loffler bacilli are present (Welch, Abbott). The bacillus diphtherise grows readily on a variety of culture media. It is killed at 58° C. in ten minutes (Welch, Abbott). This bacillus, inoculated in the lower animals, produces symptoms resem- bling diphtheria, with pseudo-membrane, underlying necrosis, paralyses, and albuminuria. In man it comes in contact with the faucial or other raucous sur- face or the abraded skin, and propagates there, but it does not penetrate deeply into the mucous membrane, nor is it taken up by the blood-vessels or lymph- atics. The bacilli therefore do not invade the entire bodv, but remain at the site of the local lesion, imbedded in the pseudo-membrane. As a result of experimental inoculation of the Klebs-Loffler bacilli in animals typical microscopic changes occur in various organs, notably the liver and kidneys. In the liver Babes observed swelling, degeneration, and also ])roliferation of the hepatic cells. Leucocytes accumulate with frag- mented nuclei. The capillary endothelial cells are swollen, and the vessels themselves contain hyaline and yellowish granular matter. Similar changes occur in the renal ej)ithelium and blood-vessels. These results have recently been substantially confirmed by Welch and others. At the site of inoculation a gray pseudo-membrane ajipears over necrotic tissue with extreme fragmenta- tion of nuclei. This is surrounded by an area of hypersemia and congestion with ecchymoses. The neighboring, and even the distant lymph-glands are swolUsn and hsemorrhagic. The various serous cavities contain increased exudation. Oertel lias shown that these visceral and local changes accompany human diphtheria ; and it is of the greatest interest and value to know that they may be experimentally produced by pure cultures of the Klebs-Loffler bacillus. The Klebs-Loffler bacilli produce one or more ptomaines or toxines, which are absorbed by the lymphatic and blood-vessels and give rise to the constitu- tional and toxic symptoms. The toxines can be generated by cultivation of ETIOLOUY. '?>17^ the germs in artificial media, and tlu'v have been nreutly isolated ami iivcd from bacilli by Roux, Brieger, Fraenkel, and others. The Ptomaine. — The princij>al ptomaine when s\valk>wed, like many other poisons, produces but little eU'ect, but when inoculated it causes unknown chemical alterations in the tissues of the bodv ; and it is suQ-o-csted that a certain degree of immunity which follows an attack of diphtheria is due to this cause (Fraenkel, Behring). It is destroyed at a tem])eratm-e of about 140° F. It is soluble in water, but is precipitated by alcolu)!. It resembles proteids in composition. There is reason to believe that the bacilli themselves are really innocuous apart from their production of the specific ptomaines. One ptomaine has been isolated which, if injected into animals, causes increased secretion from the mucous membrane of the eyes, nose, and mouth, together with chill and fever. This is followed by convulsions, involuntary evacua- tions, paralysis, dyspnoea, and death. Immunity. — By recent experiments with inoculation of attenuated cultures of diphtheritic virus Behring, Kitasato, and Fraenkel have succeeded in ren- dering certain animals immune to di})htheria. With guinea-pigs and rabbits Behring has been able to regulate the dosage with almost mathematical accu- racy, so as to produce the disease with varying grades of intensity — with paralyses or without, \\\i\\ constitutional symptoms or with only slight local infiltration. What is still more im[)ortant, he has been able to cure already infected guinea-pigs by inoculation with the blood of animals rendered immune by previous inoculation. This occurs even w\{\\ the inoculation made at some distance from the local lesion. Behring and Kitasato have shown that in rabbits the action of the attenu- ated diphtheritic virus destroys the toxines formed by the bacilli, rather than the bacilli themselves. According to recent experiments of D'Espine, the bacillus diphtheria; is killed by local applications of aqueous solutions of the strength of 1 : 8000 for corrosive sublimate, 1 : 2000 for salicylic acid, and 1 : oO for carboli<- acid. The bacilli still live at temperatures below that of the body, even at 68° F. Boiling destroys them. They thrive and multiply in milk. They preserve their vitality for four or five months or more in dried membrane. C'ultures of bacilli have been kept for sixteen months without losing their virulence. A brush used to swab the throat of a diphtheritic child was put aside in a drawer unclcaned : after four years it was taken out and infected a man who used it. In a Normandy village, twenty-three years after an cpitlcmic of diphtheria, some of the bodies of those who died of the disease were exhumed, and an epidemic at once broke out, first among those wIk. opened the graves, and extended to others (Sevestre). Diphtheria in vl?i/ma/.s.— l)i|>hth< ria is common among Iie<|>. 'V\\vy ac(|uire a false niend)rane in the throat with constitutional symptoms, mid various l.Mcilli are f..nnd at tlir site of th( w 376 DIPHTHERIA. inflammation. These bacilli are not in every case identical with the Klebs- Loffler bacillus. In birds, at least, the bacilli are different, but it is highly probable that true diphtheria may be transmitted from cats to man, and con- versely. In cats the disease principally affects the lungs and bronchi. Filthy stables, dirty poultry-yards, and dove-cotes favor the spread of diphtheria among domestic animals. It is claimed by Power and others that bovine diphtheria can be transmitted to man through infection of the milk by an eruptive disease of the udders, and cows inoculated under the shoulder with diphtheritic microbes exhibit the germs in their milk after developing local lesions of the udders. Transmission of diphtheria to man through milk is certainly rare, if it be possible. Roux and Yersin have isolated a microbe which excites diphtheria in fowls, rabbits, etc., and have also separated from it a toxine which when injected causes asphyxia and paralysis in those animals. Pseudo-Diphtheria. — Some authors are disposed to describe two varieties of diphtheria — one accompanied and occasioned by the Klebs-Loffler bacillus, and the other due to some different virus or germ (possibly the streptococcus pyogenes). The latter variety they call " pseudo-di])htheria." Prudden has recently made exhaustive researches in cases of diphtheritic inflammation occurring in connection with measles, scarlatina, etc., in order to determine the character of the bacilli present. In such cases he failed to find the Klebs-Loffler bacillus, although he obtained a streptococcus. He concludes, therefore, that the latter germ is the cause of these secondary cases of diphtheria. The statements regarding the etiology of pseudo-diphtheria and the germ or germs associated with it are very conflicting, and further research will doubtless throw much light upon the subject. Abbott^ concludes a report of a recent investigation of this question by saying : " From these observations we feel justified in agreeing with the opinion that has been advanced by other observers, particularly Hoffmann and Roux and Yersin, that under varying conditions the virulence of the true diphtheria bacillus may be observed to fluctuate in the degree of its intensity — at one time })ossessing the property in a high degree, at another presenting a decided attenuation, and not unfre- quently a complete absence of pathogenic power." The pseudo-diphtheria germ has been found in the pharynx in healthy children. In pseudo-membranous angina, occurring in connection with scarlatina, a streptococcus is found, but the true bacillus diphtherife is absent. Germs are also found in inflamed conditions of the mucous membrane accompanying measles and erysipelas, but the Klebs-L5ffler bacillus occurs only in diph- theria. False membrane closely resembling diphtheritic membrane, excepting the absence of the diphtheria bacillus, is formed on mucous surfaces after the application of various irritants, such as hot steam, cantharis, strong corrosive ' Johns Hopkins Hospital Bulletin, vol. ii. No. 17, p. 146. ETIOLOGY. Til sublimate, arsenic, ammonia, etc. Hnebner has shown that a false membrane may even form as a result of mechanical obstruction to the local vascular supply. Hence the presence of the germ of diphtheria is not essential for the production of a false membrane. Much of this bacteriological work is so recent that it is both difficult and unwise to adopt positive conclusions from it until further evidence, which is now being diligently sought, shall be brought to light. The habitat of the microbe when outside of the body is not known, but it is believed to live in surface soil which is contaminated with organic matter. It is known to grow on excretory refuse. Mode of Infection. — Infection is not believed to occur through the aliment- ary canal. Some observers claim that it is possible for the diphtheritic virus to enter the lungs by inhalation, and, being absorbed by the pulmonary ves- sels, develop constitutional symptoms before the local lesion in the throat is manifest ; but the weight of evidence is decidedly in favor of regarding the mucous membrane of the upper air-passages as the common site of infection. It is not proved definitely that in man an abraded surface is necessary for the virus to find lodgment, but many believe that a diseased, denuded, or catarrhal mucous surface is essential in man, as it is for inoculation in the lower animals. It is certain, iiowever, that diseased mucous surfaces are far more susceptible to the infection than healthy surfaces. Moreover, it is very easy to overlook slight abrasions after the local symptoms have become manifest. The mode of infection is cither by direct contact of shreds of diphtheritic membrane, or more frequently through infected air, or tlirough the agency of various fomites, such as contaminated clothing, iiandkerchiefs, toys, books, etc. Shreds of fibrin are frequently expelled with a violent cough, and if they hap- pen to lodge in the eye or mouth of the physician or nurse, they seldom fail to infect. Many valuable lives have been sacrificed in this way. Physicians have lost their lives from endeavoring to clean out a tracheotomy-tube by sucking a plug of mucus or memlirane from it which threatened to suffocate the patient. The disease has been transmitted by kissing. Diiihtheria is highlv contagious within the immediate neighborhood of the patient, but the radius of direct contagion is limited to a fi'W feet. For this reason a diphtheritic patient may be perfectly well treated at home without endant^erint'- other members of the household, provideeiiee of sewer-gas, et*-. There is some dduht :is lu Ikiw far the hitter is directly concerned in the jn-opiigation of diphtheritic virus. Imt it is ccrlaiidy tnu- that persons who live nndei- nnra\. The Klebs-L«jffler bacilli are found scattered through the meshes of the fibrillateity varying from congestion, with a thin, grayish or yelIowi>h lihu spread over the surface in isolated irn-iil:ir patches or in a single layer, up to the forniMlic.ii of a thick, firmly attached pseudo-membrane covering a tinnelied nnicous surface with more or less necrosis of the (Iccpii' layers. 380 DIPHTHERIA. The 3Iembrane. — The character of the pseudo-membrane varies somewhat with the structure of the particular raucous membrane aifected. It is apt to be more fibrinous and more firmly adherent to a surface covered originally by squamous cells instead of by ciliated or other forms of epithelium. The membrane is of a grayish-white color, and if superficial can be stripped off, and is found to be elastic and firm. Shaken in water, it does not disintegrate. It swells in acetic acid. If the deeper tissue be involved, the membrane is more adherent, and attempts at its removal may lacerate the sur- face and produce bleeding. This is especially the case over the irregular ton- sillar surfaces. The color deepens as the membrane becomes older. It grows yellowish, and may be streaked with red from admixture of blood, or it bec6mes dark brown. It may soften and break down into an offensive, ichorous, brownish discharge. After death it is apt to decompose and soften rapidly. Very rarely the membrane may be absent, in which case the inflamed surface is swollen and of a grayish-white color from infiltration. When the pseudo-membrane is advancing the edges are thin, and they shade into the surrounding area of inflammation, but if repair is about to take place, the patches may thicken or wrinkle at their edges, which become dis- tinctly separated from the mucous membrane. The pseudo-membrane is loosened by effusion of serum and immigration of leucocytes beneath, and by ulcerative process, so that it sloughs off' in fragments or, less often, as one piece. Lesions of the mucous membrane undoubtedly aid the spread of the virus, and hence the injurious effect of forcibly stripping off the false membrane and exposing raw bleeding surfaces. It is said that the reason the tonsils are more frequently the starting-point of diphtheritic inflammation is partly because of their prominence, but also on account of the fact that their epitlielial cover- ing is not always everywhere continuous, and hence the virus has easier access to their mucous membrane. The virus may, however, undoubtedly attack a mucous membrane in which no abnormality is discoverable, possibly because a slight abrasion is so readily overlooked after the local inflammation has begun. The heart shows more or less fatty infiltration between the muscular fibres and around the blood-vessels. The muscle-fibres themselves may have swollen nuclei. Both ventricles are often dilated. Tlie epiglottis may be congested, but it is exceptional for it to become sufficiently oidematous to impede respiration. The bronchi may appear normal or present a catarrhal or croupous inflam- mation. The diphtheritic membrane may extend over their mucous surfaces down to the bronchioles. There may be broncho-pneumonia or lobar pneu- monia from inhalation of shreds of fibrin and putrid material from sloughs in the mouth. If death has occurred from suffocation, the lungs may be slightly emphysematous (Flint). The lymphatic glands near the site of the local inflammation are the seat of hyperplasia. The lymphatic glands at the angle of the jaw and in the neck SVMPTOMA rOLOG Y. 381 are most apt to be affected, esj)ecially if the nares are involved. The variou^ salivary glands may also be enlarged. As a rule, the glandular swelling sub- sides without suppuration. Sometimes the periglandular tissue becomes infil- trated and greatly swollen. In malignant eases there is deep sloughing, or even gangrene, at the site of local inflammation, and there mav be haemorrhages from the various mucous membranes, or general purpura and parenchymatous degeneration of viscera. The spleen may be somewhat enlarged, and both spleen and liver may be hyper?emic. The blood will coagulate poorly, and it* is very dark. Ante- mortem heart-clots and venous thrombi may occasionally form. Small liaMuor- rhages have been found in the meninges of the brain and spinal cord. Symptomatology. — The period of incubation of diphtheria may be very brief, lasting only twenty-four or thirty-six hours, or it may occupy a week. It will depend somewhat upon the severity of the epidemic, the incubation period being shorter where the poison is concentrated or propagated l)y experimental inoculation. The symptoms are both local and constitutional, and they may vary con- siderably, for mild and malignant types may develop side by side. There is no definitely fixed relation between the general symptoms and the intensity of the localized inflammation. Prodrornafa. — Diphtheria usually commences with certain prodromal symjv toms, such as malaise, anorexia, headache, and sometimes nausea and vomiting. There may be chilly sensations, but a distinct chill is not common. Invasion and Course. — In a few hours the patient com})lains of slight dryness and soreness of the throat on swallowing, but the pain is seldom as acute as in tonsillitis. There may be pain also on speaking, or aphonia. Sometimes the throat is slightly amesthetic. There is a feeling of increas- ing weakness and more or less general muscular soreness. There is a slight rise of temperature. Upon examining the throat the tonsils are found slightly swollen and reddened, and there may be hypenemia of the pillars of the fauces and uvula. One or two small grayish or yel- lowish sj)Ots will be observed upon the inner surface of one or both tonsils. They are covered by a thin, firmly-adherent membrane. The spots remain inicliaiia(i<-nt i'vr\> ill and looks pallid. The Inn- perature mav rise in a day or two to KM.'/-' l'\, or even liiglirr. bin in many cases it remains below 102. r/Mlirouglioiit 1 In- disease. TIicwIk.Ic c-ourse of the fever is iire.rular. The i-espiralioii is not |.,irli<'ularly all'cctcd, but it may 382 DIPHTHERIA. he quickened. The hreath is foetid. The tongue is coated and sometimes swollen. There is complete anorexia, and nausea may be present. The bowels are costive. There is more or less swelling of the cervical lymphatic glands, with pain or soreness on opening the jaw, which is sometimes felt also in the ears. The glandular enlargement is usually symmetrical. By the second or third day albumin may be found in the urine, which may become scanty and high colored, or, in other cases, may still appear normal to the eye. After a week or ten days the throat begins to improve, the constitu- tional symptoms abate, and the patient, somewhat enfeebled, slowly convalesces; or the disease proceeds to a fatal issue, in which case, instead of the membrane ceasing to extend, it advances, passing either upward or downward. If the membrane reaches into the vault of the pharynx, it passes the posterior nares and comes forward to fill the nasal cavities. There may be deafness from swelling of the orifices of tlie Eustachian tubes or extension of the inflammation into them. When the nares are involved there will be a thin, muco-purulent discharge from the nose, which may excoriate the septum, alse, and upper lip. It later becomes brown, and is frequently hsemorrhagic and extremely offensive in odor. Tiiere are snuffles and sneezing, and young infants cannot suckle, and must be fed with a spoon. Mouth-breathing becomes necessary. The nose itself and the upper lip become somewhat red and swollen. The glands at the angle of the jaw and the submaxillary glands become enlarged and tender, owing to their connection with the Schneiderian lymphatic vessels. This gland- ular swelling is often the first sign of nasal diphtheria. Sometimes the con- nective tissue between the glands is infiltrated, and the entire neck may be greatly swollen, so as to interfere with the motion of the head. In bad cases the inflammation may extend along the lachrymal ducts and reach the con- junctivae, which become red, swollen, watery, and finally are covered by pseudo-membrane. There may be uncontrollable epistaxis. In other cases the inflammation extends along the Eustachian tube, and finally excites an otitis media, with perforation of the tympanum and other grave lesions. Should the membrane spread downward, as is very frequently the case, the larynx is lined with pseudo-membrane which obstructs respiration. The first symjitom noticed is hoarseness, which occurs between the third and sixth days. Then the breathing becomes quick and shallow or noisy and stertorous. There may be aphonia. There is a peculiar characteristic harsh-ringing, croupy cough. The patient becomes cyanotic, cold, anxious, and sits up or tosses about in bed, gasping for breath, with the head extended, the mouth open, the alae nasi working vigorously, and all the accessory respiratory muscles called into action. Owing to the impeded entrance of air, the supraclavicular spaces and the lower intercostal spaces are sunken by atmospheric pressure during inspiration. Breathing is super- ficial, rapid, and irregular. The patient may cough up pieces of membrane and secure temporary relief, but the dyspnoea returns promptly, as new mem- brane rapidly forms. A new membrane sometimes appears in half an hour. SYMPTO.VA rOLOa Y. 383 The cougli may ho paroxysmal troin a t'lUR'tiuiial spasm of tlic vot-al cords. Salivation may be present, and there is repugnance to food of anv kind. In bad cases the vomitintj may continue and be accompanied by diarrhoea. AVhile the local inflammation is augmenting the constitutional symptoms become very unfavorable. The pulse grows more and more rapid, feeble, and irregular. There is increasing pallor, and sometimes a cold perspiration covers the body. The fever continues or diminishes. The albuminuria increases; granular and epithelial casts, with sometimes a few red blood-cells, appear in the urine. The prostration is extreme. Neurotic symptoms are not prominent, and the mind is usually clear, but a typhoid condition witli delirium may ensue. Young children sometimes have mild convulsions. Paralysis may ajipear at this time, involving the uvula, nuisclcs of deglutition, or one or more of the extremities. Finally death results from suffocation unless tracheotomy or intubation be performed [vide infra), or from asthenia and cardiac par- alysis. Special Symptoms. — The temperature may remain low throughout the disease, or, beginning high with an initial angina, it may fall, later on, to 101° F., with increasing blood-poisoning. A continued high temperature is not at all characteristic of diphtheria. The dyspnoea may have several causes. It may be due to obstruction in the larvnx from swelling and accumulation of thick pseudo-membrane or to a piece of membrane, partly detached, which acts like a valve, flapping to and fro with the respiratory movements and closing the glottis in inspiration. Again, it may be due to alteration or disintegration of the red blood-disks, and their inability to convey oxygen, produced by a toxic condition of the system. It may arise from heart failure and impeded pulmonary circulation, or it may occur from sudden spasm or paralysis of one or both vocal cords. When death ensues from extreme dyspnoea and suttbcation, the mind becomes dull or there is coma, followed by convulsions and o})isthotonos. The heart becomes very feeble and the cardiac sounds are inaudible; the radial pulse cannot be felt. The surface of the body is cold, moist, and blue. The urine presents the features commonly found in acute febrile disease. The urates are increased, the color is deeiXMied or normal, the specific gravity is raised, and the quantity is lessened. There is more or less albumin in over 50 per cent, of the cases. There are epithelial and gramilar casts, and some- times a few blood-cells. Albuminuria is rare in the first day or two. It usu- ally occurs between the third or flfdi and the tenth day. It may be (luc to acute nephritis or to toxines which modily the albuminous ingredients of the tissues and ijlood, or it may occur late in the disease from renal congestion in connection with dyspnoea :iiid faiihy :ieiati..n ..f tli.> bl 1. In the latter case it sometimes disapjicars aCl-r iiitul):iti.iii m- tracheotomy. The intensitv of the all)nminiiriM is ni.t to .•onfuiiM to the severity of the disease. The albuminuria usually subsides as the symptoms abate, and the parenchvmatous nephritis seldom be...iues .•hroiiic. It is exceptional for it 384 DIPHTHERIA. to occasion urremia or oedema. When acute interstitial nephritis occurs there is great infarction of the stellate veins (Synipson). The pulse is uin'formly rapid. In infants it often reaches 180 or 200 ; in older children, 140 or 150. It may drop suddenly below the normal, which is always a serious indication of increasing cardiac weakness. There is often sudden cardiac paralysis during convalescence, which may appear after the patient has been walking about. The right side of the heart may become suddenly dilated, with feeble sounds, irregular action, and absent impulse. Malignant Cases. — In any severe epidemic of diphtheria, and some- times sporadically, a certain number of cases assume a distinctly malignant type. They may be of two classes, in both of which the invasion is acute, with rigors, headache, vomiting, and sudden prostration. In the first variety the system is overwhelmed with diphtheritic poison, so that death occurs in two or three days, from disintegration of the blood and heart-failure, before the membrane has had time to extend. In these cases there is somnolence, stupor, or delirium, the heart-action rapidly fails, the skin is cold and clammy, and there may be ecchymoses in it. In the second variety the membrane spreads very rapidly, simultaneously covering a large surface, and laryngeal and bronchial inflammations quickly supervene. In the worst cases the entire tonsils, fauces, uvula, buccal cavity, posterior pharynx, larynx, and nasal cavities are covered with thick, brown, foul-smelling membrane. Extensive sloughing, and even gangrene, may result. Such cases are almost hopeless from the commencement, and every eifort must be made to quarantine and disinfect them. As a rule, adults are more apt to suffer from severe constitutional symp- toms, and children from laryngeal extension of the inflammation. Adults often die while there is comparatively little membrane present. Duration. — Diphtheria is a disease without definite duration. The average case lasts about ten days or a fortnight. Very mild cases may recover in a week, while others, more severe, last three or four weeks. There are cases which continue for two months without the throat becoming entirely well, although the constitutional symptoms may abate. Bacilli have been found by . Klebs lingering in the throat after the false membrane had disappeared. Terminations. — Diphtheria may end in recovery, or death ensues from one or other of the following causes : extension to the larynx and suffocation by occlusion ; laryngeal spasm or jjaralysis ; asthenia ; cardiac paralysis, and syncope. Complications. — The two most frequent complications, which are also the most severe, are albuminuria and paralysis. They are so frequent, in fact — especially the albuminuria — as to be regarded by some authors as symptoms. On the other hand, they may occur later as sequelae. Endocarditis is a rare and fatal conq^lication of diphtheria. A rare complication is the invasion of the conjunctiva by the diphtheritic inflammation. This is always an exceedingly grave accident, and it may D UliA TIOX. — 9£Q UEL^. 385 result in the destruction of the cornea inside of two days, with u total loss of vision. Fatal epistaxis or severe hremorrhages from the diseased mucous surfaces are unusual complications. Extreme alterations in the pulse-rate on either side of the normal may occur, but a very slow pulse is exceptional. Seqiielge. — The scquelfe of dij)htheria are both mild and severe, and they may last throughout several months. Cougostion of the fauces and tousillar hypertrophy may continue for some time. Tlie uvula is often hypertropiiicd, and chronic nasal catarrh may be instituted. The paralyses which follow diphtheria, or which in some cases appear in connection with the height of the disease, are various. They are connuoulv trophic motor paralyses, but may be both motor and sensory, and com- monly occur within two or three weeks after disappearance of the throat symptoms. They are peculiar, for one set of muscles often regain their function while another is losing it, and they are as likely to occur in uiild as in severe cases. As a rule, recovery takes place in from six to eight weeks, but some cases are protracted for a year or two. The tendon-reflexes are very frequently abolished, and the normal knee- jerk may be absent for some time. Absence of pain or tenderness along the nerves, such as occurs in multiple neuritis, is noted. The soft palate is oftenest affected. It hangs loose, is insensitive, and the voice becomes nasal. Occasionally one-half only is paralyzed, and it is drawn toward the opposite side. This paralysis may occur irrespective of any iuflam- mation of the uvula. The reflex action is abolished. The tongue and j)har- vngeal muscles mav be involved. The various ocular muscles are often paralyzed, giving rise to loss of accommodation, double vision, or strabismus. One or both vocal cords may be paralvzed 'and seriously interfere with respiration. The diaphragm aud intercostal or cervical muscles may be paralyzed. Exceptionally there is paralysis of the sphincters of the bladder and rectum, with retention of urine and faecal incontinence. There may be loss of tendou-roflcx at the knee, with inco-ordi nation in gait and without loss of muscular ])(>wcr in the legs. This ataxia is accompanied by loss of sensation in the feet and legs, by swaying of the erect body, and loss of bahuicc wlicn the eyes are closed (the Romberg symptom). The legs are more apt to be paralyzed than the arms. Paralysis of the h(,'art is quite frequent, and is supposed to follow degeneration of the i-ardiac nerves or ganglia. Various forms of aufesthesia aud ilysiesthesia are some- times present. The paralyses are, in part at least, due to degenerative changes in the periph- eral nerves, though in some c-ases cent ml lesions may occur. As a rule, the iruiscles sup])licd by the afl'ected nerves do n(»t atrophy, and they retain their response to electric stimulation, both galvanic and faradic. Some one of these forms of paralysis occurs in 10 per cent, of eases in u Vol.. r.— 25 386 DIPHTHERIA. bad epidemic. The prognosis is generally good for final recovery from the paralysis unless the muscles of respiration or deglutition or the heart are affected. Chorea and epileptiform attacks have been observed exception- ally, and there may be peripheral hypersesthesia. There are often persist- ent anorexia and obstinate anaemia. Diagnosis. — It is more common to mistake various lesions of the throat in adults for diphtheria than to overlook diphtheria when once fairly estab- lished. Young children, however, seldom complain of the throat symptoms in anv manner, and their throats should be examined as a matter of routine in any doubtful illness. Otherwise, cases of diphtheria may advance beyond •control before they are discovered. In simple inflammation of the pharynx and in follicular tonsillitis, as com- pared with diphtheritic inflammation, the invasion is more sudden, the tem- perature higher, and the redness of the throat more diffuse, and not con- fined to one side, as is often the case in commencing diphtheria. In tonsillitis the uvula is not involved, but in diphtheria it usually is, and the nasal cavities may be also affected. Moreover, in follicular tonsillitis the yellowish-white spots can often be removed from the crypts which the secretion occupies, and the inflammation frequently abates in thirty-six hours, whereas in diphtheria it continues for a week or two. A doubtful-looking layer of mucus is often removed by having the patient gargle the throat with salt water. Cases of difficult diagnosis occur occasionally from the fact that the mem- brane is concealed by originating in the nares or, as reported by Jacobi, in the trachea before other surfaces are affected. The tracheal origin is denied by many observers. There are cases of inflammation of mucous surfaces which are traumatic, and which closely reseml)le diphtheria from an anatomical standpoint, except from the absence of bacilli — such as are caused by irritating substances swal- lowed or inhaled by mistake, as, for example, chlorine, ammonia, live steam, etc. When an epidemic originates many cases occur which pass undetected as an ordinary " sore throat," and their real nature is not apparent without very careful investigation. The separate identity of diphtheria and membranous croup has occa- sioned much discussion. It has been held, on the one hand, that the two diseases are etiologically and anatomically identical, however much their clinical aspects may differ ; and, on the other hand, that throughout they are two very distinct diseases. If the Klebs-L()ffler bacillus be accepted as a sine qua nan in the etiology of diphtheria, then croup must necessarily be separated from it. As a matter of fact, the anatomical appearance of the membrane in both diseases is identi- cal, excepting only the absence of the Klebs-Loffler bacillus, the two lesions differing only in degree, while the clinical histories are very different. In croup the inflammation begins in the larynx, whereas in diphtheria it rarely commences there, but passes by extension from the pharynx. In croup the necrotic change is more superficial and may be limited to the epithelium, PNoaxo.s/s. 387 whereas in diphtheria tlie deeper layers of the mucous membrane are involved, and even the submncosa may sometimes slonjrh. AHhouoh the membranes may appear alike, excepting in regard to the i)resenee of the Klebs-Loffler bacillus, clinically the two diseases are verv uidike. ^Membranous croup is a local disease; diphtheria is a general disease with a local inflammation. Croup is not epidemic or contagious, and very rarely affects adults, as diphtheria may. Albuminuria does not occur, no paralytic sequelfe follow, and the lymjihatic glands are less apt to be enlarged than in diphtheria. In croup the inflannnation begins suddenly in the larynx, and does not readily tend to spread to the trachea or oesophagus. The invasion of croup is apt to be more sudden and severe than it is in diphtheria. The sore throat occurring with scarlatina is sometimes mistaken for diph- theria, and, in fact, the latter disease may sometimes occur in conjunction with scarlatina. In the scarlatinal throat the redness is much more diffuse than in diphtheria, and there is the characteristic "strawberry tongue." In doubtful cases a careful bacteriological examination should be made, when streptococci may be found, but the Klebs-f^offler bacillus will be absent. In erysipelas of the throat the cervical glands are less apt to be enlarged, and the tonoue is brown and drv, and the mode of extension of the two dis- eases is very different. Occasionally, syphilitic mucous patches in the pharynx, with inflammation of the fauces, may resemble diphtheritic inflannnation, but the history of the case and the absence of acute constitutional symptoms, with the course of the disease. Mill soon establish the diagnosis. In adults in any doubtfid case of throat lesion the urine must be exam- ined. The sudden appearance of albumin favors the diagnosis of diphtheria, for it does not occur in simple tonsillitis or pharyngitis. Moreover, the pecu- liarities of the pseudo-membrane, its extension, and the ])rogress of the con- stitutional symptoms will seldom fail to distinguish diphtheria from the former affections. Prognosis. — The ])rognosis should always be guarded. It varies in differ- ent epidemics. It is flivorable in the absence of extension of the mend)rane to the throat or nose, in the absence of albumiiuiria, and with fair digestion and a strong heart-action. Patients seen early and properly treated stand a very fair chance of recovery. Cases of nasal diphtheria are ai)t to end fatally unless vigorously treated. It is probable that this is so because of the great vascularity and abundant Ivmphatic ves>«els of tiie Schneiderian membrane, whieh ic:idily Mbsorb sejitic material and distribute it in the system. A brownish, watery, nasal discharge, streaked with blood and having an offensive, sweetish odor, is a worse omen than a thick membrane. Involvement of tln> hard p:il:i(e ;uid in.iuth to an extreme deirree is worse than extension to the n(i>e. The f|nautity of the membrane formed does \uA alway> indicate the severity of the disease. Patients may exliii)i( a mere trace of it in the fauces while they are in collapse from systemic blood-i)oisoning ; (.r the membrane may 388 DIPHTHERIA. be an eighth of an inch in thickness and cover a wide area, and yet recovery may take place. As a general rule, however, a rapidly-extending, uncontrol- lable inflammation makes the prognosis very grave. The temperature affords very little guidance in prognosis. The disease is the more fatal the younger the child. The worst cases occur while the epidemic is advancing, not when it declines. The prognosis is worse when scrofula exists, and when the diphtheria follows an attack of measles or scarlatina which has already exhausted the child. Mortality. — The death-rate of diphtheria varies with different epidemics. It sometimes exceeds 40 per cent, and has even reached 76 per cent. With 900 cases recently treated in Strasbourg the mortality was 46.7 per cent. In New York it averages above 47 per cent., and may reach 55 per cent. When cases are isolated and favorably placed and treated it is much less. Over 50 per cent, of the deaths from diphtheria occur in children under five years of age, and about 75 per cent, occur among those under ten years of age. Despite every effort for the control of diphtheria, the death-rate has remained undi- minished for many years, and it often proves fatal to very robust children. Treatment. — Prophylaxis. — The greatest danger in the spread of diph- theria is through the agency of " ambulatory " cases — i. e. cases in which the symptoms are so slight as not to prevent the patient from going about, and which nevertheless communicate the disease readily to other persons. A mild case in one individual may by contagion beget a severe or malignant one in another. When diphtheria is epidemic precautionary measures should be taken wherever children are crowded together in school-rooms, asylums, or hospi- tal wards ; strict personal and general cleanliness should be enforced ; and any child having the least indication of a sore throat should be kept apart from the rest. Cleanliness of streets, yards, privies, etc. is very important, for the disease thrives in filth. An abundant supply of pure water is highly essen- tial, and good ventilation of dwellings and school-rooms should be insisted upon. It is often desirable to close the public schools temporarily to prevent contagion. Isolation and disinfection are cardinal principles in regard to the treatment of diphtheria, no matter how mild it may appear. Any infected animals should at once be killed. In the event of a death from di])htheria the body should be wrapped in a sheet wet in 1 : 3000 corrosive-sublimate solution, and placed immediately in a sealed casket, and the funeral sliould be strictly private, for the disregarding of this precaution has been a fertile source of epidemics. The Hygiene of the Sick-room. — The patient should be placed in a bare room, free from superfluous hangings, rugs, or furniture, and kept very quiet in bed. The temperature of the room should not rise above 68° F. The air should be kept pure by free ventilation. If an adjoining room can be secured in which windows can be opened, it will greatly facilitate ventilation without exposure to draughts. In cold weather an open fire is desirable for ventilation TREA TMENT. 389 as well as warmth. In wariuer weather a lamp should he kept constantly burning inside the fireplace in order to make a current up the chimney. The bed should be so placed that both sides can be rcadilv accessible. All discharffes from the patient should be carefully disinfected. Cheese-cloth rags should be used instead of handkerchiefs, and immediately burned. Brushes used in the throat or nose should be kept in corrosive-sublimate solution, and swabs should be burned after a single application. No one should be admitted to the room excepting the physician, nurse, or such members of the family as may be in constant attendance. Those in charge of the patient should be held in strict quarantine from the other occupants of the house. It is advisable for the phy- sician on entering the sick-chamber to don a long linen apron or a sheet, for in examining the patient shreds of membrane arc sometimes coughed up and light on the clothing, and the disease has been carried to others in this manner. In making applications to the throat which excite coughing one should be particu- larly careful lest the membrane be expelled in the face, and plain glasses may be worn to save the eyes from such danger. On leaving the room the clothing should be brushed, and the hands and beard should be washed in corrosive sub- limate, and it is well to pass promptly into the open air. Those in constant attendance upon diphtheritic cases do well to spray their own nostrils and throats several times a day with weak corrosive-sublimate solution (1 : 10,000) or a similar disinfectant. When dij)hthcria is epidemic the patients should not only be isolated from the healthy, but from each other, for crowding them together in wards greatly increases the virulence of the disease. Many of the foregoing details may seem trivial, and they are often over- looked, but experience with infection from truly malignant cases of diphtheria has demonstrated that they are of the utmost importance. The patient should be disturbed no more than is necessary for the accom- plishment of treatment. Local applications in diphtheria should always be vigorously employed, un- less the patient is a very young or nervous child who is almost frightened into convulsions by their use. As a rule, a little tact and perseverance on the j)art of the physician and nurse will in time overcome any resistance. If the patient be very feeble or unconscious, care must be taken that no poisonous applications are swallowed. The pharynx can often be reached by pouring disinfectants in the nose — an operation which is innch less alanniiig to a young infant llian forcibly opening the mouth. Local applications are useful— (1) as germicides; {'!) for cleansing pur- poses; (3) to dissolve the false meml)ran(' ; (4) to allay irritation. As a rule, the apj)lications should be warm ami mild. The most successful htcal treat inciil, h(.\vcvcr, is lh:il which is employed with the object of disinfecting and cleansing uiianected surfaces, and of (here- by making them less lial)le to inflainmatioii niid to beget noxious products for absori)tion. Local treatnicnt is of very little avail as a curative measure wIkm the lesion is once established. It is well to constantly disinfect the nasal pas- 390 DIPHTHERIA. sages in every case, to prevent possible extension of the inflammation in a direction in which it is often overlooked. The common methods of making the local applications are by an atomizer or spray, a nasal syringe or douche, gargle, insufflation, or by the use of a camel's-hair brush or a piece of absorbent cotton on a swab. The choice of method will depend upon the conditions to be met in a given case. Gargles are not very effectual. As a rule, the syringe is best for nasal diphtheria, and the spray is most useful for applying antiseptics or solvents to the false mem- brane, while the swab is of service when single stronger applications are indi- cated or where a piece of loosened membrane is to be detached. It is some- times useful to combine several methods. A small syringe, with a small piece of rubber tubing slipped over the nozzle, serves well for cleansing the nose. The nurse should be instructed to apply the stream horizontally and very gently. A nasal syringe has been devised with a soft-rubber top which fits the nostril conveniently. In syringing the nose the head should be held well forward and the child told to breathe through the mouth. Should pain in the ears be complained of after the syringing, it must be abandoned, and the fluid may be poured in with a spoon or medicine-dropper. If the nares are entirely occluded by thick membrane and secretion, they may be cleansed by a probe carrying cotton dipped in a little 50 per cent, solu- tion of carbolic acid. This strong solution should only be used upon the false membrane. Afterward the nasal cavities may be kept clean by a saturated solution of boric acid, or one of ten minims of carbolic acid to the ounce of lime-water. It is ob\-iously unwise and unnecessary to attempt the use of a laryngo- scope to facilitate examination. All applications to the nasal mucous mem- brane should be very mild and warm. Frequently warm local applications to the throat give more relief than cold, but many patients crave the cold and enjoy cold water, cracked ice, simple water-ices, ice-cream, etc. In order to keep down a rapidly-spreading inflammation and an accumida- < ion of false membrane, which would be inevitably fatal, it is absolutely neces- .sary to adopt measiu-es which at the time may appear severe. Thus in very bad cases local applications must be made continuously every half hour by day and every hour by night, and exceptionally even oftener, although they inter- fere with sleep. Sometimes patients become so fatigued that they will drop asleep while the application is being made, or they will bitterly complain of being so frequently disturbed. Experience teaches, however, that vigorous local treatment is the only means of preventing the extension of inflammation to the larynx and nares, and many lives may be saved by firmness in this respect. When children once pass into a septic coma it is wellnigh impossible to arouse them. It taxes the physician's best judgment to avoid the danger of exhausting the patient's strength by too energetic local treatment, and the even greater dangers of sepsis and occlusion of the air-passages by rapidly- spreading false membrane. If there be an accumulation of false membrane already formed in the larynx, THE A TMENT. 391 an emetic of tiirpeth mineral will sometimes enable the child to discharge a considerable portion of it, with immediate relief to the accom pan vino- dys- pnoea.. Much tact is required in the management of young infants, who are apt to be greatly alarmed by attempts at local treatment. In such instances firmness and gentleness will often overcome objection. It must be remembered that hard crying with deep inspiration may loosen a bit of false membrane, which is carried into the larynx or trachea to set up a fresh infection with fatal result. Often, however, the infants are too ill to cry violently. Any application should be abandoned which tends to derange the stomach. Very young children, as a rule, will not tolerate the spray, and they are unable to gargle. In such cases the tincture of the chloride of iron may be given in doses of five, ten, or fifteen minims in glycerin and peppermint-water every half hour. A child a year old will take a drachm or more in the course of twenty-four hours with benefit. Swallowing the frequently re- peated doses serves the purpose of local application fairly well, for a certain amount adheres to the diseased mucous surface. A useful formula for a young child is — I^. Tinct. ferri chloridi, f^jss ; Glycerin i pur., f^ss ; Aquae menth. piper., f.SJ ; Aquffi, q. s. ad f^iv. — M. Sig. Give fsj every half hour. The iron acts beneficially by constricting the blood-vessels, and possibly also the lymphatic vessels, and by diminishing absorption of septic products. It is also antiseptic, reduces local hypenemia and swelling, and toughens the membrane already formed. The chlorate of })otassium is sometimes given with iron, but it is a])t to impair digestion, and, in large doses, may excite hsematuria. Since the kidneys are often more or less inflamed, this remedy should be used with great caution. The pseudo-membrane should never be torn off or rudely removed, so as to expose a fresh bleeding surface to reinoeulation and extension of tiie inflammation, but a good deal of loosened membrane may carefully be dis- lodged by a bit of dry flannel fjistened to a strip of wood and used as a probe. After the pseudo- membrane has been coagulated and hardened by topical apidications it is often freer, and can be more readily removed, but unless it comes off very easily it should be let alone. Loosened membrane, unless it be removed or coughed out, is liable to be swallowed or inhaled. If it becomes necessary to remove loosened false membrane or make a local application, a kieking child may be rolled in a blanket and held up by the nurse while a swab is used. A teaspoon or a medicine-droj)per may be employed to pour fluid into the nostrils, instead of the rubber tubing and syringe. 392 DIPHTHERIA. A great number of local applications are made with a view of hardening and freeing the pseudo-membrane and checking its extension. Such are the following solutions : tincture of the chloride of iron, 10 per cent., in glycerin and watci- (applied with a brush) ; common salt, f per cent. ; salicylic acid, \ per cent. ; creolin, 1 per cent. ; creasote ; resorcin, 10 per cent., in gly- cerin ; menthol ; carbolic acid, 1 per cent. ; boric acid, saturated aqueous solu- tion ; corrosive sublimate, 1 : 2000 or 3000; potassium permanganate; sodium hypophosphite. Applications of strong solutions of silver nitrate, hydrochloric acid, or car- bolic acid to the diseased mucous surface have been extensively tried, but such harsh measures are now universally condemned ; for, if local applications are made too strong, they weaken the neighboring healthy mucous. membrane and render it liable to infection. Nothing caustic or irritating should ever be ap- plied, for, although such substances may temporarily destroy the membrane, it soon re-forms over a larger area, with increased inflammation and tumefac- tion, and deep sloughs may follow. Vapors of turpentine, eucalyptus, carbolic acid, etc. are sometimes em- ployed about the room and for the patient to inhale, but they are of doubtful efficacy. Considerable relief is often obtained by the use of steam generated in a " croup kettle" or, in an ordinary kettle, the steam being directed under a sheet arranged as a hood over the patient's head. Lime-water or eucalyptol is sometimes added to the vapor. The steam favors suppuration, and the false membrane is loosened thereby. Such inhalations are especially valuable in the laryngeal form of the disease. The continued use of a corrosive-sublimate spray may over-stimulate the membrane and produce too much mucous secretion. Should this be the case, it must be employed less frequently and in alternation with some less irritating application. Single applications of corrosive sublimate on a swab may be used in the strength of 1 : 1000, but the spray should be diluted to 1 : 2000 or 1 : 3000 and used with care. For young children it should be still weaker — 1 : 5000 or 1 : 10,000. A little common salt is often added. Jacobi recommends the use of a s])ray containing a grain of corrosive sublimate to the pint, with a drachm of table salt added. In young infants there is some risk in the free local use of corrosive sublimate, because it is difficult to estimate how much is being swallowed and absorbed. In such cases salicylic acid, 1 : 1500, makes a less injurious wash for the nasal cavities. A saturated solution of boric acid in water is also serviceable as a douche ; as is common salt, one drachm to a pint of warm water. For solvents of the mucous membrane preparations of ])ancreatin or papayotin, 1 : 20 in water, are used witli benefit as sprays or topical applica- tions. It is somewhat doubtful whether these substances really dissolve the false membrane to any great extent, but they do seem to check its extension TREATMENT. 393 and to cleanse the surface. A good spray for use when corrosive sublimate cannot be safely employed consists of — I^. Acidi carbolici, lU^'j ; Liquor calcis, fsiv. — M. Sig. Apply with an atomizer every half hour or hour. Recently hydrogen peroxide has been extensively tried, with excellent results, as a spray in a 5 per cent, or 10 per cent, aqueous or glycerin solu- tion of the 1 5-volume-strength solution. This does not dissolve the mem- brane, but it acts as a cleansing and disinfecting agent. It does not corrode, nor does it injure, sound tissue when properly diluted. liocal applications to the outside of the throat are useless to relieve the inflammation of the mucous surfaces. If the cervical glands are swollen and painful, thev may be relieved by application of belladonna liniment or iodo- form ointment, and an ice-bag. Should they sn})purate, which is unusual, they must be actively poulticed and then incised. When the eye becomes inflamed the opposite one should be protected from infection by a pad and adhesive plaster. The constant application of cold to the lid and ihe use of a saturated solution of boric acid are the best remedial agents. Intubation and Tracheotomy. — Intubation of the larynx is a method devised by O'Dwyer of New York. It consists in the operation of insert- ing a small gold-plated tube between the vocal cords and leaving it there, so that air can freely pass in and out, tiie channel previously blocked by false membrane being kept open by the tube. The tube is carefully adapted to be held between the vocal cords, and various sizes are made to fit any larynx. The tube is passed into the larynx by an ingenious holder, which releases it when in position, and an instrument is also employed for its removal for the purpose of cleansing it, extracting plugs of membrane, etc. The holder is grasped in one hand, while the index finger of the other hand serves as a guide for the tube, a gag being usually necessary to protect the finger. As a precaution against the tube being coughed up and swallowed a thread is tied to it, which may be brought out of the mouth and fastened. The practice of intubation has many and decided advantages over trache- otomy. It does away with the necessity for tracheotomy, a surgical operation which the patient's family usually abhor, if they do not actually forbid it. It is speedily performed by one skiHed in the use of the instrument, and it can be done at a moment's notice. The tube can be readily cleansed and rein- serted. The relief afforded is as instant as that of tracheotomy, and the ope- ration of inserting the tube is more quickly performed and it may be done earlier. The tube irritates the throat no more llian a tracheotomy-tube. In case of recovery the tube is more promptly removed than a tracheotomy-tube — in five or six instead often days — anft to close. Tiic disadvantages which it may have are— first, that it is said to push the 394 DIPJITITERIA. false membrane from the larynx down into the trachea, whereas the trache- otomy-tube passes in below the larynx ; second, it is sometimes coughed out by the child, who suffocates before it can be replaced ; third, it may be diffi- cult for the child to swallow without drawing food into the trachea. This trouble is chiefly confined to fluids and not to semifluid or solid food. With proper precautions, however, these shortcomings can be reduced to a minimum. If necessary, rectal alimentation may be temporarily resorted to, or a small oesophageal tube may be passed, though the latter method is apt to be too irri- tating. Many children can learn to swallow well with a little practice after the tube is inserted. The operation of tracheotomy cannot be here detailed, as it belongs to surgery. After either intubation or tracheotomy the tube should be watched con- stantly with great care, lest it become occluded with mucus or pseudo-mem- brane and cause suffocation. If a tracheotomy-tube be employed, it should be covered by a compress of cheese-cloth or other light material soaked in a warm antiseptic solution. The tube should be fitted with a proper attachment, so that a piece of rubber tubing can be fastened over it, and with the aid of a hard-rubber syringe mucus may be sucked out of the tube by the nurse. A soft-rubber catheter should also be in readiness to pass through an obstructed tube when necessary to clean the passage. Jacobi recommends a long feather for the same purpose, as bits of membrane and mucus are apt to adhere to it. Symptoms which make either tracheotomy or intubation urgent are quick- ened, stertorous respiration, unremitting dyspnoea, cyanosis, increased restless- ness and anxiety of the patient. Aphonia with difficulty in both inspiration and expiration indicates the presence of false membrane in the larynx (Jacobi). There is also marked falling in of the suprasternal and epigastric regions accompanying the inspiratory effx)rts. If the lungs are already involved or if the pseudo-membrane has passed down beyond the larynx, opening the trachea is of no avail. Either operation may be performed when there is no real hope of recovery, simply to save the patient from a very distressing death from suffocation. Unless immediate relief follows tracheotomy or intubation when done early, there is strong probability that the trachea and bronchi are already invaded by the inflammation. A statistical comparison between the mortality of tracheotomized and intubation oases is of little value, for tracheotomy is usually left as a last resort, and both methods are only employed in laryngeal diphtheria, which is exceedingly fatal in young children. Both methods serve to prevent the child's dying of suffocation, and a small percentage are actually saved. In 1890 statistics from various sources were collected of 2368 cases in which intuba- tion had been practised, with a recovery of 27.3 per cent. The mortality from tracheotomy, however, is quite as high. Fully 95 per cent, of the cases of laryngeal diphtheria in children and infants die unless relieved by intubation or tracheotomy. TREA TMEXT. 395 Treatment of Special Symptoms. — Paralyses of the pharvngeal muscles, soft palate, or tongue may interfere with deglutition and articulation. Attempts to swallow fluid result in its regurgitation through the nose. Such patients must be fed by an oesophageal tube. For the paralyses strychnine and other tonics, such as quinine and iron, are of service. Massage or a mild electric current, galvanic or faradic, may be used, but the latter is of doubt- ful efficacy, for most cases recover of themselves. If there be cardiac paraly- sis, absolute quiet in a recumbent position must be enjoined, and strychnine and brandy must be given hypodcrmically, with ammonia or camphor internally. If the temperature be high, sponge-bathing of the surface with cold water and alcohol in equal parts is useful. Dyspnoea is sometimes relieved by placing the child in a warm bath for a few minutes. Internal Remedies. — The internal use of corrosive sublimate in diphtheria has greatly gained in favor during the past few years, and it is now accepted as the best remedy. It seems to be particularly well tolerated by children having diphtheria, and they are soon able to take large doses, gradually increased. As much as one-fortieth of a grain may be given every two hours to a child three or five years old. The rule is to administer small, frequent doses, carefully watching the effect, and the drug must be diluted in water or milk to 1 : 5000. Jacobi states that a child a year old may take as much as half a grain in the twenty-four hours, divided into small doses. Should stomatitis or any indication of intestinal derangement, such as irritable diarrhoea, occur, the drug must of course be stopped at once ; and in every case its effects should be most carefully observed, and the doses should be very small at first until it is ascertained that they are well tolerated. The method of using the tincture of the chloride of iron has been detailed above, for the benefit derived from it seems quite as great locally as in any other way. It is commonly combined with glycerin, diluted in water, and is given in large, frequent doses. Stimulation and cardiac tonics should be employed early in the disease, and constantly, for there is much more hope of preventing heart-failure than of counteracting it when present. Digitalis, strophanthus, cafieinc, ammonium carbonate, strychnine, (;amj)hor, and alcohol are the remedies most favored. The citrate or sodo-benzoate of caffeine, when the urine is scanty, is useful for its diuretic effect. Alcohol is demanded early in nearly all cases. In those which commence with severity it should be given at once to prevent cardiac fiiilurc, in the form of diluted whiskey or brandy. Infants tolerate brandy well. An infant may be given twenty dro])s of brandy, or a child of four or five y(^nrs from one to two drachms, every hour or two, or oftencr if very firble. When swalU)wing is difficult or if the stomach be enfeebled, stinndants must be given by the rectum. Half an ounce atients, but it is always best to isolate such <'ases. II. LoccJ Treatiiient — The local burning and })ricking may be relieved by mild astringent and soothing applications. A^aseline oil containing 5 per cent, of carbolic acid, linseed oil with lime-water (carron oil), are useful for this purpose. When such ipplications are made, the skin should first be gently washed with soap and warm water, and the preparation then slowly rubbed in around the infiamed area, the friction being made toward the affected surface, not away from it. Among the various to])ical applications the writer has obtained the most relief by the use of a mask of soft lint cut to fit the face (with holes for the eyes and nose), which is frequently wrung out in a cold lead-and-opium wash, such as I^. Ij\([. [)hanbi subacetatis, f.5jss ; Tinct. opii, f.lss ; Aqua', q. s. ad fsviij. — M. Sig. For external use. If the skin be very tense and painful, it is sometimes more benefited by a hot poultice than by c(^ld. W the tension be extreme and gangrene seem imminent, small linear incisions may be made in the skin, but this is to be avoided if j)()ssible. Dusting powders relieve the burning, but have the dis- advantage of obscuring the outlines of the eruption. In order to limit the spread of the cutaneous inflammation caustics have been vigorously used, :uh1 even incision of the healthy skin has been tried with the hope that the advan- cing lesion woidd stop at such barriers. Strong solutions of carbolic acid, caus- tic alkalies, chloride of iron, iodine, turpentine, nitric acid, ointments of mercury and zinc, ])owders of iodoform and resorcin, subcutaneous injections of ])henic acid, and the actual cautery, have all l)eeu tried repeatedly and in turn abandoned. At times they seem to temjwrarily hold the march of the (lisease in check, but more often it defies their limits, and is even aggravated TRKA TMKNT. 403 by the irritation of the applications. Koch recommends painting the inflamed snrface witli a thin hiver of the foHowintr mixture: R. Creohn, 1 • Io(h)form, 4 ; Lanohn, 10. — M. Sitj. For external nse. •r>' Elastic conipression of the intejj;nment surronncling- the inflammation has been empl(»ye(l in some instances to limit the inflamed area ; and contractile collodion painted over the surface is another ap])licatioii which has been used, but both of these means, while they are (piitc iiarmless, are of uncer- tain advantay;e. If the cavity of the mouth be invaded, oarjrlos of alum or boric acid should be used. III. >S(iiitii/(()ifs and Diet. — The diet should be nutritious and adaj)ted for easy digestion. If the fever be high and there be a tendency to vomit, nour- ishment should be given in small quantities and at very frequent interval.-^, as every hour. In ordinary cases peptonized milk, beef juice, egg-nog, milk punch, and light starchy foods are given. Stinudauts should be prescribed freely in cases which begin with severity or in milder cases where the syni])- toms are prolonged. Alcohol is well borne, and \S or 20 ounces of whiskey or brandy given in twenty-four liours may be perfectly assimilated without toxic effect. If the pidse be feeble or irregular, auimoniiuu carbonate, cam))h()r, tligitalis, or strophanthus should be added to the brandy. Patients in whom the disease spreads rapidly over the body require particularly energetic stinui- lation. The tincture of the chloride of iron has long been employed in Kng- land and the United States, and many believe that it is a speciflc in ervsi])elas. This is not the fact, although it seems to beueflt some cases. It is usuall\- well tolerated, even if u'iven everv two houis, in half-drachm doses in fflvcei-iii and water. IV. Trcdfiiiod of ('oinpU('cdio}\H (Did Vcrii Srrrrr Si/m/tfoms. — The delirium is best controlled by hypodermic injections of morphine, or, if it become vio- lent and maniacal, by the one-hundredth of a grain of hyoscine hydrobromate, provided that the heart-action be not too feeble. An ice-cap shoidd l)c kept on the head. The tem|)cratui'e, wlieii high, is to be controlled by cold alco- holic sj)onge-baths or wet packs and compresses. Antipyicti*- drugs should be avoided on account of the depression which they cause. Abscesses should be poulticed and evacuated early. (Jaugrcnous areas innst be ^in of malarial fever to [)ois<)nons (exhalations arisin*;- from marshes. In 1879, Klebs and Tommasi-Crndeli succeeded in isolatine of malarial fevers exhil)it several varieties of form and size, and it is jiossible that there may be several species which are capable of exciting the distinct types of the disease, as tertian, quartan, etc. To what extent these various forms are related to one another as different stages oi' the same growth, or to what extent they represent different species, cannot in all eases be detinitelv decided at present. Laveran is inclined to think that the malarial gei"m is a .single but polymorphic organism, and that the type of fever depends in part on the particular form of the germ, and also upon the condition of the patient, his tolerance of the germ, etc. Osier believes that difl'ereut foi-ins of the germ l)elong to distinct species, and that they are not all different stages in the development of one microbe. Laveran describes the chief forms of his malarial hematozoon as consi.sting of (1) amoeboid spherical bodies with miclei ; (2) crescentic shaj)es with nuclei; (3) rosettes ; (4) flagellate bodies. (See Fig. 24). The Hagelhe are very delicate. They are only to be found in fresh blood, and they are difficult to see unless Fui. 24. f.:- Kiirms of the llfimili>/.<""iii of Miliaria lal'Icr I.avfraii). they are in motion. The other forms may be discovered in |)reserved sjh'ci- mens. His method of examination of a droj) of" blood was by rapirolonged in order to develop a bad attack. Malarial fevers arc undoubtedly spread by winds. There arc manv localities in whicii the wind, ehanging to a certain direction and blow- ing across an infected marsii, will provoke outbreaks of fever. This is espe- eially true in regard to the salt marshes near Rome. The malarial germ has been found in the air to a limited extent. A heavv rainfall washes down the germs from the atmosphere. INIalaria is more potent in infection at night. The reason for this is ascribe from their mouths. It flourishes in fresh-water marshes, but ])artieularly in stagnant pools and in marshes near the sea tainted with brine and not elcani'd freely by the tide. It has been known to develop in bilge-water in dirty vessels at sea. Malarial fever does not always develop in pr<»portion to the amount ot decomposing vegetable matter present. Ovei'turning the soil in a malarial region or removing the upper layers of earth usually i^recipitatcs an outbreak of malarial fever. Malarial fever was almost unknown in the island of Mauritius up to the year 1865. At that time it was suddenly contracted by immigrants from India, who were employed in draining and filling a nuid flat. Malarial fevers at times ))revail throughout extensive regions for years until cultivation of the soil aixl drainage gradually desti-oy the lionie of tlie miasm. On the other liand, (cultivated regions when abandonecl may again Ixvunie malarious, as tliey were before being occupied by man. KleratUm Above the Sm. — It is frequently stated that malarial fi'ver does not o<-cur at high elevations, but this is n(»t strictly so. WlsWo it is true that it 412 MALARIAL FEVERS. flourishes along seacoast marshes, and that the nn)st malignant types of fever are found in low-lying lands generally, it may be present elsewhere. Thus Parke speaks of encountering it near tiie Albert-Nyanza on a dry plain at 4800 feet above the sea-level, where there was more fever than in the lower damp forest, and he met with it again in Africa at an elevation of 10,000 feet. Ague is common in the elevated plateaus of Northern India. I Antagonism. — It has been claimed that a certain degree of antagonism | exists between ague and phthisis. This, however, is not the case. Ague occurs i in connection with a variety of chronic and acute affections, and when so doing exerts a distinct paroxysmal influence upon their course. The lower animals may contract malarial fever independently of inocula- tion, but it is not common among them. It has been known to occur in horses, donkeys, and oxen. Classification. — For convenience of description it is customary to subdi- vide malarial fevers into several groups, and clinically the different types are verv distinct. It should be borne in mind, however, that anatomically, as well as etiologically, all malarial fevers are very closely related, if not actually identical, and the manner in which one variety of fever may occa- sionally merge into another, or in which two types coexist in the same indi- vidual, indicates rather a diiference in degree or intensity of poisoning than multiplicity of diseases. The final outcome of the present study of the life-history of the malarial, germs and their relations to the symptomatology of ague is anticipated with great interest in regard to the theory of the unity of malarial fevers. Malarial diseases are usually classified under the following heads : I. Intermittent Fever ; II. Remittent Fever ; III. Pernicious Intermit- tent Fever ; IV. Pernicious Remittent Fever ; V. Typho-malarial Fever ; VI. Malarial Cachexia. I. Intermittent Fever. Morbid Anatomy. — The anatomical lesions of intermittent fever are few and simple. The spleen is engorged with blood during the febrile paroxysm. It is enlarged considerably in each attack, and at first it regains the normal size during the intervals. It soon fails to do this, and finally becomes per- manently enlarged, and is called an " ague cake." In exceptional instances it may extend to the umbilicus or below it. The size of the spleen is not always an indication of the duration of the disease. In not a few cases of very long duration it is scarcely enlarged at all, while it may suddenly enlarge very much after one or two attacks. A rare lesion of malarial fever is rupture of the spleen, producing almost instant death from hremorrhage into the peritoneal cavity. The spleen occasionally presents hemorrhagic infarcts of various .sizes. Its capsule is sometimes adherent. The liver, like the spleen, is somewhat engorged during the paroxysm, and the hepatic area may be tender on pressure. Tiic heart is sometimes acutely dilated, though this accident is rare, and it I INTEIUnrTENT FEVER. 413 is more apt to occur in patients rendered antemic and debilitated by protracted attacks of ague. The blood during; the febrile jiaroxysm contains fewer than normal corpus- cles of both red and white varieties. The condition of the red corpuscles and their pigment has already been detailed in the description of the malarial eerm. The brain and spinal cord have not been found to present any typical lesions, but it is believed by many that certain of the prominent symptoms of ajirue are occasionetl bv functional disorder of these organs. In the severe types of malarial fever they are pigmented. Incubation. — The length of the incubation period of intermittent fever depends upon the intensity of the miasm. The exact limits are not known, and are variously stated, from an hour or two up to twenty days. There are exceptional cases in which this period seems to last for several months. Eichhorst relates the case of a patient who resided for some time in a mala- rious region without havins; ague, but nine months after leavinsi; the district and residing in a healthful locality he was attacked by intermittent fever. During the incubation period there may be no symptoms, and the patient be in apparent health, or there may be certain indefinite prodromata, such as malaise, dyspepsia, constipation, dulness, sleepiness, irritable temper, etc. Symptomatology. — Intermittent fever presents three distinct stages : (1) a cold stage; (2) a hot stage; (3) a sweating stage. Collectively, they consti- tute the malarial " paroxysm." The cold stage is characterized by subjective sensations of cold and l)y rigors, while the thermometer records an elevation of the internal temperature; the hot stage is characterized by high temperature and the symptoms of pyrexia ; the sweating stage, by profuse perspiration and the subsidence of pyrexia. The individual symptoms of ague vary much in intensity in different cases and in different seasons and localities. The following is the history of a typ- ical case of intermittent fever: History of a Ti/picdl CW.«r. — In an ordinary case the chill usually comes on gradually, and is jireceded for two or three hours by a feeling of languor, dulness, yawning, and headache. In some cases, however, the chill begins very violently and suddenly. When it begins slowly the malaise is followed by a chilly feeling, commencing in the back and loins and gradually extend- ing over the entire body. This is accompanied by muscular tremors, and sometimes by cramps. There are often nausea and vomiting, which arc prob- ably due to congestion of the stomach, and there is headache. The tongue is l)ale and coated. The chill becomes more and more violent; the teeth chatter; the surface of the body feels cold to the touch ; the tips of the fingers, nose, and ears become livid ; tliere is pronounced pallor of the features, which look shrunken and haggard ; and the skin is roughened, dry, and presents the appearance of "goose-flesh," or cutis anserina, in a marked degree. There is great bodily discomfort, and the patient calls for more covering, bii( is not relieved by it. I'lie museidar rigors become so violent as to shake the entire 414 MALARIAL FEVERS. bed, and the voice is feeble, or there is inability to speak on account of the constant chattering of the teeth. The respiration is hurried and short and there is precordial oppression, and sometimes palpitation. The urine may be voided in increased quantity. During this time there is a gradual accession of fever. The surface temperature may be below normal, but the oral and rectal temperatures show an increase of two or three degrees. The peripheral vessels an; contracted, so that the prick of the finger fails to draw blood. The blood passes in larger volume to the viscera, producing (congestion of the more vascular internal organs. This congestion accounts for the gastric or enteric symptoms which accompany the disease, and it interferes grenrly with the fimctions of the organs affected. The greater blood -pessure of the internal vessels in organs like the liver and spleen modifies their nutrition and the elimination of waste material. The spleen is enlarged during the paroxysm, and the splenic area is often quite tender on [)ressure, ami a sensation of fulness may be experienced there. The luind remains clear. The cold stage continues for a varying time. It may be very mild and unaccompanied by rigors, lasting but a very brief period — ten or fifteen min- i,te.s — or it mav be prolonged for an hour or two. There is no constant rela- tion between the length or severity of the cold stage and that of the hot stage. The cold stage is said to be shorter in the quotidian than in tertian ague, but Avith the hot stage the reverse may obtain. The average diu-ation of the chill is from one-half to three-quarters of an hour. In young children the chill is replaced by one or more convulsions, or else the first stage is very mild or wanting altogether, or the child grows sud- denly })ale and has pronounced ners^ous symptoms. The first stage passes into the second by gradual abatement of the chill and rigors, which are replaced by a feeling of warmth. The second or hot stage is characterized by fever and high temperature. The peripheral vessels now have their constriction relaxed, and the pallor of the face and lividity give place to flushing and redness, the skin feels smooth, hot, and dry, and the thermometer in the rectum records 103°, 105°, or 106.5°, or even a higher temperature. Respiration grows deeper, and the pulse is full, bounding, and rapid — 130 or more — and it is frequently dicrotic. There may be an anaemic bruit heai'd at the base of the heart. The patient becomes rest- less and irritable, but the mind is clear. The mouth is dry and the throat ])arched. Sometimes there is herpes labialis. There is continued throbbing frontal headache, and the vomiting may be repeated. The tongue is coated with thick white fur, and the breath is foul. There is constipation. There nuiy be slight dizziness or a "sinking feeling," tinnitus aurium, and muscjB volitantes. This stage lasts from three to six hours, when the fever gradually declines and tiie patient becomes easier. The third or sweating stage is characterized by profuse perspiration and the disaj)pearance of the \'v\v\\ The fever may subside before the perspiration oc-curs, or it may continue into the third stage; hence the perspiration caniu)t JNTKR MITTENT FK \ 'KR. 415 be regtirtled as the cause of the .subsidence of the temperature. The sweating eoniniences on the tureliead and face, and soon the whole body is profusely bathed by it, so that the bed-clothing is thoroughly wet. The j)ulse becomes slower and returns to the normal tension, and the spleen gradually i-eturns to its natural size. With the subsidence of the tever the restlessness disapjH'ars, and, although the headache may continue, the j)atient becomes much more comfortable, and, feeling greatly exhausted, he usually [)asses into a (juiet sleep, from which he awakens more or less fatigued. The sweating stage lasts from two to four or six hours. The entini })aroxysm lasts from six to ten or twelve hours, according to its severity. In the interval between two paroxysms the patient may feel in perfect health, but there are apt to be more or less debility, anorexia, and auicmia, with a dimin- ishetl number of red blood-disks and a reduced quantity of luenu)globin in the blood. SPEt'iAi. Symi'Toms. — TtnniK'raiure in Intennittent Fever. — The tempera- ture, although it may be very high for a few hours, is not regarded with the Fig. 25. F 107° 106° 105° 104*^ 10.V 102" 101° 100° 99° 98° 97° : c L410 11-40° j-39° 1-50° ^37° -36^ '"" ■■" — 1 ''~~ "^ * 1 - " >j «2 ^ (W A ? ■'^ ■■- 1 M ^ *a — — 1 — 4 T- -. — 1 ' " — ^ — — — — — , -^ V — - A. -^ -^ ^T^ - ^ - 1 s ^ *<3 - « • I — ■ ^ I - — * — T -_ _, — ^ "^^ ■? — — «"f 1 — "" V :; 1 i '* n, j ^ 1 Y -- - \ 1 - \-- * ! j «. \ ^ \ ' — A* ^ I ,">- """ \ ■ V-'' V - -- .^::. " ^ 1 * ^ 4 1 ) Ct t 1 r J M ^ L » •^ / >;. 1/ ^ ? ]* ^ ■0 t^ Ofi «>> k • .y ...-■ ,.•'' ,..'••■' ..'■■ ..'"' ..-■■" ,-•' U atr ^.^ • ^ ' • ^ m .^ « ^ ^ <5) Teni|>cnitiirc-cliHit of ti ('use of tiiicitiiliim IiiiiTinillciil I'V-vcr. solicitude that it would engender in other affections. The same degree of tcm- perjjturc might be fatal in a case of insolation which in malarial fever sooJi 416 MALARIAL FEVERS. subsides of its own accord. Parke ^ states that in Africa he has seen every officer of the Emin Pasha Relief Expedition "do a day's march with a tem- perature of over 105° F." Of course this was exceptional and required undaunted pluck, but in many other diseases the same degree of fever would mean utter prostration or delirium or coma. The temperature rises more rapidly than it falls. It rises slowly but uni- formly in the cold stage, and more rapidly during the hot stage. The maxi- mum temperature lasts for one to three or four or more hours according to the severity of the paroxysm. The decline is sometimes uniform, but it is fre- quently interrupted by "steps" — /. e. it falls one or two degrees, remains stationarv for half an hour or an hour, then falls again, and so on (Wunder- lich). After the paroxysm it is quite common for the temperature to drop a degree or a degree and a half below the normal for a few hours. The accom- panying temperature-charts (Figs. 25 and 26) illustrate the periodicity of the high temperature attained in the quotidian and tertian types. Fig. 26. F .107° 106° 105° 104^ 103° 102° 101° 100° 99° 98° 97° : c. L410 ^-40° ^9° —<— 1 ! 1 ' ^ "? V i 1 ^ oa ^ V f ^ i " j| 7 3 J i "^ g ^ ■i t ^>S ^ Sj ' ' ^v "V ' ^ ■ N ,N s X i Sj S^ 1 3> ' .< S ? — ^ ^ k>f- ^J _ 1 »v _ „ ^ .^ , * — — I ;i^_-i=a — ^ ^ — — ii — k- ' — 1 1 --+--ni --I-I ■ ' — ^8° [-37° [-36° "T rr ! 1 1 i ' 1 \ I r f I' 'I. — - -j — -V i ^ 'V \ f J A - 1 J / A A / \t rf \ 1/ V V \ \/ , / \ VT^T V V n 1 1 I 1 PuUc *• V:, ^ Si K ■^ ^ ^ ^ ^ ^ ^ ..-■' y'' --■ ..■• ■ ,■" Z hUf. S.- ^ ^ ■> N» ■f^ ■^ ^ ^ ^, ^ ^ Temperature-chart of a Patient with Tertian Intermittent Fever. The Urine. — After the chill the urine is often increased in amount and is of low specific gravity. This is attributed in part to alterations in the renal l)l()od-pressure from the constriction of the superficial blood-vessels of the * My Personal Experiences in Equatorial Africa, p. 424. INTERMITTENT FEVER. 417 body. The malarial fever gives rise to waste products which are taken up by the blood and eliminated by the kidneys. This elimination sometimes attains its maximum before, sometimes during, the paroxysm. There is always an increase in the elimination of urea during a paroxysm, and Jaccoud has noted that this increase commences even before the chill, so that careful quantitative estimation of urea will foretell the approach of a paroxysm. This increase of urea-excretion he observed two hours before the chill in quotidian and six or eight hours before in tertian fever. He regards the estimation of the increased urea as a reliable indication for the proper time for administering quinine in order to anticipate the chill. Rarely there is temporary albuminuria during the pyrexia. Temporary glycosuria has also been reported in a few cases. Exceptional Cases. — In the vast majority of cases of malarial fever each succeeding paroxysm conforms in its duration and stages to the type with which the disease began, but this is not invariably the case, and there are some curious anomalies in the type itself. Thus, the cold stage may be omitted entirely or the sweating stage may similarly be absent, or they may both be wanting, leaving only the hot stage. When the chill is absent the disease is sometimes called "dumb ague." This form is more common among the older residents of a malarious rey-ion. In severe cases of intermittent fever the several stages, and especially the hot stage, may all be j^rolonged, and the sweating stage of one paroxysm may overlap the cold stage of the next. In rare instances the cold stage may be replaced by various neurotic symptoms, such as neuralgic pains, general ner- vousness, or periodic hysteria, and, if the temperature be high, there mav be drowsiness, partial coma or delirium, etc. Intermittent deafness, blindness, vomiting, diarrhoea, and asthma are all symptoms which may at times pre- dominate or which may precede a typical paroxysm. " Latent intermittent fever" is a name given to a condition among certain persons living in malarious regions. There are no definite paroxysms, but the condition is best described by the term " bilious." There are anorexia, vomit- ing, headache, constipation, weakness, and lassitude. Sometimes there is a very slight periodic elevation of temperature. Such persons at any time are liable to be seized with a veritable paroxysm. " Mofiked malarial fever''' is a variety of intermittent ague which is commonly neuralgic. The ordinary malarial paroxysm is replaced by violent neuralgic pain, lasting from half an hour to six or eight hours, and recurring, like the true paroxysms, at regular intervals. Tliese attacks are usually unaccom- panied by fever, which makes the diagnosis still more diilicult. The nerves most often affected are the supraorbital or infraorbital branch of the trigem- inus. Other branches of that nerve may be affected, or the sciatic, the nerves of the brachial ))lexus, or intercostals. In cliildren there is sometimes bron- chial catarrh. The term " masked ague" may also refer to nudarial fevers in which other disorders having pronounced symptoms occiu', such as ])ueuinonia, dysentery, etc., and which by their greater intensity obscure the original ague. Course. — Simple intermittent fever runs a mild course, and the number of Vol. I.— 27 418 MALARIAL FEVERS. paroxvsms may be cut short at any time by treatment, by removal of the patient, or by change of season. If left to itself, the disease may run on for several weeks or months, and in a bad malarial region at any time it may sud- denly be converted into one of the severe types of ague. Quartan fevers are often more obstinate than either quotidian or tertian. Relapses are very frequent in all forms of ague, and they may undoubtedly occur without fresh exposure to the miasm, as may be the case with sailors at sea. It is a curious feature of such relapses that they often occur on the day on which there would naturally be a paroxysm had the disease been uninter- rupted. A relapse at periods of two, three, or seven weeks is sometimes noted, or the interval may be very mnch longer. It is said that in such cases there may be modifications in the urine with increase in urea corresponding to latent paroxysms. While there is any elevation of temperature indicated by the thermometer there is very likely to be a relapse, or if the spleen remains enlarged relapses are apt to occur. Sometimes the spleen becomes periodically enlarged, reaching even to the umbilicus. This enlargement is accompanied by local pain and tenderness, and severe vomiting, while the chill and fever may be entirely absent. Between the attacks the engorged spleen returns to nearly normal size. Terminations. — The majority of mild cases of malarial fever recover by themselves, but the recovery is greatly accelerated by apjjropriate treatment. Severe cases become more or less chronic, and repeated attacks develop the malarial cachexia. Even the graver forms of malarial fevers, such as the bil- ious or haemorrhagic types of remittent fever, are frequently amenable to treat- ment if seen early and if treated very promptly. Otherwise they may prove fatal from various causes. One attack of malarial fever affords no immunity, but, on the contrary, it is apt to predispose the subject to others. Secondary attacks may occur within a few weeks or after an interval of years. The number of individual paroxysms that the same person may have at varying intervals while in a badly- infected district is sometimes extraordinary. Parke ^ states that among the Europeans who crossed the continent of Africa on the Einin Pasha Relief Expedition the average number of separate attacks was one hundred and fifty for each man in a period of three years, during which time they marched five thousand miles. Diagnosis. — The diagnosis of malarial fevers is easy when the attack is simple and typical, and Avhen the patient can furnish a clear history of exposure or of previous attacks. It is far more common to mistake other diseases for ague than to err in the opposite manner. Simple intermittent fever is readily distinguished from remittent fever by the use of the thermometer, which in the latter demonstrates a continuance of the fever in the interval between two paroxysms. There are usually other symptoms besides the temperature that persist during the interval in remittent fever. * My Personal Experiences in Equatorial Africa, p. 483. INTERMITTENT FEVER. 419 In all doubtful cases the presence of an enlarged spleen and the effect of a large dose of qumine will aid the diagnosis. The quinine can scarcely ever be harmful, and its prompt employment often serves to clear away very obscure symptoms. Moreover, the blood should always be examined for the malarial plasuio- dium. This is easily done by pricking the thoroughly cleansed finger and drawing a minute drop of blood, which is to be flattened out into a very thin layer by pressing it between a cover-glass and a microscope slide until the corpuscles are only one layer deep. The slide is then placed under a high- power lens [^ oil-immersion), when the germs, if present, may be detected by careful search. Osier says that the crescentic forms may be detected with a lower power, such as an |^-inch objective. The sudden occurrence of a severe chill and rigors lastiug three-quarters of an hour, followed by a sharp, brief fever, the temperature reaching 105° or more within a few hours, is very suggestive of malarial fever. In but few other affections attended by an initial chill is the latter so protracted and severe. It is exceptional in any other disease for the temperature to reach such an elevation so suddenly and to promptly subside again to the normal. Pneumonia may be ushered in by a severe chill and rapid rise of tempera- ture, but the subsequent course of the disease, the development of physical signs in the chest, the sputum, and the continuance of the fever will soon con- firm a doubtful diagnosis. Deep-seated suppuration, producing sudden general septic infection, may be mistaken for malarial fever. In such cases a searching physical examina- tion, with a careful history of the case, the absence of splenic enlargement, and the lack of regularity in the recurrence of chills, fever, and perspiration, will aid in eliminating malarial fever from the diagnosis. Pulmonary phthisis is occasionally mistaken for ague when there is sup- puration with recurring chill, hectic fever, and perspiration. In such cases the correct diagnosis can be made upon a thorough physical examination of the chest, the detection of tubercle bacilli in the sputum, the normal spleen, and the negative effect of quinine upon the hectic. Catheterization, or the passage of a sound, occasionally produces a paroxysm resembling that of ague. Prognosis. — The prognosis of uncomplicated intermittent fever is most favorable for speedy recovery under proper treatment, but it should always be remembered that in a region where malignant types of the disease sometimes- occur a simj)le unchecked intermittent fever may rapidly merge into a most j)ernicious form M'ith fatal issue. Prophylaxis. — To some extent malarial fevers may be restricted by drain- ing and filling in marshes and improving the general sanitary condition of a locality. * Favorable influence has been attributed to the eucalyptus tree (Eitcnlyptus; fflohulus) planted along the edge of marshes. These trees grow rapidly and absorb a considerable amount of moisture, thereby drying the marsh ; and 420 MALARIAL FEVERS. c]osely-j)lanted trees, like high fences, prevent the dissemination of the heavy malarial poison in the atmosphere to a very limited degree. Experiments on a large scale, as made by the French in Africa and the Italians near Rome, have, however, failed to demonstrate any special preventive influence from the eucalyptus. Proper attention to the general health is important. Many persons living ill a uialarial region who have had the fever find that when they allow them- selves to become constipated for two or three days they are apt to precipitate an attack of the ague. Excesses in eating or drinking, mental strain, ov^er-fatigue, and exposure should be strenuously avoided. Persons are far more liable to acquire malarial fever if exposed to the miasm while fasting than after eating. Persons living on the upper floors of buildings in a malarial region are less likely to have ague than those who occupy the ground-floor or basement. The susceptibility to the miasm is greater after sunset, at night, and in the early morning than in broad day. Sleeping out of doors should be especially avoided. By proper attention to these facts many persons can avoid exposure while residing in an infected locality. Those who are obliged to live in malarial regions do well to take quinine in daily moderate doses — three or four grains twice a day — and arsenic is also of value as a prophylactic. Fowler's solution, in doses of four to six minims well diluted, nray be taken three times a day after meals. The quinine should be taken only in the season w^hen ague is active, for, if too long continued, the system after a time becomes accustomed to it, and very large doses are required to obtain any effect in an emergency. Care should be exercised to maintain the general health by proper regula- tion of the diet, bathing, clothing, exercise, etc., and it is important to av^oid constipation. Treatment. — The chief indications for treatment are to prevent the return of the paroxysm, to restore the blood to a normal condition, and to re-estab- lish the functions of the congested viscera. The urgency with which ti'eatment must be employed in the various malarial fevers will depend upon the severity of the case. Fortunately, in the salts of quinine we possess a specific for malarial fever, and in very mild cases of intermittent fever no treatment is required beyond a few grains of that remedy. In severer agues, however, prompt and energetic action is imperative in order to save life, for it may result in the rescue of appar- ently moribund cases of the worst forms of pernicious malarial fever. Trcabaent of the Chill. — When a paroxysm of ague is expected, the patient should go to bed and keep warm. As the chill approaches a diffusible stimu- lant, such as aromatic spirits of ammonia, with fifteen or twenty drops of chloroform, may be given with some simple hot drink. Hot-water bottles should be placed at the feet. Warm blankets are needed. An opiate, such as Dover's powder, is often beneficial. This treatment is sometimes successful in aborting the chill, and it may lessen the severity of the entire paroxysm. INTi:h'JfITTEXT FEVER. 421 Treatment of the Fevei\ — In the hot stage the covering should be lessened and the patient may be sponged with cold alcohol and water in equal parts. Cooling draughts of carbonic-acid water, Vichy, or lemonade may be given. Except for the administration of quinine, described below, the temperature rarely requires any more active treatment, as its duration is brief in any event. During the sweating stage the patient is made more comfortable by having the perspiration wiped away with warm cloths as fast as it forms. The Administration of Quinine in Malarial Fevers. — The dos- age and metiiod of administering quinine must vary somewhat with the con- dition of the patient, the severity of the attack, and the quantity which the patient may be accustomed to take. Some persons are put in a state of most uncomfortable cinchonism bv a dose of five grains, while others are not dis- agreeably affected by thirty. Small doses of quinine are often efficacious in those persons in whom cin- chonism is readily produced, whereas larger doses are commonly needed by those in whom toleration is much greater. In very mild cases five or ten grains given some ho'urs before a paroxysm will avert it, but in the severer types forty, fifty, and in very malignant types even one hundred, grains must be given within a few hours. Quinine acts most promptly when administered iu solution, but the taste is so bitter, lingering, and difficult to disguise, often causing vomiting, that it is generally preferable to give the drug in powder, in a wafer, in black coffee, or in a soft gelatin capsule. Pills are apt to become hard and insoluble. AVhen not given in solution quinine is rendered more soluble and assimilable by prescribing ten or fifteen minims of dilute hydrochloric acid to follow each dose. Young children refuse the bitter solutions of quinine, and they cannot swallow pills or capsules : in such cases the drug may be given in solution or suppository by the rectum, or it may he rubbed into the abdom- inal wall as an oleate or ointment. In this way the constitutional eilects are usually obtainable. Some clinicians give quinine at stated intervals without regard to the par- oxvsms, aimins: merely to a(bninister a certain dose within twenty-four hours ; and in very mild cases this will accomplish the desired result, but in the majority of instances it is better to prescribe one or two large doses, carefully timed to meet the paroxysm, .so that one dose shall not be eliminated before the next exerts its influence. Thirty to forty grains given four to five houi-s before the paroxysm in a very severe case will accomplish far more than if the same amoiuit be distributed throughout the day, for it is quickly eliminated from the system. It is sometimes desirable to precede the quinine by a purgative dose of calomel, for the bowels are apt to be constipated, the tongue coated, and the patient more or less "bilious;" but it is not advisable ever to delay the administration of the quinine on this account. In severe cases of the ]ier- nicious fi)rm it is higldy injurious t(t weaken the patient by purgation, and it 422 MALARIAL FEVERS. is a mistake to drive the quinine out of the alimentary canal by calomel before it has had time for complete absorption. It is of no use whatever to give quinine during a paroxysm of simple intermittent fever, for it requires so long a time for its complete influence upon the system to be established that tlie paroxysm is over before it can be absorbed. In fact, it is very often vomited when taken during the seizure. It is from four to six hours after the administration of quinine before its maxi- mum effect is attained. In quotidian fever quinine should be given eight hours before the expected chill, because the real onset is two hours before the chill. In tertiary fever it should be given twelve hours before, and in quartan fever fifteen or eighteen hours before, and repeated. A fifteen-grain dose of quinine given only two hours before or given during a paroxysm does not affect it, but given at the close of one paroxysm it aborts the next paroxysm either wholly or in part. It may have to be continued in this manner for four or five days before the fever entirely ceases, and quinine should be taken in smaller doses for a week or two thereafter. The effect of quinine in intermittent fever is to prevent a second paroxysm only in a certain number of milder cases. In other cases it either postpones the next paroxysm, or, without postponing it, renders it much milder than it presumably would have been, causing the chill to be abbreviated or omitted. A third paroxysm is usually prevented by the quinine. Many believe that o[)ium acts as an adjuvant to quinine in controlling malarial paroxysms. Schauffler recommends the bromide of potassium in doses of forty to eighty grains to relieve cinclionism and quiet the nerves. In certain patients quinine possesses but little influence over the fever. This may be due to some idiosyncrasy or to the fact that the system from long-continued use of the remedy has become inured to it. Warburg's tinc- ture and arsenic may then be of service. The former is a compound remedy which has been long used in India and elsewhere. Besides preparations of cinchona, the original formula contained chiefly aloes, rhubarb, opium, and camphor. A modified Warburg's tincture is prepared by omitting the aloes and some of the minor ingredients. This remedy has a very disagreeable taste, and, since the dose is f^ss in water, it is apt to prove nauseating. It may be given by the rectum, where it is usually well borne, or in pill form after evaporation, but the latter method is not so efficacious. Warburg's tinc- ture sometimes succeeds in breaking up obstinate malarial fevers when quinine has failed. It is of more use in the severer forms of ague than in simple intermittent fever, and quinine may be given in combination with it. Besides controlling the fever, it has to some extent a sudorific action. Arsenic is administered as arsenious acid, one-thirtieth of a grain thrice daily, in pill or in the form of Fowler's solution, liquor potassii arsenitis, four to six minims thrice daily, after meals, w^ell diluted. It is often useful to combine this drug with iron on account of the anaemia, which is more or less marked. Neither Warburg's tincture nor arsenic have any effect upon a paroxysm already begun. REMITTENT MALARIAL FEVER. 423 Many attempts have been made to find substitutes for quinine for use in those cases in whicli it is not well tolerated. Other jM-eparations of cinchona, such as quinidina, chinoidina, cinchonidina, have all been used. Salicin in doses of a drachm in twenty-four hours, strychnine and nux vomica, ammo- nium chloride and eucalyptol, with a long list of other remedies, have been faithfully tested for antiperiodic action, but none of them can really replace quinine. n. Remittent Malarial Fever. This fever, from the prominence of the gastro-intestinal symptoms, is often called bilious remittent fever or gastric fever. This type of ague is charac- terized by the same symptoms that occur in intermittent fever, but the tem- perature continues elevated through the interval. It is supposed to be due to a greater intensity of action or of concentration of the miasm, or to a greater .susccjitibility on the part of the patient. Morbid Anatomy. — In fatal cases of remittent fever the characteristic lesions are a deep pigmentation of the spleen, liver, and brain, and the ])res- ence in the blood of free altered blood-pigment — a condition known as melan- semia. Organs having deposits of such pigment are said to be in a state of melanosis. The pigment occurs in granules. It is found in remittent fever, in ])ernicious malarial fevers, and occasionally in protracted intermittent fever and malarial cachexia. The pigment in melana^mia forms Prussian blue when tested with the ferrocyanide of potassium ; hence the iron which it contains does not all exist as an organic compound. The extent of discoloration of the different organs affected varies with time. In recent cases they are slightly darker than normal, but in protracted cases they are deejjly bronzed or of a grayish or bluish-black color. The spleen is at first hyperfemic, soft, and swollen, but as the paroxysms return it fails to contract in the interval, and it gradually becomes perma- nently hypertrophied and firm, instead of remaining soft. There is hyper- plasia of the connective-tissue elements of the organ. The pigment is found deposited within the lymphoid splenic cells in granular masses. It is also found around and in the walls of the veins. The liver is enlarged, but in old cases it may be atrophic (Flint). It is often hyperaemic, and is strongly pigmented. It is commonly called the "bronze liver." Pigment is found in granular masses both in and between the lobides, in the vessels, and vessel-walls. The marrow of the long bones is similarly pigmented. The granules are foinid in the lymphoid cells, around and within the blood-vessels. The gray matter of the brain is dark gray or almost black. In severe cases the white matter is also pigmented, and it exhibits minute luemorrhages, which arc thought to be produced by emboli oC small masses of j)igment which enter the ca|)inaries and occlude them. Jn tlic brain, as elsewhere, the j)igment is foimd in the walls and outside of the blood-vessels. 424 MALARIAL FEVERS. Other vascular organs, such as the pancreas, thyroid gland, kidneys, the mucous membranes, lymphatic glands, and the skin, are more or less pig- mented. There may be ecchymoses in the mucous membranes of the ali- mentary canal. Symptomatology. — This variety of fever is apt to begin with a more pro- nounced paroxysm than occurs in intermittent fever, although the cold stage may be more brief. Sometimes, however, there are prodromata, such as may precede any febrile disease, or there may first be one or two mild intermit- tent paroxysms. When \\\e paroxysm commences there is a good deal of nausea and eraesis, which continue. Often large quantities of bile are vomited. There are ten- derness over the epigastrium and splenic area and loose watery diarrhoea. Not infrequently there is jaundice. The temperature is high, often rising to 106° F. or higher. The second stage of febrile exacerbation often lasts for a Ionu:er period than in intermittent fever, and it may not subside before twelve or even twenty-four hours. (See Fig. 27.) In milder cases the temperature falls in Fig. 27. r lOo 102= 101= 100= 99= 98= 97= 3-09 = ^37° —36= — ■1 ■ 1 "^ A \ I \ A i\ i\ ; \ /\ n \ A ' \ A A — \\ /\ ' ' / /\ /\ ^ / \ \ ' \ / / 1/ ' , J \/ A \/ V \ \ \/ Y A /\ V \, 1 \ \ V \ , / / I \ \ ' ' A A '\ /\ \/ ^ — 2""' A — -- V lA ' * , A L^ , J ^yf \ ■■■■1 — 1 Y Y \ (■ 1 1 DayofBLr. 7VtT.»e Jietp. 1 v^ <>^ >> to ^o K ^^ <=N ^ ^ ^ ^ ^ ^ ^ ^ > ^ .--'■ .-•■■ ..--■' .,-•■■ ..--■■' -' ,.'-■ ..--■'■ ^y .-■-■■ ,-'' ..'■' ..'-■ .,-'-' .--'' ..-'' JJ,U e. 'leiiipL'rature-fhiirt of ii ratieiit with Keiiiittf iit Fuver. » throe hours. This is followed by a sweating stage of moderate degree, and the fever continues at 101° to 103° F. until the next paroxysm. In the sec- ond paroxysm the chill is frequently omitted. During the interval, besides the increased temperature there may be nausea, lassitude, and muscular soreness. The frequency of the paroxysms PERNICIOUS INTERMITTENT FEVER. 425 may correspond to any type, quotidian, tertian, etc. After about a week of severe fever the pyrexia gradually subsides, and in another week or two it dis- appears and the patient recovers. The fever may subside by becoming con- tinuous and slowly decreasing, or it is not uncommon for it to pass into a dis- tinct intermittent type and end in that manner. The remission usually com- mences between juidnight and the early morning. Occasionally the disease ends by crisis. Duration. — The duration of the disease can be curtailed by treatment. It may last anywhere from three or four days to three weeks, or it is still further protracted, and the patient may pass into the typhoid state. As a rule, remit- tent fever is more grave than intermittent ague. Complications. — Remittent fever may occur in connection with many other diseases or be complicated by them. Among the more frequent compli- cations are to be mentioned acute nephritis, dysentery, and lobar pneumonia. Diagnosis. — Remittent fever is liable to be confounded with typhoid fever and with certain eases of yellow fever occurring at the commencement of an epidemic. Since this is also true of the pernicious type of ague, the diagnosis will be considered in connection with that disease. {Vide infra.) Prognosis. — The prognosis for simple remittent fever is favorable. In this type of malarial fever there is more danger than in intermittent fever of sequelae, such as extreme anaemia, " ague cake," and dropsy. The disease is much more severe in hot climates than in temperate regions. Treatment. — The treatment involves the early production of cinchonism, as in the intermittent type. Large doses of quinine, twenty to thirty grains, should be given every three or four hours until there are ringing in the ears and throbbing of the temples. It is not necessary to await the termination of the paroxysm, but the quinine should be begun at once, for it is the prolonged hot stage which especially demands attention. As a rule, severe purgation or any depleting measures should be avoided. In certain cases, however, when the bowels are very constipated, the tongue thickly coated, and the urine diminished and overloaded with solids, a dose of calomel or of blue mass is indicated. Care must be taken not to hurry off the quinine by ])urgation ; and, if the (juinine has just been given, the bowels can be moved by a stimu- lating enema of half an ounce of tur})entine and an ounce of castor oil in a pint of warm soaj)Suds. If, on the other hand, severe diarrhoea or depressing emesis exist, such symptoms should be controlled by an opiate, and poultices or hot turpentine stupes placed upon the abdomen. Wiien the kidneys are congested, mi], and conges- tive intermittent fever or congestive chills. As the name implies, it is a very 426 MALARIAL FEVERS. severe type of ague. In the late Civil War in the United States this type of fever constitnted nearly 24 per cent, of the mortality from disease. It is a relativelv uncommon form of malarial fever, but it aj)pears from time to time in tropical countries, and in the United States in the South and West. The disease may commence in a malignant manner and he fatal at once, or it may be ushered in by one or more paroxysms of ordinary severity. When one })aroxysm grows very severe, the following one is frequently fatal. The pernicious tvpe soon becomes manifest through one or more of the following features : deepening coma, delirium, violent vomiting and purging with blood and mucus in the stools, intense weakness, hsematuria with hgemorrhage from various mucous surfaces, and collapse. The prominence of certain of these symptoms in pernicious malarial fever makes it convenient to subdivide the disease into several varieties, which will be briefly described under the following heads : I. Bilious intermittent fever, in which the gastro-intestinal irritation with vomiting of bile is the most striking symjjtom ; II. The hsematuric or hsemorrhagic variety, with bloody urine and hsem- orrhages from muccKis surfaces ; III. The asthenic form, with great prostration and feeble circulation ; IV. The algid form, resembling the algid stage of Asiatic cholera ; V. The comatose variety, with sudden and profound unconsciousness. Symptomatology. — I. Bilious Intermittent Fever may attack the ]>atient very suddenly, the first symptom being a severe chill and vomiting, or it may be preceded by dyspeptic symptoms, constipation, flatulence, a coated tongue, and offensive breath, with muscular pains. In patients who have had several attacks, often one of the first symptoms noticed is an extreme irrita- bility of temper with great mental and bodily restlessness. There is frontal headache, the muscular pains increase, and the entire body aches. The pains are mostly in the loins and knees, and sometimes they begin quite suddenly, as though the muscles had been pounded. These pains are occasionally so severe as to require morphine for their relief. There are often cramps in the muscles of the calves. The pulse is rapid and the heart-action irritable. Pallor is succeeded by congestion of the face and injection of the eyes, which acquire a typical staring, glistening appearance. The temperature rises to 105° or 106.5° F., or even higher. The vomiting begins early and continues. Large quan- tities of bile may be ejected. Pressure over the stomach and liver is painful. The prostration is very great and there is rapid emaciation. In severe cases there is a sense of fulness or constriction in the chest, and neuralgic pains may be felt in the larger nerves, as the sciatic, median, or anterior crural. The spleen becomes greatly enlarged, and the splenic region mav be more or less tender. There are increasing anfemia, and decided consti- pation from lack of power in the muscular coat of the intestine. The urine becomes dark, of high specific gravity, is loaded with urates and phosphates, and may contain blood or bile-pigment. In some cases rapidly-deepening jaundice is a prominent symptom, coming on within five or six hours. PERNICIOUS INTERMITTENT FEVER. 427 In certain cases of bilious intermittent fever, as in the simple form, the chill and sweating are absent, the recurrent fever being the main symptom. In other cases the chill and fever are present, but the third stage, that of sweating, is omitted. In an intestinal variety there are frequent diarrhoeal stools, with flatulence, tormina, and abdominal distension and tenderness, especially over the stomach and liver. The stools contain large quantities of mucus, and at times they become so copious and watery as to suggest choleraic discharges, or they con- tain blood and mucus, as in dysentery. II. The H.ematuric Type. — The haematuric or hemorrhagic form is always very serious. The paroxysm commences with a prolonged chill and rigors, and the temperature rises rapidly. In the second stage blood-disks and blood-pigment appear in the urine, which is diminished in quantity and contains more or less albumin with granular and bloody casts. The patient a})pears very ill and is restless and anxious. Soon a condition of general pur- j)ura develops : there are ecchymoses into the skin, and there are epistaxis, haemorrhage from the mouth, stomach, rectum, or vagina. The skin becomes more and more yellow, or even of a bronze hue. Suppression of urine is apt to occur, and then the toxic condition of uraemia is added to the existing blood-poisoning. The emesis continues : there are violent headache, delirium, and finally deepening coma, with Cheyne-Stokes respiration, a rapidly failing heart-action, pulmonary oedema, and death. These haemorrhagic symptoms may occur in either pernicious intermittent or remittent fever. In less severe cases the mind remains clear throughout. When delirium or coma ensues the case becomes very critical. Death is not caused by excessive haemorrhage, but by toxaemia or asthenia. There is intense congestion of viscera, and the haemorrhages are believed to be occasioned by a combination of altered blood- composition, impaired nutrition of the capillary walls, and changes in the local vascular pressure in the various congested organs (Bemiss). The hem- orrhages usually bear a direct relation to the intensity of the chill, which favors internal congestion. III. The Asthenic Type, — In this variety there are irregular neu- rotic svmptoms, restlessness, and great weakness. The (;irculation becomes extremely feeble and the cardiac sounds are scarcely audible. The pulse is reduced to a mere thread and is intermittent. In other cases exhausting ))erspiration is a very prominent feature, which continues into the remis- sion. IV. The Algid Type. — The algid form of pernicious malarial fever sug- gests the algid stage of cholera, and is very fatal. There arc the same prostra- ticm and collaj)sc, with cold extremities, cramps, cyanosis, dilated pupils, feeble, husky voice, shallow resj)irati()M, vomiting, pm-ging, and great thirst. There are often very profuse ])ersi)irati(Mi ami ollrnsivc (luid alviiH> evacua- tions. The ])iil^c is very feeble and invn-nlar. The internal temperature is very high. The intellect remains clear. In some cases the disease resembles yelhiw fever, niul there are profound 428 MA LABIA L FEVERS. jiiuiulice, serious neurotic symptoms, and severe emesis. The brain and cord are usually found ansemic, dry, and firm (Hertz). V. The Comatose Type. — The comatose variety is rare, excepting in hot climates and where the miasm is greatly concentrated. The patient is early overwhelmed with profound coma, from which it is impossible to arouse him.. He may die suddenly in collapse. The coma is not necessarily due to cerebral congestion (Bemiss), although the brain and meninges may both be congested, but to general toxsemia. The surface of the body is hot ; there are elevated temperature and pulse-rate ; and stertorous breathing and jaun- dice may be present. This variety of pernicious fever develops especially in |)ersons who reside in regions where ague abounds, and who have neglected proper treatment in repeated attacks. It may be associated with one of the other graver forms. In the United States the congestive varieties of pernicious ague are much more common than the comatose. Should the patient survive the first attack of coma, the second is usually fatal, but third attacks sometimes occur. In some cases, instead of coma, there is sudden, violent delirium, with cephalalgia, congestion of the face, staring eyes, and great excitement. At the autopsy there are found more or less hypersemia and oedema of the brain. Complications. — Complications of infrequent occurrence, but which have been from time to time noted in connection with the pernicious types of malarial fevers, are hemianopsia, transient amblyopia, optic neuritis, and haemorrhages (Sulzer), muscular contractures and choreic or ataxic movements, convulsions (in children), local anaesthesia, transient cortical paralyses, such as aphasia with hemiplegia, spinal congestion, etc. It has been suggested, although there is as yet no proof, that some of the neurotic symptoms and lesions may be due to embolic plugging of small arterioles by the plasmodium or by pigment-granules. In a case of per- nicious malarial fever with bulbar paralysis Marchiafava found the plasmo- dium in the nuclei of the facial and hypoglossal nerves, with necrosis of their cells. Periodical delirium has exceptionally been noted. In some patients there is a decided tendency to syncope, while others pass into a condition of "sus- pended animation," in which the radial pulse and respiratory movements almost disappear, and the cardiac sounds are so inaudible that the patient seems almost dead. Asthma sometimes occurs, or there may be severe and sudden localized pulmonary congestion, with signs of consolidation, and sometimes rusty spu- tum and dyspnoea resembling pneumonia, but disappearing under the use of quinine. Sequelae. — Repeated attacks of the severer forms of malarial fever leave the patient in a weakened and very irritable condition. There may be paral- ysis, dropsy, extreme anaemia, or the malarial cachexia. {Vide infra.) Diag-nosis. — The different varieties of pernicious malarial fever at times resemble the following diseases, froni which they are to be diagnosed : typhoid PEliXICIOUS INTERMITTENT FEVER. 429 fever; yellow fever; cholera; ulcerative endocarditis; pysemia and septicfemia; urtemia and meningitis. Typhoid Fever. — Simple remittent and j)ernicious malarial fever are dis- tinguished from typhoid fever by the absence of the rose-colored rash, epistaxis, tympanites, and pea-soup evacuations which so frequently occur in the latter disease. Moreover, in typhoid fever the invasion is slower, and usually with- out distinct chill ; the fever is more continuously high after reaching a maxi- mum than in remittent fever; and the delirium, carj)hal()gia, subsultus, and other neurotic or ataxic symptoms tire more pronounced. The tongue in typhoid fever is red and small at first, afterward brown and dry. In malarial fevers it is large and more heavily coated. In severe malarial fevers there is often a history of one or more previous paroxysms and of exposure to infec- tion, and the gastric symptoms are more pronounced at the onset. There is also a tendency to become jaundiced which is absent in typhoid fever, and the skin is sallow at the commencement of the disease. The symjUoms of gastric irritation appear earlier, and are more pronounced, than in typhoid fever. The face during the j)aroxysm is more flushed, the eyes are congested, and the ex- pression is more animated than in typhoid fever. The detection of typhoid bacilli in the stools would render the diagnosis cer- tain, but their demonstration is difficult. Yellow Fever. — In remittent fever typical black vomit never occurs, as it may in yellow fever ; the pulse is more firm ; the temj)eratui'G is higher ; and the influence of quinine and the subsequent course of the disease are to be noted. The icteric foi'm of pernicious ague affects those who have been long resident in an ague district, but yellow fever selects particularly the recent arrivals. The jaundice appears later in the course of yellow fever. In per- nicious ague free pigment should be sought in the blood. Yellow fever is apt to be more quickly fatal. Cholera. — The algid form of pernicious ague is to be distinguished from <'holera by the free pigment in the blood, and tlie fact that the copious watery evacuations are often ])receded by bloody stools, which is not the case in cholera. In cholera there is the presence of an epidemic and the history of infection. Ulcerative Endocarditis and Pyaemia. — Remittent and pernicious malarial fever may resemble acute ulcerative endocarditis or pyjcmia and septicaemia. In the former the physical examination of the heart and the presence of embolic infarctions will aid in establishing the diagnosis, and in the latter the diagnosis can be made by the exclusion of a source of septic infection and by the greater regularity of the paroxysms occiu'ring in pernicious fever. Uraemia and Mrninr/ifis. — The comatose form of pernicious fever nnist be distinguished from uraM)iia and meningitis. The presence of free pigment- granules in the blood and tiie enlarged sj)leeu are to be noted, with a history of ])rcvious malarial jiaroxysms. In meningitis the case is of longer duration before coma aj)j)ears ; it is ])rece(led by |tliotophobia and delirium, and the temperature is lower than in comatose ague. 430 MALARIAL FEVERS. Mortality. — In the rural parts of the Southern Atlantic States the num- ber of fatal oases of malarial fevers is 70.6 in every 1000 deaths. In cities the number is 11.5 (Johnston). Treatment. — The treatment of pernicious malarial fevers demands the utmost care and promptness. Quinine must be given at once by hypodermic injection in doses of fifteen grains in distilled water, using a soluble salt, such as the tannate, hydrochlorate, or hydrobromate, combined with a grain of sodium chloride (Bocelli). The sulphate and bisulphate, which are the preparations most frequently employed when quinine is given by the mouth, are not adapted for hypodermic use on account of the difficulty of dissolving them in a small bulk of water without the use of acids, and the consequent liabil- ity to abscesses at the site of injection. Free stimulation by the mouth, rec- tum, or subcutaneously must be employed. Everything depends upon tid- ing the patient over a present paroxysm and preventing the recurrence of o. second, which is so apt to be fatal. The patient must be kept absolutely quiet. Opium in full doses, given early, is often serviceable. Morphine and atropine may be given with whiskey or brandy, and diffusible heart stimulants, such as chloroform or ammonia, are required when there is any evidence of enfeebled circulation. Hypodermic injections of strychnine are also service- able. Warm alcoholic stimulants should be given by the rectum. Hot bottles should be applied to the surface for the collapse, while vigor- ous rectal and Ivypodermic stimulation is maintained. By stimulating and nourishing such cases even the worst of them are rendered not necessarily fatal, and everything depends upon careful attention to all the details of the treatment. In the violently congestive type, with delirium and a full pulse, venesection has been employed ; but it is of doubtful efficacy, for the patient is soon in greater need of stimulation than depletion. Saline laxatives, cold sponging, cold applications to the head, and sedatives, especially opium, are indicated for this type of fever. Vomiting and purging must be controlled by opium. Warburg's tincture may be given in the intermission or remission, but cinchonism must be steadily maintained. Patients have become both blind and deaf under the excessive use of quinine in these cases, but fortunately such results are almost invari- ably temporary accidents, and the patient's life depends upon the prevention of another paroxysm through the agency of this invaluable specific. In the haemorrhagic form the vomiting may be controlled by morphine, and very mild diuretics and diaphoretics are serviceable. Ergot and turpen- tine have been given with the idea of checking the haemorrhages, but such remedies are of very doubtful efficacy. With signs of improvement the patient's strength must be supported by a nourishing and concentrated fluid diet and nutrient enemata. Beef juice, beef peptonoids, egg-albumin in sherry, and milk should be given in small quantities repeated every hour or two. As convalescence advances, tonics, such as simple bitters, iron, quinine, and hypophosphites, will be required to build up the impoverished blood and restore the greatly reduced system. PEBXICIOT'S REMITTENT.— TYPHO-MALARIAL. 431 IV. Pernicious Remittent Fever. This type corre.sponds .so nearly with perniciou.s intermittent fever, except- ing in regard to the temperature-curve, that a separate description is super- fluous. The fever is sometimes called African fever, jungle fever, etc. None of the .severe types of ague correspond as closely in regard to the time and duration of the paroxysms as do the simple forms of paludal fever, and it is therefore less easy to separate them with distinctness. When death occurs early in the disease it is difficult to ascertain whether the type were intermittent or remittent. V. Typho-malarial Fever. The name typho-malarial fever must not imply a specific disease, but rather a combination or coexi.stence of the two diseases, typhoid fever and malarial fever, in the same individual. It is at best a misleading term, and ought to be abandoned. Nevertheless, the name has entered medical literature exten- sively, and it is still in common use in a large .section of this country. Typho-malarial fever should not be confounded with the '' typhoid condi- tion " which may supervene in protracted and severe remittent fever. Etiology. — Typho-malarial fever may occur in malarious regions where men are crowded in camps or prisons under bad hygienic conditions and with a water-supply contaminated with sewage. For this reason it is sometimes called " camp fever." In the United States this fever occurs chiefly in the autumn and in the Southern Atlantic and Gulf States. To produce the fever there mu.st be a double infection with the typhoid bacillus and the malarial Plasmodium. Unfortunately, positive evidence that these two germs can co- exist in the same individual has not yet been obtained, since the natural his- tory of both germs has been studied for only a brief cfecade. Autopsies, too, are infrequent, for many of the patients recover, and hence the description of the double disea.se is based solely upon clinical features. In 1888, Johnston' published an exhaustive paper containing researches on the question of the separate existence of a tyi)h()-malarial fever. The paper was ba.sed upon answers received from three hundred and fifty physicians living along the Atlantic and Gulf coa.sts of the United States and in other malarial regions, and their belief was about evenly divided as to the existence and non-existence of the disease in question as an inde})endent fever. Accumulating evidence is very convincing that the majority of cases reportod as typho-malarial fever arc simply modified or irregular forms of ty|)hoid fever, without any malarial admixture. Whatever view is taken, however, of the etiology of .so-called typho-malarial fever, it is an imdoubted fart that in a malarious region a number of cases occur from time to time which present, from a clinical standpoint, the features of both di.seases in combination. These .symptoms are as follows : Symptomatology. — Theon.set is often more abrupt than in typhoid fever. There are one or more .severe chills, and the temi)erature ri.. Etiology. — Predisposing causes are privation, famine, debauchery, fatigue, debilitating diseases, alcoholism, mental distress, eating decom])osing meat or spoiled fruit, drinking unwholesome water. These are merely the common causes which favor the spread of any infectious or contagious disease, and beyond this ftict they have no s})ecial influence upon the spread of cholera, except in the case of unwholesome food and water, which, in addition to dis- ordering the digestion, may convey the cholera germs. Cholera has never been known to spread more rapidly than the ordinary rate of human travel by land or sea, and it is essentially a disease of densely populated districts. It advances along the seacoast from town to town, fol- lows the lines of traffic by land and along great rivers, and lingers in crowded cities and encampments. The infectious principle is conveyed by ships, in foul water, soiled clothing, filth of any kind, vehicles, baggage, etc. It has been carried by a box of clothing from Euroi)e to the Mississippi Valley. It is possible that flies serve as carriers of some of the contagion, and it is there- fore well to protect food from them and to keep them from access to excrement. Climate and Hea-son.— It is now generally believed that cholera is not ]>rop- agated through the atmosphere, but to aid its extension the locality and season must be favorable, for alterations in its intensity are eflected by certain meteor- ological changes. Its spread is not affected, however, by prevailing winds, as it would be if the germ were l)onie through the atmosphere. Cholera has been known to occur in all climates exeepfing the arctic, and 436 CHOLERA. at all seasons, but as a rule its progress is arrested completely by cold, while a warm, moist season favors it. In a given locality an epidemic may cease with the onset of winter, only to be revived in the spring. Age and Sex. — The disease is of commonest oectn-rence between twenty- five and fifty years of age. It may occur in childhood, and it is rare in old age. Cholera attacks males somewhat more frequently than females. Jiace. — In India, Hindus and Mohammedans are more susceptible to cholera than are Europeans, but this is no doubt due in great part to differ- ences in hygienic surroundings rather than to race influence. Social Position. — Cholera is essentially a filth disease, and is therefore com- moner in the lower strata of society, among the very poor and ignorant. Its chief victims are found in the slums and dirty tenements of the over-pop- ulated quarters of large cities. Those who are convalescing from other diseases are liable to be attacked by cholera. Thus at Helonan, near Cairo, in 1883, 9.34 per cent, of such cases were afflicted, but only 2,63 per cent, of the pre- viously healthy were seized (Parke). The agent which causes the disease is capable of very rapid increase, both within the body and apart from it, and it is discharged from the body in the stools. The evacuations of preliminary choleraic diarrhoea, as well as the cha- racteristic serous stools, are highly infectious. The cholera bacillus undoubt- edly enters the system through the medium of contaminated food and drink, especially the latter. The extension of cholera is so far controllable by proper drainage and san- itation that if ideal hygienic measures could be realized, quarantine would be unnecessary and the disease might be almost exterminated. In Calcutta the spread of epidemics has been greatly diminished of late years by a more copious supply of water to the city. Physicians, nurses, and others in attendance upon cholera patients are not especially liable to be attacked by the disease, provided that they are not over- worked and that they take proper precautions. They are, however, by no means exempt, and many cases are recorded where the disease has been trans- mitted by direct contagion. Nurses are more apt to be attacked than physi- cians, because they are constantly with the patients and have to remove the evacuations. When patients, debilitated by other diseases, have been allowed to remain in wards with cholera patients, inhaling the emanations from their evacuations, they liave been frequently attacked by the disease. Those who wash the soiled clothing of cholera patients are often seized, proving that the disease can be conveyed by fomites. It has been communicated through the medium of the mails. The Cholera Bacillus. — Animals were at first thought to be immune to cholera, but recent careful experiments upon dogs and guinea-pigs have proven the contrary, and the disease has been demonstrated in them after inoculation (Pasteur). Koch,' in 1884. was the first to describe a distinct bacillus associated with ' Berliner klinische Wochenschrift, Marcli 31, 1884. ETIOLOGY. 437 cholera. In 1885 he announced that he coiihl reproduce cliolera in guinea- pigs without making the inoculations directly into the intestine. It is believed that, whether inhaled in the mouth or swallowed with food or drink, the germ must always tirst reach the intestine by way of the stomach before becoming active, and that the alkaline intes- tinal contents constitute its most favorable habitat. It is found most abundantly in the !( ,\ T',' i^ /j'' t '-T. '.' ..---tt ileum, on its surface, and within the tubides of the mucous glands. The bacillus which was discovered by Koch in the stools of cholera patients presents the following cha- racteristics : It is from one-half to two-thirds ^ the size of the tubercle bacillus, but thicker and somewhat curved, reseml)hng a crescent, i I'V-'j^'' '^ /'''-* /' ; ''fij comma, or half circle, or a double curve like i J^"" Ji I j \\i'/ ill ' an S. (See Fig. 28). When freshly obtained / '^ j/ 7 /V from the stools the length of the bacillus ^ u ^ « li ^ r^-^ ■, ,v x.s ^ Comma-shaped Bacillus of Cholera (Koch). seldom exceeds 1//, and many are only .5/i long. The germs are frequently aggregated in small groups or arranged in spirals, when they resemble the genus Spirillum. The bacillus grows rapidly in and upon various culture media. It thrives in alkaline nitrogenous media, such as milk, meat juice, or peptone, and it grows well in a slightly alkaline gelatin, which it causes to liquefy. It also grows upon solid substances, such as potatoes, damp dirty linen, and moist earth. A decided acid reaction of the culture medium stops its reproduction ; hence it develops in the intestine, and not in the .stomach. It is destroyed by drying for a short time and by a temperature of 143° F. (Sternberg), but not by freezing to even — 10° C. It exhibits one or two cilia at one end, and is actively motile in the fluids in which it grows. It reproduces by fission with enormous rapidity, and spores have not been identified with it. The bacillus thrives in foul water, especially briny water, and Koch considers the Delta of the GanMS to be its natural home. This bacillus is so constantly associated with cholera stools, and so constantly found in the intestines of those dying of cholera, that it may be regarded as causative as well as pathognomonic of tiie disease. According to Klein and Gibbes, who investigated the cholera in India on behalf of the British government, there are several allied species of the bacil- lus, which difi'cr in their size, mode of growth, and effect on the lower animals. Bacilli which closely resemble the cholera bacillus in appearance have been foiuid ill the saliva and in some healthy stools, and in the al vine discharges of dinrrhfea and dysentery; hence tin; cholera bacillus may be overlooked, for, while it only occurs in Asiatic cholera, it is not |)resent when the stools become normal, or even in the diarrhcca of convalescence. At the latest, it is to be 438 CHOLERA. detected ten davs after the commencement of an attack, and it often disappears by the fourth day of the disease. It is apparently shorter-lived than many bacilli. To facilitate its detection cultures should be made from the stools and frequently repeated in order to keep the germs alive for any length of time. Microscopic examination alone does not establish its identity, but it may be cultivated and inoculated in the lower animals, and through such inoculation, together with its behavior in the various nitrogenous culture media, it is pos- sible to demonstrate that the germ is typical. Since the germ multiplies rap- idly in the intestine (which contains little or no free oxygen), it follows that it is anaerobic ; but it has been proved that immediately after leaving the intes- tine it is more easily destroyed by various agents, such as the acid of the gas- tric juice, than after it has been exposed to the air for some time, when it Ijecomes aerobic. Hence the practical importance of the immediate disinfection of all choleraic discharges as soon as they are voided. As is the case with several other infectious diseases, when a warm, dry sea- son closely follows a very wet one cholera becomes more active and virulent. This is explained by the fact that such conditions promote putrefaction and fermentation and furnish favorable products on which the germs thrive. It needs but the access of a few germs to such a soil to soon contaminate a very extensive area. The facts which support the belief in the bacillus of Koch as the cause of cholera are as follows : I. It is the almost invariable accompaniment of the stage of collapse. II. It is not found apart from the disease, and disappears with it. III. It occurs in the stools and in the small intestine, which is the region particularly affected by the disease. IV. When inoculated in certain of the lower animals it produces symptoms similar to those of cholera, with collapse and death. Since the germs are not found in the tissues generally throughout the body, it seems probable that they produce a poisonous substance, a toxalbumin, or ])tomaine in the intestine, which, on being absorbed, occasions the constitu- tional symptoms of the disease. Similar action has been clearly demonstrated in enteric fever and diphtheria. Ptomaines and toxines have been isolated from cultures of cholera germs, which, injected into animals, cause fever, cramps, diarrhoea, and collapse. Gamaleia and Lowenthal have succeeded in rendering certain animals immune to cholera by the use of attenuated cultures. The following is a summary of the present beliefs in regard to the nature of cholera which have been discussed in the previous. pages ; Tiie disease is due to a specific virus — namely, a germ which enters the body through the alimentary canal and attacks the small intestine, where it develops ptomaines, which on being absorbed into the system produce consti- tutional symptoms. The disease is propagated by fomites and by direct con- tact with the stools. The chief ay-ent for its dissemination is contaminated drinking-water. The contagion multiplies with extreme rapidity both inside MOB BID ANATOMY. 439 and outside of tho body, and it thrives especially in warm, moist putrefactive organic matter. Morbid Anatomy. — The local action of the morbific agent of cholera is chiefly directed against the epithelia and subjacent tissues of the small intes- tine, especially its lower end. The general or constitutional ^esions are not distinctive. They are produced through the influence of poisonous material absorbed from the intestine which chiefly affects the vaso-motor centres and other parts of the nervous system. In an autopsy made half an hour after death in a typical case of cholera Milles noted the following appearances : The small intestine was of a rose-red color, and distended as if paralyzed. It contained a typical clear stool. The mucous membrane was swollen and denuded of its epithelium. The follicles were filled with epithelial detritus and comma bacilli, and their orifices appeared as red spots. Comma bacilli were also discovered in the subepithe- lial tissue, to which they are supposed to penetrate by their own activity. In those cases in which death occurs very early in the course of the disease there are no pathological changes. Rigor mortis appears early, and lasts during a longer period than usual. There may be post-mortem spasmodic muscular twitchings, lasting for two or three hours. In typical cases there is dryness of all the tissues, including the muscles, connective tissues, and skin. As a result, decomposition proceeds very slowly. The serous outpouring in the intestine must be regarded as a simple transudation, rather than as the result of a true inflammatory process. In typical cases the mucous membrane of the small intestine, especially the ileum, is congested or soft and oedematous, and it is frequently the seat of ecchymoses. The villi are swollen, stripped of epithelium, and the blood- disks in their capillaries are destroyed and free pigment is found (Sutton). The congestion may extend over a large part of the intestine, or it may nearly surround the swollen agminated or solitary glands. There is sometimes croup- ous inflammation of tiie large intestine, Avith necrotic changes at the surface of the membrane. The mesenteric glands are enlarged. There may be more or less gastric catarrh, with congestion and abrasion of the mucous surface. The serous membranes, such as the pleura and peritoneum, are dry or covered with a layer of sticky albumin. The brain and its membranes may appear normal or very dry, and the pia may be oedematous or ecchymotic. The cerebral sinuses contain thickened, dark blood. The spleen and liver are either normal or anaemic or the seat of parenchymatous degeneration. A uremia of tlie liver results from the dniin upon the intestinal division of the ])oi'tal .system and paresis of the vessels. The kidneys j)resent the appearances com- monly produced in the course of infectious fevers. The tubidcs contain des- quamatrd epithelium and hyaline, granular, or fatty casts. The cortex is often tiiickened and the pyramids are congested. The bladder is contracted and emptv. The heart is soft, and there may be ecchymoses in the jiericar- dium. When the patient has died f)f asphyxia the left ventricle, as usual in such cases, is comparatively emj)ty, while the right ventricle is over-distended 440 CHOLERA. with dark blood. The thickened blood coagulates more slowly than usual, and, owing; to diminution in the quantity of fibrin, the clot is less firm. The solid ino-redients are present in quantity one and a half times greater than nor- mal (C. Schmidt), and the chlorides are found to have transfused into the intestine, leaving a relatively larger quantity of phosphates behind. The red blood-corpuscles appear shrivelled, and both red and white corpuscles are apparently increased in number on account of the diminution in serum. The lungs are contracted, dry, pale, and anamic. Pulmonary cedema is rare. Congestion is sometimes found at the bases of the lungs. The lungs may weigh as little as twenty ounces (Sutton). Symptomatolog-y. — The latent period or incubation which intervenes between the time of infection and the development of the first symptoms is not accurately known. In a majority of cases it is two or three days ; it may, however, last for a fortnight. The symptoms of cholera may be due in part to toxaemia and in part to the sudden and extreme drainage of water from the system. Thus by some observers the final collapse is attributed to toxines in the circulation which cause vaso-motor spasm and impeded pulmonary circulation (Johnson), while others believe it to be due to the exhaustion occasioned by the profuse watery evacuations which cause desiccation of the nerves and other tissues of the body. It is convenient to divide the symptoms into four typical stages, as follows : I. The premonitory diarrhoea ; II. The stage of serous diarrhoea ; III. The algid stage, or stage of asphyxia or collapse ; IV. The reaction. These stages usually occur in the order mentioned, but any one may be omitted. Thus, the premonitory diarrhoea may be absent when the disease begins with the second stage, or it may be the only symptom present in cer- tain cases during the progress of an epidemic. Whether this stage develop or not, the onset of the disease is usually sud- den, and in the majority of cases the invasion occurs in the night. More rarely there is an indefinite prodromal period of a day or two, with more or less prostration, vertigo, anorexia, and gastric oppression with flatulence. I. The first stage, when present, commences with a diarrhoea, and the stools are alkaline, watery, yellowish or pale, very profuse, and frequently voided. There may be fifteen or twenty within twenty-four hours. These stools are (|uite as dangerous as regards spreading the contagion as are those of the fully-developed disease. There are borborygmi, but no severe colic. There is frontal headache, and there are nausea and possibly vomiting. There are apt to be mental depression and a feeling of dread. The tongue is clean, pale, and moist at first, bnt later becomes dry. Thirst is present and the voice grows tiiint. These symptoms may continue for a day or two, or even for four or five days, and either end in recovery or merge into the second stage. I I . The second stage presents very active and alarming symptoms. If diar- SYMPTOMA TOLOG Y. 44 1 rlioea has pre-existed, it continues or it begins anew. In citiier case the stools are very copious, alkaline, and watery, and their passage is painless. They are often excited if the patient turn over in bed or if pressure be made over the abdominal wall. The stools of the premonitory diarrhoea are sero-mucous and contain more or less bile and faecal matter. They are soon followed in the second stage by more typical evacuations. The typical cholera stools are voided after the bowels have been emptied of their ordinary faecal contents, and are usually described as having the ap])earance of "rice-water" or ''macaroni-water." They have no odor or only a faint "meaty" smell. They are frothy, and contain no bile or faeces, but show, in suspension in an 0])alescent fluid, whitish flakes which are composed of desquamated intestinal ei)ithelium. They deposit considerable sediment on standing. It is observed by Milles that the stools are almost transparent, and thus differ in appearance from rice-water, which is opaque. They are occasionally colored by extrav- iisated blood, in which case they are described as resembling the lees of wine. The specific gravity of the rice-water evacuations is 1005-1013 (Flint). The reaction is alkaline from ammonium carbonate, but the principal salt is found to be chloride of sodium. The quantity of the fluid discharged in a single evacution may exceed two quarts, and its passage often is followed bv a tem- porary feeling of ease. The typical cholera stools contain a lesser variety of micro-organisms than is found normally, and they yield an almost pure culture of the comma bacillus. The germs are not found in any quantity until the stools become characteristic. Later, in the stage following the collapse, the stools become darker, even brown or black or bloodstained, and they are slimy and very malodorous. It is believed that the cause of the excessive transudation is a paralysis of the intestinal nerves (Brunton). As soon as a considerable quantity of fluid has been drained off in the frequent serous evacuations the thirst becomes more and more intense, so that drinking water does not relieve it. There is rapid emaciation, and in a few hours the victim, who may have been previously robust, presents the aspect of an emaciated and old man, with loose, wrinkled, inelastic skin, sunken, glaring eyes, and a parched, dry tongue. The scrotum is markedly retracted. The stomach is highly irritable and rejects nearly everything which is swallowed. There are nausea, sudden vomiting, and epi- gastric distress. The ejecta consist at first of the food or other contents of the stomach, then become bilious, and finally are clear and transparent, with floc- culi of mucus resembling the rice-water stools. The quantity of fluid vom- ited exceeds tiiat which is druid<. The vomiting may occur only at the coni- mencement of the disease, but it usually continues. The urine is thick, turbid, and contains an excess of urea, and later more or less all)umin, with granular and hyaline casts. Urcn is said to be also eliminated by the stomach, and in increased amount in the perspiration. The j)ulse becomes small and feeble, and arterial tension is (b'niinished. The (linnho'a is finally ac('()iii])anie(l by abdominal cramps, and the pains extend down the hgs and l)econie agonizing. The j)atieiit is restless, anxious, and distressed, and becomes more and more 442 CHOLERA. feeble and prostrated. The pulse becomes very weak and accelerated, and the respiration may be shallow and somewhat increased in frequency. All tiiis occurs in a few hours' time. The temperature of the surface is low and the skin feels cold to the touch, but the internal temperature is elevated. A cold, clammy perspiration frequently covers the entire surface of the body. The mind, as a rule, remains unclouded, but the voice is feeble, husky, and high-pitched. More or less complete suppression of urine ensues, due either to a loss of water or to local action of the poisonous products of the disease. There is an occasional variety of cholera which is very fatal, and in which the diarrhoea is wanting but the other symptoms are present. This is known as "dry cholera" or " cholera sicca." In these cases the intestine is found at the autopsy to be greatly distended with serous exudate. Hence the amount of diarrhoea is not an infallible indication of the severity of the disease. Sometimes in these cases the patients are seized with great prostration. While walking about they suddenly become faint, dizzy, and unable to stand. There are headache and mental confusion. In the worst cases the prostration rapidly increases, and the patient dies in two or three hours. In the serous stage the amount of water lost from both stomach and intes- tines is very great. It comes away in gushes, frequently from both stomach and rectum simultaneously, or it may flow from the rectum in an almost con- tinuous stream. There may be spasm of the diaphragm, producing hiccough, and often the abdominal muscles become tense. The spasms and cramps of the various muscles become extremely painfid, particularly in the legs. These spasms may be explained 4n one of three ways : they may be due to toxic prod- ucts in the blood, to reflex gastro-intestinal irritation, or to desiccation of the nerve-centres (Weir Mitchell). The latter explanation is probably the most correct. There are sometimes involuntary contractions of the flexors and extensors of the digits. The serous stage lasts during one to three hours or longer. If tlie symptoms are very violent the second stage will be more brief, on account of the exhaustion of the T)atient. It is followed sometimes by reac- tion, but more frequently by the stage of collapse. III. TJie Stage of Collapse. — In this stage the prostration, emaciation, and enfeebled heart-action continue. The face becomes shrunken and expression- less, the cheek-bones are prominent, the cheeks are depressed, the nose is sharp, the eyes are dry and hollow, and the whole physiognomy is highly typical of the disease. The deeply sunken eyes are half closed and sur- rounded by dark circles. Tiie forehead is wrinkled, the lips are thin and set, the fingers are shrivelled, and the radial pulse is scarcely perceptible. The skin is duskv or blue, and feels verv cold to the touch. A sudden increase in the diarrhoea or vomiting is apt to be accompanied by a rapid fall in the surface temperature (Shakespeare). The oral temperature falls to 90^ or 95° F., and it has been observed as low as 79° F., and the axillary tem- perature may fall to 75° F., but the fact of a rise of deep internal tempera- ture has been confirmed recently by a number of competent observers (De SYMPTOM A rOL O G Y. 44:i Renzi, Gnterbock). A thermometer carefully pa.ss;ed high up iuto tlie rec- tum may record an elevation of temperature amounting to two degrees above the normal. The patient complains of a sensation of internal heat. The fever is said to be of a remittent type Avith evening exacerbations. It is often over- looked on account of the stone-cold feeling of the surface and from the diffi- culty of taking the temperature in the rectum while the stools are being almost constantly voided. The vomiting and diarrhoea finally cease, apparentlv from exhaustion or because there is no more material to be discharged. 'J'he tips of the fingers and toes become livid and rigid, and the breath feels cold. The respirations are shallow and irregular, and dyspnoea is often extreme. The loss of so much fluid from the blood through the alvine evacuations causes diminution in all other secretions of the body, excepting sometimes the per- spiration. The tears, saliva, and bile are withheld, and menstruation is checked. The dryness of the eyes may result in their inflammation from exposure to the air (Stille). The suppression of urine contimies, and it may become complete. If any urine is v^oided, it is albuminous, and fre- quently contains sugar. The mind remains intelligent, but the patient is too feeble and too greatly prostrated in every way to speak or to take note of his surroundings, and lies as though dead. Tlie blood, thickened by deprivation of so much M'ater, flows but slowly through the capillaries and lingers in the veins until it becomes highly venous all through the body, and imparts a cyanotic hue to the entire surface, and the condition of asphyxia ensues, which Brunton believes is due to spasm of the pulmonary vessels preventing the free flow of blood through the lungs. The post-mortem appearances of the lungs confirm this view. There is less interchange of the gases of respiration than there should be, and elimination of carbon dioxide is diminished. The pulse is feeble, not usually above 100 or 120, and it may fail entirely at the wrist. The second sound of the heart is inaudible. The entire body is shrunken almost beyond recog- nition. This stage lasts for several hours as a rule, or it may be j^rotracted for a day or two, and it either terminates fatally or in a reaction with recovery. Death may be due to asthenia or to asphyxia, but profound coma is uncom- mon. It may come suddenly, without premonition, and patients in whom the symptoms have not been very severe have been known to jump out of bed and walk about just before death overtook them. More often death supervenes gradually with progressive coldness of the surface and insensi- bility. "When it results from asphyxia from stagnation of the blood, the temj)erature usually rises and may reach 108° F. In other cases, after death the temperature may continue to rise to 106° F., and there may be post- mortem contractures of the muscles of the extremities and of the facial mus- cles, producing grimaces. It will be observed from the foregoing account (hat nearly all (he symp- toms of cholera are induced by the excessive loss of fluid from the blood. This occasions the dryness of all the tissues, the diminution in biliary, renal^ 444 CHOLERA. and other glandular secretions, the paralysis of the nervous system, the exhaustion, and the asphyxia. IV. The Reaction. — The great majority of patients who recover pass through a reactionary febrile stage. The reaction follows either the stage of serous diarrhoea or the collapse. The external temperature rises, while the inter- nal temperature falls, and the condition of tlie circulation is gradually restored to the normal. The face regains its natural expression. Tlie cramps and vom- iting cease. The pulse becomes slower and of better volume, and thirst is no longer complained of. The stools become of firmer consistence, and finally resume their Isecal character and contain bile-pigment, except in those cases in which there has been extensive denuding of the epithelial surface of the intes- tine, when the stools may be hsemorrhagic for some time. The secretion of the urine is gradually restored. In some cases convalescence is interrupted by absorption of septic matter from this denuded surface, and a typhoid con- dition or septic fever results, with considerable elevation of temperature, a dry tongue, delirium, and coma. Various cutaneous eruptions may accompany the fever. If, on the other hand, convalescence be not delayed by typhoid symp- toms, there are usually pronounced aneemia and prolonged irritability and fee- bleness of the digestive organs and of the nervous system. There are severe frontal headache, and often vertigo and fainting. In still other cases ursemic symptoms develop, the function of the kidneys not having been restored. In such instances nervous symptoms predominate, and there is delirium with con- vulsions. In some cases the intestines fail to recover their tone, and an exhausting diarrhoea still further debilitates the patient. Relapses may occur, either as a result of indiscretion in diet or exertion or without assignable cause. In the variety of disease called "cholerine" the symptoms are compara- tively mild, although they may last for a week. Asphyxia, cramps, and total suppression of urine are sometimes absent. Complications and Sequelae. — Diarrhoea, dysentery, and malarial fevers are apt to prevail in the same localities with cholera and at the same time with cholera epidemics, though the latter disease is so acute that it is rarely compli- cated by other affections unless they already exist in the individual attacked. Various exanthemata, such as roseola, urticaria, etc., may occur during the reaction or the convalescent period. Sometimes furunculosis and ulceration ensue, especially upon the emaciated extremities. Bed-sores are apt to occur. Excessive perspiration, with elimination of increased urea, is sometimes observed. There may be painful swelling of the parotid glands, rarely progressing to the formation of abscess. Sometimes a painful contraction of the nmscles of the extremities resembling tetanus takes place, and lasts for several hours or a day or two. Gangrene and peritonitis have been rarely present as sequelae. Corneal ulcers sometimes appear. More or less gastro- intestinal irritability, with gastralgia and anorexia, is apt to remain, and it may last for many weeks, greatly retarding convalescence. There may be enfeebled circulation, with cold extremities and wakefulness. Various kidney B URA TION.—DIA GNOSIS. 445 lesions have sometimes followed, and cerebral congestion may be a sequel to the reactionarv jieriod. Pneumonia is an occasional com[)lication. Duration. — Fatal cases end usually in two or three days. Death has occurred within two hours after the first typical stools have appeared. In such cases all the symptoms of the algid stage occur with incredible rapidity. The duration of a single epidemic is often brief, and it seldom remains a month in any one locality. Diag-nosis. — Cholera is liable to be confounded with one or two other diseases in its early stage and before the epidemic has been recognized. After the establishment of an epidemic the disease is, however, readily identified by the typical stools, ra])id emaciation, great thirst, prostration, and algid con- dition. The diseases and conditions with which cholera may be confounded are septicaemia, typhoid fever, pernicious malarial fever of the gastro-enteric variety, cholera nostras, and ptomaine or mineral poisoning. In the typhoid or reactionary stage of cholera the patient is really in a septic condition, and the prostration, emaciation, and general ataxic condition suggest enteric fever. The latter disease, however, has a protracted history : there is a characteristic temperature curve, a rose-colored abdominal eruption, and diarrhoea, if present, is of a different sort, and the stools are less watery and colorless than in cholera. The gastro-enteric variety of malarial fever is oflen so severe as to resemble cholera in its earlier stage. In the former the temperature is high, 106° or 107° F. ; the stools may be bloody at first; v^om- iting, if present, is more painful, with decided retching ; and free ])igment is found in the blood, with possibly the malarial plasmodium. Very severe cases of cholera morbus may prove fatal in one or two days, and every symptom of cholera may be present, rendering diagnosis extremely difficult. Fortunately,, such cases are quite exceptional. Usually in cholera nostras, or sporadic cholera, the symptoms of extreme cyanosis and total sup- pression of urine are wanting. The alvine evacuations are loose and watery, but unlike the typical "rice-water" stools. The disease is less rapid than true cholera in its progress, much less severe in its symptoms, and recovery is more frequent. The cases are isolated and non-contagious. The typical cholera bacillus is absent. The cramps are apt to be more severe in the stomach, but less severe in the legs, than in true cholera. Asphyxia from coal-gas (CO) poisoning may produce symptoms resembling the asphyxia stage of cholera, but the absence of intestinal irritation and of the typi(!al choleraic stools will at once confirm the diagnosis. In cases of mineral poisoning there may be visible corrosion within the mouth, a metallic taste, and the epigastric pain and burning is very pro- nounced. The stools are bloody or foetid, instead of clear and watery. Among such cases the symptoms produced by arsenic are the most difficult to diflf'erentiate from those of cholera, for in both instances there may be great prostration, collapse, thirst, cramps, and supj>r(>ssion of urine. In acute arsenical poisoning there is usually constriction felt in the throat or oesophagus, and there is epigastric pain of an intense burning character. 446 CHOLERA. The symptoms commonly follow very soon after the taking of drink or food. In any doubtful instance the discovery of the cholera bacilli in the stools will decide the case. Prognosis and Mortality. — The prognosis depends uj^on the severity of the epidemic, the sanitary condition of the environment, the habits of life, and the promptness with which the patient comes under treatment. For cases seen very early the prognosis is good. It is bad in densely-populated districts, and worse near the seacoast than inland. The mortality from Asiatic cholera remains practically unreduced by every effort of treatment, although if seen early and faithfully treated many cases may be brought to recovery. The disease, once established among those of filthy habits, is, however, nearly as fatal as ever. The total number of cases occurring in a given locality is diminishing where hygienic laws are duly respected. Thus, in 1868 the cholera mortality among foreign soldiers in India was 18.6 per 1000, while to-day it is only one-sixth as great. The general mortality varies between 20 and 80 per cent, with different epidemics, but it is always high, and the hospital death-rate may often exceed 60 per cent. It has been as grave as 90 per cent. The worst mortality occurs during the earlier and middle period of an epidemic : toward the end the cases are less fatal. The disease is very fatal in childhood and old age, but is less com- mon among such subjects ; hence the mortality is greatest in adult or middle age. An epidemic may aifect a very large number of persons, and yet the death-rate may be lower than in a less extensive epidemic. Prophylaxis. — The prophylactic treatment consists in a rigid enforcement of sanitary rules and personal hygiene. All healthy persons should, as far as practicable, be removed from the infected district. Great importance attaches to immediately stopping any diarrhoea which occurs while an epidemic of cholera is prevalent, and to further this end it is advisable for the local gov- ernment to appoint special medical inspectors to go from house to house. In this manner many lives may be saved. The digestion should be particularly cared for, and some advise the internal use of dilute acids to maintain a moderate hyperacidity of the stomach, which is thereby rendered inimical to the germs. Fatigue and excesses of all sorts should be strenuously avoided. All sewers, privies, cesspools, and water-tanks should be thoroughly cleansed and disinfected. Drinking of impure water should be avoided, and all water should be thoroughly boiled before use. During the prevalence of an epidemic all public funerals or large gatherings of people shoidd be absolutely interdicted. Treatment. — No one drug or system of treatment has proved of much avail for cholera. The objects of treatment are, therefore — (1) to support the strength ; (2) to allay pain and fear ; (3) to relieve the severity of certain symptoms, notably the thirst, emesis, diarrhoea, and cramps ; (4) to prevent thickening of the blood and suppression of urine. The treatment must be adapted to each stage of the disease. TREA TMENT. 447 Treatment of the First Stage. — If promptly taken in lianil at tlie outset and carefully watched and nursed throughout the disease, a certain projMM'tion of oases may be saved, and in some the disease is apparently aborted. With the first indication of diarrhoea the patient must go to bed and remain there, warmly covered. He must be kept absolutely quiet throughout the disease. Hot stupes may be placed over the abdomen and food should be withheld. A dose of laudanum or chlorodyne is to be given at once, and then salol or sali- cylate of bismuth may be administered every two hours. It is believed that the salol acts as an antifermentative and prevents the absorption of ptomaines from the intestine. In many cases this prompt treatment will stop the diar- rhoea, and the disease may advance no farther. In the early stages of the dis- ease it is useless to attempt to give food. The stomach is too irritable, and broths and milk serve only as cidture media for the further development of the bacilli. Treatment of the Second Stage. — If, on the other hand, the diarrha-a ])ro- gresses, and the alvine discharges become serous and are accompanied by cramps, more active measures are imperative, and every effort should be made to keep up the patient's hope and courage for the struggle which is before him. The abdomen may be wrapped in flannel, or turpentine stupes are useful if the abdominal pains are severe. For the vomiting morphine should be given hypodermically, and a mustard paste placed over the epigastrium. Cracked ice, cold lime- wafer, carbonic-acid water, or iced champagne sometimes afford relief. When it can be obtained, fresh lime-juice, iced, is very serviceable. Cocaine in small doses sometimes allays the gastric irritability. The cramps in the calves of the legs and other muscles may become so intense as to require inhalation of chloroform for their relief. Kneading the muscles is sometimes of use, as well as rubbing them with mustard-water and applying hot-water bottles and turpentine stupes to the legs. It is strongly recommended by certain writers of extensive experience to place the patient in a hot bath, at 106° or 108°, for twenty minutes during the stage of cramps and commencing serous diarrhoea. The patient is then put back to bed, rubbed dry, wrapped in warm blankets, and is given warm, stim- ulating, and aromatic drinks. Of course he should be moved as little as ])()s- sible, and should be lifted into and out of the hot bath. Should his condition warrant it, the bath is to be repeated once in two or three hours. It quiets the nervous system, arrests the vomiting, controls the painful cramps, restores the skin to a more natural condition, and stimulates the circulation ; besides which it is usually very grateful to the patient. For the agonizing thirst cold water, acidulated with a little dilute hy(h"ochloric or ph()s))iiori(! acid or lemon-juice, sliould be irivcn. Cracked ice is useful, but the relief alTorded bv it is slio-ht. Carbonic-acid water or seltzer may also be given. Fluid held in the mouth for ten minutes at a time affords more relief than when imnic There is cloudv swelling of the epitliclia of the tubules with granular fatty degeneration. There are granular easts in the tubules. The whole alinientarv canal is the seat of acute catarrh, but the gastric mucous wall especially is soft, turgid, and ecchymotic, and it may present erosions and contain " black-vomit" material. Similar material is found in the small intestines. The brain is hyperjemic, especially the pons and medulla, and the meninges are congested. Schmidt describes certain degenerative changes in the sympa- thetic ganglia, with disappearance of the nuclei of the nerve-cells. Symptomatolog-y. — The incubation period of yellow fever lasts from twenty-four hours to six days : it may c\cn extend over ten days. It is short in severe epidemics. Stages. — The disease has three stages : I. The " paroxysm," consisting of a cold period, followed by a febrile reaction; II. A remission or " stage of calm ;" III. A urfemic stage, or a second exacerbation or collapse. First Stage. — The invasion is in all cases sudden, and it may occur at anv hour. It is characterized by a chill, rigors, frontal headache, vomiting, lum- bar pains, pains in the calves of the legs, and great muscular prostration. There is capillary congestion, and the patient soon acquires a typical expres- sion, with shining, staring, watery eyes and congestive cheeks and conjunc- tivae. There is photophobia. There may be excessive sweating. The mind, as a rule, is clear, delirium being exceptional. In children the disease often begins with convulsions. The cold period is followed by one of pyrexia, with a rapid rise of temperature, 104° or 105° F. being the maximum reached in twelve or eighteen hours. The tempera- ture, as iu malarial fever, begins to rise during the chill. The fever, which is seldom very high, gradually subsides after the maximum is reached, and after three to five days, with very slight remissions, the temperature reaches the normal degree. There is continued vomiting, first of nuicus, then of bile, sometimes of blood. The stomach is intensely irritable, and the vomiting is of the projectile type. Pressure over the epigastrium excites emesis. The bowels are costive. The gums are sore and swollen, the mouth is dry, tiie tongue is red at the tip, and is often narrow. The skin may be dry and hot tiiroughout the febrile stage, or it may be bathed in a profuse perspiration, which emits a peculiar sickly, disagreeable odor. There is scanty acid urine, which shows a trace of albumin on tiic third day. There are great restlessness and ])()ssibly delirium. On the third or fourth day the conjiinctivte, and later the entin; body, begin to show an icteroid hue. The pulse is slow iu proportion to the fever, seldom rising above 110, and fre(jucntly kcc])ing within 100. It is often described as "gaseous," or highly compressible and feeble. It may grow slower before the fever declines. Sometimes the cold stage is inappreciable, and the disease seems to commence with the fever. The symj)loms thus far deseril)ed con- stitute the " ])aroxysm." On the fouitli or lilth day the fever and other symj>toms abate and the "stage of calm " is reached. Second Stage. — The temperatur<', having attained th<; noiniai degree by 456 YELLOW FEVER. lysis, may become subnormal and the patient feels greatly relieved. In mild cases convalescence begins from this time. The "calm stage" rarely exceeds two days in duration, and frequently lasts but a few hours, when the patient becomes much worse again, grows deeply jaundiced, and passes into the third stage. In severe cases there is sometimes a reactionary fever of remittent type and irregular duration (Sternberg). The urine is diminished in amount and there is albuminuria. Thhxl Stage. — The striking features of this stage are tendencies to haem- orrhages from all the mucous surfaces and to complete suppression of urine. The temperature either rises again for a day to 103° or 104° F., or it remains normal while symptoms of uraemia develop. The pulse-rate may be abnor- mally slow, falling sometimes to 40 per minute. Bleeding occurs uniformly from the stomach as " black vomit," and in addition it may take place from any other mucous surface or into the skin. The '^ black vomit" is present in about one-third of the fatal cases, and is due to passive haemorrhage, but is not by itself patliognomonic of yellow fever, as it may occur in other affections. The stomach at first ejects whatever food it may contain, then mucus tinged with bile, and finally brown or black semifluid acid material resembling coffee- grounds, and consisting of red blood-corpuscles, pigment-granules, degenerated mucous and epithelial cells and leucocytes, fatty matter, and serous fluid. The acid gastric juice, acting on the blood-pigment, makes it dark brown or black. The quantity of this fluid ejected varies from a few drachms to several pints. It is acrid and irritates the fauces and mouth. The blood, altered in compo- sition, oozes from the capillary walls of the congested mucous membrane of the stomach. The fluid is not always vomited, but in fatal cases it is very excep- tional not to find it accumulated in the stomach. The intestines mav be the seat of similar haemorrhages, giving black diarrhceal stools. The swollen gums bleed readily, and there may be epistaxis. Rarely there is haemorrhage from the respiratory tract, the nose, the ear, and the urethra. Females who are capable of menstruation bleed profusely from the vagina and uterus. Dur- ing pregnancy yellow fever causes miscarriage. The jaundice deepens and the skin becomes of a dark olive or mahogany hue. If there be perspiration, it stains the linen yellow and emits a cadaveric odor. The urine becomes more and more scanty. It is acid, of high specific gravity, and it may be stained by the altered blood-pigment. The chlorides are diminished. It contains granular and hyaline casts, and its suppression adds uraemia to the existing toxaemia of the yellow fever. Sometimes cutaneous eruptions appear, such as roseola, pustules, or herpes labialis. Exceptional cases arc those (a) in which the cold period is omitted, and fever inaugurates the first stage ; (6) cases in which no fever follows the cold period, or the febrile reaction is delayed, while the patient becomes stupid or semi-comatose, and the skin is congested and livid, the pulse being extremely feeble, albuminuria occurring on the first day, and the patients dying within three days; (c) cases commencing with delirium or maniacal excitement. Should recovery take place, the jaundice continues for several days, grad- DURATION AND TEJiMINATTONS.— DIAGNOSIS. 457 iially fading out. If the case be fatal, the jaundice persists after death. Other expressions are used in describing various types of yellow fever in which certain symptoms predominate, such as ataxic, algid, adynamic, con- gestive, etc. Duration and Terminations. — In a violent epidemic a patient may die suddenly from et)llapse within the first few hours of the disease, being stricken down while walking or at work. Death is most apt to take place from the third to the fifth day. Relapses are infrequent, but they may occur. If the patient do not improve or ^lic before the fourth or fifth day, he passes into a typical typhoid state, with sordes, hard, dry, black tongue, muttering delirium, diarrhoea, petechise on the skin with large ecchymotic patches, extreme albu- minuria, increased epigastric tenderness, black vomit, and finally suppression of urine, followed by convulsions or coma and death. In cases which recover the average duration of the disease is six days. Death occurs from the poison of the disease itself, exhaustion, urcemia, or black vomit. It is not very common for patients to die from the hemorrhage alone, though it should always be borne in mind that death may result sud- denly from this or other cause at almost any period of the disease. It may occur in syncope after violent maniacal excitement. Complications. — There are no special complications of yellow fever. It may exist in the course of various chronic diseases. The black vomit and jaundice in many cases do not appear at all, but when present they are symp- toms rather than complications. Sequelae. — The sequelae of yellow fever are few. Convalescence, always slow except in the mildest cases, may be further retai-ded by general furuncu- losis, suppurative parotitis, hepatitis, or by a very weak and irritable stomach and diarrhoea. Errors in diet have been known to produce fatal gastric hem- orrhage two or three weeks after establishment of convalescence. The heart is apt to be feeble, and reparative and nutritive processes proceed slowly. Phlebitis and thrombosis of the femoral vein sometimes follow. The stomach often remains irritable for a long time. Relap.ses occasionally occur during early convalescence. Diag-nosis. — The diagnosis of yellow fever is based upon the following features: its portability by fomites, the sudden invasion by chill and rapid rise of temperature, with a slow ])ulse, pains in the forehead, lumbar region, and calves, tenderness over the epigastrium, redness of the eyes, excessive gas- tric irritability, black vomit, jaundice, and diminished uiine with albuminuria. Typical cases presenting all these features are unmistakable. In mild cases a correct diagnosis may be difficult. In any doubtful case occurring in a mala- rial district at the commencement of an epidemic of yellow fever it is well to give a large dose of quinine with a purge, and favor free diaphoresis by hot diluent drinks and a warm bath. If the tem]>orature yield to these measures and the patient improve, he has not taken yellow fever. The jaundic<> itself is a very misleading diagnostic featiu'c, for it is oflen absent in yellow fever, and may be present in malignant types of malarial fever. It may occur only 458 YELLOW FEVER. as a post-mortem pigmentation in yellow fever, and even in the severe eases it is not common before the fourth or even fifth day. ]\Iild cases and the earlier cases of an epidemic may be confounded with relapsing fever, severe malai'ial fevers, such as bilious remittent or pernicious malarial fever, acute yellow atrophv of the liver, or jaundice of local hepatic origin attended by fever. Relapsing fever has a typical spirillum found in the blood, is non-con- tagious, the spleen is enlarged, there is no black vomit, there is a typical relapse, and both temperature and pulse are higher than in yellow fever. Malarial fevers are non-portable, are controlled by quinine, the spleen is enlarged, the fever is distinctly periodic, either remittent or intermittent, albu- minuria is much less frequent, and one attack of the fever favors subsequent ones. In bilious remittent fever there are usually several paroxysms instead of one ; the remission commonly occurs abruptly, within twenty-four hours instead of upon the fourth day ; the tongue is coated heavily, and is broad, flabby, and indented by the teeth, instead of sharp, dry, and pointed ; the spleen is large; the splenic area is tender; delirium is more common; and copious vomiting of bile occurs, in distinction from the mucus and black vomit of yellow fever. Albuminuria is rare, and the ague is more apt to occur in inland rural districts than in seaport towns and cities. Free pigment and the malarial plasmodium may be found in the blood. Death, if it takes place, comes earlier than in yellow fever. Hsemorrhagic remittent malarial fever, accompanied by jaundice, sometimes resembles yellow fever quite closely, but previous attacks of ordinary ague will have occurred, the jaundice appears very early, and the symptoms fluctu- ate with the temperature, and melanuria appears with each paroxysm. Phosphorus-poisoning has some features in common with yellow fever, but the odor of the drug is obtained in the breath and traces of poison may be found in the ejecta. In acute yellow atrophy, which is non-portable and not epidemic, the spleen is enlarged, the liver is reduced in size, black vomit is absent, and the disease begins slowly without fever or pain. In local jaundice with pyrexia difficulty in diagnosis may arise, but care- ful attention to the special diagnostic symptoms of yellow fever above enume- rated will seldom fail to decide the case. Prognosis. — The prognosis depends upon the severity of the epidemic. As in many other epidemics, the maximum mortality in yellow fever is usually attained in a middle period, the earlier and later cases being less severe. The hospital mortality is always worse than that of private cases. It is seldom less than 20 per cent, among unacclimated adults, and it may exceed 50 per cent. This is in part due to the fact that the cases come under treatment late, many being brought in moribund. In mild epidemics 1 patient in every 15 or 20 dies; in severe epidemics 1 in 3 dies. In the epidemic of 1878, 36,000 cases occurred in Louisiana witii a mortality of 16.66 per cent. (Bemiss), and in New Orleans the mortality at the Charity Hospital was 50 TREA TMEXT. 459 per cent. Among the fatal cases nearly three-fourths of the deaths occur during the first week. The prognosis is particularly bad — (1) if the initial paroxysm is unduly intense; (2) if severe gastric irritability is persistent; (3) if black vomit occurs, but especially if there are passive haemorrhages from various mucous surfaces ; (4) if albuminuria increases and the volume of urine diminishes ; (5) if jaundice appears early and is intense; (6) if patients have been greatly worried or fatigued, or if they are suffering from inanition or cachexite ; (7) in pregnancy and the puerperal state; (8) if capillary congestion of the skin is excessive in the first stage; (9) if there are delirium and irregular pulse and respiration. C'omplete suppression of urine is more fatal than black vomit. The com- bination of black vomit and complete suppression of urine is certainly fatal. If necessity for removing the patient arise after the attack has begun, the prognosis is rendered worse thereby. Prognosis is bad in certain rare cases in which the earliest symptom is delirium or stupor. Prognosis is fav^orable when the gastric irritability and the amount "of albumin in the urine diminish. Ordinary bilious vomiting is not an unfavor- able sign. The disease is more fatal among men than among women and children, and more fatal among alcoholic and plethoric subjects. When the temperature remains below 103.5° during the paroxysm the course of the disease will probably be mild. If a certain locality has enjoyed long immunity from yellow fever, the epidemic is apt to be severe, because there will be more unprotected persons exposed to the disease. Treatment. — While there is no specific for yellow fever, which is a self- limited disease, many lives may be saved by prompt and vigorous measures. There is no disease of which this can be said with greater emphasis, and as much depends upon the faithfulness and efficiency of a thoroughly trained nurse as upon the physician. . ]Maintaining the patient's courage and hope is of great service. The indications for treatment are — I. To adopt prophylactic measures by rigid quarantine, etc. ; II. To keej) the patient absolutely quiet ; III. To control the emesis and prevent the suppression of urine ; IV. To support the strength until the crisis is past. I. Prophylaxis. — When an epidemic breaks out all ])crs()ns whose duty does not keep them with the sick do well to leave the infected district immediately. It is well to avoid the presence of fever-stricken patients when suffering from fatigue, loss of food or sleep, or depressing emotions, — all of which factors ren- der one more liai)le to the disease. Nurses and attendant:^ should secure all the fn'sh air possible, and hospital |)atieiits are often best treated out of doors in tents. The patient should be (|uarantined, ami all caic nuist be taken to prevent the distribution (»i" alible with maintenance of lifi', this treatment has yielded discouraging re- sults, besides being very expensive* and uncomfortable for llic patient. TETANUS. By JAMES T. WHITTAKER. Tetanus (rsrai'oc, tscuo), to stretch) ; Trismus ; Lockjaw ; Opisthotonos {oTTcffdi, backward, ztivto, to stretch) ; Starrkranipf, Wundstarrkrampf (Ger.), — a grave, often exquisitely acute, infection, caused by a specific bacillus, the tetanus bacillus, introduced through a wound or some break of the surface, characterized by excessively heightened reflex under the action of toxines, wdiich induce spasmodic contraction of the voluntary muscles, first and espe- cially of the jaw (trismus, lockjaw), face, and neck, and extensors of the spine (opisthotonos), of short duration, often of rapidly fatal termination. Among the larger animals the horse, sheep, and goat are especially liable to the disease. The clinical features of tetanus are so coarse and obtrusive as to have been remarked in the most ancient times. Some of the finest descriptions of Aretseus were based upon observations of tetanus. Hippocrates devoted a whole section to its treatment, ancl certainly appreciated the gravity of the disease. " Such persons," he says, " as are seized with tetanus die within four days, or, if they pass these, they recover." Aretseus declared tetanus to be a spasm of an exces- sively painful nature, very swift to prove fatal, and not easy to be removed. " It supervenes," he declares, " on the wound of a membrane or of a muscle or about punctured nerves, when, for the most part, patients die; for spasm from a wound is fatal." .... Women are more disposed than men ; children are frequently affected, but less fatally. " In all the varieties," he says, " there are pain and tension of the tendons and spine and of the muscles connected with the jaws and cheek, so that the jaws could not easily be separated even with levers or a wedge." No such graphic description of the symptomatology of the disease as detailed by Aretseus has ever since been written. The distor- tion and suffering are so great as to make the spectacle painful even to the beholder. *' The physician," he declares, "has no power over the disease; he can merely sympathize. This is the great misfortune of the physician." Most of the contributions of later times have been presented by the sur- geons Laurent, Larrey, etc. Curling wrote his famous treatise on tetanus (Jacksonian Prize Essay) in 1834 ; Rose (E.) made the most valuable clinical contribution of modern times to the Handbuch der AUgem. u. Specielle Cliirurgie, Pitha u. Billroth, Bd. 1, Abtheil. A., 1870. Nikolaier discov- ered the bacillus of tetanus in 1885. Brieger (1887) obtained from sterilized cultures of the tetanus bacillus a toxine which, in mice, in the smallest doses, produced the typical symptoms 40.2 ETIOLOdY. 463 of trismus and tetanus with fatal termination. Besides this body, Briesrer eliminated various tox-albumins with specifie properties. Etiology. — Tetanus is now known to be a s])eeitic disease. It arises in no case spontaneously, and demands for its development a break of the surface through which its specific cause may be introduced; hence tetanus follows most frequently in the course of and in consequence of some external injury. Though the extent and severity of the injury stand in no direct relation to the disease, the seat and character of the woinid have much to do with its devel- opment. For, while tetanus may occur in consequence of any kind of wound, it does occur much more frequently after contused wounds with penetration of foreign bodies. It is therefore very frequent after gunshot wounds, and is especially frequent in wounds of the extremities. Wounds of nerves are also attended with special liability. Tetanus may follow a lesion as trivial as the extraction of a tooth, a vene- section, the sting of an insect, a simple scratch of the surface, the application of a blister, a slight wound of the foot as from a nail in a shoe. It occurs not infrequently in the newborn from lesions of the umbilical cord, and has been repeatedly observed after a wound of the cervix uteri, as after parturi- tion. The intrusion of a splinter of wood, the lodgment of a fish-bone in the throat, have broken the surface sufficiently to introduce or give entrance to the cause of the disease ; but, as the cause conies from without, tetanus occurs in the great majority of cases in wounds of the extremities. Curling found wounds on the extremities in 111 of 128 cases, and Thamhaym in 395 cases found the locality of the injury in the hand and finger 119 times. Though the frequency of tetanus varies at different times, it is on the whole a comparatively rare disease. True, Lind saw 5 of 6 cases of amputation die of tetanus, and once in modern times — namely, at the battle of Lyon in 1834 — 12 of 277 wounded died of the disease. The experience of Blanc, who saw 30 cases in 810 wounded, is also unusual. More in accord with the rule is the rarity of the disease in the Civil War in America and the Franco-Prussian AVar, in one corps of which there were observed but 45 cases among 24,262 sick and 7182 wounded. In civil life the disease is still more rare. Thus, at Guy's Hospital in thirty-two years there occurred but 1 case of tetanus to 1570 patients; in Vienna in ten years, but 1 case to 4798 patients. Rose states that the mortal- ity of tetanus in Berlin was but .04 per cent., and this included 266 cases in newborn infants. The di.sea.se is most frequent in hot countries. Aside from attack of the newborn, the period of greatest liability is between ten and thirty. The fact that the disease oc(aM's after minute, almost undiscoverable, injuries as readily as after the most extensive lesions, long ago excited susj)icioji of its infectious nature. Carle and Rattone (1881) furnished the first proof of coni- municability of the disease by the inoculation of rabbits with pus from the wound in a case of human tetanus. Nicolaicr in the following year discovered widely disseminated in all kinds of earthy matter bacilli which, introduced 464 TETANUS. subcutaneoiisly into mice, guinea-pigs, and rabbits, produced typical trismus and tetanus with fatal termination. Roseubach in the next year (1886) dem- onstrated the tetanus bacillus for the first time in man, and a number of com- petent observers confirmed these demonstrations in other cases, including tetanus neonatorum (Beumer, Piper), including also castration tetanus and tetanus traumaticus in animals (Bonome). Thus was established the genetic relation to the disease of the bacillus of Nicolaier. The tetanus bacillus is a delicate rod, a little longer than the bacillus of mouse septicaemia. It occurs in irregular masses iu the aifected tissue, and is recognized by the characteristic development of its spores. One end of the bacillus swells to show an oval, sharply-defined, shining spore, and presents the appearance of clock bell-strikers, drumsticks, or, better, pins. This spore for- mation occurs in great abundance in the body of the animal as well as in artificial culture. Tiie bacilli are easily colored with methyl-blue and fuchsine. Artificial culture is difficult. The bacillus is a strict — l. e. an obligate — anae- robe, so that in artificial culture particles of infected matter must be introduced into the deeper layers of blood-serum to secure growth. The culture is so commonly contaminated as to often require subsequent separation to obtain it pure. The bacilli and spores of tetanus are so widely disseminated in soil and dust as to be almost ubiquitous. They abound most on the surface of inhab- ited soil, and are not entirely absent in uncontaminated virgin soil. The rubbish and dust of sti'eets and houses are soils of predilection. The wide dissemination of the parasites accounts for the cases of apparent spontaneous or idiopathic tetanus, while the fact that the free access of oxygen prevents its growth furnishes explanation of the comparative rarity of the disease and greater liability in case of penetrating wounds. The tetanus spores found in the earth develop virulent cultures upon serum in the course of sixteen days. Of 23 soil-tests taken in Copenhagen, 16 proved virulent in the inoculation of animals ; 7 tests taken at a depth of two to four feet all produced tetanus ; 4 of 5 soil-tests, taken from gardens outside of the city, showed no spores and produced no infection. The bacillus is innocuous in the stomach. In an examination of 25 specimens of earth Verhoggen and Baert found the genuine tetanus bacillus 15 times, demonstrated in all cases by inoculation. The bacilkis may not, however, be demonstrated in the blood. The injection of the substance of the spinal cord of animals dead of tetanus produced tetanus in other animals only when introduced under the dura, and never when intro- duced under the skin. The same results were observed with the use of strychnine, which lias much the same effect as the poison of tetanus. The dis- ease is sometimes conveyed by contact with horses affected with tetanus, though the bacillus is found much more frequently in the soil than in the body of animals. Tureina demonstrated in the dust of the floor of three wards of a military hospital, as well as in the dormitories, the presence of the tetanus bacillus. The demonstration was made by means of the inoculation of rabbits. ETIOLOGY. 4()5 Dor inoculated rabbits with the cerebro-spinal fiiiid of a man dead of tetanus. The animals quickly sueeumbed without showing any pronounced picture of tetaiuis. Pure cultures were made with the tetanus bacillus obtained from the spinal cord of these animals. Rabbits inoculated with these cultures showed the distinct picture of true tetanus. The bacilli perish very rapidly after the death of the patient, hence the dithculty of their detection. Pure cultures are best obtained by great dilution in sterilized water and stroke inoculations of the serum of horses' and sheep's blood. Brieger demonstrated the presence of tetanine both by chemical analysis and physiological experiment. Particles from an infiltrated arm whieh showed, under the microscope, tetanus bacilli, other long bacilli, sta]>hyl()cocci, and streptococci, were introduced untler the skin of mice, guiuea-])igs, and rabbits, with the result that tetanus occurred in every case. A dog j)roved refractory both to this substance and to the injection of tetanine. A large abscess developed in a horse. Injections of large doses of tetanine produced long, persistent, violent muscular contractions, but the rigidity characteristic of tetanus in the horse did not develo]). Beunier first succeeded in producing the characteristic picture of tetanus by the inoculation of particles taken from a wound at the umbilicus in a child dead of trisnuis neonatorum. The denuju- stration was thus offered that trismus and tetanus in the newborn may be no longer looked upon as a neurosis, but nnist be regarded as a traumatic infec- tion. Kischensky examined three cases of tetanus neonatorum in consequence of an omphalitis. Inoculation of the pus produced tetanus in one case. In all three cases the streptococcus was found in the pus, and in one case it was also found in the internal organs. Nissen succeeded in demonstrating toxines of like effect in the circulating blood of a patient affected with tetanus. The blood, withdrawn by venesection twenty mimites before death, showed itself free of tetanus germs in agar cultures, but the injection of six mice with but .03 ccm. of blood-serum produced a fatal tetanus within a few hours, while other mice injected with the blood-serum of healthy or n(m-tetanic men remained unaffected. Pestana concludes that the poison of tetanus is absorbed by the blood, and is thence taken up by and retained in the lungs, the sj)leen, the kidneys, and, above all, the liver. The toxine is conveyed by the urine in imj)erceptible quantities. It can be demonstrated in nerve- and muscle-substance. Faber secured a filtrate, by means of Chamberland's filter, entirely free of bacteria — a" sterile, clear, yellowish, nearly alkaline fluid of e(jual virulence with the culture-soil itself. Inoculation of this substance is followed without local sign.s — /, e. spasms — by general tetanus which begins with trisnuis. The tetanus shows itself sooner than after infectiou. The filtrate loses its virulence entirely after heating for five minutes at 0")° ('. luti-oduccd into the aliment- ary canal, it has no poisonous elle<'t. Kitasato observed that the filtrate jjerfcctly free of germs pi-odueed the same tetanic effect as the culture of tetanus bacilli ; lieiuie tetamis is not a question of infection, but of intoxication by a specific product of the tetanus Vol. I.— .'.0 466 TETANUS. bacillu.'-. Of the auiiual.s i'X])erinioiit('d upon, tlu' most sensitive were guinea- pigs, then miee, then rabbits. Tetanus sometimes sliows itself at once, at tiie latest on the third day. The inoculation of organs of animals dead of tetanus into other animals remained without effect, but the inocidation of blood or transudations from the chest-cavity, though free of germs, always produced tetanus in Juice. The tetanus poison therefore penetrates to the blood and pro- duces here its toxic effect. A filtrate exposed to tlaylight at a window loses its virulence in the course of several weeks, but M^hen kept in a dark room it is, after three hundred days, as virulent as when fresh. Direct sunlight absolutely destroys the poison of tetanus in fifteen to eighteen hours. Dilu- tions witli water do not affect it. Morbid Anatomy. — Tetanus shows no distinct and definite lesions. The t^use of the disease often disappears to leave no trace, and, since this cause has been determined to be of chemical nature, questions of morbid anatomy have lost interest. I^oc^khart (larke mentions the discovery of areas of fluid or of granular disintegration in the gray matter and in the white columns of the spinal cord. Coates found the same appearances in the bulb and the pons. Dickinson looked upon these changes as exudations. Recent necro})- sies show extensive hypersemia, which in the course of time entirely fades away. Bruscattini studied the condition of the different parts of the organism after inoculation. He made inoculations witli emulsions of the central nervous system, kidneys, liver, blood. The animals having been killed when the sym})toms were at their height, the blood and kidneys were found virulent, the liver and suprarenal capsules innocent. The poison is dissemi- nated gradually along the course of the nerve-substance, and rather in ascend- ing than descending direction, whether it be injected directly, subdurally, or subcutaneously, after the manner of the })oison of hydrophobia. Symptomatolog-y. — The period of incubation varies from one to two weeks. Of the 75 cases recorded by Faber observed in the course of thirty- five years, the period of incubation could be accurately established in but 64. In 74 per cent, of these cases it ranged from seven to eleven days, never less than four or more than twenty-two days. In 11 of these 75 cases no contact with tetanus could be observed ; 28 of the remaining 64 cases were infected by the soil, 11 by contagion in the hospital. The disease begins, as a rule, with spasm of the muscles of mastication. Contraction of the masseters locks the jaws to produce the condition known as trismus, lockjaw. Contraction of the muscles of the neck occurs at the same time or may ])recede the conti-action of the jaws. Rose delares that the contraction of the masseters may be felt by the insertion of the finger within the mouth, antl that tiie stiffness of the muscles of the back of the neck is best recognized, as in cerebro-s])inal meningitis, by attempts to lift the body by the head. The affection of the muscles of the face soon ])ro- duces a pecidiar physiognomy. The lips are usually stretched over the closed teeth to prcMluce the characteristic smile, the riaus .iardonicus, so graj)hicaily scribe(l bv Ilippocratcs. Faj^p' sju-aks of tlu> case of a *;irl who was rcpri- maiKlod l)v licr mother on account of a siiigiihir tjrinnin*;' expression of the ia(^e, over which she had, of course, no control. This alteration of the })hvsi- ((•rnoniy gives to the patient the a])j)earan('c of ap-. ^^n•r savs a man a^ed twentv-six was taken for sixty. The disea.se begins usually mildly and increases gradually and i)rogressivi'ly. There is, iu association with the stiffness of the neck or diminished mobilitv of the jaw, some difficulty of deglutition, 'i'he muscles are affected from ai)ove downward. The spasm extends to involve the muscles of the back. Impli- <*ation of the groups of great muscles in the spine soon distorts the bod v. The whole trunk is stiffened like a statue (orthotonos), or is moiv frequently arched with its convexity upward (o])isthotonos). It is said to be sometimes arched ibrward (emprosthotonos), or laterally (|)leurosthotonos). The forearms and hands are spared for a long time. Motion, either active or passive, is soon iidiibited or lost altogether under the board-like induration of the nniscles. During these states of rigidity convulsive attacks occur with .shocks like .strokes of lightning. They show themselves iu consequence of effort, even of invohnitary effort, (^r as the result of any outside irritation, and express the intense reflex excitability of the spinal cord. In the intei-val the body assumes \\\^i position of rigidity Irom which it has been distorted by the violence of the spasm. The suffering of the j)atient at this time is indesca-ibable. The sjiasms are attended with excruciating ]>ain. The mind is pei'fcctly clear, but is weak from loss of sleep and anxiety. The ])atient may not satisfy either hunger or thirst on account of the loi-king of flic jaws. The arching of the body from (contraction of the muscles of the spine (o})isthot()nos) ])rcvcnts a proper decu- l)itus. Individual muscles, es])ecially the recti abdominis, have actually rup- tured under the ])owerful contracction, to discharge masses of blood at their eats. Rapid inci'case to 170 to ISO usually precedes a fatal termination. List(»ii declares that the ncsscU may be so nuich cxjntracted as to ])revent the escape of" a w('al,:i |)oint often of diagnostic \aliie. The bowels are constipated. There is (»ften suppression, and more fi-e(|iieiit ly retention, of urine. Diagnosis. — The diagnosis largely rests upon the early a|)pearance of trismus. Lockjaw from sore thr<»at, nnimps, synovitis, rheumatism at the tem|)oro-maxillarv articulation, shoidd be easily «listinguished l)y the most superficini examination. fhe feel of the rigid nnisseters inside the mouth and 4(i,S TETANUS. the associate stiiFiiess at the back of the neck speedily dissipate doubts. Hys- tei-ia and hystero-epilepsy may show the typical opisthotonos of tetanus, but hvsteria is, as a rule, unattended with trismus, and when trismus is simulated by the fixation of the jaws, hysteria is recognized by the fact that the intervals of attack are irregular and always entirely free from spasm or pain. The regular invasion of tetanus from above downward, first of the muscles of the face and neck, later of the trunk, distinguishes the disease from the spasmodic contractions of spastic myelitis. Cerebro-spinal and basilar menin- gitis, which have in common with tetanus stiffness of the neck and opisthotonos, almost never show trismus. They have also a diiferent origin and history, are epidemic or tuberculous, with associated symptoms, such as vomiting, headache, hyperfesthesia, herpes, etc., not seen in tetanus. Tetany is distinguished by its typical spasms of days' and sometimes weeks' diu'ation, and absolute intermissions ; by the peculiar contraction or position of the hand, Avhich may be called out by long pressure upon the nerves or arteries of the arm, the so-called Trousseau phenomenon ; by the frequent laryngo-spasm ; and by the increased mechanical and galvanic excitability of the motor nerves. Hydrophobia, which has in comuion with tetanus spasm of the muscles of deglutition, is distinguished l)v the much shorter period of incubation, by the trismus and o])isthotonos of tetanus, and by the psychical exaltation and anxiety of hydrophobia. By far the most important question in differential diagnosis concerns the recognition of poisoning by strychnine. The poisonous effects of this alkaloid are most closelv simulated bv the effects of the toxines of tetanus. The diag:- nosis rests upon the following jjoints : The history of origin where it may be ascertained, the existence of a wound, the period of incubation. Signs of strychnine-poisoning supervene at once. Tetanus begins with trismus, and gradually descends, sparing as a rule, except in children, the arms and hands. Strychnine often shows its first signs in irritation of the stomach, and in the affection of the muscles seizes by preference upon the extremities. In tetanus there is persistent rigidity; in strychnine-poisoning there are intervals of ab- solute relaxation. Thus, in the interval between the paroxysms the mouth remains closed in tetanus, but may be freely opened in strychnine-poisoning. The reflex spasms of tetanus occur later in the course of the disease, and increase in intensity, while those of strychnine occur at once, intense from the start. Strychnine-poisoning is quickly terminated by dealh or recovery ; tetamis is [)rotracted to days and weeks. Golding-Bird reported the case of a boy affected with tetanus with spasms for fifty-one days, with subsequent ]iersistent rigidity and death on the one hundred and seventh day. Eiselberg establishes as a difference between tetanus and other wound infec- tions the fact that in tetanus local Avouud reactions are entirely absent. So- called cases of rheumatic tetanus are therefore really of traumatic origin. The prognosis is exceedingly grave. Death may occur in any attack of convulsions. The heart has, actually under observation, suddenly ceased to PROPHYLAXIS.— TRF.A TMKXT. 4»i!> boat. Death occurs, as a rule, belore tlic ciul of the first week, so that, as Hippocrates said, '' jiatieuts die withiu lour days, or, if they pass these, they recover." In excei>tioual eases, however, the lata! tenniuatiou may not occur for tliree weeks. The disease rarely lasts longer in children than two or three days. The prognosis is so grave in the newly-horn that Bauer ileclares that the occasional cases of recovery have been looked upon as probable errors in diagnosis. The prognosis may be determined in some degree by the length of the period of incubation — that is, the interval between the injury and the a])pear- ance of the trismus ; tor an interval of less than ten days gives a prognosis (tf 96.6 per cent., while the general })rognosis, inclusive of the cases of long and short interval, ranges from 84 to 87.5 per cent. The ])ix)gnosis stands in direct relation to the frequency of the paroxysms and th(> rapidity of increase of rigidity. Death may take place in cases of rapid recurrence and short intervals in the short space of two to ten hours. According to Rose, 03 per cent, of cases die within the first five, and 88 per cent, within the first ten, days. The relief of the later periods is probably to be exj)lained by at least partial elimination of the toxines. Rigidity may persist for some time, even for months, after recovery. The ability to sleep is always a lavorable sign. Prophylaxis. — In ])revention of tetanus it is to be emphasized that the minutest wounds soiled with earth, dust, or foreign bodies, as splinters, are to Ije scrupulously cleaned and disinfected. The minutest fragments of splinters must be removed immediately. With regard to the fact that the secretions of tiie wounds of patients contain bacilli, and that the poison has such great resistance to desiccation, it is further strictly enjoined that all materials in contact with the wound, dressing, bandages, etc., are to be destroyed by fire — that separate intruments are to be used for such patients, and the })atients them- selves are to be isolated from otlier surgical cases. In prophylaxis of the newborn it must be observed that the wound at the navel is attended with the utmost care. The asej^tic treatment already recom- mended by various authors meets thus with scientific justification ; fi)r all the investigations concerning the origin of thoii|»s, stimulants, as wine, whiskey, or brandy, should be regularly administered. Where the act ofdeglu- 4 TO TF/rANUS. tition oxciti's spasm tlie patient may be aiia^stlietizcd, and, according to the sug- gestion of" Rose, fed tlirougli a tube, wliieh may be, as in the ease of insane or refractory patients, inserted through the nose. Foreign bodies should certainly be inimediateh' extracted and irritated nerve-trunks excised. Angry wounds, *' festering sores," may be treated with the powerful antiuiycotics, as carbolic acid, corrosive sublimate, or with the actual cautery. More extensive exsec- tion, and especially amputations, are surgical barbarities of the past. Spas- modic contractions are best relieved by the administration of anodynes. Opium, on account of its associate discomfort and distress, is better substituted in our day by chloral. A large dose, 1 drachm at first, may be followed by smaller doses, 15 to 30 grains every houi- or two, or as often as necessary to subdue spasm. Calabar bean and c-nrare have been administered with success in indi- vidual cases, sometimes of ([uestionable diagnosis, but these remedies have failed, as a rule, to secure other than temporary relief. Baccelli recommended the injection of 1 eg. of carbolic acid every hour or two until the spasms entirely ceased. Caliari reported the case of a child three years of age which cut itself in the left thumb with a kitchen knife. The father stopped the blood with cobweb. Tetanus set in in twentv-seven days, and was treated by the method of Baccelli : 1 gramme of a 1 per cent. solution of carbolic acid was injected subcutaneously three or four times a dav. At the same time there were administered clysters of potassium bromide, 0.75, and chloral hydrate, 0.25, with warm baths. Perfect cure was secured in twenty-seven days. Proof that the cobweb carried the tetanus was established by experiments on a guinea-pig and a rabbit, in whose bodies was introduced cobweb taken from the same ])lace. The animals died in three davs. The rabbit showed exquisite tetanic sym])toms. Tizzoui and CattanI, as the result of a large number of disinfection experi- ments with [)ure cultures of the tetanus bacillus, found the most effective sul)- stanee to be the nitrate of silver, which destroys the spores of the tetamis bacillus in a 1 per cent, solution in one minute; in the proportion of 1 : 1000, in five minutes. Sublimate solutions of the same strength require ten minutes. Creolin in o ])ei' cent, solution destroys tetanigenic spores in five hours; iodine in six hours; <'arbolic acid, -5 ])er cent., in eight hours; permanganate of ])otassium, 1 per crutii of inunune animals (dogs) or from the bodies of the hacteria themselves. Jk'hring and Kitasato concluded, first, that the blood of rabbits rendered imnnnie to tetanus j)ossesses antitoxic properties ; second, these properties exist also in extravascular blood, and are demonstrable in the serum of such blood free of cells ; third, these properties are so permanent that they remain effective in the organism of other animals, so that it is possible by means of the transfusion of blood — i.e. sci-um — to secure thera[)eutic effects; fourth, TREAT.UI'jyr. 471 tlic antitoxic properties do not exist in the blood of animals \vhi(Oi enjoy no irnnuniity to tetanus, and the tetanus poison introduced into the bodies of such animals remains demonstrable in the blood and other Huids after the death of the animals, A normal rabbit succumbs to the injection of 0.05 ccm. tetanus poison, A protected animal may be inoculated with 10 ccm. without injiuy. Such an animal has immunity not only against the tetanus l)acillus, but also iiirainst the tetamis poison, and may receive without damage twenty times as much poison as would be absolutely fatal to normal rabbits, hi ancient times the transfusion of blood was regarded as an heroic, but in certain cases an extremely valuable, remedy. The results obtained by these experiments with the serum of blood furnish new proof that " the blood is a very ]H'culiar juice," Vaillard was able to contirm the conclusions of Behring and Kitasato con- cerning immunity from tetamis. The serum of rabbits rendered refractory to tetanus possesses protective properties; but immunity secured in this Avay is n(»t permanent. It begins to diminish in the mouse in fourteen days, and dis- appears in the guinea-pig between the eleventh and fourteenth days. Neither aqueous humor nor the spleen of refractory animals extracted during life possesses the properties of .serum. The fowl is insensitive to large do.ses of tetanic poison, yet the serum of the fowl has no antitoxic effect. The sennn of a rabbit which had resisted every effort at inoculation had not the slightest antitoxic effect. This effect occurs only in animals to whom immunity has been given artificially. It is conferred by the injection of a large (jnantity of a filtrated culture. Thus it may be im])arted to the serum of the fowl by the intraperitoneal injection of lo to 20 ccm. of filtered culture. Schwarz i-cports a case of cure of tetamis traumaticus with the antitoxine ])repared by Tiz/oni and Cattani, This case, after failure of other remedies, yielded to the inj(»ction of antitoxine 20 ctg. The |)atient had been previously ])ut under chloroform, A j)art of the wound had been excised and the wound disinfected with a 3 })er cent, scdntion of sublimate and a 4 per cent, solu- tion of nitrate of silver. The antitoxine was injected during amesthesia, and was repeated on the following day. The patient left tlie hospital perfectly cured. The author quotes from Gagliardi a similar unpublished case in which 1 gramme of the agent sufficed to remove ail symptoms of tetanus and bring about a complete recovery. Paschini recorded a third, ( 'asali now a seventh, case rescued in this way. The treatment consists in the injection of the tetanus antitoxine obtained fioni th<' blood of a dog i-eiidered immiuie to the disease, 25 eg. being injected twice a day. Such imj)rovcment occiu-s in the course of a week as to render the further use of the rcnuMly unneees- sary, and the treatment is usually eoncluded with the hycb-atc of chloral. Unfortunatclv, all th*,- best observers do not confirm these conclnsious. Kita- sato was not able to get inuiuniity by tolerance nor by the use of fdtratcs attenuated by lu-at. Rabbits were rendered immune in 40 per cent, of cases with the trichloride of iodine, but the immunity was lost in the course of (wo months. Immunity i.> conferred upon mice by the injection of the .serum of 472 TETANUS. iininmiizcd rabl)it,s, but this immunity is lost in forty or fifty clays. The fowl is by nature immune to tetanus, but the blood of the fowl does not confer im- munity upon other animals. By the second method, Ehrlich, Brieger, and Wassermann utilize the anti- toxines developed by the bodies of bacteria themselves, after the manner of Koch with tuberculin. These antitoxines or protective bodies are to be obtained in the milk of parturient animals previously rendered immune in ])rcgnancy by the inoculation of an attenuated culture which is gradually increased in virulence. The protective principle remains in the whey after coagulation and separation of the casein, so that it may be preserved indef- initely. Some of the most sensitive of the lower animals, mice, goats, et«., liave already been protected in this way, but at the tiraeof tlie present writing no account has been published of any work with man. ACTINOMYCOSIS. By JAMES T. WIIJTTAKEK. Actinomycosis {axrcz, axrti^o::, ray ; /xOxr^::, f niigns), Big jaw, Swelled head, Bonetiiiuor; Ger. Kinn-beule, Holzzunge, Knoehenkrebs, — a peculiar infec- tion of cattle communicable to man, caused by the ray fungus, actinomyces, characterized by development of the fungus in mass with ex'cessive overgrowth of the soil in which it grows, attended by metastases to different organs, marked by symptoms of pysemia and marasmus, and distinguished always by the detec- tion of particles of the fungus itself in the mass, in its metastases, and in its discharges. Bollinger (1877) first saw the fungus as the cause of the disease known as the big jaw in cattle. In this affection, which the veterinary surgeons had considered hitiierto a purely local disease, especially of the jaw, and sometimes also of the tongue, throat, stomach, etc., and which they had called big jaw, wooden tongue, throat boil, bone cancer, etc., Bollinger discovered for the first time an extraordinary fungus as its cause. He took a specimen of it to Harz, a botanist of Munich, who gave it the very appropriate name it bears — actino- myces, ray fungus. Hereupon Bollinger designated the disease M'hich it \n-o- duces as actinomycosis. Israel of Berlin also saw the parasite in man in the year of its discovery in cattle, and described it as a new mycosis of man. Ponfick (1879) estab- lished the identity of the disease caused by it in man with the actinomycosis of cattle. In tiie first observation in man the disease ran its course as a peculiar form of chronic pyfcmia. Israel succeeded in distinguishing the ])arasite itself during life in the discharges from various abscesses from the skin, the hu-gcst «if which, as post-mortem examination subsequently showed, communicated with the left lung. Fragments of the parasite, varying in size from a niillet- seeractice of liangenbeek, a liitnl jucvertebral ])hlegmon, had deju'iuled on the same cause. In subsequent observations the author demonstrated the origin of the disease not only from teeth, l)ut also from tonsils, in whose crypts frag- •I7;i 474 A (^rrxoMYCOsrs. inente were foniui. These (>l)serv:itioiis were speedily cHjntirmed by others, so that the disease imniediately took u recoij:nized place in pathology. Belfield of Cliieao-Q first reeotrnizcd the parasite in cattle in our own country as the cause (»(■ the disease known as swelled head, technically as jaw sarcoma. Actinonivces constitutes a mass so large tis to he visible to the naked eye. It consists of" a (Conglomeration of innumerable threads of mycelia about a central mass of the same structure, from which the threads radiate in every direction to construct the ray shape. The mycelia can be always recognized by their clubbed extremities (see Fig. 29), and the mass, on an average about Kiu. 29. W0^ ^^^ 9 •m 'sMv mm *^^-: .VftinoiuycL's \\ . Jakscln. one-fortieth of an inch, is as large at times as one-tenth of an inch in diameter. Agglomerated masses may be as big as a fist. Frngments detached and dis- <'harged have a tallowy consistence and a distinctly greasy feel. Peripheral protrusions divide dichotomously, and show, as stated, distinctly clubbed or pear-shaped extremities, to resemble in certain fragments the apj^earance of a hand or glove with outstretched fingers. The j)eripheral radiation from a <'entral mass gives, under the microscope, something of the appearance of an aster or sunflower. Many deviations, however, may occur from this classical type. The size of the individual mass m;iy vary from barely visible granules iij) to masses of measurable diameter. Besides the typical yellow color, particles may be seen colorless, trans- ])arent, greenish, oi- brown. The young granules are whitish-gray, the very youngest gelatinous, almost (lifflu(>nt ; the older colonies are opaque, and the oldest yellowish-brown and yellowish-green. The surface may be gran- ulated, mulberry-form. Harz and Johne tried in vain to cultivate it. Israel finally succeeded with coagulated blood-serum, but with such different appear- ance from the normal structure as to make it impossible to decide upon the exact botanic relations of the microphyte. Bostr<)m succeeded best with granules floating free in pus or lying loose in granulaiion-tissue. Wolff finally inoculated the disease with pure cultures of actinomyces. The mass is colored with difficulty, though the mycelia at the j)eriphery absorb the aniline dyes, especially gentian violet, and retain them. Fine pictures are made with dou- PATHOLOdY. 475 l)le colorations, as by the method of Gram, and subsequent stain with eosine. (See Fig. 30.) Fio. 30. Actinomyces: Double Stain l»y Gram's Method. Tiie patholog-y of the affection differs in man from tiuit of the lower ani- mals in that the process in the animal is a local swelling, a so-called granula- tion tumor, while in man the tendency is toward a suppurative process with metastatic dissemination, so that the disease in man runs its course with the formation of multi])k' abscesses and showing the characteristics of chronic j)y{emia. The difference is explained by the belief that the process is not ])ure in man, but is attended with mixed infections, especially with the penetration of the [)yogenic micro-organisms. Of the 9 cases reported by Baracz, in onlv 1 was there a pure actinomycosis : in all the others there was subsequent infection with the micro-organisms of pus. The suppurative process in man is attended also with a distinct tendency to extensive fatty degeneration. Prej)arations of the granulation-tissue show great accumulations of fatty degenerated cells. The most tVequent avenue of entrance in man is, as stated, the cavity of the mouth, and especially tlic teeth whose surface is broken with caries; next the bones of tlie jaw ; less fre(|uently solutions of conti?uiity in the pharynx and tonsils. More than half of" all the eases hitherto observed in man have arisen in this wa\-. The origin of the disease is ascribed to the ingestion of vegetable food, especially certain cereals. The fact that the disease occurs so frcfjuentlv in cattle excites si\spicion in this direction. I*riclroper the disease gives rise to the symptoms of tuberculosis, and has been not infrequently mistaken for this disease. The gradual decline of health and strengtli, the progressive emaciation, cough, suppuration, night-sweats, make it closely resemble tuberculosis. In cases of more ra})id progress the disease may simulate jjneumonia with its glutinous muco-purulent or rusty sputa, dul- ness to percussion, and bronchial respiration. Metastatic processes from these centres disseminate the parasite to distant organs, most frequently to the sub- cutaneous and intermuscular connective tissue, and also to the various viscera — DIA GNOSIS.— TRIL 1 TMKNT. 477 liver, kidnevs, intestine, heart, and hrain. The irrnption into thi' vari»)U.s serons eavities, })leni'a, perieaixlinni, peritoneum, meninges, qniekiy ean.ses fatal inflammation. Cases whieli escape these calamities survive to succuml) to amyloid degeneration with anasarca and more protracted marasmus, the dis- ease lasting, mayhap, two or three years. In the intestine the mucous membrane shows whitish patches covered with yellowish granules, firndy adherent to the membrane upon which it rests. Various swellings appear, therefore, in its course, some of which suppurate and discharge their contents at times into the peritoneal sac, or, after aggluti- nation to the parietal peritoneum, with subse((uent discharge externally. Metastases, which are rare on account of the size of the growth, carry the disease to the liver, where the growths may attain considerable magnitude. So metastasis through the jugulars has develo})ed masses in the lungs and heart. Diagnosis. — The disease may be distinguished from ordinary affections of the jaw by its long duration, its tedious suppuration, its recurrence after incom]dete exsection, its periods of quiescence, and its defiance of all ordinary treatment. In the lungs it affects the posterior and lateral ])ortions, rarely the apices, and jn the intestine it reveals nodular masses which may, at times, be felt beneath the surface. Neither the enlargement, suppuration, nor general symptoms, how- ever, absolutely declare the disease, whose nature is only definitely established by the recognition of fragments of the parasite with the eye and its characteristic elements under the microscope. Certain apparently inscrutable cases of cryp- to-genetic infection have been unveiled as actinomycosis. One of the most remarkable of these cases was that mentioned by Bollinger of an apparently primary actinomycosis of the brain. Fischer remarks that the presence of vegetable fibres in any purulent discharges should excite susjiicion of the eti- ology of the disease. Prophylaxis includes the supei'vision of the food of animals; the avoid- ance of tlK)rny or })rickly twigs and plants, as well as of moist or wet food ; the absolute destruction, as by fire, of all actinomyces in diseased organs of slaughtered animals ; and enjoins above all things the most scruj)ulous care of the tcetli and mouth. Treatment. — The treatment is almost entirely surgical. It consists in the complete ex.section and enucleation of the (Mitiije mass with the knife or its thorougli eradication and destruction with caustic. The parasite seems to be singularly suscejitible to the nitrate (»!' silvci-. Kitttnitz cui-ed four cases witii the solid stick, aj)j)li(Hl and inserted freely in every dii-ection. Favorable results — /. ('. death of the growth and rescue of the patient — have been secured in individual eases by injections of the ferric sidphate, tincture of iodine, car- bolic acid, or coi-rosive sublimate, as also by eniitei'izatlon with zinc chloride and the internal u.^e of potassium iodide. Jiillroth succeeded in curing a case with tuberculin. ANTHRAX. By JAMPIS T. WHITTAKER. Anthrax {dvOfw.^, coal), Carbiinclf, Malignant })u,stule, Splenic fever, Bloody murrain ; German. Milzbrand ; French, Charbon, Pustule maligne ; Russian, Jaswa (boil-plague), — an ex(jnisitely acute, often fatal infection, caused by the bacillus anthracis, and chara(!terized by the formation of a boil with a black centre (anthrax), extensive circumjacent intiltiation, and subsequent sepsis; in internal form by rapid toxicsemia and the development of metas- tatic carbuncles in the skin. Anthrax existed in the most remote antiquity. It is recognized that most of the fatal plagues which formerly affected animals, and not infrequently men, correspond to the symptomatology of anthrax. The plague of murrain, with boils and blains on man and beast, mentioned in Gen- esis, is believed to be of this nature (Blanc). The disease is universal, but is manifest in intensity more especially under the primitive agriculture of the lower civilizations as connected with the nature of the soil and the food. In its internal or intestinal form it is exquisitely infectious and fatal. In San Domingo, in 1770, 15,000 })ersons perished in six weeks froui eating the bodies of animals dead of the disease. Law declares that in the worst anthrax years in some of the Siberian steppes as much as one- fourth of the wdiole population was attacked \vith anthrax. Kircher ascribes the death of 60,000 peoj^le in the vicinity of Naples in 1617 to the same cause. The bacillus anthracis is famous as the first micro-organism discovered as the actual cause of an infectious disease. It is the longest known and best studied of all the micro-organisms. The real acquisitions of modern bac- teriology, with attenuations, involutions, toxines, antitoxines, have been made n)ostly Avith the anthrax bacillus. This bacillus was first recognized by Pollen- der (1855) and Brauell (1857), but was regarded as a lifeless crystal by the op- ponents of the germ theory because it showed no motion. Davaine demon- strated its infectiousness, and Koch the growth of the rods in long threads, the formation of endogenous spores, the liberation of these spores, and their development into new rods. When it was opposed to all these disclosures that tiie symj>toms of the disease were produced by a chemical substance, anthracin, independent of any micro-organism, it was immediately demonstrated by Koch that the disease arises only from such substances as are evolved from the bacil- lus anthracis and its spores. The milzbrand bacillus is a motionless rod of elongated, jointed cells .005-.0125 mm, in length — /. e. two to ten times as long as a red blood- corpnscle — .001 to .0015 mm. broad. (See Fig. 31.) Under pro})er con- 478 ANTHRAX. 479 (litiont! it f■orms^ in the culture-soil, but nevoi- inside of the body or tissues of the living animal, endogenous spores, in which process it requires absolutely an abundant admission of free oxygen and a tietinite temperature ranging Fig. 3J. / f, -* Bacillus Anthracis. between 18'' C. and 34° C, best at 30° V. It is easily colored by any of the aniline dyes and readily yields its color. The sjiores are colored with grciit difficulty, so that double coloration is easy. Anthrax bacilli, like all endogenous bacilli, are not very tenacious of life, but the spores are extremely resistant and constitute the permanent forms. The bacilli ])erish under desic- cation in several days ; the spores resist it for many years. They can Avith- stand a 5 ])er cent, solution of ciarbolic acid for thirty-seven days, while the bacilli are destroyed by a 1 per cent, solution in ten seconds. I)ecomj)osition or the action of the gastric juice quickly destroys the bacilli, but fails to attack the spores. The ingestion of meat free of spores produces no infection ; the ingestion of meat with spores infects infallibly. This destruction of the bacilli is probably jteptic — /. c. metabolic. ]t is certainly not due, as formerly believed, to the action of the hydrochloric acid of the gastric juice, for Dyrmont demonstrated that milzbrand bacilli maintain their virulence forty- eight hours in a ] j)er cent, solution of hydrochloric acid ; wh(!rcas the gas- tric juice of man contains at most but 0.2 per cent of hydrochloric acid. Freezing affects neither the bacilli nor the spores. Anthrax infects chiefly herbivora, next onniivora, among which is man, and least of all carnivora. The disease is therefore not quite so dangerous in man as in some other animals. The ba<;illus anthracis is a sa])roi)hytc. It goes through with all its phases of development outside, and makes only acci- dental incursion into the body of man. Martin succeeded in extracting from cultures certain chemical products: first, ))roto- and dcutero-albumose ; second, an alkaloid ; third, small (|nantities of leucin and tyrosin. Mice injected with the proto- and i(tpliylactic against the disease. Anthrax is peculiarly malignant in small animals. It is so surely and (|uickly fatal to mice, guin(!a-]»igs, and rabbits as to make ol" tlicir bodies flic i)cst physio- logical tests in c^ise of tloubt as to the nature (»f a micro-organism. Anthrax is usually citnvcycd to man by contact with a diseascHl animal oi' bv the ingestion ol it- Mcsli as food. Indisidnals most chf-cly coinicctcd with 480 ANTHRAX. cattle are cliieHy affected — butchers, stable-boys, shepherds, veterinary physi- cians, etc. On account of the great tenacity of the spores people who come in contact at anv time with the skins, hairs, bristles, cloths, horns, or hoofs — as tanners, brnshraakers, upholsterers (horse-hair), wool-sorters, rag-sorters, glue- makers, etc. — may be affected through open wounds in the skin or through inhalation of dusts. Since Bollinger demonstrated the bacillus in the stomach of carnivorous flies and with Raimbert and Davaine produced the disease by inoculation -with the stomach, legs, and feelers of these insects, it must be admitted that malio-nant pustule may be conveyed by insects. It had long been remarked that malignant pustule occurs more especially on the exposed parts of the body, face, and hands. Bell of Brooklyn found 56 of 60 cases on the face, 2 on the hands, 1 on the Avrist, and 1 on the forearm. It was evident that the bite of !x fly or mosquito had often originated the disease. Extensive epidemics have been caused, as stated, by the ingestion of raw or insufficiently cooked flesh. Animals rarely contract the disease from each other; they get it from the soil. It has often been observed that certain regions are centres of infection wherein the disease shows itself year after year. The superficial burial of carcasses leads to infection of the soil, which, once produced, is seldom eradicated. The disease is spread chiefly in the warm months of summer, when the soil is softer, bv animals grazing upon its surface, and is transported by streams of water, which convey the infected soil to a distance. Floods may disseminate the dis- ease to places previously free. Stable utensils, fodder, hay from anthrax fields, litter, harness, sui'gical instruments, have been known to convey the disease. The foetus is not infected as a rule. The placenta when sound acts as a filter. Exceptional cases have been accounted for by lesion of the placenta. Immunity is not secured by a single attack. Morbid Anatomy. — There is usually marked cadaveric rigidity, some- times, but seldom, cyanosis. Decomposition occurs early. The blood, which is black, thick, and uncoagulable, shows, especially in the lungs, liver, kid- neys, and spleen, abundant bacilli or spores. The skin, when the disease has located itself in its structure, shows the signs of an extensive destruction of tissue, with intense oedematous infiltration, sometimes with gangrene. The outlying lymphatics are swollen and luTemorrhagip. In the internal mycosis the surface may show metastatic carbuncles and petechi;^. The spleen shows constant lesions (hence the terms splenic fever, milzbrand). It is increased to double or quadruple its natural size, and is distended with blood, often to rupture. Sometimes it shows gangrene. When the affection originates in tiie intestine this structure shows hsemorrhagic infiltration and gangrene. The retro-peritoneal lymph-glands and mesenteric glands are hyperaemic and haem- orrhagic. Hiemorrhages into the serous sacs, degeneration of the heart-mus- cle, of the liver, and of the kidneys, belong to .this disease, as to all the ex- quisitely acute and grave infections. Syin])tomatolog-y. — The disease presents itself in two distinct forms — one as it originates externally, the other internally. The external disease is the SYMPTOM A TOL O G Y. 48 1 antlirax, malignant pustule, or oliarbon, with its lesions in the skin and sub- jacent tissues: the internal is the intestinal or thoracic mycosis, which is recognized by the general signs of toxicsemia, the nature of which may be, if unsuspected, overlooked. The external disease is confined to individuals ; the internal may assume, as stated, endemic and epidemic proportions. The period of incubation varies from one to several da)s. Symptoms may show themselves in a few hours after inoculation ; they may be delayed as late as four days. A slight itching, prickling, or burning sensation is first per- ceived on the face or neck at the site of inoculation. Sometimes the patient feels as if he had just been stung by an insect. Very soon there appears a pap- ule with a central vesicle, the rupture of which discharges bloody contents, to be converted into a dark red-brown or black crust, the anthrax. Smaller vesicles may appear about it. The parent nucleus, as Virchow called the first eruption, rapidly extends, the skin swells about it, becomes indurated, livid, and hard. The subcutaneous tissues are extensively infiltrated with serum. The appear- ance is characterized as a " brawny oedema," wdiich rapidly spreads to involve a mass of tissue, the whole of one arm or of one side of the neck, in the course of a few days. Lymphangitis and swelling of the lymph-glands with phlebitis are frequent complications. For the first day or two there may be no disturb- ance of the general health. The patient may even continue at w^ork, but toxic signs set in, as a rule, by the end of the second day with delirium, diarrhoea, sweating, vomiting, and collapse, and so the patient may die of heart failure in five to eight days. This result, however, is not so frequent as was formerly- supposed. In the majority of cases the local inflanmiation begins to abate in the course of a few days. The anthrax sloughs off and the subjacent ulcer closes over by granulation. A subvariety of this condition was first described by Bollinger as anthrax oedema. In this form the local lesion is absent. Tiic poison seems to be introduced more deeply into the tissues, and chemical products produce an oedematous state of wide area. This variety is most often noticed in the region of the eyelids. The internal mycosis announces itself more distinctly as an infection. The disease begins suddenly with chill, pain in the head and joints, vomiting, and diarrhoea. The case looks like a poisoning, which it is. Free haemorrhage may occur from the mouth, nose, and kidneys. Nearly always (excei)tions being noted by Bouisson) there is an outbreak upon the skin of small, |)lileg- monous, carbuncular inflammations, the so-called metastatic carbuncles. Ti)ere is jisually but little fever. Tiiere may be much delirium, convulsions, some- times oj)isthotonos. There is often precordial anxiety and intense dyspnoea. Cyanosis and heart failure usually precede the termination, which may occur in the course of a very few days. Where tlie disease originates in the chest, respiration soon becomes difficult, though auscultation reveals, as a rule, only the signs of a light bronchitis. Diarrhfjca is usually absent. The nervous system may be depressed or so little affected as to lead jjatients to decline medical advice even a few hours bcibro Vol.. I.— .'?i 482 ANTHRAX. death. The case bears the aspect of a rapidly-spreading pneumonia with heart faikire. Most of these cases succumb in three to five days. Bell declares that they who survive for a week recover. This form of the disease has been observed more especially among the sorters of wool. Most of the fatal cases have been hitherto unrecognized. Bell thinks that many of the cases diagnos- ticated as pneumonia, bronchitis, congestion of the lungs, etc., occurring among workers in carpets, blankets, furs, etc., are really cases of thoracic anthrax. It is not improbable that some of the cases ascribed to poisoning by mush- rooms, meat ptomaines, etc. are really cases of intestinal anthrax. Diag-nosis. — Anthrax is distinguished by its origin as a red papule with a 'dark centre and its rapid extension with brawny oedema. The black central crust is absent, and any extensive surrounding inflammation is absent in a common boil or furuncle. Carbuncles show themselves much more frequently on the back of the neck, trunk, and extremities ; anthrax occurs on uncovered surfaces. Anthrax spreads from one central point or parent nucleus; carbun- cle results from the coalescence of a number of points. Anthrax oedema in the absence of a central papule is distinguished by its sudden appearance, its yellowish-green hue, and septic symptoms. Erysipelas is more superficial, has no anthrax or parent nucleus, and shows no bacteria in the blood. The diagnosis of intestinal and thoracic anthrax is sometimes reached only by exclusion : the nature of the avocation, the exposure to the cause, is the most common index to the condition. The sudden occurrence in the midst of health of the intense signs of a grave infection — headache, nausea, and vom- iting, dyspnoea, cyanosis, convulsions, free hseniorrhage, especially skin car- buncles — in connection with the history of the exposure, should lead to the recognition of the disease. In any case of doubt the diagnosis may be estab- lished by the examination of the blood under the microscope or by a physio- logical test. A rabbit, guinea-pig, or a mouse shows dyspnoea, dilatation of the pupils, and convulsions, with death in the course of two or three days after inoculation. The blood of these animals swarms with bacilli. The prog-nosis is always grave ; that of malignant pustule depends upon the stage of its recognition. The disease can be always eradicated at first. In places where its picture is familiar and where the disease is attacked at once, the mortality is reduced to 5 or 9 per cent., and even this mortality is ascribed to delay in treatment. Under neglect the mortality may reach 50 to 60 per cent. Intestinal and thoracic anthrax, being recognized only after general infection, have always, at least at present, a fatal prognosis. Prophylaxis consists in the proper disposition of the bodies of dead animals by deeper burial or by cremation ; in the avoidance of the use of the hides or other products of these animals ; in the destruction of their discharges, as by fire; in shutting off affected pasture-fields, damming up streams of water, etc. ; in the abundant use of disinfectants — carbolic acid, chloride of lime, cor- rosive sublimate — in handling suspected wools, horn, and other products; and in the protective inoculation of cattle and sheep with attenuated cultures or antitoxines. TREA TMENT. 483 Treatment must be radical. Every local manifestation must be attacked promptly and powerfully. Before absorption a diseased mass may be excised, or incised as by crucial incision, and thoroughly and profoundly cauterized, by the actual cautery, by caustic potash, or by a concentrated solution of car- bolic acid or corrosive sublimate. Carbolic acid may also be injected subcu- taneously — 5 to 10 per cent, solutions — especially in a case of anthrax oedema. Cauterized surfaces should be dressed with weaker solutions of these or similar antiseptics, as of iodized phenol, 1 : 100, or creolin, 1 : 50. Camera best expresses the principle of treatment with the most successful practice in countries where the condition is most frequently encountered, as follows: The mass is to be circumscribed by a deep incision and penetrated by numerous crucial incisions. In the bottom of all these cuts is to be strewn corrosive sublimate itself in powder, gr. 0.04-0.15. The liquefaction of the sublimate produces extensive, thoroughly penetrating destruction of the entire mass. Where the surface is so great as to lead to the fear of poisoning by the sublimate itself, its action may be modified and poisoning prevented by admix- ture with a proportion of calomel. Weil first anesthetizes the mass \\\\\\ cocaine, scoops it out, and applies to the wound dressings saturated with a 1 per cent, solution of corrosive sublimate. Contento injects into, under, and about the mass, subcutaneously, 3 per cent, solutions of carbolic acid. In the ojdematous form the whole infiltrate must be abundantly scarified, cut deep down to the healthy tissue in the same way, and dressed in solutions of iodine and carbolic acid. In cases of general infection metastatic carbuncles are to be treated in the same way, and the patient supported with brandy or subcutaneous injections of ether, camphor, or other analeptic. Defi)rmities about the nose and lips, which may follow destruction of tissue, may be subsequently relieved by jilas- tic operations. The therapy of internal anthrax is wellnigh hopeless. Where it is known that poisoned meat has been ingested, the stomach should be immediately washed out or a powerful emetic administered, followed by a purgative dose of castor oil. For an internal mycosis it has been recommended to administer carbolic acid in doses of 3 to 5 drops three or four times a day. It might be better to saturate the blood with creasote, as in the treatment of the sepsis of tuberculosis, and with alcohol, as in ])oisoning by snake-bites. Not much hope is to be entertained of either plan. The hope which seemed justified by the experiments of Fodor regarding protection by saturation of the blood with an alkali has proven futile, according to the subsequent investigations of Chor. Future success must be obtained i)y means of toxincs or antitoxines. llankin of Cambridge finds defensive proteids in the serum of the blood of certain animals. There is a protective albuminoid, a non-dialyzablc globulin, insol- uble in alcohol and water, in the blood and spleen of a rat, which nMuicrs a mouse immune against the most violent anthrax. The same matter from sus- ceptil)le animals has, however, nuich less destructive elTcit, and does not confer the same immunity upon mice. Wild rafs, whi<-h enjoy natural immunity, lose 484 ANTHRAX. it when put upon a diet of bread, and, losing it, lose also protective proteids in the blood. Very young rats, which are susceptible to anthrax, contain only traces of the protective proteids. Kostjurin and Krainsky reached the con- clusion that certain toxines from decomposition, introduced at the proper time into the bodies of rabbits affected with anthrax, totally prevent the develop- ment of the disease. The toxines must be obtained from decomposing extracts freshly prepared and well protected against the influence of light and air, else they inhibit, but do not prevent, the development of the disease. The injection must be made in five to eight hours after the inoculation, though it may be sometimes effective after twenty-four hours. More perfect results are obtained by repetition of the injection on the third or fourth day. The dose for the first injection is 0.1 gr. ; for repeated injections, half of this amount, 0.05 gr. The essential principle in the extract is not the product of a definite micro- oro-anism, but a number of them. The addition of the smallest amounts (0.1-1 per cent.) to the culture media totally destroys the virulence of anthrax bacteria without in the least hindering vegetation. Ogata and Jasuhara claim that the blood of immune animals — e. g. dog and fowl — contains a ferment which, injected subcutaneously in but one- or two-drop doses, acts as a certain preventive and curative remedy. This fer- ment also prevents the development of the cholera and typhoid bacillus. These disclosures of much promise have not yet been utilized in the treat- ment of anthrax in man. HYDROPHOBIA. By JAMES T. WHITTAKER. Hydrophobia (ixJcop, water, (f<6[:ioz, fear) ; Gi-eek, Lyssa, Xuaaa, rage ; Latin, Rabies ; French, La rage ; German, Wuth, Hundswuth ; Italian, Rab- bia; Swedish, Hundsjuka, — is an intensely virulent infection of the lower ani- mals — dog, fox, wolf, cat, and skunk, in the order of decreasing frequency — communicable also to man, having the most variable, often the longest known, period of incubation. It is distinguished by melancholia, terror, intense hy- peraesthesia of the medulla, evinced as a spasm of the pharynx and larynx excited by attempts to swallow or the presence or the mere thought of liquids, and a subsequent very short stage of paralysis, and almost inevitable death. The name is appropriate as expressing the most prominent symptom of the disease in man, but is inappropriate for the lower animals, as precisely this symptom, the fear of water, so obtrusive in man, is in them entirely absent. Emphasis should be laid upon this point at the start. The gravest errors have arisen in consequence of ignorance or disregard of it. Rabid dogs have been considered safe because they drank water. Rabid dogs love water. Rabies is with them a hydrophilia rather than a hydrophobia. It is strange that while the disease appears to have been known to the ancient Indians, Egyptians, and Israelites, Hippocrates makes no mention of it. Aristotle (322 b. c.) recognized it unmistakably in dogs : " Dogs suffer from rabies. This induces a state of madness, and all animals who are then bitten by them are likewise attacked by rabies." Democritus considered it an inflammation of the nerves allied to tetanus. It is mentioned by Virgil, Horace, Ovid, Plutarch (130 b. c). Celsus, who first uses the word, speaks of it as the disease which '' udo)fj(fOj3cav Grceci oppellnnt." The wound should be sucked out, he says, by means of dry cups, and should be afterward destroyed by the actual cautery. If the wound be not so treated, hydrophobia ensues — "a most deplorable malady, one in which no hope of recovery can be enter- tained." Galen declares hydrophobia to be the worst of all diseases, and recommends excision of the wound in protection against infection. Cfclius Aurclianus discusses its modes of origin and absorption, the differential diagnosis from inflammation of the brain and mania, the course of the dis- ease, and its treatment. A thorough elaboration of the symptomatology in tiie lower animals as well as in man is chiefly due to English observers, especially to Youatt. Pasteur has connected his name with hydrophobia for all time by his studies of prophy- laxis — studies which established the nature of the disease as an infection whose 48J 486 HYDROPHOBIA. symptoms are clue to toxines from some as yet undiscovered micro-organism, and which fixed the fact of the first importance that rabies may in no case arise spontaneously, but always and only from itself. Hydrophobia, like syphilis, is communicated by inoculation through a broken skin, and, while it may be transmitted by any animal, it is actually communicated to man in the great majority of cases, 90 per cent,, by the bites of rabid dogs. It is therefore essential to a true understanding of rabies, as well as to the prevention of the disease, that some knowledge should be had of its main features in the dog. Rabid dogs are mad, but mad dogs are not necessarily rabid. Mad dogs may be only angry or insane, for dogs are very near to man in nervous organization. The popular idea that a dog in a fit is mad is wrong. Epilepsy is not rabies. The idea that rabies is more com- mon in summer is not incorrect, though the ratio of cases is not greater than 7 to 15 per cent., and this increase is not due to temperature, but solely to the increased number of inoculations. It is a period of rivalry and wrangling, intensely heightened by the cruel disproportion of sex. The preponderance of male dogs affected (10 to 1) has always been observed, and is readily under- stood, for dogs are actually more considerate to their females than are men. It is now known, however, that rabies is not due to lack of sexual congress. Habies is communicated by the saliva, but is not confined to that secretion. Paul Bert found bronchial mucus virulent. Eckel and Lafosse communicated the disease with the inoculation of blood — Lafosse from dog to dog, Eckel from goat to sheep and from man to dog. Saliva has been repeatedly successfully inoculated from numerous animals, as by Berndt from ox to sheep, by Eckel from goat to sheep, Rey from sheep to sheep, Lessone from ox to horse and sheep, Youatt from horse and ox to dogs, and Ashburner from ox to fowls. King from cow to fowls, Earle from man to rabbits, Majeudie and numerous other observers from man to dog. The disease has been communicated acciden- tally from horse to man, from sheep to shepherd, and from man to man (Law). The average period of incubation in the dog is from thirty to fifty days. It varies, however, from six to two hundred and forty days. It is certain that the animal may communicate the disease during the whole of the period of incubation. As a rule, there are no symptoms until the end of it, when there is observed some change in the disposition ; and any change of this kind is to be regarded with suspicion. In some cases there is unusual dulness and indifference, and in other cases unusual vigilance and nervousness. A morbid appetite, which leads the animal to pick up foreign bodies or devour its own excrement, is very characteristic. A dog which, hitherto affectionate, becomes morose and resentful should be regarded with distrust. Per contra, a sudden excess of affection in a dog hitherto lacking in this regard may betray the dis- ease. If a social dog seeks seclusion or bears punishment without a cry, he is to be strongly suspected. " Barking without object, constant moving and search- ing and scraping, a disposition to tear wood, clothing, etc. to pieces, and, above all, absence from home for a day or two, should beget grave apprehensions" (Law). A dog in this stage of rabies is in a state of suppressed excitement, SYMPTOMA TOL OGY. 487 to which, with uplifted head, he gives vent from time to time in a hoarse and muffled howl, a cross between a bark and a howl, the so-called rabid bark or howl, wherein one loud sound is followed by several others in diminishing force. It is impossible for a mad dog to keep (piiet; he must wander; lie makes long excursions, it may be of many miles, flying at any animal or man he meets as if possessed by demons. In a state of evident mania he is seized with paroxysms of wicked fury or is at intervals affected with evident hallucina- tions. A mad dog will oflen glare into vacancy, then suddenly collect him- self, as from some horrid dream, with a violent start, jump to his feet, rapidly open and close his eyes, wrinkle his forehead, snarl and snap at an imaginary foe, or viciously attack any object, animate or inanimate, that he can reach, or he will gnaw to shreds an offending paw or tear off j^arts of his own body. He will seize and hold a stick of wood or iron bar until his teeth are broken or dislodo-ed. Finallv, exhausted bv his efforts or in the further course of the disease, he gradually sinks into a state of paralysis, shown first as a para- plegia, a weakness of his hind legs, with swaying motion in walking, and by the fall of the lower jaw, which permits the escape of viscid saliva, which he still makes frantic efforts to detach. The manifestation of ]>aralysis pres- ages death, which occurs in the course of eight to ten days from the beginning of the disease. Throughout this whole period there is, as stated, never any hydrophobia. The dog suffers intense thirst, which he attempts to allay l)y plunging his head in water and lapping every fluid he meets, including his own urine. So far from showing aversion to water, he rather seeks it, and in his journeys will swim a river rather than turn from his course. In about one-fifth of the cases the second stage — that is, the rabid stage — is entirely absent in the dog. The disease passes at once from melancholia to paralysis. In tliese cases there is an absence of the desire to destroy and to bite, as well as of the impidse to wander away. Paralysis may set in in the course of a single day, to show itself first in paresis of the lower jaw, which drops to permit the more or less constant escape not only of saliva, but also of everything taken into the mouth. The animal is at first able to close the mouth under ])owerful effort, as after extreme irritation, but rapidly loses the power altogether. Paraplegia soon sets in, and the animal dies within two or three days. Timid animals, like foxes or badgers, lose their shyness; wolves become still more ferocious; cats are less liable to attack, but do not hesitate to use teeth and claws on occasions ; infected horses and cattle bite and kick, and even fowl show disposition to inflict wounds with the beak. Animals affected with rabies are therefore truly said to be " mad." The disease prevails verv much less in some countries than in others, though statistics in the same country vary at different decades or centin-ics. Prevalence or absence in a country is of course wholly a matter of introduction and inoculation. Thus, hydrophobia was most common in Prussia in the last century, in one decade of which there were reported 1()G() deaths, whereas at the present time the disease is actually nidatt insists, however, that tliis con- 490 HYDROPHOBIA. dition of the stomach is often found in or after other diseases, and that a diagnosis may not be declared from post-mortem evidence alone. From almost the first recognition of the disease in man attempts have been made from time to time to deny its existence altogether, and to consider hydro- phobia a fright and form of hysteria or of tetanus. The fact, however, to say nothing of inoculation experiments in animals, that so many children under the ao-e of five — 9 per cent, of all cases in France — and so many idiots and imbeciles, in whom the imagination could play no role, have succumbed to the disease, sufficiently disproves this view. The symptoms, as will be seen, dis- tinctlv differ from tetanus, and the most that may be said of the hysterical origin is the fact that hysteria may simulate hydrophobia or any other disease. Notwithstanding the searching investigations at the hands of the best observers, especially in connection with the study of prophylaxis, the cause of hydrophobia remains unknown. The analyses of chemistry have failed to disclose it. No specific micro-organism has been detected in the saliva or other fluid, and no distinct toxine has been eliminated from any of the secre- tions or tissues of the body. The poison is in all cases fixed, never volatile. It is produced only within the body, never outside of it. It acts in every respect like a chemical poison which is evolved from micro-organisms, but differs from all the known poisons by the length of time in which it may remain innocuous in the body. Other secretions than the saliva, as well as the flesh of animals, as a rule, fail to convey the disease. Though the poison is in the cord, the cerebro-spinal fluid is not infectious (Wyssokowicz) ; the aqueous humor is certainly not infectious (Cardelli) ; the gastric juice destroys all virus (Wyrskowski), as is shown by the fact that a fox ate without dam- age the cords of several affected foxes and dogs (Nocard). The poison of hydrophobia (rabies) is certainly fixed in the nervous system in the large nerves, and especially in the medulla, and eminently in the salivary glands. Introduction of matter from these tissues directly into the brain (dura) develops the disease in from two to seven days; introduction into other parts of the body develops the disease only after a long interval — one to six months — as after bites of rabid animals. Whether the blood be infectious is a ques- tion upon which authorities are nearly evenly divided. It is probable that the blood is infectious only for a short time, and that it then secretes the poison in the nervous tissue. The injection of large quantities of a concentrated virus directly into the blood not only does not infect large animals (sheep and goats), but actually protects them against inoculation even after trephining. Roux, Nocard, and Protopopow confirm this fact and propose to utilize it in prophylaxis. Helmann found that the introduction of concentrated virus into the subcutaneous tissue not only did not infect, but absolutely gave im- munity to, dogs, moid-ceys, and even rabbits. Thereupon, Ferran ventured to inject as much as 40 ccm. of the "virus fixe" into the subcutaneous tis- sue of man in the treatment of hydro]>hobia. Pasteur found such injections sometimes fatal to dogs, and Celli succeeded in producing rabies in ten to MORBID ANATOMY. 491 twenty clays after the introduction of the cord of rabid animals into the peritoneal sac of rabbits. Various theories have been proposed to account for the long latency of the disease — to wit: First, the virus inoculated remains latent at the wound until it may accumulate to sufficient extent to inundate the blood and the body. This view would seem to iind support in the prevention of the disease by the exsec- tion or destruction of the wound ; but the fact that the disease may be con- veyed at any time during the period of incubation is a sufficient refutation of it. Second, that the poison is not taken up by the lymphatics about the blood- vessels, but travels slowly along the course of nerves until it finally, in the course of weeks or months, reaches the central nervous system. This mode of invasion has been more frequently considered in tetanus. Einhorn went so far as to declare that he had been able to trace up a line of inflammation along the course of the ulnar nerve in a case of hydrophobia. The nerves on the bitten side contain more virus than those on the sound side (Roux). Third, the poison lies latent at the wound, and from it chemical products are gradually introduced into the blood, but are neutralized from time to time by the serum of the healthy blood, by the so-called protective proteids which act as antitoxines or antidotes, until finally they fail to permit intoxication. This view has now the best support. It accounts for the esca})e of so many cases, with the simultaneous infection of others. It furnishes an explanation of the fact that the bite of a dog in the stage of incubation may be, but is not always, infectious. It accounts also for the favorable influence, even to the prevention of the disease, of the destruction of it at its origin. It allies it with other poi- sons, as in a case of septicaemia, where the removal of a local depot may put a stop to a long train of septic signs. This view is, however, only a theory as yet. It is claimed by the Pasteur school that exsection and cauterization will not prevent infection, any more than such treatment will prevent vaccination. Escape from infection in this doctrine means failure of inoculation. Morbid Anatomy. — Notwithstanding the tempestuous and terrible signs of the disease, little or no lesion may be discovered upon autopsy. The symp- toms are explained by the action of a virulent chemical poison which does its work, disappears, and often leaves no trace. The negative evidence thus en- countered is testimony of great value. Some signs of catarrhal inflammation are usually to be seen in the throat, more especially in the larynx. The lungs show both hyperemia and oedema. Spots of ecchymosis are sometimes found in the pericardium and heart. The kidneys are deejily injected ; the e})ithelial lining of the tubules is more or less opaque, and sometimes shows molecular degeneration. The blood is black and thick. The only really important changes are encountered in the brain, and very frequently they are entirely lacking. On removal of the calvariinn the brain is found wet. The longitudinal sinus is filled to distension with fluid, black blood. Sometimes there is evidence everywhere of extensive hyper.Tmia. The only changes which can be said to be at all characteristic are microscoi)ic, and tluiv are, with the rest, sometimes entirely absent. The suiall vessels are 492 HYDR OPHOBIA . dilated, and invested upon their exterior with leucocytes which invade also the circumjacent tissues. These changes are most marked in the medulla and the upper part of the spinal cord, as well as in the cerebral cortex, whence the symptoms of hydrophobia arise. (See Figs. 32, 33.) Gowers observed this condition in 7 of 9 cases. Emigration or accumulation of leucocytes is at times so great as to fill up the whole space within the lymphatic sheath. Fig. 32. Fig. 33. , f.//"f m% mwmmii^^^ Fig. 32.— Hypoglossal Nucleus : leucocytes around a vessel and extending into the adjacent tissue (Gowers). Fig. 33.— Accumulation of Corpuscles ("miliary abscess") in the Fibres of Origin of the Hypoglossal Nerve (Gowers). The.se escaped and accumulated cells constitute what may be called miliary absces.ses. In association with them are observed at times small heemorrhages, seldom large enough to be visible to the naked eye. This perivascular accu- mulation of leucocytes, especially in connection with the vessels of the medulla and cortex, constitutes the most constant and characteristic lesion of hydro- phobia. Unfortunately, as .stated, this sign, with all the rest, is sometimes entirely absent. Symptomatolog-y. — Hydrophobia is divided into three stages — the melan- cholic, spasmodic, and paralytic. The disease is usually announced by changes at the seat of the wound, which, as a rule, has long since healed. There is, it may be said, nothing in the nature or course of the healing process in an in- fected different from that in a simple wound. The bite of a mad dog heals as quickly and kindly as that of a healthy dog. The wound may .show no change from the beginning to the end of the disea.se. Sometimes no trace of it can be discovered, but not infrequently, as stated, inflammatory changes set in at the cicatrix, which may become reddened or swollen. The wound may open anew or become the seat of pain, itching, numbness, or other parsesthesia. Sometimes pain i-adiates from it in various directions. Sometimes the first feeling is in the nose or throat, a sneezing, a dryness, or a rawness which is considered a " cold." A peculiar state of depression or irritability .soon sets in, sometimes sud- denly, with headache, anorexia, insomnia, anxiety. Mental symptoms assume ])romincncc according to the temperament of the individual. A man may deny the fact that he ever was bitten by a doo;, while he is unable to divert .SVJirTOJfA TOLOG Y. 493 his mind from the actual occurreuce and the terrible consequences which are liable to ensue. The inquiry or suggestion of" a thoughtless, meddlesome, or inquisitive neighbor will plunge the strongest man into melancholy or mania. The mental distress is, however, always an exaggeration of a state of appre- hension, of a sense of impending danger or imminent death, and, though a man may show under the stress of this suffering signs of insanity, there is no time when he may not be recalled to himself by a right address. A patient affected with the first stage of hydrophobia is a pitiful })icture. He sits quietly, apparentlv listlessly, his whole mind intensely concentrated u})on the one thought, from which no a[)peal or address may really divert him. It is only in the very first hours of the attack that he may find relief in walking about or in change of scene. He soon becomes exhausted, and sits with an expression of intense anxietv, to which he makes total surrender. At the same time, the special senses are keenly alert, so that a flare of light, a draught of air, a noise, may produce intense excitement. The very first day shows the characteristic sign of the disease, the fear of ^<^ater. The patient suffers with thirst, but is unable to allay it. He may make the attempt, may succeed at first in swallow- ing a mouthful or two, but soon abandons it, either on account of the intense suffering which ensues or from the fear of its certain following. An unmis- takable sign of the disease is the occurrence of burning, more especially a sense of tightness or constriction, of the larynx. The fear of water is the fear of exciting s})asm of the larynx, and the reflex excitability of the larynx becomes so intense that spasm is later precipitated by the sight, the sound, or the mere thought of water or the mere sight or touch of a smooth or cold surface. A coachman under Watson's observation had to desist from sponging himself, according to his habit, M'ith cold water, though he said he "could not think how he could be so silly." Frequent sighing is a common sign at the inception of the disease. The first stage usually lasts about twenty-four hours, when the second stage, the spasmodic or true hydrophobic stage, sets in. This stage is characterized by an exaggeration or an intensification of the spasmodic con- traction of the larynx. Every attempt to swallow is attended with frightful anxiety. The contraction is so powerful as to lead to dyspnoea, with maniacal excitement. The patient may strike about in every direction, roll his head from side to side, while the mouth opens and closes convulsively, sometimes with snapping sounds, whereby wounds are occasionally inflicted upon minis- tering hands, and the disease has actually been conveyed in this way. These convulsive seizures gave rise to the stories that hydr()i)hobic patients bite and snap like dogs, and led, through the fear whicii they excited, to the cowardly assassination of i)atients by shooting them down— a practice still in vogue on the confines of Austria — or by smotliering them between feather beds. The })aroxysms seem all the more dreadful because they are attended with the escape of glutinous, foaming saliva, which is sometimes ejected with great force in every direction. Tnsjiiration is also attended with gaping and sighing and various sounds, sometimes simulating the baik and howl of dogs. These 494 HYDROPHOBIA, symptoms occur in paroxysms, in the intervals between which the mind is clear, though sometimes, in those of highly nervous temperament, it may be excited to show more persistent hallucination. The pulse is quickened and rendered irregular, but with all the struggle there is, as a rule, but little ele- vation of temperature. The inspiratory spasms and convulsive attacks may cease entirely. The patient may become able to swallow with perfect ease. The recovery is illu- sorv, as the case usually suddenly succumbs to heart failure. The second stage is thus characterized by the severity and intensity of symp- toms. It is easy to be seen that the convulsions are in all cases of reflex ori- gin, and the disease is characterized by extreme hypersesthesia of the medulla, wiience the convulsive manifestations emanate on the very slightest outside irritation. Another distinguishing feature is the mental anguish, the unspeak- able terror, which is depicted upon the face. During the paroxysms the patient may lose his self-control. He may foam at the mouth, make snapping move- ments in convulsions, whereby he may even accidentally or apparently pur- ])osely inflict wounds upon attendants, but so soon as the paroxysm is over he recovers consciousness, and usually apologizes pitiably for his excess. He may even warn his attendants to subject him to greater restraint in protection of themselves. The employment of any forcible measures, however, as a rule, aggravates the explosion. The second stage usually lasts from one to three days, rarely as long as four days. The patient now becomes gradually exhausted. Paroxysms occur, but they are less intense. The extreme anxiety of mind is diminished ; there are intervals of nearly complete tranquillity. It is plain to see, however, that while the breathing is easier and the explosions less severe, and while there may be even ability to swallow, the patient becomes more and more prostrated and reduced. The strong man is broken. The heart's action is weak, the ])ulse flutters, the surface is covered with a cold sweat. The movements of the body are so much enfeebled as to present the appearance of paralysis ; hence this second stage has been characterized as the "stadium paralyti- cum." Death, which may occur suddenly in a convulsion or from as- j)hyxia, usually comes on quietly from failure of the heart. Hydrophobia is, as stated, an exquisitely acute infection. However long the period of incubation, the whole duration of the disease proper is measured in a few days. Of all cases, 82 per cent, perish in from two to four days. Individual cases may succumb in two, or may last as long as five or six, days. The diagnosis is generally easy, and rests chiefly upon the heightened reflex of the medulla as manifested by S])asm in the muscles of deglutition and respiration. The disease is differentiated from tetanus by its much longer period of incu- bation. Tetanus occurs in from three to ten days after the wound or injury. Tetanus usually begins with trismus, and is often attended with opisthotonos. It lacks the laryngeal symptoms and spasms of hydrophobia. It lacks also PROGNOSIS. 495 the psychical exaltation and mental anguish of hydrophobia. Tetanus aiay also be distinguished by its special niiero-organism. The disease is often distinguished with irreat diflficidtv from the imao;inarv condition known as lyssophobia, or fear of hydrophobia. These cases have a common origin, though in the one case the wound comes from a non-affected animal. It might be imagined that lyssophobia occurred more frequently in nervous subjects or in women. This is not tiie case. The strongest men have suffered, and not infrequently actually succumbed to fright or fear of hydro- phobia. Some of these cases have been rescucxl by knowledge of the fact that the animal was not rabid ; hence the advisibility, when possible, of secluding the animal, that the existence or course of its disease may be observed. The fact that the animal recovers at all almost necessarily excludes hydrophobia. Abundant cases are recorded where information of the recovery of the animal or the sight of the animal itself has allayed the most intense nervous symptoms. The prognosis is fatal. It is commonly said that the physician who cures is death. Bollinger goes so far as to say that the cases of alleged recovery may be invariably found to be due to some other disease or to the fact that the animal was not rabid. Yet it must be admitted that dogs have recovered from the disease. Law mentions eight such cases, two of which were attested by successful inoculation of other animals. The possibility of spontaneous recov- ery may therefore be entertained in man. Wounds on i\\Q face are, as stated, always the most serious. Bouley declares that 90 per cent, of these cases are followed by hydrophobia, whereas the mortality from wounds of the hands is 63 per cent., of the lower extremities 28, and of the u})per extremities 20 per cent. Bites in the vicinity of motor nerves are the most dangerous ; the wilder the animal and the longer the teeth, the shorter is the incubation and the more grave the prognosis (Babes). Many cases are certainly rescued by prompt treatment. Bollinger quotes in proof of this the foUow'ing statistics in France : Of 200 human beings bitten by rabid animals, 134 were cauter- ized. Of these, 92 — that is, 69 per cent. — remained healthy, while 42 — that is, 31 per cent. — died of hydrophobia. Of those non-cauterized, 83 per cent, succumbed to the disease. In one case 16 persons and 1 ass were bitten by the same animal. The human beings were cauterized and rescued without exception. The ass, which received no treatment, died of the disease. The only true prophylaxis is through the enforced use of the muzzle, which renders all other prophylaxis sn|)erHuous; but for various reasons, including a kind of sentimentality, the process of muzzling has never been rigidly enforced outside of a military country like Prussia. The disease, which was formerly common in Prussia, was actually extinguished, as stated, for nine vears bv the rijiid enforcement of universal muzzlinu. Holland secured the same exemption in the same way. The miinber of dogs may be limited by imposition of higher taxation. Every dog should have a known master. Suspected dogs must be carefully confined for as long a period as six months. Dogs imported from countries of lax laws in this regard should be quaran- tined for six months. Actually rabid dogs or other animals that need not l)e 496 HYDROPHOBIA. preserved to determine the condition of human beings or other animals at- tacked should be killed at once. Filing the teeth or attachment of blocks of wood about the neck, confinement by chains, attempted prophylaxis by injection of virus, are all means too unreliable for practice. Treatment consists in the destruction or elimination of the poison in the wound. i\bsorption should be first prevented where practicable, as on the extremities, bv a ligature above the wound. A piece of cord or handkerchief should be firmly twisted about the limb with a piece of wood. Where it may be done the patient should withdraw the poison from the wound by suction. With proper precautions this act may be substituted by another person. The act of suction is, however, dangerous in cases of carious teeth or wounds in the gum, cheek, or other parts of the mouth. The operation may be performed, j nevertheless, if the individual take tlie precaution to rinse the mouth thor- ouglily after every suction with carbolic acid. Hertwig found that the virus of hydrophobia applied to the mucous membrane of the mouth and digestive tract was entirely innocuous. This process, which has been resorted to from the most ancient times, has never yet proven infectious. In the first decades of the present century in Lyons certain women, hundsdugnerinnen, pursued this business as an avocation. They received ten francs for the first, and five for each succeeding act. On the surface of the trunk and some parts of the face the poison may be exhausted by cups. Immediately after suction the wound should be cauterized. Youatt relied entirely upon such a superficial caustic as the nitrate of silver. As he was himself bitten seven times and operated on 400 persons, only 1 of whom died — and that one, as he declared, from fright — this caustic may be considered sufficiently strong if applied immediately. Caustic potash burns deeper. The actual cautery, as from a poker, a nail, the galvano-cautery brought to a white heat, would certainly destroy the poison more effectually. Where wounds are very extensive or numerous, the effect may be best accomplished with stronger solutions, 1 : 500 or 1 : 1000, of corrosive sublimate. Extensive laceration of extremities may require amputation. Psychi(;al treatment is of supreme importance. Romberg first advised the necessity on the part of the attendant and friends " to preserve a calm demean- or, to avoid all allusion to the previous injury, and to appear cheerful." To secure diversion without effort or remark is an essential factor in the relief of suffering at least. The intense reflex excitability of the medulla is best met by seclusion in a quiet and rather dark room. The exhibition of cases as curi- osities or as objects of morbid sympathy is a cruelty, if not a crime. Frequent warm baths where at all permissible, as at the very start, tend to allay exci- tability and spasm. Very soon, however, resort must be liad to anodynes and anaesthetics. Violent cases may require the use of chloroform. The same ol>ject may be at first obtained with chloral. The various remedies recom- mended as specifics — curare. Calabar bean, pilocarpine — have proven useless except in allaying spasms. The use of animal poisons has proven equally futile. Watson speaks of cases treated with the virus of snake-bites. One TREA TMEXT. 497 man was bitten by nine vipers without effect. Opium is the best shield. Sooner or later resort must be had to morphine, in the later course of the disease preferably subcutaneously, with a view to at least secure euthanasia. With this history hitherto it may be appreciated with what acclamation was hailed the claim by Pasteur of the discovery of a means of preventing the disease by the use of attenuated virus. It had been always known that the disease expends its main force uj)on the medulla. Whatever lesions are encountered in the disease are seen here. As soon as Pasteur had determined that the virus of hydrophobia comes to be located in the central nervous system, especially in the spinal cord, he began his experiments with this substance to secure attenuated matter. He found that a continued inoculation of the virus from rabbit to rabbit increased its virulence to such degree that after about twenty-five generations he got a virus which showed its effect after an incubation of but eight days. In twenty- five generations further the period of incubation was limited to seven days. This virus was taken as a so-called virus fixe as a basis substance for protective inoculation. Pasteur discovered that desiccation of the medulla from such an animal in sterilized glass vessels in which had been put pieces of caustic pot- ash brought about a gradual reduction of virulence. Tiie medulla became less and less poisonous. The drying process was continued, until after two weeks' desiccation it was entirely innocuous. Injections were now made with an emulsion of the non-virulent medulla, and were followed by emulsions of medullar of increasing virulence, up to those whicli had been dried but one or two days. Dogs so treated were immune to infection with fresh hydropliobic matter. In the treatment of the hydrophobia of man Pasteur began with weaker preparations — to wit, with the medulla of the rabbit after fourteen days' desic- cation, and increased the following days up to that of the fifth day, whereby immimity or protection was secured. The attempt to use stronger preparations in a shorter time in protection against the more dangerous and extensive lace- ration of wolf-bites had to be discontinued. This treatment has been used now in thousands of cases, and, while it cannot be said to have furnished perfect results, as a number of cases thus treated have nevertheless succumbed to the disease, it must be admitted that the majority of cases have been rescued from the horrors of hydrophobia. A better method is promised in tlie conclusions of Centanni, \\\\o utilized the princij)le of antirabic vaccination (inoculation), first devised by an ohi Italian physician, Eusebio Valli, in the production of an innocent virus obtained by tlie action of gastric juice upon tlic cords of infected rabbits. The cord, emulsified in peptones, gradually parts with its vindence, and loses it altogether in twenty iiours. Tlie essential substance is a flocculent deposit, which may be preserved for weeks in glycerin or dried with sulphui-ic acid. Rabbits can be thoroughly inmiunificd with this material. The protective substance is jirepared as follows: I\)ur grammes of spinal cord are emulsified with artificial gastric juice (solution of English peptones) Vol.. I.— -.',2 498 HYDROPHOBIA. for nineteen hours. At the end of this time a few drops are aspirated from the mixture and injected into the sheath of the sciatic nerve of two rabbits. The rest of the emulsion is neutralized with bicarbonate of sodium and fil- tered. The essential substance which remains on the filter is repeatedly washed for several hours Avith distilled water, and then dried. The nearly dry matter is divided into three equal parts, two of which (each with 5 ccm. of neutral glycerin) are put into tubes ; hydrogen is introduced into one, the air is exhausted from the other, and the two tubes are united by fusion. The third part is dried by sulphuric acid. The glycerin emulsion in the tube suffices, in five subcutaneous inocula- tions, to render rabbits absolutely immune in six days after infection with the ordinary virus (strassengift), while one of the two non-protected control animals died in seventeen, the other in eighteen, days. In subsequent experiments made by Tizzoni and Centanni it was ascer- tained that this matter not only protected against, but actually cured, the developed disease (guarire negli animali la rabbia sviluppata). Five rabbits infected by injection into the sheath of the sciatic nerve with virus, which killed control animals in fifteen to seventeen days, were inoculated with the protective matter, 11-26 ccm. in doses of 3-5 ccm., twice on the seventh, once on the eighth, once on the eleventh, and once on the fourteenth day after infection. The injections were intravenous, subcutaneous, and intraperitoneal. In all five cases the symptoms of rabies had more or less fully developed. All five remained without a sign of subsequent infection, and the effect was the same in all three, regardless of the method of application of the serum. This discovery, which promises results of inestimable value, has, up to the period of the present writing, not yet been utilized in the treatment of hydro- phobia of man. TRICHINOSIS. By JAMES T. WIIITTAKER. Trichinosis is an acute infection caused by the ingestion of the trichina {dpi^, rpiyo^^ hair) spiralis in raw or underdone pork, — cliaracterized by gastritis and enteritis, followed, in consequence of migration of the parasite, in the course of a week by pains in the muscles and contraction of the joints, with cedema of the eyelids and face, prostration, insomnia, profuse sweats, and exhaustion. The history of the trichina is wholly modern, and is all included in the present century. Calcified cajjsules were seen in the muscles as early as 1821, when Hilton first described them as minute white masses, which he regarded as cysticerci. Peacock made a preparation for the museum of Guy's Hospital in 1828. Paget, at that time a student at St. Bartholomew's, distinctly noticed them in the muscles of man. He took a specimen to Owen in 1835, who gave the parasite the very appropriate name it bears. Leidy in 1847 discovered in a piece of ham upon his plate the same immature nematoid, but neither he nor his predecessors appreciated the significance of its presence. Horbst (1851) bred muscle trichinae in doo^s bv feeding; them with the infected flesh of a bad- ger. Leuckart (1855) first saw the escape of intestinal trichinte from their cap- sules in the body of mice. In the same year Kiichenmeister maintained that the trichina was the larval state of the trichocephalus disj)ar. This erroneous view was more widely disseminated l)y Leuckart, who declared that he had bred trichocephali in myriads by feeding trichinous flesh to hogs. Virchow was unable to confirm this conclusion, as he observed tiie immature trichinse become in all cases mature in the intestine of \\\q. dog. Cases of muscle trichinae continued to be occasionally reported in England and America, as well as Germany, from this time on, l)ut the capsules were still looked upon as dissecting-room curiosities, spriid nialurc in- testinal trichina (see Fig. 30) is round, elongated, white, and, as its name inijilies, extremely filiform, on which account it is barely visible to llic naked eye as a fine wool hair or silvery thread. The head, formerly regarded as the tail, is drawn out almost to FtG. 34. Fig. 35. Micscher's San, X 100 (Lcuckart). End of Sap, with kidney- shiipcd bodies free and en- eldscd (Leuc) lands. The submaxillarv and sublingual glands may suppurate to discharge externally. Affection of the bronchial nuicous membrane is evidenced by harassing cough, with ihe profuse expectoration of the same foetid matter and the subse- quent development of dyspnoea. Fever may be entirely absent, or may, in an individual case, assume prominence, with a temperature of 106° F., and a feeble, irregular pulse, like that of pysemia. The chronic distinguishes itself from the acute form by its less intense manifestations and more protracted course. The affection of the nose, when present, does not vary in any essential from that already described. It is, however, less frequently present in man than is the acute form of the disease. There is the same purident discharge with its excessive fcetor, the same swell- imr of the whole structure, while the nares are blocked with offensive crusts. Peculiar repulsiveness is added to individual cases by gangrenous changes which may occur at the root of the nose. The manifestations in the skin are much more common, and upon these the diagnosis is for the most part established. Nodular masses may form any- where over the body, more especially upon the extremities, to discharge san- guineous serum and pus. Sometimes the affection is more superficial, and shows itself in the form of blebs, which may, as stated, closely simulate small- ])ox, chicken-pox, or pemphigus. These blebs or bullae later show, however, ])urulent contents or break to leave sluggish, indolent ulcers and erysipelatous appearances, which are liable to occur in the course of the disease, not only on the surface of the body, but also about the face. Lymphangitis and lymph- adenitis develop as in the case of acute glanders. The whole disease runs a much more sluggish and less intense course. The fever is even more irregular than in cases of acute glanders. It is sometimes absent for a certain period, but shows itself sooner or later, if only in consequence of the extensive sup- purative process, as a pyaemia. Profuse sweats with colliquative diarrhoea, as a rule, soon exhaust the patient. It may be said that the picture of glanders, like that of anthrax, varies according as the disease shows itself in local signs at its point of entry, or constitutionally as the result of absorption and dis- semination in the various tissues and organs. In the first case the disease shows itself in the skin or the mucous membrane in the form, as stated, of nodules, which undergo suppuration with lymphadenitis, erysipelatous and ])hlegmonous inflammation. The discharge from the nose, with its character- istic ha&morrhagic appearance and foetid odor, is often the first sign to excite suspicions of the nature of the disease. Violent ]iain in the frontal region indicates extension to the frontal sinuses. Chills and fever announce absorp- tion of the bacilli into the blood. The |)rof()und jirostration, more especially the depression of the sensorium, leads often to a diagnosis of typhoid fever, small-pox, or i)yicmia, but the localizations in the skin, the abscesses, and idcerative processes in the mucosae declare the character of the disease. The various complications of pyaemia may subsequently ensue: arthritis, serous or suppurative inflammations of the various serous membranes, with exudations, 516 GLANDERS. suppurating nodules, and masses in the muscles and bones, followed by exten- sive destruction of muscle and necrosis of bone, with deep erosions in the mucosse and subcutaneous tissues, are common phenomena of marked cases. These various complications may follow each other rapidly in acute cases. The blood is quickly poisoned, and the patient succumbs in the course of a week, in the more subacute cases in two to four weeks, with delirium and coma. The disease is much more protracted in chronic cases. It may last for several weeks, months, even years, and finally cause death by marasmus. There is during all this time constant liability to the development of the acute form with its more rapidly fatal consequences. Morbid Anatomy. — The surface of the body presents the appearance of a case of pysemia in that various eruptions, pustules, abscesses, and ulcers show themselves upon the surface, especially on the face and extremities. The pre- dominance of blood in the contents of the pustules or nodules distinguishes the lesions of glanders from those of a simple pyaemia. The appearance of the face, the condition of the nasal and frontal bones, may at once reveal the nature of the disease. Extensive erosions, the result of masses of cicatricial tissue in the nasal mucous membrane, with necrosis of bone, are further signs of local lesion. Sometimes the septum nasi, vomer, the bones of the palate are broken down and disintegrated as in the case of the horse. Nodules may also be found in the respiratory tract, in the lungs, and in almost any of the internal organs, the brain, liver, spleen, and kidneys. The skin shows the farcy-buds, the pustules, and abscesses. Lymph-vessels and glands in the vicinity of these nodules show signs of infection. Erysipelatous and phleg- monous inflammations may be seen upon the surface and in the various mem- branes. Serous and purulent effusions may be found in the joints and serous cavities, where also bloody effusions are not uncommon. The diagnosis is made to rest upon the nature of the avocation and the possibility of exposure. It is further determined by the two signs which have given names to the disease — to wit, the glanders, which finds its analogue in man in the term ozaena. It is to be remembered, however, that ozeena applies also to foetid discharges from the nose from various other causes, notably from syphilis. The second factor is the farcy, the nodular eruptions, abscesses, and ulcers found in the skin. The disease is recognized in its constitutional form by the signs of pyaemia — that is, by the chills, fever, and sweats, hebetude, delirium, and coma, together with the various metastatic depots. Syphilis may be separated in a doubtful case, ex juvantibus, as iodine and mercury have no effect upon glanders. Tuberculosis shows, as a rule, predominating signs on the part of the lungs, and while it may affect the bones, as in a case of glanders, tuberculosis dis- tinguishes itself by sparing the nose and skin, organs of selection in glanders. Small-j)ox is more uniform in its eruption. The pustules of glanders appear in successive crops and rapidly ulcerate (Livcing). Pyaemia usually results from a single centre or depot, which may be recognized or discovered. Cryp- PROGNOSLS.— PROPHYLAXIS. 51 7 togenetic cases may be distinguished at times only by the discovery of the specific micro-organism of glanders. The diagnosis of glanders really rests absolutely upon the recognition of the bacillus mallei. Travers, long before the discovery of the specific micro- organism, established the diagnosis in doubtful cases by inoculation of goats and rabbits with matter discharged from some of the ulcers. Bollinofer recoff- nized the disease in the same way by the inoculation of a horse. The inocu- lated animals showed the special lesions and succumbed in the course of two or three months. Cornil succeeded in inoculating two of fifteen guinea- pigs by rubbing cultures into the intact skin. Washbourne and Schwartz- necker established a diagnosis of human glanders by the isolation of the micro-organism, its cultivation, and the inoculation of animals. Jackowski called attention to the affection of the testicle that occurs in these cases, and Strauss adopted the method of intraperitoneal injection as the quickest means of absolutely identifying the disease by implication of this organ. He was led to adopt this method on account of the difficulties attending the inoculation of animals with the products of the disease. Subcutaneous injections in dogs do not always give definite results, and the inoculation of less susceptible animals — e. g. guinea-pigs — is unsatisfactory because of the length of time before death, twenty-five to thirty days. Field-mice and marmots succumb in two to five days, but these animals are often difficult of access. After the intraperitoneal injection of the discharges of glanders into the bodies of male guinea-pigs there is observed first, as a prominent lesion, affec- tion of the testicle as early as the second to the third day. The scrotum becomes tense, red, and shining ; the epidermis desquamates. Suppuration speedily occurs to perforate the integument, and in the pus is to be found the bacillus mallei. The animal succumbs at some time between the fourteenth and fifteenth days. The complication results also under subcutaneous injec- tion, but much later, ten to twelve days. Ijofflor showed that it was not only the tunica vaginalis, but also the parenchyma itself, which showed nodules of the disease. The tunica vaginalis is covered with granulations, and by the third to the fourth day its layers are agglomerated by an exudation of pus rich with bacilli. A means of diagnosis is also offered with the injection of mallein (Preusse), which, as in the case of tuberculin in tuberculosis, produces a peculiar reaction in glanders. The prognosis in a case of acute glanders is absolutely unfavorable. The only possible rescue may result from the speedy destruction and thorough annihilation of the first infection. Nearly all of the acute and more than half of the chronic cases succumb to the disease. Prophylaxis. — Animals affe(;ted with glanders are to be isolated and killed. According to the records of the Berlin Health Office (1890), there were reported as affected with glanders 1337 horses; 80 died, 93 were killed at the request of their owners. There were destroyed by the police 1598 518 GLANDERS. animals. In all, 1771 horses perished. For those killed by the police there was paid by the state 459,834.08 marks indemnity. The cadaver is to be cremated or buried deep. Litter and fodder are to be likewise burned, and stables thoroughly disinfected. All persons who have come in contact with infected horses should be warned of danger. Treatment. — Local depots are to be treated thoroughly and promptly by the application of the actual cautery, strong carbolic acid, mineral acids, and corrosive sublimate. Chronic cases are to be supported with quinine, arsenic (Gamgce), and alcohol. I FOOT-AND-MOUTH DISEASE. By JAMES T. WHITTAKER. Synonyms. — Lat. Ai)hth8e, from Greek aupdm (Galen), Epizooticse; Ger. Maulklaiienseuche, Klauenseuche ; Fr. Stomatitie aphtheuse ; It. Febbre aftosa. Definition. — A mild, acute infection of the lower animals, especially of cattle, sheep, pigs, less frequently of the goat, horse, much more rarely of fowls, dogs, and cats ; evidently caused by a peculiar micro-organism not yet exactly defined ; characterized by tiie formation of vesicles and ulcers in the mucous membrane of the mouth, with the development of eruptions and ulcers in crevices about the feet, sometimes about the udder, communicable to man for the most part through the milk of diseased animals, to appear, with malaise and light fever, as vesicles and ulcers in the mouth, of benign course and short duration. Tiie disease was recognized in animals in antiquity, but was in the early history of veterinary medicine evidently confounded with anthrax and actino- mycosis. Hierocles, a Greek veterinary surgeon, seems to have been familiar with it. Livy certainly described it. Fracastorius (1513) speaks of the vesicles in the mouth and cleft of the hoof as they occurred in animals in an epidemic in Italy and France. Sagar (1764) first noticed the disease in man as caused bv the ino-estion of the milk of cows. It was attended with a sense of iieat and dryness in the mouth and throat and difficulty of swallow- ing, due to an inflammation and aphtha} which were to be observed in the mouth. Brosche (1820) first saw eruptions upon the fingers and toes in the case of two yoiuig girls who had to do with diseased cows. Bollinger makes mention of an epidemic which prevailed in Bohemia in 1827, affecting both man and mule. Hertwig (1834) established the contagiousness of tlie disease by cxj)erimenting upon himself and two other medical men. They drank daily for four days a quart of fresh milk from diseased cows. Symptoms of fever, headache, dryness and heat in the mouth, and it<,'hing in the hands and fingers began in two and lasted for five days, at the end of which time vesicles a|)peared in the mouth. The disease has now, therefore, a recognized place in human ])athol(»gv. Though benign in its manifestations and course, it is never- theless a serious affection, from the fact that so many young animals, sucklings, succumb on account of degradation of the milk. It is stated that in some epizootics as many as 75 per cent, of surkiug calves perished. The disease, once developed, is exceedingly i)ersistent ; stables remain infectious for a long 51!) 520 FOOT-AND-MOUTH DISEASE. time. It is then gradually transported along the lines of travel, hence along the courses of rivers, and with a general tendency westward, to assume at times very wide range. Thus in the year 1871, 700,000 animals were attacked in England alone, entailing in the same year in France a loss of 30,000,000 francs. In 1869 the disease ranged over nearly all Europe. Switzerland alone loses by it about 10,000 francs per year. It makes up for its mildness by its range, and costs a country more than the malignant diseases, anthrax, glanders, and rinderpest. The infectious principle, evidently a micro-organism, has not yet been dis- tinctly isolated. It is certainly distinctly communicable by inoculation. Nesswitzky (1891) conveyed it with the contents of vesicles and secretion of ulcers as well as with milk. The period of incubation is variously stated at one to twelve days. Some of the animals were attacked in twenty-four hours after inoculation, some not until four or five days, some not until five to seven days. Inoculation failed in the experiments of the Berlin Health Office in 30.3 per cent, of cases. Klein (1886) in his studies of the disease in sheep eliminated a streptococcus which he believed to be the cause of the disease. It had much resemblance to the streptococcus pyogenes. Pure cultures of it injected subcutaneously developed in sheep no symptoms of the disease. On the other hand, sheep fed with these pure cultures showed the typical symptoms of foot-and-mouth disease. The curious observation was made with these studies that animals previously treated to subcutaneous injections remained exempt after feeding experiments. Klein hence concluded that inoculation conferred immunity. Some doubt pertains to these conclusions, because of the lack of control experiments and the means of excluding spontaneous infection. The immunity conferred by inoculation is a discord in the records of artificial immunity. The infectious matter exists in the contents of the vesicles, in the saliva, in nearly all the secretions, and certainly in the blood and milk. Siegel found in an epidemic of stomatitis in man a very delicate bacterium, ovoid in shape, an elongated coccus or a very short bacillus, which developed in agar or gelatin without fluidifying the soil and without being colored in the usual way. He believed it to be derived from cattle affected with foot-and- moutli disease. Schottelius in his studies discovered a peculiar streptococcus, some examples of which were rounded, while others had a peculiar elongation or protuberance like that which shows in the prolongations of white blood-corpuscles. He called these bodies strcptocytes. They differed in many j)articulars from the ordi- nary streptococcus, but gave only negative results in inoculations of various animals. Schottelius was never able to observe the micro-organisms described by Siegel in cases of foot-and-mouth disease. The disease shows itself in the lower animals as a mild fever attended with a catarrhal inflammation of the mucosa of the mouth. There soon develops on the inner surface of the lips and along the edge of the jaw, where the teeth are absent, at the tip and borders of the tongue, yellowish-white vesicles, which iS YMPTOMA TOL OGY. 521 show later purulent contents, and rupture in the course of one to two days, to leave superficial erosions and ulcers. The ulcers heal in the course of three to six days. The affection of the feet may show itself at the same time or later than that of the mouth. In the clefts and at the crown of the hoofs there is to be observed the development of the same vesicles, which rupture to dis- charge purulent contents, which in turn inspissate to form crusts and leave more or less extensive ulcers. The affection of the feet renders the animal unable to stand or walk, so that at the height of the disease it must maintain the recumbent posture. Similar appearances are to be observed also about the udder, especially at the orifices of the milk-ducts. Thus, vesicles, pustules, crusts, and, in consequence of their detachment, more or less extensive ulcers, show themselves about the bag. The milk of the affected animal is altered in quantity and (piality. It is reduced often as much as one-half in the human, assumes a yellowish colostrum-like appearance, and coagulates prematurely. It has a bitter, nauseating taste and develops a dark-yellow sediment. The disease terminates usually in twelve to fourteen days. Man is usually affected throu«;h diseased milk, which retains its infection even when added to coffee or when diluted with normal milk in the proportion of 1 to 10. Boiling absolutely destroys the poison in the milk and I'enders it perfectly harmless. It is doubtful if the disease can be conveyed by the meat of diseased animals, but instances of infection have been reported from the ingestion of butter and cheese made from the milk of diseased cows. Infec- tion by direct inoculation, as in milking, is not uncommon in those who have the care of diseased animals. The chief interest in connection with foot-and-mouth disease occurs in rela- tion to aphtha, which is declared to be the expression of the disease in man. It has been observed that aphtha prevails coincidently with outbreaks of the foot-and-mouth disease in cattle. What lends also especial suj)p()rt to this view is the fact that the appearance of the disease is much the same in man as in animals. The question is not yet settled. The period of incubation in man ranges from three to five days. The disease may begin with chills or chilly sensations, followed by fever, anorexia, and malaise. Vesicles now appear upon the inner surface of the lips and tongue along with a sense of heat and dryness ; there is difficulty in speak- ing, chewing, and swallowing. The mucous membrane is very much reddened and swollen, and saliva flows abundantly. There is also often noticed at this time a vesicular eruption on the fingers and hands, sometimes in association with intestinal disturbance. The vesicles upon the fingers are at first small and trans])arent. They soon increase in size, and change in color to show purulent contents, and sometimes closely simulate the eruptions of small-pox. Cases have been reported where the eruj)li<)U was so extensive as to cover the entire body (Biercher). Ilolni saw vesicles on the nipj)le of a woman who drank daily large f|tiaiitities of milk from cows alfected with the disease. Tiie catarrhal inflammation may assume such |)roj)orlion as to constitute 522 FOOT-AXn-MOUTH DISEASE. an extensive stomatitis. Briscoe saw a case in which the tongue was so much swollen as to project more than an inch from the mouth. Prophylaxis includes proper care of the animal regarding pasturage and stables. Man is best [)rotected by the ingestion of milk from healthy cows, or, if that be impossible, by the thorough boiling of milk from diseased cows. The diagnosis is usually easy. It may be known that the disease exists at the time in animals. The peculiar coincidence of eruption in the mouth and extremities, sparing the rest of the body, is unlike any other eruptive disease. Thus, the mycoses of the mouth are unattended with affection of the feet, and eczematous and other eruptions of the feet are unassociated with eruptions in the mouth. The prognosis is favorable. The disease runs a mild course, and termi- nates, as a rule, in from five to eight days. Extensive affection of the hands, with the difficulty of proper protection, may extend the disease to several weeks. Fatal cases have been reported in very delicate children. Treatment. — Stomatitis is best treated with weak solutions of borax as mouth-washes. Erosions and ulcers should be cauterized with the nitrate of silver, which not only protects an abraded surface from irritating contact, but also by its antimycotic properties directly addresses itself to the cause of the disease. The superficial lesions of the extremities may be best treated by lead washes, diachylon ointment, light bandages, etc. The fever and general dis- tress of infection may call for mild or repeated doses of phenacetin, chloral, or Dover's powder. GENEPxAL SYMPTOMATOLOGY OF DISEASES OF THE NERVOUS SYSTEM. By HORATIO C. WOOD. The symptoms of disease of the nervous system are due to disturbance of the functions either of the nerve-centres or of the peripheral nerves, and are therefore best studied in outline under the headings of Motion, voluntary and reflex ; Co-ordination ; Sensation ; Vaso-motor and Trophic Alterations ; and Disturbance of Intellection, including memory, speech, and emotion. Motion. Paralysis, or true loss of motor power, must be distinguished from the loss of motion due to local disease and to arrest of function of the muscles or of the joints by pain on movement. This ])seudo-paralysis can usually be recognized by the fact that passive motion and local pressure give pain. It must be remembered, however, that when contractures exist or when peripheral nerves are diseased true paralysis may exist, although passive movements are painful. Paralysis may be complete or incomjilete. Wiien it affects the whole body below the head it is spoken of as a General Paralysis. A general paralysis can never be absolutely complete, since the subject muse die from loss of pow- er in the respiratory muscles before such condition is reached. Hemiplegia, strictly speaking, is a paralysis of one lateral half of the body, but the term is universally used not only when one-half of the face, arm, and leg are para- lyzed, but also when only the arm and leg of one side are affected. It is indeed very rare for the trunkal muscles to participate in a hemiplegia. A spinal hemiplegia is conceivable, but in fact hemiplegia is almost universally of brain origin. Paraplegia is paralysis of the lower transverse half of the body : with the rarest exceptions it is spinal. Monoplegia, paralysis of one part, may ha facial, brachial, or crural. It may be due to lesion of the brain, of the spinal cord, or of the nerve-trunk. A cerebral lesion causing monoplegia is almost always cortical, and a spinal lesion is almost invariably situated in the ganglionic cells in the anterior cornua. A Local Paralysis — i.e. a palsy of a single muscle or muscle-group — is produced by lesions situated like those of monoplegia, but less extensive. A Multiple Paralysi.'i is a ]xiralysis of more or less scattered groups of muscles not directly connected either fimctionally or anatomically with one another, and may be looked uj)on as an association of" local palsies. It is usually due to 523 524 SYMPTOMATOLOGY OF NERVOUS DISEASES. disease of various groups of 8j)inal ganglion-cells, but may be peripheral, and in rare cases is the outcome of multiple cortical brain lesions. In paralysis of the face the mouth is always drawn toward the opposite side, unless con- tractures in the paralyzed muscles have taken place, when the mouth may be drawn toward the paralyzetl side. In paralysis of half of the tongue the tip in motion turns toward the paralyzed side. In the examination of the para- lytic it is customary to note the exact power of grasp by means of the dynamometer : a pulley and weight apparatus may be used for the upper arm and leg, but in practice a sufficiently accurate judgment may be made by noting the extent of forced movements, the endurance in walking or in stand- ing on one leg, the ability to get out of a chair, etc. Convulsions. — Three types of convulsions are recognized : the epUepti- forin or cerebral, in which consciousness is completely lost ; the hysterical, in which consciousness is disturbed ; and the tetanic or spinal, in which con- sciousness is normal and reflex activity grossly exaggerated. In nature these varieties of convulsions grade imperceptibly one into the other. A detailed discussion of convulsions will be found in various articles, especially in those on epilejisy and hysteria. Automatic Movements. — The condition sometimes seen in epilepsy and in various abnormal states, in which a series of seemingly voluntary acts are performed without clear consciousness, is spoken of as automatism. An auto- matic act often involves an elaborate series of movements, such as those that occur in bowing, getting out of a chair, and the like. The chorea major of some German writers represents a form of automatism, and has no relation with true chorea or choreic movements.^ Reflexes. — For the performance of a reflex action an arc composed of affer- ent nerve, motor ganglion-cell, efferent nerve, and muscle must be complete. Disturbances of reflex activity must be due to disturbances of this arc, in which are of course included such portions of the nerve-fibres as are in the nerve-roots and spinal cord itself. The superficial reflexes are excited by irritations of the skin and mucous membrane, either by tickling, pricking, pinching, or gently scratching the sur- face, or by means of a dry electric brush. As the superficial reflexes are not constant in the normal individual, the absence of a skin reflex is of uncertain diagnostic import, whilst the presence of the reflex shows the integrity of the nerve-arc implicated. The most important of the superficial reflexes are : the plantar reflex, contraction of leg, evoked by tickling the sf)le of the foot — reflex arc involving the lower end of the cord ; the gluteal reflex, consisting of con- tractures of the gluteal muscles produced by stimulating the skin of the but- tocks — arc, through the fourth and fifth lumbar nerves ; the cremasier reflex, causing the drawing up of the testicle when the skin of the inner side of the thigh is stimulated — arc, the first and second pair of lumbar nerves and their spinal centres ; tiie abdominal reflex, causing contractions of the abdominal ' The confusion is made still worse by the fact that some Continental writers speak of very bad cases of St. Vitus's dance as chorea riuujna. MOTION. 525 muscles, cliiefly the rectus, when the skin of the sides of the abdomen is stroked from the ribs downward — arc, from the eighth to the twelfth dorsal nerves; the epigastric refiex, causing a dimpling of the epigastrium on the stimulation of the same side of the chest in the sixth and fifth intercostal spaces, and some- times even in the fourth — arc, from the fourth to the seventh pair of dorsal nerves; the erector-spinal re/lex, causing contraction of the erector-spinfc muscles when the skin along their edges is stimulated — arc, in the dorsal region of the spinal cord ; the scapular rejiex, causing contraction of some or nearly all of the scapular muscles on superficial irritation of the scapular region — arc, the upper two or three dorsal and lower two or three cervical nerves; the palmar refcx, producing contraction of the flexors of the fingers on tickling the palm of the hantl — arc, through the cervical enlargement of the cord ; cranial reflexes, such as contractions of the palatal muscles by irritation of the fauces, sneezing bv irritation of the nasal mucous membrane, cough bv irritation of the larynsreal mucous membrane, closing of the eyes by irritation of the conjunctiva, move- ments of the iris by light. Of the deep reflexes — that is, of those connected with such deep-seated tissues as tendons and bones — the most important are elicited by striking the patella tendon ( WestphaVs symptom, patella reflex, knee-jerk) or by flexing the foot forcibly, so as to stretch the Achilles tendon {ankle clonus). In some cases tap])ing of the biceps or flexor tendons in the arm will produce contractions of the muscles; a jaw or chin reflex is obtained by allowing the jaw to hang pas- sively or by gently supporting it with one hand whilst with the other the blow is struck on the chin with a hanmier in a downward direction. Ankle clonus ^ is never (elbow-, wrist-, and jaw-jerks rarely) present in normal individuals. In testing the knee-jerk the bared leg is so supported that the foot swings free from the floor, and the tendon above or below the patella is struck with the edge of the hand, with the fingers, or with a small hammer having an elastic steel handle and an India-rubber head. Any vohmtary movement, such as clinching the hands at the time of the delivery of the blow, increases (techni- cally, " reinforces") the contraction. Tiie knee-jerk is probably absent in about 2 \^eY cent, of normal indiviMir of points, one of which slides uj)on a bar s(^ that the distance between the points when separated is known. On the surface of tlic butly these points arc ielt as tw(j points or as a single point according as they are more or less widely o28 SYMPTOMATOLOGY OF NERVOUS DISEASES. separated and as the skin is more or less sensitive. The sensibility varies greatly in different parts of the skin and also on the same portion of the skin in different individuals. Any wide deviation from the following scale may, however, be regarded as pathological : the top of the tongue, 1.18 mm. ; the end of the fingers, 2.25 mm. ; the side of the first phalanx, 16 mm. ; the back of the hand, 3.1 mm. ; the upper arm and thigh, 3.7 mm. The smallest required distance is ofitener less in the transverse than in the longitudinal direction of the limbs. In practice it will usually be found better to compare the affected part with the opposite side of the body, rather than with any theoretic formula. Care should always be taken to apply the points simul- taneously and with equal force. The sense of pressure is tested by laying the hand, foot, etc. upon a firm, hard surface, like that of a table, and placing graduated weights upon it. Several forms of apparatus have been devised. A very convenient method is to more or less partially fill a series of ordinary shot-gun cartridge-shells with shot, so as to form a regular series of weights which resemble one another exactly to the eye. The muscular sense may be tested in the arms by testing the power of the patient for recognizing the amounts of various weights when lifted. Thermic sensibility is tested by tlie alternate application of hot and cooler bodies. More or less complicated instruments have been constructed under the name of therino-cesthesiometers, but vials of water of different temperatures are sufficient for practical purposes. The temperature-range of most accurate sensation lies between 27° and 30° C, then between 33° and 39° C, and lastly between 14° and 27° C. The variations above or below these limits produce simply sensations of pain. According to the experiments of Noth- nagel, the smallest perceptible differences of temperature are the following : on the breast, 0.4° C. ; on the back, 0.9° C. ; on the back of the hand, 0.3° C. ; palm of the hand, 0.4° C. ; arm, 0.2° C. ; back of the foot, 0.4° C. ; lower extremities, from 0.5° C. to 0.6° C. ; the cheek, 0.4° C. to 0.2° C. ; the tem- ples, 0.4° C. to 0,3° C. In practice few normal individuals will recognize, I believe, differences of temperature so small as those here mentioned. The results of vaso-motor and trophic alterations are so evident to the senses that no discussion of them is required here ; whilst the difficulties that surround the apprehension of symptoms due to disturbance of intellection are so great as to require elaborate discussion in the article upon Mental Diseases. MENTAL DISEASES. By HORATIO C. WOOD. General Considerations. At least in the United States, alienists have long been so set apart from other physicians that they seem hardly to form an integral part of the profes- sion, whilst to a large proportion of the practitioners of medicine the subject of insanity is, as it were, a closed book, unopened in the medical schools, unstud- ied in the after-years. Nevertheless, in the great majority of cases the general practitioner alone has opportunities to study the beginning of mental aberration, and too often his failure to apprehend works ruin to the patient. Within the limits assigned in the present volume it is practically impossible to write a treatise on insanity which siiall meet the needs of the specialist, but it does seem to me possible to make such a statement of the general principles and the important clinical facts of alienism as shall serve to the student or prac- titioner of medicine as a general guide, and as a foundation upon which can be built, if wanted, more detailed knowledge. More than this, I believe that the great danger of all specialism is lack of breadth of view ; and possibly the fact that the writer of this article has worked for fifteen years in general clini- cal medicine in the wards of large hospitals, and has had large experience as a general medical practitioner, may give a flavor to the writing different from that of the work of the pure specialist. Under the circumstances it has seemed es- sential to devote proportionately more space to the general consideration of the subject than would be allotted in a treatise on insanity. For the purpose of studying the symptoms of mental disorder the human intellectual faculties may be separated into the will, the intellectual facul- ties proper, such as reason, imagination, etc., and the emotions, such as fear, anger, etc. Disorder of one mental faculty is almost invariably accompanied by a greater or less degree of disturbance of the other mental faculties, but, a priori, there seems to be no reason why one faculty of the mind should not suffer alone, and cases are said to occur in practice in which a single faculty appears to be under the influence of disease when no other evidences of mental disorder can be detected. The human will acts chiefly upon the lower intellectual and emotional brain- functions as a repressive force. It inhibits or puts aside this thought or that distraction (»r this emotion, rather than brings forwaid another thought or emotion. W<' cannot will oni'sclvcs into a passion, though wc can by a direct effort of the will inhibit or repress a rising anger. IT we desire to produce a fitof anger, we do it by bringing before the mind thoughts which act as stimu- Voi.. r.— :U 529 530 MENTAL DISEASES. lants to the desired emotion : the almost unconscious recognition of this fact has led to the expression '' working one's self into a passion." As is usually the case in disorders of inhibitory nerve-function, affections of the will are most plainlv and frequently manifested by weakness or failure of power. It is true that the excessive obstinacy and self-assertion so often seen in insanitv at first sight appear to indicate abnormal exaltation of the will, but these extravagances of thought and action may be due to the overpowering influence of some emotion or some idea which so dominates the will as to gov- ern entirely the actions of the individual. The obstinacy and self-assertion are, under these circumstances, really the outcomes of a weakened will rather tlian of an overpowering egoism, the person being obstinate or aggressive because his will is enslaved by a lower intellectual or emotional nerve-centre. Thus, in melancholia inflexible obstinacy may result from the absolute despotism of an overwhelming sorrow. In hysteria the will is probably always abnormally feeble, but the persistence and apparent wilfulness of hysterical subjects are proverbial. Weakness of the will is produced by various organic bra in -diseases which lower the nutritive tone of the cerebral cortex. It is caused very frequently by chronic poisonings, being one of the most pronounced symptoms of alco- holism and of opiumism. Under these circumstances the subject may show an extraordinary determination and persistency when dominated by his appe- tite, and yet he is really most infirm of purpose, entirely unable to decide upon a course of action in regard to ordinary matters or to carry out his decis- ion when reached. He is liable to be inordinately influenced by his associates and by his environs, cannot resist entreaty and temptation, and so becomes more and more the sport of his desires and of external influences. Acute illness, starvation, hardships, age, chronic diseases, any influence which lowers the nutrition of the higher nerve-centres, may produce weak- ness of the will. So varied are the causes of abulia (or abnormal weakness of the will) that the symptoms have no further diagnostic import than to show a serious functional or structural alteration of the cerebral cortex. Exaggeration of the will-power is known as hyperbuUa, and reveals itself in some forms of mania and cerebral cortical excitement. The emotional nature may be by disease depressed, exalted, or perverted : the alteration often affects persistently a single emotion or a single class of emotions, or it may attack successively, at shorter or longer intervals, emotions that are antagonistic. Thus, a subject may be in a continual state of joy or of emotional depression, or he may rapidly or slowly pass from one state of emotional excitement to another, now carried away by anger, now prostrated by fear, now soaring with joy, now overwhelmed by sadness. In advanced stages of cerebral disease a condition of true emotional enfee- blement or lethargy may be ])resent, so that external circumstances which nat- urally affect most vividly this or that emotion fail to produce any response. This mental condition ought logically to be known as emotional depression. It is to be clearly distinguished from excitement or over-activity of the depres- GENERA L ( 'OXSIDERA TIONS. 63 1 sive emotions, such as sorrow, and their congeners. Viewed in this way, the melancholic person is not in a condition of emotional depression, but in one of emotional excitement — /. e. of excitement of the depressive emotions. Mel- ancholia is, it is true, fre(piently associated ^itli depression of the nervous system, but this is not always the case, and the victim of melancholia asritata may be in a condition of general nervous ervthrism as pronounced as that which affects the maniac with widelv-expansive delusions. On the other hand, high hopes and abundant joy are in advanced general paralysis closely linked \vith the most profound evi lences of failing nerve-puwer. If melan- cholia is to be considered a state of lowered emotional activity, whilst joy and anger are the outcomes of emotional excitement, it logically follows that the antagonistic emotions are different manifestations of one cerebral function, joy being the result of excessive stimulation, sorrow of excessive depression, of the same brain-cells — a conclusion which I think few persons would be ready to accept as correct. The relations between the diverse emotions of which I have just spoken are of some importance as explaining the fact that in various mental affections mania and melancholia, or opposite emotional states, may follow each other, and even appear to be produced by the same brain lesion. Thus, in paretic dementia the persistent hyperseraia of the brain-cortex may cause thi'oughout the attack intense sadness, or an emotional depression may suddenly replace the expansive happiness usual to the affection. To account for such a change it is only necessary to suppose that there is a shifting of the hypersemia and the excitement from one portion of the brain to another. The lethargy due to absolute loss of mental powder spoken of on page 552 really is closely associated in its origin and nature with stupor, differing, how- ever, from that condition in that consciousness is not lost : both stupor and emotional lethargy may in the insane be closely simulated. An insane patient may lie in bed absolutely still and inert, with closed eyes, giving no response to the loudest questioning and making only a feeble and slow resistance to per- sonal violence ; or when, with head bent forward, joints flexed, and face frozen into an immobile apathy, he sits motionless in his chair, he may seem to be lost in unconsciousness, but none the less may he have knowledge of his surround- ings and of his sorrows. The pseudo-lethargy may be the direct result of an intense emotion or of delusion, and not be consciously assumed ; but not rarely it is put on for a definite end, and maintained with a tenacity of piu'- pose which defies detection even during the intoxication caused by ether or by alcohol. The occasional revelations made by ])atients after they recover their reason show that a delusion may act very directly in the ])roduction of an assumed stupor. A man i)elieves that he has received commands from the Almighty to isolate himself from all eonununioii willi his fellows, and in maintaining the assumed stupor battles for his eternal salvation ; or the lima- tic conceives that his attendants are cons])iring against hiin, and will do him great evil if once they are assured he is alive. In some eases the |)seu(lo- ^ethargv is the result of an overwhelming (^notion j)rodueed by the delusion. 632 MENTAL DISEASES. The man about to be devoured by foul beasts or by the flames of hell is dumb through fear, or, as the German alienists say, is thunderstruck. Occasionally the insane sleeper is convinced that he is dead, and by this delusion his will is. so far paralyzed that it is unable to act, and the man really cannot move,, althougii the lower nervo-muscular apparatus is intact. The intellectual functions proper may suffer from actual exaltation, giving rise to increase of power ; from an exaltation which is so unbalanced as tO' produce a derangement of action ; from a real depression or loss of power. Absolute increase of mental poioer is a rare condition, and is never present in any advanced stage of disease. The subject of a pronounced mental exal- tation has a passion for intellectual laboi', accompanied by a corresponding power of accomplishment. It is no longer an effort to fix the attention upon an intricate subject for successive hours. The sense of fatigue is lost, and the brain works on without pain, the quality as well as the quantity of the result being beyond that which the individual in his normal condition can produce. This state of mental exhilaration sometimes comes on during protracted mental labor. It is probably always associated with hyperseraia of the brain-cortex, and is usually accompanied by pronounced insomnia. It is a very dangerous condition, and should be the signal for immediate cessation of mental effort and for medical treatment. It is sometimes developed with- out obvious cause as a prodrome of severe mental disease. Thus, I have seen it precede a fatal outbreak of acute phrenitis, and it may usher in paretic dementia. If one or more of the mental functions are excited entirely beyond the control of the will and judgment becomes impossible, a mental condition is produced which in its most severe acute form is sometimes spoken of as delirium, and in its milder or more chronic forms as insanitv. Failure of the mental powers is a very common result of functional and organic brain disease. When complete it constitutes the condition known as dementia. It is often of vital importance to recognize the dawnings of mental failure. The failure usually manifests itself first in loss of memory. This will be sufficiently discussed later. (See page loQQ.) Next to memory in the order of implication, and sometimes even preceding it, is the power of fixing the attention. The mind of man naturally wanders from subject to subject. A continuous thoughtful application depends upon the exertion of the inhibitive power of the will in repressing distracting thoughts and shutting out new per- ceptions. The power of persistent attention to one subject is to a great extent ac(piired by training. Its exercise is a large feature in all severe intellectual work. Consequently, when the brain is exhausted not only do the reasoning faculties labor with difficulty, but increased effort is required from the weak- ened will to maintain the necessary fixity of attention. Mental toil becomes, therefore, most irksome, as is recognized by the common expression of sufferers that '' work is becoming more and more of an effort." Failure of memorv and failure of the power of fixing the attention have no particular diagnostic GENERAL CONSIDEBATIONS. 533 import. When they coexist and are associated with any other evidences of mental derangement they indicate a serious disease of the brain itself. The loss of the power of fixing the attention, however, when it exists alone, nsu- ally depends upon simple cerebral asthenia — a condition in which there may also be some loss of memory. A symptom which may dcjiend upon either mental excitement or loss of mental power is incoherence. An incoherence due to a heightened but irregu- lar cerebral activity results from the excessive rapidity of the intellectual acts, as well as from their lack of connected sequences. Before one idea is fully translated into words another rushes into expression, and a hopeless confusion •of talk results. The ideas tumble out as it were over one another. Incohe- rence from lack of mental power, on the other hand, arises either from the ina- bility to complete the mental act or from the lack of the power of translating it into suitable words. In typical cases there is little difficulty in distinguishing between these varieties, which it is allowable to call respectively active and passive incoherence. The rapid utterances of the raving maniac usually show most plainly that his mind is pouring out broken hints of an infinite series of jostling ideas ; whilst the slow, confused, disconnected, hesitating words of the t to make a sharp separation between pscudo and true hallucinations. It is affirmed that the pseudo-hallucination always remains to the individual who has it a subjective phenomenon, whilst the genuine hallucination aj)pears to the individual as reality itself. It is clear that the pseudo-hallucination of some writers is simply an hallucination which is recognized by the intellect as a subjective phenomenon, and therefore does GENERAL COySIDKRA TIONS. 535 not give rise to an insane delusion. The true liallueination of such writers is a eombination of an hallucination Mith an insane delusion. In nature there seems to be every possible gradation between the faintest delusion or hallucina- tion and the illusion or hallucination which is completely believed in by the individual and most completely dominates him. The word delusion may be defined to be a false belief, but as it is used by alienists the term means something more than this. By Spitzka the insane delusion is said to be " a faulty belief out of which the subject cannot be rea- soned by adequate methods for the time being." The objection to this defini- tion is that there are many faulty or false beliefs held by perfectly sane persons out of which such jiersons cannot be reasoned, but which are not insane delu- sions. Thus, either the Christian or the Mussulman, under such definition, is the victim of an insane delusion. To meet the necessities of the case the defini- tion should be modified so as to read, "A faulty belief concerning a subject capable of physical demonstration, out of which the person cannot be reasoned by adequate methods for the time being." The parallelism between a delusion and an hallucination is very close. A delusion is a false belief; an hallucination is a false perception. The delu- sion becomes an insane one only when the false belief cannot be dissipated by absolute proof of its incorrectness. The hallucination becomes an insane one only when the false ])crception cannot be corrected by the judgment through the other senses. In either case the essence of the insane mental state is loss of power to receive and weigh adequate evidence. Thus, John Smith hears voices where there are none : he is insane only when he is unable to correct the evidence received through the sense of hearing by that received through the senses of sight and feeling. If ,he persistently l)elieves that persons s])eak to him, although he cannot see or touch them, his judgment is in abeyance. On the other hand, John Jones believes that a cer- tain barn exists upon a certain field where there is no barn. Under these circtmistances he has a delusion, a belief which has grown up in his mind from some cause unknown. Now, if, when taken to the field, he is incapable of receiving the evidence of his senses and persists in his belief that the barn is there, he is insane; but if he receives the evidence of his senses and per- ceives that the barn does not exist, he is not insane. In case of insane hal- lucinations or delusions the truth or falsity of the vision or of the belief is not essential. The essential thiny; is the condition of the mind of the individual — a condition which prevents it from receiving evidence. Hence an insane belief mav be true althou*;!! insanely hchl. In the sup])osititious case given above assuredly the mental state ol" the individual is in no wise dej)endent u])(»n the absence of tlie barn, although such absence renders a test of the subject's mental condition possible. 'J'he distinction just drawn may seem iiiiiiMj)ort;iiit and so trite as to Itc unworthy of discussion, but the failure to understand it has Ixcii one cause, in my ('xj)c- riencre, of tiie inability on the ]>art of learned lawyers to comprehend the subject of insanity. 536 MENTAL DISEASES. Not long ago, after due process of law, an insane man by the name of Taylor was hung in Phila(lel])hia for the unprovoked murder of a prison- warden. It was in evidence that the mail believed that all the attendants of the prison were Catholics, and were "down on" him because he was a Protestant, and were destroying him. The ])rosecuting attorney asked, " Sup- ])osing it were proved that the prison attendants were Catholics, would it not have to be acknowledo;ed that the man's belief was correct, and that he was not insane?" Apparently neither lawyer nor judge could be made to under- stand that the falsity or thfe truth of the prisoner's belief in the Catholicism of the attendants had little to do with the question of his insanity. It was proved that he had other delusions of persecution, and his having adopted a belief in regard to the Catholicism of his attendants which was in accord with such delusions, without any evidence of their alleged Catholicism, and having reasoned insanely upon the subject and acted in ac(X)rdance with conclusions so reached, showed that his action rested upon mental unsoundness. Surely the ^'■Because I am a Protestant, therefore they are destroying me," ought to have made the mental condition of the prisoner clear. In the language of Spitzka, *' Repeatedly does it occur in the alienist's experience that the facts of a case and the delusion happen to correspond." This is well illustrated in a case reported by him. An artist's model asserted that he was the finest-built man in the United States. He really had a magnificent figure, but his announce- ment was, notwithstanding, that of a paretic dement, for inquiry elicited the statement that the " girls looked at him because he had a pecidiar expression in his eyes which they fancied," and he revealed other unmistakable evidence of general paralysis. An insane bplief or delusion may rest upon an hallucination, may be built upon a foundation of disordered sensation, may spring from the most trivial circumstances, or may, so far as can be judged, be self-engendered in the mind. Thus, the voice that is heard as an hallucination gives rise to the delusion of an ever-present persecutor ; a persistent distress in the abdomen to a delusion of j)regnancy or that the bowels are dropping out, etc. The following case from my notebook illustrates very forcibly the curious way in which a delu- sion develops in the mind without the slightest foundation in verity : A man after a malarial fever began to have suspicions in regard to the chastity of his wife. For a time he kept these to himself, but finally he accused her of infi- delity. After this had continued for some weeks he presented himself with his wife at my clinic, saying to me, " I think my wife goes with other men : she thinks I am crazv. I am uncertain whether she or I am rio-ht." On being questioned, he stated that he first noticed her looking behind her, as though she were looking for some one, when they walked together; that he afterward saw a handkerchief lying on the bureau in her room, just as she would have left it if she had been flirtino; with some one out of the window, and that when he saw a chair by the window of her room and a man at the <-orner of the street he was convinced that his suspicions were correct : in this lie was corroborated by finding three dollars in a trunk, which he believed his GENERAL COXSI DERATIONS. 537 ■wife had received '* for evil courses," although she had declared that he him- self had given it to her. He further stated that he watciied her eyes. In a very eager, tremulous manner he said, " I got a lamp, and when J found her •eyes were dark beneath, I told her there was something wrong with her, and then she began to think there was something wrong with me. 1 firmly believed she was going with other men." Tiie man had an inherited tendency toward insanity, and had lost much sleep. When his whole case w^as thoroughlv explained to him, he said that he " now understood it, and was glad to hear it, and that it gave him power to brace himself against the notion," ending with the assertion that he believed that '' he had a good woman." In reply to a question, he said, " I do not think there is danger of ray hurting mv wife, but these things come on me so that I cannot control myself at times, and I am willing to go to an asylum if it is thought to be right." The relation between the emotional state of an insane man and his delu- sions is very close. Expansive or happy delusions accompany emotional exaltation, while horrible or sorrowful delusions go hand in hand with depres- sive emotions. Thus, the melancholic woman is oppressed with the belief that she is hopelessly damned, that her luisband is unfaithful, or that she is preg- nant with devils ; whilst the maniac, overflowing with animal spirits, is a proj)het sent of God, is owner of uncounted millions, or mayhap is about to become the mother of the Messiah. The emotional state and the delusions constantly react upon one another. Some alienists believe that the character of the delusion is directly dependent upon the dominant emotion. The nature of delusions varies so indefinitely as to render any attempt at a thorough classification futile. There are, however, certain classes of delusions which are so frequently met Avith and so characteristic as to require especial study. The most important of these are — 1. Expansive Delusions; 2. Hypochondriacal Delusions ; 3. Delusions of Persecution. Expansive Delusions usually concern the ])ersonality of the individual who has them, either as to his prowess, his mental or physical attainments, his pos- sessions, or his future prospects. The jiatient boasts that he is the strongest man in the world, asserts that his mental powers are immense, or that he is a king or other notability, or more commonly talks of his millions of money, his gold-mines, his farms of unlimited extent, his vast stables full of uinnun- bered horses of the choicest breeds, liis far-reaching and gigantic business schemes, etc. This condition constitutes the delire de (jrandew, and, whilst in the majority of cases it depends upon the existence of general paralysis, it nuiy be i)resent in many forms of mental disease. I have seen it very pronounced in cerebral syphilis, and have watched th(> millions of dollars possessed by the subject shrink to thousands, and the thousands to hinulreds, as the brain lesions grew less under the administration of mercury. Then ev(Mi the luuidreds dis- aj)|)cared, and his own j)overty was confessed ; but the assertion still remained that " his uncle was worth a million," until at last this too vanished in the recognition of the desolate truth. II ijpochondriacal JJelusions relate t(j disease of the person of tlie patient, 538 MENTAL DISEASES. and are usually, but not always, associated with a depressive emotional state. They sometimes rest upon a substratimi of ill-feeling, or even of actual disease,. in the part alleged to be hopelessly affected. They are often obviously absurd, as that the legs are made of glass. Of all forms of delusion, this is the one in which the gradations between the sane and the insane belief are most sub- tile. Every step can be found between the slightest exaggeration of symptoms and the hvpochondriacal foundationless belief. Unless a hypochondriacal delu- sion is upon its face absurd, the physician must be very careful in basing upon it an opinion that the subject of it is irresponsible, since many invalids are- hypochondriacs and have exaggerated beliefs bordering closely upon delu- sions, but are, nevertheless, of sufficiently sound mind for the performance of the ordinary duties of life. Delusions of Persecution are not always associated with a pronounced depressive emotional condition. They are always the source of great annoy- ance and distress to the subject, and are usually associated with hallucinations which I think are most apt to be connected with the sense of hearing. Very commonly obscene, reproachfnl, or threatening voices are heard at all times and in all places. Usually the delusion of persecution does not attach itself in the mind of its victim to one person, but to classes of people or to unseen spirits. Sometimes, however, the delusion does affix itself to one individual,, as in a recent case in which a woman travelled across the continent of America to kill a doctor who she believed was placing a spell upon her. Of all the quiet classes of the insane, those who have delusions of persecution are the most dangerous. They are impelled by motives of revenge and of fear to kill those who are persecuting them. This is especially the case when the delusion attaches itself to one individual ; but even voices in the air may lead to sudden violent assaults upon bystanders who are for the moment thought to be the source of the words. Moreover, the lunatic may at any time fix in his mind upon any acquaintance or notable person as the origin of his persecution and make his plans in accordance. A very important division of delusions is into systematized and unsystem- atized. A si/steinatized delusion is one concerning which the subject reasons, and which he defends more or less logically. Any character of delusion may be systematized. If a lunatic asserts that he is worth a million of dollars, and simply sticks to his belief when it is denied, he has an unsystematized delusion of grandeur; but if he should attempt to defend his delusion by describing how he had inherited his wealth or how he had acquired it through investments, or business ventures, his delusion would be systematized. Again, a person suf- fering from melancholia believes that his soul is lost. If, when opposed, he simply reavows his belief and assigns no reasons for it, his delusion is unsys- tematized ; but if he says he is lost because he has committed the unpardon- able sin, quotes Scripture to show that such a sin warrants his doom, and per- haps tells why and when he sinned, his delusion is systematized. Great diagnostic value has been attached by some recent writers to the dis- tinction between systematized and unsysteinatized delusions, and much has been GEXEIiAL (:Oy;SJlJKRATIONS. 5o*J predicated upon it in the classification of insanities. According to my experi- ence, however, in nature every gradation is to be found between the most thor- ouffhlv systematized dehision and that which is most completely isolated. I have seen various cases in which it was doubtful whether the delusion shotdd be classed as systematized or unsystematized ; and, wiiilst I acknowledg-e that in typical paranoiacs the delusions are systematized and in typical general in- sanities they are unsystematized, I am of the opinion that in this character, as in others, the two groups of general and partial insanities pass in nature insen- sibly into each other. There are certain conceptions or general ideas whi(;h may arise in the brain of a person, and to a greater or less degree dominate his actions, although the reason may not be unsettled and the falsity of the conception may be recognized by the individual whom it controls. Such a phenomenon is known as an Im- pcroiive Conception, and differs from a delusion in that its falsity is recognized, although the individual is powerless to withstand its influence. Closely allied to the imperative conception is the Morbid Impulse. Some alienists, indeed, teach that the imperative conception gives rise to the morbid impulse. In cer- tain cases this undoubtedly happens, as when the imperative conception of per- sonal defilement gives origin to the impulse of escaping from that which defiles ; but a morbid imj)ulse may arise without any discoverable imperative conception. Thus, I long had under my care a man in whose family insanity was distinctly hereditary, but in whom the only symptom that I could find was an impulse to assault bystanders — an impulse a])parently born of no reason, although felt with such urgency as to fill the patient with a terror of himself. Once, upon returninw; home, I found this man sittino; in my office terribly excited, and greeting me with, " Doctor, doctor, I nearly did it ! I nearly did it !" It appeared that he had spent forty-eight hours without intermission in a vortex of political excitement, and suddenly the inijndse to kill had come on him with such power that only by fleeing to my office was he able to save himself. The impulse to throw one's self from a precipice, caused by standing on its brink, is a familiar instance of a mild morbid impulse without an apparent foundation of an imperative conception ; whilst the reasonless dread which many pei-sons have of a snake, toad, cockroach, or other harmless creature probably depends upon an incipient imperative conception of personal defilement. Tiie act which results from a morbid impulse is sometimes spoken of as an Imperative Act. An imperative conception is viewed by some alienists as an ''■ undeveloped delusion." It is, however, not a proof of general mental unsoundness, but in some cases finally the reason of the patient fails to recognize the untruthfulness of the imperatiye conce])tion, which conception thereby l)ecomes converted into a delusion, precisely as an hallucination may give rise to a delusion. A vciy important and conmion iiuperative conception is a morbid fear. This may take almost any form, and may be simply au exaggeration of a noiiiial feeling or may arise de novo. Thii-^, in some persons the fear of a thunderstorm is so violent as to destroy for the time being all rationality; in 540 MENTAL DISEASES. others the natural dislike for filth is increased until it dominates every action of life. On the other hand, the horror of walking in an open place, which is sometimes so overwhelming, seems scarcely to be based upon any natural feeling. To many of these morbid fears names have been given by systematic writers. The fears, however, vary so in their detail that it is not possible to express them accurately and fully by any system of nomenclature. A few of these names may be cited, as representing the more characteristic forms of morbid fear. The following list, taken from Dr. Beard, portrays very well the absurdities of nomenclature : Astraphobia, fear of lightning ; Topophobia, fear of places (a generic term, with these subdivisions : Agoraphobia, fear of open places ; Claustro- phobia, fear of narrow, closed places) ; Anthrophobia, fear of man — a generic term, including fear of society ; Gynsephobia, fear of woman ; Monophobia, fear of being alone; Pathophobia, fear of disease — usually called hypochon- driasis ; Pantaphobia, fear of everything ; Phobophobia, fear of being afraid ; Mysophobia, fear of contamination. As illustrating imperative conceptions a few cases from my own experience may be cited. A very strong shoemaker, past middle life, was oppressed with the idea that he could not walk unless he had some covering over his head. On a stormy day the natural cloud-canopy sufficed, and on a clear day an umbrella carried over his head gave a measure of relief, so that he was able to command his movements. He could walk in a tliick wood, but, as he liimself said, if ten feet of clear sky intervened between the wood and a spring, he would die of thirst before he could cross over. No other symp- tom of physical or mental ailment could be detected. A lady had a dread of personal defilement. Hundreds of times daily she washed her hands, without avail ; bank-notes fresh from the press were the only money she would use; a door-knob she would never touch, but would remain in the room until some one opened the door; in putting on her clothes only the inside of each piece was touched by her fingers, and this as daintily as pos- sible. Without entering into further details, suffice it to state that her whole life was arranged in order to avoid as much as possible contact with any person or thing. On my asking her to shake hands her embarrassment was extreme : though naturally polite and feeling under some obligation to me, .she was nevertheless entirely dominated by her imperative conception. Finally she said, '' Dear doctor, don't ask me : you know you touch so many people." A gentleman entirely rational, able to manage his business affiiirs well and to converse on all subjects, was completely ruled by imperative conceptions and morbid impulses, the connection and the independence of which are well illustrated by his case. Thus, for many years he had an impulse continually to rub his arms against his sides, and this he did incessantly until coat after coat was rubbed into holes. No morbid conception could be found underly- ing this or some of the other impulses which he had. Nevertheless, he did have imperative conceptions with outgrowing secondary impulses. For many months he was markedly mysophobic. Tiien he had the conception that he GENERAL COXSIDERA TIONS. 541 must lay things down straight and could not do it. Most of his waking moments were at this time spent in putting down and arranging. AVhen he placed a book on the table, over and over and over again he would lift it up, straighten it, pick it up and relay it, etc. Often at night he would be two or three hours getting away from his coat, which he was perpetually arranging upon the chair on which he had laid it. There was no delusion, and on my asking the man why he yielded to the impulse, he said, "I can resist it for a while, but after a time the same overpowering sensation comes as when I hold by breath, and I must do it. I have found that if I say very fast, ' It is straight, it is straight,' over and over again, at the same time crack- ing my fingers briskly by shaking my hand, the impulse often suddenly van- ishes, with immediate relief'*' The end of this unfortunate victim of disordered nerve-centres was very tragic. Bv erreat care and effort he had succeeded in concealing from the gene- ral public his mental weakness, and was engaged in business enterprises of large magnitude. In the course of one of these it so happened that he became involved in a lawsuit which finally necessitated his going upon the witness- stand. The newspapers of the morning of the day upon which his testimony was to have been taken announced his sudden and unaccountable suicide. Excessively sensitive and proud, when he found himself in such a position that he must reveal to the public his extraordinary peculiarity, he preferred to such exposure death by his own hands. The relation of imperative conceptions and morbid impulses to insanity is a matter of great theoretical and practical interest. They are undoubtedly fre- quent in the insane, and usually careful examination of a case in which they are present will reveal distinct symptoms of alienation. They may, however^ exist in persons whose intellectual actions are in other respects entirely nor- mal, and in whom the judgment is not dominated by the conception, although the conception may cause him to ])erform actions which are against his judg- ment. To himself the sane subject of an imperative conception seems pos- sessey the use of the word ''mania" as a siidix numerous names have been formed which are sometimes incorrectly used as denoting the morbid impulse, although thev in fact are only correctly ap|)licable to tlie mental state miderly- intr the iiiijuil-c. In juirfniimii't the (uorbid im|)ulse is to set fire to buildings; 542 MENTAL DISEASES. in kleptomania, to steal ; in homicidal mania, to kill ; in suicidal mania, to commit suicide; in arithromania, to be perpetually making calculations or counting in abstract numbers, or perhaps reckoning a multitude of some supposititious concrete thing. The so-called "manias" are not, however, distinct insanities at all: most of them are formed of reasoning insanities ; but a morbid impulse may arise in almost any form of insanity. Again, what seems a morbid impulse is often the result of a logical deduction from false premises by the diseased mind. Thus, the man who, not believing in a future existence, commits suicide because lie is suffering from the unutterable misery of melancholia, is logical and rea- sonable in his suicide, and does not kill himself through any morbid — i. e. unreasoning — impulse. Suicidal and homicidal maniacs are simply maniacs who have a tendency to kill themselves or others. Morbid Desires are exaggerations or perversions of natural appetites, and are chiefly seen in regard to hunger and the sexual passion. Mere depravity and wickedness may convert man into a monster : neither cannibalism nor the lowest sexual degradation is necessarily the offspring of disease. Nevertheless, disease may affect the appetite for food or for sexual congress, as it does other functions of the nervous system. In mania, in paretic dementia, in hysteria — indeed, in almost any form of insanity with excitement and exaltation — the sexual passion may become an all-devouring, insatiable lust. In the female this condition is known as nymphomania; in the male, as satyriasis. The victim of it talks incessantly and indecently about sexual congress, makes furious love to all persons of the opposite sex, exposes the person, etc. Erotomania is a very frequent condition in which there is the appearance but not the reality of sexual excitement. The subject of it conceives a strong attachment for some person of the opposite sex whom perhaps he or she has never seen, and lives in an attitude of a perpetual worship. Sometimes the object is in public life, and is followed from place to ])lace with a pertinacity and publicity which may amount to actual persecu- tion. Even if opportunity offer, the erotomaniac makes no effort at cohabita- tion. Satyriasis leads to sexual excess and to rape. Erotomania is a platonic affection, which involves the higher conceptive sphere rather than the lower nerve-centres and leads to sexual abstinence. Human character is the result of the established balance between the will, the intellectual attributes, and the emotional forces of the individual. When any of the correlated factors are altered there must be a corresponding change in character. Character is, therefore, always seriously implicated in mental affections. Not rarely changes in the intellectual or emotional nature so sub- tile or hidden as not to be readily perceived register themselves with astound- ing distinctness on the dial-plate of character. Hence alterations of character are of the weightiest diagnostic import. They may be the first evidences of a aralytica is generally sexual in its direction. Thus, in a case formerly under GENERAL ('OysiDKhWTIOXS. 543 my care the first marked disorderly action was an attenipt to rape a servant- girl. After this it was discovered that very large and foolish jMirchases had been made as the beginning of a grand business scheme entirely ibreign to the <1aily occupation of the man. An estimable citizen goes to a distant city and urtempts to turn a hotel into a hawdy-house ; another, whilst still performing acceptably the duties of an imjiortaut public office, tries to seduce, and, this tailing, to rape, his own daughter. In dementia paralytica, as in the pure insanities, the moral degradation may, however, run in other than sexual channels. The temperate man sud- denly becomes addicted to drink ; the honest man all at once apjiropriates large sums of money, which, it may be, he spends in licentious revels ; he who has always been exceptionally self-controlled becomes violently passionate ; the amiable, loving husband and father changes into a household demon. Careful examination under these circumstances will usually detect other symptoms of the coming or already-present insanity. Before entering upon the discussion of the classifications of insanity the question how much of abnormal mental action is com])atil)le with sanity seems naturally to present itself. Its answer involves the definition of the words sanity and insanity, and, like these definitions, probably will always be imsatisfactorv. Insanity is not a definite disease, but an abnormal state, vary- ing indefinitely in its intensity, separated by no tangible line from sanity, arising from a number of diverse diseases, and terminating in most various ways. Moreover, the manifestations of insanity are simply alterations, exaggera- tions, or perversions of the normal faculties, and therefore offer nothing that is absolutely new. Emotional depression deepens into the jirofoundest melan- cholia, emotional exaltation lifts itself into the highest mania, by a gradation as insensible as that by which the beach slopes into the deep ocean or the mountain rises into the air ; and who shall say where the dividing-line is between the state in which the man is master of the mood and that in which the mood is master of the man ? The insane impidse is but an exaggeration of that which bids a man standing on the verge of some great height to })lunge headlong, or which, spreading from breast to breast, fills a mob with reckless rage or scatters it in causeless panic. Who shall say when the man could by violent effort control the impulse, and when llu> impulse of necessity over- j)owers the man ? Thus it is in all forms of insanity. For his own purposes of science, or even of treatment, the physician needs no definition of insanity, but the relations of man to man are so altered by insanity that the law must take particular notice of the subject of insanity. Kven, however, for the purposes of tlu; law insanity is not a fixed term, because it is a well-assured axiom that a man may be legally sane — /. c. responsible — fi)r one class of acts, and insane — /'. c. ii'r('S])ousib!c — {\)V another class of a(!ts. As already (contended, there can l)e no -eieiitiru' (leliuition of insanity except that it is a state of mental aberration. Such a definition does not meet 544 MENTAL DISEASES. the needs of the court-room, which demands an arbitrary although shifting- line between the sane and the insane. The term insanity as used by judges and lawyers is legal rather than scientific, and the law ought clearly to define the word. It does, however, no such thing. It does not frame an authori- tative definition of insanity, but through the mouths of its exponents puts; forth an abundance of contradiction. Probably as good a definition of insanity as the expert can frame to meet the clamor of lawyers is, that insanity is a condition of mental aberration suf- ficiently intense to overthrow the normal relations of the individual to his own, thoughts and acts, so that he is no longer able to control them through the- will. The difficulty of applying this definition to the individual case consists^ in tiie fact that the will does not all at once lose its grasp on the lower facuU ties, but that little by little these slip from under its control. Of degrees of responsibility none but the All-knowing can judge, and to say with assured correctness just when the lost control has been lost is not given to mortals. In a court of justice it becomes the expert to state as nearly as may be the exact mental condition of the prisoner, leaving to the judge the decision as to his leo-al responsibility — i. e. the relation of his mental condition to the law of the commonwealth in which the trial is held. Insanity being a symptomatic condition, and not a disease, it is illogical to consider its different forms as distinct diseases. The best that can be done is to describe the diseases of the brain and the insanities which accompany them so far as we know such diseases, and, when our knowledge of diseases fails, to discuss forms of insanity not as diseases, but as symptom-groups. The purposes of discussion necessitate the naming of these symptom-groups. Naming symptom-groups naturally leads to the delusion that these groups are diseases ; hence melancholia, mania, etc. are constantly written about as though they were terms of equivalent force to typhoid fever or scarlatina, whereas they are simply the names of symptom-groups of the same rank as diarrhoea, paral- ysis, or dropsy. This is shown by the following facts : 1st. Similar mental symptoms may be produced by various organic brain diseases; or, as Dr. Charles F. Folsom says,' "tumors, new growths of all kinds, exostoses, spicules or portions of depressed bone, embolisms, hasmor- rhages, wounds, injuries, cysticerci, may give rise to any of the symptoms of the various psycho-neuroses and cerebro-psychoses." 2d. Almost any form of insanity may exist without demonstrable organic lesion. This is shown by the well-known fact that in a large number of autopsies upon the insane skilled observers have failed to detect alteration of brain-structure. 3d. Antagonistic forms of insanity may be produced by lesions which are, so far as we can perceive, identical, as is witnessed by the circumstance that in paretic dementia the usual expansive delusicms may be replaced by a pro- found melancholy. Further, lesions usually accompanied by insanity may^ ^ American System of Practical Medicine, vol. v. p. 202. GENERAL COS.SIDERATIONS. 545 exist without mental disorder. Dr. Folsom says : " Indeed, nearly every pathological condition of the brain known in insanity — in kind, if not in extent and degree — may be found in diseased or injured brains where there has been no mental disease in consequence." 4th. The form of the insanity may change in the individual without appre- ciable cause and without conceivable change of disease. 5th. Almost every grade of case exists in nature, uniting by an unbroken series the various insane-symptom groups. Thus of the two most antagonistic forms of acute insanity, acute mania and acute melancholia, Bucknill and Tuke say :^ " Between acute mania and acute melancholia no distinct line of demarca- tion can be drawn. The domains of the two diseases overlap so much that, in practice, cases not infrequently present themselves which may with equal pro- priety be referred to one or the other." The considerations which have been brought forward show that the various forms of insanity are not entitled to be considered as distinct diseases, and that at present we cannot connect cerebral lesions and mental symptoms in their causal relations. More than this, the rapid recoveries which sometimes occur in apparently hopeless cases of insanity show that the symptoms cannot depend upon alterations of the brain-substance sufficiently gross to be detected by our present methods. I shall narrate, as showing this, a single case, that of a lady with whom I was thrown in almost daily contact for many years : At about the age of forty- five she was taken with religious melancholia of the most pronounced character, which was accompanied by agitation, and sometimes by frenzy. This persisted for fifteen years. There had been in all this time not the slightest wavering of the mind of the woman in regard to her future life. She firmly believed that lier soul was irretrievably lost. At the same tim& her general emotional nature had undergone a retrograde change : she had become exceedingly jealous of attentions paid to other persons, and had lost many of the peculiar traits of refinement which had been her especial characteristics. After being in an asy- lum for some time she recovered intellectual power sufficient to enable her to take charge nominally of her husband's house, which was really managed by her attendant, but there was no M-avering in her delusion nor even any tem- porary abatement of her misery. One nio-ht the attendant noticed this ladv on her knees at tlie bedside. This was the first time in fifteen years that she had been known to kneel in prayer. The nurse, being a wise woman, did not disturb her, and there she remained all night. In the morning she joined the family, and said that she had found Christ, and that she was perfectly well and ha})py. Her old disposition had returned, and her peculiar jealous sensitiveness had disapi)eared. The wumaii who had been buried for fifteen years had emerged in one night witiiout even the grave-clothes about her. This continued loi- one week. Then the old cloud came on her, and for days she was in the old condition ; but suddenly the sunlitrlit ajrain broke throuii;h the clouds, and she remained well for three ' IMiila, (.-(lition, 1874, p. 427. Vol.. I.— 35 646 MENTAL DISEASES. or four days, to relapse, and after some hours again to regain her sanity. These attacks continued to recur at gradually lengthening intervals. Finally she had been perfectly sane for several consecutive months, when suddenly she was seized with a serous diarrhoea, causeless as far as could be ascertained, and liopeless as far as relief by remedies was concerned. In forty-eight hours she was dead. I believe that the cause of that death was the same obscure some- thing which had so potently aifected for years the emotional life : that which for so many years had dominated the nerve-centres of higher life attacked and paralyzed the lower centres of animal life, and death came speedily. "We can scarcely conceive the nature of a lesion which, after having for fif- teen years held the nerve-centres in an iron grip, suddenly let go its hold. For its demonstration the microscope is useless. Our best instruments show us in human spermatozoa nothing but irregular, transparent specks of protoplasm, not to be distinguished one from the other. Yet the records of past generations are written in the little formless particles, in which also are enfolded the poten- tialities of future successions of men. Structure and function seem so widely independent that it is almost hopeless to expect that we shall ever understand the infinitely delicate changes which take place in the complex protoplasm of the brain, and to be able to say why waves of emotional and mental paralysis sweep over the individual. I believe that the changes are physical, but I believe that it is not within human power to recognize their nature. The microscope is a coarse, blundering tool, powerless to reveal the ultimate changes of nervous protoplasm gone mad. I have ventured to occupy space with the above considerations, partly because they seem to me very important, and partly because, for the purposes of brevity, I shall omit the section of Pathology in the articles upon the pure insanities. A scientific, thoroughly satisfactory classification of insanities is in the present state of our knowledge probably not possible. Holding as I do the belief that many of the so-called insanities are mere symptom-groups arbi- trarily separated, the simplest arrangement seems to me the best. In accord- ance with this I shall adopt the following classification, which is quite similar to that of Krafft-Ebing : Group I. — Complicating Insanities. — The outcome of a distinct organic disease of the brain, not dependent upon acquired or inherited constitutional diathesis. Meningitis, tumors, and most other organic brain diseases may be asso- (^'iated with disturbance of cerebration, but usually the mental symptoms are subordinate to other evidences of organic brain disease, and most of these dis- eases have been discussed in the present volume under the head of Organic Diseases of the Brain. In both the acute and chronic forms of perien- (•e]>lialitis, however, the evidences of mental aberration so predominate over the physical disturbance that the subjects usually find their way to insane asy- lums, and the disease is usually treated of in text-books on insanity, and this custom is here followed. GENERAL CONSIDERATIONS. 647 The mental aberration and deterioration of old age are commonly supposed to be dependent upon organic change. In accordance with this view I shall consider it in the present group. Amentia, or imbecility from arrest of devel- opment, may also well be considered as among the organic insanities. Ch'oup II. — CoxsTiTUTioxAL INSANITIES, in which the cerebral disorder is due to an acquired or inherited constitutional disease, including in the latter term diathesis, constitutional diseases, and subacute and chronic poisonings involving widespread areas of the body. The most important of the diathetic insanities are the gouty, the epileptic, the hysterical, and the syphilitic. Numerous poisons disturb cerebration, but the only toxaemic insanity which it seems necessary to notice at this place is that due to alcohol. Group III. — Pure Insanities, in which the mental disorder is not dependent either u{)on demonstrable organic brain lesion or upon a diathetic or other poison. The pure insanities seem to me very naturally divided into two subgroups, which may be known as the Functional Insanities and the Neuropathic or Constitutional Insanities. The Functional Insanities are those insanities which are liable to occur in almost any person, or at least which do occur in individuals who have pre- viously shown no mental warp, and who may recover and during later life remain free from mental aberration. Conditutional Insanities are the out- irrowth of an orio^inal vice of nervous construction, such vice of construction not being sufficient to reveal itself by anatomical peculiarities, but showing its presence throughout life in functional aberration. The general tendency of constitutional insanity is to increase in severity as the patient grows older, and a constitutional insanity, once developed, is rarely if ever permanently recovered from. It is especially these forms of insanity which grade so insen- sibly into sanity. At the bottom of the series is the typical human individ- ual ; then the man who is original and strikingly independent in thought and act ; then tiie man who is so set apart by mental peculiarities from his fellows that he is known as eccentric ; then the lunatic, eccentricity grading by an unbroken series into a complete insanity, the subject of which is not to be influenced by the motives which usually dominate men, and is indeed incapa- ble of reasoning correctly or indeed of controlling his own acts. Functional Insanities. Neuropathic Insanities. Melancholia. Constitutional affective insanity (folic raisonante). Mania. Moral insanity. Confusional insanity. Paranoia — insanity wilh irresistible ideas. Terminal dementia. T^eriodic insanity (folic circulaire). 548 3IEXTAL DISEASES. GROUP I.— ORGANIC INSANITIES. Acute Periencephalitis. Definition. — A very acute, usually fatal, disease of the brain, attended by stupor, wild delirium, general disturbance of the psychic functions, by rest- lessness, convulsions, and other disturbances of the motor function, and by fever; dependent upon acute hypersemia and subsequent inflammatory changes in the brain cortex. Synoxyms.— Acute peripheral encephalitis ; Phrenitis mania gravis ; Typho- mania ; Acute delirium ; Delirium grave ; Bell's disease (Luther Bell). Pathology. — P^xcessive hypersemia aifecting both the cerebral cortex and its membranes is the first alteration in the present affection. This is rapidly followed by oedematous exudation, with a choking up of the lymph-spaces both of the pia and the cortex by the corpuscular elements of the blood. The periglanglion space, as well as the interstitial lymph-sheaths, becomes crammed with these bodies. I have myself seen also minute apoi)lectic haemorrhages in the gray matter. In one case which I examined the ganglionic cells themselves appeared to have undergone some change. Etiology. — Acute periencephalitis appears to occur fully as frequently in women as in men, and usually during active adult life. Abuse of alcohol, profound grief, protracted worry, especially when accompanied by great over- work, partial starvation combined with the gnawing anxiety of deep poverty, certain acute fevers, sunstroke, blows upon the head, — these are commonly assigned as the causes of the disorder, which also in some cases appears to have been the result of chronic disease of the skull or its membranes. The affection may also develop as an exacerbation of chronic periencephalitis, and I have seen it come on without apparent cause during locomotor ataxia. Recorded cases of death from alleged acute hysteria have probably been instances of this disease. The combination of overwhelming mental and phvsical strain is ]>erhaps the reason of the comparative frequency of the dis- order during ])rcgnancy following seduction. The symptoms may come on with extreme suddenness or may be preceded l)v prodromic evidences of cerebral disturbance. These prodromes in rare cases take the form of increase of mental power, in others of brief nocturnal attacks of wandering, delirious restlessness ; or there may be short periods of impaired consciousness, especially upon waking in the morning, or, as in one of my cases, even an epileptiform convulsion. The fully- developed disorder naturally divides itself into two stages — first, that of acute maniacal delirium ; and second, that of apathy and collapse, with coma. The delirium is always of an excited type, accomjianied by violent inco- herent speech, and usually by a fury of fighting and of destructiveness. Hal- lucinations and half-formed delusions are present, and often bear a close relation to tlie cause of the attack. The abandoned mistress will in her ravings recount her past shame and present agony. The business-man will be perpetually occupied with an incoherent jumble of business transactions. ACUTE PERIEXCEPHALiriS. 549 Almost invariably along with the delirium there is great physical restlessness, which grows more intense until it causes the patient to leap from his bed and to attempt to run away. Very commonly violent assaults are made upon the attendants. Convulsions are rare. The delirium may at first be not continuous, occurring only at night, or at least be interrupted by brief intervals of compar- ative rationality during the daytime. Finally, however, there is persistent intense mania. In one of my cases the patient during the day told his wife that she must protect herself from him — that he loved her most fondly, bnt that he was o-oins; into a condition of insanity in which he would certainlv kill her. From this time until his death he was furiously maniacal during the night, although for several days he would recognize his friends during the daytime, and for a moment or two talk rationally. There is usually absolute insomnia. The pulse is rapid, and, if in the beginning it possesses a show of force, it is really soft and compressible. There is no desire for food, and generally an absolute refusal to take it. There is also distinct fever, the temperature rising some- times to 106° F. According to my observation, the temperature varies with a stormy irregularity which is almost characteristic, rising and falling many deorrees many times during; the twenty-four hours. Its variations are connected with the mental and physical excitement of the patient, maniacal outbursts producing an immediate rise of the temperature. In advanced stages the temperature may fall much below the normal. The pupils may be contracted, dilated, or normal. In the course of a few hours to several days the second stage of the disorder develops. There is now quiet, with coma or else mutter- ing, delirious unconsciousness, failing pulse, cool skin, and general evidences of collapse. In the early part of this stage, when aroused, the patient may respond incoherently or perhaps give some slight evidences of comprehending what is said to him, but rapidly sinks lower and lower until he dies from exhaustion. Early in the disorder the skin becomes very harsh, and finally cyanotic ; in the later stages irregular desquamation, or even ulceration, may occur. In a case quoted by Spitzka the ansesthesia was so complete that the patient gnawed off a portion of one of his fingers. Pemphigus-like vesicles, phlegmons, decubitus, gangrenous patches of skin, or gangrenous extremities not rarely apjiear, but are frequently absent, and are not characteristic. Diagnosis. — Diseases having no connection with the brain may sometimes sinudate an acute periencephalitis. This is especially true of the abrujit mania- cal outbreaks which sometimes occur in a latent overlooked pneumonia. Tlie fact that acute delirium is a disease of jniddle life, whilst the so-called cerebral pneumonia occurs almost exclusively in young children or in persons broken down by age, excesses, or privations, should put the practitioner on his guard, and a physical examination woidd detect a pidmonic disease. Typhomania is distinguished in.iii acnite meningitis by the absence of general hyperesthesia, ^iffness of the muscles of the back or extremities, and of |)ronounced head- ache. In acute mania the bodily temperatun; is usually normal or subnormal, and, according to Krafft-Ebing, the rise of tiie temperature in such a case to 100.5° F. indi<-at('S strongly delirium aciituin. 550 MENTAL DISEASES. Prognosis. — The prognosis is highly unfavorable: about two-thirds of the cases end fatally, and when recovery occurs the mind is almost universally left more or less affected. Alcoholic cases are especially dangerous : the more vio- lent the delirium, the insomnia, the motor disturbance, or the fever, the worse the outlook. Treatment. — In the early stages of delirium acutum general or local blood- letting by means of leeches, irritating purgatives, the local application of cold to the head, seem to be strongly indicated, whilst hypodermic injections of morphine and of hyoscine, with the administration of chloral by the mouth, serve to allay the excitement. Much better results are obtained by repeating the remedies at short intervals in comparatively small doses than by giving large doses at long intervals. The Italian physician Solivetti has claimed ex- traordinary results from hypodermic injections, every eight hours, of 1 gramme of ergotin. Certainly the use of ergot would seem to be indicated, and the se- verity of the disorder thoroughly justifies the risk of any local trouble from hy])odermics. A filtered solution of the officinal extract of ergot in freshly- boiled water should be used. In the later stages of the disorder alcoholic and cardiac stimulants may be employed p7'0 re nata. Throughout the disease everv effort should be made to obtain absolute rest, with freedom from the causes of excitement, whilst milk, eggs, and similar nourishing, non-irritating foods should be administered as freely as the patient will take them. Chronic Periencephalitis. Definition. — A chronic disease, dependent upon a peculiar inflammatory degeneration of the cerebral cortex, which gives rise to change of character ; progressive mental deterioration, with delusions of grandeur, emotional exalt- ation or emotional depression ; occasional maniacal outbreaks and epileptic attacks; progressive physical deterioration, as shown by irregularity of the pupils, disorder of speech, loss of control over the movements of the hands and legs, — all symptoms finally being swallowed up in a complete paralysis of intellection and of voluntary motion. Synonyms. — Paretic dementia ; General paralysis of the insane ; Paresis ; Dementia paralytica ; Periencephalo-meningitis. Btiolog-y. — Heredity plays a very unimportant role in the production of general paralysis, a positive taint being present only in about 15 per cent, of the cases. The disease is very uncommon in females, and exceedingly rare in females of the upper classes, whilst it is remarkably frequent in officers and other military officials, in whom, according to Mickle, it also occurs at an earlier age than in other persons. Thus in civil life the affi-ction is most fre- quent between forty and fifty, and extremely rare under thirty or over sixty, whilst in sailors and soldiers it is affirmed by Mickle that the average age is about thirty-three. These jieculiarities are, however, probably simply depend- ent upon diffiirences of exposure to tlie three great causes of the disorder — namely, alcoholic and venereal excesses, sy])hilis, and habitual long-continued over-exertion, accom])anied by the strain of excessive ambition or of worry. CHRONIC PERIENCEPHALITIS. 551 The connection between the disease and sypliilis is distinct. Mendel affirms that in general paralysis 75 per cent, of" the victims offer a distinct history of syphilis, whilst only 18 per cent, of the victims of other insanities investigated by him were syphilitic. The relations between the two diseases are evidently precisely those which exist between syphilis and locomotor ataxia : dementia paralytica, indeed, occurs not rarely as a complication of tabes dorsalis, whilst spinal scleroses are not rare in dementia paralytica. Sunstroke and blows upon the head are also set down by authorities as among the exciting causes of periencephalitis. Pathology. — At autopsies upon old cases of chronic periencephalitis are usually found hyperostosis and exostosis of the skull ; pachymeningitis in some form (often absent) ; arachnitis (with consolidation of the arachnoid with the brain); atro])hy of the convolutions, especially of the frontal lobes; and internal hy drocephal us. Two distinct views ])revail as to the nature of the disease-process : one, that it is a diffused interstitial cortical encephalitis, in which the connective tissue is primarily affected ; the second, that it is a diffused parenchymatous inflammation, which commences in the nerve-elements proper and involves secondarily the neurogliar tissue. On section the brain-cortex is usually found discolored, sometimes less, sometimes more firm, than normal, often containing minute cysts or cavities varying in size from a pin's point to a millet-seed. Microscopic examination reveals degeneration or perhaps complete disappearance of the ganglionic cells and a peculiar alteration of the white fibres, which renders them much more apparent than in the healthy brain, besides pronounced degeneration of the neuroglia and large numbers of peculiar many-processed connective-tissue cells (Deiter's or spider-shaped cells). The blood-vessels are usually injected, altered in character, with distension of the adventitial lymph-spaces. The spinal cord is very frequently degenerated. Changes in the sympathetic ganglia have also been noted by recent investigators. Symptomatolog-y. — The symjitoms of general paralysis vary so greatly that it is exceedingly difficult to reduce theui to order. Four stages of the disease are recognized by some writers, but the individual case usually passes bv such im])erceptiblc degrees from bad to worse that these divisions nnist be looked upon as arbitrary. Moreover, in various cases the time relations of these stages vary, and some of the stages are often altogether absent or jiass unobserved. Nevertheless, for the purposes of discussion I shall speak briefly of these four stages, and then take up the consideration of the individual symptoms of the disorder. The first or prodromic stage often passes without recognition. The syni])- toms may resemble those of an ordinary cerebral neurasthenia — loss of ])owcr of fixing the attention, apathy, inability for mental exertion, and some em(»- tional departure from health. Tn some cases vaso-motor phenomena arc pro- noun('cd, showing themselves in {\\i-'\\\\ congestion, headache, vertigo, tinnitus aurinin, liciiii;iiiopsia, and even pcciiliar disliirbnnccs of vision, siiiiuliiting au 552 MENTAL DISEASES. acute glaucoma. At the same time a slight alteration of character is evident to the close observer, the patient being in some way not himself. Krafft- Ebino- gives as almost characteristic the peculiar alteration of the relations of the patient to time and space, which render him exceedingly unpunctual or cause him at times confusedly to lose himself in well-known streets. Al- thouirh this stage is so often overlooked, yet after the disease has declared itself the books and correspondence of the business-man or the office histories and records of the professional laborer will, in their loss of accuracy and dignity and in their general evidences of failing power, afford a history of a slowly- progressive mental degeneration. The second stage of the disease is that in which the mental aberration is pronounced and distinct. The disordered cerebration may be accompanied by distinct disturbance of the motor faculties, but I have seen it persist for more than a year without the slightest failure of the general physical powers. The third stage of the disease is that in which motor symptoms become marked, as shown in inequality of the pupils, flabbiness and loss of expression of the face, disorders of articulation, general loss of endurance, and mayhap distinct paresis of the extremities. The fourth stage of the disease is that in which the dementia is complete, and the general widespread paralysis and loss of power profound, the patient being reduced to a mere living automaton. For the purposes of discussing the mental phenomena of paretic dementia the cases may be divided into four groups, it being remembered that in nature every grade of case exists between these groups, whilst the march of the men- tal malady is sometimes so irregular that in one portion of its career the case would be properly assigned to one group, whilst at another period it would represent another variety of the disorder. In the first form of j^aretic dementia are included those cases in which ])rogressive failure of power constitutes almost the whole mental disturbance, the mental faculties consentaneously growing less and less until the patient becomes childish, and at last completely demented, without emotional disturb- ance or delusions having been present. (It is these cases especially that are [»opularly spoken of as softening of the hrain?) The second variety of paretic dementia is that in which delusions of grandeur or expansive delirium are present. The character of these delusions lias already been sufficiently pointed out. (See page 537.) It is essential to remember that these delusions mav exist in so mild a deo:ree that thev mav be very readily overlooked. Further, in many cases they are replaced by a Inen-^tre which may be looked upon as a condition of undeveloped delusion. Thus the man sunk in the deepest poverty will be excessively happy and Jolly, misfortunes having no power to depress him, although he makes no assertion of the ]iossession of great power or wealth. In all cases of the present variety of general paralysis there is progressive mental failure, and it is there- fore evident that the cases in which a simple hien-Mrc exists may be looked upon as midway between the first and the second variety of the disease. CHRONIC PERIEXCEPHALITI^. 553 Maniacal outbursts may occur in any variety of general paralysis, but they are more common and more frequent when there are delusions of grandeur. The third form of general paralysis is that in which there is emotional depression, and even pronounced melancholia, with depressive delusions. Not rarely the depressive delusion relates to the person of the ]>atient, who believes himself ill, deformed, or wanting in some member or function. In this way arises the so-called hypochondriacal variety of general ])aralvsis. The fourth form of general paralysis is that described by Dr. Fabre, in which excitement and depression alternate so as to make a periodic or circular insanity. The existence of this variety has been confirmed by Dr. W. Julius Mickle,^ who further says that when there are only two phases these succeed each other suddenly, but that in some cases there are three periods — (1) excite- ment, (2) calm, (3) depression, in this differing, therefore, from non-paralytic circular insanity, in which the usual order is (1) excitement, (2) depression, (3) quietude or lucidity. The motor symptoms of paretic dementia consist of epileptiform convul- sions and paralysis. The paralysis is characterized by its incompleteness and its connection with tremors and disorders of co-ordination. In the earliest stages of the disorder the loss of control over complicated muscular move- ments is first manifested in the hands, and may be very ]M'onounced at a time when the general muscular ]>ower is but little weakened. Thus, a man may be able to lift many pounds, although he cannot write his own name. The acute development of such a loss of muscular control, occurring in a man of middle age, without obvious cause, is a serious symptom, and probably, in the majority of cases, is prodromic of general paralysis. It is especially to be noticed very early in engravers and other persons whose daily vocation requires great technical skill. A varying inequality of the pupils may occur very early, although more constant in the later stages of the disease. It mav be associated with exces- sive dilatation or contraction. When there is no affection of the eye or its nerves, no focal brain lesion, and no disease of the nock or of the cervical spinal cord, this symptom is very characteristic. The departure of the speech from the norm in general jxiralysis is partially of mental and partially of physical origin. As a consequence of the loss by the lips and tongue of their delicacy of movement there is a difficulty of pro- nunciation, which is especially manifested with lingual and labial consonants anart hygienic or symptomatic. In the very beginning of the case, whilst the diagnosis is still doubtful, repeated local bloodletting by means of leeches to the temple, or the re[)eated use of the actual cautery or of other counter- irritants to the nape of the neck, may be of advantage. Such measures are especially effective where cortical disease follows sunstroke or blows upon the head. It is very doubtful whether drugs have any direct power over the diseased processes, but corrosive sublimate may be given in doses of one-twentieth of a grain three times a day, continued for many weeks, or the iodide of potas- sium, five to ten grains a day, may be substituted. Some alienists have claimed very good results from the employment of massive doses of ergot. The solid extract should be employed, and it may be given in doses of from fifty to sev- COXSTITUTIOSAL IXS A DUTIES. bbl enty grains a day, continued for many weeks, unless distinct physiological effects are produced. For the relief of symptoms, hyoscine, morphine, sulphonal, and other narcotics may be used in times of wakefulness or excitement, whilst tonics and laxatives are to be employed pro re nata. The hygienic treatment consists in the protection of the patient by very warm clothing and the administration of a non-stimulating but abundant and nutritious diet ; the use of massage, moderate bathing, careful outdoor exercise, etc. In all cases it is essential that physical as well as mental and emotional excitement be avoided as much as possible. The treatment of the latter stages of the disease should be purely hygienic and symptomatic, especial care being exercised to see that the i)atient be pro- tected from fsecal and urinary discharges, and that every precaution be taken to prevent decubitus. It is often necessary to keep the patient on a liquid or semi-liquid diet, as fatal pneumonia from particles of food getting into the lungs is a not very rare occurrence. GROUP IL— CONSTITUTIONAL INSANITIES. The constitutional insanities are not distinct forms of disease, but groups of symptoms of various and varying character which are the outcome of con- stitutional vice or disease. Thus there is nothing in the symptoms of a gouty insanity which would enable us to diagnose the nature of the case. The cause of the mental aberration in such a case can be recognized only by recognizing the presence of lithsemia. The importance of distinguishing an insanity of the present class lies in the fact that relief is to be obtained not by treating the insanity, but by treating the diseased condition which is the cause of the mental disorder. The most important of the constitutional insanities are the gouty, the epi- leptic, the hysterical, and the toxa^mic. Gouty Insanity. — It is well known that gouty paroxysms are frequently accompanied and preceded by peculiar nervous irritability. At such times there is a depression of spirits, with an irritability so great that it can scarcely be controlled by the patient. In some cases these symptoms become so inten- sified as almost to amount to insanity ; moreover, hallucinations, delusions, loss of mental power — indeed, almost every conceivable manifestation of mental disorder — may be directly or indirectly caused by gout. Oarrol in 1859 said : "Gouty mania is occasionally seen;" and in 1875, Dr. P. Berthier' published a collection of 44 cases of nervous disease attributable to gout — 1 of halluci- nations ; 1 of migraine; 4 of tetanus ; 3 of chorea ; 1 of hypochondria ; 7 of epilepsy ; 1 of paralysis ; and 26 of mental affections, including in these dementia, melancholia with stupor, mania. Althougii in some of these cases the evidence is not at all positive that gout was the indtcrlcs morhi, yet in others the relation seems to have been clearly made out. In his ])aper read before the International Congress at London, 1881 (iii. 640), Dr. Raynor sujiported the following conclusions: ' Dea Nevrosea diathCsiqueH, Paris. 558 MENTAL DISEASES. 1. Protracted ofoutv toxferaia, when not verv intense, nsuallv results in sen- sory hallucinations or melancholia. 2. Sudden and intense toxaemia results in mania or epilepsy. 3. Intense and protracted toxaemia usually results in general paralysis. 4. If there be a tendency to vascular degeneration from plumbism, alcohol- ism, etc., varying degrees of dementia are produced. In the discussion which followed the reading of Dr. Raynor's paper, Drs. Savage and Crichton Browne of London both expressed the belief that gout does cause insanity, the latter, however, qualifying by the statement, " only where there is hereditary predisposition to insanity." ' The conclusions of Dr. Raynor are borne out by a case of my own. A lady at regular intervals of four years had had a number of attacks of severe gout, associated with great depression of spirits, at times amounting almost to pronounced melancholia. Finally, at the end of four years of health, the patient was seized with symptoms of acute dementia or stuporous melancholia, associated with marked tenderness of the nerve-trunks, and, in certain por- tions of the body, violent neuralgia, and a urine that was loaded with uric acid and urates. Death occurred after some weeks from oedema of the lungs. At the autopsy there were found gouty kidneys and a remarkably pronounced atheromatous degeneration of the cerebral vessels, the lumina of some of the arteries at the base of the brain being almost obliterated. Hysterical Insanity. — The peculiar mental organization (see p. 594) which underlies constitutional hysteria in its aggravated forms may amount to a distinct and characteristic pschycosis whose relations with neuropathic insan- ity is very evident. This psychosis has been characterized so vividly and succinctly by Dr. Folsom that I quote his words : " It is characterized by extreme and rapid mobility of the mental symptoms — amnesia, exhilaration, melancholic depression, theatrical display, suspicion, distrust, prejudice, a curi- ous combination of truth and more or less unconscious deception, with periods of mental clearness and sound judgment which are often of greater degree than is common in their families ; sleeplessness, distressing and grotesque halluci- nations of sight, distortion and perversion of facts rather than definite delusions, visions, hyperaesthesias, anaesthesias, paraesthesias ; exceeding sensitiveness to light, touch, and sound ; morbid attachments, fanciful beliefs, an unhealthy imagination ; abortive or sensational suicidal manoeuvres, occasional outbursts of violence ; a curious combination of unspeakable wretchedness alternating with joy, generosity, and selfishness, — of gifts and graces on the one hand and exactions on the other. The mental instability is like a vane veered by every zephyr. The most trifling causes start a mental whirlwind. There is no dis- ease giving rise to more genuine suffering or appealing more strongly for sym- pathy. Yet when this is freely given it does harm. One such person in the house wears out and outlives one after another every healthy member of the family who is unwisely allowed to devote herself with conscientious zeal to the invalid." ' For diHCUssion of Epileptic Insanity see tlie urticle on Epilepsy, page 617. TOXyEMIC IXSANITTES. 559 In nature the mildest hysteria grades without break in the series into the most severe, and the difficulty is to decide when hysteria has crossed the line that separates responsibility from irresponsibility ; bnt certainly in some cases of hysteria the mental symptoms are sufficient to indicate restraint. Further, in some cases of hysteria an acute mania or a peculiar automatism with loss of conscious self-control may occur. (See page 594.) Toxemic Insanities. The only insanities of the present class requiring notice here are those springing fi-om the abuse of alcohol. Such mental disturbances may be divided into the subacute and chronic forms, to which the names delirium tremens and alcoholic insanity may be assigned. Delirium Tremens. — Delirium tremens is a peculiar series of acute symp- toms which are produced by excessive drinking. The affi^ction is especially apt to develop upon the sudden cessation in the use of the stimulants, but may come on during the debauch. In their mildest form the symptoms constitute that condition known by old drunkards as " the horrors," in which the sleep is dis- turbed, the hand tremulous, the mind weak and confused, and the patient troubled with frightful imaginings, vague alarms, and an apparently causeless depression of spirits. When the attack is more severe, hallucinations of sight, of hearing, and, more rarely, of touch, occur. These hallucinations always have in them an element of terror or of horror. Disgusting objects, such as snakes, toads, rats, and mice, and similar unclean creatures, crawl over the bed or the person. Voices predicting evil or bringing messages of remorse or uttering threats of punishment are heard. The patient may seem violent, and may even attack his attendants, but the violence is that of terror, and not of aggression. The attack is an attempt at defence. There is great insomnia, and usually when the patient can be made to sleep the mind is clear after the awakening. This is not, however, invariably the case. I have seen delirium tremens gradually pass through successive days of wakefulness and nights of sleeping into a chronic mania not readily to be dis- tinguished from that arising from other causes. In the earlier attacks of delirium tremens occurring in very robust people, when all the mucous mem- branes are irritated, and when probably there is direct irritation of tiie brain and its meninges, there may be a slight febrile reaction and even a strong and excited pulse ; bnt the disease is typically asthenic, with loss of muscular ])ower, tremulonsness, and rapid, feeble pulse, and when death occurs it is from exhaustion. Canliac failure is in such cases always to be guarded against. Sometimes the patient suiTcring from dcliriuui ticuiens has sufficient ration- ality to receive his physician with a quiet, gentle com-tesy and to answer ques- tions without irritation. It will l)e noted, however, that he is evidently pre- occupied, and that occasionidly lie turns his Ih;ierature or a marked tendency to paroxysms of subnormal temperature. On the other hand, there may be a very distinct febrile reaction. VOXFl 'SIOX. 1 /. IXS. ( XI T } '. 573 This I li:ivo espet-ially seen in puerperal eases. When fever exists at all, the swiiio; of the thermonietrical mercurv is remarkable for its irreorularitv and its extent, and a very iiigii temj)erature is often followed by a sudden and marked fall below the norm. In order to show the peculiarities of temperature the followinii; reproduction of the chart of a case of the puerperal form of the disease is appended : Fi?. 44. >• i> 2j 24 >S <6 27 38 37 30 31 I '3456 7 8 9 10 U 12 IJ 14 The figures at the bottom represent the days of the month, beginning June I'lst. Diagnosis.— Very rarely ought there to be any trouble in recognizing the true nature of confusional insanity. The history of the attack, the know- ledge that the outbreak has been preceded by an exhausting disease, trauma- tism, or emotion, the failure of bodily nutrition and of general nerve-force, the lack of dominant emotional excitement, the stupor, the peculiar mental confusion, the kaleidoscopic character of the hallucinations, — all these make dia^-nosis easv. Prognosis. — The prognosis in confusional insanity is favorable. Kraift- Ebing states that 70 per cent, of his cases have recovered, and in my own experience, even when the mental confusion has amounted to complete and absolute imbecility, complete recovery has almost invariably occurred, pro- vided that there have been no pre-existing organic bodily lesions, such as un- sound kidneys or degenerated arteries. Death may, however, occur in com- jilicated cases. If the mental recovery be not complete, the result is lack of mental power, but never a reasoning insanity, never a state resembling that of paranoia. It must be remembered, however, that an emotional shock may produce an absolute, permanent overthrow of the intellectual faculties. Thus, Bucknill and Tukc record a case in which a young lady of refinement and education was assaultwl and raped by a band of ruffians, and became at once a speechless idiot for life. In a second case a young lady, having by mistake fatally poisoned her father, from the time of his death " was lost to all knowledge or notice of ])ei'sons and occurrences around : food she never took except wIkmi it was placed upon her tongue; the only sound which escaped her lips was a faint yes or no." Treatment. — Usually the first question to be settled in the treatment of confusional insanity is as to whether thurpose iron combined with bitter tonics, administered in small or large quantities according to the individual character of the case, strychnine given in ascending doses to the limit of physical tolerance, and phosphorus TERMINAL DEMENTI A.— NEUROPATHIC INSANITY. 575 continuously e.xliihited in such small doses (yl^ to y^ of a grain) as not to disturb digestion, I have found to be of great service. Second, to obtain sleep when there is wakefulness or to quiet delirious excitement. Here the bromides naturally suggest themselves, and they are often used in very large quantities: it should be remembered, however, that the bromides are powerful depressants, not merely to the functional, but also to the nutritive, activity of the nerve- cells ; and I am sure that I have seen very distinct injury done by their free use in confusional insanity. In an individual case the selection of a hypnotic or quietant is to be based chiefly upon the results of trial. In some instances opium seems to act favorably ; more commonly hyoscine is of advantage. Chloral and sulphonal ought certainly to be tried on occasion. As a calmative the hot-pack is often very serviceable, and I have seen a very active deliriimi apparently greatly benefited by free blistering of the scalp. Terminal Dementia. Almost any form of active insanity may be followed by a long-continued condition in which the mind is so far lost that even the distinctive character- istics of the original insanity have more or less completely disa})peared. Tiiis state is the so-called secondary or terminal dementia. The completeness of the mental ruin varies: in some cases, apathetic, mindless, without thought or emotion, the individual lives on, a mute, almost motionless, vegetating autom- aton ; in other instances, restless, full of obtrusive or destructive activity, noisy, with incoherent talk, the dement, although overflowing with animal spirits, and perhaps also possessed by a peculiar aggressive egotism, is useless for any purpose — mayhap is almost uncontrollable and very troublesome. Sometimes the mental condition is simply that of a weak-mindedness, and the harmless imbecile seems like an overgrown child. No medical, hygienic, or moral treatment can in these cases avail anything to restore the lost mental power, and the only thing to do is to take care of the individual. Not rarely a little intellectual power remains ; and if with this there be docility, the dement may be usefully employed about a farm, in the wards of a hospital, or in other situations in which he can be carelully watched over and constantly directed and taken care of. Neuropathic Insanity. Etymologically, the term " neuropathy " means disease of the nervous .sys- tem. Bv modern neurologists, however, the term is commonly us(>d in a more rei^tricted sen.se, and especially as the basis of the adjective "neuro- pathic," to designate the condition in which abnormal symptoms are produced by an original and ac(piired vicious development or failure of doveloi)nient of the nervous centres. Insanities, nervous disea.ses, drunkenni'ss, .syi)hilis, aleoliolism, excessive poverty and lack of the necessities of life, — these and other similar active causes in the parent lead to degradation in the oflspring; whilst onanism, taught perhaps even in infancy ; the overcrowding, the imder-feeding, :uid the 576 MENTAL DISEASES. miiltitiulinous ills which come to the young life born in the midst of extreme jioverty ; various injuries in early life ; acute and chronic diseases setting in before the nervous system has unfolded itself, — these and a thousand other similar possible ills frequently cause in the unfortunate children of the human race a nervous system which for ever dooms its victim to an unhappy pecu- liarity amongst his fellows. Once engendered, the neuropathic constitution magnifies itself through generations, and so root-stocks appear from wdiich spring criminals, lunatics, and a midtitude of other beings concerning whom the world wonders whether they should be considered sane or insane. In very truth, there is no line, at least none that can be drawn by the finite mind. The offspring of such parentage may perform all the duties of life, but his mental organization lacks something or has suffered some twist. Perverse, drifting almost of necessity into criminal acts, eccentric, such unfor- tunates are a long series of human atoms whose faulty brain-organization sepa- rates them from their more fortunate fellows. When this separation is sufficiently wide, when the mental organization is so bad that every one can perceive that the man is the victim of his own imperfectly-developed brain, he is said to be insane. But when the unfortunate individual is a little more like the normal human being, he is looked upon simply as eccentric, perverse, or wicked, and, unloved and unpitied, drifts through life, sometimes to poverty, sometimes to the hospital, sometimes to the jail, and, it may be, to the hangman's scaffold. Sanity, insanity, criminality, power over self, free will, mental attributes, — these and similar terms are household words with all of us, but no man knows whence they come or what they are, or how far the individual is master of himself or is driven by the hand of fate as represented in the physical con- formation of the nerve-cells and fibres of his brain. As has already been insisted upon, insanity is not a disease or a distinct entity. Necessity for an arbitrary line between sanity and insanity is not of scientific but of legal origin, and when the medical expert affirms that he is unable to measure out accurately the exact degree of human responsibility, he simply acknowledges that he himself is a finite being and that the problems of life baffle his utmost thought. It has been reserved forjudges upon the bench and lawyers at the bar to arrogate to themselves the attribute of infinity ; whilst ministers of the gosi)el but too often teach that the last and highest revelation of a merciful God is that this poor, broken humanity, helpless so often in the iron grip of its own perverse nature, shall be punished by flames eternal. In obedience to some mysterious law of nature the neuropathic victim may be possessed of very high intellectual power, there being, indeed, a close rela- tion between mental aberration and that power of original creative thought to which we give the name of genius. This has been denied by no less a physi- ologist than Claude Bernard, who lays stress upon the fact that genius is not heritable, whilst madness is. This is, however, no proof of the absence of relations between the two. Genius is not madness, but simply a possible off- shoot from a stock of mad ancestry. Genius may exist, as in Goethe, com- NEUROPATHIC jySAXITY. 577 bined with the hiuliest of reasoning pt)\v(>rs, hut jx'rhnps nioro iisuallv it is associated with mental and physical qualities which are but too plainlv the outcome of defective or peculiar mental organization. It cannot be a mere accident that so large a proportion of those whom the world speaks of as "children of genius" liave had an intellectual life spent upon the border-land of insanity, or a moral history setting them apart from the normal human being and showing but too clearly the traces of their ances- try. Space is wanting to do more than call attention to the monomania of John Bunyan, whose immortal dream was no doubt to himself often more than a dream ; to the overweeiu'ng egotism of Bvron ; to the asronics of mental depression which overshadowed the life of Cowper ; to the hereditary madness which led to orgies of insane cruelty in so many of the world's ablest despots, whether among the more ancient Romans or in the more recent Russian dvnas- ties of Rurik and of the Romanoffs ; to the hallucinations which caused Swe- denborg to affirm that the hand of Christ "squeezed my hand hard," and Luther to declare that the devil came into his cell, stamped through his cloister, and drove him from his bed ; to the glorious visions which inspired Joan d'Arc with a faith almost divine and an energy irresistible: to the direct communications with God which enabled the son of Abdallah to link together millions in a confederacy of religious belief against which Chris- tianity has beaten as yet in vain. Edgar Poe, Heine, Munger, Baudelaire, Gerard de Nerval, Maupassant, Swift, Pascal, — these and many other examples might be cited as showing how close genius is to the mind diseased ; but need of brevity forbids. I cannot, however, forbear mentioning at somewhat greater length the immortal Victor Hugo, whose uncle died insane, whose brother Charles (perhaps more talented than himself) entered for life the madhouse before twenty years of age, Mdiose daughter is insane, and of whom the Lon- don Medical Times is not far wrong in affirming that some of his finest pro- ductions are those indelil)]y stamped with madness. A remarkable fact in the mental history of this greatest of poets was that along with his extraordinary imagination there was a shrewdness almost as great. No banker could have more carefullv managed his fortune — no ])oHtician could have more tenderly nursed his popularity. He who had amassed over a million of dollars died the idol of a communistic democracy — he who had ])laved at fast and loose with all political parties was buried amidst a tmnult of universal sorrow. Already in the mildest forms of neuropatiiic brain-weakness the cases arrange themselves into two groups. Li the one tiie disordered enervation shows itself especially in the realm of intellectual action ; in the other the morbid or ill-dcv(^loped nervous system betrays itself in the sphere of morals. In (he first group belong chiefly those \\{ho are known in the community as " harmless cranks," whilst the sec(jnd group is made u|) chiefly of the so-called "criminal classes." Of course in the actii;il life cNcry grade exists between ihe man whose eccentricities show (heinselves jtei'liaps in (he extreme piety as well as in (he disoideivw] ii)(ellection, and (he ninii whose eccenlricity is in the sphere of nioial ehar;ic(er. Vol.. I.— 37 578 MENTAL DISEASES. In common witla most alienists I believe that there are neuropathic subjects who should be considered to have passed over the boundary-line of insanity, although they have no actual delusions. I am fully persuaded that some of these subjects are actually unaccountable beings, who are the sport of their own morbid nervous organizations. Pi'obabiv in all such cases both the moral and the intellectual character is affected, but in some subjects the per- turbation is most obvious in the moral; in others in the intellectual, sphere ; consequently, these cases of insanity are divided by some of the best alienists into reasoning insanity [folie ralsonnante) and moral insanity. Sometimes in reasoning insanity emotioiuxl exaltation exists, when the cases are spoken of as being maniacal ; in other subjects the depressing emotions are dominant and the individual is melancholic. Reasoning insanity includes those cases in which, perhaps along with high intellectual endowments, there exist imperative conceptions or morbid impulses of such power as to dominate the life of the patient. (See page 539.) As has already been shown, the morbid impulse is very closely related to, indeed, often springs from, the imperative conception, whilst the imperative conception has the closest of relations Avith delusions. The sequence of cases in nature from eccentricity to reasoning insanity without delusions, and from reasoning insanity M'ithout delusions to paranoia with delusions, is unbroken. A very curious form of reasoning insanity is folie du donte, or doubting insan- ity, in which the patient is entirely without confidence in the integrity and reliability of his own mental processes. This mental condition may be looked upon as an exaggeration of self-distrust, and when it is complete leads to insanity of conduct. Thus, a patient said to me, " Two and two make four ; so my intellect tells me, but how do I know that my intellect is in its conclu- sion right?" " I change my baby's diaper at night ; a moment later 1 remem- ber doing it, but how do I know that my memory is correct or that the feeling of dryness which my hand gives me is true?" ' And so the unfortunate woman and the almost equally unfortunate baby spend hours in the ])rocesses of uncov- ering and being uncovered. Moral lunatics are those who are not only devoid of all conscience, but actually are driven by their natures to what seem to others horrible crimes. Thus, in the case reported in the American Journal of Insanity the lust for blood and the sight of suffering were only satisfied with torture and murder. This man was a moral imbecile driven by a furious impulse to torture and kill : to tie uj) horses in the woods and gradually whittle them to death, to mutilate living cats, to torture chickens, to break the legs and tear to pieces, whilst living, small birds, were his greatest pleasure; but the very heaven of his joy was reached by assaulting, torturing, killing human beings. When twelve years old he took his toddling brother into the woods and nearly flogged him to death. He attempted to strangle a younger brother and to smother his infant sister; had stabbed various people, essayed to suffocate a harmless imbecile, and to choke another inmate of the asylum, and com- PAh'AAO/A. 579 mitted at least two criminal assaults on women, the last during an escape from the asylum. Lack of space, however, forbids further consideration here of tiiese strange insanities, and the curious reader is referred to larger treatises on the subject. Amongst the moral insanities must be classed the various sexual perver- sions. Without doubt, vice may gradually lead a man on to all the besti- alities of sodomy, but there are certainly individuals who are born with a perverted sexual sense which leads them to enjoy from the earliest pubertv only the embraces of their own sex. Such men often, but not alwavs, have feminine voices and feminine ways, mincing as they go, dressing in private in women's clothes, affecting all the airs and ways of the silly type of woman- hood. I have examined in prison such men, whose statements that thev did not masturbate were confirmed after careful watching and long study bv an experienced prison surgeon. They affirmed that from earliest puberty women had been to them objects of aversion, and on the rare occasions when, under stress of circumstances, intercourse had taken place, no pleasurable orgasm had accompanied emission ; but of man they spoke with raj)ture, and their eyes would glisten with lustful excitement at the mere sight of a handsome, well- formed man. Prognosis and Treatment. — In all cases of neuropathic insanity the prognosis is very grave in regard to the mental condition, but very favorable in regard to life: the insanity being founded upon original or acquired neur- opathy, remission is the most that can be hoped for. It is also evident that there can be no specific treatment. The object of the practitioner is, by moral and physical hygiene, to give robustness to the nervous system, and by means of narcotics, very carefully and sparingly used, to subdue nervous excitement when it shall rise too high. In the majority of cases the victim of an insane neuropathy enjoys life, on the whole, better within a well-regulated asylum ; and in a large proportion of cases it is only possible to protect society from the lunatic and the lunatic from himself by sequestration. When, in the neuropathi€ subject, delusions appear, the case is absolutely and undisputably one of insanity, so that, whatever may be our opinion in regard to the propriety of acknowledging the fornix, of insanity just spoken of, all must agree that paranoia, or neuropathic insanity with a more or less uniform mental state, and periodical insanity, or neuroj)athic insanity with periodical alterations of the mental condition, icpresent true insanities. Paranoia. Definition. — Insanitv dependent upon original neurotic vices accompanied by more or less distinctly systematized delusions, ])ersi.^tent, and without cycli- <»1 delusions. Etiolog-y. — In the great majority of cases of paranoia there is a distinct liereditarv neuropathy, Imt in a small inopoi'tion of the ca.scs the constitutional 580 MENTAL DISEASES. neurosis can be traced to drunkenness or oilier vice in tlie parents, or to injury or disease occurring during early childhood. Symptomatolog-y. — Paranoia usually develops slowly, blossoming out of a character which has, from the very beginning of life, shown clearly the tendency to neuropathic madness. In rare cases the symptoms of insanity are developed suddenly in an acute maniacal or delirious attack. The delusions of j)aranoia are very frequently, but not always, accompanied by or even dejjendent upon hallucinations, which are said to be most frequent in the sphere of hearing, next in that of feeling, then in seeing, tasting, and smelling. The couree of paranoia is essentially chronic, and it is doubtful whether permanent positive cure can ever occur in a disease which is so intimately connected with an original vice of nervous development. Nevertheless, inter- missions are not rare, and may continue for months or even years. They sometimes seem to be almost complete, but usually some evidences of mental aberration are discoverable. After a shorter or longer time distinct insanity recurs — not, however, in the form of a new attack so much as in that of a con- tinuance of the old, the new attack being, as it were, knotted to the insane life which has gone before it. In judging of any individual case as to the present mental condition it must be remembered that the paranoiac not rarely hides his delusions and simulates an intermission. Exacerbation also occurs in paranoia, accompanied it may be with great cerebral excitement, sleeplessness, and very pronounced psychical symptoms, such as ecstasy, violent hallucinatory delirium, fierce mania, stuporous demen- tia, etc. Again, some other form of insanity may develop during a paranoia ; thus, dementia paralytica is probably more frequent in the victims of a con- firmed neuropathy than in ordinary life, whilst alcoholic, hysterical, or epileptic madness are comparatively infrequent. Paranoia very rarely, if ever, ends in complete dementia, but rather in a condition of psychical weakness and good-natured stupidity, through which may be preserved a certain show of the artistic, professional, or technical abilities originally possessed by the subject. Almost every large asylum has in it such patients, to whom the asylum has become a beloved home, and by whom much of the work of the institution is performed. Paranoiacs may be divided into those cases in which the symptoms develop about the period of puberty and those in which the active symptoms come on later. Early Paranoia. — The paranoia of pubescence, or hebephrenia, usually occurs in children whose mental life has given evidences of abnormality very early in life. According to Kraff't-Ebing, in Europe such children are espe- cially prone to believe themselves " Cinderellas for whom no fairy has awaited ;" to become dissatisfied with their surroundings; to dream of higher positions in society; to perceive in themselves unlikeness to their own family and a like- jiess to some family of higher rank ; and as the years go by to persuade them- selves that they arc the thing that they originally longed to be — namely, the PARAXOTA. 581 neglected offspring of count or prince or otlier social digiiitarv. Probably, owing to the fact that the difference between social classes in America is comparatively slight, this ])eculiar development of paranoia is with us rare. More common is an obtrusive self-assertion, combined with a mawkish sentimentality and sexual irregularities. Xot rarely, at the time when the character of the boy should develop into that of the man, an arrest in the character seems to take place, and the silly egotism of adolescence becomes the permament stamp of the degraded mentality. The psychosis frequently conmienccs with depression of s))irits, which is, however, usually not so absolute as in original melancholia, and is very often associated with an almost iiysterical desire for symj)athy, obtrusiveness replacing the peculiar reticence of true melancholia. A^ery often the mental deterioration is rapid, and it may be so complete as to siuudate a dementia. Abnormalities of sexual life are almost universal. In the oreat maioritv of cases the patients are inveterate and excessive masturbators, and especially in women life is sometimes given up to a neurotic dream of love, which centres about some person — usually of high rank — with whom the subject may not even have acquaintance. Late Paranoia. — Late paranoia develops after the com])letion of puberty, and very frequently not until the fortieth or fiftieth year of life. Almost in- variably, however, the subject of the disorder has been from early life eccen- tric in thought and in action. In a large proportion of cases the disease develops gradually, the delusions forming in the mind so slowly that it is almost impossible to say when their seeds have germinated. On the other hand, in some cases the first distinct mental aberration is a violent attack of delirium which may simulate an acute mania. Again, a severe catarrhal attack, a sudden uterine disorder, a j)reguancy, a tyjjhoid or other constitu- tional fever, may be the abrupt starting-point for a paranoia which may readily be mistaken fi)r a coufusional insanity. The cases of paranoia differ very much in the nature of their delusions and in their general symptoms, but for the purposes of discussion they may be arranged in groups, it being remembered that these groups merge into one an- other, and that sometimes the character of the individual case changes diu'ing its course. The most common form of paranijia is that attended with delusions of per- secution. In the beginning the subject feels that the world is becoming hostile to him, or suspicion attaches in his mind to a certain individual or individuals as viewing him with distrust: as time goes by suspicion becomes more intense ; a look, a whispered word, a momentary gesture, a sermon, are in his thought proof of hostile intent. The manner becomes unquiet, whilst the face i)er- chancc puts on a hunted, anxious look. Little by little suspicion increases to belief, and graduallv or suddenly, as the case may be, the paranoiac /choice that he is the object of persecution, that attempts are being made by poison or in other wavs U])on his life, tli;it lie is aeensed of crime and thi-eatened by the police, etc. In its delusiuns the mind often responds to il> envii-oniuent. 682 MKNTAL DISEASES. Thus, in Europe the paranoiac frequently believes himself the object of political persecution : in America private individuals rather than government officials that oppress him. Very frequently the delusions have a sexual tinge : the world is conspiring against the man's sexual life or sexual power, or suspicion is directed against the fidelity of the wife or on the part of the wife against the fidelity of the husband. Usually, about the time when the delusions become fixed, halluci- nations appear, and in a majority of cases they are chiefly or wholly confined to the sense of hearing : voices of denunciation or reproach, of threatening, of obscene allusions, — these fill life with terror. Less common are hallucinations of feeling : insects crawl over the surface, snakes inhabit the interior, unclean embraces terrify the nights. Somewhat less frequent are hallucinations of taste : es])ecially in cases with delusions of poisoning, the food smacks of arsenic, chloroform, etc. The sense of smell is sometimes implicated, but it is curious how rarely, except in active delirium, optical delusions appear : to hear the ])ersecutor is most common, to see him is most rare. In persecutory paranoia the emotional state is one of depression, but in its depth and in its relations this depression differs entirely from that of true melancholia. The victim of melancholia believes himself worthy of all his sorrow — to himself acknowledges his guilt and is humiliated by remorse. The |)aranoiac, depressed though he may be by his persecutions, knows that these ])ersecutions are undeserved and rebels against them. Again, except in periods of excessive fury, the melancholic lunatic is not dangerous to others, whilst the paranoiac is always an object of danger to his fellows : his impulse is to resist j)ersecution or to revenge himself for wrong, and so, in self-defence or driven to fury by a sense of injustice, he assaults his fancied persecutor. The danger is especially great when the paranoiac believes that his persecution originates in one individual ; nevertheless, there is some danger when the persecution is thought to be general, and at any time the upbraiding voice may, in the mind of the paranoiac, attach itself to a passer-by. Closely allied to the paranoia just described is that form of the disorder in which the subject believes that his earthly possessions rather than himself are attacked by mankind. At first quarrelsome and litigious only, little by little this paranoiac, having spent his time in attempts at lawsuits, becomes when these fail a violent denunciator of judges and judiciary systems, and finally, posing to himself as a martyr or saint militant, fights society for his own rights, or perhaps, taking a wider or more ambitious sweep, contends in every possible way for the general rights of mankind. At large such paranoiacs may be anarchist leaders; shut up in an asylum, they may be most troublesome by their efforts for liberty through the law. Of difierent type is the religious paranoiac. Almost invariably this mad- ness has blossomed out from an early character of excessive piety and religious zeal, founded in a great nuijority of cases on a neurasthenic as well as neuro- pathic constitution. Tn very early life sedentary and retiring in habit, unwill- ing and perchance unable to labor, careless of social duties, these subjects from /'AnA.XOIA. 58a the age of puberty give themselves np to religion and to onanism, for the rela- tion between religious and sexual ecstasies is remarkable, and sexual perversions are in these people very frequent. At last, when the nervous system has been weakened by fasting, by sexual excess, by acute illness, or perchance without apparent cause, the visions which constitute the pathognomonic symptoms of the disorder appear, hallucinations of sight being in this form of ]iaranoia much more fre(]uent than those of other senses. The religious paranoiac sees the heavens open, the Virgin and the Son Himself smiling on him, or with strange ecstatic joy looks out upon a procession of the blessed. I^ater, voices of rapturous singing, of prophecy, or of commendation, it may be from God Himself, add to the overpowering joy of the vision. Egotism underlies alike the paranoiac hallucinations of persecution and of ecstasy, but in the one case the ego is the persecuted of mankind, the other the praised of Heaven. Often, however, the religious paranoiac has his depressed moments, when the soul contends with devils for eternal salvation. Allied to religious paranoia is erotic paranoia, in which the subject believes himself to be in love and to be loved by some person usually higher in polit- ical, professional, and social life. Such a paranoiac may spend the day in weaving to himself a romance of love and the night in erotic dreams. Hal- lucinations of hearing seem in this form of paranoia much more frequent tlian those of seeing. Paranoia finally ends in a cond as a periodical insanity, to wliich the name of (lij)sniii in his tent and be nursed and fed by his guide or may do the work of a day-laborer. Quiet travel in the mountainous distri(!ts of foreign countries is often V(M-y efficient, but sight-seeing, and even visiting cities, must be avoided. The (piicl of Switzerland or the Tyrol may bring restoration when the bustle of Ijondon and Paris might complete the ruin. In all cases strict attention must be paid 590 FUNCTIONAL NERVOUS DISEASES. to the individual tastes of the sufferer in deciding what measures should be carried out. There are cases of neurasthenia in which the slightest exercise, or even the unconscious effort and excitement of seeing personal friends, is an injury. In these cases the so-called " rest-cure " often acts most beneficially. Rarely does it itself give permanent relief, but it often lays the foundation for later com- plete restoration by means of outdoor life and exercise taken after a certain amount of strength has been gained. A word of caution seems necessary ao-ainst the routine employed in this rest-cure. It is simply the carrying out of a principle, and although, in the pages of a book like this, it is necessary to give a fixed formula, success in practical life will depend upon the skill of the practitioner in modifying this, and adapting formulae to the needs of the individual case. The principles of the rest-cure are absolute rest, forced feed- infT, and passive exercise. The rest must be for the mind as well as for the bodv, so that in severe cases complete and absolute isolation must be insisted upon : and especially when there is a decidedly hysterical element is it necessary to separate the patient entirely fi'om her friends. Under these circumstances there must be a well-trained nurse who is personally agreeable to the patient. The confinement would be very irksome to any except the most exhausted jiatient were it not for the daily visits of those engaged in the treatment. To further provide against ennui the nurse should be a good reader, so that under the definite instructions of the physician she can occupy a certain portion of the time in reading to the patient. In the worst cases the patient should not feed himself or iierself or perform any of the acts of the toilet. Directly after breakfast the sponge-bath should be given by the nurse, the patient being be- tween blankets. Hot water should be used or hot sea-brine, and after each part has been sponged over it should be momentarily rubbed with a piece of ice, followed by brisk friction with a Turkish towel. The greatest care should be given to the question of feeding. The end to be attained is to give as much food as can be digested without overdoing and deranging digestion. It is usually better to give the food, which must be both light and nutritious, at short intervals. In most cases milk should be used very largely, sometimes exclusively. Often, especially when there is a tendency to obesity or when the digestive powers are feeble, the milk should be skimmed. Frequently koumiss, matzoon, or other fi^rmented milks are advantageous. Rarely peptonized milk may be given. Beef and other concentrated meat-essences are valuable as stim- uhuits, and may be used, especially as the basis of soujjs. Various farinaceous arti(;les of food may be added to them, or if an egg be broken into the concen- trated bouillon or beef-essence just as it ceases boiling, a nutritious, and to many ])ersons pahitable, dish is obtained. When constipation exists, oatmeal porridge, Graham bread, fresh or dried fruits may be allowed if readily digested by the patient. In order to give a general plan of tiie dietary the following schedule of the daily life is given. Such a schedule should always be put into the hands of the nurse, who should be required to follow it strictly. It must be altered from day to day, so as not to weary the patient with monotony. It is especially 1 KEURASTJIEXrA. 591 important to remember that the diet must be carefully studied for each patient, and be adapted to the individual requirements of the case. Success will in a great measure depend upon the practical skill and tact of the physician in this adaptation : 8 a. m. Rolls or toast; cocoa or weak coffee, or roasted wheat coffee; beefsteak tenderloin or mutton chop. 9 A. M. Bathinff. 1 1 A. M. Oatmeal porridge, with milk, or else a pint of koumiss. 12 M. Massage. 2 P. M. Dinner : bouillon with or witlu)ut ey-y: ; beefsteak ; rice ; roast white potatoes ; dessert of bread-pudding, blanc mange, or similar farinaceous article of diet. 4 P. M. P^lectricity. 5 P. M. Milk toast. 9 P. M. Half pint of skimmed milk or koumiss. In many cases the patient at first can take very little food, and it is very frequently best to begin the treatment with an entirely liquid diet, giving milk every two hours or using Liebig's raw-meat soup, with milk or plain farinaceous food, and (nily after a time gradually accustoming the patient to solid food. Not rarely a prolonged milk-diet is of great service. The rest-cure is indeed largely ba-^ed upon a careful regulation of the food ; but a full discussion of the various dietaries to be used would require a treatise upon dietetics. Exercise is of value in health by its stimulating the general nutrition, aid- ing the flow of blood back to the heart, and increasing the excrementitious output from the emunctories. In the rest-cure these effects are obtained in a more or less imperfect manner without the expenditure of the patient's nerve- force by the use of electricity and massage. The electrical current })roduces not only muscular contractions, but probably affects the tone of the minute blood-vessels. Its action is so decisive that, as has been shown by Dr. S. Weir Mitchell, it M ill often temporarily elevate the temperature of the whole body. The faradic current alone is used. It is applied in two ways : first, to the individual muscles ; second, to the whole bodv. The stances should be dailv, the operator beginning at the hand or foot and systematically faradizing each muscle of the extremities and trnidv. The slowly-interrupted current is gen- erally preferable, l)ut advantage is sometimes gained by varying the raj)idity of the interruj)tions. The general rule is to select that current which produces most muscular contraction with the least pain. The poles should be applied successively to the n)otor points of the muscles, so as to contract each firmly and thoroughly. This process should occupy from thirty to forty minutes. The electrodes are th(.'n to be replaced by large sj)onges well damj)ened with salt water: one of these should be ])laced at the nape of the neck and fhc other against the soles of the feet, and a ra|)idly-interriiptcd current, as strong as ihc ]>atient can bear, should be sent through tlu; body for twenty minutes or half an hour. In some cases the ele(;trical j)rogrammc may be varied so as to get a local stimulant action from the general current; thus, when the digestion ia 5S2 FUNCTIONAL NERVOUS DISEASES. enfeebled and the bowels costive, for a portion of the time one of the sponges may be placed upon the epigastric region. In women, when there is great abdominal and pelvic relaxation, one pole may be placed high up in the vagina. I have seen long-standing uterine prolapse cured in this way. Some electro- therapeutists claim great advantage from'galvanization of the cervical sym- pathetic ganglia, but I do not myself believe that they have ever succeeded in reachino; these o-anglia with the current. Massage, like electricity, affects greatly the peripheral circulation, empties the juice-channels, and gives tone to the muscular system. It must be clearly distino-uished from rubbing of the skin. It consists in manipulations of such of the muscles as are not too deep to be reached, and of the cellular tissue. In order to lessen as much as may be the skin-friction by these manipulations, it is often well to anoint the surface with cocoanut or other bland oil. In })rac- tisino- massage it is essential to remember that the natural course of the venous l)lood and the juices of the cellular tissue is toward the centre of the body ; therefore all general massage movements should be practised in this direction. The manipulations are percussion, rolling, kneading, and spiral. They consist of movements made with the pulpy ends of the fingers and thumbs, and spiral movements with the whole hand so folded as to adapt its palm to the limb. In percussion the strokes should be from the wrist and should be quick and short. It is probably not possible, even by long, strong strokes, to affect deep muscles. In the rolling manipulations the effort is to roll the individual muscles beneath the pulps of the fingers. This manipulation may be varied by pinching the muscles, not the skin, and kneading. In each case it is inter- mittent pressure upon the muscles that is aimed at. The circular movements are to be in opposite directions with both hands simultaneously, the limb being grasped by one hand a little above the other, and a spiral sweep made up the limb, the ball of the thumb and the palm of the hand resting upon the patient, and the pulpy parts of the thumb and the fingers grasping the limb. It is especially such motions as these which affect the circulation of the flesh-juices. The length of time in which a patient should be kept in bed varies from three to six weeks. The getting up should be gradual, the time of sitting up and the amount of exercise carefully increased from day to day. The electrical treatment should be rapidly withdrawn, but often massage may be continued with advantage every other day for some time. So soon as can be the patient should be sent out of the city, to consolidate by outdoor life that which has been gained. Hysteria. Definition. — A functional disorder of the nervous system, characterized by depression of the will-power, exaltation of the emotional nature, and an infin- itude of shifting, polymorphic nervous disturbances more or less clearly simu- latino; various organic diseases. Etiology. — Although the name "hysteria" is derived from the Greek uarepo^, a womb, there is no direct connection between the disease and the sexual organs, except only through the tendency of sexual disturbances, and HYSTERIA. 593 » especially sexual excesses, to produce nervous exhaustion and irritation, which iu turn may aid in the development of hysteria. The aifection is vastly more common in females than in males, simply because the nervous system of the female is less robust, more excitable, more sensitive, and more readily thrown off its balance than is that of the male. Race and racial habits are of oven more importance than sex as an etiological factor. In barbarous countries the disease is practically unknown. In Northern races, with a tendency to phleg- matic temperament, hysteria is comparatively infrequent and of minor severity, whilst the mobile Southern temperament favors its development. Thus the Latin races, as exemplified in the French and Italian, are much more hysterical than the English and Teutonic, and in the extreme southern portion of the United States, where the Latin blood predominates, severe hysteria is much more frequent than in the North. In the majority of cases the disease first manifests itself between fifteen and twenty-five years of age, but it is not rare before puberty, and occasionally occurs even in very young children. I have seen it in young boys as fre- quently as in young girls. In boys it is often connected with or dependent upon masturbation, adherent prepuce, or other irritation of the sexual organs. The influence of heredity, especially neuropathic heredity rather than direct heredity, in the production of hysteria is very great, whilst education and habits of life are almost equally powerful. liuxury, license, and indul- gence during childhood, indoor rather than outdoor life, any method of edu- cation or of life which renders the nervous system more sensitive and less robust, tend very strongly to the development of the hysterical temperament. Hysteria may unexpectedly appear as the result of nervous exhaustion produced by overwork, depressing emotions, long-continued severe pain, or exhausting dissipation. Moral influences are often very effective in their action in persons of nervous temperament. The disease not rarely illustrates the contagiousness of example : a single hysterical patient will sometimes inoculate a Avhole school, infirmary, or hospital ward, transforming, it may be, the quiet retreat or educational institution into a pandemonium of nervous explosions. During the ]Middle Ages, wlien by misery, poverty, and religious excitement the ground had been especially prepared, whole communities became involved in epidemics of hysterical madness ; hence the Flagellants, Children's Crusade, etc. When the hysterical temperament exists, local iiijiuy or local disease is prone to bring about a local hysteria in the aflccted part, and when the original local disease is of such character as to wear heavily upon the general nervous system, local hysterical manifestations nuiy devcloj) after :ni organic lesion or disease in a person who previously had not shown any distinct hys- terical symptoms. Symptomatolog-y. — The symptoms of hysteria are so infinite in their numl)er, their variety, and their collocation, the liisloiy of hysterical cases is so widely diverse, the course of the disease is so al)soliil(lv without rule, that it seems impossible to give any concise dcscri|)tion of the alTcction within the ^■(.i.. I.— .'{8 594 FUNCTIONAL NERVOUS DISEASES. space allotted in this volume. It must be remembered that hysteria exists in nature in every possible degree, and that the majority of cases, as seen in this country, are those of minor hysteria, grading up from the slightest hysterical tinge in temperament or in disease. It must also be borne in mind that the ingrained hysteria due to heredity is far deeper in its seat than what may be known as accidental hysteria ; that is, the hysterical condition developed by the accidents of life. Under the latter circumstances the ordinary signs of hysterical temperament are often wanting. Hysteria often reveals itself in certain physical peculiarities : the large, full, liquid eye, the mobile pupil, the clear skin, the vivacious movement of ever-changing whims, or the slow, languid movements of the self-conscious beauty may furnish unmistakable signs of the hysterical temperament. Mental Symptoms. — The basis of the hysterical character is selfishness — a selfishness which sometimes shows itself in the indulgence of the grosser appe- tites and desires, but which more commonly seeks self-gratification in applause, in admiration, and in being the centre of sympathetic attention. Indeed, this selfishness often leads its possessor to great lengths of apparent self-sacrifice, the desire for praise and attention overmastering sensibility, pain, and even present contumely. The hysterical woman is self-conscious and self-centred, dwelling ever on her own personality, its needs, its wishes, its life, its ailments, its everything. Excessive sensitiveness in all that regards herself is the nat- ural outcome of this mental state. Self-indulgence goes hand in hand with self-consciousness, while the will is without power to assert itself and the indi- vidual knows not at all the path of self-control and true self-sacrifice. The weakness of the will is not the cause of the mental attitude, but only one of the concomitants : unwillingness to make the effort necessary for self-con- trol leaves the individual largely to the play of outside forces, especially when these forces touch aright the dominant chords of character. Hence, sugges- tions of conduct, sympathy with suffering, and even questions as to symptoms, have an inordinate influence. The pain that is not, when asked for soon becomes. The morbid desire for attention and sympathy leads to intentional simula- tion of disease, so that the hysteric will pretend what does not exist, but the mimicry of disease in hysteria has in the majority of cases a deeper seat than this. It is an unconscious simulation. Not merely do emotions dominate the forces of life, but ideas formed in the mind may express themselves in a phys- ical enactment of a disease which has been thought of. The dread of some disorder, or of the disablement and suffering which it causes, is almost as powerful as desire in multiplying the symptoms of an hysteria. A very extraordinary ruj)ture often takes place in hysteria between con- sciousness and will. Thus I have seen a patient declare that she could not see with the left eye, and yet respond correcstly to every test for the existence of blindness in the affected eye until the separate prisms were used after she had been told that prisms make a person see double with one eye. Under this belief the double images were seen and located correctly, proving that there lIYSTEJilA. 505 was vision all the time with the left eye. I do not believe that the patient purposely lied throughout, but that the belief that she could not see in the left eye so dominated conscious perception that there really was no consciousness of the image until belief in that image was established. Emotional instability, lack of control of the will over the emotional nature, is one of the most characteristic manifestations of the hysterical state. With or without reason, but always withont control, the subject laughs and cries, the emotional storms rising rapidly from the most inadequate causes. The desire for sympathy leads always to exaggerated statements, and in the examination of an hysteric this must always be borne in mind. It leads also to innumerable forms of deception. Thus I have known an hysterical woman to raise an alarm in her country-house, and be found upon the ground beneath an open window, apparently greatly injured by the fall which she asserted she had received during a somnambulistic walk, when in truth she had simply walked out of the door and laid upon the grass. Especially common is it for these simulated symptoms to take a shape that will bring great personal atten- tion by the young and inexperienced physician, and mayhap minister to the morbid sexual desire of the patient. To swallow pins and needles, or to thrust them into the tenderest parts of the body that they may be withdrawn by the doctor, is common enough. To retain urine, with absolute recklessness of the suffering involved, for two or three days, that the catheter may be used, is very frequent. I have seen the rectum and lower large intestine secretly filled day after day with starch jellies, to the utter astonishment of the practitioner, especially when the true nature of the fsecal discharge was revealed by the microscope of the consultant. A very common trick, which imposes with extraordinary frequency upon the credulity of doctors, is the placing of small bones by the woman over night in the uterus, to be removed by the doctor tlie next day as parts of a dead foetus. Disturbances of Consciousness and Motion. — Besides the major and minor hvsterical paroxysms, spasms, choreic movements, and paralytic disturbances occur in hysteria. The hysterical spasms may be localized in any portion of the l)ody ; the choreic movements are sufficiently described elsewhere in this book. (See page 634.) Into mino7' hysterical paroxysms enter all the elements of the major affec- tion, but usually some of the symptoms are wanting in individual attacks, and not rarely a single stage constitutes the whole paroxysm. The aura is not usually present, unless the so-called globus In/dericus (a sense of constriction or the rising of a ball in the throat) be considered to represent it. The emo- tional state is usually well devcl(>ped, and is especially prone to express itself by uncontrollable laughter or equally nncontrollable sobbing or crying. A very characteristic performance which I have seen, especially in children, is that which may be termed beast-mimicru, in wiiich the patient bites or snaps or snarls like a do-r or crows like a cock, or in st)nie other way imitates the movements and the vocal acts of the lower animals. Among these cases belong the nr)t rare attacks of spurious /ii/(lrnj)liobi(i, in which, cither with 596 FUNCTIONAL NERVOUS DISEASES. or without severe general convulsioo, the subject shows profound dread of water, great emotional disturbance, often crying out to be held lest he bite some person, and continually snarls and barks and attempts to bite. These symptoms do not closely resemble those of true hydrophobia, in which disease the subject never offers to bite, and does not make any noises resembling those of the dog or any other lower animal. Beast-mimicry may be considered as diagnostic of hysteria. The convulsive symptoms of minor hysteria are tonic i-ather than clonic. More or less persistent rigidity is very frequent and very characteristic. It may last for hours or may pass by in a few mornents. The disturbances of consciousness are similar to those of major hysteria (see page 598), only usually less severe. In the major hysterical convulsion the tendency is to rigid contractions of muscles which lock the body in positions like those of voluntary life. Con- sciousness may be abolished, but is usually only perverted. Thus a patient, apparently unconscious during the fit, narrates after recovery all that has occurred during the paroxysm ; or there may be the so-called automatic con- sciousness, in which the patient during the paroxysm seems to understand all that is said, but nevertheless after the paroxysm has no remembrance of what has taken place. Commonly the major convulsion is preceded by some warning, such as a special feeling of malaise, epigastric sensation, palpitation of the heart, gid- diness, globus hystericus, or an aura which appears to arise from a hyperses- thetic ovary. The patient falls, but usually gently and not with the sudden- ness of true epilepsy. Not rarely there is at this time an initial scream, which may be repeated during the paroxysms. The pallor of the face may now be marked. A simple tonic spasm develops, lasting two or three minutes; In it the limbs are usually rigid, with the toes pointed downward and the arms extended or lying at the side of the patient. It is at this period that the res- piration becomes arrested, and there is developed the stage of asphyxia of some writers. The face is swollen, with turgid veins, and suffocation seems imminent. This condition may be followed by a furious clonic convulsion, in which bloody foam gathers about the mouth, although the movements pre- serve, to some extent, the appearance of wilfulness, and the head or the arms are struck violently and with seeming purposiveness against the floor or dashed against pieces of furniture. Following these clonic convulsions, or not rarely replacing them, is the characteristic stage of opisthotonos, in which the person lying upon the back is bent violently into the arc of a circle, so that the body rests upon the head and feet, with the central portion arched from the ground. The muscular contractions may be so severe that the head is drawn completely backward and the upper portions of the body rest upon the face, which looks toward the floor, whilst the lower end of the arc is sup- ported on the toes. This condition of opisthotonos may last for some minutes. In some cases it is interrupted or replaced by violent purposive clonic spasms, the patient suddenly leaping from the bed or rising into a sitting position, and HYSTERIA. 597 as quickly falling back again in opisthotonos. This to-and-fro movement may- take place with extraordinary velocity. In some cases the body is bent violently laterally instead of backward. The opisthotonio stage may be inter- rupted by various emotional actions, or it may gradually subside into what may be called the emotional stage, when the patient assumes some attitude of intense emotion, and not rarely the so-called posture of the crucifix, in which the subject lies upon the back, absolutely quiet, with the legs stretched out side by side and the arms firmly extended at right angles to the body in the position of a cross. The widely-opened eyes, with dilated pupils, appear to be looking into indefinite distance, whilst a beatific smile is settled upon the face, so that by the ignorant the convulsant is often believed to be seeing visions of heavenly joy. Usually the emotion changes from time to time : the light of religious beatitude upon the countenance deepens into an intense voluptuousness, attended, it may be, with lustful words and gestures; or ter- ror becomes supreme, and is manifested with equal intensity ; or, in a passion of penitence, the convulsant, with sobs, bitter cries, and broken words, begs for mercy. Again the scene shifts, and, now singing, now weeping, reproach- ing alternately herself and her care-takers, the woman passes on to a slowly- perfected consciousness. Hallucinations occur during and after the fit, and are always correlated to the emotional state. Thus during the terror the subject sees rats and other disgusting objects, which, according to Charcot, are usually upon the side that is anaesthetic between the paroxysms. The character and mental states of the confirmed hysteric approach in many respects those of a paranoiac (see Hysterical Insanity, p. 558), whilst the de- lirium of a major hysterical paroxysm may simulate an acute mania. I have indeed seen recurring attacks of hysterical epilepsy replaced by a furious out- break of acute mania, lacking in none of the symptoms characteristic of that disease. It seems to me that in such a case the maniacal explosion must be looked upon as the direct outcome of the hysterical neurosis, and that there- fore the existence of an hysterical acute mania not in itself distinguishable from ordinary acute mania must be acknowledged. In most cases in which such maniacal symptoms exist the neurosis is so thoroughly engrafted upon the constitution that permanent recovery is not possible, the patient during life suffering from various forms of hysterical attack, and being always possessed of the peculiarities which have already been spoken of as characteristic of the hysterical temperament. Plysterical symj)toms may occur during almost any form of insanity, but do not warrant our looking upon such a melancholia or mania, or whatever form the affection may take, as hysterical, scarcely more tlian we should be warranted in considering pneumonia when associated with hysterical symptoms as hysterical. At the same time, the relation of the hysterical temperament to monomanias and to general insanities is distinct; and, according to iiiv belief, it is entirely possil)le for any form of insanity to be simulated by symj)toms wliieh have their origin in the original faulty organ- ization that is file basis oi' elii'onic hysteria ; moreover, such faulty nerve- 598 FUNCTIONAL NERVOUS DISEASES. organization is closely allied to the peculiar neurotic temperament which is the basis of much insanity. Closely allied to the major hysteria is hysterical somnolence, which may take the form of a true narcolepsy (the patient being continually drowsy, fall- ing asleep at all times, but passing only the nights in profound slumber), or it may assume the shape of the lethargy or trance. Hysterical trance usually, but not always, commences with marked hyster- ical symptoms which leave the subject in absolute repose. The face may be red and hot, especially in the first days of the attack, but usually it is pale. The pulse at first may be regular and slow, but after a long sleep it is rapid and feeble. The respirations, generally quiet, may at times become hurried, irregular, and even stertorous. In severe cases the movements of the thorax may be so slight as to be traceable with difficulty. The muscular system, often thoroughly relaxed, may be rigid, and in many cases muscular relaxation alternates with muscular contractions or even contractures. The eyes are opened or closed ; very frequently minute tremors affect both the lids and the eyeballs. The jaws are often set, and sometimes an excess of saliva, or even foam, gathers about the mouth. In the profoundest cases there is complete ansesthesia of both the common and the special senses, so that neither pinching nor cutting, neither cold nor heat applied to the skin, elicits response. The pupils are usually dilated, and often respond to a powerful light, which, how- ev.er, calls forth no other signs of life. Sometimes the patient can be readily fed by means of a spoon, but generally in severe cases it is necessary to use the oesophageal tube. Usually digestion is good, but the stools are at long inter- vals and scanty. The urine is in most cases scantily excreted and is passed involuntarily. Considering the small amount of nourishment taken, the bod- ily nutrition is often surprisingly maintained, but in prolonged cases there comes, sooner or later, great emaciation. The bodily temperature may in the earlier parts of the attack be somewhat elevated, but ordinarily it is distinctly subnormal. The awaking is usually, but not always, sudden. During the course of such a lethargy the subject may pass into a condition wdiich has been mistaken for death. The bodily temperature falls, the respiration becomes so passive that no movement of the thorax or abdomen is percei)tible, and, unless a feather or other light object be held over the mouth, breathing may seem to have ceased. The beats of the heart diminish in frequency and in force, so that they become imperceptible even upon auscultation. The fiice takes on the waxy whiteness of a corpse. The muscular system is in complete relaxation, the dilated pupil no longer reacts to light, and even the cornea is filmy as in a corpse. This death-like condition may last for only a few hours, or may con- tinue during from one to several days, after which, little by little, respiration and circulation are re-established. After such a crisis the subject may awake immediately or pass into a new sleep. Catalepsy is a form of hysterical lethargy characterized by the peculiar condition of the muscles, owing to which the body or the limbs remain for an indefinite time in any position in which they are placed. It may come on HYSTERIA. 599 gradually or abruptly as the result of a powerful emotion, but usually develops during a lethargy, the paroxysms being of irregular duration and sometimes continually recurring. The facial expression may be that of apathy ; in some cases it is that of devotion, of rage, or of whatever passion the subject was in at the time of the fixation of the muscles. The eyes are wide open, with quiet lids. The body is motionless in the posture in which it has been placed or in which it has settled during the arrest of active motion. There is no power of voluntary movement, but the limbs are not rigid or contracted. When taken hold of they bend with the plasticity of wax. In any position in which the body or limbs are placed they i-emain for a long time. Bcrger (quoted by Barth) is said to have seen the most bizarre and difficult attitudes steadilv maintained for seven consecutive hours by a young cataleptic woman who was constantly under observation. During the whole of the cataleptic state there is complete anaesthesia of both the common and the special senses, so that the most violent irritations of the skin produce no reaction. Respiration is reg- ular, the pulse maintains its normal rhythm and rate, and the general bodily functions appear to go on unaffected. If the patient be regularly ied with liquid food at intervals, hysterical sleep may last uninterru])tedly for many wrecks, months, or even years. Sometimes the patient will occasionally wake to take food. Ili/derical Paralysis may simulate almost any form of organic palsy. Paralysis of the whole body is exceedingly rare, but such cases are reported. The face also is not often affected, and the ocular nuiscles usually escape. Nevertheless, hysterical strabismus and liysterical inecpiality of the ])npil are occasionally seen. Hysterical monoplegia is not frequent; hysterical hemi- plegia is very common, but the most frequent variety is hysterical ]iaraplegia. Hysterical Paraplegia may coexist with nniscular relaxations or contrac- tions (see page 596), with normal, abolished, or exaggerated knee-jerk, and even with ankle-clonus. The sensory nervous system may or may not par- ticipate in the disturbance — in some cases there is excessive hyperresthcsia, with or without pain ; more frequently the sensibility is lessened or abolished ; usu- ally the muscular sense is at least as much affected as is cutaneous sensibility. Sometimes electro-sensibility is abolished. If true girdle sensation ever occur in hysterical paraplegia, it must be very rare : the real, not suggested, pres- ence of such a sensation is almost pathognomonic of organic disease. In Hysterical Hemiplegia one extremity is in most cases distinctly more affected than the other, and the face is very rarely imi)licatcd ; the presence of facial palsy tells strongly against the probability of an hysterical origin. The palsy is rarely complete, so that a patient unable to walk or even stand may be able to raise the foot when in bed. Tiiere is usually, but not always, a more or less pronounced loss of sensation in the paralyzed part, ami (he coex- istence of a hemianesthesia with hemiplegia should always arouse suspicion. Ifysterical iJisturhances of Sensation may take the form of hypera>sthesia, anffisthe.sia, or pancsthcsia. Hysterical Hypenrsthcsia may follow the regional distribution ccjnimoulv seen in an;e.sLlusia, but is usually irregular in its dis- 600 FUNCTIONAL NERVOUS DISEASES. ti'ibution and often interrupts anaesthetic tracts. Certain local hysterical hvpersesthcsias are so important as to require special notice. Hypersesthesia in the o-enitals is very common in the female, is usually associated with loss of sexual desire, and commonly lies at the foundation of the condition known as vaginismus, in which any attempts at coitus produce an overpowering vaginal spasm. Hypersesthesia of the mamma is usually attended with swelling, excessive tenderness, and violent pain, sometimes shooting down the arm. (See Diagnosis.) Hypersesthesia with vaso-motor swelling, and even true exu- dation, may in almost any of the larger joints mimic organic disease. (See Diagnosis.) Hypersesthesia of the special senses is a very common hysterical symptom : especially is photophobia both frequent and severe. Indeed, photophobia without distinct disease of the eye is almost always hysterical. A special-sense hyperesthesia may show itself simply in the pain caused by the natural stimulus of the affected organ, but may also take the form of a true functional exalta- tion, so that vision or hearing becomes much more acute than normal. In my experience this form of hypersesthesia has been especially frequent in regard to hearing. Not rarely, hysterical women will understand and repeat conver- sations spoken in apartments at such distance from their own that the ordinary ear catches no sound. Hysterical Ancesthesia may exist in any portion of the body, but in the majority of cases it takes the form of heraiansesthesia. This hemiansesthesia is apt to be interrupted by spots of hyperaesthesia, especially in the region of the groin or in the ovary itself, or in the dorsal and lumbar regions posteriorly, or in the limited vertical space from one to two inches wide stretching from the lower cervical region upward. The hypersesthesia in these cases may be superficial or may be only elicited by deep pressure. In neurasthenic women, especially young women, hypersesthesia or super- ficial tenderness all over the vertebral column is so common, and exists in so many cases without very pronounced hysterical symptoms, as to be commonly spoken of as a disease, the so-called Spinal Irritation or Spinal Ancemia. There is not, however, any reasonable foundation for the theory that the con- dition depends upon ansemia or any other recognizable lesion of the s})inal cord, or that it is entitled to a distinct place in nosology. The cases shade from the slightest form of vertebral tenderness to major hysteria.' Hysterical ansesthesia may be limited to one organ, like the cornea of the eye, may involve the mucous membranes as well as skin and deeper tissues, and may be complete or incomplete. Thermo-ansesthesia is common, whilst analgesia, existing by itself, is almost invariably hysterical. Hysterical ansesthesia is usually accompanied by the so-called ischoemia. In this con- dition tlie surface is pale and the needle prick or even an extensive superficial ■ The treatment of spinal irritation is that of neurasthenia and a mild hysteria. It is true that sometimes henefit is obtained by local ai)[)liances of belladonna plasters, or even by mild blistering, but it is impossible to determine how far this treatment acts through expectant atten- tion and how far it has any direct influence. HYSTERIA. 601 incised wound does not bleed. Anaesthetic ischaemia appears to be specially pronounced in the violent epidemic forms of hysteria, such as occurred in the Convuhionnaires of the Middle Ages ; hence the miracle that superficial AVdunds were not followed by loss of blood. In hysterical hemiansesthesia the special senses are usually affected, and there may be loss of hearing, smell, taste, and vision. Usually, however, the special senses are not completely set aside. Amblyopia is conmionly shown by a concentric narrowing of the field of vision and a peculiar loss of color sense, the achromatopsia of Galezowski. In some cases the power of seeing the colors is entirely lost, so that all objects appear of a uniform sepia tint. When the achromatopsia is not complete the colors disappear in a constant order. The first color that an hysterical person ceases to see is violet : usually, but not always, blue is lost before red, the intermediate tints fading out in regular succession.' The digestive, eircidatory , and respiratory systems are frequently deranged in hysteria. Cardiac irritability is very common, the slightest emotional or other excite- ment producing violent tumultuous palpitation, which in some cases is accom- panied by great discomfort, and even irregularity and interruption of the heart's action, with more or less cardiac distress. In some cases a violent pain in the cardiac region, shooting down the arm, closely simulates angina pectoris, the simulation being rendered more complete by the excessive rapidity and smallness of the pulse. I have seen this pseudo-angina pectoris more frequently in young men than in other hysterics, and when in such cases the general signs of hysteria are not pronounced a false diagnosis may readily be made. '' Flushings," with a sensation of intense heat and a sudden out- burst of perspiration, occur in hysteria, but are especially connected with the climacteric period in women. Unilateral flushing, local cedematous swellings, and similar phenomena, though rare in hysteria, demonstrate the possibility of local vaso-motor disturbance. Possibly as the residt of vaso-motor relaxation are the luemorrhages from the nose or stomach, which are specially j)ronc to be severe when menstruation is suppressed. Care is often necessary to avoid mistaking for a true haemop- tysis the bleeding which a designing woman produces by sucking or otherwise irritating the gums. ' It seems necessary to advert to the so-called inetallo-tlierapy first originated liy Or. Ilurk, who fonnd tliat different hysterical individuals have such relations with difloront nietaliic sub- stances that wl)cn a small disk of tlu; apijropriato snhstanre is hound over the ana-stlietic jiart a sensation of warmth, with slij,'lit ri'iiiicss and disappcarcncc of tlie ischn'mia and ana'sthesia, follows. In some cfises not only is the sensibility of tlu; skin restored, Init if tlic i)late Ite in the neifchborhood of the orbit, vision returns. Also, often the so-called " transfer " phenonicna ayipear— ?. r. loss of sensibility and ischiiniia develop ui)on the uni)araly7.ed side in the jiosition corresponding to the seat of tbc metallic application. Powerful maf;nets have been found to have a similar indnence to the metal, and even disks of wood have been succcs-sfully employed. It is very difliciilt in this country to obtain transfer phenomena, and it seems almost certain that they are the result of expectant attention. 602 FUNCTIONAL NERVOUS DISEASES. ■m Tlie bodily temperature rarely departs from the norm in hysteria, and in simulated acute disease advantage can often be taken of the fact for diagnostic purposes ; nevertheless, hysterical fever does occur. According to M. Briand and other French writers, there are three types of it — in the first form the paroxysms are irregular, of long duration, accompanied by various nervous disturbances ; in the second variety the fever continues from one to four weeks and is accompanied by disturbance of the nutrition, in some cases the whole course of the affection closely mimicking a typhoid fever; in the third form the paroxysms of fever occur with more or less regularity, so as to give the appearance of a true intermittent fever. Exaggerated temperatures, 120° or 130° F., have been recorded from time to time as occurring in hysterical patients. Most, if not all, of these high records have been due to skilful manipulation of the thermometer by a designing patient, but there is reason for suspecting that extraordinary local elevations of temperature happen in hysteria. Hysterical disturbances of respiration are common. Intensely rapid breath- ing, 50 to 150 per minute, the so-called "hysterical dysp^ioea," may occur without alteration of the pulse-rate, and may be associated with thoracic symptoms misleading to the inexperienced practitioner. Hoarse, croaking, laryngeal cough, seemingly almost luicontrollable, is a frequent hysteric phe- nomenon, as is also aphonia from laryngeal palsy. Violent paroxysms of acute dyspnoea may occur from hysterical laryngeal spasm, simulating attacks of true laryngismus stridulus. Secretion is often affected in hysteria. Excessive sweating is very com- mon, and a profuse sweating may be accompanied with a sufficient haemor- rhage to color it deep rose-red (hcematidrosis). One of the most characteristic symptoms of an hysterical paroxysm is the free discharge of limpid, light- colored urine, evidently due to vaso-motor and secretory disturbances in the kidneys. More serious is the partial or even complete suppression of urine {anuria), which may for many months almost completely prevent the excre- tion of the urinary solids through the normal channel. Under these circum- stances the sweat, the vomit, and other seca^etions become loaded with urea. Disturbances of digestion are almost universal in hysteria. Constipation is very common and not rarely very obstinate. Diarrhoea is more rare. Flatulence, gastric and intestinal, is sometimes accompanied by extraordinary distension of the bowels, and occasionally by irregular spasmodic contraction of the abdominal muscles, producing strange internal noises. Hysterical oesophageal spasm may for a while prevent swallowing, whilst hysterical vomiting is one of the most frequent of symptoms. This vomiting may be excessive and continue for days and weeks, so severely and so persistently that the patient seems to retain no food whatever, the appetite being replaced by an absolute loathing for food. Such cases constitute the so-called "fasting girls" who from time to time become the centre of attention and wonder on the part of whole communities. The ability of the hysteric to live upon the smallest quantity of food is often extraordinary, but there can be no doubt that HYSTERIA. 603 in the notorious instances of alleged fasting deception has played an important role. The vomiting may be accompanied by reversion of intestinal peristalsis, resulting in the discharge of i'seeal matter from the mouth, and cases are on record in which rectal injections were in a short lime thrown up from the stomach. Diagnosis. — The diagnosis of major or minor hysteria occurring in gene- ral paroxysmal form requires no further discussion. The recognition of the true nature of an hysterical paralysis may be very difficult. The presence of other distinct symptoms of hysteria, either in the past or in the present, is of importance. Nevertheless, a violently hysterical person may be attacked by organic palsy, and I have also seen hysterical paraplegia occurring without other symj)toms of hysteria and Avithout an hysterical his- tory that could be made out. The hysterical palsy is apt to be transient and shifting in its character, to go and come suddenly, and not to conform in its minor phenomena with the sequences and coincidences of organic palsy. Again, the hysterical palsy is often accompanied by symptoms that do not occur in the organic paralysis which is simulated. Thus an hysterical hemi- plegia or a monoplegia may be attended with ]iaralysis of the bladder, of the intestines, or of the rectum, although paralysis of the visceral walls is very rarely if ever present in organic hemiplegia or local paralysis; or an hyster- ical hemianse-sthesia is not properly situated in its relations M'ith the coexisting motor palsy ; or electro-sensil)ility is lost when general sensibility is preserved, etc. etc. An atypical paralysis should always be viewed with suspicion — in women it is usually hysterical ; in men it is usually syphilitic, but may be hysterical. An hysterical monoplegia is not infrequently attributed to an injury. If contractures conae on immediately after a real or an alleged injury, the paraly- sis is probably hysterical ; but complete relaxation may exist in an hysterical monoplegia. When after a traumatism the paralysis and the relaxation are complete and there is no wasting of the muscles, the affection is usually hys- terical, since in all cases of total or nearly total loss of power from injuries to a nerve the muscles rapidly change. Irregularities in the anatomical relations between the disturbances of sensibility and the alterations of mobility indi- cate an hysterical origin, but these relations may, in hysteria, conform to the organic type. In consentaneous organic palsies of sensation and motion sensation almost always improves first — in mimicking hysterical states motion u.sually imjiroves before sensation. In organic hemiplegia aphasia is frequent ; in hysterical it is v(!ry unusual. Hysterical affection of the larger joints sometimes so closely simulates chronic inflammation as to make the diagnosis a matter of some dilhculty. The presence of other hysterical symptoms is important, and usually the true nature of an hysterical joint can be recognized by attentidii to the following considerations: first, the muscular rigidity or contraction can be overcome by mildly persistent efforts while the patient's mind is diverted, yields n^adily 604 FUNCTIONAL NERVOUS DISEASES. during natural sleep, and disappears during slight anaesthesia or even under a full dose of chloral or opium ; secondly, there is no rise in temperature in the joint, although the part looks red and inflamed ; thirdly, the reaction of the contracted and apparently atrophied muscles to the faradic current is normal. The knee is the part most frequently implicated, but mimetic disease of the hip-joint is especially misleading. It should be noticed that the limp varies from day to day as the patient's attention is directed to or diverted from the joint — that it is exaggerated by fatigue and nervous exhaustion, and hence is usually more pronounced in the evening than in the morning. Moreover, in the onset of an organic disease the patient usually begins to limp before he complains of pain, whilst in the hysterical disorder pain generally appears first. Hysterical lateral curvature is especially prone to deceive practitioners, owing to the fact that true lateral curvature is very frequent in neurasthenic women. The hysterical curvature, being the outcome of spasm, disappears during ansesthesia ; the organic lateral curvature remains unchanged by the anaesthetic. The nature of the hysterical breast is to be recognized by the excessive superficial tenderness, so that merely brushing or handling the breast causes as much pain as hard pressure; by the diffusiveness of the swelling; by the constant variation in size and in hardness : and by the recurrence of the symp- toms at the menstrual period, at the approach of stormy weather, or after general fatigue. Not rarely in neurotic girls, and sometimes in neurotic boys, at the period of sexual unfolding one breast will suddenly become hot, exceed- ingly painful and tender, and perhaps secrete a few drops of sero-lacteal fluid. The so-called phantom tumor of hysterical women is a localized swelling in the abdomen, probably the result of local muscular spasm. The sensation imparted to the fingers may be exactly that of a hard tumor. Usually the presence of percussion clearness renders the diagnosis of the phantom tumor easy, but in obese women this sign may fail. The true nature of the phantom tumor is always revealed by its disappearance during ansesthesia. Great care is sometimes necessary to prevent mistakes when organic nervous disease develops in nervous women suffering from hysteria. Among the most difficult cases that I myself have ever met with are those in which inherited syphilis lias just revealed itself after puberty in an hysterical girl. Basal meningitis, poliomyelitis, myelitis, or any organic disease may develop in an hysterical person, and unless cases be thoroughly examined grave errors will be made. I have seen the diagnosis of major hysteria persisted in by good medical practitioners up to within a few hours of the death of a patient, when an examination of the urine would have demonstrated the ursemic nature of the disease. Usually, watchfulness will result in the detection of choked disk, trophic change, or other unmistakably organic symptom. It is usually easy to recognize the nature of an hysterical ansesthesia through the existence in the past or present of other hysterical manifestations, HYSTEBIA. 605 and especially by the fact that frequently when motor and sensory paralyses coexist, they do not conform in relative position to the organic type ; further, the organic anesthesia is fixed and does not vary from time to time in its lim- its, as does the hysterical anaesthesia ; and the organic anesthesia is not inter- rupted by islets of normal sensation or of hyperaesthesia, as is the hysterical disorder. The diagnosis of hysterical blindness can often readily be made by noting the absence of the causes of organic blindness and the presence of hysterical manifestations, with the conformity of the amblyopia to the hysterical charac- teristics already given. (See page 594.) A simulated monocular blindness can usually be detected by means of the Graefe prism test : if a jirism held before the eye in which sight is admitted cause double vision, or if, when its axis is held horizontally, a corrective squint develop, vision exists in both eyes. Another equally certain test is to let the patient read with both eyes at sixteen or twenty inches, and slip a glass of high focus in front of the eye alleged to be sound. If the reading continue under these circumstances, the amaurosis is feigned. L. Miiller's test for mimetic deafness in one ear is to have different words spoken simultaneously in a low voice in two tubes, each of which is con- nected with one ear of the patient. If the apparent deafness be real, the jiatient will only repeat that which is spoken into the healthy ear; if there be simula- tion, confusion and repetition of the words spoken into the alleged deaf ear result. In any case of simulated paralysis of special sense betrayal will often occur during the semi-conscious stages of artificial anesthesia. Prognosis. — Death from hysteria is almost infinitely rare, although Sir AVilliam Gull has described under the name of anorexia nervosa vel hysteria a condition with great emaciation, feeble pulse, fading respiration, and low tem- perature in young patients, ending sometimes in death. It is hardly probable that these cases were purely hysterical. Proper forced feeding will almost invariably prevent a fatal termination in hysterical patients who refuse food. When the hysterical temperament is once thoroughly developed, it is rarely if ever set aside completely, though it may be held in abeyance. The chances of complete recovery are therefore much smaller in those cases in which by original inheritance or by faulty education the person has become an ingrained hysteric than in those cases in which by transitory emotional pressure, exces- sive mental and emotional labor, or by other active cause a previously and iniieritedly feeble nervous system has been merely for the time being thrown off its balance. Patholog'y. — Hysteria is based upon no anatomical peculiarity of the ner- vous system sufficiently gross U) be recognized by any test that we are at jircs- cnt capaijle of apj)lying. Tiicorics almost imunnerable have from time t(» time been suggested t« exj)lain the phenomena, but in accordance with the general rule followed throughout this work no discussion of these theories Mill be hero entered upon. All that we know is that hysteria is a neurosis — /. c. a peculiar nervous state which may be the result of inhci-itancc or of moic tem- porary causes. 606 FUNCTIONAL NERVOUS DISEASES. Treatment. — For the purposes of discussion the treatment of hysteria naturally divides itself into preventive and curative. The preventive treatment of hysteria consists in the proper education of the young, it being possible to largely overcome the results of inheritance if the attempt be begun early enough. In a volume like this there is not space for the consideration of the details of this subject, but certain general principles which ought to guide all efforts can readily be stated. The attempt should be — first, to increase the robustness of the whole person, and especially of the nervous system ; second, to reduce excessive sensitiveness by accustoming the nervous system to moderate exposure and hardships ; third, to develop in the child the habit of obedience (first to those who are above him, and afterward to his own personality, led by a sense of right and wrong ; in other words, to teach the young child the habit of subjection to control from witliout, in order that the power of self-control from within may later be developed) ; fourth, to bring about so much of intellectual development as shall give to the patient abundance of interest outside of herself and her immediate surroundings, and shall form a basis for character ; fifth, to inculcate unselfishness and to develop other traits of character, such as are recognized as worthv of imitation through- out the world. The when, the where, and the hoAV these things shall be done depend upon the circumstances of the individual child. Country life is usually preferable to city life ; a moderate living to the home of luxury ; home training to training in boarding-schools or other institutions ; plain food to high living. But the environment of the individual patient may change these things. Thus if the mother in the home be weak and hysterical herself, it is essential that some one else guide the young life. Again, if it be impossible for the child to be reared in the country without its leaving a home where all the influences trend toward good, it may be better to sacrifice the country life and to attempt to gain its advantages by gymnastics and athletic outdoor sports. In the treatment of developed hysteria it is essential to remember that in the majority of cases the hysterical person is a neurasthenic, and that the basal treatment in most cases must therefore be that of neurasthenia. The rigidity with which this treatment must be enforced depends upon the needs of the individual case, but the removal from home, the putting to bed, the whole course of the so-called rest-cure by means of the isolation it requires affords opportunity for that domination and control by the physician and nurse which are so necessary in the treatment of hysteria. The success of the moral treatment of the hysteric depends upon the tact of the physician and of the nurse; and, as the latter functionary is in contin- ual contact with the patient, she is very important. Unless the nurse be proper- ly selected with view to the work at hand, all efforts at cure must fail. The object of the moral management is to develop, first, a willingness to be unself- ish ; second, the habit of self-control. In some intelligent hysterics a careful, skilful putting before them of their own nature, of its difficulties, dangers, and possibilities, has a most happy effect, but great care is necessary in the selection HYSTERIA. 607 of the individual to be managed in this way. Very frequently such treatment will do harm. In more severe cases absolute control from outside is necessary : the habit of obedience or submission, once formed, becomes the basis of advance of character. The first thing to do is to let the patient see that complaints will not bring sympathy, but will rather excite disgust in the mind of the hearer and disregard for the patient. The next point is to make the hysterical attacks as disagreeai)le as possible to the patient. This is not simply because the attacks may be simulated or brought on by a direct eifort of the will, but that a motive may be furnished the patient which will aid the will in preventing an attack of hvsteria. The hypodermic injection of apom()rj)hine will usually cause vomit- ing and arrest of an hysterical paroxysm, and where the attacks recur at short intervals the apomorphine treatment is often advantageous. When a hosjiital resident physician I found that in women who were brought in from the street by policemen the production of a ])air of shears and the commencing of cut- ting the liair off, preparatory, as was loudly stated to the policeman standing by, to the putting of a blister on the scalp, would have a more quieting influ- ence upon a furious hysterical paroxysm than would the efforts of several strong men. Even though the patient seemed unconscious, invariably the convulsive movements and the delirium ceased. In an epidemic of hysteria which occurred in one of our Philadelphia charity schools two most obstinate cases resisted the cold douche, blisters, and even the hot iron : no procedure had the slightest effect in preventing the continual recurrence of beast mimicry and other hysterical paroxysms. The two children were finally kept without food for three-quarters of a day, and then fed as much as they would take. To one of them, in the presence of the other, was then given ether, as slowly and as disagreeably as possible, so as to provoke screaming, fighting, and excessive vomiting. This put an end to the symptoms in the one that suffered and the one that witnessed the suffering. The effect of a motive in hysteria is sometimes most extraordinary. The well-known sudden restorations of power to limbs that have been palsied for years, or to patients that have been bedridden for decades, through strong religious excitement and faith, are supplemented by cases in \\\m'h. the emotion has been fear or rage. I have known a woman who had been motionless in bed for many years, enraged by the treatment of her |)hysician, leap from the bed and tear the clothes off his back before she could be restrained. These cases illustrate, however, rather the result of emotional excitement than of a motive. Not so an instance in which a poor but very beautiful hysterical girl, engaged to a rich man, was informed by the latter that though he loved her he could not live with a woman who vomited continually, and that the marriage would have to be postponed until the vomiting ceased ; and behold ! how soon that incoer- cible vomitiny dclVct of tlio eye ilscif. Tlie lael stated in the text ia probably owiiij.' to the .slow (ieveiopruent of the conrdiiiiiint -(piinl and tlie liabitual disregard by ibo brMiii-centres of the viniial itiiaRe in one of tbc two tycs. 612 FUNCTIONAL NERVOUS DISEASES. otlier poisons. The lithseraic vertigo is often severe and attended with some mental confusion. Its nature is to be recognized by detecting the lithsemia. Essential vertigo represents a class of infrequent cases in which no known cause of vertigo can be discovered. It is probable that in the brain there are undiscovered centres of equilibration disease of which may give rise to vertigo. Treatment. — The treatment of vertigo resolves itself into the treatment of the disease which produces the symptom. In those cases in which no dis- tinct cause can be discovered remedial measures should be directed to the thorough building up of the general health. There is no known specific treat- ment of the vertigo itself. Epilepsy. Definition. — A disease of unknown pathology, in which at irregular inter- vals and without obvious existing causes an abnormal disturbance of nerve- force occurs, in most cases accompanied with loss of consciousness and very frequently by convulsive disturbance. Synonyms. — Idiopathic epilepsy ; Fits ; Falling sickness.- Etiolog-y. — The importance of heredity in the production of epilepsy is shown by the fact that of 4300 cases collected from various sources by Prof. H. A. Hare, 26 per cent, afforded a distinctly neurotic family history. Very freqnently the inheritance is direct, the epilepsy attacking vai'ious members of successive generations ; but perhaps in the greater number of cases the epilepsy is an expression of a neuropathic root-stock. Especially does the disease inter- change in different generations with insanity. Alcoholism in the parent is frequently an active cause ; consanguineous marriage has a distinct but less powerful influence. Scrofulosis, rachitis, extreme poverty, or dissipation, anything which exhausts the vitality of the parent stock and tends to the pro- duction of nerve-degeneration or of imperfect development of the nervous sys- tem, certainly has an influence in the production of the epileptic diathesis. The production of what may be termed accidental epilepsy by poisons, alco- holism, extreme dissipation, violent emotion such as fright, peripheral irrita- tion, etc., may result in a permanent epilepsy, it being an established clinical fact that when, through the action of some removable cause, the nervous sys- tem has become accustomed at irregular intervals to discharge paroxysmally nerve-force, the habitual discharge is very prone to continue after the removal of the original cause. Epilepsy is somewhat more frequent in males than in females. It is espe- cially a disease of early adult life, but once established is permanent. Prob- ably about one-third of the cases have their beginning under thirteen years of age, two-thirds under nineteen, and the remaining third under thirty years of age ; the number of eases occurring after thirty being so few as scarcely to affect statistics. Symptomatology. — In the typical, fully-developed epileptiform convul- sion the first symptom is a peculiar sensation, first felt in some part of the body, and rising from its seat of origin up to the head, to be lost in uncon- EPILEPSY. 613 sciousness. This so-called aura is succeeded at once by a peculiar wild, harsh scream, known as the epileptic cry. With the first unconsciousness a general tonic "Spasm comes on, producino; rigidity of the whole body and violent distor- tions of the head, limbs, and face. The muscles of the trunk and abdomen are rigidly contracted. Often a turning of the head and eyes to one side is the first evidence of this condition, and in some cases not only the head but the whole bodv rotates. The facial muscles are violently contracted, usually most markedly on the side toward which the head turns; the jaws are fixed and often drawn to one side ; the arras are almost always flexed at the elbow, and still more strongly at the wrists ; whilst the fingers are flexed at the meta- carpo-])halangpal joints and extended at the others, the thumb being adducted into the palm or pressed against the first finger. The position of the fingers is similar to that of grasping a pen, and is due to conjoint spasmodic contrac- tions of the interosseous and flexor muscles, as in the so-called athetosis. The legs are extended and the feet inverted. The position of the arms, legs, hands, and feet is usually that which is assumed in a case of universal tonic spasm, the members being drawn always in the direction of the muscles of superior power ; but in some epileptic convulsions this is departed from, showing that certain of the muscles are more affected than others. Thus, the fists may be clinched or the legs may be violently flexed and drawn up on the abdomen. The stage of tonic spasm is usually accompanied by marked pallor of the face, and lasts from a few seconds to one or even two minutes, when it is suc- ceeded by the stage of clonic spasm. Usually the coming on of this is marked by vibratory tremors passing into vibrations, which continually grow both slower and more severe until the intermissions become long and complete, and the limbs are alternately relaxed and jerked in movements as wild and bizarre as they are violent. During the period of clonic spasm the face becomes red, congested, even bloated, and often livid. The expression changes continually, since the spasm involves all the muscles of the face, including those of masti- cation and of the tongue, the soft palate, and the larynx. Owing to the violent working of the muscles of mastication the saliva is forced from tiie mouth in the form of froth. The tongue is continually thrust in and out by the spasm of its muscles, and is apt to be caught between the convulsively moving jaws and severely bitten. If the tongue happens to be between the teeth during the period of tonic spasm in an epileptic convulsion, it is bitten in the first stage of the fit. The blood-stain which is so characteristic upon the froth is due to hajmor- rhage from the tongue. The pupils at the beginning of the fit are sometimes contracted ; absolutely immovable dilatation occurs, however, very early, if indeed it be not present from the onset, and is the characteristic condition dur- ing the whole fit. The return of the pupils to the normal state is often one of the earliest evidences that the paroxysm has exhausted itself In some cases after the fit the pupils undergo remarkable oscillations. During the height of the attack both the pupillary and the conjunctival reflexes are abolished. The spiiincters arc in the majority of (•j)ileptio convulsions not relaxed, but it is not 614 FUNCTIONAL NERVOUS DISEASES. rare for the urine and faeces to be passed, and Gowers affirms that this is more apt to occur in nocturnal fits. The pulse, in the beginning feeble or of normal force, during the height of the paroxysms is greatly increased in frequency and in force. M. Magnon states that during the tonic stage the pulse-rate falls, and the rhythm is altered so that a complete systole and diastole may occupy six times the normal period. During the clonic convulsion the respiration is noisy, stertorous, slow, or even irregular : often the pauses between the acts are so long that the patient seems to have stopped breathing, and when death occurs in a fit it is by the persistence of such arrest of respiration. During the convulsion of epilepsy the bodily temperature may remain about the norm, but, if the attack be prolonged, usually rises, very rarely, however, going above 102°. During the status epilepticus the temperature of 107° may be reached. The stage of clonic convulsion lasts from three to four minutes, when it merges into the conditi(m of quiet coma, and this in turn passes into a heavy sleep, which may continue for a few moments or for hours. After the waking the patient suffers from headache and general muscular soreness. The description which has just been given represents the epileptiform con- vulsion as it is seen in what may be considered typical epilepsy ; but even in the majority of cases of epilepsy some of the phenomena are wanting, and almost any of them may be absent. The essential or central idea of the epi- leptiform convulsion is the occurrence of complete unconsciousness, with nervous discharge taking the form of a clonic spasm, in which the movements have no relation, apparent or real, to those of ordinary life. It must never be forgotten that the epileptiform convulsion in its most typical manifestations may arise from causes other than epilepsy, and also that epilepsy may give rise to convulsive and other nervous disturbances replacing the epileptiform convulsion, but entirely different from it in their phenomena, l^efore considering these anomalous epilepsies I shall discuss in more detail one or two of the more important symptoms of the convulsive attack. The epileptic cri/ is probal)ly due to a forcing of air by the convulsive con- tractions of the respiratory muscles through a glottis narrowed by spasm of the vocal cord. It is commonly single, but may be repeated, although much repetition should always raise the suspicion that the attack is hysterical. The aura is often absent. When present it usually arises in one extremity or in the stomach, although psychical and special-sense auras do occur, and in some cases warnings are given by bilateral tremors or starts in the limbs, or by widespread indefinable sensations, which may perha[)S be looked upon as generalized auras. Various as the auras are in different individuals, they are remarkably constant in the one subject, each epileptic paroxysm conforming to those that have ])re('ed('(l it. An aura which commences in an extremity is usually first felt in the hand, but it may begin in the foot. From the hand it rises up the arm as an inde- .scribable sensation, and is not rarely traced by the patient to the neck, where it disap{>ears in the development of unconsciousness. The gastric aura is very EPILEPSY. i)|.> frequent. It is variously described — as pain, as burning, as a sense of cold- ness, as trembling, but more oi'trii as an indelinite distress. Usually there is no sensation of rising connected with it, but in some cases this occurs. An aura may be first felt in the chest, and ascend to the throat, when it gives rise to choking sensations. It may also begin in the face, tongue, larynx, pharynx, or indeed in any part of the body. In psychical aura the emotion is almost always that of alarm or excessive terror. In very rare cases a very ])eculiai' idea ushers in the epileptic convulsion, constituting a true intellectual aura. Special-sense auras are rare, the gustatory being the most infrequent, the ocular the most frequent. The ocular aura may consist in seeing colors ; in an apparent increase or lessening in the size of objects; in indescribable visual sensations; in double vision, or in loss of distinctness of sight, deepening, it may be, into complete blindness. In a few cases there are actual visions, either simple or complex. In the auditory aura abnormal sounds are heard, such as hissing or the whizz; of rushing steam, or intermittent, pulsating noises, such as beating of drums or music, and in very infrequent cases even a spoken word. The olfactory aura seems always to take the form of a bad smell. The rate of the aura varies very greatly. When it is slow enough to allow of the institution of proper measures the fit can usually be aborted. According to the observations of \\^est{)hal and of Gowers, none of the myotatic contractions can be obtained immediately after a very severe epileptic fit, but after about half a minute the knee-jerk reappears, and frequently becomes excessive ; ankle-clonus may also be temj)orarily present. The most important of the anomalous epilepsies is that which is known as ''■petit mal'' or the little sickness, in contrast to the larger attacks, which are known as '^ ep-os maV In its more ordinary form i)etit mal consists of a momentary loss of consciousness, accompanied by pallor of the face, which is not, however, invariably present. The sufferer, in the midst of a conversation, suddenly stops, is quiet for a few seconds, and then takes up the thread of dis- course as though nothing had hai)pcned, being in fact unconscious that any- thing has happened. Sometimes the period of (;onsciousness is followed by a state of confusion of thought. It must be borne in mind that every grade of attack occurs in nature between the mildest and briefest paroxysm of petit mal and the most severe convulsion. Sometimes the unconsciousness is acconq)anied with great muscu- lar relaxation and a fall to tiie earth, without further synq)tom. Sometimes the petit mal is ushered in by a distinct aiu-a or even a single loud, piercing scream, which may not be followed bv motor disturbance. So variable and so frequently absent is tiie convulsive |)ortion of the c])ilcptic paroxysm that the unconsciousness is usually considered as the essenti.il jxirtion of (lie epileptic paroxysm. I am sure, however, that in :in (•|)ilei)tic atta(;k consciousness may be preserved. In a case which was probably one of epilepsy, and in which, so long as I had opportiniity for watching the synq)tonis, llicrc w:is no change, the patient had a distinct aura in (lie hand, rising up llie arm in the usual manner. l)nt sufferiii'j arrest in the neck, at whieli time, without any loss of con- 616 FUNCTIONAL NERVOUS DISEASES. sciousness, there were violent convulsive movements of the muscles below the position to which the aura had reached. Further, I am sure that the epileptic paroxysm may show itself simply as a sensory disorder which resembles an epileptic paroxysm cut off at the end of the aura stage. Thus I have seen in various children paroxysms in which the child would crv out with a sudden painful sensation in its stomach, become extremely pallid, run to its mother, be held for a moment, and the whole attack would be over, there being, at least in some of these attacks, no loss of consciousness. That these cases represented true epilepsy has been demon- strated by their continuance in spite of all treatment; by the regularity of their occurrence ; and, beyond all, by the fact that I have watched them develop into fully-formed, unmistakable epilepsy. When the epileptic paroxysm occurs only at night (nocturnal epilepsy), its existence may be entirely overlooked. Sometimes the patient wakes before the occurrence of the paroxysm, but very frequently he passes directly from the unconsciousness of sleep to the unconsciousness of the epileptic convulsion, and on waking in the morning has no knowledge of what has occurred, although usually there is much malaise and general physical weariness. A bitten tongue in such cases ought to reveal the occurrence of the night. Frequently, but not by any means universally, the urine is passed during the attack, and whenever a new habit of wetting the bed at night is formed during late youth or early adult life suspicion should be aroused. The most characteristic feature of the movements of ordinary epilepsy is the absence of apparent purposiveness, but in anomalous epilepsy this charac- teristic may be wanting, as in procursive epilepsy and epileptic automatism. In epilepsia procursiva, either with or without a primary epileptic cry, the subject starts on a run, either forward or in a circle, and after a greater or less time wakes up or falls in a violent clonic convulsion. I have seen the arrest of such a patient by force change the attack of running into a clonic convulsion. This procursive epilepsy is rarely preceded by an aura; is often but not always associated with organic disease of the brain ; occurs usually but by no means universally in young subjects ; may continue for years unchanged or be trans- formed into an ordinary epilepsy, during the transformation the attacks being MOW this, now that, form. It is said, also, to be frequently associated with moral degradation. In a paroxysm of epileptic automatism the subject performs simple or com- plicated acts apparently involving the possession of consciousness, and^yet is in the condition in which he has no proper control or knowledge of himself or of his surroundings. The relations of epileptic automatism to double conscious- ness are very close. The condition may precede or may follow the convulsive attack, the patient running, singing, dancing, laughing, gesticulating, or doing other bizarre actions, and then falling in a convulsion. Epileptic automatism is, however, usually a ])()st-paroxysmal phenomenon, and occurs more frequently after a minor than after a major epileptic attack. In its simplest form the automatism consists of doing something which is usually incongruous, such as EPILEPSY. 617 undressing regardless of surrounding circumstances, seizing and secreting about the person small objects, cutting bread and buttering it and eating it as fast as possible, etc. etc. Sometimes the series of acts are so apparently rational and purposiv^e that it is almost impossible to persuade bystanders that the patient is not conscious. Gowers relates a case in which a London cabman would drive through the most crowded streets of IjoikIou without accident ; and a woman under mv own care would continue whatever act she was doina; at the time of the convulsion. Thus, when preparing a meal she would fall into a convidsion, get up in two or three minutes, and continue to dish up the dinner, arrange the plates, etc. in an apparently natural way, but after a time would suddenly wake up and have no knowledge of what she had been doing. In many cases of epileptic automatism no display of emotion is made : sometimes, howev^er, the patient is hilarious, and even aggressively affectionate, and still more frequently rage or violent emotion is manifested. It is through cases in which violent passion asserts itself that epileptic automatism passes into the so-called epileptic mania, which, indeed, may be very logically considered as a form of the automatism associated with excited emotions. In maniacal epileptic automatism, so called, there is violent excitement and delirium, which may take the form of an acute mania or of an agitated melan- choly : in either case the incoherence is usually less than in the corresponding non-epileptic aifection. Not rarely after a primary period of violent discon- nected speech the patient is seized with an ambitious or mystic delirium, or sometimes a delirium of persecution, or, more rarely, with an erotomania, in which sentence after sentence flows out with extraordinary volubility. The attack usually comes on suddenly, and is always accompanied by hallucinations, which sometimes develop brusquely or, more rarely, in the course of a few minutes. The hallucinations affect all the senses and give rise to delusions which conform with the type of the emotional disturbance. The delirium may last for a few moments or several days. It is especially characterized by the tendency to acts of extreme violence — to suicide in the melancholic form and to homicide in the maniacal variety. In epileptic fury the subject has no control over his actions, and when mur- der and other crimes are committed it is imjiortant that the medical jurist recog- nize the true nature of the attack. When the mania is of mild type the danger of overlo(jking its character is greatest. The diagnosis is to be made by obtain- ing the history of previous attacks of epilepsy, by the brutality and causeless- ness of tlie crime, and especially by the fact that the patient has no memory of wcurrences which took place during the mania. In a cr'rtain proportion of the cases the attacks of epileptic mania are rejieatcd in exact counterfeit one of the other. The maniacal outbreak may, however, not recur I'or a great length of time. The difficulties of the expert arc increased by the fact that the first j)aroxysm of an epilepsy may take the form of a furious outbreak of epileptic mania. Under these circumstances it nuiy be essential that the paticMit be kept for a length of time under surveillance, since, ahhough the circumstances of the f»aroxvsm may satisfy the mind of the medical expert, they may fail to 618 FUNCTIONAL NERVOUS DISEASES. carry conviction to judge and jury. Esquirol states that the homicidal mania of epilepsy is never radically cured, and that its subject is always liable to a fresh outbreak. Whether this be absolutely true or not, it is certain that the recurrence is sufficiently habitual to demand the perpetual surveillance of the epileptic criminal. Epilepsy frequently leads to mental degradation, which may end in com- plete dementia. More rarely a permanent insanity develops in the epileptic, although it is doubtful whether the convulsions in these cases are not simply the outcome of an original neurotic vice which is also the cause of the insan- ity. The type of such insanity is said to be usually melancholic, with delu- sions of persecution -and suicidal impulses. The characteristic mental state of chronic epilepsy is progressively lowered niental power, wj_th a peculiar irrita- bjlity and brutal selfishness, and outbreaks of furious anger on the slightest provocation. Even while the mental powers are still active epileptics very frequently are peculiarly irritable and revengeful. After a paroxysm these tendencies are increased. The term Cardiac Epilepsy has been given to a peculiar form of par- oxysmal attacks with convulsive movements in which it is doubtful whether the nervous or the circulatory disturbance should be considered primary. There are two forms of this affection. In Syncopal Cardiac Epilepsy the habitual pulse- rate is much below the norm, and at the moment of the attack diminishes to twelve, ten, or even five per minute. The paroxysm may be ushered in b}'^ an aura ; the face, at first pale, afterward becomes congested ; the respiration, at first often quick- ened, is labored and stertorous ; the bodily temperature usually, if not always, falls, in some cases very distinctly. Not rarely, directly before the paroxysm, the patient complains bitterly of intense coldness. Whilst unconscious the })atient may be quiet, but general or more frequently partial convulsions, with or without biting of the tongue, are not infrequent phenomena. In the Congestive Cardiac Epilepsy there is during the attack excessively violent heart-action, with intense congestion of the head, giving rise to deep flushing, to the formation of punctate ecchymoses, and even to general oozing of blood from the face. The conjunctiva is usually extraordinarily congested and swollen, and often bleeds freely. Not rarely violent haemorrhage from the nose occurs. I have never seen the attack commence with an aura, but the convulsive movements may be very violent. Diag-nosis. — In discussing the diagnosis of epilepsy it seems best, first, to consider the anomalous forms of epilepsy ; second, the relations of idiopathic epilci)tiform convulsions to other forms of convulsions. Tiie diagnosis of anomalous epilej)sy becomes easy when it is recognized that the essential character of idiopathic epilepsy is a tendency to an abnoi-mal discharge of nerve-force at irregular intervals and without obvious cause, but dependent upon some persifiient, usually irremediable, state of the nervous system. Such being the fact, whenever during late childhood or early adult life peculiar paroxysmal attacks occur, evidently not of hysterical origin nor yet EPILEPSY. 619 due to irritation, to abuse of alcoholic or sexual ])lea?nres, or to any other assignable cause, the practitioner should suspect the presence of an aberrant epilepsy. It is, however, very unwise to express such an opinion too hastily, and only after the failure of long-continued treatment to effect a cure should the probable nature of the attacks be explained to the parents or immediate friends of the patient. The convulsions produced in childhood by the peripheral irritations, etc. are distinguishable from epileptic fits only by the failure of repetition. It must be remembered that what may be called the convulsive diathesis in the child is closely associated with the epileptic diathesis, and that in a large pro- portion of cases of epilepsy there is a history of repeated convulsions during childhood. Some children are evidently born with a convulsive tendency so firmly fixed in the nervous system that its possessor is doomed from birth to a hopeless epilepsy. On the other hand, there are individuals in whom the epi- leptic tendency originally exists, but in so slight a degree as to be amenable to hygienic and medicinal treatment. Such an individual may during childhood suffer from repeated attacks of accidental convulsions and become epileptic, or by great care the early convulsions may be prevented, the diathesis or tendency be overcome, and the nervous system be allowed to harden into the nornuil mould. The characteristics of the hysterical convulsion, as contrasted with the epi- leptiform, are the peculiar disturbances of consciousness (see Hysteria, page 597) ; the presence of emotional disorder ; and the tendency of the muscular contractions to affect only a part of the body, to simulate in an exaggerated form natural movements, and to become tetanic. Persistently clonic spasms pertain especially to the epileptiform convulsion, whilst persistent tetanic rigidity is highly characteristic of hysteria. Although usually the true nature of hystero-epilcpsy can be recognized, there are cases in which .it is necessary to reserve the diagnosis until the patient has long been watched. It must also be remembered that pronounced hysterical phenomena may immediately follow a purely epileptic convulsion. Nocturnal epileptiform attacks, in which the ])atieut passes without waking into the convulsion, are probably never hysterical. It is necessary also to distinguish from idiopathic epilepsy epileptic convul- sions due to peripheral irritation, or " reflex epilepsy ; " epileptiform convulsions due to violent poisonings from within or without the body, or "toxa^mic epi- lej)sy ; " and epileptiform convulsions due to organic brain disease, or "organic epilepsy." The age at which the e|)il('ptic paroxysm has first apjieared is a matter of vital importance in the diagnosis between i(lio])athi(! epilepsy nnd the diseases wliich simulate it. It may be laid down as a ride of sufficient accuracy for practical guidance, and having very rare if any exceptions, that an epilepsy ■which develops offer the thirty-jiflh year of nr/e i.t not idiopathic, hut is due to some orr/anic brain disease, to the nhiise of ah-ohol, rejiex irritfdion, or other caxLsea, vjhich in some cases may fte so hidden, as to be exceed iv(/ly dij/indt of 620 FUNCTIONAL NERVOUS DISEASES. recognition. An epilepsy which first appears after the thirteenth year should be viewed with great suspicion. In my own experience epilepsy occurring between the age of thirty-five and fifty-five, not dependent upon assignable causes unconnected with organic brain disease, has in at least 80 per cent, of the cases been due to brain syphilis. Tlie nature of an Organie Epilepsy is often indicated by the character of the attack. In idiopathic epilepsy the convulsion rarely begins habitually in one extremity. Sucii mode of onset, and especially the confinement of the movements to one limb, one side of the face, or other muscular territory, should arouse the grave suspicion of Jacksonian epilepsy due to organic focal brain disease. An idiopathic epilepsy, or at least an epilepsy in which no change can be demonstrated in the nerve-centres, may, however, take on the Jacksonian type, so that in any case, before giving a positive opinion, it is wisest to wait for other symptoms of organic brain disease ; but here it must also not be forgotten that a temporary aphasia and a hemiplegic or monoplegic paresis may follow a paroxysm of idiopathic epilepsy. Reflex Epilepsy is not to be distinguished by any peculiarities in the convul- sion, biit only by finding the cause of the irritation and noting the effect of its removal. It must, therefore, be an invariable rule for the practitioner to search thoroughly every epileptic individual for points of irritation. Wounds of the head or other portions of the body, astigmatism and other imperfections of the eyes, diseases or malformations of the nasal cavity, carious teeth and retained milk teeth, aural disease, adherent prepuce or other irritation of the genital or- gans, intestinal worms, — are among the irritations which have in very many cases provoked a reflex epilepsy. The importance of thorough examination is increased by the fact that the reflex epilepsy may engender the epileptic habit. Of the Toxcemic Epilepsies the most important is the alcoholic, which may simulate very closely not only major epilepsy, but the simple epileptic vertigo or petit mal. Not rarely the attack is ushered in by headache, gastric embar- rassment, troubles of vision, excessive tremors, or some similar prodrome which may closely resemble an aura, and probably is of the nature of an aura. The alcoholic convulsions often occur in paroxysms, two, three, four, or more, one after the other, at intervals of a few moments, and are not rarely followed by a temporary mental derangement which may take the form of acute dementia, during which the subject is reduced to the condition of an automaton, obey- ing immediately and mechanically all impulses from without. Uraemic and plumbic convulsions may also closely simulate an idiopathtic epilepsy. In all cases of toxsemic epilepsy the diagnosis must rest upon the history of the case and the presence of other symptoms of poisoning. Much aid in the diagnosis between uraemic, hystero-epileptic, and epileptic convulsions can be obtained by a study of the temperature. Uraemic convid- sions are usually, but not always, accompanied by fall of temperature. In the severe isolated epileptic attack the temperature often rises very distinctly, and when there is a prolonged series of fits, connected by coma and occurring at short intervals, the temperature rises steadily. The single hystero-epileptic EPILEPSY. 621 attack is accorapanierl only by a slio;ht rise of temperature, and when a series of convulsions are the expression of the hystero-epilepsy, the temperature falls very rapidly immediately after each convulsion, and does not after successive attacks reach distinctly higher than in the first. Prognosis. — So far as the continuance of the paroxysms is concerned, the prognosis in idiopathic epilepsy should always be very guarded. Traumatic, toxemic, reflex, and organic epilepsies may be cured, but absolute cures of idioj)athic epilepsy, if they ever occur, are most exceedingly rare. Much, however, can be done to ameliorate the attacks and render them less frei(iii has been found in the brain of epilejitics, but the mere variety and incoiisisteiiey of these lesions demonstrate tliat tiny are results or com|)lications, and not the causes, of the epile|)sv — a conclusicju which receives positive confirmation in the fact that very frer|ueiitly no grave lesion can be founfriiiuidy many German writers the affection of childhood is known as chorea minor, whilst the term chorea major, or chorea germanorum, is used to express affections more or less closely resembling in their phenomena those of the epidemic furies of the Middle Ages. By some German writers any very bad case of ordinary chorea is spoken of as chorea magna. Again, the term chorea major or chorea germanorum is sometimes used as a name for the automatic chorea described on jjage 635. ST. VITUS' S DANCE. 629 a fright, and that in a majority of cases it is recovered from in a few weeks. It is absurd to suppose tiiat serious organic change of the nerve-centres can be present in tliese cases. Moreover, competent observers have failed to find alter- ations in the nerve-centres after death from chorea. A large number of observ- ers have, however, especially noted changes in the spinal cord, the ganglionic cells appearing shrivelled, their pi'otoplasm granular, their nuclei obscured, and their processes indistinct or absent. I have found exactly similar lesions in choreic dogs, and have noted that when the animals were killed in the begin- ning of an attack the spinal ganglionic cells showed no change : a little later the only alterations in the cells were the very frequent absence of the nuclei, the failure of granulations in the protoplasm, the loss of power to take staining fluids, and rarely the occurrence of sharply-defined vacuoles. Then the ]>ro- cesses began to drop off; and finally it was found that the places of the cells were occupied by irregular, globose, crumpled-looking masses, without sharp outline and taking carmine staining very faintly. No granulations, no nuclei, no processes, were apparent. Evidently there is in the spinal ganglionic cell of the choreic dog an altered nutrition, which first manifests itself solely in dis- order of function with choreic movements ; after a time, as the nutritive pro- cess continues, the structure of the cells becomes sufficiently affected for change to be recognized, and in fatal cases some at least of the cells have undergone total degeneration. Similar structural changes have been noted in the gangli- onic brain-cells of choreic dogs and cats. In the choreic child during life the will, the intellect, and the emotional faculties are often markedly abnormal, whilst after death structural change has been found in the spinal cell. It seems to me clear that the pathology of St. Vitus's dance is an alteration in the nutri- tion of the ganglionic structures of the whole cerebro-sj^inal axis; which altered nutrition may fail to develop structural changes sufficiently great to be recog- nized by the microscope, or may go on until it produces pronounced structural lesions. Symptomatolog-y. — The onset may be sudden or gradual in its develop- ment. The attack may come on in the midst of aj)parent health, but ordinarily it is preceded by languor, irregular action of the gastro-intestinal tract, and a pronounced nervous irritability. The motor disturbance may be first indicated bv a peculiar restlessness of the child, who is not rarely punished for fidgeting. The true choreic movements usually appear first in the fingers, afterward in the face, and then spread until they involve the whole body. In a large proportion of cases very often the two sides of the body are not equallv affected, and sometimes the symptoms arc limited to one side (liemi- chorea), or in rare cases are almost confined to one extremity. A distinct increase of electric irritability has been notcet and head would be forcibly jerked together ten or twelve times a niiiiute. A single paroxysm of these movements often lasted fourteen hours a diiy. Some cases like those described in the ])reccding paragrajih have probably been instances of epileptic automatism, whilst others h:i\'e been fi^rms of hys- ' Many of the cases described as convulsive tic l)y French and other .nithors represent spas- modic diorea. (See page 0'.\A.) Fnrllicr, as automatic chorea was well dcscrihod before the first article of Toiirette, there is no jiistilication for attaching his name to the disciise. 636 FUNCTIONAL NERVOUS DISEASES. teria, allied to the hysterical religious epidemics of the Middle Ages and to the performances which have been frequently witnessed at revival scenes dur- ing camp-meetings in the United States and among the Howling Dervishes of Mohammedan countries. Of diiferent character are probably the so-called salaam convulsions of children, in which the paroxysms recur several times a day, last from a few seconds to some minutes, and consist of a bowing forward of the head and body ])erhaps as many as two hundred times. Allied to these cases is that of a man who formerly lived in this city, who when seized with the paroxysms would spring np, rush to a table, and jam his hat down upon his head several times, uttering at the same time certain words. ^ The essential feature of latah is an extreme excitability of the patient, which causes him, upon the least abrupt excitation, such as would be produced by slapping him on the shoulder, hallooing at him, slamming a door, etc., to jump or perform other violent disorderly acts, conjoined svith a condition of the cerebral nervous system which necessitates a repetition of voices or sounds {echolalgia) or the ejaculation of some Avord, usually obscene {coprolalgid). In some cases the impulse of imitation is so great as to force the victim to repeat not only the spoken word, but also any act done by a bystander. Very fre- quently the sudden nervous excitement is accompanied by an excessive emotion, especially of fear, although such emotion may be entirely foreign to the ordi- nary nature of the individual. The disease appears to be hereditary. It often affects various members of several generations of one family. This affection was described by Dr. George M. Beard in 1880, Avho found in the so-called "jumping Frenchman" of Maine that the hearing of a sudden voice or noise caused a repetition of the words or sounds, with the performance of strange antics, whilst a loud command was always obeyed, often with a cry of alarm not unlike that of hysteria or epilepsy. Two "jumpers" standing near each other when commanded to strike each other did so with zeal. Dr. Beard tested the echo-speaking or repetition by reading portions of Latin and Greek, when the untutored "jumper" repeated the sounds of the words as they came to him in a quick, sharp voice, at the same time jumping or making some bizarre motion. M. (3'Brien makes four classes of cases, as he has seen them in Southern Asia : Class first, comprising those individuals in whom an unexpected noise pro- duces great alarm, with an irresistible impulse to rush upon the nearest object, and at the same time forces an exclamation Avhich is always obscene. Class second, comprising those persons in whom certain words when sud- denly pronounced will produce an excessive paroxysm of sudden terror. Thus, in an individual noted for his courage and who faced the living alligator with- out a sign of fear, the sudden pronouncing of the word " buaya " (Malay for "alligator") produced a paroxysm of overpowering terror. In class third the individuals imitate the words, gestures, or sayings of those in their neighborhood. Jf, HEREDITARY CHOREA. 637 In i\iQ Jourtli cla.ss the individuals become completely abandoned to the will of some other person, performing every act, however outre or improper, which they are commanded to do by such individual — standing on their heads, attack- ing a spectator, etc. In these cases the person who suffers from latali recognizes his enslavement and is greatly depressed thereby, but is unable to prevent it. Patholog-y. — It seems to me that those cases of chorea major which are neither hysterical nor epileptic, and all cases of latah, are more closely related to reasoning insanity than to spasmodic disorders, the paroxysms of movement being ])roduced by morbid impulses similar to those which occur in various neuropathic insanities. (See page 578.) It is probable that the subject of latah is under the influence of a dominating idea which compels him to obey or to imitate as the case may be. I have seen a feeble neuropathic child develop such a mental condition that, under command, the most bizarre positions were taken and maintained for an extraordinary length of time, giving an appear- ance easily mistaken for catalepsy. The relations of this mental state to certain stages of hypnotism are very evident. Treatment. — There is no reason for believing that any specific medicinal treatment is of avail in the affection now under consideration. Hereditary Chorea. Definition. — A peculiar hereditary affection, characterized by the j)re.senco of general choreic movements, usually associated with other evidences of dis- turbed innervation, and probably due to a developmental organic affection of the nerve-centres. Synonym. — Huntington's chorea. Etiology. — So far as our present knowledge goes, this affection always depends for its existence upon direct heredity. It is commonly a.sserted that, if the di.sease fail to ap})ear in one generation, all succeeding generations remain free, but clinical experience shows that this is not invariably the case. It is not known that exciting causes play any important role in the develop- ment of the disease. Pathology. — Hereditary chorea aj^pears to be very closely allied to hered- itary ataxia, and, like the latter disorder, probably depends upon some devel- opmental departure from the norm in the nervous .system, although at present we have no positive knowledge as to this point. In the spinal cord of a patient who had been affected with this di.sorder Dr. Wharton Sinkler found in the antero-lateral columns of the cord an abnormal amount of connective tis.sue, thickening of the walls of its blood-vessels, and absence of many of the axis-cvlinders. The central canal was occupied by a mass of nuclear tissue. Symptomatology. — Hereditary chorea u.sually develops in middle life, although in simie cases it has a])peared at or even before |)uberly. The choreic movements resemble those of St. Vitu.s's dance, but .nc more c(m.stant, more rhythmical, and less under the control of tlic will. While standing or sitting the j)atient is continually repeating the .same irregular jerking movements. The gait is especially peculiar, for flic first few .steps perhaps nearly normal, 638 FUNCTIONAL NEBVOUIS DISK ASKS. when siitldenly it is interfered witii by one leg being thrust violently forward and the other one jerked uj) to it, so that the subject seems to go with a quick, short hop, almost like a dancing step. The course of the disease is exceedingly slow, and in some cases many years are required before the subject becomes unfit for physical labor. The mental condition is usually but not always abnormal : excessive irritability, moroseness, melancholia, chronic mania, and dementia have all been noted in cases which have been reported as instances of liereditary chorea. The reflexes are often exaggerated, but may be sluggish. The sensations are normal. In some instances a peculiar muscular stiifness has been noted. Treatment. — So far as is known no treatment is of any avail in this dis- order. Tetany. Definition. — A chronic affection of unknown pathology characterized by tonic muscular spasm accompanied by tingling and formication. Synonym. — Tetanilla. Etiolog-y. — Tetany is more frequent in males than in females, is almost confined to childhood and young adults, is very often associated with rachitis, and has repeatedly followed removal of the thyroid. It is said to be directly produced by excessive lactation, by the puerperal state, by exposure to cold, by prolonged fatigue, by exhaustion from diarrhoea or other cause, by the irri- tation of intestinal worms, by exposure, and even by the rheumatic diathesis or the infectious fevers. Further, it is affirmed that it may result from exces- sive emotion and spread from patient to patient as an epidemic. Such epi- demics have, however, probably been hysterical in nature. Pathology. — There is no known lesion in tetany. Symptomatology. — Tetany consists essentially of successive tetanic con- vulsive attacks separated by intervals of quiet and repose. The paroxysms may continue for some minutes or for many hours, and may cease gradually or abruptly. Arthralgic pains, formications or numbness in the hands, radi- ating pains in the fingers, temporary partial blindness, headache, sense of fatigue, etc. are assigned as occasional prodromes. Usually the spasms are most marked in the upper extremities, and sometimes are confined to them; the fingers are often drawn together so as to form a cone. Rarely there is a more accentuated flexion of the fingers, and still more infrequently the hand and the fingers are stiffly extended. The feet may be attacked ; sometimes cramps of the calf occur without distortion, but in other cases the feet are violently extended, with the toes pointing downward ; more rarely the feet are flexed. The thigh usually escapes, but spasm of the abductors and cross- ing of the feet have been noticed. Only in the severest cases are the trunk- muscles affected, but opisthotonos and menacing dyspnoea do occur. Even more exceptional than these are spasmodic closures of the jaw and distortions of the face. The course of the disease may be painless ; sometimes, however, neuralgic pains run along the nerves, and usually cramp-pains are present in the affected muscle. Anaesthesia and analgesia are ordinary phenomena. PARALYSIS AGITANS. 639 According to Erb, the iaradic excitability of all the muscles of the body is increased. The reflexes are said to be usnallv lessened in adults, but exair- gerated in children. The so-called " facial phenomena " of tetany consists of contractions of the facial muscles produced by a rapid series of taps with a percussion hammer upon the cheek just above and parallel with the horizontal ramus of the lower jaw. Schlessinger affirms, however, that the phenomenon is not constant in tetany, and is often demonstrable in persons not suifering from tetany. Prog-nosis. — Tetany usually ends in recovery, although it frequently lasts for months or even years, and has a distinct tendency to relapse. Diagnosis. — Trousseau discovered that in tetany, during the periods of relaxation, and in some cases even as long as three days after the occurrence of a convulsion, an attack can be brought on by pressing upon the principal nerve-trunk or artery. By this symptom, by the complete relaxation between the attacks, and by the partial character of the convulsion tetany is distin- guished from tetanus. Treatment. — The treatment of tetany should be primarily directed to the relief of the bodily condition underlying the disorder. Chloral, bromides, the anaesthetics, will to some extent control the movements. The value of arsenic has not been determined. Paralysis Agitans. Definition. — A disease of advancing life, characterized by tremors con- tinued during waking hours, associated with muscular weakness and rigidity. Pathology uncertain. Synonyms. — Parkinson's disease ; Shaking palsy. Etiolog-y. — Paralysis agitans rarely occurs under forty years of age, is most frequent between fifty and sixty, more common in men than in women, and is very rarely the result of hereditary influence. Violent fright, prolonged anx- iety, exposure to cold, violent physical injury, especially when accompanied with great emotional disturbance, are occasional exciting causes of the disease. In the majority of cases, however, the development of the disease is gradual and without apparent reason. Pathology. — Some of the most noted neurologists have failed to detect any anatomical change in any portion of the nerve-centres in persons who have long suffered from paralysis agitans. Under these circumstances speculation has been rife as to the nature of the disease, and various theories have been brought forward. None of these theories seem to me very plausible, and certainly none of them are at all established. Symptomatology. — Paralysis agitans usually comes on insidiously and gradually, although in some cases the symptoms hav<' (l(Vflo|M'd a( oucc after a sudden fright or other emotional storm. The nttciiiion of the patient is first attra(;ted by a treiinu- in tln' liniid (.r foot, or even in one finger or toe. This tremor at first is transitory, ••an l»c citntrolled, at lc:i'<'; 1^77, No. 48. Vol. I.— 41 642 FUNCTIONAL NERVOUS DISEASES. ular lite, with absolute avoidance of physical or mental labor. Various nerve-sedatives, especially morphine, conium, hyoscyaraine, and Indian hemp, are accredited by authorities with the power of temporarily quieting the tremors. It is evident, however, that the habitual use of such remedies must in all probability lead to the narcotic habit. Arsenic has been recommended, but is of very doubtful utility. Electricity has been much employed, but does not seem to have real value. In the advanced stages, when there is much sutfering, the hot bath is sometimes of service, and not rarely it becomes neces- sary to use narcotics at night to bring sleep and a measure of relief from pain. I have seen a nightly dose of hydrobromate of hyoscine keep a patient com- fortable for several years after the failure of more frequently used analgesics. Remote Effects of Traumatism. Blows upon the body or upon the head, as well as violent shaking or other concussion upon the body without actual violence, may produce, first, local in- jury and inflammation at the seat of the violence; second, traumatic hysteria; third, the condition for which I prefer the name of "traumatic neurasthenia." In most cases local inflammation and traumatic neurasthenia coexist with a certain amount of hysterical disorder. Before taking up traumatic neuras- thenia it seems necessary to discuss briefly the local effects of traumatism. The paralysis sometimes seen in a muscle which has been violently struck, though not lacerated, is probably due to a suspension of the functions of the nerve-endings. The condition is rare except in the deltoid muscle, whose position renders it exceedingly liable to be severely bruised in falls. If at first local inflammation be set up, local antiphlogistic treatment may be required, and if later the nerve-trunks be found tender, blisters may be applied. If there be any hardening in the immediate neighborhood of a nerve, the latter should be dissected out and thoroughly freed from any cica- tricial or otherwise altered tissue. The hypodermic injection of strychnine, massage, and the electrical cur- rents are to be employed for the restoration of power. One object of the massage is to thoroughly free the muscles and muscular fibre-bundles from binding exudations. The current to be used is that which produces the great- est muscular contraction with the least pain to the patient. When the blow has been upon the back, the result is often the condition to which I have given the name of "traumatic back." The symptoms are — tenderness more marked upon deep firm pressure than upon slight pressure, also iii)()n jarring; restriction ' of movement by pain and by spasm of the erector-spinse muscles. Reflex spasms are also usually producible in the back muscles l)y jarring, pressing upon the head, or even upon the vertebral column. The symptoms of " traumatic back " are probably due to deep-seated inflammation primarily situated in the fibrous structure of the vertebral column, and in bad cases invatling neighboring tissues and even involving nerve-routs. The treatment consists in the use of local rest and continued counter-irri- SPINAL NEURASTHENIA. 643 tation, the general health being, of course, steadily maintained. In bad cases the plaster jacket or some of its substitutes may be essential. I have seen suspension very useful. The human trunk is composed of two cones, of which the shoulders and hips are the respective bases. In the Sayre jacket the upper of these cones is supported upon the latter after the two cones have been dragged well apart by hanging the man from his arm-pits. Some years ago it occurred to me that the upper cone of the body might be used instead of the arm-pits for the purpose of suspending the patient and stretching the back. In accordance with this thought I found that suspension from the upper cone can be sustained without suffering for many hours, and that in diseases of the vertebral column situated low down it is very advantageous. When the trau- matism has affected the lumbar region of the back this treatment avails much. In carrying it out the patient should be suspended in the ordinary way for putting on the plaster jacket, and when the first layer of the plaster jacket has been put in place, two broad strong linen bandages, well wetted, are to be so placed, one over each shoulder, that they shall form above a loop, whilst the ends hang down front and back eight inches below the plaster bandage. With new turns of the plaster bandage the linen bandage must now be fastened intt> its place. After this the loose ends of the linen bandage hanging below the plaster jacket are to be taken up and incorporated into the turns of the plas- ter bandage necessary to complete the jacket. Spinal Neurasthenia. Definition. — A condition of neurasthenia, usually with hysterical symp- toms, produced by severe injuries. Synonyms. — Spinal concussion ; Railway spine. Etiology. — Railroad injuries, falls from hatchways, press of steam from exploding boilers, any violence acting upon the trunk through crushing local force so as to greatly shake and shock the whole system, may produce spinal neurasthenia. Symptomatology. — The symptoms of traumatic spinal neurasthenia may appear at once after the injury or they may come on insidiously in the person, who has at first believed himself uninjured. The symptoms are subjective and objective. The most important of the subjective symptoms are malaise, loss of ambition, marked increase of nervous irritability, failure of the power of mental and physical labor, depression of spirits, occasional headache, pro- nounced tinnitus aurinm, broken slee)), loss of sexual power, and general failure of health. Almost invariably to these symptoms are added various hysterical manifestations. Probably among these must l)e classed the extra- ordinarv cerebral attacks which come and go often without obvious cause or explanation. Sometimes these attacks reseml>le petit mal, in tiiat they con- sist of short moments of unconsciousness; sometimes th(> paroxysm is pni- longed and consists of an active delirium,' which may amount to a fin*ious and aggressive mania. Often the patient has no remembrance of any of these attacks. Distinctly hysterical j)aroxysms are not ran-. Neurasthenic vaso- 644 FUNCTIONAL NERVOUS DISEASES. motor weakness is common, so that sudden flushings of the face and abrupt outbreaks of sweating are frequent. The muscular irritability is often greatly augmented, and the knee-jerks are exaggerated. Paradoxical contractions may often be produced in the anterior muscles by flexure of the foot ; and, as I have seen in some cases, the slightest irritation may cause a general reflex contraction of the erector pilse muscle, with a consequent " goose-flesh." The activity of the knee-jerk is apt to vary from day to day, and often, when exao-o-erated soon becomes exhausted bv excitation, so that the muscles by and bv fail to respond well when the patellar tendon is repeatedly and rapidly struck. General fatigue will often register itself in the knee-jerk. Ankle- clonus is rare. The sexual power is commonly not altogether lost, but sexual irritability and weakness are usually shown in men by premature emissions. True diabetes may be present and produce its ordinary results. With these various symptoms there are usually pronounced local evidences of the sore back. The course of this disorder is excessively slow. It has very little influ- ence upon life, but it produces a disablement and much suffering that usually last many years, and which in bad cases may never be recovered from. Diagnosis — The diagnosis of this disorder would be very easy were it not for the medico-legal complications which surround most cases. The chief ques- tion always is whether the symptoms are real or feigned. Exaggeration of symptoms in many cases is almost a necessity of the situation. The ques- tions to be determined by the physicians are — first, how much exaggeration or feigning exists ; second, how much the symptoms are those of hysteria and how much those of neurasthenia ; third, how much of local disease there is. The importance of these questions rests upon the fact that traumatic hysteria yields much more readily to treatment than traumatic neurasthenia, and that local symptoms which have already lasted for some time are only to be over- come by very long-continued careful treatment, and are indeed prone to increase rather than decrease. Treatment. — The foundation of the treatment in these cases consists in absolute rest, mental and bodily. Long-continued rest in bed, with massage and careful use of electricity, is often of the greatest service. This rest must continue for a great length of time, as a little over-exertion will overthrow any good results already obtained. Tonics are of very little service. Narcotics for the relief of pain and malaise often seem called for, but their use is always attended with more or less danger of the narcotic habit. In one of the most successful cases I have ever seen, the patient, a medical man, treated himself, chiefly by drinking three or four pints of strong ale a day. In a person of less resolution this would have resulted in the development of the alcoholic hal)it. The narcotism of the alcohol and the hops in this case made life endurable, whilst the stimulating effects of the beverage were very useful in maintaining the vital functions. Results of Excessive Exposure to Heat. Two distinct bodily conditions, accompanied with disorder of conscious- HEAT EXHAUSTION.— THERMIC FEVER. 645 ness, arise during exposure to heat : they may be respectively known as heat exhaustion and thermic fever. Heat Exhaustion. Definition. — A condition of profound general exhaustion, with paralysis of the vaso-motor system and failure of the general bodily temperature, due to the combined action of heat and exertion. The sense of weakness which often accompanies exertion in feeble persons during the hot weather represents in the mildest possible form the condition under consideration. In more severe cases there is distinct pallor of the coun- tenance, with failure of the muscular force and of the circulation, accompanied by an overpowering feeling of exhaustion. In the worst cases of heat exhaustion the svmptoms develop ra]>idly, and sometimes with such absolute abruptness that the patient falls in a syncopal condition. Under these circumstances uncon- sciousness or semi-consciousness may exist, and be accompanied by muttering delirium, great restlessness, facial expression of collapse, rapid, feeble, scarcely perceptible pulse, and a lowered bodily temperature. I have myself known a mouth temperature of 95° F., with complete collapse. It is essential for the purposes of treatment that heat exhaustion be not con- founded with thermic fever, from which it is at once diagnostically separated bv the temperature being markedly below instead of above the norm. The only condition readily confounded with heat exhaustion is collapse from cardiac disease, internal haemorrhage, malarial fever, or other affections occurring in persons picked up in the street and brought to the physician without history. In such cases, however, it is very rare for the temperature to fall as decidedly as in severe heat exhaustion, and peculiar and characteristic symptoms are usually present. The treatment of heat exhaustion consists in the free use of external heat (when it is possible, by means of hot-water baths), the hypodermic injection of atropine, strychnine, and digitalis in order to stimulate the heart and vaso- motor system, with the very moderate internal use of hot alcoholic drinks and ammonia. Thermic Fever. Definition. — Fever produced by exposure to heat. Synonyms. — Heat fever ; Sunstroke ; Coup de .soleil. Etiology. — The immediate cause of thermic fever is always exposure to heat, natural or artificial. Owing to the interference with evaporation, and the consequent cooling of the body, heat in a moist atmosphere is much more efficient than is dry heat ; hence sunstroke is very rare in dry hot climates and frequent in tropical lowlands, as well as in sngar-refiueries, laundries, and other places where men work in damp hot air. Exposure to tli(> direct rays of the sun is not necessary, and many of the worst epidemics have occurral during tropical nights. Whatever lessens the power of the human system to resist external influ- 646 FUNCTIONAL NERVOUS DISEASES. ences may be a predisposing cause to sunstroke. Chief among these predis- posing causes are race, excessive bodily fatigue, and intemperance. The fact that males are much more frequently affected than females depends simply upon the habitually greater exposure of men to heat. Races which by long living in tropical countries have become accustomed to heat rarely suffer from sunstroke. Symptomatolog-y. — In its severest forms sunstroke is very apt to come on suddenly and witiiout distinct prodromes, although there may be a sense of great distress or of a general burning heat before the loss of consciousness, which may also bo immediately ushered in by chroraatopsia, or colored vision, the whole landscape being deluged in a blue, yellow, or red light. The uncon- sciousness ordinarily develops abruptly, and is complete, although very fre- quently it is associated with muttering delirium. There is usually great mus- cular restlessness, which in some cases becomes convulsive or is replaced by violent epileptiform convulsions. Sometimes the patient is profoundly relaxed and quiet. The surface of the body, at first dry, often later in the attack gathers upon itself an excessive perspiration, which does not, however, reduce its burning heat. The face is flushed and the eyes are suffused. The rapid pulse is sometimes bounding and apparently strong, although almost invari- ably compressible ; frequently it is feeble and even thready, especially if the symptoms have lasted for some hours. Vomiting is very common ; purging is in bad cases almost always present. The whole body is apt to exude a pecu- liar odor, which is especially strong in the faecal discharges. The characteristic symptom is the high temperature, which, as measured in the mouth or rectum, may reach 112° or 113°, and is rarely below 108° in cases severe enough for unconsciousness to be present. The urine is scanty, sometimes albuminous, not rarely finally suppressed. The breathing is more or less labored, and often irregular, and toward the last generally becomes more and more shallow. Although at times the patient suffering from thermic fever may be partially aroused by shouting, shaking, etc., the unconsciousness is often absolute. The pupils are variable, sometimes contracted, sometimes dilated. Even in the most severe forms of thermic fever, as seen in this country, death rarely occurs under half an hour, and usually is postponed for a much longer period. Sometimes it is caused by asphyxia, more frequently by a slow, consentaneous failure of respiration and cardiac action. There is, however, a form of sunstroke rarely seen except in soldiers during battle, in which the death is due to arrest of the heart's action, and is almost instantaneous. Many years ago, under the name of ardent continued fever, the physicians of India recognized a mild form of heat fever, and in 1885, Dr. John Gui- teras showed that the typhoid fever of Key West is of this nature. The symptoms are irregular continued fever, without apparent cause or local dis- ease, with a tendency to weakness and the typhoid state, and not rarely with .severe but not permanent local, nervous, abdominal, or other disturbance. Writers in India state that in that climate these cases are apt to end in sudden collapse and death. THERMIC FEVER. 647 As was first pointed out bv Dr. Comegys, many of the cases of so-called entero-eolitis occurring in young children during the hot months are reallv forms of thermic fever. The symptoms in these cases are high fever, dry tongue and mouth, rapid pulse and respiration, intense thirst, vomiting, purg- ing of greenish, watery, faecal or serous matters with undigested particles of food, and more or less pronounced evidences of cerebral disturbance, such as insomnia, headache, contracted pupils, delirium, and finally coma. In some cases the bodily temperature rises before death to a point comparable with that which it reaches in sunstroke of the adult. Pathology. — The results found in the body after death from thermic fever depend much upon the course of the disease and the time at which the })ost- mortem is made. Owing to the intense heat of the body, post-mortem changes begin in the course of a very few minutes, and some of the lesions described by early writers were really due to beginning putrefaction. When the post- mortem is made immediately, the left heart is found contracted, the right heart usually engorged, the blood semifluid and collected in the venous trunks, with petechial spots upon the arterial coats or scattered through the system. In an elaborate research made many years ago I proved that the cause of the symptoms and of the lesions of thermic fever is simply the excessive heat. There is in the pons or higher portion of the nervous system a centre whose function it is to inhibit the production of animal heat, and in the mcdidla a centre (probably the vaso-raotor centre) which regulates the dissipation of the bodily heat : fever is due to disturbance of these centres, so that more heat is produced than normal, and proportionately less heat thrown oif. Let it be sup- posed that a man is placed in such an atmosphere and that he is unable to get rid of the heat which he is forming. The temperature of his body will slowly rise, and he may suffer from a general thermic fever. If early or late in this condition the inhibitory heat-centre becomes exhausted by the effort which it has been making to control the formation of heat, or becomes paralyzed by the direct action of the excessive temperature already reached, then suddeidy all tissues will begin to form heat with the utmost rapidity, the bodily tempera- ture will rise with a bound, and the man drop over with some one of the forms of coup de soleil. Under this view of the case the widespread popular belief, that protecting the back of the head and upper neck from the direct rays of the sun is useful against sunstroke, gains in significance, because it is ])ossible that local heating of the parts spoken of may occur and aid in the j)r()(luction of inhibitory paralysis. Respiration often ceases in thermic fever through the paralyzing influence of the heat upon the respiratory centres, though in long-continued cases asphyxia may be due to changes in the blood itself Cardiac rigidity usually occurs directly after death by the coagidation of the myosin, the temperature of the body in sunstroke reaching very nearly the |)oint at which normal myosin coagulates. Excessive exertion so alters the nature of myosin in muscle as to cause it to coagulate much more readily than is normal. I)ur- iuf a battle the mvosin of tlx' whole body is afl'ected by the excessive eflbrt, 648 FUNCTIONAL NERVOUS DISEASES. and frequently men are found stiffened in the attitude in which they have been stoi)ped by the bullet, instantaneous death being followed by instanta- neous post-mortem rigidity. In simstroke occurring in battle or in times of excessive exposure death, as has already been stated, may be instantaneous, the man being instantly overwhelmed, because, under the conjoint influence of vio- lent exertion and intense heat, the heart-muscle has suddenly set itself from life into the rigidity of death. Treatment. — All persons who are constantly exposed to high temperature should keep the bodily health as perfect as possible by avoidance of alcoholic, sexual, or other excesses and of great bodily or mental fatigue. The diet should be largely farinaceous, and the emunctories be kept active by the eating of fruit, the free use of water, and mild salines if necessary. Large draughts of intensely cold ice-water may do harm in heated persons by sud- denly chilling the stomach, but cold water taken in moderate quantity, at short intervals, by its action in reducing the general temperature and in aiding free perspiration, does good. The addition of claret or some other substance which mildly stimulates the gastro-intestinal tract and the skin may be of great ser- vice in special cases. In mild cases of continued or subacute thermic fever the basis of the treat- ment should be the use of the cold bath. The plan adopted by Guiteras at Key "West was to wrap the patient in a dry sheet, lift him into a tub of water having the temperature between 80° and 85°, and then rapidly cool this water by means of ice. The time of the immersion lasted from fifty to fifty-five minutes, it being regulated by the thermometer in the mouth of the patient. The patient was then lifted out upon a blanket, the skin partially dried, and the body covered. Guiteras found great advantage by giving a moderate dose of whiskev and thirtv minims of the tincture of dio-italis twentv minutes after the bath. He states that it is very important to avoid currents of air blowing upDii the patient, and to have the bath given in a small warm room. The result of the bath was invariably a lowering of the temperature, a reduction of" the rate of the pulse and respiration, and a refreshing sleep. After the second bath the course of the temperature seemed permanently influenced for the better. It was never necessary to give more than two baths in the twenty- four hours, but in some cases they had to be used for many days. In acute thermic fever immediate reduction of the bodily temperature is urgently indicated. Any prodromes should be the immediate signal for with- drawal from exposure to heat, and the use of the cold bath if the bodily tem- perature be above the norm. As soon as a patient falls with sunstroke he should be carried into the shade with the least possible delay, his clothing removed, and cold affusions over the chest and body be practised. This must not be done timidly or grudgingly, but most freely. In many cases the best resort will be the neighboring pump. In the large cities of the United States during the hot weather hospital ambulances should be furnished with a medical attendant and with ice and antipyrin, so that when a sunstroke patient is reached he may be immediately stripped underneath the cover of the ambulance, and THERMIC FEVER. 649 remedial measures applied during: Ids ])assage to the hospital. I believe many lives are sacrificed hy the loss of" the critical moments in the interval between the finding of the patient and his reaching the hospital ward. If circumstances favor, instead of the cold affusion rubbing with ice may be practised. The patient should be stripped and the whole body freely rubbed with large masses of ice. When practicable, a still better plan is to place the patient in the cold bath (50° F.). The employment of enemata of ice-water, as originally sug- g(>sted by Parkes, may sometimes be opportmie. In using these various meas- ures it must be borne in mind that the indication is the reduction of tempera- ture ; if the means employed do not accomplish this, they do no good. The thermometer should always be placed in the rectum or the mouth, the amount of cooling of the axillary surface not being a correct guide. Care is sometimes required not to overdo the use of the cold bath. In the cases which have come under my own observation after the use of the cold bath but little treatment has been required. If, however, the period of insensibility has lasted too long, there may be no return to consciousness, even though the bodily temperature be reduced to the norm. Under such circumstances the case is almost hopeless, but the symptoms may be met as they arise, and a large blister applied to the whole shaved scalp. When relapses of fever occur, they should be met by the use of cold, but such relapses can generally be prevented by giving antipyrin with small doses of morphine. In thermic fever hypodermic injections of morphine should be given when severe convulsions occur. Venesection may sometimes be advan- tageously practised in the onset of a severe thermic fever, especially when the means of applying external cold are not immediately at hand ; but much care and judgment are required in using the measure. When excessive headache with strong pulse follows immediately upon a sunstroke, free venesection may be required to save the brain or its membranes from an acute inflam- mation. Sequelae. — The mildest sequelae after thermic fever are inability to bear exposure to heat without cerebral distress or pain, with more or less marked failure of general vigor, dyspeptic symptoms, and other indications of disturbed innervation. In other cases the symptoms are more decided. Pain in tiie head is usually prominent: it may be almost constant for months, but is always subject to exacerbations. It sometimes seems to fill the whole cranium, but not rarely is fixed to one spot, and I have seen it associated with pain in tlu! upper cervical spine and decided stiffness of the muscles of the neck. With it may be vertigo, decided failure of memory and of the power of fixing the attention, with excessive nervous irritability. When the symptoms aj^proach this point in severity there is usually marked lowering of the general health, loss of strength, ])ossibly some emaciation, and the j^ecidiar invalid look produced by chronic disease. In rare cases ejjileptic convulsions and very pronounced evidences of chronic cerebral inniimmatiou are j)resent. The symptom which I believe always to be present, and to be of diagnostic import, is the inability to withstand heat. This is shown not oidv (luring the summer 650 FUNCTIONAL NERVOUS DISEASES. months, but in most cases headache and severe general distress are produced by going into hot rooms even in winter. The lesion underlying these sequelae of sunstroke is raeningo-cortical irri- tation, with in severe cases distinct chronic meningitis. The treatment is, first, absolute avoidance of any exposure to even moderate heat, combined with intellectual and physical rest ; second, the treatment of non-specific chronic meningitis — i. e. local bleedings and very free counter-irritation, especially by means of the actual cautery, combined with the internal administration of mer- curials and the iodide of potassium in small continuous doses; third, the restriction to a farinaceous, non-irritating diet, and the careful attention to all minor symptoms as they arise. The persistent, merciless use of the actual cautery T have seen achieve extraordinary results in severe cases. Caisson Disease. Definition. — A peculiar aifection produced by continued exposure to a highly compressed atmosphere. Synonym. — Diver's paralysis. ^tiolog-y. — The only known cause for this affection is working in caissons during bridge-building or other enterprises in which water is kept out of the caisson by highly compressed air. In passing from these chambers the men go through an outer compartment, so arranged that the pressure can be grad- ually brought back to the norm. A too rapid passing from the innermost caisson to the outer air is exceedingly deleterious, but no precautions can pre- vent the disease from attacking a proportion of the workmen. Pathology. — The pathology of caisson disease is j^ractically unknown. The theory that the symptoms are due to sudden evolution of compressed gas from the blood into the nerve-centres is not proven. It may be that the dif- fi(nilty lies in the coats of the small blood-vessels. In a few cases in which autopsies have been obtained long after the commencement of the disease dis- seminated focal myelitis has been found. Symptomatolog'y. — The symptoms of caisson disease usually develop in from half an hour to two hours after the return of the subject to the surface of the earth. Violent pains occur in the limbs and in the hands, followed in a few minutes by progressive loss of motor and sensory power in the legs. Notwithstanding the ansesthesia may become complete, the pains continue, whilst headache, dizziness, double vision, incoherence of speech, mental aberration, and sometimes unconsciousness, rapidly develop. The patient may convalesce in a few days, or death may take place quickly with apoplec- tic symptoms, or may follow from paralytic bedsores and cystitis after some months. Usually, however, recovery occurs after a prolonged period of atro- cious suffering and motor disablement. Treatment. — There is no specific treatment of this affection : all that can be done is to meet the symptoms as they arise. OCCUPATION NEUROSES. 651 Occupation Neuroses. Definition. — Localized motor affections produced by the excessive use of groups of muscles in professional or other business pursuits. Etiolog-y. — Whenever, as in many of the occupations by which men earn their livelihood, there is required an almost indefinite repetition of a more or less complicated set of movements on the part of certain groups of muscles, peculiar local disturbances of muscular action are liable to be developed. The symptoms are usually so entirely local as naturally to lead to the supposition that the affection is purely a peripheral one, but a wider study shows that the disease must be connected with a disordered condition of the nerve-centres. Thus, if the victim attempt to substitute the left hand for the disabled right hand, the disorder usually soon appears in the left hand. Again, general overwork, anxiety, and depressing emotion sometimes play a very distinct etio- logical role, and in a number of instances I have seen the ''writer's cramp" appear as the first symptom of a general nervous breakdown. Occupation neuroses may indeed be looked Jipon as local neurasthenia, having the same relations to general neurasthenia that every local neurasthenia has. (See page 587.) Occupation neuroses are more frequent in middle adult life than in either extreme of age, and are much more abundant among men than among women, simply because the active period of male adult life is that of labor. The most common of the occupation neuroses is the so-called '' writer's cramp/' but the variety of cases which occur in real life is almost indefinite. Professional pianofortists frequently suffer pianoforte-player's cramp, which for obvious reasons is more frequent among women than among men. Vio- linists are liable to a similar affection in either hand ; seamstresses, tailors, sailmakers sometimes develop the sewer's cramp. The telegraphist's cramp is esjiecially frequent among those who use the Morse machine. Dancer's palsy, or cramp affecting especially the muscles of the calf, is very rare among men, being seen almost exclusively in the professional danseuse. Hammer palsy attacks chiefly the muscles of the right upper arm, and is especially frequent among gold-beaters, but is occasionally seen among smiths ; the latter artisans are also liable to suffer from chisel cram,p, affecting the left hand, produced by the continuous holding of the chisel or similar instrument. Money-counters, watchmakers, knitters, engravers, indeed the whole list of artisans, are occa- sionally disabled by peculiar occupation neuroses. Pathology. — No anatomical changes are known to exist in writer's cramp and allied disorders, and it does not seem worth while to discuss the various theories in detail. The condition is probably one of local ncMirasthcnia, with irritabilitv of tlio affected centres. Symptomatolog'y. — The symptoms ol" occupation neuroses arc due to the excessiv(! repetition of" movements which require exceedingly fine co-ordination, and differ essentially from the siriiple muscular exhaustion which occasionally is produced by severe muscular efforts. The ciiaracteristic symptom of the 052 FUNCTIONAL NERVOUS DISEASES. occupation neuroses is, therefore, that, although the disablement for the habit- ual fine action may be almost complete, muscular power remains, at least at first, for coarse actions. Thus, a man that cannot grasp the pen may readily wield a fifty-pound dumb-bell. The most marked symptoms of these neuroses are pain and spasm. In 1868, Moritz Benedict stated that there were three forms of occupation neuroses — the paralytic, the spasmodic, and the tremulous. These varieties undoubtedly exist in nature, although not absolutely separated from one another, the dis- tinction between them being simply that in some cases the paralytic symptoms are most marked, whilst in others the spasm or the tremor is the most pro- nounced. According to ray own observation, the paralytic form of the affec- tion is much the most frequent, although some authorities assert that the spasmodic is the ordinary variety. As it is not possible in the allotted space to describe in detail even the majority of the occupation neuroses, I shall take the most common of them, the writer^s cramp, as a type of the disorder. In the paralytic form of writer's cramp the first symptom is usually a painful feeling of fatigue in the arm, which is often associated with formica- tion and numbness, but usually not with true ansesthesia or hypereesthesia. Only in rare cases can tenderness be found over the nerve-trunks. The pain is always increased by writing, and at last it grows so intolerable as altogether to forbid the use of the pen. With this fatigue and pain there are usually a sense of stiflPness and often a distinct muscular resistance when the eifort is make to grasp the pen. At first no pain is felt when the arm is not used, and during use the pain is confined to the arm itself; but by and by, if efforts be persisted in, the sense of fatigue becomes more or less permanent, and extends upward from the arm, and may often be felt as a distinct pain between the shoulders. During all this time the power of the muscles for coarse work is in most cases not sensibly impaired, but the execution of any form of fine work is usually interfered with. Even in the paralytic form of writer's cramp there is a certain amount of irregular spasmodic contraction in the muscles during the act of writing, as is esj)ecially shown by the stiffness and, occasionally, by the cramp of the fingers around the pen ; but in the spasmodic form of the affection irregular muscular contractions are the dominant symptom. At first these are only simple, slight spasmodic movements of the thumb and first finger, so as to produce an irreg- ular stroke in the writing, but after a time the spasms become stronger and more widespread. By a sudden extension of the finger the pen is dropped, or by a spasmodic action of the opponens pollicis, with abduction and coincident flexion of the index fingers, the pen is rapidly moved from the paper, or occa- sionally a violent spasmodic flexion of all the concerned fingers holds the pen as in a vice. In extreme cases all the muscles of the forearm are involved ; and it is asserted that the muscles of the arm and shoulders may be affected, although I have never seen an instance of this. Much the rarest form of writer's cramp is that in \vhich tremors are the OCCUPATIOX NEUROSES. 653 most prorninont manifestation. When any attempt to write is made, trem- blings in the hand and forearm, and in extreme instances in the arm itself, come on. The pen, following the tremors rather than the effort of the will, soon makes nothing but irregular undulating or angular strokes, in which not even the \'estige of a letter can be made out. I have never seen a case in which tremors existed as the sole symptom, but I have seen them very marked in the spasmodic form of telegrapher's cramp, and have noted their per- sistence during almost all forms of voluntary movement, even after the occu- pation had been abandoned for months. Prog-no^is. — The prognosis in writer's cramp is good, provided that absolute rest from the original cause of the disorder can be obtained. The course of the attection is, however, slow, and the disablement has a great tendency to return, even after apparent health has been restored, upon any repetition of the work. Treatment — In the circumstances which surround most patients the treat- ment of writer's cramp, as in other occupation neuroses, is troublesome, since, except in the very slightest forms of the affection, total abstinence from writ- ing for a protracted period is essential to the cure. Moreover, the symptoms have a great tendency to recur upon recurrence to writing. Much can be done to prevent the original development of writer's (!amp, and also relapses, by writing with the arm rather than the hand. Any person who begins to feel discomfort during writing should at once adopt the freer style, A penholder of cork, half an inch in diameter, is of great advantage; the quill pen is said to be superior to any steel pen, and certainly the blunt-pointed steel pen made in imitation of the quill pen is much better than the ordinary sharp- pointed instrument. In free writing the movement is chiefly from the shoul- der-joint; for the development of the method Gowers suggests that the learner should draw a line across a sheet of paper with the arm moved as a whole from the shoulder ; then that he should make a similar but wavy line ; then increase the wavy character of the line and then the slope of the waves, so that at last he forms the line like a series of m's — mmmmm — the letters being joined together. From these letters the transition to other letters will be easy. A person learn- ing this method should learn to form a whole line of words without lifting the hand from the paper, the hand holding the large pen-holder lightly. Much better even than this method of writing is the use of one of the type-writing machines.' When it is necessary for the subject of the disease to continue the writing at all hazards, the left hand may be employed. In writing with it, it will be found easier to reverse the lines — i. e. to write with the slope from ' Authors and other persons who compose as they write will find an exlraordiiiiiry savinfc of nerve-force and time by the use of the short-hand amanuensis. The hahit of dictalion can by most persons be readily formed: it nnist be remembered, however, that the person will dictate as much in one liour as lie will write in three, so that the dictation means more expen- diture of })rain-force in the same period of time than occurs in composing by writinp. The author who dictates must work fewer hours a day, but even then will accomplish more than he would with his own pen. 654 FUNCTIONAL NERVOU^S DLSEASIu^. left to right. Usually the left hand soon develops cramp, but occasionally it remains free if great care be taken not to overwork it. The direct treatment of the arm suffering from writer's cramp yields very unsatisfactory results. No internal medication is of any use, save only as it may benefit the general health of the patient and overcome the neurasthenic tendency apt to exist in these cases. Rest, massage, and electricity are the tiiree asencies at hand. As alreadv stated, rest must be absolute and long continued. Massage seems to be of distinct value. Electricity has been very largely employed, and is by some authorities strongly commended, by others spoken of with despair. It seems, in fact, to do good in some cases, but very often its influence is scarcely perceptible. Faradization may do harm, as the muscles are commonly irritable; it rarely, if ever, does good. The best appli- cation is the long-continued use of a mild current of galvanic electricity })assed down the nerve of the affected member, of just such strength as to be distinctly but not painfully perceived. A small positive pole should be placed over the nerve-trunks in the groove of the inside upper arm, whilst the hand rests upon a large well- wetted sponge connected with the negative pole. Headache. Although pain in the head is a symptom, yet it so frequently constitutes the main complaint of patients that it seems necessary to give it here separate consideration. For the purpose of brief discussion headaches may be arranged in four classes, as follows •} 1. Organic headaches, due to disease of the brain or its membranes. 2. Toxsemic headaches, due to a poison either produced within the body or received from without. 3. Sympathetic headaches, due to some peripheral lesion. 4. Headaches which are not included in the other groups, and to which the name of nervous may be given, with the understanding that the title carries no etiological significance. In this group are placed many headaches of whose ultimate cause we are ignorant. Unfi)rtunately, it is not possible, by any character of the headache itself, to ' It seems proper here, also, to give anew a warnin": against mistaking the pain of an acnt« glaucoma for a headache. The pain of glaucoma, which may develop abruptly, often centres in the eyeball, but may seem to have its chief focus in the supraorbital notch: not rarely it shoots over the foi-fhead and into the cheek and temple, reaching even to the occiput, and filling the whole side of the head with agony. If, as usunlly happens, there be fever, with severe vomiting, the patient may be thought to be suffering from a bilious or malarial attack, and the eye be irretrievably damaged before the true nature of the paroxysm is discerned. This can be avoided by ])aying attention to the following points: the eye shows evidences of inflammation in congestion and swelling of the conjunctiva and even of the lids; the cornea is somewhat misty, presenting the appearance sometimes spoken of as " steaminess," and its sensitiveness to the touch of a canicl's-lKiir pencil is diminished ; the ])Ui)il is sluggish, often somewhat dilated ; on palpating the two eyeballs simultaneously with the forefingers the aflTected eye is felt to be the liarder, and the patient often complains of a sense of tension in the ball; vision is less acute in tlie affected than in the sound eye. In case of doubt it is the duty of the practitioner to call in an oculist at once. HEADACHE. 655 u enforced for a month. The dull, heavy headache of habitual indigestion, with hepatic torpor (the so-called "biliousness"), is usually frontal, may be occii)ital, and is often asso- ciated with defective vision, giddiness, and great depression of spirits. Severe head-pain is sometimes due to gastric acidity. This headache is often ushered in by sudden blindness and dizziness, and usually yields at once to the admin- istration of ammonia and bicarbonate of sodium. Headache may be the only complaine TluHi; Paris, 1H84, No. .lO. Vol.. I. -42 658 FUNCTIONAL NERVOUS DISEASES. the sweating is unilateral. By compression of the carotid upon the affected side the pain is lessened, but it is increased by pressure upon the artery of the opposite side. It is affirmed that in some cases the dilatation of the arteries and veins can be detected in the fundus of the eye. Toward the close of the attack the face becomes pale. Dr. Anstie of London states that the pain-storm or migraine may be accom- panied by a temporary whitening of the hair at the seat of the pain, and that this paroxysmal bleaching, so to speak, finally leads to a change of color. I have never been able to confirm the existence of the described varieties of migraine or of the trophic changes just spoken of, nor yet have I ever seen a case in which migraine has produced, by continually recurring paroxysms, a condition parallel to the status epilepticus, such as has been described by Dr. F^re of the Bicetre. Visual prodromes are pronounced in migraine ophthalmica (hefniopia peri- odica). The most frequent form of visual disturbance is an amblyopia, accom- panied by vivid scintillations passing zigzag, like the lines of a fortification, over the field of vision. When heraiopia occurs it may be either monocular or binocular ; sometimes it is lateral ; in other eases it occupies the superior half of the visual field. In the binocular form a lateral half of the field is attacked. The vision is completely abolished in the affected portion of the field, although the total acuity of vision may remain normal. This sensory . Insomnia may be connected either with excessive anaemia or with excessive congestion of the cerebral cortex. The best explanation of sleep, then, is that when exhausted bv effort the cortical brain-cells pass into a condition of functional inactivity, during which their power of further effort is recuperated. Because conscious- ness is the expression of functional activity in these cells, therefore when these cells do not exercise their function there is unconsciousness — i. e. sleep. In treating of sleep and its disorders I shall divide the subject into three parts : first, abnormal wakefulness ; second, abnormal somnolence, or morbid sleep ; third, accidents or groups of symptoms which occur during sleep, and which are not elsewhere spoken of in this book. Abnormal Wakefulness. — In simple insomnia the form of the sleepless- ness varies. In some instances the subject is simply unable, when bedtime comes, to go to sleep. In other cases he goes to sleep readily, but in the course of two or three hours wakes, and is unable to slumber again. The latter form of insomnia, in my experience, is not commonly the precursor of severe mental affection, but is often obstinate. Insonmia may be prodromic of various diseases of the brain. It is very common in the insanities. It is also present not rarely in such general organic brain diseases as general paralysis of the insane, but is seldom a symptom of tumor or other focal brain-lesion. It may be produced by various diseases of organs other than the cerebrum. It may exist, however, in its most aggra- vated form without other evidences of cerebral disturbance, and in some cases cerebral exhaustion, and even more severe mental symptoms, are without doubt produced by the loss of sleep. The diagnosis of the cause of an insom- nia is to be made by exclusion. If other symptoms of cerebral disease are wanting, the condition of the heart and kidneys should be carefully examined, because latent disease of these organs occasionally has sleeplessness for its chief manifestation. When no disease of the brain or other portions of the organ- ism can be made out, the diagnosis of simple or functional insomnia must be settled upon. The treatment of insomnia requires much tact, and at best is often very unsuccessful. The foundation of it consists in the removal of the condition which is the cause of the insomnia. If the wakefulness be lithsemic, anti- gout treatment must be instituted; if it be due to a local or general neuras- thenia, this must be combated. In rare cases of active determination of blood to the head local abstrac- tion of blood may be required. More commonly insomnia seems to be connected with exhaustion ; at least it is not infrequent to find that food taken at bedtime, or when the patient wakes sleepless-in the middle of the night, has SLEEP: ITS DISORDERS A XD ACCIDENTS. 661 a very beneficial eifect. This food usually acts best when it is iiot and easily digestible. Bcjuilloii thickened with some nutritive starchy material, oyster soup, milk punch warm, liave often been found serviceable. Alcohol in the form of whiskey or brandy, taken with a little hot water, is often efficient. It may well be that in these cases the good is achieved by stimulating the stomach and drawing excitement, nervous and arterial, from the brain. Cer- tainly midnight wakefulness may sometimes be overcome by a single glass of hot water taken in the middle of the nioht. In some patients massage taken just before the time of sleep has a distinct quieting influence, whilst upon others it acts as an excitant. A procedure which I have seen act very happily in insomnia with active congestion of the brain is to allow the jxitient to sit in a bath of very hot water and have a cold douche on the head from three to five minutes. The effects of exercise vary in different individuals, and the amount ordered must be judged of by the result. In neurasthenic insomnia tire usually causes wakeful nights. In most cases of insomnia it is essential that intellectual activity and emotional excitement during the latter third of the day be avoided ; that the suj>per taken be light ; that the patient sleep by himself or herself in a well-venti- lated apartment ; and that no catfeinic drinks be used after the morning meal. The treatment of insomnia by drugs is always to be avoided as much as ])ossible. In some cases, however, these agents have to be employed, and sometimes it is possible by making a strong nightly influence for a few weeks to break up the habit of insomnia and then gradually to withdraw the remedy. Hypnotic remedies are numerous, and in long-continued insomnia it is better to periodically change them. Sul phonal has seemed to me the least harmful, though by no means the most certain of the class. It should always be given in the form of the powder about an hour before the expected time of sleep. The compressed pill of sulphonal, so much used, very fre- (piently passes through the intestines without change. Chloral still remains the most efficient remedy of the class. Chloralamide has some virtue, but is uncertain. Urethan seems to be even less active, whilst paraldehyde is so dis- agreeable and irritating to the stomach that it is only to be employed on rare occasions. Except in the case of old })eople opiates are to be avoided for fear of producing a narcotic habit. Morbid Si>eep. — INIorbid somnolence may be due to an almost infinite number of causes, including various acute diseases and poisonings. As almost all of these affections have been sufficiently descril)cd in this work, it only re- mains to say a word in regard to the so-called " Xc/(ir((n" Afrlccni Iii/piiosis, or African fileepinr/ dlfirase, an acute, very fatal fever, the most characteristic symptom of whicth is excessive somnolence. It is endemic on the west coast of Africa, but ap])ears to occur e])idemically in some (»f the West India Islands. It attacks tlie negroes especially, but has in a inunber (•(" instances d(>cimated regiments of French troops. In most cases i( comes on gradually, but it may begin brusquely. There is at first a slight frontal headache, with a sense of fifi2 FUyvTloyAL NERVOUS DISEASES. constriction in the forehead, attended by a mild fever. The vision may at this period be disordered. The gait becomes irregular, and not very infrequently there is a distinct ataxia. Even during the first hours of the headache an intense desire for sleep is manifested. This continually increases until the j)atient is overpowered by an irresistible somnolence. During the period of sleepiness the strength fails, the spirits are depressed, and there is some fever, but usually neither diarrhoea nor constipation develops, and the forces of the circulation are well maintained. The somnolence when once developed con- tinues to become more and more intense, and the patient gradually sinks into a profound coma, which may pass quietly into death : violent convulsions and sloughing bedsores are liable to develop. There are no pathognomonic post- morten lesions unless it be swelling of the glands. Omitting toxsemic somnolence, most of the cases of morbid sleep seem to be referable to one of five groups: Group 1. Sleep due to reflex irritations. Group 2. Narcolepsy, or idiopathic sleep of unknown cause. Group 3. Hysterical and epileptic sleep. Group 4. Sleep of insanity. Group 5. Somnolence connected with organic brain disease. Of the third and fifth of these groups sufficient has already been said. (For Group 4 see article on Mental Disease.) Reflex sleep is very rare, but Dr. Katerbau has recorded a case in which a seventeen-year-old Jewess, who had slept four days and nights, immediately awoke after the jiassage from the rectum of a knot containing; twentv-four round-worms, whilst Dr. Maver has related a similar case of a boy nine years old. Narcolepsy. — The cases of morbid sleep which are here grouped together under the name of narcolepsy vary in the intensity of their symptoms from drowsiness to a sleep which ends in death. It is most probable that the cause of the sleep varies, and that several distinct affections are represented in the group, and that some of the recorded cases have also been instances of hys- terical or orgam'c disease. The best that can be done at present is to separate the cases into three subgrou])s, which are not very clearly distinguishable, and indeed are probably closely connected by intermediate cases. In the first of these groups the subject passes many hours in what seems to be the ordinary slumber. In some cases the sleep comes on daily, in others at longer inter- vals. In some instances there is a perpetual drowsiness, in others the patient when awake is not sleepy. The second class of cases com])rises those in which the paroxysms of sleep come on at irregular intervals and continue for days, as in a Jewess who shortly after her marriage fell into a prolonged sleep which ever afterward recurred periodically. The average length of the sleeping period was five and a half days, the longest time that she had ever slept being seven days. The intervals of wakefulness lasted from two to twenty days, during which time she did not sleep at all or had only a very little restless slumber. A third class of cases is that in which the sleep comes on without apparent SLEEP: ITS DISORDERS AND ACCIDENTS. 663 cause, and becomes more and more profound until the patient dies. These cases as recorded seem to have been due to brain congestion, and some have yielded to very free venesection. Other cases have been instances of cerebral organic disease, but there remain cases like that reported by Dr. S. Weir Mitchell, in which death after a prolonged seemingly causeless sleep has resulted, and in which a most careful post-mortem examination has failed to detect any lesion. Accidents of Sleep. — Sense-shock, so called, occurs in hysterical M'omen and overworked men, usually whilst passing from sleep to waking. A sensa- tion like an aura rises from the feet — or, more rarely, from the hands — and passes upward to the head, where it disappears in the sense of a blow or shock or of a bursting in the head. Not rarely at the time of the explosion the patient hears a loud noise or sees a vivid flash of light or perceives a strong odor. In some cases two or even more of these sensory manifestations are present together. The paroxysm may occur during the daytime. These attacks have no serious significance, and there is no special treatment. Night Palsy consists simply of a feeling of numbness in one or more extrem- ities of the body when the sleeper awakes. The most common seat is one arm, but the symptom may be hemiplegic or may affect the whole body. I have seen it in hysterical women, especially after the climacteric. Dr. S. Weir Mitchell speaks of it as occurring in locomotor ataxia. It is certainly not indicative of failure of the circulation, and seems indeed to have no especial significance. Somnambu/lsm. — Somnambulism is defined by Dr. H. Barth' to be a dream with exaltation of the memory and of the automatic activity of the nerve- centres, combined with absence of consciousness and spontaneous will. It is common for a sleeper to give evidence of his thoughts by movements and mut- tered words : a step beyond tliis and the dreamer acts. Every grade between the slightest dream-movement and the most active sleep-walking exists ; but whenever a dreamer rises from his couch he mav be said to be a somnam- bulist. If the somnambulist be ajjproached, his eyes will be found to be closed, or, if open, they, with the rest of the face, are impassive and without expression, paying no attention to the brightest lights, and appearing to have no ])ower of sight in them ; yet obstacles are avoided, narrow places passed through, feats of balancing performed, and numerous complicated movements made so per- fectly that the bystander can hardly persuade himself that the sleej^er is not awake. When seized hold of, the somnambulist usually resists with vigor. Left to himself, after wandering for a greater or less length of time he returns to his bed, covers himself up, and sinks into the quiet ibrgetfulness of noruuil sleejx In the milder forms of soinuambulisin it is sometimes possible to turn the thoughts of the sleeper by speaking to hiui, and in obedience to a firm com- mand he will return to his bed without waking. Acts the most dillicult and ' Du Sommcil non-nalurel, Paris, 1880. \ 664 FUXCTIOXAL NERVOUS DISEASES. complicated are often pertbrined by the somnambulist, and even murder has been done in obedience to the impulse of the dream. The so-called night-terrors of childhood, although frequently spoken of as a distinct affection, are, in truth, only a form of somnambulism, or, in rare cases, epileptoid seizures. Nothing is more common than for a young child to go in the night to its parent's bed, trembling with terror or weeping bitterly, with the statement that it has had a bad dream. Such a dream may be so vivid as completely to enchain the attention, and if at the same time there be outward manifestations of the overpowering emotions from which the child is suffering, a paroxysm of night-terror results. Very frequently during the paroxysm the child shows terror of some one object — a cat, a dog, a white ele- phant, a monster of some kind, is indicated by its incoherent cries. In a large majority of cases night-terrors are of no more serious import than an attack of somnambulism. They often depend upon gastric irritation or too much emotional excitement during the day. In a few recorded eases the cause of the attacks has been intestinal wornis. Those rare night-terrors which are due to serious disease can only be distinguished by their tendency to continually recur and by their concomitant symptoms. I have seen one or two cases of night-terrors occurring in adults which by their frequency and severity absolutely destroyed the usefulness of life, and were not removed by any of the innumerable treatments instituted by various physicians. It is stated that the habit of somnambulism can sometimes be broken up by sutldenly awaking the patient with a shock. The ircneral treatment must be that of neurasthenia and hysteria. In the case of night-terrors of children special care should be taken to remove intes- tinal worms, glandular swellings, or any other possible source of local irrita- tion. The use of stimulating foods and of caffeinic drinks must be avoided, and only light suppers should be allowed. Correlated Disorders op Memory and Consciousness. All functional acts are accompanied by, or dependent u[)on, a nutritive dis- turbance. It matters not whether the functional act be connected with thought, consciousness, or secretion, the generation of nerve- force by the ganglionic cell and its transmission by nerve-fibre are accompanied by nutritive changes in these bodies. A nutritve act, although temporary, has a distinct tendency to impress permanently the part implicated; and this tendency is especially pronounced in nervous tissue. All nervous tissue is, therefore, liable to be permanently affected by its own functional actions. This, it must be remem- bered, applies e([ually to normal and to pathological activities. Thus, the child in learning to walk by repeated efforts trains the lower nerve-centres until, in response to ai)propriate stimuli, a definite series of nervous discharges and transmissions occur independently of the will, and walking becomes automatic. This, in short, is the history ol' all training, mental and physical. All nerv- ous tissues therefore, have memory — l. e. the faculty of being permanently DISORDERS OF MEMORY AXD CONSCIOUSNESS. 6G5 impressed by temporarily actiiiij; .stimuli, the tliino- remembered being, in fact, the funetional excitement. The recognition of the universality of memory in nerve-tissues is of great importance in the consideration and treatment of disease. Thus, an epileptic fit is produced by a peripheral irritation. If that peripheral irritation be at once removed, the fit does not recur and the patient is cured. If, however, the irritation be not soon taken away, but produces a series of convulsions, the fits may continue after the removal of the irritation, simply because of the permanent impress which has been made upon those cells in the brain-cortex, whose discharge of nerve-force is the immediate cause of the epileptic parox- vsm. The nutrition of the cells has been so altered that at irregular intervals they fill up and discharge nerve-force. Owing to this power of memory a physical habit may become so perma- nently engrafted uj^on the nervous system that the jiatient is unable to control it. An example of this is seen in the so-called habit choreas : movements at first controllable, mere bad habits, become at last fixed, not to be altered by any power. The hysterical woman who gives way to hysterical nervous impulses thereby strengthens their hold upon the system, so that in time she may lose all power of control over the lower nerve-centres. Moral habits are formed in obedience to the same law. Self-control, enforced at first by dis- cipline, may become at last in the child an integral function of the nervous centre by a method parallel to that by which an accidental epilepsy is converted into a permanent disease. In the prognosis and treatment of disease, as well as in the training of the young, the full recognition of the power of habit — /. e. of unconscious memory — is a matter of vital importance. What is true of the lower nerve-centres and fibres is true of the upper ones. Intellectual acts or thoughts and perceptions tend to stamp themselves upon the centres connected with them, and when the function of the nerve-cell is connected with conscioiisness the changes which occur in the nutrition give oriirin to conscious memory — /. e. to memorv in the usual sense of the term. The methods of ordinary mental action seem to indicate either that special ganglionic cells are set apart for special forms of memory, or else that the sintrle l' receiving impressions, but not that of recognizing impressions which were made long before. The sepai-atiou of different forms of memory is, however, distinct from this. Thus in a case 666 FUNCTIONAL NERVOUS DISEASES. of dementia recently under my care memory for ordinary events was almost entirely lost, and yet a joke or a ludicrous story would be remembered in all its details without ajiparent effort. It is well established that one form of memory — namely, that connected with language — has in most individuals a definite brain-location ; and it may be that each variety of memory has its own territory. In considering the disorders of memory I shall omit the discussion of dis- turbances of specialized forms of memory, because the most important of these, aphasia, will be elsewhere fully elucidated by Professor Osier. (See page 701.) Failure of Memory is a frequent symptom, which, when not due to obvious acute disease, is a strong indication of an organic affection of the brain, although a slight degree of it may be produced by simple brain- exhaustion. In some cases careful examination is needed to detect it. Under such circumstances the physician must question the patient as to the small events of the last twenty-four hours, and not be misled by that vividness of recollection of the long past which sometimes causes the sufferer to declare that his memory is even stronger than normal. It is evident that what is first lost is not the power of recalling impressions already made, but of receiving or taking new impressions. Old impressions come readily into the scope of consciousness, but passing events leave no stamp upon the brain-cells. In doubtful cases of general paralysis of the insane failure of memory is of special value in enabling us to distinguish the organic insanity from functional mental disturbances which may simulate it. According to my own experience, failure of memory which is not accompanied by paralysis for the time being of all the functions of the mind, as in insanity, is of serious import in propor- tion to its completeness. True Exaltation of Memory — i. e. exaggeration of the power of receiving new impressions or acquiring new facts — is a rare phenomenon, which nuist be sharply distinguished from the peculiar exaggeration of recol- lection spoken of in the next paragraph. It is sometimes present in the insomnia due to exaltation of the cerebral cortex, Avhen it is an extremely alarming symptom. Cases are also on record in which it has preceded an attack of apoplexy or even of general paralysis. As has already been stated, a memory is possessed by all varieties of gan- glionic nerve-cells, but that intellectual function to which the name is usually restricted is so closely related with consciousness that we can scarcely conceive of its existence without consciousness ; nevertheless, the connection of memory with dreaming shows that it is a separate function from consciousness. There are a good many reasons for beliving that the impressions of all events with which an individual has been connected are indelibly recorded upon his brain-tissue, although he may not be able to bring such impressions into conscious perception. At the approach of death or under the stimulation of disease at a time when consciousness is wanting persons will frequently sj)eak in foreign tongjies, recite passages of prose or poetry long since forgot- ten, or give detailed accounts of events that occurred in their earliest child- DISORDERS OF MEMORY AND CONSCIOUSNESS. 007 hood, and of wliicli they have in tlieir normal condition not tlie slightest remembrance. It would therefore appear that two distinct functions or acts are involved in conscious memory — one the preservation of the records, th<' other the dragging out of such records into the light of consciousness and their recognition by the personality of the man. In certain diseases when consciousness is obliterated the connection between the stored records of the cerebral cortex and the automatic speech-centres is so close that the hitter act in obedience to the records, and the unconscious patient speaks in an unknown tongue or relates occurrences of which he has no conscious mcmorv. When the link that binds consciousness to memory is broken by disease consciousness may exist without memory. Under these circumstances con- sciousness is isolated from the past, although the past may still be connected with the present by an automatic unconscious memory. This is illustrated bv the famous case of the French soldier, who, as the result of a wound in the head, was subject to attacks lasting many hours in which he had no sensitive- ness of any part, although if put in the position of marching or writing or smoking, etc. he would go through the whole complicated series of acts neces- sary for the performance of these acts, all of the time evidently unconscious of what he was doing and changing from one performance to another as he was taken hold of and put into a new position. The sense of personal identity is dependent upon the existence of memory and consciousness. The unbroken chain of events recorded from an indefinite past correlated with the consciousness of the present gives the realization of the unity of the jiresent with the past. This sense of personal identity is destroyed by a complete loss of memory, which loss may be abrupt and be unaccompanied by impairment of consciousness or of rationality. I have seen tiiis association of symptoms continue for several days after a sunstroke, so that the patient, who had been brought by ambulance into the hospital, was unable, after he had recovered his mental faculties and was perfectly rational, to give any clue to his personality which could lead to his identification. Double Personality, the condition in which the subject feels as il" ho were two distinct personalities, the one alternating continually with the other, has no connection with loss of personal identity nor yet with double consciousness. Its explanation is very difficult : it is occasionally seen as the result of hash- eesh or other poisonings, and also in insanity, in which affection it may become the basis of a delusion, as in the case of a patient of my own w ho was over- whelmed by the constant doubt whethci- he was himself or his own double. Double Consciousness, so called — periodical failure of memory, or periodic amnesia — is a disorder of memory which also involves all the intellectual func- tions and the character of the individual. In a typical case there is, first, an abrupt loss of memory at the beginning of each paroxysm for everything that has liappencd during paroxysms not of the same series ; second, a diaugc in the personal character of the indiviasles or who()j)ing cough. In some cases the symptoms have followed shortly after a fidl. The child may show marked alteration in the disj)ositioii and becomes peevish, irri- table, and fretful, sleeps badly, comj)lains of headache, and foi- two or three weeks may display various manifestations of ill lieahh. Then the symptoms pointing to the disease set in, either siiddeidy with a eonvulsion or more G72 ORGANIC DISEASES OF THE BRAIN. commonly with headache, fever, and vomiting. The pain is sometimes very intense, and may cause tlie child to give short, sharp cries, the so-called " hydrocephalic cry." Nocturnal delirium is present. The vomiting is with- out apparent cause and independent of the taking of food. The fever grad- ually rises, reaching 102° or 103° F. The pulse is at first rapid; subse- quently it becomes slow. There may be twitching of the muscles or sudden startings, and the child may wake up from sleep in great terror. The pupils are usually contracted. These are the chief symptoms characterizing the early stage, or, as it is sometimes called, the stage of irritation. In the second period of the disease these irritative symptoms subside ; the bowels become constipated ; the child no longer complains of headache, but is dull and list- less, with more or less delirium ; the vomiting ceases ; the abdomen becomes retracted and boat-shaped (carinated) ; the pulse becomes slow and irregular ; sighing respiration is common ; and the pupils vary in size, being often dilated ; there may be strabismus, and in some instances optic neuritis. Gen- eral convulsions may occur; more commonly there is retraction of the head and tenderness in the nape of the neck on pressure. A blotchy erythema about the chest and abdomen may occur. The temperature ranges from 100° to 102.5° F. When the finger-nail is drawn across the skin a red line quickly appears, the so-called tache cerebrale, which has, however, no diagnostic sig- nificance. In the final period, or stage of paralysis, the child can no longer be roused, and gradually sinks into a condition of coma. Convulsions not infrequently occur, or there are spasmodic contractions of the muscles of the back and neck, or there are irregular movements in the limbs on one side. The pupils again become dilated ; the eyeballs may be rolled, so that the cor- nese are only covered in part by the upper eyelid. Optic neuritis and paral- ysis of the ocular muscles may occur, and tubercles may in some instances be seen in the choroid. The pulse becomes rapid, diarrhoea may develop, and the child sinks into a typhoid state, with low delirium, dry tongue, and involun- tary discharges of urine and faeces. The duration varies from ten days to three or four weeks. There are cases which run a rapid course, setting in with great violence and proving fatal within a week. This occurs more commonly in adults, and the convexity of the brain is often more involved. There are other instances much more chronic, in which the meningitis is limited, and the symptoms are rather those of cerebral tumor, sometimes with pronounced psychi(!al disturbance. Certain symptoms require a more special description. The temperature is usually elevated, but there are instances in which it does not rise above '100° throughout the entire disease. In other instances the daily oscillations are very great. Toward the close the temperature usually falls, and may sink as low as 93° or 94°. An ante-mortem elevation may occur, the fever rising as high as 110°. The pulse is often rapid at the onset, then becomes irregular and slow, and toward the close again becomes rapid. The respirations are often irregular and sighing, and in the second and third week the Cheyne- Stokes type may be very marked. The ocular symptoms are important. Nar- SIMPLE MEXIXGITIS. 073 rowing of the pupils is the rule in the early stage. Toward the ch«e they are dilated and irregular. Conjugate deviation of the eyes sometimes occurs. Paralysis of the third nerve is common. Optic neuritis is rarely intense, and is not a very common symptom. Tubercles in the choroid are rare, and are less frequently seen during life than in the post-mortem room. I^itten found them in 39 of 52 necropsies in tuberculous meningitis. Of 26 cases examined clinically by Garlick they were present in only 1, and Pleinzel examined 41 cases with negative results. Of motor symptoms the convul- sions have already been mentioned. Tremor and athetoid movements are occasionally seen ; more rarely there is a tonic contraction of one limb. Hem- iplegia may follow involvement of the cortical branches of the middle cerebral artery or is due to softening of the internal capsule. Mono})legias are not uncommon, particularly of the face, which may occur with aphasia. Brachial monoplegia may exist \\\i\\ it. In the more chronic cases, in which the symptoms persist for months, there may be characteristic Jacksonian epilepsy. The prognosis is, as a rule, very grave. It is doubtful whether recovery ever occurs. (2) Simple Meningitis. In contrast to the tuberculous form the exudation is more apt to be u])ou the cortex, and is less lymplioid and more purulent in character. A primary meningitis of this description occurs as a manifestation of the poison of cerebro- spinal meningitis, sporadic cases of which occur from time to time in certain localities in this country, and present great difficulties in diagnosis. The dis- ease is almost always secondary and is met with — (1) In the acute infectious diseases, such as small-jwx, tyj)h(»id fever, rheu- matic fever, scarlet fever, measles, and ])neuraonia. In erysipelas, iuHamma- tion of the meninges may arise either by direct extension, which is rare, or by infection throup-h the blood. Pneumonia is the only acute disease which is frequentlv followed by meningitis. In 100 autopsies in this disease at the Montreal General Hospital meningitis was present in 8 cases, and I saw sev- eral charcteristic examples at the Philadelphia Hosjjital. Acute meningitis is not uncommon in sei)tic processes. In ulcerative endocarditis its frequency may be gathered from my statistics — 29 examples in 209 cases. It is very rare in typhoid fever. No case occurred in my 64 autopsies, and it was pres- ent in only 1 1 of the 2000 Munich sections. (2) Injury and disease of the cranial bones are very common causes, par- ticularly caries of the ])etrous portion of the temporal bone. Here the disease pa.s.ses through the thin wall of the tympanum or extends from tiie mastoid cells, and is, in a majority of instances, associated with throml)osis of the dural sinuses, a condition which will be considered later. Extension from di.s- ca.se of the nose is very rare. The majority of instances of injury exciting meningitis cause fracture, though the possibility of its following trauma alone without an open wound must be acknowledged. (3) Certain constitutional condition.s, such as gout and Jiright's disease, are Vol. I.— 4.3 674 ORGANIC DISEASES OF THE BRAIN. occasionally complicated with raeningiti.s. In gout it is extremely rare. In Bright's disease cases occasionally occur, and are usually mistaken for uraemic poisoning. They are sometimes associated with inflammation of the pericardium and of the pleura. The exudation may be chiefly basilar. (4) Among doubtful causes which are mentioned are sunstroke and exces- sive study. Syphilis rarely induces acute meningitis. Occasionally the dis- ease extends from abscess of the brain. Morbid Anatomy. — The lesions are practically identical with those described in cerebro-spinal fever. The exudate is usually purulent and as a rule cortical, particularly in the cases following the specific fevers. In the meningitis of Bright's disease and of cachectic states the basilar meninges may be chiefly involved. In the form secondary to pneumonia the exudate may 'be extremely abundant, completely covering the convolutions. In the simple forms of meningitis the ventricles rarely present the distension and softening of the walls so frequent in the tubercidous variety. In many instances the condition is a meningo-encephalitis, and the cortical portions of the brain are infiltrated, cedematous, and sometimes present small abscesses. The spinal meninges are often affected. Symptoms. — Many of the cases present a clinical history similar to that already described in the tuberculous form. The secondary affection occurring in the specific fevers is very difficult to recognize, as almost identical symp- toms may be caused by the poisons of the fevers without the existence of positive inflammation. For example, in cases of so-called cerebral pneumonia in which, from the outset, brain symptoms are marked (the preliminary excite- ment, headache, delirium, and then gradual depression, sinking into stupor and coma), unless the basilar meninges are involved, causing local palsies of the nerves — which is not usual — there is no single feature which may not be present as a result of extreme congestion. So also in typhoid fever, the cere- bro-spinal manifestations may lead to a positive diagnosis of meningeal inflam- mation, and the twitchings, spasms, retraction of the neck, and the gradually deepening coma very frequently lead to error in diagnosis. It was from a consideration of these cases that Stokes remarked, *' There is no single nervous symptom which may not and does not occur independently of any appreciable lesion of the brain, nerves, or spinal cord." The onset is more apt to be sudden than in the tuberculous form. Occa- sionally the disease sets in with a chill. Headacheof a severe, continuous cha- racter is the most common symptom. In the fevers, however, the patient may make no complaint. Delirium is early, and often bears some ratio to the height of the fever. Sometimes the patient is maniacal. Convulsions are much less common in simple than in tuberculous meningitis. Rigidity, spasm, and twitching of the muscles are frequent symptoms. Stiffness and contrac- tion of the muscles of the neck are common when the inflammation extends to the meninges of the cervical cord. Vomiting occurs in the early stages. Con- stipation is usually present. Important symptoms are due to involvement of the cranial nerves; thus, optic neuritis may develop, but it is not common in LEPTOMENINGITIS INFANTUM. 675 the meningitis of the cortex. IMucli more frequently the third nerves are involved, causing strabismus and ptosis. The facial nerve may be attacked, causing paresis of the face on one side, and a lesion of the fifth may be followed by disturbances of sensation ; and in one of my cases, in which the Gasserian ganglion was infiltrated with pus, the cornea ulcerated. Tiie pupils vary : they may first be contracted or unequal ; later they become dilated and react very slowly to light. The pulse is rapid, sometimes irregular, and in cases in which there is much exudation and compression of the brain it may be slow. The temperature range varies, and in tiie forms following pneumonia may be very high. In other instances, as in the form secondary to otitis media, the variations are greater. In non-tuberculous meningitis in children and in the disease occurring in cachectic individuals the fever may be very slight. From what has been already said it is evident that the diagnosis of puru- lent meningitis is extremely uncertain. It may be stated, indeed, that unless the nerves at the base are involved, causing paresis of the ocular or other muscles, and optic neuritis, there are no positive criteria by which the disease can be distinguished from the so-called cerebral form of the specific fevers. It has been a common experience of every pathologist to have cases sent down from the w'ards with the explicit diagnosis of meningitis, cerebral or cerebro- spinal, when the section showed typhoid lesions or a local patch of pneumonia. In typhoid fever w^e may be in doubt for days until the abdominal symptoms become plainly manifest. The cases secondary to bone disease, to otitis media, and those occurring in pysemic processes are less likely to escape recognition. (3) Leptomeningitis Infantum. While a majority of the cases of meningitis in children are tuberculous, there is a form affecting infants under two years of age which has very striking anatomical and clinical peculiarities. The disease may ajipcar shortly after birth, and is particularly prone to affect debilitated, cachectic children. Occa- sionally it follows traumatism, and sometimes is associated with the specific fevers. Anatomically, the inflammation is confined chiefly to the base and to the posterior part, particularly about the cerebellum ; hence it has been termed posterior meningitis, or, from the fact that the foramen of Magendie is closed, leading to an acute, often purulent hydrocephalus, the condition has been termed occlusive meningitis. The exudation may be very abundant at the base, infiltrating the membranes and covering the nerves with a thick, purulent exiidate. In many instances the most striking features arc in the ventricles. The posterior and descending cornua of the lateral ventricles may be enor- mously distended with a greenish, ])uridcnt fluid, and the ependyma thickened and infiltrated. The choroid plexuses and the velum may be covered with a thick grayish-white exudate, and the ependyma of the third ventricle may be similarly involved. In some cases the aqueduct of Sylvius and (he finirth ventricle are greatly enlarged, and the ependyma thickened and infiltrated with a grayish pus. In one instance which I saw the basilar meninges were but 676 ORGANIC DISEASES OF THE BBAIN. slightly involved, while there was a condition of purulent ependyniitis in the posterior part of the lateral ventricles and in the fourth ventricle. Fever, vomiting, convulsions, and rigidity are present in this as in other forms. The most striking feature is the holding back of the head — cervical opisthotonos — which may be the only important manifestation. Under this title the affection has been described by Gee and Barlow.' The child may remain for weeks in a condition of extreme weakness, with slight irregular fever, without convulsions or rigidity, but with this strong tonic contraction of the cervical muscles. In cases which have lasted for some time the head has enlarged, and a few have recovered or have terminated in chronic hy- drocephalus. Treatment of Meningitis. — Absolute quiet should be enjoined. An ice- bag may be applied to the head, and if the subject be young and full-blooded, and particularly if under these circumstances there be maniacal delirium, local or general bloodletting may be practised. Saline purges may be employed to relieve the blood-pressure. Bromides, chloral, sulphonal, or morphine may be required to procure sleep and rest. There are no remedies which influence in any way the course of an acute purulent or tuberculous meningitis. Mer- curials are recommended for the purpose, and iodoform inunctions hav^e been used on the scalp in tuberculous cases, but they are of very doubtful efficacy. If counter-irritation be thought necessary, the thermo-cautery lightly applied is the most satisfactory means to employ. In traumatic cases and in disease of the ear the surgeon should be early in attendance, and if symptoms occur which justify interference trephining should be performed. Chronic Leptomeningitis. This usually results from the growth of tubercles or gummata in limited regions of the meninges. It sometimes follows trauma. The symptoms are very variable, depending upon the situation of the disease, and in some cases are identical with those of tumor. When in the motor region there may be Jacksonian epilepsy. The leptomeningitis infan- tum may really be a chronic meningitis. Some of the cases reported by Gee and Barlow lasted for more than a year. n. AFFECTIONS OF THE BLOOD-VESSELS. Hyperemia (Cerebral Congestion). About no question in cerebral pathology is there more obscurity than in relation to hypersemia and anaemia, particularly their symptomatology. Any one wlio reads the report of the discussion which took place recently at the ' St. Bartholomew's Hospital Reports, 1878. CEREBRAL ANuEMIA. 677 New York Neurological Society upon the subject of congestion of the bruin will be convinced that the extraordinary lack of unanimity can only be cor- related with a corresponding absence of all positive and satisfactory know- ledge of these conditions. Unquestionably, variations occur in the amount of blood in the cerebral vessels, but how far such changes are associated with a definite group of symptoms is not at all certain. The hypertemia is usually described as either active or passive. Active hyperemia is stated to follow chilling of the surfiice, sudden sup- pression of some customary discharge, excessive brain-work, and sunstroke. Alcohol and amyl nitrite also cause acute hypersemia of the cerebral vessels. Passive hypersemia follows obstruction in the cerebral sinuses and veins, engorgement in the lesser circulation, as in mitral stenosis and emphysema, pressure on tiie superior vena cava by tumors, and from prolonged straining efforts. The anatomical changes in congestion of the brain are not at all striking. The organ looks full and the dura is tightly stretched. The sinuses and the cortical veins are full, and often the gray matter has a rosy tint, and on sec- tion it is seen that the smaller vessels are distended. Active hyperaemia does not persist after death, as is well seen in the disappearance of the areola of congestion about a pustule on the skin. The most intense engorgement of the vessels is met with in death during the early stages of the specific fevers and in the cases due to venous obstruction. There are no characteristic or constant symptoms of cerebral hypertemia. In the passive form it may exist in the most extreme grade and without the slightest disturbance of function. In other instances, as in pressure on the superior cava, there may be tor{)or, but rarely couia. The headache and delir- ium of the early stao-e and of fevers are often attributed to congestion of the brain, but it is more likely they are due to the agents which excite the pyrexia. The dizziness, throbbing, and unpleasant sensations described in aortic iusuf- ficiency and in hypertrophy of the heart may be due to the sudden overfilling of the cerebral vessels during systole. As a definite (clinical affection congestion of the brain is very rare. Per- sonally I have no knowledge of the cases described by some authors setting in with fever, delirium, and insomnia ; still less of the apoplectiform, convulsive, and comatose forms. Perhaps the most definite cases are those met with in persons of a full habit, who are subject at times to headache, flushing of the face, throbbing of the carotids — symptoms which may be relieved promptly by an attack of epistaxis or whicli yield to a brisk mercurial jmrge. Cerebral Anemia. The anjcmia may be confined to locnl areas in the brain, as in narrowing of vessels by endarteritis or occlusion l)y emboli. It may be limited to the brain itself, as in cases of ligature of both carotids, or in dimitiished blood- supj)Iy, as in extreme aortic stenosis, or it may follow the sudden dilatation of a vascular territory, as in rapid distension of the intestinal vessels. The cere- 678 ORGANIC DISEASES OF THE BRAIN. bral anemia may be part of a general bloodlessness due to haemorrhage or is part of an anaemia, primary or secondary. The brain in anaemia is pale ; only the large veins are full ; the small ves- sels over the dura are empty and the membranes are moist ; and tliere is an unusual amount of cerebro-spinal fluid. On section the gray and white mat- ter looks very pale, and the cut surfaces moist and show very few puncta vasculosa. The consequence of cerebral anaemia when suddenly produced is well seen in a fainting fit, in which loss of consciousness follows tlie sudden sinking of the arterial pressure in the cerebral vessels. When it results from haeraor- rhao-e the patient complains of drowsiness, giddiness, a feeling of faintness, flashes of light, and noises in the ear ; the respiration becomes hurried ; the skin is cool and covered with sweat ; and gradually, if the haemorrhage con- tinue, consciousness is lost and death occurs with convulsions. In the more chronic forms of brain anaemia the patient may be subject to fainting s[)ells, and in some instances headache and rambling delirium. In the anaemia of wasting disease or of starvation there is gradually induced a condition of irritable weakness, in which all mental effort is difficult and the slightest irri- tation is followed by undue excitement. The patient complains of giddiness, noises in the ear, and there is finally developed the delirium of inanition, characterized by marked hallucinations. An interesting group of symptoms is met with in the prolonged malnu- trition of young children, associated usually with diarrhoea. The pupils may be narrow or unequal ; the head is thrown back and the child is in a semi- comatose state, but with the eyes open ; convulsions may occur and the fon- tanelles ar^ usually depressed. The body is usually cool, the pulse feeble and raj)id, and the respirations normal. It was to this condition that Marshall Hall applied the term "spurious hydrocephalus," and it is also spoken of as the hydrocephaloid (hydrencephaloid) condition. The cases are not infre- quently mistaken for tuberculous meningitis. The treatment of cerebral anaemia is that of the conditions with which it is associated. The suddenly-developed form leads to syncope or fainting, for which, as a rule, the recumbent posture, the dashing of cold water upon the face, superficial friction, and the inhalations of ammonia suffice to restore con- sciousness. If the syncope persist, a tight bandage can be applied round the legs or the abdominal aorta compressed in order to take advantage of the col- lateral fluxion. (Edema of the Brain. This is often only a complication of cerebral anaemia. An increase in the subarachnoid fluid is common in all atr()])hic states of the brain. In extreme passive hypersemia there may be a congestive oedema, in which the brain- substance not only contains an increased amount of blood, but is unusually moist. The most extreme oedema is met with as a local process about tumors and abscesses. A very intense infiltration, localized or general, is met with CEREBRAL HAEMORRHAGE. 679 sometimes in chronic Bright's disease, and to it Traube referred certain urteraic manifestations. When a sequence of atrophy, the fluid is chiefly within and beneath tiie membranes, and the amount of fluid in the ventricles is usually increased. In antemic states and in death from cachexia the brain-substance is pale, moist, and glistening. The symptoms are not well defined, and are chiefly those of the associated anaemia. As mentioned, Traube thought that ursemia was due to cerci)ral oetlema consequent upon the hypersemia and high arterial tension — a view which has not received general acceptance. On the other hand, of late years cases have been reported of localized convulsions and of paralysis in Bright's disease in which, after death, no lesions other than oedema have been found. Cerebral Hemorrhage. Cerebral hseraorrhage, the common cause of apoplexy, is almost invariably the result of rupture of an artery. It may be from the central vessels which pass at once into the substance of the brain, from the large branches of the circle of Willis, or from the cortical group which is distributed upon the sur- face of the convolutions. In a majority of the cases the hjemorrhage is from the central branches, particularly from those which pass in at the anterior per- forated spaces. The largest of these vessels passing to the third division of the lenticular nucleus and the hinder part of the internal capsule is so frequently, involved that it has been called by Charcot the artery of cerebral hamorrliage. The extravasation may be into the substance of the brain, into the membranes, or into the cerebral ventricles. Etiology. — The imjiortant factors are those leading to degeneration of the blood-vessels. The natural tendency to arterial degenerations as years advance makes hfemorrhage much more common after the fiftieth year. It is, how- ever, not unknown in early life, and in ciiildren may be due to rupture of an aneurism or to local degeneration. It occasionally is caused by the paroxysms of whooping cough. Cerebral apoplexy is not imknown in the foetus. As will be mentioned, the meningeal hfemorrhage is a very frequent and imjK)rt- ant event in protracted labor, but hemorrhage into the substance of the brain may itself cause death in the foetus. Men are more fre(juently attacked than women — an association doubtless due to the greater liability in the former to arterial disease. Heredity is believed to play an important part, and the ai)0])lectic build or habitus is still spoken of, by which is meant a stout, plethoric frame witli a short neck and a congested condition of the superficial vessels. The influence appears to be exerted through the arteries, as (here arc families in which they degenerate early, usually in association with renal changes. The three special factors in inducing artcrio-sclerosis — namely, the abuse of alcohol, syphilis, and prolonged muscular cxcrlion — arc important antecedents in a largo number of cases of cerebral luemorrhage. In adult's hypertrophy of tlie left ventricle and sclerosis of (lie kidneys are almost con-, stant concomitants of hemorrhage into the brain. The endocarditis following". 680 ORGANIC DISEASES OF THE BRAIN. rlieumatism and i)ther fevers may indirectly lead to apoplexy. The cases are not verv infrequent in young persons. Emboli are carried oif from the valves and lead to softening or weakening and subsequent aneurismal dilatation of a cerebral vessel, and haemorrhage may follow rupture of the aneurism. Haemorrhage occurs sometimes during the course of the specific fevers; more common still are the cases due to profound alteration in the blood, as in anaemia and lenkgemia. Occasionally, too, cerebral haemorrhage occurs in pur- })ura haemorrhagica and in scurvy. The exciting causes are not often evident. The attack may be sudden, with- out any preliminary symptoms. In many cases the rupture occurs during vio- lent muscular efforts, such as straining at stool, vomiting, or coughing, or in very excited action of the heart during emotion. Morbid Anatomy. — Lesions are found in the cerebral arteries and com- prise the following changes : (1) A diffuse periarteritis of slow development, which causes weakening of the coats and the formation of small miliary aneurisms. These are present in the great majority of all cases of haemorrhage in adults, and are almost invariably found if carefully sought for. They occur most frequently on the central arteries, but also on the smaller branches of the cortical vessels. They are often to be seen on section of the brain-substance as small dark bodies from 1 to 3 millimetres in diameter. They may be present in numbers upon the arteries withdrawn from the anterior perforated space. Charcot and Bouchard, who first accurately described them, state that they are most fre- quent in the central ganglia. (2) Larger aneurisms on the branches of the circle of Willis, which are by no means uncommon, and will be considered in a separate section. (3) Endarteritis and periarteritis usually lead to haemorrhage by the forma- tion of aneurisms, either miliary or coarse. There are cases, however, in which careful examination fails to show anything but a diffuse degeneration of the smaller vessels, and doubtless haemorrhage may occur without the previous formation of aneurism. Finally, there are instances of cerebral haemorrhage in which macroscop- ically and microscopically the changes in the arteries seem insignificant. The bleeding may be into the meninges, into the cerebral substance, or into the ventricles. Meningeal haemorrhage may be outside the dura, or more fre- quently subdural, and often between the arachnoid and the pia mater. In fracture of the skull causing laceration of the meningeal vessels the blood is usually outside the dura or between it and the arachnoid. In rupture of aneurisms of the larger cerebral vessels the haemorrhage is usually meningeal and very extensive, and may extend high up on the cortex and on to the cord. Owing to the more frequent presence of aneurism in the middle cerebral ves- sels, the Sylvian fissures are often found distended with blood. Intracerebral haemorrhage may burst into the meninges. The meningeal haemorrhage of infants resulting from injury during labor will be subsequently discussed under the section upon the Cerebral Palsies of Children. More or less ex- I CEREBRAL H^EMOERHAGE. 681 tensive effusion may be found in the meninges in fevers, and oceasionally in constitutional diseases. Intracerebral Hiemorrhage. — The most common form is extravasation in the region of the strio-lenticular arter}', about the outer section of the len- ticular nucleus. If small in extent, it may be limited to the lenticular body and the internal capsule. In other instances it extends outward to the insula or upward into the centrum ovale or inward to the lateral ventricle. Haemor- rhage into the centrum ovale is not nearly so common, and still less frequent are localized extravasations into the pons, medulla, or cerebellum. The haem- orrhage breaks tiie tissues, and the clots occupy an irregular cavity and are mixed with brain-substance. The walls are at first irregular and composed of blood-staint^d and softened cerebral matter. Ventricular Hccmorrhage. — Primary bleeding into the ventricles is rare. The blood in almost all instances comes from rupture of an extravasation into the ventricle. It is not very infrequent in early life, and may occur during birth. Of 94 cases collected by Edward Sanders, 7 occurred during the first year and 14 under the twentieth year. It occasionally occurs dur- ing parturition and in the puerperal state. There is in the jNIcGill Uni- versitv Museum a remarkable instance of this in which both lateral ven- tricles, the third, the aqueduct of Sylvius, and the fourth ventricle are enor- mously distended with clots which formed a complete mould in blood of the ventricrlar system. The blood may be found in one ventricle only ; more commonly it reaches the other ventricle, either bursting through »tiie septum or finding its way through the foramen of Monro. In all instances where the extravasation is at all large the liemisphore on the side involved looks fuller and larger, and the convolutions are fiattened, and the dura on the affected side is unusually tense. In time the blood-clot undero-oes chano-es. The hsemog-lobin is converted into reddish-brown lucma- toidin and pigment-granules. The rapidity with which these changes proceed varies: as a ride, in cases which prove fatal within a month brownish-yellow remnants of the clot are found with disintegrated brain-tissue, molecular (lehria, and compound granular corpuscles. A limited irritative inflamma- tion occurs about the clot, and, if large, a definite wall is formed, enclosing a cyst with fluid contents. In smaller clots a pigmented scar is left. In men- ingeal hsemorrhage the effused blood may be gradually absorbed, leaving only a brownish stain. In this form of hsemorrhage in infants, when the extrav- a.-ation is abundant, wasting of certain of the convolutions may take place, and sometimes cvsts form in the meninges. It is possible that certain of the cases of porencephaly are produced in this way. >Secon(lan/ Defjeneration. — After a lesion of the motor centres or of the j)yramidal tract secondary degeneration occurs in the motor |»ath. Thus in a case of hemiplegia, caused, as is often the case, by a ha'ini.rrhage in the neigh- borhood of the internal capsule, a descending degencnitiou is seen in the cms, in the anterior part of the pons, in tlie pyramldiil lil>i-es of the medidla on the same .side, in the direct fibres of the cord on the same side (coliunn of Turek), 682 ORGANIC DISEASES OF THE BRAIN. and in the crossed pyramidal fibres of the opposite side of the cord. In per- manent cortical lesions the secondary degeneration may be traced through the fibres of the corona radiata and into the internal capsule, and through the course of the pyramidal fibres just mentioned. Symptoms. — These may be divided into the primary, or those connected with the onset of the attack, and the secondary, or late, symptoms, which develop after the early manifestations have passed away. Premonitory indications are not common. There may be for some days or even for weeks headache, feelings of numbness and tingling, or even pains in the limbs. Still more rarely there are irregular choreiform move- ments of the muscles on one side, the so-called prehemiplegic chorea. As a rule, the patient is seized while in ordinary health about the performance of some every-day action, occasionally such as requires exertion or strain. When the haemorrhage causes sudden and complete loss of consciousness, with relaxation of the limbs, it is known as apoplexy or an apoplectic stroke. In other cases the onset is more gradual, and the loss of conscious- ness does not occur for a few minutes after the patient has fallen or after the paralysis of the limbs is manifest. In an apoplectic attack the patient is seized with giddiness or feelings of faintness, sometimes is sick at the stomach, or has a slight convulsion. In rare instances of large extravasations the patient dies in a few minutes, but instant death is rare in cerebral haemorrhage. There is deep unconsciousness from which the patient cannot be aroused. The face is injected, eometimes cyanotic or of an ashen-gray hue. The skin is usually moist with perspiration. The pupils vary in size, but as a rule are dilated and inactive. They may, however, be strongly contracted. The respirations are slow, noisy, and accompanied with stertor, which, as Bowles, has shown, is only marked when the patient is on the back, and is owing to the falling of the tongue to the hinder part of the mouth. The Cheyne-Stokes rhythm may be present. The pulse is usually full, slow, increased in tension, and sometimes irregular and small. The tempera- ture may be normal, but very often falls within an hour after the onset, and may even sink below 95° F. An exception to this is found in h:«morrliage into the pons or medulla, in which within an hour of the onset the tem- perature may reach 104° or 105° F. The urine and faeces are usually passed involuntarily. Albumin and sugar may be found in the urine very shortly after an attack. Convulsions are not common in an apoplectic seizure due to haemorrhay;e. It may at first be difficult to decide whether the condition is apoplexy asso- ciated with hemiplegia, or whether the coma is due to other causes, such as uraemia or opium-poisoning. An indication of the hemiplegia may often be discovered, even in deep coma, by a difference in the tonus of the muscles of the two sides. If tlie arm or the leg be lifted, it drops " dead " on the affected side, while on the other it falls more slowly. One side may present marked rigidity, and in watching the movements of the facial muscles in the stertor- ous respiration, if paralysis be present, it will be noticed that the cheek on the CEREBRAL HEMORRHAGE. 683 affected side is puffed and blown out in a more marked manner. The head and eyes may turn strongly to one side — conjugate deviation. The patient may at first not lose consciousness, but be sligiitly dazed, and in the course of a few hours there is loss of power on one side, and gradual unconsciousness, deepening into a profound coma. This is sometimes termed ingravescent apoplexy. The attack may occur during sleep and the patient be found unconscious, or he may wake and find the power lost on one side. Cere- bral haemorrhage is not necessarily accompanied by the symptoms of apoplexy ; that is, with loss of consciousness. A small hoemorrhage, particularly in the region of the central arteries, may involve the motor path, causing hemiplegia without any loss of consciousness. The subsequent course varies greatly. In the severer cases the respirations become more rapid, the pulse feeble, the skin is bathed with sweat, the color of the face becomes ashen-gray or livid, noisy rales are heard in the trachea and larger bronchi, and death may occur within twenty-four hours of the onset. In other instances the patient remains unconscious, and within forty-eight hours there is some febrile reaction and constitutional disturbance, which is associated with inflammatory changes about the haemorrhage. The patient may die in this reaction, and if consciousness has been regained there may be delirium or recurren(!e of the coma. At this period also the so-called early rigidity may develop in the paralyzed limbs, and, more important still, trophic disturbances, such as sloughing or the formation of vesicles. The most serious trojihic change is the sloughing eschar which develops about the middle of the lumbar region on the })aralyzed side, and is different from the eschar of acute myelitis, which develops in the centre of the sacral region. It may appear within forty-eight hours of the onset, and is of very grave significance. Some have regarded the congestion of the lungs so common in apoplexy, and which is sometimes unilateral, as an evidence of a trophic change. Certain symptoms of cerebral haemorrhage require more description : Hemiplegia. — If the hemiplegia involve tiie motor centres or path, loss of power occurs in the muscles of the opposite side of the body. It is known as complete hemiplegia when it involves face, arm, and leg; partial when it involves only one or other of these parts. It may follow a lesion in the motor cortex, the white fibres of the corona radiata, the internal cajjsule, the cms, or the pons. Haemorrhage is perhaps the most common cause of hemi- plegia, but it is alsi) produced by embolic and thrombotic softening and by tumors. In a majority of severe cases of haemorrhage the face, arm, and leg are involved on the opjwsite side. In other instances the leg and arm may be chiefly involved, or the face and arm. Tlie face is involved on the same side as the arm and leg. The facial muscles stand in precisely tlie same relation to the cortical centres as do those of the arm and leg. The fibres of the upper motor segment of the facial nerve cominjr from the cortex decussate just as do those of the nerves of (he limbs. The facial paralysis, however, is partial, involving oidy the lower 684 ORGANIC DISEASES OF THE BRAIN. face, sparing the orbicularis oculi and the frontalis muscles. There may be, however, slight difficulty in elevating the eyebrows and in closing the eye on the paralyzed side. The signs of the facial paralysis are usually well marked, and the mouth is drawn toward the healthy side. The tongue may be pro- truded toward the paralyzed side, owing to the unopposed action of the genio- hvodossus of the sound side. It is to be remembered, however, that the position of the tongue must be taken from the incisor teeth, not from the lips, which are drawn toward the healthy side, so that the tongue even when pro- truded straight may appear to deviate to the paralyzed side. With hemi- plegia on the right side there may be also asphasia. As a rule the arm is more completely paralyzed than the leg. The loss of power at first may be complete, and then gradually returns in the leg, still remaining in the arm. The muscles associated in symmetrical movements, such as those of the eyes and of the thorax and abdomen, usually escape. It may be noted in the deep stertorous respirations that the chest does not move so freely on the paralyzed side. Broad bent's explanation, the one most satis- factory, is thus clearly given by Frederick Taylor : " It is first to be observed that the parts that are least paralyzed or not paralyzed at all are those which rarely or never act independently of their fellows on the opposite side ; whereas the parts that are most paralyzed are much more independent, and may be capable of performing acts that the corresponding muscles on the opposite side are une(|ual to. As extreme instances may be mentioned the eyes, of which one never moves except in association with the other, their muscles not being affected. In contrast with these are the hands, of which the right may be able to do things the other cannot, and vice verm; and these parts are most affected. Dr. Broadbent's theory supposes that in the case of the muscles most commonly associated the commissural fibres between their nerve-nuclei become functionally active, so that in the event of a lesion preventing one, say a right- side nucleus, from receiving stimuli from the left brain, it may be stimulated from the right brain by impulses passing first to the left-side nucleus, and then by the commissure to the right-side nucleus. On the other hand, if in the case of the less associated muscles the commissure remains functionally inactive, such a transference would not take place, and the right-side nucleus would remain completely cut off from the cortical centres. Another view has been l)ut forward to the effect that fibres for the face, arm, leg, and trunk as they pass through the internal capsule have positions corresponding to those of the motor centres for these parts on the cortex ; and that since vessels mostly rup- ture below the internal capsule, and the pressure would most injure the fibres which were nearest, the arm Avould suffer more than the leg, and the leg than the trunk." The face and limbs may be paralyzed on opjwsite sides, forming what is known as the crossed or alternate hemiplegia. This occurs when the hsemor- rhage is in the lower segment of the pons Varolii, involving the facial nerve in its way through the pons after it has left its nucleus ; whereas the motor fibres of the arm and leg which are involved in the lesion arc above their CEREBRAL HAEMORRHAGE. 685 decussation in the medulla, so that the paralysis occurs in the face on the same side as the lesion, and in the arm and leg on the opposite side. Hemiancesthesia is rare in hemiplegia. Slight numbness or tingling may be present, or there is loss of sensation after a day or two, which gradually j)asses off. According to Dana's study, the anaesthesia of organic cortical lesions was generally incomplete and more pronounced in certain parts than in others ; total anesthesia was either functional or due to subcortical lesions. Sensory disturbances are more common in softening than in haemorrhage. Disturbance of the special senses is not common. There may be diminution in the acnteness of hearing, taste, and smell. The eye-symptoms in hemiplegia are important. Hemianopia may occur with haemorrhage in the occipital lobe or in the fibres of the optic radiation. It is, however, not common in ordinary hemiplegia. The most important ocular symptom is — ConjiKjate Deviation. — The head and eyes, as a rule, are turned away from the affected side; thus in a right hemiplegia the eyes and head are turned to the left side ; that is to say, the eyes look toward the cerebral h^sion. AVhen spasms or convulsions develop, or if the state of early rigidity supervenes, the liead and eyes may deviate in the opposite direction ; that is to say, the patient looks away from the lesion and toward the convulsed side. This symptom occurs in lesions in different localities of the brain, particularly with cortical lesions. It is also met with in lesions of the internal caj)sule, and in those of the pons or in the latter situations it has been found that the deviation is just the reverse of that which occurs in other cases, as in paralysis the patient looks away from the lesion and in spasm or convulsion looks toward it. As a rule, there is no wasting of the paralyzed limbs, and the muscles react well to both the faradic and the galvanic currents. The deep reflexes are increased on the paralyzed side ; the superficial reflexes, plantar and cremas- teric, are often diminished or absent. The sphincters are not often involved in hemiplegia. The course of the disease depends upon the situation and extent of the lesion. If slight, the paralysis may disappear completely in a few days or in a few weeks. In severer cases partial recovery gradually takes place, asso- ciated with which are the changes Avhich may be grouped as Secondarij >Sympfom.s. — These correspond to the chronic stage, which follows in some weeks or months after the initial lesion. The paralyzed limbs undergo certain changes. The leg, as a rule, recovers suflicient i>()wer to enable the patient to walk about, "init with a characteristic hemiplegic gait. The loss of jiower is most marked in the muscles of the foot, so that to prevent the toes from dragging the knee is much flexed and the foot swung round in a half circle. In both arm and leg the condition known as secondary contraction or late rigidity supervenes; the arm is flexed at llic elbow and resists all attempts at extension; the wrist is flexed ui)on the Ibrearm .-iikI the fingers upon the hand. The position assumed by the arm and hand is very character- istic. Frequently as this contraction develops there is nuicli pain. In the 686 OliGANIC DISEASE^S OF THE BRAIN. leff the contractures are not so extreme. Unlike the contractures of hysteria, the secondary contracture of hemiplegia is not relaxed under chloroform, and is an incurable condition, associated with a descending degeneration of the motor tract. Occasionally after hemiplegia secondary contracture does not occur, but the arm remains more or less flaccid, the leg having regained partial power. This condition is met with most frequently in the hemiplegia of chil- dren. The reflexes are greatly increased on the paralyzed side. Atrophy of the muscles is not a marked feature in hemiplegia, but develops in certain instances, due possibly to secondary alterations in the gray matter of the ante- rior horns. It may, however, follow as a direct result of the cerebral lesion, and from this cause is not very infrequent in the cerebral palsies of children. Other secondary changes in hemiplegia are post-hemiplegic disorders of movement, either tremor, choreiform movements, or the mobile spasm known as athetosis. These will be more fully considered in the hemiplegia of chil- dren, with which they are most commonly associated. Arthropathies may develop early in hemiplegia, but more commonly develop late, and are most frequent in the joints of the arm. They take the form usually of a synovitis, with swelling, redness, and pain. Diagnosis. — This may be extremely difficult if the patient be seen for the first time in a condition of deep coma, as this may be due to alcohol or opium or to ursemic poisoning. The first thing to be determined, if possible, is the existence of hemiplegia. Even in very deep coma the limbs on the paralyzed side are, as a rule, very flaccid, and drop instantly when lifted, whereas on the other side the muscles retain some tonus. Conjugate deviation of the head and eyes, rigidity on one side, or spasm on one side are suggestive of a hemi- plegic lesion. In a majority of these cases it is practically impossible to say at first whether the lesion be due to haemorrhage, to embolism, or to thrombo- sis. Stiff" arteries, an hypertrophied left ventricle, and a sudden onset, with complete loss of consciousness, are decidedly in favor of haemorrhage or of embolism, while a more gradual onset in a man with degenerated vessels is more commonly due to thrombosis. The most puzzling cases are those in which large haemorrhage occurs into the ventricles or into the pons, producing sudden loss of consciousness and com[)lete relaxation. The previous history and the mode of onset may give valuable information. In epilepsy the con- vulsions have preceded the coma and there have been previous attacks. In alcoholism the odor of the breath, the history of drinking, and the more gradual onset are points to be considered. In opium-poisoning the coma develops slowly and the pupils are strongly contracted. In ventricular haem- orrhage sudden and rapidly deepening coma occurs. There may be no hemi- plegia, but the muscles on both sides are equally relaxed, sometimes with a l)reliminary rigidity or with convulsions. These symptoms may be the very ones to lead astray, as in a case occurring in a puerperal patient, in whom albumin and tube-casts were present, the condition was naturally enough believed to be uraemic. In haemorrhage into the pons convulsions are frequent, the pupils may be strongly contracted, and conjugate deviation may occur, the CEREBRAL HJEMOUHHAGE. 687 eyes looking away from the lesion, and the pupils may be strongly contracted, so that opium-poisoning may be suggested. The temperature may rise rapidly — a point of considerable diagnostic value. At first it may be quite imjwssible to give a definite diagnosis. In emergency cases special care should be taken upon the following points : The head should be examined for injury; the urine should be drawn off at once and tested for albumin and sugar ; the limbs should be inmiediately examined with reference to their degree of relaxation, the presence or absence of rigidity, and the condition of the reflexes. The state of the pupils should be noted and the temperature taken. Serious mistakes are often made in the case of individuals who, as not infrequently happens, are drunk at the time of the apoplectic seizure. The condition may be regarded as due to alcoholism or to uraemia. In pontine hsemorrhage respiration is often disturbed, and may be slow as in opium-poisoning. Prognosis. — From a limited cortical haemorrhage the recovery may be complete, particularly if the haemorrhage occurred after injury. The infantile meningeal haemorrhage causing tiie birth-palsies is very frequently followed by idiocy and hemi- or dii)legia. Large extravasations into the white sub- stance of the hemispheres and into the ventricles and about the base prove rapidly fatal. The hemiplegia following a lesion of the internal capsule is usually persistent and is followed by contractures. If the posterior fibres have been involved, there may be hemianaesthesia, and later hemichorea or athetosis. The following symptoms in a case of cerebral haemorrhage are of grave moment : Persistence or deepening of the coma during the second or third dav, rise in temperature witiiin the first twenty-four hours after the initial fall. After the reaction on the second or third day, with which there is usually moderate fever, a gradual fall on the third or fourth day, with a return of con- sciousness, is a favorable indication. The early formation of a sloughing bed- sore is very unfavorable. The presence in the urine in large quantities of albumin and sugar is an unfavorable symptom. With the return of conscious- ness and the improvement in the general condition the question is anxiously asked by the friends as to the persistence of the paralysis. In adults, if the hemiplegia has been complete, involving the face, arm, and leg, and if it per- sist for a week or ten days, there is little hope that it will entirely disappear. Slight paralvsis of the arm and face without profi)und loss of consciousness may be recovered from com])letely, but complete hemiplegia which persists for a month usually leaves permanent disability. The leg imi)roves as a rule, and the patient is able to walk about and power gradually returns in the fiice, but the hand rarely regains control of the finer movements. If complete motor aphasia has occurred, the chances are against full re-establishment of the power of speech. The late rigidity with contractures is a iioj)eless condition. 688 ORGANIC DISEASES OF THE BRAIN. Embolism and Thrombosis. (1) Embolism. — The most common cause of embolism is a fresh warty endocarditis or a recurring vegetative inflammation on sclerosed valves. Some- times fragments are carried off from segments involved in an ulcerative process. The miti-al endocarditis is by far the most common source; less frequently por- tions of clot in the appendix of the auricle or small white thrombi are respon- sible for it. Portions of thrombi from an aneurism or from atheromatous patches on the aorta, or thrombi from the territory of the pulmonary veins, may also block the branches of the circle of Willis. In the puerperal con- dition cerebral embolism is not infrequent, occurring sometimes in women with heart disease, but in many cases the heart is uninvolved, and the condition is thought to be associated with the development of heart-clots owing to an increased coagulability of the blood. Practically, a large proportion of all cases of embolism occur in chronic valvular disease, particularly in those cases of recurring endocarditis so commonly present on the sclerotic segments. It is much less common in the acute endocarditis of rheumatism, chorea, and the acute fevers. The emboli pass most frequently to the left middle cerebral arterv, owing; to the fact that the left carotid is more in the direct course of the blood-current than the innominate. The posterior cerebral and the verte- bral arteries are less often involved. A large embolus may lodge at the bifur- cation of the basilar artery. Embolism of the cerebellar vessels is rare. The statement is usually made that embolism of the cerebral arteries is more fre(|uent in women, owing to the more common occurrence of mitral stenosis in them, but statistics seem to indicate that cases are quite as frequent in men, if not more common ; thus Newton Pitt's recent statistics of 79 cases at Guy's Hospital give 44 cases in males and 35 in females. (2) Thrombosis. — Clotting of blood during life in the cerebral vessels may be due to — (a) The presence of an embolus. About a fragment of clot or a vegetation which blocks a cerebral artery the blood coagulates usually as far back as the first large branch. The embolus may be completely surrounded by recent coagulum. (6) Local disease of the cerebral arteries, either a simple or a syphilitic endarteritis. In elderly persons with advanced atheromatous changes in the larger branches of the circle of Willis it is not very uncommon to find adherent thrombi. The most advanced atheroma may exist without a trace of separation of the fibrin, and in all probability other factors, such as debility and changes in the constitution of the blood, are necessary. The syphilitic endarteritis is a nmch more common cause of thrombosis. The growth of tubercles in the vessels more rarely causes thrombosis. The blood may clot in aneurisms, both miliary and coarse. Ligature of the carotid has in a few instances caused the formation of thrombi in the arteries, and, as a rule, of course under these circumstances the collateral circulation is readily established. In certain blood-conditions there is a tendency to clotting in the cerebral vessels, EJIIiOLTSJr AXD rilROMBOSIS. 689 a.s in marasmus from any cause, }>hthisis, chlorosis, and in the puerperal state. Anatomical Changes. — The immediate eticct of blocking of a cerebral artery is degeneration and softening of the vascular territory sup})lied by it. The affected district is rarely in a condition of deep hnemorrhagic infarcti(jn, as in embolism of the arteries of the spleen or kidneys. ^Nlore commonly the change may not be very striking, and the affected area nuiy look only a little paler and slightly softer than nornud. Gradually the consistence of the j)arts lessens, owing to the infiltration of serum, and the nerve-fibres become degenerated and fatty, and the neuroglia swollen and cedematous. The hanuoglobin undergoes a gradual transformation, and the color, which is red at first, changes to yellow. Microscopically, disintegrated nerve-fibres, fatty and molecular debris, pigment-grains, and compound granular corpuscles are present. Much stress was formerly laid uj)on the red, yellow, and white soft- ening, but they are varieties of one and the same process. The red .softening is met with chiefly in the gray matter of the cortex and of the ganglia. It may show punctiform haemorrhages (capillary apoplexy), and the appearance may be almost hsemorrhagic. The white softenim/ is most common in the centrum ovale, and its most typical forms occur in tiie neighborhood of tumors and abscesses and in septic processes. YeUow softening is usually an advanced stage of the red. There is a variety of yellow softening, the jjlaque jaune, which is common in elderly persons. The spots are from 1 to 2 cm. in diameter, with cleanly-cut edges, and the softened area represented either by a turbid vellow material, or in the advanced stages a small excavation filled with fluid and crossed by fine trabecule. A dozen or more of these patches mav be met with on different convolutions. They ]u-obal)ly result from fatty or hvaline chauge in the smaller cortical arteries. Inflammatory changes occur about the softened areas, and when the embolus is derived from an infected focus, as in ulcerative endocarditis, there may be suppuration. The final changes vary greatly. It is surprising for how long a period red and yellow softening may remain unchanged. Months after the attack the involved area may be oidy slightly depressed, flattened, somewhat softer than normal, and of a yellowish color. Finally the degenerated and dead tissue-elements are removed, and in a small area replaced by new growth of connective tissue. In larger regions the perii)heral portion of the softened area becomes condensed, while the degenerated elements arc absorbed aud a cyst is graduallv formed, sometimes crossed in different diicctious by connec- tive-tissue trabeculse. Softening occurs in all parts of the brain, more ])articularly on the cortex and in the central ganglia, in which the vessels arc terminal arteries. The extent of the softening de])cii(l> ii|)()n the position of the (Mubolus and tiic j)os- sibilitv of establishinfr a collateral circulation; thus an end)()lus blocking the middle <•( lebral at its origin involves both the central arteries passing into the anterior perforated space and the cortical branches. Softening in th(> corpus striatum and the internal capsule in such a case is inevitable, and as a rule in Vol. 1.-44 690 ORGANIC DISEASES OF THE BRAIN. part, at any rate, of the territory supplied by the middle cerebral. The extent of this varies very much, as the freedom of anastomosis between the cortical branches appears to differ. There are instances of embolism of the middle cerebral artery in which the softening has only involved the territory of the central branches, in which case the blood must have reached the cortical area through the anterior and posterior cerebrals. When, as is perhaps most often the case, the middle cerebral is blocked beyond the region of the central arteries, one or other of its branches is most involved. The embolus may lodge in a vessel passing to the third frontal convolution, or in the artery of the ascending frontal or ascending parietal gyrus, or it may block the branch passing to the supramarginal and angular convolutions, or enter the lowest division distributed to the upper convolutions of the temporo-sphenoidal lobe. These are practically terminal arteries, and when involved in embolism or thrombosis softening follows in part, at least, of the territory supplied by them, producing in this way some of the most accurately focalizing lesions which we meet. Symptoms. — The most extensive softening may occur without causing any symptoms, as when the occlusion involves arteries passing to the silent regions, as they are termed. In elderly persons it is quite common to meet with multiple areas of the plaques jaunes which have not apparently caused any symptoms. In many instances the symptoms are identical with those produced in hemorrhage, and transient or permanent hemiplegia is produced with or without loss of consciousness. There are certain peculiarities asso- ciated with the attacks of embolism and thrombosis respectively. In embolism premonitory symptoms are rare ; the onset, as a rule, is sud- den, without any headache, numbness, or tingling. The patient is the subject of heart disease, or there exists some of the conditions already mentioned as favoring embolism. When the embolus blocks the left middle cerebral artery, aphasia is usually associated with the hemiplegia. In thrombosis premonitory symptoms are usually present and the onset is more gradual. The i)atient has complained of headache, vertigo, numbness or tingling in the fingers, transient weakness on one side or in the arm or leg. The speech may liave been embarrassed for some days, or the patient has loss of memory and is incoherent. The paralysis may begin in one arm and extend slowly. Abrujit loss of consciousness is much less common than in embolism, and still less so than in cerebral haemorrhage; thus, with thrombo- sis due to syphilitic disease the hemiplegia may come on without the slightest disturbance of consciousness. There are instances, however, of extensive involvement due to syphilis in which the patient becomes somnolent and is unconscious for days or even weeks. Convulsions may occur with embolism, rarely with thrombosis. The general symptoms in thrombosis and embolism are, as a rule, not nearly so striking as in cerebral haemorrhage, and the profound apoplectic condition with stertorous breathing is not so often seen. The focal symptoms are practically the same, and the hemiplegia has the primary and secondary EMBOLISM AND THROMBOSIS. 691 characteristics described under Hferaorrhage. The following are the eifects of blocking of particular vessels : («) Vertebral. The left branch is usually plugged, and results in an acute bulbar paralysis from involvement of the nu<-lei in the medulla. It may be unilateral and associated with hemiplegia. More commonly there is with it (6) Occlusion of the basilar artery, which may cause sudden death from involvement of the respiratory centres. In complete occlusion of this vessel there may be bilateral paralysis from involvement of both motor j)aths, and bulbar symptoms. The temperature rises rapidly, and there may be hyper- pyrexia. Death occurs as a rule within a few days. {(■) The posterior cerebral artery supplies the occipital lobe on its inner face and the greater part of the temporo-sphenoidal. Localized areas of soft- ening may exist without symptoms. Occlusion of the branch passing to the cuneus may be followed by hemianopia, and hemianaesthesia may be caused by involvement of the posterior part of the internal capsule. ((•/) Internal carotid. The symptoms are very variable. In a majority of the cases the vessel may be ligated without any risk. Sometimes transient hemiplegia follows. In rare cases the condition is persistent and death has occurred. These variations depend upon the anastomoses in the circle of Willis, which if large and free readily permit of the collateral circulation, but when the anterior and posterior communicating vessels are very small or are absent, the paralysis may persist. When the internal carotid is blocked within the skull, and particularly by the formation of a thrombus, the results are much more serious, as the process is apt to spread into the branches. Hemi- plegia, coma, and early death usually follow. (e) Middle cerebral. This is the artery most commonly involved, and, as already mentioned, when plugged before the central arteries are given off, permanent hemiplegia may follow from softening of the internal capsule. Blocking of the branches beyond this point may be followed by henn'plegia, which is more likely to be transient, involving chiefly the arm and face, and, if on the left side, associated with aphasia. As already mentioned, the indi- vidual branches passing to the third frontal, the ascending parietal, the supra- marginal and angular gyri, and to the temporal gyri may be })lugged. (/) Tlie anterior cerebral. Cortical softening in the district supplied by this vessel is rare, as the branches from the middle cerebral are usually able to effect a collateral circulation. Softening of the orbital lobule and the olfactory bulb may occur. Hebetude and dulness of intellect may exist \w\i\\ obstruction of this vessel. Treatment of Cerebral Hsemorrhage, Enibolisni, and Thrombosis. — In ccM'ebral lueniorrhage the patient should be placed with the head high, and, if stertor ])(■ ])resent, turned on the paralyzed side. ]>owles, who has written a most suggestive work on the subject, calls attention to the great ini]>ortance of position in an apoplectic seizure, holding that the stertor arises largely from the tongue falling back in the supine jxisition of tlie ixxly, thus offering a serious impediment to respiration. In the lateral position, also, the mucus 692 ORGANIC DISEASES OF THE BRAIN. and sputa drain away more readtly. In a majority of instances the pulse- tension will be found high, and measures should be taken to reduce it. In part this increased tension may be due to the suffocative symptoms associated with the stertor, and Bowles states that the pulse-tension is lowered with the relief of the stertor by proper posture. The most rapid and satisfactory method of reducing the tension when very high is venesection, which is indi- cated in the case of middle-aged men with arterio-sclerosis, high tension, hyper- trophied left ventricle, and a ringing aortic second sound. With a small pulse of low tension and signs of cardiac weakness bleeding is contraindicated, and in the cases of apoplexy due to embolism and thrombosis venesection would j)rob- ably do more harm than good, by favoring the tendency to clotting. Recently, on experimental grounds, Horsley and Spencer have recommended the practice formerly employed empirically of compression of the carotid, particularly in the ingravescent form of apoplexy. In suitable cases they would advise even the passing of a ligature around the vessel. An ice-bag may be placed upon the head. It is not at all likely that sinapisms to the feet or blisters on the back of the neck are of the slightest benefit. The bowels should be freely opened, either by calomel or by croton oil placed on the tongue. Stimulants are not necessary unless the pulse becomes feeble with signs of collapse, when ammonia and brandy may be administered. Especial care should be taken to avoid bed-sores, and if hot bottles are used to the feet, it should be remem- bered that in this condition burns are more readily caused than in health. In the fever of reaction aconite may be cautiously used. The treatment of softening from thrombosis or embolism is unsatisfactory. Venesection, as it lowers the tension and promotes clotting, should not be em])l()ycd. If the pulse be feeble and irregular, alcohol and small doses of digitalis, with ammonia and ether, may be used. The bowels should be kept open, but it is not well to purge actively as in cerebral haemorrhage. In the thrombosis following syphilitic arteritis we see very satisfactory results from treatment. In such cases, met with most frequently in men between the ages of twenty and forty, the hemiplegia may set in without any loss of conscious- ness. Iodide of potassium should be given freely in from thirty- to sixty- grain doses three times a day ; and, if the infection be recent, mercury may also be employed. Not much can be done for the residual hemi])legia of cerebral haemorrhage or embolism. The paralyzed limbs may })e rubbed once or twice a day to maintain the nutrition of the muscles and to prevent, if possible, contractures. Electricity is probably of no special benefit, and it is certainly not comparable in value to frictions and systematic massage. In complete hemiplegia which persists for more than a few weeks the chances of full recovery are slight. Power returns in the leg sufficient, as a rule, to enable the patient to get about. The movements of the arm at the shoulder-joint are regained, but the finer movements of the hand are permanently lost. In permanent hemiplegia in persons above the middle period of life mental weakness is apt to super- vene, and the patients often become emotional and irritable. When con- AXEUBISM OF THE CEREBRAL ARTERIES. 693 tractures develop the friends should be .plainly told that the condition is past all relief, and that medicines and electricity will do no good, and that nothing remains but to look after the general health and comfort of the patient. Aneurism of the Cerebral. Arteries. Miliary aneurisms are not here included, but only the coarse aneurisms of the larger branches. The condition is by no means uncommon. I have reported 12 cases met with in 800 autopsies at the Montreal General Hospital. This is a much larger proportion than in Newton Pitt's statistics from Guy's Hospital, in which there were only 19 cases in 9000 autopsies. Males arc more frequently atfected than females. Of my 12 cases, 7 were in males. The condition may be present in early life. One of my cases was a lad of six, and Pitt describes one at the same age. The chief causes are endarteritis, simple or syphilitic, leading to weakness of the wall and dilatation, and more frequently embolism. As pointed out some years ago by Church, the aneurisms are usually found associated with endocarditis. In his recent study Pitt concludes that it is exceptional to find cerebral aneurism unassociated with fungating endarteritis. The dilatation follows the secondary changes in the coats of the vessels at the site of the embolus. The middle cerebral arteries are most frequently involved. The distribu- tion in my 12 cases was as follows: Internal carotid, 1 ; middle cerebral, 5; basilar, 3; anterior communicating, 3. Of 154 cases which make up the statistics of Lebert, Durand, and Bartholow, the middle cerebral was involved in 44, the basilar in 41, internal carotid in 23, anterior cerebral in 14, pos- terior communicating in 8, anterior communicating in 8, vertebral in 7, pos- terior cerebral in 6, inferior cerebellar in 3 (Gowers). The size varies from that of a pea to that of a walnut. The aneurism is most frequently saccu- lated, and communicates with the lumen of the vessel by an orifice smaller than the circumference of the sac. A cerebral aneurism may attain considerable size and cause no symptoms. In a majority of the cases the first intimation is rupture with fatal apoplexy. Symptoms are most frequently caused by aneurism of the internal carotid, which may com])ress the optic nerve or the chiasma, causing optic neuritis. The third nerve may also be involved. When large then^ may be irritative and pressure symjitoms at the base. In a case reported by Weir Mitchell and Dercum an aneurism compressed the chiasma and jiroduced bilateral tem])oral hemianopia. Occasionally a murmur may be audible on auscultation of the skull, but it is to be borne in mind that in a great majority of instances in which a murmur can be heard over the temporal region, even at a distance from the skull, it indicates simply an ordinary systolic brain-miu-inur which is of no special significance. Aneurism of the vertebral or of the bnsilnr artery may involve the nerves from the fifth to the twelfth, and on the latter artery it may compress the third nerves and crura. 694 ORGANIC DISEASES OF THE BRAIN. The diagnosis is, as a rule, inijiossible. When symptoms exist they are those of tumor. Thrombosis of the Cerebral Sinuses. The condition may be primary or secondary, and the clot may occur in the sinuses alone or in the cortical veins as well. Primary Thrombosis, which is rare, occurs — (1) In children, particularly during the first six months of life, following diarrhoea ; in older children after any exhausting disease. In my experience it has not been very common in children, and the only records among my notes relate to two instances of meningitis, both with thrombosis in the corti- cal veins as well. Gowers believes that infantile hemiplegia is not infrequently caused by thrombosis of the cortical veins. (2) In connection with chlorosis and ansemia, an extremely interesting asso- ciation to which Brayton Ball has called si)ecial attention, having collected 9 cases from the literature. (3) In the terminal stages of cancer, phthisis, and other diseases causing cachexia. In hospital and general practice these are the most common cases, and the clot formed under these circumstances is usually spoken of as " maran- tic thrombus." Secondary Thrombosis is very much more common, and is due to exten- sion of inflammation to the sinus-wall in disease of the internal ear, in frac- ture, in suppurative disease outside the skull, more particularly erysipelas. The lateral sinus is most commonly involved. The thrombus may be small and mural, or large, filling the entire sinus and extending into the jugular vein. Newton Pitt states that of 56 cases in which aural disease caused death with cerebral lesions, in 22 thrombosis existed in the lateral sinus. In more than one-half of the cases the thrombus was suppurating. The inflammation arises usually from necrosis of the posterior wall of the tympanum, rarely from disease of the mastoid cells. The most extensive sinus thrombosis may follow erysipelas, rarely from extension directly through th* bone into the longitudinal sinus, more commonly from extension along the nerves. Symptoms. — In cases of prolonged cachexia in which death has taken place slowly a thrombus is sometimes accidentally found. In other instances there is mental dulness, headache, and gradual torpor, deepening to coma, without any localizing symptoms. In involvement of the longitudinal sinus there has been occasional oedema of the forehead, and distension of the veins has occasionally been noticed, and sometimes epistaxis. In children the fon- tanelle becomes prominent, and there may be exophthalmus. Convulsions occur in some cases, and there may be vomiting. In the chlorosis cases the head-sym])toms have, as a rule, been marked; thus the patient under Ball's care was heavy and lethargic, the pupils were dilated, and there was double choked disk. There was also slight paresis of the left side. In the cases to which he refers, reported by Andrew, Church, Tuckwell, Owen, and Wilks, headache, vomiting, and delirium were present. In Powell's case, with similar THROMBOSIS OF THE CEBEBRAL SINUSES. G95 .symptom.";, there was })aresis oji the left side. Bri:?to\v's ease, an aiuemie g-irl aged nineteen, had eonvulsions, drowsiness, and vomiting ; tenderness and swelling developed in the position of the right internal jugular vein, and a few days later on the opposite side. The diagnosis was rendered positive by the oecurrence of ])hlebitis in the veins of the right leg; swelling also occurred in the left leg in Brayton Ball's case. The diagnosis of primary thrombosis can sometimes be made, particularly in chlorosis eases, in which the thrombi are multiple. In infants and in the forms due to cachexia the symptoms are more doubtfid. In thrombosis of the cavernous sinuses there mav be oedema of the eyelids and marked prominence of the eyeballs. I The symptoms of secondary thrombi are those of secondary septicaemia. As already mentioned, the condition most frequently follows extension from disease of the middle ear, and involves the lateral sinus. The frequency of this accident may be gathered from Pitt's Guy's Hospital statistics, already mentioned. Headache, chills, and fever are the most constant symptoms. Earache is of course very commonly present, and of other symptoms vomit- ing, coma, delirium, and convulsions occur. Sometimes there is great j)ain at the back of the head and the neck is stiff. When the thrombus extends into the internal jugular vein, there may be local fulness in the lateral region of the neck or abscess-formation along the course of the vein. Optic neuritis may be present. The duration after the first onset of the symptoms may be from ten days to eight or ten weeks. As a rule, the patient passes into a typhoid condition, with dry tongue, rapid })ulse, and all the symptoms of septicannia. In three-fourths of the cases death follows from pulmonary pyaemia. Pitt's deductions from his cases of lateral sinus thrombosis are important : 1, the disease more often spreads from the posterior wall of the middle ear than from the mastoid cells ; 2, the otorrhoca is generally of some standing, but not always ; 3, the onset is sudden, the chief symptoms being ])yrexia, rigors, pain in the occipital region and in the neck, associated with a septicaemic condition ; 4, well-marked optic neuritis may be present ; 5, the apjwarance of acute local pulmonary mischief or of distant suppuration is almost conclusive of thrombosis ; 6, the average duration is about three weeks, and death is gen- erally from ))ulmonary ]>vaemia. Th(! treatment of these cases is most unsatisfactory, as the dangers of ])yaemia are extremely great. Pitt recommends that the internal jugular vein be ligatured in the neck, the lateral sinus opened, and the clot scra])ed out. He gives an interesting case of a boy aged ten with chronic otorrhani who was admitted with earache, tenderness, and oedema. A week later he had a rigor, and o])tic neuritis developed on the right side. The mastoid was incised with- out results. TIk' rigors and pyrexia continuing, two days later the lateral simis was explored, a mass of foni clot removed, and the jugular vein tied, after which the boy made a satisfactory recovery. 696 OBGAXIC DISEASES OF THE BBAIN. Cerebral. Localization. Onr accurate knowledge of the functions of the different portions of the brain dates from the observations of Fritsch and Hitzig. Previous to this time interesting attempts at localization were made by the study of pathological cases, and to Broca and Hughlings Jackson, more than to any others, we owe the stimulus to the clinical study of this question. In the cerebral convolutions there are areas concerned with the muscular movements — motor centres ; with sensation — sensory centres ; with the special senses of sight, hearing, smell, and touch. Tliere are also psychical centres about the situation of which we as yet know very little. Motor Centres. — The area for the representation of movements is in the Rolandic region, and comprises the two ascending convolutions, the hinder part of the three frontal convolutions, and a part of the parietal lobule. (See Fig. 45.) Weak electrical currents in this region produce muscular move- ments in the opposite side of the body. The centres presiding over the different groups of muscles are thus classified : Fig. 45. Lateral Surface of Brain of Monkey (Horsley and Schafer). (a) The centres for the trunk-muscles are situated just within the longitudi- nal fissure in the marginal gyrus, in the region sometimes spoken of as the paracentral lobule (Sehiifer). (See Fig. 46.) {b) The leg-centres are situated at tiie upper part of the Rolandic region. The representation of movements of the different portions of the leg is as follows : most anteriorly, the hip ; next in order, the knee and ankle ; then the big toe, the centre for which surrounds the upper end of the fissure of Rolando ; and still farther back centres for the small toes. (c) The arm-centres correspond to about the middle two-fourths of the motor area. The studies of Horsley and Beevor have shown that the different segments of the limb are represented in the following order from above down- ward : shoulder, elbow, wrist, fingers, the index finger, and last of all the thumb. CEREBRAL LOCALIZATION. 697 {d) The centres for the face, tongue, pharynx, and hirynx are situated in the hnvest portion of the Rolandic region, next to tiie fissure of Sylvius. From behind forward we have here the foUowing centres : (1) opening of the mouth, Fig. A(S. Median Surface of Brain of Monkey (Horsley and Schafer). around the lower end of the fissure of Rolando ; (2) movements of mastica- tion ; and (3) contraction of the vocal cords. Anterior to this, in the posterior part of the third left frontal convolution, there is the area concerned with the motor mechanism of speech. In front of the j^rjccentral sulcus are centres for tiie representation of movements for the turning of the head and eyes to the opposite side. The determination of these various motor areas has been worked out accurately in animals, and has been established in the case of man partly by careful clinical observation and partly by the direct ajiplication of elec- tricity to different regions of the cortex cerebri during operation. The various areas for the representation of movements in the cortex must not be regarded as accurately limited and defined, but as blending one with another. Uniting these cortical motor centres and the gray matter of the spinal cord are the fibres of the pyramidal or motor tract, which enter the white matter of the hemispheres, the corona radiata, and gradually converge to what is known as the internal cai>sule, which lies between the thalamus and the two divisions of the corpus striatum. The position of the fibres from the various centres has been pretty carefully determined and represented in the annexed figure. (See Fig. 47.) The fibres from the centres of the face, tongue, eyes, and head occupy the most anterior position, just at the knee, as it is called, of the cap- sule; the fibres from the arm-centres lie close to these; while the fibres from the leg-centres occupy a position in the middle of the |»()sterior j)art. After leaving the internal capsule the motor fibres ])ass into the cms, oecu|)ying the lower and medial position. Passing through the pons, they enter tlir medulla, of whi(;h they fijrm the anterior or pyramidal tract, which then decussates, a large portion of the fibres passing to the opposite side of the spinal cord, form- 698 ORGANIC DISEASES OF THE BBAIN. ing the crossed pyramidal tract, a smaller number of the fibres descending in the anterior column of the same side, forming the direct pyramidal tract or Turck's column. Ultimately the fibres enter the gray matter of the spinal cord and join the plexus of the protoplasmic processes, uniting in this way with the large nerve-cells of the anterior horns. Lesions of the Motor Centres and Cerebral Motor Path.— The integrity of the fibres of the motor tract depends upon the vitality of the cortical ganglion- FiG. 47. Diagram of Horizontal Section through the Basal Ganglia and Internal Capsule (left side), showing the position of the chief tracts in the internal capsule. The region of the capsule marlced by the letters L A F is occupied by motor fibres ; L corresponds to the leg-fibres, A to the arm-fibres, F to the face fibres (including fibres to face muscles, and tongue). The region F-C contains the fronto-cerebellar tract (intellectual tract). The region marked S contains the general sensory tract from the opposite side and the fibres from the optic and olfactory nerves of the opposite side, sometimes called the" sen- sory crossway" (Herter). cells. If the cells from which they arise are destroyed, the fibres degenerate throughout their length ; that is, to the beginning of the lower or spino-mus- cular motor path. This process, known as secondary or Wallerian degenera- tion, is a very common event in disease of the brain involving the centres or the pyramidal tract. The various lesions may be grouped, as Hughlings Jackson suggests, into negative or positive, or, as they are now more commonly termed, destructive and irritative. A negative or destructive lesion anywhere in the motor path results in loss of function in the parts — that is, paralysis ; while a positive or irritating lesion causes perversion of the function — i. e. abnormal muscular eoutraction. (1) Destructive Lesions. — These cause paralysis, with secondary de- generation and certain characters which distinguish the lesions of the upper or cerebro-spinal tract. Thus the paralysis is accompanied by a condition of spasm shown in an exaggeration of the reflexes and an increase in the muscle- tension. How this is brought about is not yet accurately known, but the explanation usually offered is that under normal circumstances the upper motor centres constantly exert a restraining influence upon the lower (spinal) centres. When this influence is abolished on account of disease in the pyra- midal tract, these lower centres take on increased activity, which is manifested by an exaggeration of the reflexes. As the segments of the motor path are CEREBRAL LOCALIZATION. 699 separate for nutritional purposes, the muscles neither undergo degenerative atrophy nor present the reaction of degeneration. As the motor centres of the cortex are separated more or less from each other, a localized lesion may cause limited paralysis contined to one limb or to one side of the face — tiie cerebral monoplegias. Where the pyramidal fibres run in a compact bundle, as in the internal capsule, a destructive lesion is more apt to cause paralysis of all the muscles on one side of the body ; that is, hemiplegia. (2) Irritative Lesions.— Our knowledge of such lesions is confined for the most part to those acting on the cortical motor centres, and we know a number of processes which have as their result abnormal muscular contrac- tions. These have as their type the localized convulsive seizures classed as Jacksonian or cortical epilepsy, which are characterized by the convulsion beginning in a single muscle or group of muscles and involving other muscles in a definite order, depending upon the position of their representation in the cortex — for instance, such a convulsion beginning in the muscles of the face next involves those of the arm and hand, and then the leg. The convulsion is usually accompanied by sensory phenomena and followed by a weakness of the muscles involved. A majority of lesions of the motor cortex are both destructive and irrita- tive — i. e. they destroy the nerve-cells of a certain centre, and either by their growth or presence throw into abnormal activity those of the surrounding centres. Sensory Centres. — Our knowledge of the exact position of the areas for representation of the sensory impressions is still defective. Ferrier places it in the hippocampal convolution, but the experiments of Schiifer suggest that tiie gyrus fornicatus is also concerned in sensory impressions. As the tactile and muscular senses play such an important role in all muscular movements, and are sometimes disturbed in lesions of the motor cortex, it seems not un- likely that their centres are associated with those of motion. Horsley has suggested that tliey are localized in the motor cortex, and that two of the chief layers of cells in this region may possibly subserve their functions. Dana's study of a large collection of cases indicates that anesthesia is very frequently associated with lesions of the motor cortex, more particularly in the posterior half of the motor area. Centres for the Special Senses. — As already mentioned, the cortical itjm-c- sentation of the sense of sight is in the occipital lobe, more particularly in the cuneus, unilateral destruction of which is followed by hemian()i)ia. The rela- tion of the angular gyrus, which Ferrier believes is concerned with vision, is still undetermined, and it seems probable, so far as man is concerned, that the visual area is in the occijiital hjbe. The cortical centre for hearing has not yet been fully determined, though it seems to bear very closf- rrlatit)n to the tcm- l)oral lobe, as lesion of the posterior part of the first left temporal convoludon is followed by llic |)henomenon known as word- deafness, and l)ilateral destruc- tion of these parts in the monkey jjroduces, as shown by l"\'rrier, complete 700 ORGANIC DISEASES OF THE BBAIN. deafness. The centre for smell has been placed by Ferrier in the teraporo- sphenoidal lobe and in the uncinate gyrus. The centre for taste has not yet been accurately localized. The parts of the brain which subserve the higher psychical functions are believed to be in tlie frontal lobes. This opinion is based upon the greater development of these lobes in man and the frequent association of mental impairment when they are diseased. The following is the summary of the functions and the eifects of lesions in other reg-ions of the brain : Centrum Ovale. — The white substance situated between the gray cortex and the basal ganglia contains (1) the projection system of fibres, which unites the cerebral cortex with the other ganglionic masses and with the spinal cord ; (2) the commissural fibres, which join corresponding portions of the hemispheres; and (3) the association tracts, which unite adjacent convolutions. Lesions of th.e fibres of the projection system cut off communication with the cortical centres, the effect of which naturally depends upon the portion in- volved ; thus lesion of the fibres of the motor path causes paralysis, which is practically the same as if the centre itself was destroyed. Subcortical lesions involving only a limited number of the projection fibres of the motor path may cause monoplegias. Lesions in the white matter, as the fibres converge to the internal capsule, are more likely to be followed by hemiplegia. Involve- ment of the white fibres of the optic radiation in the occipital lobe may cause hemianopia and word-blindness, and of the fibres of the temporal lobe, word- deafness. Sensory disturbances are rare from lesion in the centrum ovale proper, but hemiansesthesia is caused by destruction of the fibres near the hinder part of the internal capsule. Interruption of the association tracts between the auditoiy and visual centres and Broca's convolution may cause forms of disturbance of speech, and a lesion interrupting the fibres from Broca's centre causes motor aphasia. There is much uncertainty in the diagnosis of lesions of the centrum ovale, and there may be extensive disease, particularly in the prefrontal region, with- out special symptoms. Internal Capsule. — As already stated, this important tract of white matter lying between the thalamus and the two divisions of the corpus striatum con- tains the pyramidal fibres, the sensory fibres, and those of the special senses. The diagram already given shows the position of the motor fibres. Briefly stated, lesions of the posterior part of the hinder limb of the internal capsule cause hemianesthesia and hemianopia, and there have been instances in which the special senses of hearing, taste, and smell have been involved. In asso- ciation with lesions of the hinder part of the internal capsule and the con- tiguous portion of the optic thalamus, choreiform and athetoid movements have been described. So far as we know, lesions confined to the caudate and lenticular nuclei and of the optic thalamus produce no definite symptoms, unless, as is so often the case, the internal capsule be simultaneously involved. The corpora quadrigemina are rarely diseased alone. Lesions of the APHASIA. 701 anterior pair result in blindness. Pupillary symptoms are common, and there is usually paralysis of the oculo-motor nerve. Involvement of these parts by tumors is very apt to be followed by hydrocephalus. In the cms cerebri the motor and sensory fibres are collected in a very small space, and a lesion may cause hemiplegia of both motion and sensation. The third nerve is frequently involved in lesions of the crus, causing paralysis of the muscles of the eye on the same side with hemi))legia on the opposite side. Lesions of the pons in the lower part may cause paralysis of the leg and arm on the opposite side, and, involving the nucleus or fibres of the facial nerve, cause paralysis of the same side of the face. This is known as crossed hemiplegia. In the upper part of the pons the lesion produces the ordinary type of hemiplegia. Extensive lesions of the pons involve botii pyramidal tracts, causing loss of power in both sides of the body. Aphasia. The central apparatus concerned with speech is made up of receptive, per- ceptive, and emissive centres in the cerebral cortex, the disturbances of which are considered under the term "aphasia." Disturbance of the centres which preside over the peripheral speech-mechanism, the muscles of phonation and Fig. 48. h rn Lichtheim's Schema. articulation, produces the condition known as anarthria, as in the gradual loss of the power of speech in buli)ar j)aralysis. Articulate language is gradually acquired by imitation : thus in teaching a child to say the word '' bell " the sound of the word as uttered enters the afferent path, reaching the auditory perce])tive centre, from which the impidse is .«ent to the motor or emissive centre presiding over the nuclei in the nicdiilla, from which the mu.sclcs of articulation are set in action. 'I'hc aiv in Lulit- heim's .schema (.see Fig. 48) is a\, Mm. In this way the child gradually acquires word-memories which are stored at the centre A, and ni(»((.r incin- orics — that is to say, the memories of the co-ordinating muscular movements necessary to utter the word — which arc .stored at the letter M. So also when 702 ORGANIC DISEASES OF THE BRAIN. shown the bell, visual memories are acquired of its size and shape, which are conveyed through the optic nerve to the visual perceptive centre along oO. In the auditory perceptive centres is also stored the sound of the bell when struck. The memory picture of the shape of the bell or its sound when struck, of the appearance of the word when written, the motor memories of the movement required to write the word, are distinct from each other, may be separately disturbed, and yet are intimately connected and together form what is termed the wo)'d- image. In addition to this, the child gradually acquires ideas as to use of the bell — intellectual concepts, the centre of which is represented at I in the diagram. In volitional speech, as in uttering the word " bell," the path Avould be represented in I, M m; in writing the path would be represented in I, M, W, h. The various " memories " are, as a rule, centred or stored in the left half of the brain. Aphasia in the widest sense of the word may be taken to embrace disturb- ances either at (a) the sensory perceptive centres of hearing and sight and in the blind of touch ; (b) of the emissive or motor centres of speech and writ- ing; or (c) of the psychical centres through which we gather rational concep- tions of what is said or written, and by which we express voluntarily our ideas in languao;e. Two chief forms of aphasia are recognized — the sensory, in which the psychical and sensory ])erceptive centres are disturbed ; and the motor, in which the emissive for speech and writing are involved. SeTisory Aphasia. — Loss of the jiower to recognize the nature and charac- teristics of objects is known as apraxia, which is thus clearly and accurately defined by Starr: "It is a fundamental position involved in the accepted theory of cerebral localization that memories are the residua of perceptions, and are therefore localizable in the regions of the brain concerned in percep- tion. It follows that these memories forming the idea of an object or an action, being distinct from one another, may be lost by disease of the brain having a limited extent, and that the character of the memories lost will depend on the location of the disease. Now, cases have been recorded in which persons acted as if they no longer possessed such object memories, for they failed to recognize things formerly familiar. A fork, a cane, a pen may he taken up and looked at by such a person, and yet held or used in a manner which clearly shows that it awakens no idea of its use. And this symptom, for which at first the term ' blindness of the mind ' was used, is found to extend to other senses than that of sight. Thus the tick of a watch, the ^ound of a bell, a melody of music, may fail to arouse the idea which it for- merly awakened, and the patient then has deafness of mind ; or an odor or taste no longer calls up the notion of the thing smelt or tasted ; and thus it is found that each or all of the sensory organs, when called into play, may fail to arouse an intelligent perception of the object exciting them. For this general symptom of inability to recognize the use or import of an object the term apraxia is now employed. And since apraxia is a symptom which is very frequently associated with aphasia, and which, in fact, may lie at the APHASIA. 703 basis of apliasia, it should always be looked for in a patient. To test for jipraxia it is only necessary to present various objects to a person in various -ways, and notice whether he gives evidence of recognition. Have him watched by his friends, and they will be able to tell whether he still chooses his articles of food at the table intelligently — whether he still knows how to put on his <-lothes, to use various toilet articles, to sew or knit or embroider if the patient is a lady, to admire pictures, or flowers, or perfumes, as before the illness began. The patient may or may not be able to name these objects :' that, at l)resent, is not the question. But is it evident that the object awakens an idea in the mind?" There are instances in which apraxia may be the only symp- tom. Thus, a young man in the secondary stage of sy[)hilis was r^eized while at his office-work with a convulsion. A day or two subse(juently, when I saw him, there was no paralysis and no motor aj)hasia, but he had completely lost the memory-pictures of faces and places. The street in wliieh he lived was quite unfamiliar to him, and he did not know his way to the office at which he worked. He also did not recognize for some time his parents or brothers. As a rule, apraxia is associated with varieties of sensory and motor aphasia. The patient may be able to read, but the words arouse no intelligent ideas in his mind. While blind to memory-pictures aroused by sight, tiic j)crceptions may be stimulated by touch ; and there have been patients imable to read by .sight who, on tracing- the letters bv touch, named them correctly. Mind- blindness and mind-deafness are the common and imj)ortant forms of a])raxia. Mind-blindness, which is the equivalent of visual amnesia, may be func- tional and transitory or associated with organic disease, often with mental disturbance. The cases collected by Starr indicate that the lesion exists in the left hemisphere in right-handed persons, and in the right hemi- sphere in left-handed persons. The disease usually involves the angular and supramarginal gyri or the tracts proceeding from them. In a remarkable case reported by ^lacewen the patient, after an injury to the head, had suf- fered with headache and melancholia, but there was no paralysis. He was psvchicallv blind, and, though he could see everything perfectly well and could read letters, objects conveyed no intelligent impression. A man before his eyes was recognized as some object, but not as a man until the sounds of the voice led to the recognition through the auditory centres. Tiie skull was trephined over the angular gyrus, and the iinier table was found to be depressed and a portion had been driven into the I)rain in this region. The patient recovered. "Word-blindness may occur alone or with motor aphasia. TIk' patient is no longer able to recall the appearances of words, and does not recognize them on a printed or written page. The patient may be able to pronounce the let- ters and can often write correctly, but he cannot read understandingly what he has written. It is rare, however, for the patient to In- able to write with any degree of facility. There are instances in wliieli llie patient, unable to read, lias yet been able to do mathematical ])roblems and to recognize play-cards. The lesion in cases of word-blindness is, in a majority of eases, in the angular 704 ORGANIC DISEASES OF THE BRAIN. and supramarginal g}^'! on the left side. It is commonly associated with hemianopia, and not infrequently with mind-blindness. Mind-deafness, or auditory amnesia, is a condition in which sounds, though heard and perceived as such, awaken no intelligent conceptions. A person who knows nothing of French has mind-deafness so far as the French language is concerned, and though he recognizes the words as Avords when sjxjken, and can repeat them, they awaken no auditory memories. The musi- cal fjiculties may be lost in aphasics, who may become note-deaf and unable to appreciate melodies or to read music. This may occur'without the existence of motor aphasia ; and, on the other hand, there are cases on record in which with motor aphasia for ordinary speech the patient could sing and follow tunes correctly. Word-deafness is a condition in whicih the patient no longer under- stands spoken language. The memory of the sound of the word is lost, and can neither be recalled nor recognized when heard. It is usually associated M-ith other varieties of aphasia, though there are cases in which the patient has been able to read and write and speak. The lesion in word-deafness has been accurately defined in a number of cases to be in the posterior portion of the first and second temporal convolutions on the left side (Plate II.). Motor or ataxic aphasia is a condition in which the memory of the efforts necessary to pronounce words is lost, owing to disturbance in the emissive cen- tres. This is the variety long ago recognized by Broca, the lesion of which was localized by him in the third left frontal convolution. In pure cases the patient is able to read (not aloud), and understands perfectly what is said. He may not be able to utter a single word ; more commonly he can say one or two words, such as " no," " yes," and he not infrequently is able to repeat words. When shown an object, though not able to name it, he may evidently recog- nize M'hat it is. If told the name he may be able to repeat it. A man know- ing the French and German languages may lose the power of exj)ressing his thoughts in them while retaining his mother-tongue, or, if completely aphasic, mav recover one before the other. As the third left frontal convolution is in close contact with the centres for the face and arm, these are not uncommonly involved, with the production of a partial or, in some instances, a complete, right-sided hemiplegia. Alexia, or inability to read, occurs with motor apha- sia and also with word-blindness. As a rule, in motor aphasia there is also inability to write — agraphia. When there is right brachial monoplegia it is difficult to test the capability, but there are instances of motor aphasia without paralysis in which the power of voluntary writing is lost. The condition varies very much ; thus a patient may not be able to write voluntarily or from dictation, and yet may copy per- fectly. It is still a question whether there is a special writing centre. It has been placed by some writers at the base of the second frontal convolution, but in a recent study Dejerine concludes that it is not separated from the speech- centre. There is a form known as mixed aphasia or paraphasia, in which the patient understands what is said, and speaks even long sentences correctly, APHASIA. 705 but constantly tends to misplace words, and does not express his ideas in the proper words. All grades of this may be met with, from a state in which only a word or two is misplaced to an extreme condition in which the patient may talk jargon. In these cases the association-tract is interrupted between the auditory perceptive and the emissive centres; hence it is sometimes known as Wernicke's a{)hasia of conduction. The lesion is usually in the insula and in the convolutions which unite the frontal and temporal lobes. Naunyn's figure (Plate II.) gives an accurate representation of the localiza- tion of the lesion in the forms of motor and sensory aphasia. Lichtheim's schema will assist the student in obtaining a rational idea of the varieties of aphasia : 1. In the condition of apraxia or mind-blindness the ideation centres, I, are involved, often with the auditorv and visual perceptive centres, A and O. 2. A lesion at A, the centre for the auditor\' memories of words (first left temporal gyrus), is associated with word -deafness. 3. A lesion at O, the centre for visual memories (angular and supramargi- nal gyri), causes word-blindness. 4. Interruption of the tracts uniting A M and O M causes the conduction aphasia of Wernicke — paraphasia. 5. Destruction of the centre M (Broca's convolution) causes pur(> motor aphasia, in which the patient cannot express thoughts in speeeii. A lesion at M usually destroys also the power of writing, but, as stated, it is believed bv manv that the centre for writino;:, W, is distinct from that of speech. In this case a lesion at M, which would destroy the ])ower of voluntary speech, might leave open the connections between O W and A W, by which the patient could copy or write from dictation. The following tests should be applied in eacli case of aphasia : (1) The power of recognizing the nature, uses, and relations of objects — i, e. whether apraxia be present or not; (2) tlie jiower to recall the names of familiar objects seen, smelled, or tasted, or of a sound when heard or of an object touched ; (3) the power to understand spoken words; (4) the capability of understand- ing printed or written language ; (5) the power of appreciating and understand- ing musical tunes ; (6) the power of voluntary speech — in this it is to be noted ])articularly whether he misplaces words or not; (7) the power of reading aloud and of understanding what he reads; (8) the ])ower to write voluntarily and of reading what he has written ; (9) the power to copy ; (10) the |H>wer to write at dictation ; and (11) the power of repeating words. Treatment. — In the young aphasia associated with hemiplegia lV(»ni what- ever cause is usually transitory, and they quickly learn to talk, proi)al)ly by education of the centres of the opposite side of the brain. In adults the con- tlition is nnich less hopeful, parti(;ularly in cases of eomijlete motor aphasia with right hemiplegia. Sometimes the recovery is raj)id ; in others partial rew)very occurs and the |)atient is able to talk, l)ut lie misplaces words. If motor aphasia has persisted for seveial months without improveiinrit, the eon- VoL. I.— 4a 706 ORGANIC DISEASES OF THE BRAIN. dition is generally hopeless and the patient may remain speechless, thongh capable of understanding . everything that is said. The education of an aphasic demands the utmost patience, and when the patients are emotional and irritable the attempts are often futile. Detached letters should be at first used, with which small words of one syllable may be constructed, and prog- ress made slov^dy. The most distressing cases are those of permanent aphasia with rio-ht hemiplegia. When the mental condition is good, the patient may with great care be taught to write with the left hand, and so have a medium of communication. Too often the utmost care and pains prove fruitless in these cases. Cerebral Palsies of Children. In children palsies due to cerebral disease occur with a frequency almost equal to those of spinal origin. 1. Hemiplegia. — The disease appears to be somewhat more frequent in girls; thus in my series of 135 cases, comprising cases from the Infirmary for Diseases of the Nervous System, Philadelphia, from the Elwyn Institution for Feeble-minded Children, and from my clinic at the Johns Hopkins Hospital, 75 were girls. In a large majority of cases .the disease sets in during the first or second year ; thus of the total number of cases, 95 were under two years of age. Above the fifth year the disease is rare — there were only 10 cases in my series. Neither alcoholism nor syphilis in the parents plays a role in the affection. Injury with the forceps in instrumental delivery is an occasional cause, though not so important as in the spastic diplegia and para- plegia of children. Falls and punctured wounds are occasionally causes, and in one instance in the Elwyn Institution the hemiplegia followed ligation of the common carotid. A certain number of cases set in during the height of or follow an infectious fever. In my series cases are mentioned after scarlet fever, measles, whooping cough, and vaccinia. There are cases in the litera- ture mentioned also after mumps. In some of these instances the paralysis followed the initial convulsion ; in others it was not until the fever had sub- sided that fits came on, and with them paralysis. In the whooping-cough cases the hemiplegia may follow a prolonged spasm of coughing, but in the three cases in my series it occurred with convulsions during the disease. In a large majority of the cases the disease sets in with severe convulsions, often without any premonition, and in children who have previously been robust and healthy. The imjiortance of convulsions in this affection may be gathered from the combined statistics (those of Wallenberg, Gaudard, Gowers, Sachs, and my own), numbering 428 cases, of which nearly one-half set in with convulsions. Morbid Anatomy. — The nature of the primary lesion is, in a majority of the cases, unknown. The autopsies which have been reported have almost invariably been late, years after the onset of the hemiplegia. In an analysis which I made of 90 autopsies from the literature the lesions could be grouped as follows : CEREBRAL PALSIES OF ClflLDREX. 707 (a) In 16 eases tliere was embolism, tlirombosis, or hfeniorrliagc. In 7 of these a Sylvian artery was oeelnded ; in 9 there was lueinorrha(2;e. It is interesting to note that in 10 of these cases the pears almost completelv, leaving scarcely a trace. In one of the KIwyn cases the mental legia is failure in mental development, in consequence of which children drift into the institutions for feeble-minded children. There may be idiocy, which is most common when the hemiplegia has existed from birth or has come on at a very early period ; imbecility, which may increase with the development and persistence of epilepsy ; and a condition of feeble-minded- ness, a retarded rather than arrested mental development. Epilepsy is one of the most common and distressing of the residual symp- toms of infantile hemiplegia. Of the cases in my series, 41 were subject to convulsive seizures. In other cases there is only petit mal. The convulsions may begin in, and be confined to, the affected side without loss of conscious- ness — true Jacksonian epilepsy — or there are general convulsions, usually l)eginning in the paralyzed limbs. Post-hemiplegic movements. — It was in cases of this kind that Weir Mitchell first described the post-hemiplegic movements. They are extremely com- mon, and were present in 34 of my series. There may be only post-hemi- plegic tremor, in which the arm or the leg vibrates gently; more commonly the movements are inco-ordinate and choreiform ; or, lastly, there may be athetosis. In this condition, which was described by Hammond, there is a remarkable spasm in the paralyzed limbs, chiefly in the fingers and toes, and in rare instancies in the muscles of the face. The muscular movements are involuntary, often rhythmical, and in the hand the motions of adduction and abduction and of supination and pronation may follow each other in orderly s(^quence. The fingers are frequently hy*perextended and spread far apart. The movements are usually increased by emotion, and in some cases persist during sleep. Athetosis is very much more frequent in hemiplegia of children than in adults. In the latter it may be combined with hemianaesthesia, in which case the lesion is usually not cortical, but basic, in the neighborhood of the thalamus opticus. 2. vSpastic Diplegia. — A condition dating, as a rule, from birth, in which there is paralysis with spasm of the extremities. As stated in a previous section, infantile hemiplegia occurs usually during the first two years of life. On the other hand, the instances in which both sides are involved very commonly date from birth, and constitute the most serious of all forms of so-called birth-palsies. In some instances the arms are so CEREBRAL PALSIES OF CHILDREN. 709 slightly affected that there niav be a doubt whether the case shuuld bo rey;arded as one of diplegia or paraplegia. Tiie relation of abnormal parturition to the disease is the most important })oint in its etiology. In very many of the cases the patients have been born in first labors or have been instances of instru- mental delivery. In feet presentation too there is the possibility of laceration and tearing of the cerebro-spinal membranes. Asphyxia or convulsions have been present in a very considerable number, and it is very common to hear the statement made in these cases that the child at birth was a " blue baby." Morbid Anatomy. — The birth-palsies which ultimately induce the spastic diplegias and paraplegias appear to result more frequently from meningeal hemorrhage, in which the cerebral cortex is damaged, leading ultimately to sclerosis or atropiiy. The frequency of meningeal apoplexy in the new-born has been demonstrated by the studies of Litzmann and Sarah J. INIcNutt. The hseraorrhage has been found thickest over the motor region. Clinically, these cases present the symptoms of asphyxia or convulsions, the manifesta- tions present in a great majority of instances of birth -palsies. It seems not inireasonable to conclude in cases which recover and subsequently present signs of motor disturbance that a similar though less extensive lesion has existed. There are instances, however, which are probably due to foetal meningo- encephalitis. The anatomical condition in spastic diplegia in 16 cases which I collected from the literature was either a diffuse atrophy or porencephalus. Symptoms. — As stated above, the child has usually been resuscitated with difficulty or has had convulsions. For some months nothing abnormal may be noticed ; then, at an age when the child should begin to walk it is found not to nse the limbs readily, and the mother may say that she finds in dressing the child difficulty in moving the arms and legs. The child sits up with diffi- culty, or may be quite unable to do so, at the age of two years, and very often the head is not well supported, but tends to fall forward. The rigidity is most marked in the legs, and it was this symptom which gave several names to the disease, such as spastic rigidity of the neic-honi, essential contraction, and tonic contraction of the extremities. When made to stand up, the child either rests upon its toes or upon the inner surfaces of the feet, with the knees close together, or, if the adductor spasm be very great, the legs may be crossed. Tiio stiffness of the arras is rarely so marked, and is sometimes scarcely noticeable. Irregular movements of the arms are not infrequent, and the child has diffi- cidty in grasping objects. The spasm and weakness may be more pronounced on one side. Convulsive seizures are not uncommon, and the menial con- plication of forceps. At the onset of a case of infanti](> hemiplegia the physician, as a rule, thiididly and are soft and highly vascular. While verv many of them consist of a fibriUary network and branching cells, there are others, called neuro-gliomata by Klcbs, wliich have enormous spindle-cells with single large nuclei, and others not unlike the large ganglion-cells. Some of these large spindle-cells undergo a nniMrkable vitreous transformation. The slow growth of ccrfaiii gliouiMla is a point of great interest. Ilughlings Jackson has rei)orted an iii^laiuv in which the symptoms ])ersisted for more than ten years. Sarcomata, round- and spindle-celled forms, are not infrertant symptom, often associated with the vomiting. It is most frequent in tumors at the base and of the cerebellum. It is particularly manifested as the patient rises from the recumbent posture. Fever is present in some rapidly-growing tumors, and the local temperature of the head may increase, and in many instances the thermometer has registered higher on the surface nearest the site of the tumor. A slow pulse is not infrequent, and sometimes there is irregularity. Toward the close Cheyne-Stokes breathing may be present. (2) Focal Symptoms. — (d) The motor area. The sym])t()ms may be cither irritative or destructive in character. In the lower third of the motor region the irritative effects of a growth may be manifested in s})asin localized to the muscles of the face or of the tongue. In the middle region containing the <'cntres fi)r the arm and hand the irritation may cause sj)asin in (Iu> lingers, in the liml)s, in the muscles of the wrists, or in those of the shoulder ; while in the upper third of the motor area the effects may be manifested in spasm beginning in the toes or the musdes of the foot or in those of the leu. With these there are usuallv important sensory (iisturbanees. sneh as niimbiiess and tingling or aniesthcsia, which may be felt befi)re the spasm oeenrs. Convul- sive seizures localized in this way to certain gron|)s and extending are known as Jacksonian spasms, and they are strictly comparable to those which may bo induced bv electrical stinuilation oftlie eoitex. In the stndv ofilie cases it is 720 ORGANIC DISEASES OF THE BBAIN. of the utmost importance to determine the region first affected by the numb- ness, tingling, and spasm. Together, these constitute what Seguin has termed the signal symptom. The spasm is not necessarily accompanied by sensory disturbance. The effects of local irritation in the cortex radiate from the point of origin, involving successive groups of motor cells, and often inducing an orderly sequence of spasms in the muscles which they control ; thus, an irri- tative lesion in the lower third of the motor area causes first spasm of the facial muscles, then, if it increase in intensity, of the centres above this point con- trolling the arm and hand, and may ultimately reach the centres higher in the convolutions which control the muscles of the leg. Following the spasm there may be anaesthesia and frequent inability to use the muscles which have been convulsed — paresis. In studying the localized convulsions from tumor three special points are to be observed : first, the starting-point of the spasm or of the preliminary sensory symptoms ; second, the order of march of the spasm ; and third, the condition of the parts after the spasm has passed, whether there be any paresis or anaesthesia. Destructive lesions in the motor areas cause a paralysis which is often pre- ceded by the localized convulsion. It is frequently monoplegic in type, affecting the face or face and arm together, more rarely the leg alone. The paralysis is usually slow and gradual in its onset. In large growths involving the internal capsule the hemiplegia may be complete and may be accompanied with hemiauEesthesia. Tumors of the pons may cause paralysis of the arm and leg on one side and of the face on the opposite. A not infrequent symptom in tumors situated in the motor area on the left side is asphasia from involvement of the third left frontal convolution. The tactile and muscular senses are also impaired in cortical lesions in the motor area, and should always be carefully tested. (6) Prefrontal area. Tumors in this region may not present any localizing symptoms whatever. The general symptoms are usually well marked, and stupor and gradual impairment of the mental powers are not infrequent. On the orbital surface the olfactory bulb may be destroyed, producing loss of the sense of smell, and in many cases the growth of the tumor backward involves the motor centres and causes spasm or convulsion, or on the left side aphasia. (c) In the parietal lobe tumors may attain some size without causing any local symptoms. Sensory changes have been noted in many cases, particularly l)ar8esthesia and partial anaesthesia on the opposite side of the body. In the lower portion of the parietal region involvement of the angular and supra- marginal gyri on the left side causes a form of sensory aphasia in which the patient is unable to recognize written or printed words. Another important localizing symptom in tumors which invade deeply the white matter of the parietal lobe is hemianopia, due to involvement of the visual tract. (r/) Tumors of the occipital lobe cause no motor disturbance, but produce hemianopia on the side opposite the lesion. More rarely the irritation of a new growth causes hallucinations of light or of sight, which are often followed by spasms or convulsions. I^arge growths in the left hemisphere may be TUMORS OF THE BRAIN. 721 associated with word-blindness and a condition known as mind-blindness. Passing forward, the tumors may invade the internal capsule, causing hemi- plegia and hemianesthesia. {e) In the temporal lobe tumors may reach a large size without causing any symptoms. In the left hemisphere invasion of the first and second gyri is associated with word-deafness, and not infrequently a condition of para- phasia in which words are misplaced. There are a few eases which indicate that involvement of the uncinate convolution and the hippocamj)us causes dis- turbance in the sensations of taste and smell. (/) Tumors of the insula cause symptoms which are chicHy indirect ; thus, involvement of the arteries as they pass over the convolutions is followed by softening in the motor area and mono- or hemiplegia. Paraphasia, in which words are misplaced, is a frequent symptom, due to interruption of the asso- ciation tracts uniting the auditory perceptive centres and Broca's convolution. Owing to the close proximity of the internal capsule to the island of Rcil hemiplegia is not infrequent from ])ressure. ((/) Basal ganglia. Limited growtiis in the nuclei of the corpus striatum do not necessarily cause symptoms. Tumors of the thalamus opticus are also, if small, latent in their growth, but when large they involve the fibres of the optic radiation and the internal capsule, causing iiemianopia and hemi- ansesthesia. By far the most important symptoms of tumor in this region are those produced by invasion of the internal capsule which lies between these ganglia. The anterior part of the capsule may be invaded without symptoms. Destruction of the central portion causes hemiplegia, and of the posterior portion hemianesthesia and hemianopia. Tumors of the corpora quadrigemina are rarely limited, l)ut involve the crura cerebri as well. Ocidar symptoms are most frequent — loss of pupil reflex, nystagmus, and motor-ocular paralysis. There may be involvement of the third nerve as it passes through the crus, causing motor-oeuli palsy on (me side and hemiplegia on the other. Oi)tic neuritis is an early symj)tom, and hydrocephalus from pressure very freciuently occurs. (/<) Tumors of the pons and medidla. The symptoms are chiefly tiiose of involvement of the nerves emerging from this region. In the pons the ])yra- midal tracts and nerves may be involved separately or together. Of hi cases analyzed by Mary Putnam Jacobi, there were 1.3 in which the cranial nerves were involved alone, 13 in which the limits were afTc(;ted, and in 26 there were hemi|)legia and involvement of the nerves : 22 of tiie latter had what is known as alternate i)aralysis; that is to say, involvement (»f the cranial nerves on one side and of the limbs on the opposite side of tin' liody. A tumor growing in the lower region of the pons invctKcs the sixth ihtvc, producing internal strabismus; the seventh nerve, causing facial paralysis; and the auditory nerve, causing deafness, sometimes willi vertigo. Conjuate devia- tion of the eves to the side o|)|)osite tlie fa<'iiil paralysis also oeciiiv. Tumors of the medulla involve the cranial nerves alone, or cause a com- bination of hemi|)legia with paralysis ;h there are instances in which the symptoms have yielded. The headache is usually the symptom for which the patient seeks relief, and the ice-bag may be applied, or in the case of occipital headache the Paquelin cautery to the back of the neck. In the syphilitic cases the pain is often relieved promptly with the iodide. Chloral and cannabis Indica may be used, but in the severer forms morphine alone gives relief. The bromides are not of much service in reliev- ing the .symptoms of brain-tumor. (6) Surgical. — The cases suitable for operation are limited in number. Some tumors are quite inaccessible, and in others which are accessible the invasion of adjacent parts contraindicates removal. The most satisfactory forms are those which grow from the membranes and only comjircss the brain-substance, as in the case reported by Keen. The impunity with which large sections of the calvarium can be removed and the cortex cerebri exposed warrants the exploratory operation in suitable cases. Chronic Hydrocephalus. Diagnosis. — A condition, congenital or acquired, in which there is a great accumulation of fluid in the ventricles of the brain, usually with enlargement of the head. An external hydrocephalus is described in which the fluid is in the arachnoid sac, but this is met with in ca.ses of atr()])hy of the brain, the .so-called Iii/drocephalas ex vacuo. In a few instances a .sacculated exudation occurs, forming a meningeal cv.st. In cases of extreme enlargement of the lateral ventricles the brain-substance may be so thinned at the cortex that the ventricular and arachnoid .spaces communicate. Cases of true hydrocephalus mav be divided into two group.s — the congenital or infantile and the accpiired. (1) Congenita li OR Infantile Hydrocephai.u.s. — The condition nuiy develop in the foetus and the enlarged head may ob.struct labor. No reason- able ex|)lanation has been offered of its occurrence. Several children in suc- cession have been known to be affected in the .same family. INIuch uuu-v fre- quently nothing abnormal is noted at the time of l)irth, but gradually the head enlarges. The anatomical condition is very striking. The ventricles, particularly the lateral, are enormously di.stend(!d. The ependyma is clear, occasionally a 724 ORGANIC DISEASES OF THE BRA IX. little thickened and granular ; the veins are large ; the choroidal plexuses are vascular, sometimes sclerotic, but often natural-looking. The third ventricle is enlarged, the aqueduct of Sylvius dilated and fiuinel-shaped, and the fourth ventricle may be, but is not always, distended. The fluid, which may reach several litres in amount, is limpid and contains traces of albumin and salt, sometimes urea and cholesterin. The cortex cerebri is stretched and thin. Over the Rolandic region there may be a layer of not more than 2 or 3 mm. in thickness, and all trace of sulci and convolutions is obliterated. The basal ganglia are compressed in the floor of the sac. The most striking feature in the appearance of the child is the great enlargement of the skull, which in a child of three or four years of age may reach twenty-five or even thirty inches in circumference, and looks enormous in proportion to the size of the face. The bones of the cranium are extremely thin, the sutures widen, and Wormian bones develop in them. The subcutaneous veins are usually large and well marked. The orbital plates of the frontal bone are depressed, causing exoph- thalmos, and the eyeballs cannot be completely covered by the lids. Tlie fluctuation Avave may sometimes be obtained, and Fisher's brain-murmur is often present. The child learns to walk late, and in extreme cases the legs become feeble and spastic. The reflexes are increased, and occasionally con- vulsions occur. The mental condition is variable: the child may be bright, but as a rule there is some grade of imbecility and the child learns to talk slowly. Nystagmus frequently develops, and in the congenital cases death usually occurs within the first four or five years. Occasionally the disease is arrested and the patient may reach adult life, as in the case of Cardinal, described by Bright, who lived to the age of twenty-nine, and whose head was translucent when the sun was shining upon it. The diagnosis is rarely difficult. In moderate enlargement the disease may be confounded with the rickety head, which, however, is distinguished by the squarer outline, the flattened vertex, the absence of bulging of the fontanelles, and more particularly by the presence of other rickety mani- festations. (2) Acquired Hydrocephalus. — In the adult, distension of the ventricles is met with most commonly as a result of interference with the circulation in the straight sinus or in the vense Galeni. In a majority of instances there is oedema at the base. In other instances the foramen of Magendie, by which the ventricles communicate with the spinal meninges, becomes closed, or the foramen of Monro is occluded, or the passage from the third to the fourth ventricle is closed by tumor. A rare cause is meningitis, particularly the epidemic cerebro-spinal form, after which hydrocephalus has been known to develop. There are other instances in which the inflammation is a meningo- ependymitis. In rare instances the hydrocephalus develops in the adults with- any observable cause. The skull, as a rule, docs not enlarge in the hydro- cephalus of adults, though occasionally the sutures may separate and there is some increase in size. In the cases associated with tumor, even when the dis- ease begins early in life, there may be no enlargement of the skull. In the CHEOXIC HYDROCEPHALUS. 725 case of a girl aged sixteen, blind from her third year, the ventricles were enormously distended, owing to the presence of a tumor in the third ventricle. The head was not at all enlarged. The symptoms of acquired hydrocephalus arc very variable. Headache, attacks of somnolence, progressive optic neuritis leading to atrophy and blind- ness, have been i'requently present. The diagnosis is rarely possible. Gradually progressing optic neuritis without focalizing symptoms, severe headache, stupor, and attacks of somno- lence, are suggestive symptoms. One patient, whose case I described, was imconscions for more than three months. Treatment. — ^Medicines are useless in this condition. Gradual compres- sion may be made by means of broad plasters applied so as to cross each other on the vertex, while others are made to encircle the head. Puncture of the distended ventricle has frequently been made, and when pressure symp- toms are present this is a rational operation. The aspirator needle may be inserted at the outer angle of the anterior fontanelle. Only a few ounces should be removed at a time : convulsions and acute meningitis have been known to follow. Quincke recommends and has practised in acute as well as chronic hydrocephalus, puncture of the subarachnoid sac beween the third and fourth lumbar vertebne. The spinal cord cannot of course be injured at this point, and the fluid can be removed more slowly and with much less danger of collapse. SYPHILIS OF THE NERVOUS SYSTEM. By HORATIO C. WOOD. Syphilitic Disease of the Brain. Etiology. — Cerebral syphilis is usually a late phenomenon, but may appear within three months after primary infection. I have myself seen it at every period from one to thirty years. It is especially liable to develop when the secondary symptoms have not been severe, and in common with other observers I have repeatedly seen it when both primary and secondary symptoms have been so slight as to escape observation on the part of the victim. Inherited syphilis is less prone to attack the nervous system than is acquired syphilis, but cerebral gummata may develop during intra-uterine life and at any time subsequently ; indeed, nervous syphilis may develop after puberty as the first open outbreak of inherited disease. Pathology. — The cerebral gumma probably always has its origin in the membranes, is usually surrounded by a reddish zone, and does not become so uniformly and completely caseous as the tubercle, from which it is further dis- tinguished by its proneness to cause cerebral softening. In gummatous men- ingitis the exudation forms an extended, shapeless, gelatinous mass, which is in the majority of cases situated at the base of the brain. Microscopically, the cerebral gumma differl from other similar bodies only in the presence of very large, spider-like cells containing an exaggerated nucleus and a granular proto- plasm, which extends into the multiple, branching, rigid prolongations. Under treatment gummata may disappear completely or may leave behind them cicatrices, imperfect cysts, or even calcareous masses. A gumma may involve a blood-vessel, and, extending along its wall, give rise to a thrombus with secondary softening. A gimimatous inflammation commencing in the pia mater may infiltrate a wide extent of the cortex. Syphilitic atheroma of the cerebral vessels is not rare, and the arteries of the base are especially prone to suffer from a peculiar destructive specific lesion which renders them whitish, opaque, and hard, and finally almost obliterates their lumen. Symptomatology. — Although acute or fulminating sypkilitic coma may devcloj) abruptly in the midst of apparent health, it probably is, in fact, always preceded by headache, vertigo, or other prodrome. The coma pro- duced by the obliteration of the cerebral vessels is usually progressive, the true fulminating coma being commonly the outcome of gummatous inflammation. It may or may not be accompanied by delirium or convulsions. A patient of my own, about thirty years of age, became very drowsy one afternoon, and fell asleep. In a few minutes sleep changed to coma, interrupted an hour or so 72.; SYPHILITIC DISEASE OF THE B/iAIX. I'll later by violent delirium, alternating with furions eonvnlsions. The coma may, however, be accompanied with comj)lete muscular relaxation or in rare cases by local or hemiplegic paralysis. The pulse-rate may fall below the norm or may become rapid ; the arterial tension may be high or low, and the pulse- wave large or small. It is of vital importance to recognize that the symptoms of syphilitic coma are the same as those of congestion and inflammation of the brain from other causes, and that the first treatment in a serious case should be directed not so much to the specific disease as to the brain congestion which it has provoked. The symptoms of chronic brain syphilis are so protean, so varying, that it is almost impossible to reduce them to anv order. Possiblv, the most dan- gerous cases are those in which the symptoms are least severe and so elusive that they fail to cause alarm. Malaise, a little brain fiiilure, a succession of causeless headaches, — these may for a time be all the outcome. After a greater or less continuance of thcoC prodromes epileptic attacks usually develop, with a hemiplegia or a monoplegia which is almost invariably incom])lete and usually progressive; very frequently diplopia is manifested before the epilepsy, and on careful examination is found to be due to weakness of some of the ocular muscles. Not rarely oculomotor palsy is an early and pronounced symptom, and a marked paralytic squint is very common. There is almost always dis- tinct failure of the general health and progressive intellectual deterioration, as shown by loss of memory, failure of the power to fix the attention, mental bewilderment, morbid somnolence, perhaps aphasia, and toward the end of life not rarely dementia. If the case convalesce, the amelioration is gradual, the patient travelling slowly up the road he has come down. If the case end fatally, it is usually by a gradual sinking into complete paralysis, or the patient is carried off by an acute inflammatory exacerbation, or a very violent epileptic fit may produce a sudden fatal asphyxia. Death from brain-softening around the tumor is not infrequent, but a fatal apoplectic haemorrhage is rare. It is almost impossible satisfactorily to reduce to any order or types the various forms of cerebral syphilis. Besides those cases which resemble demen- tia paralytica, Henbner makes two types: (1) psychical disturbances, with epilepsy, incomplete paralysis (seldom of the cranial nerves), and a final coma- tose condition, usually of short duration ; and (2) genuine apoplectic attacks with succeeding hemiplegia, in connection with peculiar somnolent conditions occurring in oftcn-reix'ated episodes; frequently phenomena of unilateral irri- tation, and generally at the same time paralyses of the cerebral nerves. The only conformity of meningeal syphilis, as I have seen il, witli these tyjK-s is in the fact that when e[)ik'psy is pronounced the basal cranial nerves arc not usually paralyzed; and it seems necessary to adtl Iwo other types of disease — namely, (3) Psychical distinliance witliout complete epilepfic convulsions, associatexl with palsy of the basal nerves and often wilh j)ai'(ial hemiplegia. (4) Paraplegia associated wilh ocular ov other symptoms indicative of lesions at the base of the brain. 728 SYPHILIS OF THE NERVOUS SYSTEM. Ill nature, however, there are no distinct varieties of cerebral syphilis, all forms cradino- one into the other, and it is most satisfactory to study the important symptoms separately. Headache is the most constant, and usually the earliest, of the symptoms of meningeal syphilis, but it may be entirely wanting. It may last for several years without the development of other distinct symptoms, and sometimes dis- appears when these appear. It has no fixed character, but is usually paroxys- mal, and may occur solely in the form of very distinct and very violent par- oxysms, accompanied by partial unconsciousness or other marked congestive symptoms. ])istinct soreness of the head indicates disease of the skull or its periosteum. Insomnia is a frequent prodrome of cerebral syphilis, but a peculiar somno- lence is much more characteristic. The foudroyant coma has already been described : in the second variety of syphilitic stupor the symptoms develop gradually. The patient sits all day long or lies in bed in a state of semi-stupor, indifferent to everything, but capable of being aroused, answering questions slowly, imperfectly, and without complaint, but in an instant dropping off again into his quietude. In other cases the sufferer may still be able to work, but often falls asleep while at his tasks, and especially toward evening has an irre- sistible desire to slumber, which leads him to pass, it may be, half of his time in sleep. This state of partial sleep may precede that of the more continuous stupor or may pass oflP when an attack of hemiplegia seems to divert the symp- toms. TiiG mental phenomena in the more severe cases of somnolency are jieculiar. Tiie i)atient can be aroused — indeed, in many instances he exists in a state of torpor rather than of sleep ; when stirred up he thinks with extreme slowness, and may appear to have a form of aphasia, yet at intervals he may be endowed with a peculiar automatic activity, especially at night. Getting out of bed ; wandering aimlessly and seemingly without knowledge of where he is, and unable to find his own bed ; passing his excretions in a corner of the room or in some other similar place, not because he is unable to control his bladder and bowels, but because he believes that he is in a proper place for such acts, — he seems a restless nocturnal automaton rather than a man. Apathy and indifference are the characteristics of the somnolent state, yet the patient will sometimes show excessive irritability when aroused, and will at other periods complain bitterly of pain in his head, or will groan as though suffering severely in the midst of his stupor — at a time, too, when he is not able to recognize the .seat of the pain. I have seen a man with a vacant, apathetic face, almost com- plete aphasia, persistent heaviness and stupor, arouse himself when the stir in the ward told him that the attending physician was present, and come forward in a dazed, highly pathetic manner, by signs and broken utterances begging for something to relieve his head. Heubner speaks of cases in which the irrita- bility was such that the patient fought vigorously when aroused — this I have not seen. After some days of excessive somnolence and progressive deepening of the ijtupor, or sometimes more rajjidly, the victim of cerebral syphilis may pass SYPHILITIC DISEASE OF THE BRAIN, 729 into a condition of profounfl coma, out of which he cannot hv aroused, and during which his fseees and urine are either not parsed at all or are voided involuntarily. This condition of coma may end in death, but even when the symptom, seem most serious the patient may gradually recover, slowlv emerg- ing from coma into stupor, and from stupor into wakefulness and normal litK Motor paralysis is very frequent in cerebral syjihilis. It sometimes develops gradually, but it may appear suddenly, with or without the occurrence of an ajioplectic or epileptic fit. When under these circumstances the paralysis is, on the first return to consciousness, complete, it is almost alwavs due to a clot or thrombus. The characteristic syphilitic palsy is ]>rogressive and incom))lete. Any por- tion of the body may be involved, but the syphilitic exudation especially haunts the base of the brain, and a rapidly but not abruptly apjiearing strabisnnis, ptosis, dilated pupil, or any other paralytic eye-sym])tom not readily accounted for in the adult is, in the majority of cases, syphilitic. Tiie specific palsy is often temporary, transient, and shifting. Sensm'y palsies are less frequent than motor palsies, but hemianesthesia, localized anjesthesia, indeed any form of sensory paralysis, may occur. Special sense-palsies are sometimes present, whilst specific aphasia is common. It may be incomplete, transitory, and par- oxysmal, but is more apt to be complete and to have permanency than are motor paralyses. Owing to the tendency of syphilis to produce multiple lesions, a lack of ap])arent agreement between the })alsy and the aphasia is almost characteristic. Thus, Tanowsky found that out of 32 cases of syphilitic aphasia with hemiplegia, in 14 the paralysis was on the left side. Polyuria and true saccharine diabetes occur in cerebral syphilis, probably as the result of vaso-motor disturbances. Epileptiform comuilsions are a most characteristic symptom. A history of intense and protracted headache, followed by an epileptic fit, in an adult should excite the greatest suspicion. My experience is in accord with that of Four- nicr, that epileptiform convulsions not due to alcoholism or unenn'a, and not appearing until after thirty years of age, are in nine cases out of ten specific. The aura is rarely present ; the symptoms may \>v unilateral or even mono- ])legic, but any variety of epileptiform convidsions may be simulated. Furious attacks of local spasms also occur without loss of consciousness. Then, again, the movements may be continuous and distinctly choreic. Psychical Symptovis. — Apathy, somnolence, loss of memory, and general mental failure are the most frequent and characteristic mental symptoms of meningeal syphilis; but almost any fijrni of insanity — mania, niclaucholia, erotic mania, delirium of grandeur, etc. — may be of specific origin. TTsiially, sooner or later, distinct symj)toms of organic; lesion a|)p( :ir. i^spccially common is a loss of mental and physical power similar to that which occurs in dementia paralytica. Diagnosis. — In the udroyant c(jma, iC (licrc be pronounced ni'terial excitement or if the patient's strength be good, venesection should be resorted to at once. T have seen life saved by the abstraction of nearly a (piart of blood, whilst in other cases a few ounces suflice. Cure nui>) be exercised not 732 SYPHILIS OF THE XERVOUS SYSTEM. to mistake a simple epileptiform convulsion for a pronounced congestion of the brain, but if there be epileptic status with repeated convulsions, or if there be violent delirious excitement, venesection may be resorted to if the patient's general condition permit. In severe cases the bleeding should be as rapid as possible, and be continued until a distinct impression is made upon the pulse. When the heart's action continues violent after venesection, the hypodermic injection of the tincture of aconite-root (two to four drops) may be given every half hour until physiological eifects are manifest. In feeble cases cup- ping to the back of the neck, stimulating injections, sinapisms to the extrem- ities, cold to the head, croton oil as a derivative, and other classical remedial measures for brain congestion may be used. In chronic cerebral syphilis remedial measures looking to the relief of symptoms may occasioually be employed with teuiporary advantage, but are of comparatively little importance. The first therapeutic question to be decided is usually as to the choice between mercurials and the iodides. Cerebral gummata may develop in per- sons showing marked evidences of cachexia, but in the great majority of cases cerebral syphilis aj^pears at a time when there is no general breaking down of the tissues or of the general system. The choice between the alternatives should rest upon the existing symptoms, and not upon the time which has elapsed between the primary infection and the outbreak. When cachexia con- traindicates the free use of mercurials, or even of iodides, tincture of iron and corrosive sublimate may be given together, as in the following formula : II. Hydrarg. chlor. corrosiv., gr. iss ; Tr. ferri chloridi, fjij ; Glycerinse, f ^j ; Ol. earyophylli, Tllxviij ; Syrupi, q. s. ad f^xviij. — M. Sig. Teasj)oonful in water after meals. The slowness of the action of the iodides may be serious. In two cases I have seen death occur in an epileptic fit in patients who were rapidly improving under iodides. If mercury had been exhibited so soon as these cases came under care, the rapid removal of the lesions would have probably prevented the fatal fits. More and more has it become with me a favorite rule of action in cerebral syphilis, without evidences of cachexia or a history of recent mercurialization, to begin the treatment with mercury in such doses as are necessary to cause slight salivation, and to maintain a mercurial impres- sion just below the line of slight tenderness of the gums for some days or weeks, pro re nata. The method of administering mercury should be suited to the exigencies of the individual case. If mercurials by the mouth are well borne, they should be so administered. If the symptoms are extremely urgent, the mercury may be given both by the mouth and by inunctions. When there SYPHILITIC DISEASE OF THE BRAIX. 733 is u toiulencv to diarrhoea the mercurial inunction should be used al()n(\ I do nut tiiink that the oleate is preferable to the old blue ointment : a half drachm to three drachms of either may be used at once. An excellent plan is to give a hot bath late in the afternoon and use the inunction on ffoino: to bed, order- ing the patient to rub the ointment on Sunday night into the left axilla; Monday night, into the left flank ; Tuesday night, into the inside of the left thigh ; Wednesday night, into the right axilla ; Thui-sday night, into the right flank; Friday night, into the right thigh; Saturday night, into the region of the umbilicus; after this recommencing with the left axilla. In Europe the mercury is often given hypodermically, but I believe that the dangers of local inflammation overbalance any superiority of the plan ; at least my own experience of hypodermic injections of mercury has been siuijularlv unfortunate. After a prolonged mercurial course iodide of potassium should always be given in order to secure elimination of the mercury as well as to relieve the syphilis. The dose of the iodide must be suited to the individual case. It is usually best to begin with 10 grains three times a day ; in the course of two or three days this may be increased to 20 grains. Usually the patient who will tolerate a drachm of iodide a day will also tolerate two drachms a day. A majority of" those persons mIio can take two drachms a day without the production of iodism can take three drachms. It is therefore safe to advance the dose very ra]>idly after it has been found that a drachm a day causes no inconvenience. Not rarely it seems almost impossible to produce iodism. I have frequently given the iodides up to or even beyond six drachms a day. 1 do not believe that larger amounts than these are of any especial service, and I am not sure that any advantage is gained by going beyond a daily dose of half an oimee. The iodide is so soluble that a watery solution, one minim of which rep- resents a grain of the salt, is readily made and is permanent. I have been accustomed to use the following formula, directing the patient to add to a dessert- or tablespoonftd of No. 2 and a quarter tumbler of water the desired number of minims of No. 1 : I^. Potassii iodidi, 5J ; ^- Syr. sarsap. comp., f.^vj. Aquae, f.sj. S. No. 2. M. et ft. sol. S. No. 1. I am not sure that the abandonment by the ]»rofession of the use of the so-called "Woods" is right. I have seen "Zitmann's decocticm" do good after the failure of the other forms of the iodides and mercurials. A fair imitiition of the old " Woods" may be obtained by sui)stituting for Number 2 of the fornnda just given a nuxture of e<(ii;d j.arls of (he compound fluid extract and compound syrup of sarsa[>:iiilla. 734 SYPHILIS OF THE NERVOUS SYSTEM Spinal Syphilis. The pathology of the acute, explosive form of spinal syphilis, in which the symptoms resemble those of Landry's paralysis, is at present uncertain. It is not known whether the disease is centric or is a peripheral neuritis. The second form of spinal syphilis is that in which softening of the cord occurs as the result of previous syphilitic disease of the blood-vessels. The third form is that in which syphilitic neoplasms develo]>. The fourth variety is that in which a gummatous infiltration occurs, commencing in the pia mater and spreading inward, involving the cord even into the gi-ay matter, the first change being usually, if not always, thickening of the walls of the blood- vessels, with dilatation of the perivascular spaces and exudation of minute cells around the vessels. Heubner describes another variety of spinal syphilis in which there is found after death a condensation of the cellular tissues around the cord. This so-called sypJiiUtic callus is probably not a primary syphilitic lesion, but the resultant of true gummatous inflammation. Symptomatology. — Spinal softening and spinal neoplasms due to syphilis produce .symptoms similar to those caused by similar lesions not due to syphilis. The symptoms of gummatous spinal meningitis are those of a localized sub- acute meningitis — namely, pain and spasm, with paralysis, aifec;ting some peripheral part corresponding to the seat of the lesion. The pains are some- times exceedingly severe, furious agonies shooting along the afi^ected nerves or fulgurant crises simulating those of true locomotor ataxia. Often there is acliing in the back. When this aching is accompanied by marked soreness on pressure or on jarring, the vertebrae themselves may be considered to be aifected. Various parsesthesise, marked hypersesthesia or anaesthesia, girdle pains, tonic spasms, localized tremors, grossly exaggerated reflexes, — such are the symptoms of irritation, which may be followed by complete paralysis with trophic changes. The symptoms of diffused syj>hilitic infiltration of the cord vary with the seat of the lesion, simulating now locomotor ataxia, now spastic paraplegia, now chronic mycliti.s. Diagnosis. — The recognition of the true nature of the spinal syphilis must dejiend upon the study of the collocation of the symptoms rather than of the individual .symptoms themselves. The lesions of syphilis are prone to be multiple, and are rarely as strictly confined to individual functional tracts as in sclerosis; consequently, the symptoms of .syphilis of the cord are very apt to be mixed. Thus, there will be loss of co-ordination associated with retention of the patellar reflex ; or the ]xitellar reflex may be lost at a time when there is marked loss of power in the muscles rather than loss of their co-ordinating function ; or an apparent loco- motor ataxia will 1)e associated with loss of power over the rectum or bladder; or a case which up to a certain point offers a typical ontline of lateral sclerosis suffers from fulgurant pains or from paralysis of the sphincters. Almost any conceivable mixture or interweaving of spinal symptoms may SYPHILIS OF THE PEBIPHEBAL NERVES. 735 occur as the result of syphilis of the cord, so that the most pathognomonic evidence of the existence of the disease is an atypical aggregation of symptoms. Whenever a contradictory mass of phenomena, evidently spinal in orio;in, pre- sent themselves before the practitioner, suspicion should at once be stronglv aroused. Prognosis. — The prognosis in spinal syphilis is less favorable than in syphilis of the brain. Frequently great improvement can be obtained by treatment, and alleged cures are not rare; but even in these so-called ''cures" careful examination will usually reveal the existence of some perma- nent damage. Treatment. — In the treatment of spinal syphilis the most urgent haste should be made by the free use of the mercurials to break down the gum- matous exudation before it shall have produced secondary degeneration in the spinal cord. Only the most distinct cadiexia justifies the beginning of the treatment with iodides. Absolute or partial rest should always be enforced during the treatment, whilst the hot and cold douche, massage, muscle-beaters, faradization, and other remedial measures and appliances may be used to keep up the circulation and nutrition of the affected muscles. These palliative measures are, however, of very little im[)ortance as contrasted with tire anti- specific medication. When the vertebrae are involved, immediate treatment by suspension should be resorted to, and the plaster jacket or one of its sub- stitutes should be used. Syphilis of the Peripheral Nerves. Syphilitic Affections of the peripheral nerves are rare, but occur in three forms: first, pressure neimtis, including those cases in which the nerve-trunk is affected simply by pressure, the alterations not being in any jiroper sense specific; second, secondary syphilitic infiltration, including those cases in which the nerve-trunk is involved in a syphilitic deposit which has commenced in a neighboring organ and has secondarily infiltrated the nerve with gummatous tissue; third, primary nei've-si/philis, including those cases in which the lesion is distinctly specific and primary. Of these varieties of nerve-syphilis, only the last seems to need any pathological discussion here. I have occasionally noted, in cases in which there was evident specific dis- ease of the nerve-centres, a coincident tenderness of nerve-trunks, indicating that the latter were in a condition of inflammation, but have always been very doubtful as to whether such neuritis should be considered as due directly to the specific poison, or whether it were not simply a secondary inflammation prop- aerated alon<'- the nerve-trunk irritated bv a ginnma somewhere in its course. A case published in the Wien. vied. Blatter for 188G by Dr. S. Erhmann makes it probable, however, that the sy])liiliti(; poison may act like the rheu- matic, the alcoholic, the plumbic, an>;;i55i•'^:;:^^:•^:•■"^ " Diagranitnatic Scclioii vi Spinal Cord. The Posterior Median Column, <>r the Colunm (.((Ji.ll, lies iminediatcly in contact with the po.sterior fissure of the cord, it is ((HiiiMiscd chiefly nC fibres which enter through the posterior nerve-roots and i)ass upward. Tlic increase in the size of the column of (loll from below upward eration ever follows the course of these reofions. 3 ^"^If^ ' The gray matter of the spinal cord, besides the numerous * ^'15 ' conducting fibres which it contains, has situated in it gan- ' ^°'M} glionic cells whose processes are prolonged into nerve-fibres ° \^'j '° composed solely of the axis-cylinders. The ganglionic cells 3 ^j;^ are arranged in groups which vary in different portions of the cord, and probably in the same portion of the cord in * 7A^\ different individuals. The most readily recog-nized of the mW^ ' groups are the small inner or medial group, situated in g (/liotfTi ' the inner anterior angle of the cornua ; the large anterior « (/\ group, placed near the anterior edge of the cornua, in the '° middle or a little to the outer side of the middle of the « ^Ir " margin ; the anterior lateral group, situated in the outer >•' ^^JIt "" extremity of the front of the cornua (the last two groups * bCn,. ^ frequently consolidate) ; the external or postero-lateral ^ ( jlirr group, which is usually the largest and is extended in s o-^zm^. the posterior outer angle of the cord. The diagram (Fig. s Cml^^ - -'s 50), taken from Gowers, shows the general arrangement of these groups in four different portions of the cord. The most condensed statement of the facts necessarv fi)r alsy to become complete woidd in any case give ho])e of arrest. Treatment. — There is no known specific treatment. Absolute rest, with careful feeding, should be strictly carried out, and any sym|)tom that may arise br* met. I am not aware that the effect of early venesection has been carefully studied, l>ut with the ])resent j)robabiliti('s of {\\v. bacterial nature i>f the dis- ease local or general bloodletting, and cvm severe spinal conntcr-irritation, seem scarcely indicated. The free hypodeiinie use of exirael of ernot for (lu; pin-pose of diminishing sj)inal congestion may be Juslified. When there is any suspi(,-ion (jf rheiuuatic origin the salicylates should be adniinistei-ed with great freedom. 752 ORGANIC DL'SEASE,S OF THE SPINAL CORD. Acute Myelitis. Definition. — An acute inflammatory affection, involving the whole thickness of a shorter or longer ]>ortion of the cord, characterized by paralysis of motion and of sensation, with trophic changes. Etiology. — Acute myelitis occurs most frequently between the age of puberty and the fortieth year of life, and more often in men than in women. It mav have its origin in traumatism, in compression of the spinal cord, and especially in the implication of the cord in the growth of thin inflamed tissue producing the pressure. It is asserted by authors to be sometimes due to excessive sexual excesses, especially unnatural coitus, and sometimes to be the outcome of excessive bodily exertion. A much more potential and positive cause of tlie disease is exposure, especially of the overheated body. Thorough wetting, sleeping on the snow or damp earth, etc. have in numerous instances been immediately followed by an acute myelitis. In winter campaigns it has been especially abundant, probably induced by the conjoint efl'ects of violent emotional and physical excitement, with over-exertion and extraordinary exposure. Acute myelitis lias been noted as a complication of various acute exanthe- mata, diathetic and septic diseases, and it is said to occur with great frequency and severity among syphilitic patients, though the etiological value of syphilis is very questionable. Pathology. — The macroscopic changes produced in the spinal cord by myelitis consist of alterations in color and consistency. Even whilst still in its membranes the cord feels to the fingers much softer than normal, or even fluid-like, and in extreme cases, when the meninges are opened, the whole inner mass escapes as a pultaceous fluid. If sufficient firmness remain, so that a section can be made, the surface of the section will be reddish, yellowish, or brownish, and seemingly structureless, no distinction existing between the gray and the white matter. The situation and longitudinal extent of the lesion varies indefinitely, but the dorsal cord is especially prone to suffer. The transverse position of the softening also varies. In severe cases the whole thickness may be completely disorganized, but the gray matter is most universally and overwhelmingly attacked ; hence the term central myelitis. Very often, instead of a single considerable territory being softened, foci are scattered through the cord (insular and disseminated myelitis). The variations in color chiefly depend upon the amount of blood in the part; ruptures and necroses of capillaries, and even larger blood-vessels, are inevitable, and hence occurs the exudation of altered blood, giving brownish or reddish tints, and also not infrequently the formation of small l)lood-clots {hcemorrhagie myelitis). The line between sound and diseased tissue is never abrupt, each focal change being surrounded by a zone of diseased tissue shading off into the normal cord. AVhen life is jn-olonged and the acute disease merges into a chronic condition, the cellular or neurogliar tissue around the foci of inflammation undergoes a hyperplasia which ACUTE MYELITIS. 753 results in a pronounced sclerosis, and the focal debris becomes surrounded by a dense tissue, or in extreme cases the debris is finally absorbed and tiie sclerosed tissue more and more condensed until a thick-walled cyst remains. Under the microscope all the nerve-elements are seen to have changed. The multipolar cells of the gray matter at times show uudtii)lication oi* their nuclei : more commonly they are bloated, with their process brt)i into strings of beads, the axis-cylinder being especially prone to increase in size when the structural alteration has gone into comj^lete softening. The nerve-elements are all more or less completely destroyed. There are left glistening, structureless remains of nerve-cells, bits of axis-cylinders or fatty degenerated sheaths, or altered nerve-filaments mixed with drops and masses of myeline, large granule-cells, altered blood-corpuscles, pigment-gran- ules, and a mass of minute granules of unrecognizable origin. The walls of the blood-vessels are thickened, highly nucleated, and often filled with falty granules, whilst the connective-tissue framework, if it remain, is swollen and softened by new cells and fatty changes. The condition of the cord sometimes spoken of as gray myelitis represents an attempt at recovery, in which the escaped myelin and other results of dis- integration have been absorbed, whilst the connective tissue has been increased and hardened into the beginning of a sclerosis. As already stated, this attempted reparation may result in the formation of a cyst or of a cicatrix, but the nerve-filaments have no jwwcr to undergo repair, so that restoration of function is impossible. The process whose anatomical results have just been described is believed by the great mass of })athologists to be an inflammation, and in aa-c^rdance with this view three stages are described : first, the stage of hypera^mia and commencing exudation {red softeninc/) ; second, the stage of fatty degencrati(»n and resor|)tion {yelloio softening) ; third, the terminal stage (formation (»l" cica- trices or cysts, sclerosis, etc.). The fact, however, that true suppuration probably never occurs in pure myelitis, but is only found when the meninges are involved, and the great rarity of post-mortems during the stage of sim|)le hyperjL'mia, have led some writers to deny that myelitis is in truth really an inflanunalion ; indeed, Spitzka affirms that, although authorities describe as anatomical alterations in the first staire canillarv contrestion and infiltration of the vasculai- area, the adventitia, and the neuroglia with gramde-eells, yet he has never been able to find in literature a recorded case in which these things have actually been be(;n. Symptomatology. — The course and symptoms of acute myelitis vary so Vol. I. — 48 754 OBGAXIC DISEASES OF THE SPINAL CORD. miK'li within certain limits that it seems best to analyze them before speaking of the course of the disease. In severe, rapid cases of myelitis the fever develops very early, and may throughout remain persistently high. Sometimes the febrile reaction occurs in paroxysms, and an excessive rise of temperature just before death is not uncommon. The fever may, however, even in fatal cases of myelitis, be entirely absent, and very commonly the temperature does not rise above 101° F., whilst a primary fever often disappears during the attack. The fever of the myelitis itself must be distinguished from the fever which in the later stages is not rarely produced by septic absorjition from sloughing bedsores. The spinal sym])toms are those of irritation and those of paralysis. The symj)toms of irritation, both motor and sensory, usually appear early in the attack, and are more or less completely lost within a short time, in some cases to reappear when partial convalescence develops. Twitching of the muscles, tonic or clonic contractures, and exaggeration of the reflexes may be present ; in some cases any movement of the limbs produces violent, irregular muscular contractions. Tlie symptoms of sensory irritation may be mild or severe. Tingling, numbness, violent formication, shooting pains, excessive distress during micturition and defecation, have been frequently noted, and even after a complete abolition of sensibility an agonizing anaesthesia dolorosa mav remain. Sometimes the pain amounts to an intense agony — a burning girdle -of molten iron, a thrusting of superheated needles through the limbs, a drag- ging or tearing of muscles from the flesh, etc. Pain in the back, with exces- sive sensitiveness over the spinous processes, especially to hot or cold appli- cations, is not rare. True hyperesthesia is not common, but very early in an attack a peculiar, diffused, painful vibrating sensation may occur wdien the part is touched (the di/scesthesia of Charcot). True sexual excitement is never present in myelitis, but painful priapism is not rare during the stage of irrita- tion, and may last into the paralytic stage. The symptoms of irritation usually very rapidly disappear, more or less comi)letely, in those of paralysis, the motor paralysis becoming complete, the nuiscles being flaccid, and the limbs lying as though dead. The form of the palsy is usually paraplegic, but it follows the seat of the lesion and may be- come universal. The paralysis is accompanied with loss of the reflexes, the knee-jerk and the cutaneous reflexes disappearing entirely. In some cases in the lower part of the body the paralysis is complete and the reflexes absent, whilst higher up exaggeration of the reflexes shows that the stage of irritation is not yet i)ast. The sjihincters are almost always involved, and retention or incontinence of urine is often an early symptom. The loss of sensation is complete, involving all forms of sensibility. Probably as the result of the involvement of nerve-centres presiding over secretion, the excretions rapidly become abnormal. Thus, even in two days the urine may become highly alkaline, bloody, rauco-purulent, and loaded with the crystals of triple phosphates, whilst the ijerspiratiun is excessive, irregular, and altered in quality. ACUTE MYELITIS. Too Vaso-niotor \Y,\hy occasionally shows itself at fir.^t in a toinporarv rise of the temperature of the paralyzed limbs, bnt usually the extremities are cold and may be swollen In- a ditl'use cedematous exudation. Muscular atrophy, with loss of faradic irritability and the development of the reactions of degeneration, appears very early. The troj)hie bedsore, decubitus aciitus, Mhich in .severe cases may be unavoidable, usually attacks the sacro-gluteal region, but occasionally appears in the heels or other portions of the body. The first warning consists of one or several dark-red or violet erythematous patches, variable in extent and irregular in shai>e. Within twenty-four or forty-eight hours reddish or brownish vesicles or bidlje form in the central portions of the erythema. In rare cases, under careful manage- ment, the blebs wither and disa{)pear without further symptoms ; usually, how- ever, the elevated e])idermis is toi'n or drops off, leaving a bright-red surface with bluish or violet points or patches, and with swelling and sanguinolent infiltration of the surrounding tissue. Quickly the reddish surface becomes blackened, and a slough of variable extent forms. The whole buttock may thus melt down in the course of a few hours. Sometimes the process is arrested and the slough se]>arates, but oftener the process continues, and, uidess the patient die too quickly, the deeper muscles, with the nerve-trunks and arterial branches, are laid bare, and finally the bones themselves appear. Distinct disturbance of vision is not common in acute myelitis, but con- traction of the field of vision, amblyopia, or amaurosis due to optic neuritis have been noted, and in some cases the disturbance of vision has preceded the outbreak of more ordinary symptoms. Acute myelitis varies indefinitely in the rapidity of its course, but three types may be recognized : the explosive, the acute, and the subacute, it being understood that in nature these grade one into the other. Tiie foufh'oi/ajit or the explosive myeliiis (myelitis centralis) connnences abruptly, with disturbance of scMisation, followed in a few minutes or h(»iirs by <"omplete anesthesia, motor paralysis, trophic changes, and abolition of rcficxes. It is usually associated with more or less intense fever, delirium, coma, or con- vulsions. This central myelitis is often associated with ha}morrhage into the cord (hcematoini/elifls), when the paralysis becomes complete in a few minutes. In these cases death may occur without violent constitutional symptoms. The acute myelitis runs a very rai)id course, with or without fever, the |)ar- alvsis becoming (.'omplete in from one to two weeks. Disturbances of the cerebration are not a necessary symptom of acute myelitis, but usually in rapid cases fever, headache, and (h.'lirinin aic present. T\\G subacute myelitis \< that in whi in death from septic fever and exhaustion in a 75G ORGANIC DISEASES OF THE SPINAL CORD. few weeks or months, or occasionally may terminate in an imperfect recovery. Subacute myelitis may end in death, but very commonly passes into a con- dition of chronic myelitis, in which mild trophic symptoms and partial para- plegia may exist for years ; or it may end in an imperfect recovery with atrophies and paralysis in groups of muscles. In very mild cases recovery may occur after a prolonged convalescence. Diag-nosis. — The difficulties which hang about the diagnosis of myelitis are best discussed by considering the different forms separately. The only diseases M'ith which an explosive myelitis can be confounded are Landry's paralysis and haemorrhage into the spinal cord. The myelitis, however, is usually distin- guished by the existence of decided fever ; by the pronounced disturbance of sensation ; by the early paralysis of the bladder, and especially by the early coming on of muscular atrophy, with the reactions of degeneration ; and by the diffuse oedema, the sloughing bedsores, and other trophic alterations. Hiemorrhagic myelitis so closely resembles haematomyelia that no less an authority than Spitzka denies the existence of the latter condition ; and when headache, fatal delirium, and other constitutional symptoms are absent, it may not be possible at first to make out the myelitis, which must, however, soon be revealed by the occurrence of trophic changes. Acute myelitis may be confounded with certain forms of poliomyelitis, but the latter lack the pains and the superficial trophic changes in the skin which occur in myelitis. From a peripheral neuritis the myelitis is to be distinguished by the intensity of its paralytic phenomena, by the rapidity of the development of the muscular atrophy and other trophic changes, and by the absence of ten- derness over the nerve-trunks. In subacute myelitis the trophic changes often occur slowly or are altogether absent. Such a case, however, lacks the nerve-trunk tenderness and the exces- sive pain of porij)heral neuritis. Treatment. — The treatment usually advised in acute myelitis is founded upon the theory that the lesion is inflammatory and capable of arrest by anti- phlogistic measures. Under this view of the case, if the patient be seen in the onset the most active antijihlogistic treatment is justifiable. If it be possible to arrest so serious a local inflammation, the fear of producing a general exhaus- tion should have little consideration. Unfortunately, however, there seems to be no weighty clinical evidence that the most severe venesection, use of cold, or other anti])hlogistic measures, have distinct influence upon the disease. Never- theless, if the general constitutional condition be good, blood may be drawn from the arm, and active local bloodletting, by means of leeches or dry cups, is usually advocated by authorities. Ergot is commonly employed for the pur- ])ose of diminishing congestion, and, although our knowledge of the actual value of the drug is imperfect, its harmlessness and the possibility of useful- ness warrant its free administration. It may be given in the beginning hypo- derm ically in the form of the extract, and afterward the extract may be administered in doses of ten to fifteen grains every three hours, until disturb- ACUTE MYELITIS. 757 anco of the stomach, ergotic cohhiess of the surface, or the continuing progress of the disease indicates its \vith(h-awal. The production of diaplioresis hv the use of the hot bath or hot pack is especially recommended by Erb in cases in which the premonitory signs of myelitis make their appearance after e.^posure to cold, etc. ; but I cannot believe that these measures really avail anything, though they may in various cases have relieved rheumatic pains and general muscular soreness following exposure, which had been sujiposed to be precursors of myelitis. During an attack the warm l)ath, however, does appear to be grateful to patients and to render them more comfortable, and should always be tried. In employing it absolute precautions must be taken that the patient himself make no effort whatever, a sufficient staif of nurses to readily lift him being provided. The temperature of the bath should be in the beginning 90°, to be increased later if it be found advisable. The duration of the bath should at first be about ten minutes, but it should be rapidly increased almost indefinitely, according as it is found to agree with the individual case. The bath may be given once, twice, or three times in the twenty-four hours as seems wisest. The free use of mercurials has been largely advocated, usually on theoretic grounds. Certainly, grave doubts surround the advisability of mercurial- ization, and if ptyalism be ])roduced at all it should be done with great caution. There is not the slightest reason for supposing that belladonna, derivation to the intestines, or the production of diuresis by means of the ingestion of large quantities of alkaline waters, as recommended by Erb, are of any service what- ever. Of course if excretion fails from want of nerve-influence, care should be exercised to see that the emunctories are kept active. Strychnine has been recommended by high authorities, whilst other practitioners (myself among them) have found it to do injury. If the generally held views concerning the nature of the disease and the action of strychnine be correct, injury rather than good is t\) be expected from its use. A question which always requires very careful consideration is as to the use of local applications to the spine. The application to the spine of ice con- tained in a long thin rubber bag })ossibly may be of s^ervice, and probably is not injurious. Counter-irritation by means of the actual cautery or the blister has been largely ])ractised, and finds much commendation by some writers. The grave danger, however, of precipitating ulcers and widespread gangrene attends the use of remedies of this (;lass, and certainly no counter-irritants should i)e applied to the skin which is already distinctly anjcsthctic or to a part which may be exposed to continuous pressure. Sjjit/Ua, on tiieoretic grounds, believes that counter-irritation applied to the lower legs and feet is of much more service than are the same measures ai)plied to the bacU. The use of the galvanic current, as occasionally ])ractised, seems to be an outcome of a childish credulity. From what has been already saitl it will l»e seen thai the value of drugs in mv(!litis, save only for the relief of symptoms, must be at present considcrwl problematic. 758 ORGANIC DISEASES OF THE SPINAL. The nursing during acute spinal inflannnation is of the utmost importance. So soon as there is any reason to suspect the commencing of a myelitis absolute rest in bed should be prescribed, and, so far as possible, the patient shoukl be prevented from moving a single muscle of the body, the feeding, the making of the personal toilet, etc. all being done by an attendant. This absolute abstinence from muscular movement applies not only to the pre- cursorv stage, but is even more important when the symptoms of convalescence are developing. Under these latter circumstances any muscular activity may produce a relapse. In tiiose fortunate cases in which the patient recovers the avoidance of fatigue should be strictly enjoined for one or two years after the attack. What is true of muscular movements during convalescence is even more true concernino; the sexual functions. Various authorities lay stress upon the influence of the dorsal decubitus in increasing congestion, and consequently inflammation, in the spinal cord, and although it seems to me that this injunction is based upon a supersensitive theorism, it may possibly be correct, and the patient should therefore be kept as ranch as is convenient upon the side, or, according to some, even upon the face. If the patient can be made comfortable in the ventral position, it has the advantage of removing from pressure those j)ortions of the body most prone to development of gangrenous lesions. Such lesions constitute one of the most serious complications of myelitis, and are therefore to be guarded against by keepiiig the surfaces perfectly dry, by preventing pressure, and especially by putting the patient on a water-bed, which should be covered with one or more heavy woollen blankets so as to avoid any chilling of the body. If bedsores appear, they must be treated according to the ordinary method, irritating applications being, at least in the early stages, avoided, and antisepsis carried out as thoroughly as may be. In the very beginning of the case it is necessary to pay the strictest atten- tion to the condition of the bladder, as urinary retention and its consequent cystitis and pyelitis are so frevaters have acquired. The hygienic treatment is exceedingly important, and by change of air, careful selection of diet, and all other means the general health should be improved as much as possible. Mental depression, over-exertion, and fatigue are to be sedulously avoided, and as favorable a view of the case as possible should be given to the patient. Rest on the bed or couch is often of the greatest service, and when conjoined with daily use of massage may be main- tained for a length of time without endangering the general health or pro- ducing muscular relaxation. When circumstances favor it the patient may with great advantage spend a large portion of his time on the bed, couch, or lounge in the open air. Acute Poliomyelitis. Definition. — An acute disease de])endent upon inflammation or degeneration of the ganglionic cells in the anterior cornua of the spinal cord, characterized by paralysis, with complete relaxation, rapid atrophy, and alterations of the electrical reactions in the affected muscles. Synonyms. — Acute anterior poliomyelitis ; Infantile paralysis ; Essential paralvsis of childhood ; Acute atrophic paralysis. Etiolog-y. — Acute jwliomyelitis is essentially a disease of childhood, although it does occur during adult life. It may appear in the first month of infancv, and about five-sixths of the cases arc developed in children under ten years of age. It is indeed often claimed to be of intra-uterine develop- ment, but the correctness of this is doubtful. It attacks males more fre- (juentlv than females. So rarely is it possible to trace hereditary influence that it appears not to occur with abnormal frequency in neuroj)athic families. As was first shown by Wharton Sinkler, at least in the climate of Philadelphia, it comes on more frequently during the summer than the winter months. The attacks have in so many cases followed immediately upon ex|)osure that it is impossible to escape the conviction that the exposure had been the exciting cause. The same is true of over-exertion, es])ecially over-walking, in very young children. Traumatisms appear occasionally to atford the initial point. Dentition is frequently assigned as a cause, and certainly |)oIiomyelitis has in numerous instances been a secondary result of acute exauthematous diseases or of some local acute inflammation with high fever. The explanation of the frequency of th(! disease in childhood, and of the variabilitv of the exciting causes, seems to riic not far lo seek. The spinal structure involved is trophic in its fnn<;tions, and (lining cliildliood lias not only to maintain the nutrition of the muscles already developed, as it does in adult life, but also to preside over growth and develoj)ment in these muscles. 762 ORGANIC DISEASES OF THE SPINAL CORD. The functional activity in tliese parts must therefore be excessive during child- hood, and must be attended with a constant hyperseraia and excitement, which make the part liable to be thrown over the line of health by any transient irritation. Patholog-y. — Tlie one lesion which has always been found in modern autopsies. in cases of essential infantile paralysis has been degeneration of the multiple ganglionic cells in the anterior cornua of the gray matter of the spinal cord. Death is so rare in the early stages of the disease that there are few records of post-mortems occurring in other than the fourth stage. In one case reported by Dr. Drummond, in which death resulted after a few hours of ill- ness, the ganglionic cells were granular and swollen — a condition which prob- ably represented the incipient stage of poliomyelitis. The next change in the cells seems to be an increase in the density of the granulation, with pigmen- tation : this is followed by disappearance of the processes and shrinking of the bodies of the cells until they become irregular masses whose true nature is scarcely recognizable. Finally, the cells disappear, so that no traces of them are usually found in old cases. The cells are attacked in foci, ranging from a hundredth of an inch to more than an inch in length. All the cells in a focus may be aifected, or the destruction may be limited to certain groups in the anterior, posterior, or other part of the focus. The lesion of the cells is so constant, and is physiologically so closely related to the symptoms seen during life, that there can be no doubt as to its being the cause of these symptoms. Two theories have been and are still to some extent in vogue as to the nature of the lesions in infantile paralysis : one attributes the changes to a primary idiopathic atrophy of the ganglionic cells ; the other teaches that the cells are not affected primarily and apart from the other gray matter, but are involved in a limited central and focal myelitis. It would seem established that in some sections of the spinal cord in recent cases of infantile paralysis the tissue surrounding the cells appears normal, but I do not know of any case in which this condition has prevailed through the whole length of the affected region, and certainly evidences of hyperseniia and myelitic changes in the gray matter about the cells have been very pronounced in most of the early autopsies. In the case reported by Dr. Drummond intense f-apillary congestion, with minute extravasations of blood and swelling of the neurogliar elements, were evident in the gray matter, and in various cases a little more advanced than these the investigator has found the blood-vessels dilated, with their lymphatic sheaths infiltrated with leucocytes or surrounded by minute extravasations of blood ; the neurogliar tissue swollen, granular, containing large round granular cells; the myelin of the nerve-tubes broken ; and indeed not rarely such general disintegration as to cause minute patches of red softening. Our present knowledge trends in favor of the theory that not only the motor ganglionic cells, but also the surrounding tissues, suffer in poliomyelitis. In old cases of poliomyelitis the atrophy of the gray matter is usually ACUTE POTAOMYELITIS. 70:^ accompanied bv changes in the anterior nerve-roots and in the antero-hiteral cohnnns of the cord. The normal nerve-tubes are wasted, stripped of tlieir myelin, often without their sheaths, and are surrounded by hyperplastic neurogliar tissue. Often the parts are infiltrated with amyloid corpuscles, and sometimes the original focal lesion is surrounded by embryonic neurogliar cells, looking as though an attempt had been made to isolate it. It is not probable that these changes are due primarily and directly to the original poliomyelitis, for in no recent cases have lesions of the white columns been observed. It is therefore most probable that these widespread spinal lesions are either trophic or due to a propagation of the inflammation by physiological or anatomical continuity of structure. The microscopic changes seen in the nerve-roots resemble the degenerative atrophy that follows section of tlu^ peripheral nerve. Probably in a majority of cases the nerve-trunks tiiem- selves undergo change. As was shown by Ijeyden, this change may consist of a degenerative atrophy or of a neuritis. The discovery of the frequency of nerve-trunkal disease has given rise to the theory that neuritis is the cause of infantile paralysis. There can be no doubt that many of the symptoms of poliomyelitis may be produced by a peripheral neuritis. It is also known that certain metallic poisons, like lead and arsenic, are capable of originating either a neuritis or a poliomyelitis or a combination of the two diseases. It is therefore probable that in some cases of disease, which we call natural because we are unable to discern the cause, the poliomyelitis exists alone ; in others neuritis exists by itself; whilst in others, again, both aflleetions are consen- taneously developed. Symptomatolog-y. — The onset of acute poliomyelitis is almost invarial)ly sudden, usually occurring in the midst of apparently robust health ; indeed, so rare is any history of a preceding nervous disturbance that such disturbance must be considered as accidental rather than as prodromic. The attack may be without constitutional symptoms, the child perchance waking after a good night's rest paralyzed, or even with apoplectic abruptness developing weakness in the daytime. More frequently there is a primary fever which is in most cases of moderate intensity, although the temperature may rise to 104° F. The duration of the fever varies greatly : sometimes it continues but a few hours, but it may persist three or-four weeks. The same variability is characteristic of the cerebral disturbance: apathy grades in the series of cases into stupor, and this into coma, whilst restlessness or isolated spasms pass into convulsive twitchings, and these into the fiercest of general convulsions. A most important practical fact is that there is not a constant relation between the severity of the constitu- tional disturbance and the extent or depth of the subsequent ])alsy. The sensory disturi)ance is habitually moderate, but pains in the back and limbs are often complained of, and maybe intense. Aiiffisthesia and liypcr- aesthesia are so rare that their existence should waken a doubt as to the cor- rectness of the dia'niosis. Vomitinjx may be absent, or inav be so intractable as to suggest that the case is oii<' of gastritis, 'i'hc i'cvcr rarely lingers long after the (levehtpment of tiie palsy, and may disappear with an abrupt, 764 ORGANIC DISEASES OF THE SPINAL CORD. crisis-like defervescence. In the majority of cases the paralysis is complete before it is recognized, but, although its coming on must be very rapid, I believe the extreme suddenness of its discovery is often due to its having been overlooked. Certainly in a number of cases a progressive paresis, increasing for from a few hours to several days, has been noted, and still more often the paralysis, already complete in one limb, has under observation spread to other parts. During the period of acute constitutional disturbance there is often incontinence, or more rarely retention, of the urine, but true permanent paral- vsis of the bladder never occurs. The situation and extent of the paralysis vary almost indefinitely. Nearly the whole muscular system may be so involved that a true general paralysis results and the child be unable to move hand or foot. The face seems, how- ever, to be practically exempt, permanent paralysis of the facial or ocular muscles due to an acute poliomyelitis being, if it ever occurs, one of the rarest of nervous phenomena. The same is true of the intercostal muscles and of the diaphragm. The reason of this exemption is not known, but to it in great part is due the fact that the disease is so rarely fatal. The subsidence of the constitutional disorder and the development of the ])aralysis are followed by a period of quiescence, which after from one to six weeks is succeeded by a peculiar, almost pathognomonic, regression of the paralytic symptoms. The extent of this regression varies so much that there is little relation between the final result and the amount of original paralysis. The improvement occasionally ends in complete recovery, but in the majority of cases after from two to three months spontaneous amelioration ceases and some of the muscles settle into permanent paralysis. During the second period of the disease — i. e. that of widespread or general paralysis — the affected muscles are in a condition of extreme relaxation, with complete loss of the reflexes, and in a very short time a high grade of rapidly pro- gressive atrophy manifests itself, especially pronounced in those muscles which are to remain paralyzed, and almost from the first accompanied by trophic changes similar to those which follow division of a nerve. The first change is probably modal ; that is, the muscle simply responds more slowly to galvanic currents ti)an it normally does. Very soon, however, qualitative as well as quanti- tative changes a})pear. In order to detect these changes the current must be brought in direct contact with the muscles, for if the electrode be applied to the nerve-trunk, it will be found that the electrical reaction is diminished in quantity, but not altered in quality. If the negative pole {cathode) of a weak battery be placed over a normal muscle, but not over its motor point, a strong contraction occurs at the closure of the circuit ; when, however, the positive pole {anode) is placed over the normal muscle, the contraction is much less: in neither case is there any contraction when the circuit is broken : in other words, witli the normal muscle and a feeble current we obtain good cathodal closing contraction, slight anodal closing contraction, and no motion whatever at either cathodal or anodal opening. When a current of sufficient power is used, opening contractions are produced and the anodal contraction is greater than A CUTE POLIOMYELITIS. 765 the catliodal. The "reaction of degeneration" consists merely in a more or less })erfect reversal of the above formula. The anodal (positive ])ole) closure then causes a stronger contraction than the cathodal (negative pole) closure. When there is oidy a slight degree of degeneration present there is a corre- spondingly slight increase of anodal closing over cathodal closing contraction. A minimum degeneration would be indicated by an equality of the two closing contractions. These alterations in the electrical reactions of a degenerating muscle are readily formulated, and in this M'ay perhaps wnll be more readily grasped by the student. The symbols are as follows : An CI C represents anodal closing contraction ; An O C represents anodal opening contraction ; Ca CI C repre- sents cathodal closing contraction ; Ca O C represents cathodal opening con- traction : < represents is less than ; > represents is more than (the point of the < being toward the lesser quantity). Then the formulas are — An CI C < Ca CI C 1 , i » ^ ^ r^ r^ r^ c '""sclc uormal. An O C > Ca O C j An CI C = Ca CI C 1 i • z- , , ^ i }• muscle m nrst stage oi degeneration. An U \^ ^=^ v^a \j \y ) ^ ^ ^ ' ^ ' > muscle in more advanced stage of degeneration. An O C < Ca O C ) "= ^ After the reaction of degeneration (D R of some authors) has been estab- lished, if the muscle continue to undergo change, the galvanic irritability slowly diminishes, stronger and stronger currents being required to produce an effect. When a certain stage is reached all reactions cease save a feeble An CI C, and at last this is lost and the muscle does not respond at all. When recovery occurs the electrical reactions of the muscle pass upwai-d along the pathway they have descended,' The distribution of the permanent paralysis varies indefinitely, but mo- noplegias are much more common than bilateral symmetrical ])aralysis. A more or less complete crural paraplegia is indeed often seen, but paraplegia cervicalis, or paralvsis of both upper extremities, is so rare that its existence has been denied. Even when a bilateral or symmetrical paralysis occurs, it ' The diagnostic importance of the reaction of degeneration is greatly lessened by tlu- cir- cumstance that its demonstration on the person of a terrified or enraged struggling eiiild usually requires much skill and patience, and that it probably is never ]>resent when a muscle retains its integrity as regards the faradic current. For the puri)Oses of diaKiinsis the failure of response to the rapidly-interrupted fiiradic current is usually a sullicieut tt'st of the con- dition of a muscle. When a muscle loses its i)ower of responding lo the rapidly-interrupted faradic current in a week or ten days after the occurrence of paraly>is, wlielher the reaction of degeneration can or cannot b(! satisfacioriiy detnonslrated, the inference is positive that trojjhic changes are taking place in the muscle. If a f<\v days later sudi muscle is unal)le to respond to any faradic current, this inference becomes a certainty. For tiie purpose of i)rognosis the study of the reaction of degencrati')n may be necessary, but it will, according to my experience, often be found disappointing. 766 ORGANIC DISEASES OF THE SPINAL CORD. can usually he made out that the paralysis is really a multiple palsy — that is, is due to the separate implication of various centres — because it will be noted that in each involved limb certain groups of muscles escape altogether or in part, and that there is no close correspondence between the affected groups in opposite sides of the body. Crossed palsies and hemiplegias are infrequent as a result of poliomyelitis, and, like paraplegia, are to be looked upon as formed out of a number of multiple palsies. Indeed, the paralysis of poliomyelitis is a paralysis of muscle-groups, and the selection of the grouping seems to depend not so nuicli upon the proximity of the muscles in the limbs as upon their being habitually used together in the activities of normal life. In the description of the symptoms of poliomyelitis I have followed the ordinarv division into four stages: first, that of constitutional disturbance; second, that of general paralysis with quiescent symptoms ; third, that of regression ; fourth, that of the permanent paralysis. This fourth stage is, however, not a portion of the disease, but a condition which has resulted from the disease. It is the wreck left by the storm. The permanent paralysis has no direct tendency to shorten life, the disablement being confined to those organs which are connected with locomotion, the digestion, the general nutri- tion, and the sexual functions remaining intact. The affected limb is limp or rigid, often bluish in color (always, if the paralysis be entirely complete, hab- itually cold), and losing its heat with the greatest rapidity upon any exposure. The electrical reaction of the muscles, as well as the atroj)hy, varies with the original lesions. When this is complete the muscles waste to a fibrous band, incapable of responding to any electrical current. Other structures of the limbs also suffer. The growth of the bones is retarded, so that in the growing child gradually the arm, the leg, the hand, or the foot, as the case may be, becomes shorter as well as smaller than its fellows. The interference with the bone development is not always in direct pro- portion to the atrophy of the muscles; indeed, the growth may be permanently arrested, although the paralysis entirely disappears. Relaxation of the joints, due probably in part to lengthening of the tendons, caused by the limbs drag- ging upon them whilst unassisted by their natural allies, the muscles, becomes more and more pronounced as the child grows older, until at last the head of the bone may be entirely out of its socket. Even during the most acute stage of poliomyelitis bedsores are unknown, and in the chronic after-condition there are never trophic inflammations or destructive lesions of the skin. Various deformities arise, not simply from failure of development of the limb, but also from the permanent shortening of the muscles, with consequent active displacement. The contractures which produce these deformities occur chiefly either in muscles which have escaped entirely or have only been par- tially affected, though there is reason for believing that the interstitial devel- opment of" fibrous tissue in the remains of muscles sometimes plays a part in the fixation of a joint. The contractures sometimes appear as early as four weeks after the first development of the paralysis, but are usually late phenomena. ACUTE POLIOMYELITIS. 767 The mechanism of tlio production of the deformity is (lifferently viewed by different observers. The orioiiud tlieory of Delpech, that it is the out- come of contraction of sound muscles which have shortened on account of their not being opposed as they naturally should by their antagonists, has been widely but certainly not universally accepted. Another theory accounts for the deformities by supposing that they are due to the influence of weight upon joints from which have been withdrawn the natural suj)j)ort of nuiscles and ligaments. Thus, the weight of the body, pressing tinresisted on the arch of the foot, which has lost its natural stays, so to speak, gradually dis- places the bones from their normal relations, until it entirely flattens the arch or distorts the whole extremity into some form of club-foot. It does not, however, seem possible to account for some of the deformities by any theory of pressure. Thus, how could the drawn, contracted fingers seen in atrophic paralysis of the forearm and hand be the result of any pres- sure upon the part? In the lower extremity pressure probably does have a direct influence in the development of the club-foot. Thus, the weight of the body would tend to produce in the feeble foot equino-varus. It tends, there- fore, to intensify the action of contraction in the sural muscles after paralysis of the anterior tibial, but to diminish the intensity of contraction of the anterior group of muscles when the gastrocnemius is paralyzed. \u this may be found one reason for the rarity of pes calcaneus and the comparative frequency of tali])es equinus after infantile paralysis. It is probable, however, that the chief cause of the infrequeney of pes calcaneus after infantile paralysis is to be found in the flict that the calf muscles are much less frequently affected than are the anterior muscles. The most reasonable explanation of the production of the deformities seems to be tliat they are results of several coacting or reacting caus(^>^ present in varying degree in various cases. The deformities of poliomyelitis fnay affect any portion of the body. All varieties of club-foot, knock-knees and inverted knees, rigid fiexion of the knees, cyphosis, lordosis, extraordinary scoliosis, subluxation of the thighs or of the humerus, claw-like distortions of the hands, — any of these may result, or the withered, shrunken limb, mobile almost as a rubber tube, may dangle from the truid<, an untoward memory of the past. The course and symptoms which have been given of acute poliomyelitis are those seen in children. In the rare cases in which the disease occurs in the adult the general course is not essentially different from that which it holds in childhood. In the first stages, however, the cerebral symptoms are usually less severe and the vomiting more frequent than in very y<»ung subjects, wiiilst in the fourth or last stage of the disease the deformities are less pronounced than in childhood. Whether occurring in the yotu)g or the old, the disease is essen- tially the same. Diag-nosis. — 'i'lie recognition ol' the ti'ue nature of an incl|»ieii( :ittack of polioiuvelitis with irrave constitutional disorder is usually altended with much difliculty. Indeed, it is commonly iinpossil.le to for -udi :iud such reasons 768 ORGANIC DISEASES OF THE SPINAL CORD. not one of the exanthemata, etc. etc. : no cause for ephemeral fever can be found, and therefore it may be poliomyelitis. The posture of habitual distrust upon the part of the practitioner is exceedingly important, as it leads to watch- fulness for the appearance of paresis. Whenever such paresis appears the diag- nosis at once becomes plain. The only affections which may be confounded with poliomvelitis in the early paralytic stages are peripheral neuritis and ascending paralvsis. The completeness of the palsy and rapid alteration of the electrical relations of the muscles, together with the absence of nerve-pains and nerve-tenderness, demonstrate that the case is not one of peripheral neu- ritis, whilst the course of the paralysis and the occurrence of febrile and of trophic disturbances separate the aifection from Landry's paralysis. More- over, the latter disease is extremely infrequent in children, whilst acute polio- myelitis is extremely infrequent in adults. Prognosis. — In the first or active stage of an acute poliomyelitis the prog- nosis has to do with two essentially different questions : first, as to the danger to life ; second, as to the probable extent of permanent paralysis. Death has probably happened from the grave constitutional disorder that ushers in a polio- myelitis without the true nature of the malady having been recognized, but certainly death from a recognized poliomyelitis is exceedingly rare, so that in regard to immediate danger the prognosis is most favorable. No opinion, how- ever, ought to be given during the first stage as to the probable extent and completeness of the permanent palsy that may result, since there seems to be no relation between the severity of the primary constitutional disorder and the gravity of the permanent disablement. The wildest storm may eventuate most happily, and the most insidious, development may end in widespread ruin. Even in the second stage, when the paralysis has reached its maximum, the prognosis must be guarded, for although there is a general relation between the severity of the paralysis of this stage and the final result, this relation is by no means fixed : a seemingly mild case may turn out most unfortunately, and a very widespread and profound paralysis may clear up entirely. After the end of a week, if the affected muscles have suffered no loss of faradic irritability, the prognosis becomes very hopeful ; if, on tiie other hand, the electrical rela- tions of the muscles are distinctly disturbed, then long-continued atrophy and loss of function must be expected. The earlier the electrical reaction of the muscles are altered the more serious is the prospect ; and, vice iiersa, if after three weeks the muscles still respond well to the faradic current, the recovery will almost certainly be rapid and complete. When in an advanced stage the muscles are unable to respond to any electrical current, the (!ase is almost hope- less. When the powet* of responding to the direct or chemical current is re- tained, although the faradic current produces no effect, the prognosis becomes hopeful in direct proportion to the length of time during which the paralysis has lasted ; the longer the ])eriod that has elapsed the better is the outlook. The preservation of the power of reacting to galvanic currents proves that tlie spinal cells have not lost their power of influencing to some extent the nutri- r ^ ACUTE POLIOMYELITIS. 769 tion of the muscles, and affords ground f(»rtlu' liope that, aUliouoh unable to stimulate the mu.-^eular nutrition to recover that which has been lost, they may still be able to hold up a nuiscle whose nutrition has been artiiicially restored. Treatment. — When poliomyelitis commences with violent general disturb- ance, active local or even general antiphlogistic treatment may be instituted witii the hope of moderating the activity of the inflammatory process, pro- vided the strength of the patient be sufficient. After the paralysis has been developed it may in some cases be allowable to take blood locally from the back, but general venesection should never be practised. The proper treatment of the second stage of the disease is still an unsettled jiroblem. With the idea of diminishing congestion and lessening inflamma- tion authorities recommend tlie ventral decubitus, the continuous application of cold by means of ice-bags along tiie spinal column, the administration of ergot, iodide of potassium, and mercury, and the use of the actual cautery or other violent counter-irritant ; in a word, tlie treatment of an acute myelitis, Erb and some other authorities apply the direct galvanic current steadily, without interruption (from three to ten minutes by some electricians, or as long as several hours by others), the positive pole being ])laced at the nape of the neck, the negative upon the lower end of the spinal column or upon the aflected muscles. There are at least seeming-lv sound theoretical reasons in favor of the anti- ])hlogistic method, but, as has been shown elsewhere, there is no probability that the galvanic current as applied to the vertebral column reaches the spinal cord, and neither physiological nor clinical data to prove that if it did reach the cord it would accomplish any good. Its application may sometimes have salutary mental effect uj)on the little patient and upon the parents, against which is to be set tlie annoyance of the procedure. My own belief is that in the second or paralytic stage the treatment should be largely expectant, but that extract of ergot should be given in as large doses as the stomach will bear, and that calomel should be cautiously administered, and the actual cautery be lightly but freely applied, provided that the patient be old enough and intelligent enough for it to be used without causing spasms of terror. In the very young or timid, if it be decided to employ the cautery, ether ansesthesia should be induced without the patient knowing what is to be done. During the stage of regression medicinal treatment should be limited to the use of tonics and the persistent administration of very mimite doses of corrosive sublimate, whilst the health of the patient should be i)uilt up in all possible ways and the nutrition of the muscles maintained by use of electricity, massage, etc. In the fourth or permanent condition strychnine and phosphorus maybe administered with tlie hope of stinndating ganglionic repair. Tendencies to the development of deformities are to be m<'chanically combated and the nuiscles locally treated. In some instances the iiy|)odcrmic iujcctiou oi" tlie strychnine salts into the paralyzed nuiscle has seemed to do good. Vol,. I.— 49 77(J ORGANIC DISEASES OF THE SPINAL CORD. In the local treatnicnt of the muscles three distinct measures are available : First : Mechanical vibratile treatment, combined with the application of heat (and ])erhaps also of a Junod's boot), by means of Zander's or some other similarly acting mechanism ; Second : Massage, and also passive gymnastics ; Third : Electrical treatment. The action of the first of these measures is, I have no doubt, of value by stimulating the capillary circulation, and whenever the requisite machinery is at hand the treatment should be carefully and persistently tried over some months. Massage and passive gymnastics have the same aims as the mechani- cal treatment just spoken of, and are to be used when they can be commanded : to accomplish anything at all they must be employed very persistently as well as skilfully. It should be remembered that rubbing the skin by an untrained person is not massage, and does not, like that procedure, reach the deeper cir- culation : what is wanted is kneading of the paralyzed muscles. Electricity has been extensively employed in acute poliomyelitis with very widespread disappointment. It is, however, a really valuable agent when used with a proper understanding of the methods of its application and the limitations of its usefulness. It has no influence whatever for good over any of the structures involved except the muscles themselves, and its application to the spinal cord or nerve-trunks at any stage of the disease is worse than use- less. In regard to the time when electrical treatment should be commenced, my own opinion is that so soon as paralysis is detected electricity may be care- fully employed. At this time, however, great caution is necessary to avoid producing muscular fatigue or any reflex irritation of the nerve-centres. The ^seances should therefore be short and the current only sufficient to produce feeble muscular contractions. The good accomplished is largely, but probably not altogether, due to the functional excitement of the muscle by the electricity, and consequently I have formulated the law that the current to be employed is that which will produce the greatest muscular contraction with the least pain. This law applies to all stages of the disease. Ordinarily, the faradic current fails entirely, and the direct chemical or voltaic current must be employed. It must be remembered that improvement of the muscles is of no avail unless the spinal cord recovers its power, but the effect of partial rehabilitation of the ganglionic cells is greatly increased by keeping the muscles in such a condition that they are able to respond to whatever impulse may come from these cells. If the case be first seen by the neurologist in the advanced stage, it may be taken almost for granted that the amount of paralysis is greater than that which the state of the cord necessitates, so that electrical treatment offers a good hope of amelioration. This is especially true if the muscles have still some power of responding to the electrical current, and even when they seem at first entirely dead, trial for two or three weeks should be made, as sometimes muscles under these circumstances are awakened by electricity into new life and some volun- tary power is regained. SUBACUTE on CHROXIC POLIOMYELITIS. 771 111 the administration of the current a single well-wetted electrode should be put over the motor point of" the muscles, with a larger electrode at a little dis- tance, so placed that as much of the muscles as possible shall be reached by the current. This procedure may be varied from time to time by ])laciiig the poles so as to include between them the whole length of the muscle. The galvanic current may be slowly interrupted, but the eifect upon the muscles is much greater if by mechanical arrangement instead of simple interruption there is reversion of the current, so as to make alternatins; to-and-fro currents. If after eight weeks of electrical treatment no gain is achieved, nothing is to be hoped for. In all cases of infantile paralysis it is essential to prevent, as far as may be, the development of deformities. Contractures are to be overcome, if possible, whilst forming by thoroughly stretching the muscles morning and evening with the hand. When, in spite of this, the contracture persistently increases, section of the tendons should be resorted to. The operation is simple, without danger, and experience shows that the relief to the limb has a distinct effect upon the nutrition of the muscles. So true is this that I think that after such section a renewed attempt to develop the muscles by electrical treatment should always be made. The application of braces or other appliances to the legs to aid in locomotion is often imperatively demanded. It is very much better for the child to exercise the limb, even partially, than to add to the failing nutrition of spinal disease the depressing influence of loss of use. Subacute or Chronic Poliomyelitis. In 1849, Duchenne described a peculiar palsy of which various cases have from time to time been since reported, and which appears to have very close relations with acute antero-poliomyelitis. The symptoms are rapidly-(levelo])ed paralvsis, usually commencing in the l(»wer extremities and extending u])war(l, associated with complete muscular flaccidity ; loss of reflex excitability ; rapidly- progressive atrophy ; and changes in the electrical relations. This disease is said to be distinguished from the acute poliomyelitis by the absence of the stages of general stationary paralysis and of regression, and also by its pro- gressive course. It is distinguished from progressive muscular atrojihy by the paralysis producing — not following — the atrophy, and by the appearance of well-marked reactions of degenerations early in the case, as well as by the loss of the reflexes. Undoubtedly, cases of neuritis have in the jiast been reported as instances of subacute poliomyelitis, but they are to be distinguished by the nerve-pain and tenderness. When subacute poliomyelitis shows a distinct tendency to ascend, there is alwavs grave danger to life by implication of the muscles of dcghilif ion and of" respiration. In the majority of cases recovery occurs with more or less daniMge to muscles and consequent defects of motion. The treatment may !)(■ Hiat of chronic myelitis, widi the siipcraddition of local electrical treatment l"or the nmiiilciiniicc of niilrilion to the muscles, as in the acute disorder. The results which I have obtained in metallic |)olio- 772 ORGANIC DISEASES OF THE SPINAL CORD. myelitis (next paragrapli) would seem to quite justify the trial of heroic doses of strychnine. Atrophic paralysis, produced by arsenic or lead, sometimes closely simulates subacute poliomyelitis. Probably in the majority of cases it is the outcome of a peripheral neuritis, when its nature is to be recognized by the existence of nerve-pains and tenderness. I have, however, seen cases lacking in such ten- derness, in which rapid loss of power, with atrophy and atrophic changes in the muscles, occurred without pain or nerve-tenderness, precisely as in subacute poliomyelitis, and in Avhich I believe the lesion was purely centric. The true nature of metallic subacute poliomyelitis can usually be made out by attending to the following points: first, the case occurs in an adult; second, the paralysis is much more widespread than in the subacute or mild cases of poliomyelitis, and develops itself to the fullest extent only after some weeks ; third, muscles not usually affected in true poliomyelitis are impaired almost as much as their fellows (thus the sphincters are paralyzed, the bladder rapidly loses power, and the respiratory muscles grow weak) ; fourth, sensa- tion is often, but not always, affected to some extent ; fifth, suspicion being aroused, evidences of metallic poisoning can be obtained from the history, from the presence of a blue line on the gums, or by finding the metal in the urine. The treatment of this condition is that of metallic poisoning, added to the local use of electricity upon the muscles and the employment of massive doses of strychnine ; which alkaloid I have seen, when pushed to its physiological limit, act with almost as much force and certainty as does quinine in malarial diseases. Syringomyelia. Definition. — A chronic disease dependent upon the formation of pathological cavities in the spinal cord, and clinically characterized by peculiar alterations in the sensibility, and loss of power usually accompanied by trophic disturbances. Etiolog-y. — Concerning the causes of syringomyelia we have no definite knowledge. The disease usually begins between fifteen and thirty -five years of age; is more frequent in men than in women; and does not appear to be distinctly hereditary, although there is some reason for believing that it depends upon some embryological affection of the cord which diminishes the power of the nerve-elements to resist the hyperplastic tendency inherent in neurogliar tissues. Patholog-y. — The principal lesion in syringomyelia is spinal, with secondary trophic lesions in muscles, bones, cellular tissues, skin, and probably also in the peripheral nerves. To macroscopic examination the cord presents the appearance of a large blood-vessel empty and collapsed. It is irregularly increased in size, deformed, soft and fluctuating to the touch, or feeling like a hard, firm, rigid cord, as the case may be. Section reveals a cavity, or more rarely two or even three cavities, situated in the horns of the gray matter. The size of tiie cavity and its length vary indefinitely, and its shape and cross dimensions also vary not only in different individuals, but in different SYRIXGOMYELIA. 773 parts of the same cord. Its contents are liquid or gelatinous, and even to the naked eye it is surrounded by a smooth, yellowish membranous coating. The majority of investigators believe that the j)rimary histological lesion of syringomyelia is a neoplastic hyperplasia of the neuroglia of the gray matter, but others insist that it is a hyperplastic myelitis. The new tissue is vellowish- brown, and usually composed of one or two nucleated, spider-like cells, heaped together and anastomosing with one another by their nervous branch-like pro- cesses. In the interspaces thus made are granular elements, pigment-granules, and small, illy-defined, yellow retractile bodies of doubtful character. The limiting layer lining the whole of the cavity is a dense, fibrillary felting, which is not sclerotic, but has probably been formed from prolongations of the cell-process. The parts around the new growth are compressed and irritated, and so secondary inflammation, hemorrhage, and widespread sclerotic degen- eration are set up. The peripheral nerves have been in various cases found altered, enlarged, with parenchymatous and interstitial neuritis, or finally atrophied. In a very careful study of Dejerine it was found that the intra- muscular nerves were normal or atrophic according as their muscles were normal or atrophic, indicating that the changes in the nerves are secondary and trophic, and not primary lesions. Symptomatolog-y. — Syringomyelia commences insidiously, with weakness and some disorder of sensation in the upper extremities, fi)llowed after a time by muscular atrophy, with increase in the sensory disorders; then by sjiinal curvature in the form of scoliosis ; and finally development of motor palsy in the lower limbs. Vaso-motor and trophic changes in the skin, subcutaneous cellular tissues, and perhaps in the joints and bones, soon follow the apj)ear- ance of the muscular atrophy. The symptoms of syringomyelia are best discussed in detail by an analysis of the individual groups : Sensibility. — The disturbances of sensation are the most characteristic of any of the symptoms. The ordinary sensations are disassociated, so that whilst sensibility to touch, the muscular senses, and the special senses remain ])erfect, the sense of pain and the power of recognizing heat and cold are more or less completely lost. In some rare instances the general rule is deviated from, either in the ]>reservation of some form of sensibility commonly lost, or more frequently in the depression of some of the sensibilities commonly pre- served. Cases are on record in which pain and thermic sensibility have been increased ; further, thermic sense perversions may exist, so that hot bodies feel cold and cold bo(li(>s hot. The degree of the thermic anaesthesia varies from the sim|)l(' inability to note slight differences of temperature uj) to such complete loss that a |)atient may be burned without being aware of it. The loss of (he power of recog- nizing heat does not ne(tessarily coincide in degree or ])osition wilh ihc loss of the perception of cold. The distribution of the thcnno-aiia'sthcsia varies in different cases, and to a limited degn^e fidin time (o tiiiir in the sam<' case. It usually occuj)ies considerable zones — sometimes nearly ihc whole surface of 774 ORGANIC DISEASES OF THE SPINAL CORD. the body, and even the mucous membranes, as well as the skin. Analgesia varies in intensity and in distribution, precisely as does the thermo-anaesthesia. In spite of complete analgesia and thermo-ansesthesia the slightest prick will be recognized by the tactile sense, wliilst the eye, the nose, the mouth normally perform their seeing, smelling, and tasting functions. In some cases the patient complains of subjective pains which may mock the sensations of burning or of freezing. As already stated, loss of motor power in the arms is a common primary symptom. In the legs the disturbances of motion, which are usually secondary and develop late in tiie disorder, commonly consist of spasmodic paraplegia, but sometimes are especially shown in marked ataxic inco-ordination. Fol- lowing one or other of these, the patellar reflexes may be either exaggerated or abolished. Loss of motion is followed in tlie upper extremities by muscular atrophy and secondary contractures, with the production of claw-like deformi- ties like those of progressive muscular atrophy. The muscles of the back suffer paralysis and trophic disturbance almost as soon as do the muscles of the upper extremities, and therefore scoliosis is an almost constant and some- times an early symptom. It is said almost universally to affect the dorso- liunbar region and to produce convexity to the left. The atrophy which first appears in the muscles of the forearm usually extends slowly and symmetrically up the arm, and is sometimes accompanied by the reaction of degeneration, although usually tiie electrical excitability is only diminished. It should be noted that both paralysis and atrophy may first appear in the scapular region, or even in the lower extremities, and that a few cases of facial paralysis with atrophy have been reported. The superficial trophic changes are very marked. The skin may become glossy or covered with a thick epidermis or with bullous, eczematous, or her- petic eruptions. Perforating ulcers have been described, and in rare cases there has been a primitive gangrene of the skin, followed by loss of sub- stance and leaving a whitish cicatrix. Tiie distorted, thickened, often fur- rowed nails sometimes fall out. The subcutaneous cellular tissues may be oedematous or the seat of abscesses and especially of whitlows. The bones and joints sometimes undergo arthropathic changes similar to those seen in loco- UKjtor ataxia ; and acromegalia, coinciding with, if not dependent upon, syringo- myelia, has been reported. The secreting nerves seem to suffer; at least sweating becomes irregular, absent in some regions, or it may be exaggerated. The vaso-motor system is also atta(^kcd, the extremities cyanosed, with their temperature distinctly below tlu" norm, or else they become swollen, scarlet, and hot. Polyuria has also been noted. Sometimes cystitis is severe, and perforating ulcer of tiie bladder has been reported. The general type of syringomyelia is departed from when the lesion is atypically located. Thus, bulbar paralysis, with disturbance of deglutition and of speech, may occur when the change is very high up in the nervous system, .\maiirosis, unequal ]iupils, cardiac disturbances, all have been noted. SYlilXaOMYELTA . 775 More strangely, the characteristic lesions of syringomyelia have been found after death in cases where no symptoms have been nuinilcstcd during life. The only plausible explanation of this is that offered by M. Bruhl, which is that these latent tonus occur only in young patients in whom there has not been time for develojiment of symptoms. Two clinical varieties of the disease are described by Blocq. In the first of these the atrophy commences in the muscles supplied by the ulnar nerve, and is followed by si)astic paraplegia ; in the other the atrophy conmiences in the muscles of the radial nerve, and is followed by tabetic iuco-ordination. The course of syringomyelia is a prolonged one, disturbed often by exacerbations and remissions. If the patient do not die of some intercurrent disease, death results from some of, the trophic lesions (gangrene, cystitis, perforating ulcer), from bulbar com])lications, or occasionally from sheer exhaustion. Diagnosis. — Syringomyelia is distinguished from cervical pachymeningitis by being much less painful and not accompanied by rigidity of the neck, and by the existence of the peculiar disturbances of sensation. In cases of sclero- dactylitis, simulating syringomyelia, sensation is preserved, whilst the inflam- mation of the skin is a dominant, not a secondary, feature of the case. In alcoholic paralysis thermo-anassthetic disturbances resembling those of syringo- myelia sometimes occur, but the symptoms usually appear in the lower extrem- ities and are developed very rapidly, whilst tenderness of the nniscles or nerve- trunks upon deep pressure can be made out. Charcot has pointed out that hvsteria mav closely mark syringomyelia, but an error of diagnosis can always be avoided by carefully examining the patient and her or his history. Hys- teria is rapid in its onset, and manifests its presence by nervous symptoms not belonging to syringomyelia. The question as to the distinctness of Morvan's disease is still sub judice : those who believe in the non-identity make the diagnosis to depend u})ou the following points : In Morvan's disease the tactile sense nearly always disappears with the other forms of sensibility ; the trophic changes predominate, and almost exclu- sively consist of multiple whitlows, deep cracks and fissures in the skin, and arthropathies of the smaller joints. Moreover, in certain cases these affections are symmetrical on both hands and feet and do not attack the remninhilitic treat- ment. Professor Striitnpel's theory that it occurs only in the sy|)hilitic, and is ])r<»duced by a ])ost-syphilitic chemical poison, is iiighly improbable. The old belief that sexual excess is the ordinary cause of locomotor ataxia is certainly not true, though such excess may aiains in the region of the heart, associntcd with great dyspntea, intense dis- tress, and irregularity of the jmlse, witii or without iutciniissioii of the heart- beats. The lart/ngeal crises consist of violent paroxysms of hoarse coughing, ending 780 ORGANIC DISEASES OF THE SPINAL CORD. ill a raucous inspiration like that of whooping cough, and attended by great lar- yngeal disturbances of respiration and atrocious fulgurant pains in the shoul- ders and along the spinal column. The expectoration is of a scanty, saliva-like secretion, or rarely of little pellets of mucus stained with blood. Asphyxia may in these cases be so extreme as to produce coma and even death. In some eases laryngeal paralysis or anaesthesia occurs, and death has resulted from the pneumonia produced by food i)assing into the larynx. Amongst the various parsesthesias of locomotor ataxia are formications, the feeling that water is running over the part, crawling of ants, etc., and espe- cially the so-called girdle sensation, a feeling as though a tight band was drawn around the head, the neck, the body, or the limbs, in accordance with the seat of the lesion in the cord. Numbness may develop early or late. When it is situated in the feet the patient feels as though he were walking upon velvet or upon cushions of down. The mucous membrane of organs, such as the larynx and rectum, in which the crises occur is often completely anaesthetic. In the earlier stages the numbness is not invariably associated with loss of sensibility, and the jesthesiometrical points may be distinctly recognized, but later tactile sensation becomes impaired. The anaesthesia may exist with or without analgesia, although the pain sensation is usually also lost. Sometimes a separation occurs between tactile and pain perception, so that a distinct inter- val exists between the perceiving of the contact of a sharp point and the pain which it causes. The temperature sensation is usually diminished, but Donath affirms that there are cases in which it is exalted. The lack of co-ordination of tabes is, I believe, largely due to loss of muscular sense, but as physiolo- gists are not all agreed even as to the existence of this sense, the discussion Avould require more space than can be afforded here. Delayed sensation is not uncommon, and five, ten, or even fifteen seconds may elapse between the time of the contact and its perception. Mendelssohn affirms that the normal reac- tion of the sensory nerve to electricity may be reversed, so that on closing of the circuit the earliest sensation is at the positive instead of at the negative pole, as in health. The localizing power is sometimes curiously perverted : a single prick may be felt in many places (polycesthesia), or a prick on one leg may be located on the other (allocheiria). 3Iotion, including the Reflexes. — The influence of locomotor ataxia upon the cutaneous reflexes varies. In the onset of the case they are, in rare instances, increased; when anaesthesia exists they are usually diminished; but sensation may be well preserved and the cutaneous reflexes be lessened or even abolished. The deeper reflexes are profoundly affected. Complete loss of the knee-jerk {Westphal's symjytom) is one of the earliest and most constant phe- nomena. When, however, the disease commences in the upper portion of the cord, it mav be late in comino- on. Loss of co-ordination shows itself both in station and in locomotion. When it exists only in a slight degree, the patient may be able to stand with the feet close together or on one foot, or may be able to walk fairly well ; LOCOMOTOR ATAXIA. 781 but if the eyes he closed, the lack of control becomes at once manifest, and as the disease develops a gait so peculiar as to be spoken of as the ataxic (/ait results. In the earlier, but fully-developed stages the })atient walUs with his head a little bent forward and the eyes directed to the ground. The trunk inclines upon the thighs, whilst the feet are held in advance of the buttocks, with the legs widely separated from each other. At the same time, owing to the excessive contractions of all the muscles of the lower extremities, the leg proper is extended somewhat rigidly uj^on the thigh, and there is very little movement at the knee-joint. The advancing leg is therefore raised from the ground in some degree by an elevation of the pelvis, although at the same time some flexion does occur at the knee-joint. By these conjoint movements the foot is freed from the ground, and, having been flung forward and outward by a rapid muscular jerk, comes down with a thump like a solid mass. In some cases the heel is the Jast to leave the ground and the first to touch it. Not rarely the pelvis is so much inclined during walking as to carry the centre of gravity too fjir toward the side of the stationary leg. To counteract this and maintain the balance of the body the upi)er portion of the trunk is curved toward the advancing leg by a contraction of the erector spinae muscles, or the arm corresponding to the advancing leg is thrust out laterally. The alternation of these movements at each step may give a pendulum-like swing to the body. In a more advanced stage of locomotor ataxia the patient is able to walk oidy by the help of two sticks or crutches. The body is thrown forward in order to counteract the tendency to fall backward produced by the peculiar position assumed by the legs, which are held in advance of the buttock on account of the tendency to undue contraction of their extensor muscles : the foot is usually at an obtuse angle to the leg, and the thigh at an obtuse angle to the trunk. Jf under these circumstances the trunk be erect, the line of the centre of gravity would fall through the buttocks posterior to the point of support — i. e. the foot — and consequently the patient would fall backward. To overcome this, the trunk is often bent so far forward that the line of the centre of erformed with great stiffness and by sudden jerks. The straddle is usually very marked, and the leg js raised from the ground by an elevation of the pelvis in the method already described. Still later in the disorder the legs are entirely beyond the control of the patient. They are thrown around in wild, irregular, ehf)reiform movements, which render them of no use whatever in walking. Tinder these circumstances j)rogression is inipossible. When the lesion travels up the spinal cord, all power of co-ordinating the nuisch>s of the truid< may be lost, so that the ])atient is net longer able to sit in a chair. OrganH of l^pecinl Sense. — Of the organs of s]>ecial sense, the eye is the OIK! most fre(piently attacked in Idconiotor ataxia. Of the external oeidar nnisdes, the rectus is the affected. The loss of j»ower inav be transient or |ierni:iMenl. 'i'ransient 782 ORGANIC DISEASES OF THE SPINAL CORD. s ocular palsy, with its resultant transient diplopia, belongs to the earliest period of the disorder. The permanent palsy is seen in the later stages, and may ])roduce ptosis, internal or more rarely external squint, and even a general ophthalmoplegia. The pupil is affected sooner or later in a majority of oases of locomotor ataxia. It is usually contracted, but mydriasis may occur, and irregularity of the pupil is sometimes seen. The most characteristic alteration is that known as the Argyll- Robertson pupil, or as reflex iridoplegia. In this con- dition the pupillary reflexes are abolished, although the normal relatione between the pupil and accommodation are preserved ; consequently, no pupil- lary movement occurs when the skin of the neck is violently pinched or when light is thrown suddenly into or shut off from the disordered eye, although the pupil dilates when the gaze is suddenly directed from a near to a distant object. The most characteristic visual results of locomotor ataxia are contractions of the field of vision, with disorder of the color sense. The contraction is concentric, but is usually somewhat irregular. The power of perceiving yellow and blue is kept for a long time, whilst blindness for green or red is early developed. The contraction of the field of vision and the disorder of the color sense are due to degeneration of the nerve-fibres of the optic nerve ; which degeneration usually commences in the periphery. I know of no observations on disorder of either taste or smell in locomotor ataxia. Deafness occasionally occurs either as an early transient or a late permanent symptom. According to Gowers, it is accompanied by a progressive limitation of the range of hearing analogous to the contraction of the range of visual field ; the notes of the scale, beginning at the top, dropping out of the range of hearing, one after the other, until all are alike inaudible. Trophic Changes. — The most important trophic changes in locomotor ataxia are alterations of the bones and joints, perforating ulcer, and })erhaps cardiac disease. Sclerotic arthropathy may first show itself by a peculiar articular crepitus, but the first fully-formed stage is that in which a serous effusion, free from blood, pus, or albuminous flocculi, occurs in the articular cavity, whence it may extend into the tissues around the joint and even into the affected limb. The joint at this time is enormously swollen, hard, usually pale, and so resistant as not to pit on pressure. In rare cases the effusion is. absorbed, but usually the second stage is soon developed. At this time the joint is much swollen, hard, and bony, with an evident increase in the size of the bony surfaces. In the third stage there is destruction of the articulating surfaces, and in some oases so much absorption of the bone and changes in the ligamentous structure as to produce great alterations in the power of movement. The epiphyses espe(;ially undergo atro|)hy and ohange ; the ligaments are elongated, probably as a consequence of prolonged stretching by the excess of fluid; and at last a condition of subluxation, or perhaps of complete luxation, of the joint occurs, so that the ataxic may be able voluntarily to ])nt out of joint a shoulder, a knee, or other joint without pain, though marked grating can be felt during L O CO MO TOR A T. 1 AT. 1 , 783 movement. The ataxic arthropatliy is sometimes unilateral, but is frequently more or less symmetrical. It attacks especially the knees, and next in order of frequency the other joints of the lower extremities, but it may occur in any articulation of the body. When the small joints of the hand or foot are affected, peculiar deformations result, constituting r Fig. 52. Fk;. Tabetic Feet (after nature). - ^ U y Impression of Tabelic IV-ct lafter Hall). Fig. 54. the so-called " tabetic foot " and " tabetic hand." (See Figs. 52, 53, and 54.) The shafts of the bone may atrophy and spontaneous fractures occur. The primary change is probably always an hypertrophy, which is followed by a pronounced atro])hy. When the jaw is attacked the wasting of the alveolar ])ro- cesses results in the dropping out of the teeth, which, though entirely sound, may be shed one by (tnc (»r tumble out en masse. Perforatinc/ ulcer may attack the hands or probably even the internal organs, but especially affects the vicin- ity of the metatar.so-phalangeal articulations of the feet. The first symptom usually is a severe pain. This pro- dromic pain may, however, be entirely wanting. A small hemorrhagic or ecchymotic ^p(>t now a|)pears under the epidermis: in the course oi' a H \v hours the skin detaches itself, or more fre(iu('nfl\- becomes excessively thickened into a large, dry, corn-like ma.'^s ; a small slough soon separates, leaving the ulceration round, with sharp, acute edges, piercing usually t(t the dcejHT tissues and in many cases reaching the articu- \round the ulcci'ation there is apt to be serous infiltration and swellinrs of diatrnosis or of observation or in the too carlv report of the ease. fiummat<»us svphilis may give rise to symptoms very closely resend)ling those of hteomotor ataxia, and be iclievcd by antisyphilitic treatment. I iii|ii(.\ rmciit ofthe.syni])- V.M.. I.— 50 786 ORGANIC DISEASES OF THE SPIXAL CORD. toms under treatment, and indeed arrest of the disease, do, however, occur in locomotor ataxia, especially in the early stages. Treatment. — In the management of a case of locomotor ataxia it is of the first importance that all sources of exhaustion or of nervous depression be cut off. Rest, both bodily and mental, is vital. The life of the patient should be permanently arranged in such a way as to avoid all unnecessary expenditure of vital force. Physical labor is of course impossible, and mental work should be so reduced that it will only be sufficient to divert the attention of the patient from himself. There can be no doubt that the disease may be sometimes arrested, temporarily at least, by placing the patient in bed for a series of weeks, and at the same time using niassage to prevent the bad effects upon the general health which such confinement tends to produce. Even when the patient is going about and in the best condition, long walks should be avoided, it being remembered that a single hour's exhaustion may overthrow the good achieved by many Aveeks of rest. The diet should be nutritious, but non- stimulating, and a moderate use of wine is not harmful, although the slightest excess of alcohol is certainly very deleterious. Tobacco must be used only in the greatest moderation. Sexual intercourse should be as far as possible avoided. It is affirmed by good authority to be especially harmful in those cases in which there is a tendency to atrophy of the optic nerve, with increasing impairment of vision, rapid blindness having, under these circumstance, followed a newly-contracted marriage. Whilst open-air life is useful, the most scrupulous care should be exercised to avoid exposure to wet or cold, and, when it is possible to the patient, the winters should be passed in a Avarm, dry climate. The effect of internal medication upon pure locomotor ataxia is very slight. Antisyphilitic treatment is of no value, even though the history of syphilis be very clear. It is true that medical literature abounds with reports of cases which seem to oppose this statement, but I have no doubt that in such cases the diagnosis has been incorrect. Minute doses of mercury — one-fortieth of a grain of corrosive sublimate — are believed by some writers to be of service. As in these minute doses mercury has a distinct tonic influence, it is allowable to employ it in locomotor ataxia with the hope, rather than the expectation, that it may have some influence upon the spinal lesion. The free use of mer- cury is distinctly contraindicated. Nitrate of silver Mas at one time very com- monly employed : I have never seen it achieve any good, but the large his- tory of its use justifies its employment by those therapeutists who have more respect for the statements of authorities than for the results obtained under their own eyes. Chloride of gold and chloride of barium, more recent rem- edies, are probably harndess when not given in too large doses. If phosphorus have any influence upon the spinal cord, it is that of causing nutritive excite- ment, and its administration would therefore ap])ear to be contraindicated in tabes. Almost all of the nervine vegetable drugs have been given in tabes, but there is no reason for believing that any of them have a direct influence upon LOCOMOTOR ATAXIA. 787 the lesion. The active influence of ergot upon relaxed blood-vessels has led to its very free use in locomotor ataxia. There is, however, no sufficient reason for believing that the spinal lesions are in any degree due to a preceding relax- ation of the blood-vessels. The effect of ergot in producing tabetic aifections shows that the drug has some influence u]>on the nerve-centres, and justifies those who believe in the doctrine oi' simi/ia similibiis cumnfui' in the me of it in small doses. I have myself seen it used frequently, and have never been able to perceive the slightest good effects from it. The favorable results which have been reported from it have usually been in the earlier stages of the dis- ease, and are alleged to have been seen in the lessening of pain. These i)ain- symptoms, however, vary so greatly and so inscrutably in the indivi(hial case that not much importance seems to me to attach to any apparent improvement. Certainly in locomotor ataxia it is dangerous to give ergot in the enormous doses which have been employed by some practitioners. My own belief is that the employment of drugs should be confined to the administration of harmless remedies, which should give to the patient, when necessary to be given, the moral support that comes to certain individuals from the feeling that something is being done; to the giving of tonics, laxatives, and other mild remedies from time to time as symptoms may call for them ; and to the careful use of narcotics for the relief of pain. In severe crises hypodermic injections of morphine are often necessary, but the practitioner must never forget that the attempt to relieve the frequent attacks of sclerotic jiain by opiates greatly endangers the formation of the opium habit. Anti- jn'rin, antifebrin, and phenacetin certainly have a distinct controlling influ- ence over nerve-storms even when due to such deep-seated cause as posterior sclerosis. They are much safer than o])ium, and I have seen them relieve a crisis which oj)iuin in moderate doses had failed to control. It is necessary, however, to carefully husband these remedies, so that their influence may not he worn out in the course of so long a disorder. So far as the disease itself is concerned, I do not believe that any counter- irritation is of avail, although some j)ractitioners claim to have had good results from the use of the actual cautery along the sj)ine. In the very earliest stages of the disease this may be justifiable, but certainly in the later stages the amount of relief does not compensate for the suffering and distress involved in the treatment. In cases of crises repeated mild counter-irritations, in the form of sinapisms, over the seat of the pain and also over the root of the nerve supplying the affected part, are urgently called for by moral reasons. They sometimes seem to bring relief, and may therefore always be aj^plied, care l)eing taken to see that the application he not sufficiently severe to pi-odiicc local destruction. Blisters must be employed undri- these circumstances with the greatest care, as there is danger of the local inflaminalion becoming uncon- trollal)le. This is especially true when antesthetic portions of the skin are involved. Any bh'sters or soi'cs upon the feet should always receive the most careful attention, it being affirmed by cojupeteut authorities that a perforating ulcer has followcpen during the night, and is usually painless, but is sometimes accompanied with cramp-like sensations. The functions of the sexual organs, the bladder, and the rectum are usually not implicated until very late in the disorder. Sensory symptoms are com- monly not present, or at most are confined to slight dull pains or a feeling of weariness or slight numbness or paraesthesi a. When rheumatoid pains with distinct disorder of sensibility occur, the probabilities arc that a neuritis has been set up or that the disease has extended to other portions of the sjiinal cord. There is no wasting of the muscles and no trophic changes in the joints or other part. For reasons which at present are not very apparent tiie lesion has little tendency to spread throughout the nervous system, as it does in locomotor ataxia, and hence ocular and laryngeal implications are rare, as is also mental confusion or insanity, although lateral sclerosis and general jiaralysis may coexist. Very early in the disorder the reflexes, both superficial and deep, will be found involved, and their increase soon becomes excessive. The slightest tap upon the patellar tendon produces a quick and violent response, and it is usually possible to produce not only an ankle-, but also a knee-clonus; but in advanced stages of the disease the rigidity of the muscles may be so great as to in a measure mask the condition of the reflexes, the muscles being already in such violent spasm that no open effect follows further irritation. In raic instMuccs the excitement of the reflexes dominates the condition of the nniscles, which may be partially relaxed and quiet when the patient is in bed, but are instantly thrown into violent contraction by tiie touch of the floor during M(tem])ts to walk. The course of spjistic paraj)l('gia is usually chronic, the discasi; generally continuinor for manv vcars and having little direct tendcncv to shorten life. Chronic kidney disease is nnich less frequent than in locomotor ataxia, because the l)ladder is so seldom iiii|»lica)e(l. Diagnosis. — Althoiigli the recognilioii of the nature of a case of lateral sclerosis is usually easy, sometimes it is almost imjjossible. 'I'lie diagnosis of 792 ORGANIC DISEASES OF THE SPINAL CORD. lateral sclerosi.-? rests upon the slowness of the development of a gradual loss of power, which is accompanied by muscular contraction and heightened re- flexes, and so situated as to be evidently of spinal origin, combined with the absence of girdle sensation, of pain, and of disturbance of sensation, of paralysis of bladder or rectum, of trophic changes, and of disorder of co- ordination. The diseases which produce groups of symptoms more or less closely simu- lating lateral sclerosis are spinal meningitis, chronic cerebral disease with sec- ondary degeneration, and hysteria. Spinal meningitis is accompanied by excessive pain, and any attempt at the extension of the affected limbs produces suffering which is so much greater than that produced by similar procedures in lateral sclerosis that the diagnosis should always readily be made out. Cerebral or secondary contractures, especially as seen in the disease known as spastic paralysis of childhood, are probably always due to degeneration of the antero-lateral motor tra(;t of the brain and spinal cord, produced by a chronic inflammation having its origin in the seat of the original cerebral lesion. The lesions in lateral sclerosis and in descending degeneration follow- ing brain disease are so similar tliat of necessity the cerebral contractures must simulate those caused by antero-lateral sclerosis; but the distribution of the spastic paralysis differs in the two affections. Cerebral lesions are usually uni- lateral, spinal lesions usually bilateral. Except, therefore, in rare cases, con- tractures due to secondary degeneration are readily distinguished from those of the primary spinal disease by their being one-sided. It is true that in spinal scilerosis one side of the cord may be, at least in the early stages, more affected than the other, and that under these circumstances the symptoms are more pro- nounced upon one side than the other ; nevertheless the opposite side does offer some manifestation of disease. In the diagnosis between secondary and pri- inar}- contractures the history of the case also plays an important part. Spinal spastic paralysis always develops slowly and insidiously ; secondary contractures almost always have followed an acute attack with cerebral symptoms or are accompanied by symptoms plainly of cerebral origin. When spastic paralysis dates back to birth, unless due to hereditary syphilis, it is probably always of cerebral orio;in. The greatest difficulties of diagnosis are in the separation between hyster- ical and spinal contractures; indeed, it would appear that organic contractures may supervene upon the hysterical variety. Charcot reports the case of a woman in whom contractures of all four extremities developed suddenly and continued for ten years, with but few temporary remissions. After the last seizure the contra(^tures remained initil death, and at the autopsy symmetrical sclerosis of the lateral columns was found to extend almost the entire length of the cord. In one of my own cases contractures which had apparently been originally hysterical did not relax during antethesia, and Avere accompanied with much atrophy of the aff('(;tcd muscle. In accordance with the rule laid down by Charcot, that whenever marked atrophy of the muscles and persistence ATAXIC PARAPLEGIA. 793 of the eontrachires during amrsthesia are present ortible stiffness. Occasionally a tendency to a hem- iplegic arrangement of the symptoms is seen, and very commonly the trophic changes predominate in the arms, the spastic symptoms in the legs. The cranial nerves are usuallv affected verv earlv, and the svmptoms mav closelv simulate those of glosso-labial paralysis. Inability to whistle, difficulty of speech, fibrillary contractions, loss of power of retaining secretions in the mouth, and finally impairment of deglutition, occur. Amyotrophic lateral sclerosis is much more serious, so far as life is concerned, than other forms of sclerosis, death frequently occurring in two to four years from changes in the motor cells in the medulla involving the vital functions. Diag-nosis. — The recognition of the tr\ie nature of a typical case of amyo- trophic lateral sclerosis is so easy as to need no further discussion here. It does, however, seem necessary to point out that there occur in nature all grades of lesions between the pure poliomyelitis and the pure lateral sclerosis, and that if the motor cells degenerate very rapidly the loss of muscle-tone may be sufficient to more or less completely mask the sclerosis of the white matter. Under these circumstances a slight stiffness of gait (" the frozen attitude") may alone reveal the true nature of the case. In a case of spastic bulbar par- alysis the symptoms of bulbar poliomyelitis may be so closely simulated that the only evidence of the sclerosis is an increase of the jaw reflex. Prognosis. — The prognosis is very unfavorable, the disease being very rarely if ever arrested, and death almost invariably resulting in from one to five years. Treatment. — The only treatment of amyotrophic lateral sclerosis which seems to have the least chance of influencing the patient for good is long-con- tinued rest in bed, with massage and careful nursing. Friedreich's Ataxia. Definition. — A disease which occurs in various members of the same family, dependent upon degeneration of the posterior and lateral columns, characterized by ataxic symptoms, nystagmus, contractures, and widespread paresis, with subordinate disorder of sensation. Syxonyms. — Hereditary ataxia ; Family ataxia. Etiology. — In the causation of so-called hereditary ataxia direct inherit- ance from parents very rarely ai)pcars, but in flic great niajority of cases the ancestors of the affected j)ersons have sufl'cred from various forms of nervous disease, so that the family stock is distinctly neuroi)athic. The iiuj)()rtance of this is shown in the fact that there an- on record only live or six isolated cases — i.e. cases in which only one member of the family was affcdctl. Among the generallv recognized causes of the disonlci- an' citlici' iiitciii|>ci;uicc, (uber- cnlosis, or .svphilis occurring in tli<' parent, and consanguineous marriage. Of these alleged causes, tuberculosis seems the iiuisl important. It is |)lain that 796 ORGANIC DISEASES OF THE SPINAL CORD. these various fausations have only this in common — namely, a tendency to lessen in the offspring general vitality and the power of development of the various organs of the bodv. In not rare cases Friedreich's ataxia seems to have been precipitated by the occurrence of some acute disease, the symptoms having developed after tyT)hoid fever, scarlatina, inflammatory rheumatism, diphtheria, etc. in a remarkable number of patients. Morbid Anatomy. — The characteristic pathological changes of hereditary ataxia consist of sclerosis of the pyramidal tract and of the posterior columns. In almost all of the autopsies this sclerosis has extended the whole length of the cord, and in a majority of the cases it has involved the anterior pyrauiidal or direct cerebral tracts. It seems, however, not to have been traced up into the cerebrum itself. In a proportion of the cases a large part of the periphery of the lateral column, the so-called cerebellar tract, has been found sclerosed. The gray matter of the cord, especially the column of Clarke, is usually more or less degenerated, and indeed not rarely the nerve-fibres seem to be materially " reduced in number throughout the whole cord. We have no knowledge as to which portion of the nervous system is first affet;ted, but it seems probable that no portion of the sclerosis can really be con- sidered as secondary to other portions, the widespread changes being the result of a common cause. The nature of these changes reuiains in doubt, but there is reason for accepting as correct the original thought of Kahler and Pick, that the foundation of the affection is the imperfect development of certain fibres of the nervous system. There is appearance of truth in the further general- ization of Pick, that this failure of development is due to early vascular de- generation, which naturally would especially and primarily affect the posterior columns of the cord, because this is the most vascular part of the cord. It must be stated, however, that recent observers' affirm that there is no alteration of the vessels, and that in this fact the lesion absolutely differs from that of true locomotor ataxia. Sclerosis and degeneration of the posterior nerve-roots were noted in all of the eight autopsies collected by Griffith — a fact which seems to negative the assertion of Dejerine, that Friedreich's disease separates itself from true locomotor ataxia in that the root-zones of the cord are not usually affected. Very few examinations of the peripheral nerves are on record, but Auscher states that whilst these nerves have not undergone degeneration, they are characterized by the presence of a considerable number of filaments with- out myelin — true embryonal nerve-tubes. If this be correct, it seems possible that the same condition may have been originally present in the spinal cords of cases of Friedreich's disease, and predisposed their subjects to the develop- ment of sclerotic lesions upon the slightest provocation. In this view of the pathology of the disease the fact that in so large a proportion of cases the symptoms have followed some acute infectious disease is very interesting. What is needed is microscopic examination of spinal cords taken from mem- bers of strongly affected families who have not themselves manifested the disease. ' Compl. Renduis Soc. Biolog., 1890. FRTEDREICH'S ATAXIA. 797 Symptomatolog-y. — Friedreicli's ataxia almost invariably appears diiriiifij childhood. Out of the 143 cases tabulated by Crozer Griffith, about 30 jier cent, developed the disease before the sixth year of ajjo, about 60 per cent, before the tenth year, and only 3 per cent, between the twentieth and twenty- fifth years. Usually the attack comes on insidiously, without prodromic s,vm])toms, but eclam})sia, vomiting;, vertigo, curvature of the spine, flexion of the toes, palpi- tation of tlie heart, choreiform movements, and other evidences of irregular nervous disturbance have been noted. The first characteristic svmptom is commonly a peculiar awkwardness of movement, which may develop directly in any portion of the body, although in the majority of cases it is first ])resent in the legs. In rare cases speech and the lower and upper extremities hav(> been simultaneously atfected. A monoplegic and even a hemiplegic form of attack have been recorded. In contrast with true locomotor ataxia the inco-ordination is not always increased by closure of the eyes. In the fully-formed case the gait varies : sometimes it resembles that exactly of true tabes ; sometimes the aberration from the norm sliows itself only in a strong tendency to the lateral projection of the foot; sometimes the walk is rolling like that of a drunken man. In the upper extremities the loss of co-ordination is evinced by irregular jerky movements and the inability to perform delicate acts. Late in the disorder inco-ordination often becomes so extreme that in the impossibility of properly ap])Osing the fingers one to another the action of the hand resembles that of the paw of an animal. The peculiar condition which Friedreich designates the " ataxia of quiet action,^' and which he states to be characteristic of the disease and never present in true locomotor ataxia, is usually a rather late symptom, and is shown in the inability of the subject to hold the arm still in extension or in other quiet though somewhat forced j^ositions. In its most advanced stage this ^^ static ataxia" even produces peculiar athetoid symptoms in the fingers -when lying in the lap, or a wavy or non-rhythmic os(;illation of the arms and leg's wdien at rest. It is verv common in the head, causing a ])eculiar oscillation -which is sometimes described as tremor or, w luii the oscil- lations are excessive, as choreiform movements. Sometimes these oscillations occur only under excitement, and sinudate somewhat an intention tremor. Spasms and cramps are rarely present. In hereditarv ataxia the knee-ierk is usually abolished early in the history of the c-ase. It is, however, not always absent, as it has been fi)und normal in a nund)er of re))orted cases, and in some cases which seem in all other rcsju'cts to liave represented the disease it has be(>n exaggerate* 1. The most probal>le explanation of these rare instances is that in them the liunbar enlargement of the spinal eord has not JK-en involved. In some of the cases in which the knee-jerk has been found exaggerated ankle-elomis is asserted (ct have been present. The cutaneous reflexes escajte in the majorily of cases, but are oeea- sionallv diniiuished, mihI have been n(»t<arts of the body. In the majority of cases the changes are somewhat symmetrical. Thus, if one region of the hand be attacked, the same region upon the other hand will be affected. This rule is not invariable, and even when the symmetry is decided, it may often be noted that not precisely the same muscles are affected upon the opposite side of the body. Although loss of endurance, or even partial par- alysis, may apparently precede the loss of muscular substance, the loss of power is due to the loss of nuiscular substance, and not the loss of substance to the loss of power ; or, perhaps more correctly, it may be considered that both PROGRESSIVE MUSCULAR ATROPHY. 801 symptoms have a common basis — i. e. when a spinal ganglionic cell is attacked the fibras of the mnscles individually supplied by it suffer simultaneously in their luitrition and in their motor functions. Usually the hands are the first portions of the body to be affected, the symptoms frequently being much more severe in the right hand. According to Eulenberg, the interosseous muscles are almost invariablv the first to be attacked, whilst Roberts, Wachsmuth, and Friedreich state that the Ijall of the thumb is usually implicated before the interosseous muscles. The- first external interosseous is said to be the fii-st to feel the influence of the dis- ease, whilst the opponeus and the adductor pollicis are more apt to suffer than the extensors, the abductors, and the flexors of the thumb. In the few cases in which I have had an opportunity to see the disease in its earliest stage the interosseous muscles were the first affected. The wastins: of the muscles of the hand is usually readily perceived by the flattening of the thenar eminence and by the falling in of the interosseous spaces. The diminished power of the interosseous muscles can usually be detected by noticing that when the ])atient attempts to abduct the index finger he separates it with less vigor from the middle finger than normallv. "When onlv (»no hand is attacketl the con- trast of movement is often decided. Instead of attacking the hand, progressive muscular atrophy may first make itself felt in other portions of the body, and especially is this true of the del- toid muscle ; but it is stated that the pectoralis major, the scrratus magnus, or even the lumbar muscles may have to bear the onset. The upper extremities, the neck, and the trunk are certainly much more frequently affected than are the legs ; nevertheless, the latter do not always escape. Owing to the loss of power in certain muscles and to the tendency to con- tractures in their antagonists, the sufferers from progressive muscular atrophy are prone to assume peculiar positions or to have extraordinary deformities. In a patient under my own care the loss of power in the nniscles of the neck was so great that the head perpetually fell forward, the chin resting upon the breast. In this case the upper arms were much more prominently affected than were the forearms, so that whilst the man still preserved a good grip the arms were perfectly flaccid and helpless, owing to the complete paralysis of the deltoid, biceps, and triceps. The most characteristic of the deformities is tliat which is known as the ''clawed hand" (main en grife, Khuenhand). iind which is j)rodiieed by the l)ermanent flexion oi' the last two plKilau<_res of the fingers, which an- extendcHl at the metacarpal joint. As was shown l»y Dnehenne, this defijrmity is the result of atrf>phy of the internal and external interossecjus nuisdes with the preservation of power Ijy the extensors and flexors of the fingers. It nuist be remembered that this deformity is really pathognomonic of paralysis of the interosse"if- 804 ORGANIC DISEASES OF THE SPINAL CORD. replace them with his fingers. If the palate be markedly affected, the voice becomes nasal. Deglutition may be affected early or late in the disorder, and, as the loss of power of swallowing is paralytic, liquids are swallowed with much difficulty and are apt to be returned through the nose. In some in- stances the larynx is attacked and the voice becomes almost inaudible, witfiout, however, being completely lost. In those cases in which the nuclei of the respiratory nerves are implicated the respiratory muscles undergo wasting and the respiration becomes much affected. Any attempt at violent movement, or, later in the disease, even ordinary walking, may cause a severe attack of dyspncea. At last these cyanotic crises comes on spontaneously in furious paroxysms, which may occur either by day or by night. A peculiar symptom which especially characterizes this dyspnoea is a sensation of excessive fulness of the chest, which is probably produced by the feebleness of the muscles pre- venting them from thoroughly emptying the lungs. In some cases the nuclei of the cardiac nerves appear to be attacked, and cardiac crises become violent and alarming. These are especially apt to be present in those persons in whom the respiration is affected, l)ut may occur without the respiratory mus- cles suffering. The pulse in the cardiac crises is very feeble, irregular, inter- mittent, and at last may be imperceptible. The face is exceedingly pale and anxious, and there is habitually an intense terror, with a sense of impending death. The ocular muscles may be affected in glosso-labial paralysis, although they usually escape. The "ophthalmoplegia externa" of Hutchinson is in some cases the expres- sion of a progressive muscular atrophy. Diagnosis. — The slow progression of the symptoms, the occurrence of atrophy before paralysis, the preservation of the electrical relations of the muscles, the absence of distinct disturbances of sensation and of pronounced tenderness, make the recognition of progressive muscular atrophy usually very easy. The only disease with which it can be confounded is pseudo- hypertrophic paralysis. This disease, however, belongs to childhood, and is usually attended with apparent increase in the size of some of the muscles. (For further details see Pseudo-hy[)ertrophic Paralysis.) Prog-nosis and Treatment. — The prognosis of progressive muscular atrophy is hopeless. The treatment is to be conducted upon general principles, with especial avoidance of muscular fatigue. We have no known agent capable of curing the degenerative lesion, but possibly the conjoint use of rest and massage may delay the process. Experience seems to show that the local treat- ment of the muscles by electricity, massage, etc. is of very little avail ; it may, however, be essayed, care being taken not to overdo the matter. DISEASES OF THE NERVES. By WILLIAM OSLER^ NEURITIS. Inflammation of the nerve-fibres may follow direct injury, disease of neighboring parts by extension (as in suppurative processes), exposure to cold, and is frequently due to toxic agents. For convenience of description localized and general forms may be recognized. Localized Neuritis. Etiology. — (1) Injury is the most frequent cause, either direct laceration by fractures, gun-shot and other wounds, or bruising, as in prolonged pressure upon a nerve-trunk. In the subcutaneous injection of ether an intense neur- itis may be excited by puncture of a nerve. A rare cause is the direct mus- cular compression of a nerve during sudden, violent muscular exertion. In certain occupations pressure on the nerves, as upon the ulnar in glass-workers, possibly, too, the constant straining of the muscles and of the nerves in re- peated movements, as in rolling cigarettes, may cause local neuritis. (2) Extension of inflammation from neighboring parts, particularly from disease of the bone. In otitis media the facial nerve may be involved, and in caries of the spine the intercostal nerves. Syphilitic disease is a loss fre- quent cause. Tumors of various sorts, particularly cancer, may involve the nerve-trunks and produce an intense neuritis. (3) Cold. The direct action of cold may cau.ee neuritis, a common exam- ple of which is in the facial nerve after exposure to a draught of air, as from an open window of a railway-carriage. This is .sometimes spoken of as a rheumatic form. Less commonly other nerves, such as the sciatic or branches of the brachial plexus, are affected by cold. (4) Neuritis is not an infrequent accom|>aiiitnent of joint-disease, particu- larly periarthritis of the shoulder, hip, and knee. And lastly, the various toxic agents, which will bi' considered under Midti- ple Neuritis, though nioi'c fi('r|uently causing disseminated lesions, may act upon a single nerve or a single ncrvc-i"oot. Morbid Anatomy. — \n acute neuritis tlic iicrvc-lrunk is swollen, the sheath reddened and infiltrated, and in the nuirc intense grades, du<> to exten- sion of inflammation from carious bone, then may be a suppurative perineur- itis. In the majority of examples the connective tissue uniting the ncrve- 806 DISEASES OF THE NERVES. fibres is infiltrated with serum and leucocytes, the nuclei of the sheath of Schwann are increased, and there is marked fragmentation of the medulla. The axis-cylinders become varicose, and finally granular and disintegrated. In the final stage the nerve is represented by a very fatty connective tissue. Symptoms. — There is no constitutional disturbance unless the process extends and involves many nerves. There is pain both in the part of the nerve-trunk involved and in the region to which it is distributed. There is sensitiveness on pressure, and the nerve-trunk may be felt to be enlarged. As Weir Mitchell states, the pain is in all probability due to the irritation of the nervi nervorum. In the region of distribution there are marked sensory dis- turbances, such as numbness, tingling, and often pain of a shooting or a stab- bing character, which may radiate over adjacent nerve-territories. INIovements of the muscles to which the nerve-fibres are distributed may be impaired, and occasionally there are tvvitchings or spasms. Trophic changes are sometimes seen, the temperature in the affected part may be raised, the skin is sometimes reddened, local sweating may occur ; more serious changes are herpes zoster and arthritis. The duration of the symptoms is variable. A slight traumatic neuritis may pass away in a week ; very frequently the process becomes chronic and persists for months. In the more chronic cases, such, for instance, as the neuritis of the brachial plexus after dislocation, the nerve-cords are swollen and painful, the pains persist for some time in the arm and hand, and the muscles gradually waste ; in the more extreme cases the skin becomes red- dened and glossy and there are trophic changes in the joints and in the finger- nails. Although, as a rule, the symptoms of a localized neuritis are confined to the part of a nerve affected and its peripheral distribution, there are instances in which the process ascends the nerve, the so-called migrating neuritis; thus, after an injury to a finger in which the nerves are involved, sensitiveness and swelling of one of the nerve-trunks of the arm may supervene, and the pro- cess may even extend to the corresponding cord in the brachial plexus. Gowers thinks that the ascending neuritis may even reach the spinal cord and cause subacute or chronic myelitis, and that the so-called reflex ])aralysis in vis- ceral disease is perhaps caused in this way. The electrical changes in localized neuritis are variable, depending on the extent of the inflammation. If slight, the nerve and muscle reactions may be but little disturbed. In other cases the reaction of degeneration develops rapidly. Multiple Neuritis (Peripheral Neuritis ; Polyneuritis). Etiology. — The cases may be classified as follows: 1, those in which the disease sets in after exposure to cold or follows exertion, the so-called idio- pathic form ; 2, toxic form, by far the most important variety, causing which the following poisons may be mentioned : (a) Diffusible Stimulants: alcohol, carbon monoxide, carbon bisulphide, dinitro-benzine (roburite), aniline. NEURITIS. 807 (6) Metallic Poisons: lead, arsenic, mercury, and phosphorus. (c) Animal Poisons: diphtheria, typhus and other fevers, syphilis, tubercle, malaria, and leprosy. (d) Vegetable Poisons: ergot, morphine, etc. (e) Endof/enous Poisons: rheumatism, gout, arthritis, diabetes, the puer- peral state, chorea (James Ross). 3, dyscrasic form, in which the neuritis develops in the cachectic states, such as cancer, anaemia, and marasmus ; 4, endemic neuritis or beri-beri. Morbid Anatomy. — The lesions are those already described under Local- ized Neuritis. In a majority of the cases it is a degenerative process not associated with much connective-tissue or nuclear proliferation, and no super- ficial changes may be observed. The alterations are invariably more marked at the peripheral distribution of the fibres than in the trunk. The medulla is swollen, fragmented, and granular, and in extreme cases forms a molecular debris. The axis-cylinders also become granular and subdivided, and finally all trace of separation between the two essential constituents of the fibre becomes lost and the sheath of Schwann alone remains. The change may exist for a variable extent along a nerve, and may not be contimious, but interrupted. The nuclei of the sheath of Schwann in many cases show active proliferation, and they probably play a very important part in the regenera- tion of the fibres. In other cases interstitial changes exist with the parenchy- matous degeneration. They are usually much more marked in the medium- sized and larger nerve-trunks. Symptoms. — It will be best, perhaps, to describe certain well-character- ized types, as the symptomatology of multiple neuritis is extremely complex. Acute Febrile Polyneuritis. — The attack may begin acutely or subacutely after exposure or after prolonged exertion, occasionally during convalescence from an infectious disease. The affection may set in with a chill, followed by pain in the ba(rk and limbs, and moderate fever, reaching in some instances to 103° F. Headache, loss of ajipetite, and the general features of an acute infection are, as a rule, present. Pain, numbness, tingling, or hyperaesthesia is felt in the peripheral parts. Sometimes the pains are lancinating, and are usually more intense in the legs than in the arms. The nerve-tnuiks may be painful on pressure, particularly, according to Leyden, in the vicinity of the joints. By the second or third day loss of power is noticed, first in tiie legs, chiefly in the extensors, and in the course of a few days it extends, reaches the muscles of the thighs, attacks the arms, and within a week there may be wide- spread paralysis, which may even extend to tiie muscles of the thorax and to those of the face. The muscles may rapidly waste, and there is marked diminution of the faradic and galvanic contract ility. The rcfiexes, as a ride, are abolished. Vaso-motor changes are not infrerpient, such as congestion of the extremities and sweating. The clinical picture in many cases is that of an acute ascending paralysis. In the most intense forms death niav occur within a week ; more commonly not until the thii-d or fi»iirth week. In other instances the atient is more comfort- able uj)()n a water-bed. The diet should be light and nutritious, and in the alcoholic cases special care must be exercised that the patient is not surrep- titiously given beer or spirits. The fever of onset rarely demands treatment. In the cases following cold and exposure the salicvlates mav be tried. For the pains in the joints and limbs antifcbrin or antipyrine may be given. In some instances morphine is necessary. Local applications are often very serviceable, particularly chloroform liniment. T]\o thernio-cautcry, lightly a])plicd along the sensitive nerve-trunks, is sometimes of the greatest service. As the patients often suffer from cold, the limbs should be wrajiped in cotton- wool, and it is advantageous when much congestion is present in the hands to keep them slightly raised on pilhiws. After the acute stage has jiasscd arsenic and strychnia may be administered, either together oi' alternately. Systematic massage should at this time be thoroughly carried out, since It Is probably tlie most serviceable of all measures in the paralysis and wasting of nnilti|)le neur- itis. Electricitv mav be applied to the affected nnis<'les, one pole placed over the truid< of the nerve, and the other over the nniscle. The slowly interrupted current is the best. Care must be taken to prevent, if possible, contractures, 812 DISEASES OE THE NEBVES. and when they exist they can usually with patience be overcome by passive movements and systematic rubbing. Neuroma. Properly speaking, this term should be applied only to growths containing nerve-substance, but it is applied somewhat indiscriminately to all tumors of the nerves. The distinction, however, may be made of true and false neuro- mata. The true contain either nerve-cells, neuroma celhdare, or nerve-fibres, which may be either medullated or non-medullatcd. The neuroma celhdare, also knowai as the ganglionic or medullary neuroma, is an extremely rare form of growth met with occasionally in the basal ganglia and in other parts of the central nervous system, more rarely attached to the auditory or olfactory nerves. Certain forms of ueuroglioma may resemble it very closely. Tumors containing nerve-fibres are met with most frequently on the nerves of the skin and in the ends of the nerves in amputation stumps. The former constitute the small painful tumors which have been termed tubercula dolorosa, which sometimes occur in numbers about the joints, occasionally in the skin of the face or on the scrotum. Though painful to the touch, particularly at certain seasons, these are not always true neuromata, but may consist of firm connective tissue, and sometimes are adenomata of the sweat-glands. The amputation neuromata, perhaps the most common, form ovid growths the size of peas or beans on the extremities of the nerve-trunks in a stump. They are made up of connective tissue and medullated or non-medullated nerve-fibres, and are sometimes extremely painful. Neuromata are occasion- ally met with on the nerves of the cauda equina and on the peripheral nerve- trunks, in which situation thev mav be felt as definite bead-like swellings. The most remarkable variety is the plexijorm neuroma, a congenital con- dition in which the nerve-cords in various parts of the body are the seat of tumor formations. In the remarkable case described by Prudden, the speci- mens of which are at the Medical Museum of Columbia College, New York, there were eleven hundred and thirty-two definite tumors on the various nerves of the body. The false neuromata consist of nodular formations of connective tisssue — fibroma, more rarely myxoma, sarcoma, or lipoma. There may be no symptoms even when the tun)ors are multiple. In other instances there is pain, which is often referred to the peripheral distribution of the nerve. The subcutaneous, painful tumor may be exquisitely sensitive, and when in a situation exposed to friction or to knocks exceedingly trouble- some. The amputation neuromata often cause great pain in the stump. Muscular twitching may occur, and it is stated that in some instances epileptic seizures have been caused by them. When painful the tumors may be excised. The amputation neuromata may recur after excision. DISEASES OF THE CRANIAL XERVES. 813 DISEASES OF THE CRANIAL NERVES. Affections of the Olfactory Nerve. Tlie sense of suiell uiay be lost or perverted, rarely inereased. Anosmia, loss of the sense of smell, may depend upon — 1. Involvement of the nerve-fibres in the mueoiis membrane. This, by far the most common eanse, results from chronic nasal catarrh, the presence of polypi, and occasionally from strong irritants. Paralysis of the fifth nerve mav be associated with loss of the sense of smell, owinir to disturbance in the secretion and absence of the necessary moisture. 2. Lesions of the olfactory nerve and bulb, unilateral or bihiteral, in frac- ture of the skull, caries, local meningitis, and tumors. A jirimary atrophy of the nerve is stated sometimes to occur in locomotor ataxia. 3. The loss of the sense of smell due to central disease is less common. The centre for the sense of smell is placed by Ferrier in th(> uncinate gyrus, and in a few instances the disturbance or loss of the sense lias been noticed in connection with disease of this part. Occasionally the olfactory nerves and bulbs are congenitally defective. Parosmia, or subjective sensations of a disagreeable nature, is met with most frequently in hysterical patients and in the insane. In epilepsy the aura may be olfactory in character, and the patient complains of an unpleasant odor, such as of the burning of rags, paper, or feathers. In other instances the parosmia exists alone in an apparently healthy individual : Morell Mackenzie mentions the case of a lady, aged about fifty, to whom the smell of cooked meat was so exactlv like tiiat of stinking fish that scarcely anv animal food could be taken. After injury to the head the perversion of the smell may persist and odors of the most different character )nay appear alike. Increased sensitiveness, or hyperosmia, is a rare condition met with occa- sionally in hysterical patients and in insanity. So acute may the sense become that individuals may be recognized by the odor alone. The sense of smell may be tested by such substances as cloves, musk, and peppermint. In routine neurological work the sense should be testtnl sys- tematically in brain cases, and it can readily be done by having small bottles filled with the essential oils. A careful rhinosco|)ic examination should be made in every case, as the disturbance of function not infrecpicntly depends upon peripheral, not central, causes. Affections of the Optic Nerve. The lesions may be in tiie terminal expansion in the retina, in the optic nerve, at the chiasma, in the optic tract, or in the prolongation of the fibres within the brain and in the cortical centre for vision. I^ESIONB or THE ReTFNA. (1) Retixftis. — The changes in the retina arc of the greatest importance in diagnosis, and very vahial>le information may be obtained by the systematic 814 DISEASES OF THE NERVES. examination of this membrane, particularly in Bright's disease, leukaemia, ansemia, and syphilis. The chief changes are a cloudiness or turbidity due to the eft'usion of serum in the layers of the retina, haemorrhages, which are in the layer of nerve-fibres and often follow the course of the vessels, and white spots or opacities. The haemorrhages and opacities are the features commonly regarded as indicative of retinitis. When fresh they are bright red in color, but the effused blood gradually undergoes changes, and ultimately the spots become quite black. The opacities are due to inflammatory exudation, to fatty degeneration, or to sclerotic change. The white spots also occur on the choroid as a result of atrophy of the pig- ment or the presence of new formations, particularly tubercles. Large areas of atrophy of pigment occur in certain cases of congenital syphilis. Tuber- cles in the choroid will be referred to in the section on Tuberculous Meningitis. The following are the more important forms : Albuminuric Retinitis. — In chronic nephritis, particularly the interstitial form, a variable number of the cases — 15 to 20 per cent. — present retinal changes. As disturbance of vision may be an early symptom, the diagnosis of Bright's disease is very frequently made by the oculist. The retinal arte- ries may be very small, and may be bordered by white lines, the result prob- ably of perivascular changes. Small aneurismal dilatations may sometimes be seen. Gowers recognizes two forms of albuminuric retinitis — degenerative and inflammatory. The degenerative variety is characterized by small whitish spots, either punctiform or elongated, which are most abundant about the macula. Linear and flame-shaped haemorrhages occur, and sometimes a diffiise opacity. In the inflammatory form there is much swelling of the retina and the arteries are obscured. Haemorrhages are numerous. There is a group of cases met with both in arterio-sclerosis and in chronic Bright's disease in which the optic nerve is chiefly involved, the disk being greatly swollen and striated, the vessels obscured, while the retina is either slightly involved or also presents haemorrhages and signs of intense retinitis. When, as sometimes happens, this condition is associated with headache and transient aphasia, the diagnosis from brain tumor is very difficult. Among the complications of albuminuric retinitis may be mentioned haemorrhage into the choroid, detachment of the retina, haemorrhage into the vitreous, and em- bolism of the central artery. A retinitis not unlike that of albuminuria also occurs in diabetes. In profound anaemia, in whatever way produced, retinal changes are common, chiefly in the form of haemorrhages, more rarely as a neuro-retinitis. They occur particularly in pernicious anaemia, occasionally in chlorosis, in which the condition is more commonly a neuritis, and in malarial cachexia. Leukcemic Retinitis. — A remarkable form occurs in leukaemia, usually in the splenic variety. There may be onl}' a diffuse thickening and infiltration, with turbidity of the membrane or extensive haemorrhage, but the most dis- tinctive form is characterized by the presence of opaque white or yellowish- white spots, which may even resemble little tumors. So characteristic is this AFFECTIONS OF THE OPTIC NERVE. 815 condition that the diagno.sis has been suggested by the ophthahnoseopic exam- ination alone. Haemorrhages are also met with in jiurpura, scurvy, an., oculus sinister; 0. l>., oculus dexter; N. T., nasal and temporal halves of retina' ; J\'. 0. >., nervus oi)tious sinister ; N. O. I)., nerviis opticus dexter; F. C. S., fasciculus cruciatus sinister; F. L. I)., fasciculus lateralis dexter; ('., chiasina, or decussation of fasciculi cruciati ; T. 0. />., tractus opticus dexter; C. (1. A., ciir))iis gciiiculatum lat- erale; A. O., lobi ofjlici (corpus quad.) ; P. O. C, primary optic centres, including lol)\is ojyiicus eorp. genie, lat. and pul vinar of one side ; F. O., fasciculus opticus (Gratiolel) in the internal capsule ; C. P., cornu po.sterior; G. A., region of gyrus angnlaris ; L. O. S., lobus occip. sinister; A. O. J)., lobus occip. dexter; C"u., cuneus and subjacent gyri, constituting the cortical visual centre in man. (The heavy or shaded lines represent parts connected witli the right halves of liotli retin;f.) (Scguin.) tion. Each tract contain.s ncrvc-fibrcs wliicli supply (lie (ciiiporal li:iir of the retina on the same side ami the nasal li.ill' '•(" the opiiositc. 'Plic nasal or (locnssating fibres are more numerous ami (Mciipy (Ik- midtllc pardon of fho chiasma. Lesion of one tract ean.ses lu.^s ot" I'liiiftitjii in thr (b has shown, this skin reflex is usually, but not necessarily, lost with the reflex contraction. Iridoplegia is usually associated with small pupils ; thus in locomotor ataxia the pupils are often much contracted — spinal myosis. Inequality of the pupils — anisocoria — is met with not infrequently in gen- eral paralysis of the insane and in locomotor ataxia. It also occurs in healthy persons, and may persist for years. Fourth Nerve. The nucleus of this nerve is situated in the upper part of the floor of the fourth ventricle. Coursing around the cms in its passage to the orbit, it is liable to be involved in tumors, in the exudation of basilar meningitis, and niav be compressed by aneurism. It supj)lies the superior obli(iue muscle. Nuclear paralysis is seen in connection with involvement of the centres of the other eye-muscles. ]*aralvsis of the suj)erior oblique causes defective down- ward and inward movement of the eyeball. There is double vision when the patient looks downward, which is obviated when the patient inclines the head forward and toward the sound side, 'fhe ])aralysis may lie too slight to be noticed. Six III Nkiivk. Arising from its nucleus in the floor (»f the fourth ventricle, i( passes forward through the pons and emerges at the junction of the pons and medulla. Enter- 822 DISEASES OF THE NERVES. ing the orbit, it supplies the external rectus. The nerve is apt to be involved in tumors and meningeal morbid processes, and it is stated also to be sometimes paralyzed by cold. Paralysis of this nerve causes internal strabismus, and there is double vision on looking toward the paralyzed side. The defect in lesion of the nucleus is thus clearly and briefly described by Beevor : " When the nucleus is affected there is, in addition to paralysis of the external rectus, inability of the internal rectus of the opposite eye to turn that eye inward. As a consequence of this the axes of the eyes are kept parallel, and both are conjugately deviated to the opposite side, away from the side of the lesion. The reason of this is that the nucleus of the sixth nerve sends fibres up in the pons to that jnirt of the nucleus of the opposite third nerve which supplies the internal rectus : we thus have paralysis of the internal rectus without the nucleus of the third nerve being involved, owing to its receiving its nervous impulses for parallel movement from the sixth nucleus of the opposite side. As the sixth nucleus is in such close proximity to the facial nerve in the sub- stance of the pons, it is frequently found that the whole of the face on the same side is paralyzed, and gives the electrical reaction of degeneration, so that with a lesion of the left sixth nucleus there is conjugate deviation of both eyes to the rigid — i. e. paralysis of the left external and the right internal rec- tus, and sometimes complete paralysis of the left side of the face." General Features of Paralysis of the Motor Nerves of the Eye. — Gowers recognizes five groups of symptoms : 1. Limitation of Movement, which is in proportion to the grade of the par- alysis. 2. Strabismus. — In consequence of the paralysis the axes of the eyes do not correspond. Paralysis of the internal rectus causes a divergent squint — of the external rectus, a convergent squint. The deviation of the axis of the aifected eye from parallelism with the other is known as the primary deviation. 3. Secondary Deviation, which depends upon the fact that when two mus- cles act together, if one is feeble and an effort is made to contract it, the increased innervation acts powerfully upon the healthy muscle, causing increased contraction. '' Its existence and amount may be best ascertained by subsequently covering the paralyzed eye and making the patient fix with the unaffected eye, which, to do so, moves back to its former position. The hand or a piece of paper may be so placed as to intercept the vision of the one eye, while leaving it exposed to observation. A piece of ground glass ])laced over the eye answers the same purpose. The occurrence of secondary deviation depends on the fact that normally two muscles which act together are equally innervated for a given movement. If one is weak, and an effort is made to contract it (as in fixing with that eye), the increased innervation influences also the other muscle and causes an undue contraction. It is as if a rein acted equally on a hard-mouthed and a tender-mouthed horse yoked together ; the effort to make the former deviate would cause an excessive deviation of the latter " (Gowers). AFFECTIOyS OF THE MOTOIl . yERVES OF THE EYE. 823 4. Erroneous Projection. — " We judge of tlie relation of external objects to each other by the relation of their images on the retina; we judge of their relation to our own body by the position of the eyeball as indicated to us by the innervation we give to the ocular muscles" (Gowers). If an object moves, we follow it with the eyes and judge of its position by the amount of move- ment. When one muscle is weak, the increased innervation " gives the impression of a greater movement of the eye than has really taken place, and suggests that the objects seen are farther on that side than they really are," and in attempting to touch it the finger goes beyond it. As equilibration in great part depends upon knowledge of the position and relation of external objects derived from action of the eye-muscles, the erroneous projection result- ing from paralysis " destroys the harmony between the visual imi)ressions and the others that are correct," and leads in this way to giddiness or ocular vertigo. 5. Double Vision, or Diplopia. — Owing to paralysis of the muscles the visual axes do not correspond, and there is a double vision : that seen by the sound eye is called the true, that by the paralyzed eye the false, image. When the false image is on the same side of the other as the eye by which it is seen, it is known as simple or homonymous diplopia, in which, for example, the right-hand image corresponds to the right eye, and the left-hand image to the left eye. In crossed diplopia the false image is on the other side; for example, the right-hand image belongs to the left eye, and the left-hand image to the right eye. The diplopia is simple in convergent squint, crossed in divergent squint. Ophthalmoplegia. Under this term is described a chronic progressive paralysis of the ocular muscles which may involve the external or internal groujis alone or in com- bination, hence the names, " ojihthalmoplegia externa" and ''ophthalmoplegia interna." The condition is due to a degenerative change in the nuclei of the ocular nerves, and is described by Gowers as nuclear ocular ]ialsy. In the external form the levators of the eyelids are usually first involved, then grad- ually the power is imj)aired in the other muscles, and finally the eyeballs become almost fixed, so that in order to view objects out of a straight line the patient has to move his head in a very characteristic manner. The eyelids droop and there is usually slight protrusion of the eyeballs. The affection is met with in association with general paralysis, locomotor ataxia, and sometimes in pro- gressive muscular atrophy. Hiit(!hinson regarded syj)hilis as the most important cause, but in the recent monograph of Siemerling it is stated that of the 62 cases on record, in only 11 could syphilis be definitely detcnniiicd. Atrophy of the optic nerve and afT'cctions of the other cranial nerves are frequently associated with if. ^IcDtMl disorders were present in 11 of the 02 cases ana- lyzed bv Siemerling. Jiristowe has rcportcfl 2 cases in which (he cNtcriKd oph- thalmo))legia was ])robal)ly functional. Ophthalmoplegia inf<'rna is a term applied to slow progressive loss (»r power of the ciliary muscle and the iris. The condition may occur alone, but more 824 DISEASES OF THE NERVES. commonly is associated with tiie external form, and is then spoken of" as total ophthalmoplegia. Possibly in some cases the internal form may depend upon disease of the ciliary ganglion. Although, as a rule, the ophthalmoplegia is a chronic process, there is an acute form which may lead to complete loss of power within ten or fourteen days, due to rapid softening of the nuclei of the ocular nerves. There are cerebral disturbances and sometimes ataxic symp- toms. It was to this condition that Wernicke gave the name polio-encephaliiis superior acuta. Spasm of the Ocular Muscles. In hysteria there may be an intermittent spasm causing rapid lateral move- ment of the eyes, with or without associated jerkings in other muscles of the body. In hysterical convulsions the eyes are usually drawn up, so that the cornese are completely covered by the lids. In disease at the base of the brain, particularly meningitis, tonic, more rarely clonic, spasm may occur. The form known as conjugate deviation of the eyes, which is present in cere- bral lesions, will be subsequently described. The most remarkable form is the clonic rhythmical spasm known as nystagmus, in which the movements are bilateral and as a rule horizontal. When one-sided the movements are most frequently vertical. It occurs under very many conditions, particularly in congenital and acquired brain lesions associated with blindness, in albinism, in miners, and in many forms of sclerotic and chronic cerebro-spinal lesions, such as disseminated sclerosis and Friedreich's disease. The pathology of the condition is not yet well understood. Spasm of the levator palpebrse is occasionally met with, and here may be mentioned the condition of hippiis, or rhythmical contraction and dilatation of the iris. Treatment of Ocular Palsies. — The paralysis due to diphtheria as a rule disappears with time and under a course of tonic treatment. When due to syphilis, iodide of potassium and mercury should be given, and the condition frequently improves rapidly under the use of these drugs. The forms asso- ciated with locomotor ataxia are the most obstinate and may resist all treat- ment. The group of cases due to chronic degenerative changes, as in progres- sive paresis or bulbar paralysis and the forms of ophthalmoplegia, are little if at all amenable to treatment. When there are acute symptoms hot fomenta- tions, counter-irritation, or leeches may be used. The direct treatment of the paralyzed muscles by electricity is occasionally followed by good results, but in a large number of cases no special effect can be seen even after prolonged appli- cation. The diplopia may be relieved by the use of a prism. It is sometimes found necessary to cover the affected eye with an opaque glass. Various forms of spasm of the ocular muscles are little if at all affected by treatment. Lesions of the Fifth Nerve. W^e shall consider here paralysis, spasm, and neuralgia. (1) Paralysis. — In comparison with the facial and other cranial nerves, AFFECTIOXS OF THE FIFTH XFliVE, 825 lesions of the trigeminus causing paralysis are rare. The nerve may be affected within tlie pons by luvmorrhage or tumors, rarely in chronic nuclear deaeneration, which mav be widespread without aifectino; the fifth nerve. At the base of the brain its position guards it, to a certain extent, from compres- sion, but it is sometimes involved in fracture, caries, or meningitis. Tiie branches may be affected as they pass to their distribution, the ophthalmic in the cavernous sinus by tumors or aneurisms, the superior and inferior maxillary branches by growths which invade the spheno-maxillary fossa. Symptoms. — (a) Sensory. — When the whole nerve is involved there is loss of sensation in the skin of the corresponding side of the face and head, the conjunctiva, the mucous membrane of the lips, tongue, hard and soft palate, and of the nose on the same side. Tingling and numbness may precede the ana?sthesia. The sense of smell is usually affected in consequence of dryness of the mucous membrane. Trophic changes sometimes occur, the salivary, lachrymal, and buccal secretions diminish, the gums may swell on the affected side, the teeth occasionally become loose, and abrasions of the mucosa tend to ulcerate. Herpes may develop about the eye or about the lips, and may be accompanied with much pain. The cornea may become opaque, and finally ulcerates. This is not, however, a constant sequence, and is absent unless the Gasserian o-ano-lion is affected. Involvement of the individual branches of the sensory division causes loss of sensation in the skin and mucous surfaces upon which they are respectively distributed. (6) Motor. — Inability to use the muscles of mastication on the affected side is the characteristic feature of paralysis of the motor division. It can be tested by asking the patient to close the jaw forcibly, when the temporal and masseter muscles on the affected side are not felt to contract or do so with great feebleness. Owing to involvement of the pterygoid, which cannot be moved toward the affected side in the act of chewing, the jaw when depressed deviates to tiie paralyzed side. Paralysis of the motor branches of the fifth nerve usually follows a lesion of the trunk. Occasionally the paralysis is due to cortical lesion, usually bilateral. Hirthas reported an instance of unilateral lesion, a psammoma involving the lower third of the ascending frontal convo- lution and the adjacent portions of the second and third frontal convolutions, associated with paralysis of the muscles of mastication. Guddtory Symptoias. — The sense of taste is, as a rule, lost in tlic anterior two-thirds of the tongue on the affected side. The gustatory fibres pass from the chorda tympani to the lingual branch of the fifth. Loss of taste does not invariably follow paralysis of the fifth nerve. " Probably the exceptions are cases of partial disease or disease within the pons, where the taste-path has a sejxirate course " (Gowers). The diagnosis of trifacial ])aralysis rarely offers any special dillicultics, the distribution of the anaesthesia and the loss of jxtwcr in the muscles of mastica- ti(jn fi»rm such characteristic features. The j)rclimiii;n y pain and liypera\sthesia may be mistaken for neuralgia. The determination of the site of the lesion dejjcnds on the distribution of the anajsthesia and associated paralysis. When 826 DISEASES OF THE NERVES. the ophthalmic division is involved alone, the lesion is usually at the sphenoidal fissure or within the orbit. The lower divisions are not infrequently involved in tumors of the superior maxillary bone. (2) Spasm of the Muscles of Mastication. — Trismus, or the masti- catory spasm of Romberg, is often an associated feature in general convulsive attacks, sometimes an independent affection. The contractions may be either tonic or clonic. In the former the muscles of mastication are in firm contrac- tion, so that the jaws are kept close together, the condition know'n as lockjaw, a symptom which occurs early in tetanus and is met with in some cases of tetany. Occasionally it is an hysterical manifestation. Less frequent causes are reflex irritation from the teeth and organic disease near the motor nucleus of the fifth nerve. Clonic spasm occurs either in a series of quick contractions, as in chattering of the teeth, or as forcible single contractions, which are some- times seen in chorea and in iiysteria. Treatment. — For the organic lesions involving the fiftii nerve little can be done beyond relieving the pain, which may require morphine. The prelim- inary irritation and hypersesthesia are relieved by warm applications. If there be a history of syphilis, mercury and iodide of potassium may be given. Fric- tions and faradization of the affected side of the face are recommended. (3) Neuralgia. — Neuralgia of the fifth nerve (prosopalgia ; tic doulou- reux) is the most common and distressing of all painful affections of the nerve.«. All of the branches are rarely involved ; most commonly the ophthaluiic alone or the two upper divisions. Wlien the ophthalmic division is involved, the pain is referred to the dis- tribution of the supraorbital branch, as a rule on one side only. There are tender points at the supraorbital notch, at the inner angle of the or))it, and sometimes on the nose at the junction of the cartilage with the bone. The pain is usually paroxysmal and may be of extreme severity. It is usually accom})anied with intolerance of light, sometimes wath spasm of the orbital muscles, lachryraation, and redness of the conjinictiva. The whole eyeball may ache or there may be an intense pain at the back of the eye. The pain extends over the brow and forehead, and the skin may be so tender that the patient may be unable to wear his hat. Owing to the paroxysmal character and the supposed association with malaria, neuralgia of this branch was for- merly spoken of as " brow ague." The affection must not be mistaken for migraine, the painful symptoms of which are, however, due to involvement of this branch of the fifth nerve. It is to be remembered, too, in bilateral cases that errors of refraction may lie at the root of the whole mischief. Herpes may occasionally develop during an attack. Spasmodic contractions of the face-muscles on the affected side are occasionally present. The superior maxillary is less frequently involved. There is a tender point at the infraorbital canal, and the pain is rather more concentrated and limited than in the neuralgia of the upper division, being chiefly along the upper teeth and gums. Salivation may occur with it. In inferior maxillary neuralgia there are painful spots along the auriculo-temporal nerve, and the pain radiates AFFECTIONS OF THE FACIAL NERVE. 827 about the ear and along the course of t.he inferior dental nerve. Tender points occur about the side of the head, particularly at the parietal eminence. Trifacial neuralgia is most commonly met with in enfeebled subjects, par- ticularly in women and in association with aujijmia and chlorosis. There are instances in which it seems dependent upon malaria, but the malarial charac- ter in many of the cases has been attributed to the periodicity of the attacks. The cases vary extremely in their character and duration. There are instances in which the trophic and vaso-motor disturbances arc particularly marked; thus the skin may become glossy and indurated and the subcutaneous fat may increase. Pigmentary changes sometimes occur on the skin, and the hair or the beard on the affected side may become gray. The cases associated with spasmodic tic are sometimes of the most aggra- vated character, and tiie attacks occur with frightful intensity and render the patient's life unendurable. Treatment. — Careful investigation should be made into possible sources of reflex irritation. Tonic and hygienic measures of all sorts should be utilized, as in very many cases neuralgia is, as has been expressed, the cry of a badly- nourished nervous system. A change of air will sometimes relieve a severe neuralgia, and even obstinate cases may yield to a prolonged residence in the mountains with an out-of-door life and plenty of exercise. Iron is often a specific in the cases associated with chlorosis and anaemia. Arsenic is also very beneficial in these forms, and should be given in full doses. Quinine, which is so much used, has probably no greater value in neuralgia than any other bitter tonic, except in the rare instances in which neuralgia is definitely associated with malarial poisoning. Strychnine, cod-liver oil, and ])hosphorus are sometimes useful. For the relief of the j)ain antifebrin and antipyrine may be tried, though their value has been much exaggerated. Morphine should be given with great caution, and only after other remedies have been tried in vain. Small doses given hyj)odermically are usually very efficacious, but on no consideration should a patient be allowed to use the hypodermic syringe. Gelsemiura may be tried, and in frequent doses of the tincture is sometimes of value. Valerian, ammonia, ether, and above all alcohol, some- times allay the pain. The last-named remedy should be used with the greatest caution, particularly in women. The pleasant, soothing clfcct of it in many cases of neuralgia has been the starting-point of habits which have finally enslaved the patient. Nitro-glycerin in full doses is a remedy which is some- times efficacious, particularly in the chronic cases. Of local applications, liniments of belladonna, chloroform, and menthol, the ointments of acouitine and veratrine, and counter-irritation with the thcrmo-cautery or small blisters over the painful points, may be tried. P]lcctricity is often of nnich service, particularly the continuous current, and wIkmi frc(|M(Mitly repented is very soothing. Lesions of the Facial Nerve. Paiialysis (Bell's Palsy) may be due to — (1) iiivolvcnicnl of the nerve-fibres from the cortex cerebri to I he nucleus in the medulla; (2) to 828 DISEASES OF THE NERVES. lesions of the nucleus iti^elf; and (3) to peripheral lesions involving the nerve-trunk in its tortuous course witliin the pons and through the wall of the skull or in its course after leaving the styloid foramen. (1) Facial Paralysis of Cerebral Origin. — This, also known as the supranuclear form, may be due to a lesion of the cortical centre presiding over the lower facial muscles which is situated in the lower part of the ascend- ing frontal convolution. Cases of limited lesion involving the facial centre alone and causing facial hemiplegia are rare ; more commonly on the left side the speech-centres are also involved and the centres for the hand and arm. Softening from arterio-sclerosis, tumors, and localized meningitis, tuberculous or syphilitic, are the common causes of cortical facial palsy. The fibres may be involved between the cortical centres and the nucleus in the medulla, and with them, as a rule, the motor fibres of the arm and leg, so that the facial palsy is part of a hemiplegia. The supranuclear facial paralysis is distinguished from the peripheral form by several well-marked features. The orbicularis palpebrarum and frontalis muscles are not involved, so that, for instance, in hemiplegia the patient can close the eye and frown on the paralyzed side. While voluntary movements are lost in the paralyzed muscles, during emotion, as in smiling, the paralyzed muscles may be moved, which is never the case in the periplieral form. Another difference of great importance is the persistence of the normal electrical excitability of both nerves and muscles. In rare instances of hemiplegia the orbicularis palpebrarum is involved in association, it is said, with lesion of the lenticular nucleus. Broadbent explains the immunity of the upper facial muscles in hemiplegia by the fact that the bilateral move- ments of the body, such as those of the eyes and trunk and the larynx, are represented in both hemispheres ; that is to say, either hemisphere can excite bilateral movements. (2) Nuclear Facial Paralysis. — The facial nucleus forms a group of large ganglion-cells, occupying that portion of the gray substance of the fas- ciculus teres which lies immediately behind the nucleus of the sixth nerve in the floor of the fourth ventricle. The nuclei are rarely attacked alone, but may be in tumors, haemorrhage, and softening; more rarely in acute poliomyelitis. In lesions in the neighbor- hood of the pons the facial nucleus on one side, that of the sixth nerve too, and the motor path may be involved, producing facial paralysis on the same side as the lesion and paralysis of the arm and leg on the opposite side — a condition known as crossed paralysis. (See Fig. 57.) The symptoms of facial paralysis of nuclear origin are identical with those of involvement of the nerve itself. The superior facial muscles are involved and the electrical changes are present. (3) Paralysis from Involvement of the Nerve-trunk. — The nerve may be involved as it passes through the pons from the nucleus, at the base of the skull, in its prolonged course tbrough the temporal bone, or at its point of emergence. In the pons the fibres may be affected between the AFFECTIONS OF THE FACIAL NERVE. 829 nuclei in the floor of the fourth ventriele and the point of emergence of the nerve, in which case there may be an akernating or crossed paralysis, in which the face on the same side and the arm and leg on the opposite side are paralyzed. This only occurs when the lesion is in the lower region of the pons. At the base of the brain the nerve is liable to be compressed by meningeal exudation or tumors, and is occasionally torn in fractures. Within tiie tem- poral bone the nerve is frequently attacked in c)titis media. At the styloid Crossed Pyramidal Fibres -•>''■}! _coRo Oima PYRAMIML FIBRES Motor Tract (after Starr): .% fissure of Sylvius ; NL, lenticular nucleus; 07", optic thalamus; 0, olivary body. The tracts for the face, arm, and les gather in the capsule, and i>ass lo-iether to the lower pons where the face-fibres cross to the opposite seventh nerve nucleus, while the others i>ass on to tlie lower medulla, where they partially decussate to enter the lateral columns of the cord : the ndu-decussatiiiK fibres pass to the anterior median columns. The ellect of a lesion situated at three points in the tract is sliown on the left side of the fiKtire at A', }'. Z. At ^^ the lesion would involve the left facial nerve and tlie left pyramidal tract above the decussation, producing fiicial paralysis on the left side and paralysis of the arm and leg on the opposite side— crossed paralysis. foramen the nerve may be involved in blows, injuries, as by the pressure of forceps in an instrumental delivery, and the nerve may be cut in the removal of tumors in the parotid region. The mo.st common cause is ex])osure to cold, l)articularly to a draught when riding in a carriage with the window down. This is usually attributed to a neuritis of the nerve in (he Fall(»|)iaii a(|iicdMct. Symptoms. — The onset is, as a rule, abriii)t, and is not oltcn preceded by pain or discomfoit. In the cases following exposure to cold it is a commiMi hi.'^tory to find that the patient walCCC) the outlook is favorable, and recovery will jjrobably take place in from four to six weeks or may be delayed for from eight to ten weeks. If the faradic and galvanic excitability of the nerves and the faradic excitability of the nuiscles are lost, and the galvanic excitability of the muscle quantitatively increased and qualitatively changed (reaction of degeneration), and if the mechanical excitability is altered, the prognosis is relatively unfavorable, and recovery may not take place for from two to eight months, or may even be delayed for as long as twelve or fifteen months. The duration of the paralysis is variable. Recovery usually follows the paralysis from cold, though it may be delayed for months. In the traumatic cases recovery is possible, but the loss of power in these may be permanent. AFFECTIOXS OF THE FACIAL XFRVF. 831 When due to syphilis recovery is common. In tlie cases clue to middle-ear disease the outlook is less favorable. In any case the electrical reactic>n gives the most valuable indications upon which the prognosis can be based. When the paralysis is permanent, the muscles are toneless and there are no contractures. Spontaneous twitchings may be noticed at times in the muscles. In these late cases without any improvement there may be contractures in the muscles, drawing the mouth toward the paralyzed side, and the wrinkles may again appear, and in looking at the face the first impression may be that the affected side is the sound one, but this is soon corrected by asking the patient to smile, when it is seen which side of the face has the active movement. Diagnosis. — The existence of facial paralysis is usually determined at a glance. The diagnosis of the site is sometimes difficult. The following resume may be given : (1) Paralysis due to a lesion of the nerve outside the stylo-mastoid foramen involves both the upper and lower divisions. All reflex movements are lost and the reaction of degeneration is present. (2) When due to lesion within the Fallopian canal the features are the same as those just mentioned, and there are, in addition, alterations in the sense of taste and increased sensitiveness in hearing. (3) A nuclear lesion produces a paralysis similar in distribution to the peripheral form. There may be crossed paralysis, involvement of the facial on one side and of the arm and leg on the other, and the sixth nerve on the same side is usually involved, causing internal strabismus. (4) The facial })alsy of cerebral origin (supranuclear) involves, as a rule, only the lower facial muscles, so that the patient can elevate the eyebrows and close the eye. The reflexes are preserved, and there is not the reaction of defeneration. If due to involvement of the fibres in the cortico-bulbar motor path, there is usually hemiplegia and the paralysis of the face and of the limbs is on the same side. The paralysis due to a cortical lesion may be a monoplegia confined to the facial muscles. On the left side it may be accom- panied with aphasia, and in some instances the arm-centres are also involved. Treatment. — In the so-called rheumatic cases hot aj)])lications may be made, but the disease rarely seems to be progressive, and the damage is done before any palliative treatment can be adoj)ted. The thermo-cautery may be lightly api^lied at intervals over the mastoid region and over the course of the nerve. This is much more satisOictory and very much less painful than blis- tering. Iodide of potassiinn should be given internally, and in increasing doses, if svphilis be suspected. Sui)se<|uently (he galvanic current should be systeiiiaticallv employed, and persevered with so long as there is any reaction, as when this is present there is always a prospect of recovery. The positive pole may be placed behind tlic car and tlic negative pole passed over the zvgomatic and other nmscles. The :i|)plication siioiild be made daily for from ten to fifteen minutes. With the electricity may be cond>ined mas.sage of the mu-scles of the face. 832 DISEASES OF THE NERVES. Spasm of Facial Muscles (Mimic Spasm ; Convulsive Tic). — The contraction, which is usually clonic, may be limited to certain groups of mus- cles or involve all those of one side ; occasionally it is bilateral. Various groups of cases may be recognized : («) The secondary form following paralysis, and consisting in spontaneous clonic twitch ings recurring at irregular intervals in the paral^'zed muscles. (6) Cases due to the irritation of an organic brain lesion, either of the cor- tex, as in a case of Berkley's in whi(;h a lesion of the ascending frontal con- volution caused persistent clonic spasm limited to the zygomatic muscle, or pressure on the facial nerve by a new growth or an aneurism at the base of the brain. (c) In many cases, particularly in adults, no cause can be assigned. This, which Gowers calls the idiopathic form, is most frequent in females, and fol- lows in some ilistances mental anxiety and shock. {d) Cases which appear to have a reflex origin, and which are associated with irritation in branches of the fifth nerve, as in eye-strain, diseased teeth, and naso-pharyngeal disorders. Some have attributed the affection in children to the irritation of worms. Cases due to these causes are much more common in children, in whom the spasm, known also as habit spasm and by some as hab- it chorea, may be limited to the facial muscles, but may be met with in other groups." Lastly, facial spasm may form a })art of the affection described by the the French as tic convulsif or as Gilles de la Tourette's disease, which is characterized by involuntary spasmodic jerkings in certain muscle-groups, particularly those of the face, explosive utterances, often bad language — coprolalia — and fixed ideas, such as arithmomania. Symptoms. — The contractions are usually of a rapid, electric-like charac- ter, sometimes a series of quick, quivering contractions. The orbiculares oculorum are most frequently involved, causing a form known as the nicti- tating and blepharospasm, in which the eye is closed with lightning-like rapidity. In some cases, when both sides are affected, the patient can scarcely see, owing to the constantly-recurring contraction. More frequently the lateral facial muscles are also involved, and there is constant twitching of the side of the face, with partial closure of the eye. The frontalis muscle is not often involved. In severe cases the depressors of the angle of the mouth, the levator menti, and the plastysma myoides are affected. Occasionally the muscles of the tongue, which is protruded quickly as the patient talks, and occasionally the muscles of the palate and uvula, are involved. The contractions are aggra- vated by emotion and reduced by rest and quiet. There is no loss of power in the muscles and no pain. Tender points are sometimes found in the course of the fifth nerve, particularly in the supraorbital branch. The spasm occa- sionally extends from the face to the muscles of the neck and arms. The outlook is favorable in the cases in which a source of definite irritation can be traced. The idiopathic cases coming on in the middle life in women are as a rule incurable. AFFECTIONS OF THE AUDFrORY NERVES. 833 Treatment. — In cliiklrcn the sources of reflex irritation should be carefully sought for. Eye-strain should he excluded, the naso-pharynx explored, and decayed teeth removed or fdicd. When tender spots exist along the fifth nerve, small blisters may be applied or the thermo-cautery. Electricity, which is given in nearly all cases a thorough trial, rarely proves successful. Hypodermics of strychnine are recommended. Freezing the face with the ether spray is in some instances beneficial. Stretching or section of the facial nerve has been employed in many cases, and the spasm has often disappearal temjK)- rarily. Strychnine, arsenic, and iron may be used. Lesions of the Auditory Nerves. The central relations of the auditory nerves are with the first temporal gyri. Experimentally, bilateral destruction of these gyri in monkeys causes deafness. Cases of disea.se in man indicate that the situation is the same. On the left side destruction of the first temporal gyrus causes the condition known as word-deafne.ss, an inability to understand the meaning of words, thouo;h thev may still be recognized as sounds. Disturbance of function is not common as a result of lesion of the centre or of the auditory path ; much more commonly deafness results from disease of the nerve after it has left the nucleus in the floor of the fourth ventricle, or much more frequently from involvement of its branches of distribution in the vastibule and cochlea. Desreneration of the anditorv mujlei is rare even in extensive and wide- spread bulbar disease. The nerve may be compressed at the base of the brain by tumors or the exudation of meniiigitis, or may be torn in fracture. In epidemic cerebro-spinal meningitis the auditory nerves are not infrequently involved : permanent deafness may result, which in the case of very yoinig children leads to deaf-mutism. A primary degeneration of the nerves has been met with in locomotor ataxia, but it is extremely rare in comparison with the atrophy of the optic nerve in this disease. In a large ])roportion of all cases with auditory-nerve symptoms the l(>sion is in the distribution ; that is, in the labyrinthine branches. Three groups of .symptoms may be produced : hyperaesthesia and irritation, diminished func- tion or nervous deafne.s.s, and vertigo. True hyperesthesia — hyperacusis — a condition in which sounds, even those inaudible to other persons, are heard with intensity, is met with occasionally in hysteria, more rarely in cerebral disease. The term dvsresthesia or dvsacusis is ap|>lied to the .state in whieh ordinary noises are badly borne, as in headache. Tinnitus au'rium is a term used to cliarMeteri/e the subjective sensation of noises in the ears, .such as roaring, ringing, buzzing, singitig, ticking, v\i\ Tinnitus may accompany very many \nrm< of ear din'Msc". such as w.ix i>ressin'r f)n the drum, otitis media, aiiuch as p('j)per, vinegar, and hot sauces, may dull the sense of taste. Affec- tions of the nerve mav be followed by a loss of the sense. From the tin and sides of the tongue the impressions are conveyed through the gustatory divisions of the fifth, and in disease of the middle ear there may be loss of taste in these ])arts of the tongue, owing to involvement of the chorda tympani, the nerve through which the gustatory fibres are distributed. As we mentioned above, it seems n(jt improbable that the fifth nerve subserves the sense of taste in the posterior part of the tongue as well. Perversion of the sense of taste — parageusis — is occasionally met with in hysteria and in the insane. Sid)iective sensations of taste may be present as an aura preceding the e])ile])tic attack and in the hallucinations of the insane. To test the sense of taste various substances should be placed up(»n the tongue in small cpiantities, and the taste must be perceived befi)re the tongue touches other parts of the mouth. The patient's eyes sliould bo closed and the following tests a})plied : for bitter, (juininc; for sweetness, a solution of sac- cliarine; for acidity, vinegar; for the saline test, common salt. An extremely delicate test of the sense of taste is the feeble galvanic current, which gives the well-known metallic taste. Pneumogastric Nerve. Nuclear lesions, eitlicr degeneration or luL-uiorrhage, occur as an important part r»f bulbar paralysis, associated, as a rule, with similar changes in (he spinal accessory and hvpoglossal. ^Vithin the skull the ncr\'c-roots may be com- j)ressed bv tumors, meningeal exudation, or aneurism, in the neck (he ncrvc- truuk within the carotid sheath mav be involved in aneurism or injured bv 836 DISEASES OF THE NERVES. stab wounds or compressed by tumors. Occasionally the nerve is involved in a neuritis, either diphtheritic or alcoholic. The branches of distribution are both motor and sensory, the former being supplied to the pneumogastric chiefly, if not entirely, througli the spinal accessory.^ Involvement of the pharyngeal branches which supply the constrictors and the levator palati causes difficulty in swallowing, as the food is not passed on into the gullet. Unilateral involvement does not cause much impairment in deglutition. Spasm of the muscles supplied by the pharyngeal branches is met with in hydrophobia and occasionally in hysterical patients. The laryngeal branches are frequently involved, pai'ticularly the recurrents, which, owing to their remarkable course, are liable to pressure by tumors within the thorax, particularly by aneurism. The superior laryngeal nerve is sensory to the mucosa and supplies also the crico-thyroid muscle. The recurrent branch supplies the mucosa below the cords and the other intralaryngeal muscles. The various forms of paralysis and spasm will be described under the section on Diseases of the Larynx. Here it is sufficient briefly to mention the com- mon sequence of hoarseness, loss of voice, and inability to cough, owing to unilateral abductor ])aralysis in involvement of the recurrent laryngeal nerve by aneurism or tumor. Bilateral abductor paralysis results occasionally from involvement of the spinal accessory nuclei in the medulla in bulbar paralysis and in locomotor ataxia. Less frequently it is produced by pressure upon both vagi or both recurrent nerves. It has also been met with in hysteria. The characteristic symptoms are difficult respiration and a prolonged inspiratory stridor, with little or no impairment of the voice. Paralysis of the adductors is not uncom- mon in hysteria and causes the characteristic aphonia. It may follow also laryngitis. There is no dyspnoea and no stridor, and complete loss of voice. Spasm of the muscles of the larynx is met with in laryngismus stridulus or child-crowing, in whooping cough, and in locomotor ataxia, forming the so-called laryngeal crisis. Paroxysmal attacks of laryngeal spasm may occur in hysteria. Anaesthesia and hyperajsthesia, owing to paralysis of the laryngeal branches, are rare. The former, which occasionally occurs in diphtheritic paralysis, is a dangerous event, as the particles of food may enter tlie glottis and lead to deglutition-]>neumonia. Our knowledge of the disturbance of function in the pulmonary branches of the vagi is still uncertain. Motor fibres are distributed to the muscles of the bronchi, spasm of which is believed to play an important part in bron- chial asthma, and which in consequence has been described as a vagus neurosis. Changes in the respiratory rhythm, such as the Cheyne-Stokes breathing, and the various forms of hurried respiration probably depend upon central, not peripheral, changes. The vagus fibres of the cardiac plexus of nerves subserve motor, sensory, and probably tro])hic functions. Through the motor fibres the inhibitory and regulating impulses pass to the AFFECTIONS OF THE SPINAL ACCESSORY NERVE. 837 heart, tlie action of which in a few instances, as in tlie ease of Colonel Town- send, can be slowed at will. Forcible pressure on both pneninogastrics in the neck is followed by slowing of the action of the heart. A similar effect has been produced by ligation of one pneumogastric. The central irritation of the vagus nuclei may be accompanied with retardation of the heart's action. With complete paralysis of the vagi the heart's action is greatly increased. This is sometimes seen in diphtheritic paralysis. Loss of the function of one vagus is not, however, necessarily followed by symptoms. Normally, we receive no sensory impressions from the heart unless it be beating at an unusual rate or unless the rhythm be disturbed, when we may experience the sensation known as palpitation. The various disturbances under this heading, including angina pectoris, which is sometimes spoken of as a neurosis of the cardiac branches of the vagus, will be considered in the section on Diseases of the Heart. The oesophageal and gastric branches preside over the muscular movements of the gullet and the stomach, and are concerned in the act of vomiting and in si)asm and spasmodic affections. Gastralgia is in all probability a neuralgia of the branches of this nerve, though some attacks may be due to cramp in the muscles of the stomach. The gastric crises in locomotor ataxia are probably due to central irritation of the nuclei of the spinal accessory. The various forms of nervous dyspepsia and the motor disturbances of the stomach due to lesions of this nerve will be considered under the appropriate section. And, lastly, exophthalmic goitre is sometimes considered as a neurosis of the vagi. Spinal Accessory Nerve. The smaller portion of the nerve joins the pneumogastric as its important motor root. The larger external part is distributed to the sterno-mastoid and trapezius muscles. The nuclei of the nerves are involved in bulbar paralysis, more particularly the accessory or internal part. The nuclei of tlie external portion, which are situated in the cervical portion of the cord, may be involved in the general nuclear wasting of j)rogressive muscular atrophy. The nerve may be com- j)ressed by tumors or involved in the exudation of caries or meningitis, some- times in fracture. When within the skull the paralysis which results involves half of the soft j)alate, the vocal cord on the same side, and the sterno-mastoid and trapezius. Within the spinal cord the fibres passing to these nniscles may alone be involved, causing paralysis, which in the case of the trapezius is only |)artial, as the lower portion is innervated by the cervical nerves. In loss of power of one sterno-mastoid the head is rotated witli difli<'ulty to the o])posite side. There is not necessarily torticollis, though in some cases the head is held oblifjuely. The |)aralvsis of the trapezius is well indicatei] in (he acts of shrugging the shoidders and of drawing a dccj) breath. I Ih' shoulder on the affected side droops a little and the e]evati(Hi of the arm is somewhat imj)aired, since the traj)ezius does not lix the scapula as a jxiint from which the deltoid can work. Hilatcral paralysi.-^ of the muscles supplied by the 838 DISEASES OF THE NERVES. ' spinal portion of this nerve is seen in some cases of progressive muscnlar atrophy. When the sterno-mastoids are chiefly involved the head tends to fall backward. If the trapezii are wasted, the head drops forward, a very charac- teristic attitude in many cases of this disease. Drooping of the head is an important symptom in cervical caries in children. There are cases in which the child has (lifficulty in holding up the head during the first year of life, due, it is possible, as Gowers suggests, to injury of the accessory nerves during protracted labor. The treatment of these cases is not very satisfactory. The paralysis from nuclear degeneration is, as a rule, hopeless. That caused by meningeal exu- dation and due to pressure from other causes sometimes disappears. The mus- cles should be stimulated by the use of galvanism and systematic massage. The muscles supplied by the spinal accessory are very liable to a spasmodic affection known as Torticollis, or Wry-neck. (a) Congenital Torticollis. — This is known also as fixed torticollis, and is dependent upon the shortening and atrophy of the sterno-mastoid on one side, most commonly the right. It is usually attributed to injury during birth. It may not be noticed in a child for some years on account of short- ness of the neck. The sterno-mastoid on the affected side is shortened, hard, firm, and in a condition of more or less advanced atrophy. This condition must not be confounded with local thickening of the sterno-mastoid muscle and the formation of a muscle callus following rupture at birth. In some instances the fibrous atrophy involves a part of the trapezius muscle. An inter- esting symptom in this form of torticollis is facial asymmetry, described by Wilks, which may not be noticed until the child is eight or ten years old. Golding-Bird suggests that the facial asymmetry and torticollis are parts of a central affection, the counterpart in the head and neck of infantile spinal paralysis. (6) Spasmodic Torticollis. — Two varieties occur, the tonic and the clonic. Tonic spasm is usually limited to the muscles of one side : the occiput is drawn toward the shoulder of the affected side, the face is rotated toward the opposite shoulder, and at the same time the chin is raised. When the tra- pezius is affected, the depression of the head toward the same side is more marked, and the siioulder is also raised by its action. In long-standing cases the muscles are very prominent and rigid. Both muscles are rarely involved in the tonic form. The splenius capitis may be involved alone, or more com- monly with the sterno-mastoid. The clonic form is much more distressing. The jerking contractions recur every few minutes, either in the sterno-mastoid alone on one side or more fre- quently in several of the cervical muscles, particularly tlie splenius and the trapezius. More rarely the muscles on both sides are involved. There are instances of rotatory spasm of the head, due prol)al)ly to clonic contractions of the obliquus capitis. In other cases there is a nodding spasm, in which the AFFECTIOys OF THE HYPOGLOSSAL XERVE. 839 deopiT-placecl m-ti capitis miisclcs are involval. Tlio spasm not infrequently extends, and involves the muscles of the face, and even those of the arms. The disease is most common in adults. In females it mav be an hvstencal manifestation. Cases have followed exposure to cold or have resulted Ironi injury tc the necU. In the majority of instances the cause of the disease is obscure, and nothino- reallv is known of its essential nature. It is reo-arded as a functional neurosis, but it is possil)ly ilue to disturbance in the cortical centres presidino- over the nuiscles. Cold is i)t'lieved by some to have an important influence, and eases have been described as rheumatic torticollis. The disease must be distinguished from the nodding spasm of ei)ilepsy, which is usually seen in young children, accompanied with slight loss of con- sciousness. There is also seen in children about the time of dentition a uni- lateral jerking of the head from side to side, which, as a rule, is not of any special signiticance. Spasm of the muscles of the neck occurs in cervical caries, usually associated with tenderness over the spines : examination of the pharynx may reveal swelling and tenderness beneath the anterior ligament. The disease varies greatly in its course. A majority of the cases persist for a long time, and too often the cure is only temporary. Treatment. — In the tonic form section of the muscle with the application of a suitable apparatus may effect a cure. In the clonic variety fixation of the head mechanically can rarely be borne. Drugs are of little or no value, though it is stated that very large doses of potassiiun bromide lessen the inten- sity of the spasm. Morphine, which has been highly recommended, should be employed with great care. Electricity has been warmly recommended. Counter-irritation, particularly with the thermo-cautery, may be tried. In very obstinate cases surgical measures may be em})loyed, and division or stretching of the nerve and section of the muscle have been resorted to, sometimes with benefit : as a rule the condition recurs. Personally, I have not seen a permanent cure in any case of spasmodic torticollis. Hypoglossal Nerve. This is the motor nerve of the tongue and for the extrinsic muscles except the mylo-hyoid and digastric. The cortical centre is in the lower part of the ascending frontal gyrus. Paralysis. — This may follow a lesion of the cortical centre, as in hemi- plegia, with which it "vvill be considered, or is due to affection of the nuclei in the medulla oi' to involvement of the nerve in its eoiii'se. Nuclear disease is usually part of a l)ulbar paralysis, and is bilateral and associated w ith par- alysis of the lips and ])harynx. Speech is greatly impaired, as the linguals and dentals eniniot l)e ])rononneed. Mastication \un\ deglutition are p<'rforme(l with dillieulty. The tongue usually wastes and there aic lii)rillary tremors. The nnicous membrane is thrown into folds, and in extreme eases the tongue lies motionless in tlu; floor of the nidiitl) :in(l (■•■innot i»r prodiidcd. l^nilateral paralvsis and atrophv more commonly fdlow involvenicnt ol'llic nerve outside the nucleus^ due to meningitis, syphilis, tumors, or caries, s(»metimes following 840 DISEASES OF THE NERVES. injuries of the neck and jaw. The atrophy is usually marked, and the mucous membrane on the affected side is thrown into folds. When protruded the tongue is pushed toward the affected side. The cases are rare. Birkett in a description of a remarkable instance states that he iias only been able to collect thirteen cases in the literature. In his patient the paralysis resulted from inflammatory changes about the cervical glands at the angle of the jaw ; and in such cases there may also be involvement of other nerves. The diagnosis is rarely difficult. In supranuclear paralysis there is associa- ted hemiplegia ; the muscles do not waste and there are no electrical changes. The nuclear disease is almost invariably bilateral and part of a bulbar paral- ysis. The muscles waste and the reaction of degeneneration is present. Uni- lateral paralysis and atrophy are most common in infranuclear lesions. Spasm. — Tiiis may involve one or both sides, and is usually part of some convulsive disorder, either chorea or facial spasm. It may occur in hysteria, and cases are said to result from reflex irritation in the fifth nerve. It is not uncommon to see the tongue protruded in a spasmodic manner just before the explosive utterance of words in stuttering. There are cases of clonic spasm in which the tongue is thrust in and out forty or fifty times a minute. The spasm in these instances may be unilateral. The prognosis is good, as the spasm is rarely due to organic disease. The treatment of jiaralysis of the hypoglossal nerve is rarely successful, except in the cases of unilateral disease due to syphilis. When due to bulbar atrophy it is incurable. LESIONS OF THE SPINAL NERVES. Cervical Plexus. (1) Oceipito-cervical Neuralgia. — This involves the occipitalis major and minor and the auricularis magnus nerves. The patient complains of pains in the neck, in the occiput, and in the ear, which sometimes radiate to the face and to the arm. It usually follows cold, and may be associated with a stiff neck or with torticollis. Occasionally it is caused by pressure, as in carrying a heavy load on the nt^ck. Painful points may be present midway between the mastoid processes and the spine. Tlie prognosis is, as a rule, good except when the neuralgia is due to dis- ease of the cervical vertebrse. Occasionally in sypliilis there is a cervico- occipital neuralgia, which yields readily to iodide of potassium. (2) Phrenic Nerve. — In the neck the nerve-trunk is occasionally divided by ])unctured wounds, and in tlie thorax compressed by tumors and by aneurism. Paralysis follows involvement of the motor centres in the cervical cord in progressive muscular atrophy. It may also result from lead-poisoning and neuritis. Owing to the inaction of the diaphragm, res])iration is carried on by the intercostal and accessory muscles, the movements of the thorax are increased, and the abdomen is retracted instead of being pushed out during inspiration. When the patient is quiet and at rest there may be very slight AFFECTIONS OF TIIF BRACHIAL PLEXUS. 841 disturbance, but on exertion tiie respiration is (juiekened aiul there may be dyspnoea. When paralyzed on one side only, inspiration nuiy show thai the descent of the diaphragm is much less on one side. The diflieulty of coughing and expelling the mucus renders pulmonary complications very dangerous. The diagnosis is not always easy. In hysterical women the breathing may be entirely thoracic and the diaphragm scarcely moves during inspiration. Immobility of the muscle is present in diaphragmatic pleurisy and in large purulent effusions. The muscle may itself be degenerated, and instances are recorded by Callender of primary degeneration of the muscle-tibres. The prognosis is unfavorable in the cases due to neuritis. W. Pasteur states that of 15 cases following diphtheria, only 8 recovered. A serious risk is in the tendency to oedema and engorgement of the bases of the lung, owing to the lessened action of the diaphragm. The treatment is, as a rule, that of neuritis. Galvanism of the phrenic nerve may be tried : one pole may be placed just outside the lower part of the clavicular portion of the sterno-mastoid, and the other at the epigastrium. Spasm of the diaphragm may be either tonic or clonic. The former is stated to occur sometimes and to be the cause of death in tetanus. Clonic spasm of the diaphragm causes hiccough or singultus. This may be a func- tional disorder, as in hysteria, but the spasm is not infrequently excited by the direct action of hot substances as they pass through the oesophageal opening of the diaphragm. Occasionally it arises from reflex irritation in the stomach or intestines, as in dysentery, cholera, and peritonitis. It may be caused by direct irritation of the phrenic nerve in its course. Much more rarely it is due to central irritation. In chronic alcoholism and in uraemia it may be a persistent and even dangerous symptom. In lead-poisoning it may occur without any obvious cause, and, persisting day and night, may prove fatal. Though rarely causing alarm, protracted cases in delicate or elderly people may be serious and very dillicult to relieve. Amono- remedies which mav be tried are inhalations of nitrite of amyl, which usually relieves with great promptness, and the good effect may be kept up bv the administration of nitro-glyccrin in the intervals. InhalaticMis of <;hloroform ciieck the spasm at once, though usually only for a time. The hypodermic injection of a quarter to a third of a grain of morphine may be necessary to procure sleep. Nothing relieves the persistent hiccough of acute alcoholism better than a hypodermic injection of apomorphine. The hysteri- cal form rarely resists the static electricity. Brachial Plexus. The nojrves mav be involved above or IhIow the clavicli — in the Ibrmer situation by direct injury, tumors, and other atlections of the neck. The infra- clavicular portion is siH'cialiy liablf to injury in dislocation of the shoulder, the strain of a sudden wrench orilicarm, in l;i«( r:iti( in (lie operation of turn- ing is not an uncommon form of the so-callerui>ing of this nerve in the use of the crutcli is the coiu- monest cause of the so-called "crutch-palsy." A still ni(»re fre(|uent cause is pressure during sleep when the arm is hanging over the back of a <'hair, or j)ressure of the l)<)d\- ii|tuii the arm when a person is sleej)- ing on a liaid Ix'uch oi" on the ground. XeuiMtis due to cold oi' an infec- tious (^lisease is a less cdinmon cause, and some of the eases att I'ibiited t(t these are reallv due to pressure. Dii-ed iiiiiseular actimi, :is in (liiowiiig a stone or a erieket-ball violentlv, iiiav eoinplefely paralyze ilir iicr\-e. Transient ])alsy mav be (-aiised by the accidental pimetniv n[' the iicrve in ;i liypitdermi(! injection. The common paralysis of lead-pni.-oning is the result ot" involve- 844 DISEASES OF THE NERVES. ment of branches of this nerve. A complete lesion of the musculo-spiral high up causes paralysis of the triceps, the brachialis anticus, both supinators, and the extensors of the wrists and fingers. In a lesion about the elbow the arm-muscles and the supinator longus are spared. In the pressure palsies, as a rule, the supinators are involved. The characteristic feature of this paralysis is the wrist-drop and the inability to extend the first phalanges of the fingers and thumbs. If the forearm be extended, the hand droops and cannot be raised, nor can the fingers or thumbs be extended. If, however, the hand and the first phalanges are supported, the action of the interossei and the lumbricales then extend the middle and terminal phalanges. Sensa- tion is not always affected. There may be numbness or tingling, but rarely complete anaesthesia. Musculo-spiral palsy is readily recognized, though it may be difficult sometimes to assign the proper cause. The pressure palsies are, as a rule, unilateral, and involve the nerve high enough to include the supinator longus. In the neuritis from lead the affection is bilateral, as it is also in the alcoholic form, both of which are recognized easily by their con- comitant features. The outlook is good, particularly in the pressure cases, in which the paralysis may disappear in a few days. The electrical examination is of the greatest importance in the prognosis, and the rules apply which are laid down in paralysis of the facial. {(1) Paralysis of the Ulnar Nerve. — The ulnar supplies by its motor branches the ulnar halves of the deep flexor of the fingers, the muscles of the little finger, the interossei, the ulnar flexor of the wrist, and the adductor and short head of the inner flexor of the thumb. The sensory distribution is to the ulnar side of the hand, including two and a half fingers on the back and one and a half fingers on the front. The paralysis occasionally results from pressure, more commonly from prolonged flexion of the elbow, as in sleep and in illnesses. The hand deviates a little to the radial side, owing to paralysis of the ulnar flexor of the wrist. Flexion of the first phalanges is impossible, and also adduction of the thumb. In long-standing cases the first phalanges become very extended and the others strongly flexed, producing the so-called claw-hand or main en griffc The loss of sensation is in the distribution already mentioned. (e) Paralysis of the Median Nerve. — The motor distribution is to the radial flexor of the wrist, the flexors of the fingers with the exception of the idnar half of the deep flexors, the abductor and flexors of the thumb, the radial lumbricales, and the pronators of the wrist. The sensory branches sup- ply the radial side of the palm, the front of the thnmb, the first two fingers, half of the third finger, and the skin on the back of these three fingers. This nerve is seldom paralyzed alone. It may be involved in fracture and occa- sionally in neuritis, and very rarely by violent contraction of the pronator teres. The wrist in flexion is drawn strongly to the ulnar side, and the thumb cannot be opposed to the tips of the finger. The second phalanges cannot be flexed on the first nor the distal phalanges on tlie second, but in the third and AFFECTIOXS OF THE THORACIC AND DORSAL NERVES. 845 fourth finger?? this can be performed hy tlie uhiar half of the flexor profundus. When the sensation is involved it follows the distribution of the fibres, as alreadv mentioned. The wastinn; of the thumb-muscles forms a striking: cha- racteristic in this form of paralysis. The skin may be glossy and the nutrition of the nails impaired. Thoracic and Dorsal Nerves. The anterior branches of the twelve dorsal nerves supply the intercostal muscles, the levatores costarum, the abdominal muscles, and the serrati postici. The sensory branches supply the skin in the antero-lateral region of the thorax and abdomen. The posterior branches of the dorsal nerves supply the deep mus- cles of the back and the skin over the same. Affections of these branches are not very frequent, except of the intercostal nerves, which are the subject of an intractable form of neuralgia. Intercostal nenrahjia occurs most commonly in women, and involves the nerves from the third to the ninth, most frequently the seventh, eighth, and ninth on the left side. The cases are most common in anaemic, overworked women. The nerves may be involved by aneurism or tumor, occasionally in chronic pleurisy, or in the adhesions of long-standing tuberculosis, or in caries of the spine. Though usually constant, the pain is subject to marked exacer- bations, and may be very severe ; movements such as coughing and deep inspi- ration aggravate it very greatly. Tender points are usually jiresent at the intervertebral foramen, one near the sternum, one -over the rectus muscle, and a third midway between these. The neuritis causing neuralgia is often accom- panied with an eruption of herpes zoster, forming the so-called "shingles." The pain may be most intense prior to the outbreak of the rash, and in some instances persists long after its disappearance. The diagnosis of intercostal neuralgia is usually easy, though sj>ecial <'are must be taken to exclude the presence of spinal caries, of aneurismal tumor, and of pleurisy. Many cases prove very intractable. A special form is the neuralgia of the branches passing to the breast — mastodynia. It is seen most commonly shortly after ])uberty in auicmi*' and hysterical girls. The pain may be very severe, either localized or involving the entire breast. Occasionally small hard nodules are felt beneath the skin. The condition may follow prolonged lactation. Paralysis of the muscles supplied l)y the thoracic and dorsal nerves is rarely seen alone, and in cases of hcmii)legia they arc not involved, the imis- clesof both sides being innervated from either hemisphere (Broadbent). Tn the forms of primarv nuiscidar atro])hy the weakness of the back mus<'les is very striking, and the attitude of the child, with marked arching of the lum- bar vertebne, prominence of the alxlonicn, and arching backward of the back, forms a very characteristic i)ictnre. In getting up from the floor the child has to lift his body <.n the arms and gradually climb up his legs, as in the familiar j)icture in Gowers' work. «46 DISEASES OF THE NERVES. Lumbar and Sacral Plexuses. The lumbar plexus, made up of looj).^ of communi(;ation between the anterior branches of the four upper lumbar nerves^ supplies the flexors and adductors of the hip-joint, the extensors of the feet, and the cremaster. The sensory fibres are distributed to the skin of the lower part of the abdomen, the antero-lateral region of the thigh, and the inner side of the leg and foot. The cords of the plexus itself are sometimes involved by tumors of the Ivmph-glands, in psoas abscess, and in caries of the vertebrae. Affections of the individual nerves of the lumbar ])lexus are not so common. The anterior crural nerve may be ijivolved in \\'ounds, in psoas abscess, and in disease of the vertebras, stretched in dislocation of the hip-joint, or invaded by pelvic tumors. When paralyzed there is loss of power in the extensors of the knee, and if the nerve is involved high up there may be loss of power in the psoas muscle. In prolonged involvement the muscles waste and walking may be difficult or impossible. There is anaesthesia of the greater ]iorti(jn of the skin of the thigh, except a narrow strip at the back jiart, and in the distribution of the internal saphenous nerve along the inner side of the leg to the big toe. Neuralgia of the crural nerve is not very com- mon, apart from the ])ressure symjitoms due to tuniors and growths about the spine. The pain is in the antero-internal portion of the thigh and knee and extends along the inner surface of the leg and foot. There is often a painful spot where the nerve emerges below Poupart's ligament. The obturator nerve is occasionally injured during parturition. When par- alyzed there is loss of power in the adductors of the thigh, and the ])atient cannot cross one leg over the other. Owing to involvement of the obturator externus, rotation inward of the thigh is not well performed. There are troublesome neuralgias of certain branches of the lumbar plexus. There may be pain in the course of the ilio-inguinal and ilio-hypogastric nerves, in the neighborhood of the crest of the ilium, and in the external abdominal ring. The ilio-inguinal nerve, which accompanies the spermatic cord through the inguinal canal and escapes at the external abdominal ring, is distributed to the skin of the upper and inner part of the thigh and to the scrotum. There are instances in which the distribution of this nerve is the seat of very severe pain, and the affection known as the irritable testis of Cooper is believed to be an affection of this nerve. Associated with this i)ain there may be sensations of fainting and the sickening feeling such as is felt on compression of the testis. Sacral Plexus. — This is still more likely to be damaged by pelvic tumors and various affections of the pelvic bones. The branches may be injured during parturition. Neuritis is not uncommon, and is frequently an extension from the sciatic. Of the branches, the sciatic nerve when paralyzed causes loss of power in the flexors of the leg and in the muscles below the knee. An affection or injury below the middle thigh involves only the muscles of the leg proper. AFFECTIOXS OF THE LUMBAR AXD SACRAL PLEXUSES. 847 Tliere is an8esthe;?ia of the oiitor half of tlie leg, the sole, and the greater por- tion of the dorsum of the foot. Tlie niiiseles frequently waste and there may be trophic disturbances. In paralysis of one sciatic nerve the leg is fixed at the knee by the action of the (juadrieeps extensor. Paralysis of the small sciatic nerve is rarely seen. Tlie gluteus maxinuis is involved, there is dif- ficulty in rising from a seat, an I there is usually a strip of anesthesia on the back part of the thigh in the region of distribution of the cutaneous branches. Of the branches of the sciatic nerve, the external popliteal when jiaralyzed causes loss of power in the peronei, the long extensor of the toes, the tibialis anticus, and the extensor brevis digitorum. As a result there is a foot- drop, the ankle cannot be flexed, and, as the toes cannot be raised from the ground in walking, the whole leg is lifted, producing the characteristic step- page gait seen in so many forms of peripheral neuritis. In long-standing cases the foot is permanently extended and there is wasting of the anterior tibial and ])eroneal muscles. The loss of sensation is in the outer Jialf of the front of the leg and on the dorsum of the foot. Paralysis of the internal popliteal nerve causes loss of power in the gas- trocnemius, the ])lantaris, soleus, popliteus, the tibialis posticus, the long and short flexors of the toes, and the muscles of the sole of the foot. The foot cannot be adducted nor can the patient rise on tiptoe. In long-standing cases talipes calcaneus follows, and the toes assume a claw-like })osition from sec- ondary contracture. Among other neuralgic affections of the lumbar and sacral ])lexuses are the following: coccygodynia, an affection most common in women. The pain about the coccyx is greatly aggravated by the sitting ])osture, and is usu- ally associated with other nervous phenomena. It is an extremely intractable affection, and the condition may be so intolerable that resection of the coccyx has to be performed — an operation whichj however, is not always successful in relieving the pain. There are certain neuralgic; affections of the nerves of the feet which are very troublesome. In the affection known as ])ainful heel, flic pododynia of S. D. Gross, the pain is usually most severe in the heel itself, sometimes in a very limited spot on the under surface, sometimes in the line of the metatarso- phalangeal joint. It is most common in women, and is not necessarily asso- ciated with any swelling, discoloration, or enlargement of the joint. In some instances it would apj)ear to be a manifestation of hysteria ; in others the ]>atients have rheumatism or gout. Some of the worst cases occur in shoj)- girls as a residt of standing for a long lime on the fix't. Plantar neuralgia may be assfx-iafcd wilii a dclinitc neui'itis, and is some- times seen after the s])ecific fevers, and has been des(;ribed by Hughes in cais- son disease, Tlie pain may extend along the sole of the foot or be confined to the tips of the toes, occasionally fo the ball of the great toe. Nund)ness, tingling, hvperaesthesia, and sweating may occur with it. A cm-ions tender- ness of the toes, possibly due to a ixniitis, is nse, and the patient's morale so undermined by the constant worry and the sleepless nights, that the danger of contracting the morphine habit is very great. On no consideration siiould the patient l)e permittesy. In the j)seudo-hy])ertrophic form the muscle-fibres present great variations in size. In the early stage there may be marked enlaro-ement and the nuclei of the sarcolemma are increased. The fibres have sometimes been seen to be fissured longitudinally. The enlarge- ment is chiefly due to the increase in the connective tissue and f:it, liy which in the later stages the muscle may be largely re])laced. In the j)riniary atrophic form a similar enlargement of the muscle-fibres has been noticed. The increase in the interstitial tissue is not so striking. The wasting ni" the fibres and the replacement by connective tissue and i'at seem to be gradual processes. Diagnosis. — The pseudo-hypertrophic form is recognizable at a glance. The striking contrast between the athletic a|)p<'araiii'e and the lecble condition, the attitude, gait, and mofle of rising from the floor, make up an unmistakable symptom-grouj). It is to be rememlxM'ed, howcvei-, (hat th<> gait and the mode of rising may be (piite as characteristic of the simple atrophic forms. The occurrence in finnily groups is also a point of great importance. From myelopathic or spinal muscular atrophy the forms are usually easily scj)arated. In the atrophv of chronii»n them may be followed bv a tonic contraction lasting manv seconds. Erb has described a characteristic reaction of the nerve and muscle to the electrical currents, the so-called myotonic reaction, the chief feature of which is that the contractions caused by either current attain their maximum slowly and relax slowly, and that vermicular wave-like contractions pass from the catiiode to the anode. The condition persists throughout life. In a few instances it has been arrested temporarily, and there have been changes and variations in the intensity of the manifestations. No post-mortem has yet been made upon the disease. INIany examinations have been made of excised portions of muscle, and in all instances the fibres have been found to be greatly increased in size, and in some instances accom- panied with an increase in the nuclei of the sarcolemma and of the interstitial tissue. The true nature of the disease is unknown, but it is usually placed amou": affections of the muscles. No treatment for the disease has yet been found. Affections which may be regarded as varieties of Thomsen's disease are on record ; thus, Eulenberg reported a series of cases, the history of which could be traced through six generations, in which there were tonic spasms of variable duration, affecting chiefly the muscles of the face and less often those of the extremities. The contractions are followed by weakness. As it aj>peared in some mendicrs of the family shortly after birth, he termed it congenital para- myotone. In other instances, as in a case described by Gowers, the tonic spasm was associated with distinct ataxia. Paramyoclonus Multiplex. This is an affection first described by Friedivich, characterized by clonic oontradion, chiefly of the nuisclcs of the extremities, occurring usually in paroxysms. A majoritv of the cases have been in male adults. The disease has most frc(|nciitly followed fright or violent emotion or an injury. 'V\u' clonic spasms usually begin in the muscles of the legs, and i.kiv at first ik.I be severe enough to j)revcnt the patient from working, and tli.\- .an l)e to a certain ineasure controlled. They are, as a rule, l)ilat('ral, and vary iVoni lilly to a hun and feet, and, as nieiilioned above, some of the fintrers mav be in the condition of local sNiicoite, while others are deeply cNanosed. There are usually swelling and some jiain. dne to tension of the parts. Li some ca~es there is marked anav-tiiesia and niove- 859 860 VASO-MOTOB AND TROPHIC DISORDERS. ment is much impaired. The attacks last a variable time, and as the cyanosis passes off the parts become of a bright-red color, in which the circulation is extremely active. In adjacent fingers one may be in the reaction stage of a bright scarlet red, and the anaemia produced by pressure is instantaneously obliterated, whereas the other finger may be of a deep plum color, with almost complete stagnation of the capillary circulation. When the local asphyxia is persistent in the fingers or the ear-tips, there may be slight loss of substance, or in extreme grades the condition passes on into local gangrene. The attacks recur at irregular intervals, and are most frequent in cold weather. Some patients are entirely free in the summer months. Sometimes the condition recurs with striking ])eriodicity. iVs in local syncope, the disease is perhaps most frequent in women. Some of the attacks are not unlike ordinary chil- blains. The condition may recur for years without leading to serious trouble ; thus, a woman of about thirty has had in the winter months for fourteen or fifteen years almost daily some grade of local asphyxia in the hands, which are sometimes livid and cold to the wrists. The fingers show only slight suj^er- ficial losses on the tips. In some of the severer attacks mortification of the whole hand would appear to be almost inevitable. Local or Symmetrical Gangrene. — The mildest grade of this con- dition is seen in those cases of local asphyxia in which small necrotic areas appear on the tips of the fingers or on the tips of the ears. Sometimes the terminal phalanges are quite cicatricial from repeated slight losses of this kind. In severer attacks the local asphyxia, which may be either primary or follow the syncope, persists. If in the extremities, the terminal phalanges become black, cold, and insensible. One finger only may be affected, or several fin- gers, or the entire hand or foot. More or less pain accompanies this. Instead of disappearing within twenty-four hours, the condition persists, and small blebs appear on the skin, which may be quite superficial. Sometimes without any formation of bleljs the skin becomes dry and mummified. A line of demarcation is gradually formed, and a portion of one or more of the fingers sloughs away. In very severe cases the gangrene may involve several fingers, or the ti]) of the nose may be lost or a portion of an ear. It is important to note that the loss of substance is very much less than the apjiearance of the affected limb would indicate. The gangrenous blebs may be quite superficial and result in only necrosis of the skin. In one instance in which the feet were completely livid and superficial blebs appeared on the instej) and the toes were livid and insensible, instead of an extensive loss of substance, as had been expected, the condition cleared and there were only superficial abrasions. Pcrhajis the most serious cases are those in which the patches of gangrene affect the symmetrical regions in different parts of the trunk and extremities. This severe type is most apt to occur in children. The affected regions are not necessarily symmetrical. Some of the cases have been preceded or accompanied with purpura of the skin and with haemorrhages from the mucous surfaces.^ ' Musser, "Grave Forms of Purpura Haemorrhagica," Transactions of the Association of Amer- ican Physicians, vol. vi. HAYXAUD'.S DISEASE. 86 1 A majority of these cases arc fatal, aiul death niav f )lhi\v within three or four davs. The prognosis as regards death is, as a rule, good, except in the more malignant lorms, and, as already mentioned, the destruction of tissue is, as a rule, very much less than the appearance of the affected part would warrant. The outlook for complete recovery is not very hopeful. Associated Conditions. — There are very remarkable concomitant .symp- toms in Raynaud's disea.se to which of late nnich attention has been paid. Hjemoglobinuria may occur during an attack or may take the place of an out- break. The blood-coloring matter is not always present. There may be only albuminuria. In a case which has been at my clinic on several occitsions the local asphyxia with slight loss of substance in the ears recurred for three suc- cessive winters, alwavs in association with haemoglobinuria. The attacks were usually preceded by a chill, and during them he had a peculiar sallow, subicteroid hue. The relations between paroxysmal hemoglobinuria and Ray- naud's disease is evidently very close, and some have regarded them as man- ifestations of one and the .same affection. Colicky pains, diarrluxja, nausea, and vomiting occasionally occur in Ray- naud's di.sease, but are not so common as in intermittent hemoglobinuria and any-io-neurotic oedema. Peripheral neuritis has been found in a few instances of symmetrical gan- grene, and there are instances in which the affection was a.ssociated with wrist- drop. In a recent ca.se the patient, an alcoholic, had had for some time numb- ness and tinsrlino; and formication in the hands and feet. This was followed by a condition of the most intense local asphyxia of the hands and of the toes, and scattered patches reseml)ling erythema nodosum upon the skin of the extrem- ities and the trunk. Together with the.se symptoms there were slight articular pains and swelling of the right knee, so that the condition resembled somewhat peliosis rheumatica. Urticaria, erythema nodosum, and scleroderma have been described in connection with this affection. Amons- the most remarkable are the cerebral manifestations. Mental tor- por and transient loss of consciousness have been described. In the case above mentioned with hemoglobinuria the patient had ei)il('ptic .'seizures with the attacks. Exposure on a cold day would bring on a fit, with local asjihyxia of the ear-tips and bloody urine. Acute mania has developed, and delusions. A case has recently been under observation in which during the attack theiv was aphasia with temi)orary hemiplegia. Dimness of vision has been noted, and retinal changes, chiefly great ii:in-(twing of the arteries, have becMi de.'^cribed. The pathology of this remarkable di.|»iiyxia was caused by contraction of tlie vessels, which prohablv in the extreme grades of local synco|)e in\ulve^ :iit(rlcs. veins, and eaijiilarif's. The asphyxia is dep.Mi.ieiit npuii (iilatation of the capillaries and small veins, pn.bably wit li the j)(i-sist<'iice dl" some spasm in t lie arterioles. Necro.sis onlv follows when the condition is |»ersislent, and in I he prolongcxl 862 VASO-MOTOR AND TROPHIC DISORDERS. stasis the vitality of the tissues becomes lowered beyond power of restitution. In all probability the remarkable cerebral symptoms are caused by local spasm in special vascular territories. Treatment. — So far as my own experience goes in a number of protracted cases, internal remedies have little or no influence. When hsemoglobinuria has been present and anaemia develops, iron should be given. Galvanism is recommended by Barlow, who advises immersing the affected limb in a basin of warm salt water, in which the negative electrode is placed, while the pos- itive is applied over the spine. This sometimes relieves the pain. In an attack the affected limb should be raised and kept wrapped in cotton wool. The pain may be intense enough to require morphine. As the condition improves systematic fricttons with sweet oil will be very useful. Angio-neurotic CEdbma. (Giant Urticaria.) Definition. — A disorder characterized by an outbreak of oedematous swell- ing of variable extent, sometimes accompanied by gastro-intestinal crises. The disease may show a marked hereditary disposition. Symptoms. — The most common situation for the oedema is the face, and particularly on the eyelids ; next in order, the nose. In obstinate cases it may appear on any part of the body. The mucous membrane of the lips and pharynx may be attacked, and in a few instances there has been sudden and fatal oedema of the glottis. The oedema may reach rapidly a very high grade, and the skin is tense, shiny, pale, and on pressure pits readily. Usually the condition is transient and the oedema disappears within a few hours. The onset may be abrupt without any previous distress. In many instances the attack only occurs when there is gastric disturbance. The disease may recur with curious periodicity ; thus in the case described by Matas the attack came on every day at eleven or twelve o'clock. The hereditary form is very remarkable. In the family described by me twenty-two members were affected in five generations. The swellings appeared in various parts, usually on the hands, face, or genitalia. Heat, redness, itching, and in some instances true urticaria, preceded the outbreak. Two members of the family died of oedema of the glottis. In all the cases in this group the gastro-intestinal symptoms were most pronounced — colicky pains, nausea, vomiting, and some- times diarrhoea. The colic was severe enough to require hypodermics of morphine. Quincke regards the condition as a vaso-motor neurosis causing sudden increase in the permeability of the vessels. The affection has close affinity with urticaria and with the form of purpura associated with gastro-intestinal crises and arthritis. The treatment should consist of general tonics. Strychnine, antifebrin, and antipyrine may be tried, as they sometimes seem to have marked influence in checking the outbreaks of urticaria. The diet is of great importance in the PLATE III. Case of Acromegaly (Marie). A CROMEGA L Y. 863 cases, and the outbreaks may be detinitely connected with indigestion or with overeating. Local treatment is not of much vahie. Wlien the oedema is very great and the tension painful, careful puncturing gives relief. Acromegaly. Definition. — An affection characterized by iiypertrophy of the hands, feet, and face. Tiie name, which signifies large extremities, was given by Marie of Paris. Etiology. — The condition occurs more frequently in women. Of 38 cases in the monograj)h of Sousa-Leite, 22 were in women and IG in men. The affection begins, as a rule, at about the twenty-fifth year, occasionally earlier, in .some instances as late as the fortieth. It has no apparent connection with sexual processes. Heredity has ai>parently played a part in some cases. Syphilis, the specific fevers, and rheumatism iiave occasionally preceded the development of the disease, but probably have no special connection with it. In this country only a few ca.ses have been reported. Symptoms. — A well-marked case presents a very characteristic aj^pearance. (Sec Plate III.) The hands and feet are enlarged, the increase in size involving both bones and soft parts and giving a spade-like character to the hands. The wrists may be enlarged, but the arms are not often affected. Tiie feet are uni- formly enlarged, and the size of the big toe has been in some cases out of pro- portion to the others. The nails arc usually broad and large and vertically grooved. Although they look clumsy and unwieldy, the hands fan be used freely, and even such a delicate operation as threading a needle can be well performed. The long bones, as a rule, are unaffected, but in some instances there has been thickening of the extremities of the fenuu- and of the tibia and the fibula. The enlargement involves the head and face, particularly the latter, which becomes elongated and broadened in consequence of the increase in size of the superior and inferior maxillary bones ; the latter in particular increases, and may ])roject beyond the nppcr Jaw. The alveolar processes become greatly thickened and the teeth are separated. The lc)wer li|> is thickened and the ears greatly hypertrophied. The tongue has in some instances been greatly enlarged. Increase in the si/e of the bones of the skull may be present. The neck looks short and thick, chiefly on account of the elongati(m and depression of the chin. The skin may look nornud or is coarse and flaljby. It rarely has the harsh appearance of myxocdema, and the subcutaneous tissues are not infiltrated. The bones of the thorax may slowly and progressively enlarge, and in a late stage of the disease the spinal column may be involved and there may be marked kyi)hosis. The clavicles and sternum may also increase in size. The muscles arc sometimes wasted. The irenitalia have sometimes been hvpertroi)hied. The thyroid has been normnl in some cases, atro|)hie(l in others, ;ind in a third group eidarged. Krb has noticed an aica of dnlness over tlic nianni)rium sterni which he thought to be possibly due to persistence of flic I hymns. In women menstrual distin-bance may be an early fi-alnrc, and there may be com- 864 VASO-MOTOB AND TROPHIC DISORDERS. plete suppression. The voice changes, partly on account of the enlargement of the tongue, partly because of changes in -the laryngeal cartilages. Patients often complain of headache. There may be increasing dimness of vision, ow- ing to a progressive atrophy of the optic nerve. Less commonly the sense of hearing and smell are deficient. The disease may last from ten to twenty years: a condition of cachexia ultimately develops and the patient dies of exhaustion. The morbid anatomy of the disease has been studied in several cases. The enlargement of the bones is a true hypertrophy. The increase in the size of the face is largely due to dilatation of the antrum. The lesions are essentially different from those of the osteitis deformans of Paget, in which the shafts of the bones are chiefly involved, and also from arthritis deformans. The pituitary body has been found hypertrophied ; less commonly changes occur in the thymus and thyroid. The peripheral nerves have been found deffenerated in several cases. The nature of the disease is still in doubt. According to Marie, it is a systemic dystrophy analogous to myxoedema, and associated possibly with the changes in the pituitary body, just as myxoedema is connected with disease of the thyroid gland. The most exhaustive descrip- tion of the pathological anatomy and a discussion of the relation of the affec- tion to other forms of enlargement of the bones will be found in the essay of Arnold of Heidelberg.^ Diagnosis. — The disease must not be confused with myxoedema, in which the bones are not enlarged. It is most likely to be confounded with the osteitis deformans of Paget, in which disease, however, the shafts of the long bones are chiefly affected, and in the head the cranial, not the facial, bones are enlarged. In the cases of congenital progressive hypertrophy, the so-called giant growth, as a rule, only a single member is involved and the shafts of the long bones are affected. According to Marie, the face in Paget's disease is triangular, with the base upward ; in acromegaly it is ovoid or egg-shaped, with the large end downward ; in myxoedema it is round and full-moon- sha])ed. Marie has separated a group of cases characterized by hypertrophy of the bones of the extremities and of the shafts, associated in some way with disease of the lungs. The condition of the fingers differs from that of ac- romegaly, as the phalanges are bulbous and enlarged and the nails curved, very different from the flattened terminal phalanges of acromegaly. Curva- ture of the spine is also common. The cases have been met with in connection with purulent pleurisy, with new growths in the lungs, and with chronic bronchitis. Marie terms it osteo-arthropathie pneumique. Arnold does not, however, regard this as a form which can be definitely separated from acromegalv. iL A curious dystrophy, met with only in women, involving the fingers and toes, is the sclerodactylo. The lesions are, as a rule, symmetrically dis- tributed. The fingers are atrophied and shortened, the skin is thickened and waxy, and the nails are deformed and small and often curved. The ' Zlcf/ler's Beitrage, 1891. SCLEB01JIJR3fA. 8G5 fingers may be di.slocated, and the joints become ankylosfed in irregular positions, so that the fingers are distorted. Ankylosis of the wrist and of the ankle have been observed. In some instances there have been diffuse sclerodermatous changes in the skin in other parts. The causation of the dis- ease is unknown. Many of the patients have suffered severely with cold, and the condition is much worse during the winter. In the only autopsy which has been made no clue was obtained as to the natui-e of the trouble. A good description of the disease has been given by Gordinier.* No treatment has been found of anv avail in acromegalv or tlie allied conditions. Scleroderma. A condition in which the skin becomes tense and hard, either in circum- scribed patches or in extensive diffuse areas. These two forms, the circum- scribed and the difiuse, may exist together or separately. The circumscribed scleroderma corresponds to the affection known as morphoea and to the keloid of Addison. In patches ranging from half a centimetre in diameter to the size of the hand the skin is hard, brawny, inelastic, and has a waxy, dead- white appearance. These patches occur most frequently in women about the breasts and neck, occasionally in the course of the nerves either in the trunk, the intercostal, or lumbar, and on the face in the branches of the fifth. A preliminary hypersemia may precede the development of tlie patches, and in some instances there are changes in color due to increase in the })igtnent of the skin. In other cases there is complete atrophy of the pigment and leucotlerma. Preceding the onset there may be itching or irritation of the skin, and, when fully developed, anaesthesia is occasionally present. The sweat secretion is either diminished or completely abolished. There are instances in which the disease begins with the development of small linear, cicatricial-likc spots — lineae atrophicse. A curious, remarkable feature is the rapidity with which the patches appear and their variability. They may persist for months or years with but slight change, and after lasting for some time may disapj)ear in a few weeks. According to Crocker, "The pathology appears to be that, owing probablv to some defect in innervation, an exudation occurs round the vessels, narrowing tlif lumen, obstructing therefore the blood-flow, and lead- ing to thrombosis and sometimes to a real rupture and effusion. Kach atr(»- phic s])ot seen near a growing patch is the base of a cone from which the i)lood-supplv is cut off, the violet zone being due to collateral liypcraMuia round an aiucmic area. The patch or atrophic sjjot thickens by the fibrilla- tion of the effused cells. AVlier(> the arterial su))j)ly is completely cut off an atrophic spot is produced ; where it is merely diminished partial atn.|tliy, with connective- tissue hyi)er|)lasia, or riior|»h(pa, is the residt." The diffuse scleroderma is more rare. It :i]t]tears first in the extremities or on the fa«-e, and the skin becomes hard and tense, so that the |)alienl has great diffieultv ill performing ordinary moveinents. When fully developed there is a brawnv induration of such a degree of linunes^ that the skin eamiot be ' Arnericnn Journal of tlf Mnlirul Srlijtnt^, Jan., 1889. Vol,. I.— 55 866 VASO-3IOTOB AND TROPHIC DISORDERS. picked np or pinched. The wrinkles are effaced and the skin looks stretched, dry, and glossy. Dinkier, who has recently made a careful study of the con- dition from Erb's clinic, states that of 44 cases, in 24 the first appearances were on the arms ; in 7 on the legs, in 1 on both ; in 10 on the face and neck ; and in 2 on the trunk. Gradually extending, the disease may involve the greater portion of the skin of the trunk or that of an entire limb. Occasionally it becomes universal. The joints are fixed in semiflexion, and movements are impossible on account of the hidebound condition. The face is expressionless, immobile, and it may be almost impossible for the patient to chew his food. The sensory changes are not marked, but during the development of the affec- tion there may be great itching. The mucosa of the mouth and pharynx has been occasionally involved. The disease persists for months or years, and there are instances on record of its persistence for more than twenty years. The disease is sometimes arrested, and in a few instances recovery has fol- lowed. Death usually results from intercurrent pulmonary affection or from nephritis. The nature of the disease is unknown. Some cases have been pre- ceded by rheumatism ; others have been met with in connection with endo- carditis and rheumatic nodules. It is generally regarded as a tropho-neurosis, possibly depending upon changes in the arteries of the skin, and so leading to connective-tissue overgrowth. As the patients are particularly sensitive to changes in the weather and to cold, they should be warmly clad, and when possible live in a mild climate. Frictions with oil and electricity have been recommended, and in the local forms galvanism seems to have been beneficial. Allied to scleroderma is the remarkable affection known as sclerema neona- torum, in which, either at birth or shortly after, there are large areas of indu- ration of the. skin, which is tense and glossy and does not pit on pressure. It is sometimes associated with oedema of the subcutaneous tissues. The disease may spread rapidly, and the congenital cases are usually fatal. Recovery, however, is not impossible. In a remarkable case recently seen with Dr. Ellis of Elkton a healthy, well-grown child of two and a half months had an acute pleuro-pneumonia, during which, on the sixth day, it developed gen- eral scleroderma, the entire skin becoming hard and leathery, the legs stiff, and the whole body looking rather like a model of a child in wax. Facial Hemiatrophy. This is a rare affection, and less than one hundred cases have been reported in the literature. The wasting is on one side of the face — hence the name — is progressive in character, and involves bones and soft tissues. It begins, as a rule, in childhood, and the onset may be accompanied by pains and j)ar8es- thesia. It may start at one or two spots on the skin and gradually spread, or begin diffusely and gradually involve soft parts and bones. The atrophy is strictly confined to one side, and when fully developed gives a remarkable appearance to the patient, whose face looks made up of two unsymmetrical halves. The atrophy is strictly limited to the middle line. Sensibility is not FACIAL HEMIArROPHY. 867 affected. The skin may be tlarker in color ami the hair falls out. The teeth may become loose, owing to wasting of the alveolar i)rocesses. The move- ments of the muscles are rarely aifected, though in Sachs' patient there were tonic and clonic contractures of the temporal and masscter muscles. The nature of the disease is still doubtful. In the autopsy in IToman's case, which came on rapidly and can scarcely be regarded as a typical illustration, a tumor was found pressing upon the Gasserian ganglion and the fifth nerve. In Mendel's case there was an interstitial neuritis in all the branches of the trigeminus from its origin to the periphery, most advanced in the superior maxillary branch. The disease is probably due to involvement of the troj>hic fibres of the fifth nerve. The prognosis is unfavorable, as the affection is progressive. The cases of facial asvmmetrv in children associated with congenital wrv-neck must not be confounded with progressive facial hemiatrophy. INDEX. ABASIA-ASTASIA, diugnosis of, from locomotor ataxia, 784 Abdomen, large, in scrofula, 341 protuberant, in pseudo-hypertrophic muscular atropby, 854 Abdominal form oi" typhoid fever, 102 pain in trichinosis, 507 in typhoid fever, 67, 83 reflex, 524 Abducens nerve. See Sixth Nerve. Abductor paralysis, bilateral, 836 unihiteral, 836 Abortion in relapsing fever, 158 in syphilis, 361 in typhoid fever, 97 in yellow fever, 456 Abortive form of cerebro-spinal fever, 170 of scarlatina, 220 of typhoid fever, 99 Abscess of brain, 714 of muscles in typhoid fever, 64 of parotid, 309 of spinal cord, 747 Abscesses in glanders, 514 typhoid bacilli in, 56 in typhoid fever, 90 in ty|>hus fever, 145 Abscesses, multiple, in actinomycosis, 475 secondary, in pviemia, 327 Abulia, 530 Acetanilid in typiioid fever, 123 Achr<)mato[)sia in iiysteria, 601 Acids in typhoid fever, 132 in typhus fever, 149 Aconite in cerebro-spinal fever, 183 in influenza, 195 in typhoid lever, 124 Acromegaly, 863 definition of, 863 diagnosis of, 864 etiology of, 863 morbid anatomy of, 864 symptomatology of, 863 Acromegalv, diagnosis of, from myxredema, X64 from osteitis deformans, 864 Actinomyces, 473 in etiology of actinomycosis, 473 Actinomycosis, 473 definition of, 473 diagnosis of, 477 etiology of, 473 metastasis in, 476 pathology of, 475 Actinomycosis, prophylaxis of, 477 surgical measures in, 477 symptomatology of, 476 treatment of, 477 Actual cautery in bites of rabid animals, 496. See, also, Coutitcr-irritanU. Acupuncture in sciatica, 849 Acute ascending paralysis, 748 definition of, 748 diagn(»sis of, 751 etiology of, 748 pathology of, 750 jirognosis of, 751 reflexes in, 749 sym])tomatology of, 749 treatment of, 751 Acute ascending paralysis, diagnosis of, from acute myelitis, 756 from acute poliomyelitis, 768 Acute hydrocephalu:?. See Tuberculous Men- ingitis. Acute miliary tuberculosis. See Tuberculo- s/.v, Acnlr Mllnn-ij. Acute periencephalitis. See Periencepka li- tis, Acute. Acute yellow atrophy, diagnosis of, from yellow fever, 458 Addison's keloid. See Scleroderma. Adynamic form of typhoid fever, 102 of typhus fever, 144 ^sthesiometer, 527 Afebrile form of typhoid fever, 100 African sleeping disease. See Nelnvan. Agaricin in sweats of j)ya3mia, 328 Age in etiology of aernniegaiy, 863 of cereliral haiiiorrliage, 679 of cerebro-spinal fever, 164 of diphtheria, 378 of epilepsv, 612 of hysteri'a, 593 of leprosy, 369 of locomotor ataxia, 777 of measles, 234 of miliary fever, 201 of mumps, 305 of myositis ossilieans, 851 of paramyoclonus multiplex, 857 of aeiile poliomyelitis, 761 of progressive muscular atrophy, 799 of relapsing fever, 151 of riil)ella, 255 of scarlatina, 210 tfStt 870 INDEX. Age in etiology of scrofula, 337 of small-pox, 263 of St. Vitus's dance, 628 of syringomyelia, 772 of acute miliary tuberculosis, 329 of typhoid fever, 54 of typhus fever, 135 of varicella, 298 of whooping cough, 313 of yellow fever, 453 Age, influence of, upon typhoid fever, 103 Ageusia, 835 Agraphia, 704 Agriculturalists, mortality of, 26 Ague. See Malarial Fevers. Ague-cake, 412 Albuminuria in cerebral haemorrhage, 682 in cerebro-spinal fever, 169, 176 in cholera, 443 in diphtheria, 383 in erysipelas, 400 in measles, 244 in pyaemia, 327 in Raynaud's disease, 861 in relapsing fever, 158, 1.60 in scarlatina, 218 in acute miliary tuberculosis, 332 in typhoid fever, 89, 97, 102 in typhus fever, 139, 143, 144, 146 in yellow fever, 456 Albuminuric retinitis, 224, 814 Alcohol in delirium tremens, 561 in diphtheria, 395 in erysipelas, 403 in simple insomnia, 661 in measles, 252 in pyaemia, 328 in septicaemia, 326 in typhoid fever, 116 in typhus fever, 148 Alcoholic insanity, 561 forms of, 562 symptomatology of, 561 neuritis. See Neuritis, Multiple Alco- holic. Alcoholism, acute, diagnosis of, from cere- bral haemorrhage, 686. See, also. Alcoholic Insanity and Delirium Tre- mens. Alexia, 704 Algesia, 527 Algid form of malarial fever, 427 Alkaloids in urine of scarlatina, 214 Allocheiria in locomotor ataxia, 780 Alopecia in facial hemiatrophy, 867 in syphilis, 353 following typhoid fever, 90 typhus fever, 145 Alternate hemiplegia in cerebral haemor- rhage, 684 Altitude and disease, 27 in etiology of cerebro-spinal fever, 164 of influenza, 186 of malarial fever, 411 of yellow fever, 452 symptoms produced by a high, 207 Alum in epistaxis, 131 in purification of water, 35 in typhoid fever, 131 Amaurosis, hysterical, 605, 815 diagnosis of, 605 quinine, 815 in Raynaud's disease, 861 saturnine, 815 in scarlatina, 219, 223 tobacco, 815 uraemic, 815 Amblyopia in acromegaly, 864 in hysteria, 601 Ambulatory form of typhoid fever, 101 Amenorrhcea following typhoid fever, 97 Ammonia in cerebro-spinal fever, 183 in influenza, 195 in relapsing fever, 161 Ammonium acetate in typhoid fever, 124 carbonate in typhoid fever, 132 in typhus fever, 149 Amnesia, auditory, 704 visual, 703 Amoeba dysenteriae, 9 Amyloid disease in actinomycosis, 477 in syphilis, 352 Amyotrophic lateral sclerosis, 794, 852 definition of, 794 etiology of, 794 pathology of, 794 prognosis of, 795 symptomatology of, 794 treatment of, 795 Anaemia following diphtheria, 386 in malarial cachexia, 432 following relapsing fever, 159 ■ in syphilis, 358 in typhoid fever, 72 following typhoid fever, 78, 93 Anaesthesia in cerebral haemorrhage, 685 in cerebro-spinal fever, 172 in diphtheritic paralysis, 384 in haematorrhachis, 741 in hysteria, 600 in leprosy, 371 in local asphyxia, 859 in locomotor ataxia, 780 in Morvan's disease, 775 in multiple alcoholic neuritis, 808 in myelitis, 754 in paralysis of anterior crural nerve, 846 of fifth nerve, 825 of median nerve, 844 of pneumogastric nerve, 836 of ulnar nerve, 845 in relapsing fever, 158 in scleroderma, 865 in spinal apoplexy, 746 tumor, 748 in syringomyelia, 773 in tetany, 638 in typhoid fever, 81 Anaesthesia dolorosa, 748 Analgesia in cerebral haemorrhage, 685 in hysteria, 600 INDEX. 871 Analgesia in Morvan's disease, 775 in syringomyelia, 773 in tetany, 638 Anarthria, 701 Anasarca. See CEdrnia. Anchylostomum duodenale, 9 Anemometer in testing ventilation, 42 Aneurism of cerebral arteries, 693 Angina in scarlatina, 215, 217 Angina Ludovici in actinomycosis, 476 in scarlatina, 224 Angina pectoris, diagnosis of, from the cardiac crises of locomotor ataxia, 785 pseudo- or hysterical, 601 Anginose scarlatina, 220 Angio-neurotic Q3dema, 862 definition of, 862 symptomatology of, 862 treatmentof, 862 Animal lymph, 292 Animals, anthrax in, 479 apparent occurrence of dengue in, 197 glanders in, 512 production of relapsing fe, . 152 scarlatina in, 213 Anisocoria, 821 Ankle, ankylosis of, in sclerodactyle, 865 Ankle clonus, 525 in antero-lateral sclerosis, 791 in epilepsy, 615 in hysterical paraplegia, 599 in chronic myelitis, 760 Anomalous epilepsies, 615 Anorexia in diphtheria, 382, 386 in hysteria, 602, 605 in small-pox, 266 in typhoid fever, 67, 82 Anosmia, etiology of, 813 in cerebro-spinai fever, 173 Anterior cerebral artery, occlusion of, 691 crural nerve, aftections of, 846 poliomyelitis. See PoHomi/eHfis. Antero-lateral sclerosis, 790 , definition of, 790 diagnosis of, 791 'etiology of, 790 pathology of, 790 [trognosis of, 703 symptomatology of, 790 synonyms of, 790 treatinent of, 793 Antero-lateral sclerosis, diagnosis of, from liysterical contractures, 792 Anthrax, 478 in lower animals, 479 bacillus of, 478 cause of, 11, 478 definition of, 478 diagnosis of, 482 etiology of, 478 intestinal form of, 481 morbid anatomy of, 480 mortality of, 4.S2 prognosis of, 482 I)rojjliylaxis of, 482 Anthrax, symptomatology of, 480 synonyms of, 478 thoracic form of, 481 treatment of, 483 Anthrax, diagnosis of, from carbuncle, 482 from ervsipehus, 482 Anthrax bacillus, 478 cultivation of, 479 destruction of, 16, 479 in etiologv of anthrax, 11, 478 in soil, 29, 480 Anthrax cvdema, 481 Anthrax with typhoid fever, 97 Antifebrin in angio-neurotic oedema, 862 in epilepsy, 624 in locomotor ataxia, 787 in relapsing fever, 161 in scarlatina, 228 in small- pox. 282 Antipyretics in influenza, 194 in scarlatina, 228 in small-pox. 282 in typhoid fever, 122 in typhus fever, 149 Antipyrine in angio-neurotic cedema, 862 in cerebro-spinai fever, 183 in dengue, 200 in ephemeral fever, 50 in epilepsy, 625 in influenza, 194 in locomotor ataxia, 787 in rela])sing fever, 161 in scarlatina, 228 in small-i)ox, 282 in typhoid fever, 127 in ty|)hus fever, 149 in whooping cough, 321 Antiseptics, 16 in typhoid fever, 125 Antispasmodics in hysteria, 608 Antitoxines in anthrax, 483 in tetanus, 470 Antrum, dilatation of, in acromegaly, 864 Anuria in hysteria, 602 significance of, in scarlatina, 219, 220 in tetanus, 467 Aphasia, 701 in brain syi)hilis, 729 in brain tumor, 72(1 in cerebral haemorrhage, 684 following cerebro-spinai fever, 177 of coiidiictioii, 7'*5 in infantile hemiplegia, 707 localization of lesion in, 705 temporary, in migraine, 658 mixed forms of, 704 motor, 704 in Raynaud's disease, 861 sensorv, 702 tests for, 705 treatment of, 705 following typiioid fever, 91 A{)honia in adductor paralysis, 836 in diphtheria, 381, 382 ' in hysteria, 6(i2 872 INDEX. Aphonia in trichinosis, 506 Apomorphine in convulsions, 627 in hiccough, 841 Apoplectic cerebro-spinal fever, 169 Apoplexy, ingravescent, 683. See, also, Cerebral. Hcemorrkage. Apraxia. See Aphasin, Sensory. Arachnoid, changes in, in cerebro-spinal fever, 167 Aran-Duchenne tvpe of muscular atrophy, 852 Ardent continued fever, 48, 646 Argyll-Robertson pupil, 821 in locomotor ataxia, 782 Arm, peripheral paralysis of, 841 Arsenic in cerebro-spinal fever, 183 in epilepsy, 625 in relapsing fever, 161 in St. Vitus's dance. 632 in trifacial neuralgia, 827 in the coloring of wall-paper, 23 Arteries, embolism and thrombosis of cere- bral, 688 of anterior cerebral, 691 of basilar, 691 of internal carotid, 691 V of middle cerebral, 691 of posterior cerebral, 691 of vertebral, 691 occlusion of, in typhoid fever, 93 Artery of cerel)ral haemorrhage, 679 Arthritis in cerebro-spinal fever, 171 in locomotor ataxia, 782 in localized neuritis, 806 in scarlatina, 218 in small-pox, 277 in typhoid fever, 90 Arthritis, diagnosis of, from hysterical joint, 603 Arthro{)athies in hemiplegia, 686 in locomotor ataxia, 782 in Morvan's disease. 775 Asafoetida in cerebro-spinal fever, 182 in typhoid fever, 128, 130 in typhus fever, 149 Ascarides as a cause of perforation in ty- phoid fever, 92 Ascites in scarlatina, 219 Asphyxia in cholera, 443 in diphtheria, 383 in thermic fever, 664, 647 Astasia-abasia, diagnosis of, from locomotor ataxia, 784 Asthenic form of malarial fever, 427 Ataxia, cerebellar, 722 in diphtheritic paralysis, 384 in Friedreich's ataxia, 797 hereditary, 795 in insular sclerosis, 712 locomotor, 776 in chronic periencephalitis, 554 in Thomsen's disease, 857 Ataxic aphasia. See Aphasia, Motor. gait, 780 nystagmus, 798 Ataxic paraplegia, 793 , Ataxic paraplegia, definition of, 793 etiology of, 793 pathology of, 793 prognosis of, 794 symptomatology of, 794- treatnient of, 794 Ataxic paraplegia, diagnosis of, from Fried- reich's ataxia, 793, 794 Ataxic form of typhoid fever, 102 of typhus fever, 144 Atelectasis in cerebro-spinal fever, 176 Athetosis in infantile hemiplegia, 708 Atmospheric pressure as cause of disease, 27 Atrophic paralysis, 772 diagnosis of, from subacute polio- myelitis, 772 Atrophy in ansesthetic leprosy, 371 in Friedreich's ataxia, 798 in hemiplegia, 686 " in hypoglossal paralysys, 840 in infantile hemiplegia, 708 in locomotor ataxia, 782 in Morvan's disease, 775 in multiple neuritis, 807 alcoholic neuritis, 808 in acute myelitis, 755 in myositis, 850 in localized neuritis, 806 in acute poliomyelitis, 764 in chronic poliomyelitis, 771 in progressive muscular atrophy, 801 in sciatica, 848 in syringomyelia, 774 of brain, in cerebral palsies of children, 707 in hgemorrhagic pachymeningitis, 670 in chronic periencephalitis, 551 unilateral, 707 from compression, 851 of deltoid muscle, in circumflex paraly- sis, 843 in inflammatory conditions, 851 Atropine in cholera, 449 in sweats of pyajmia, 328 in earache of scarlatina, 229 Attention, inability to fix the, 532 Attitude in pseudo-muscular hypertrophy, 854 Auditory aurse in epilepsy, 615 centre, lesions of, 833 nerves, clianges in, in cerebro-spinal fever, 167 Aura, forms of, in epilepsy, 614 Aural vertigo, 611 Automatic chorea, 635 definition of, 635 treatment of, 637 symptomatology of, 635 consciousness in hysteria, 596 movements, 524 Automatism, epileptic, 616 in brain syphilis, 728 Autumnal fever, 54 Average death-rates, 5 i IXDEX. .^73 BACILLUS antliracis, 11, 16, 478 of cholera, 12, 435 coli coimiiunis, resemblance of, to typhoid bacillus, 5G diplitherine, 11, 373 of glanders, 11, 512 of hog cholera, 12 in sputum of inHuenza, 185 lepne. 11, 370 malaria^, 407 mallei. 11, 512 scarlatiuw, 213 of tetanus, 11, 463 tuberculosis, 11 in bone lesions of scrofula, 340 relation of, to scrofula, 337 tussis convulsivoe, 313 typhosus, 11, 55 Bacteria, classification of, 11 and disease, 9 in sewage, 33 in sewer air, 12 Bacteriological examination of water, 30 Bakers, mortality of, 26 Barracks, proper dimensions of, 39 Basal ganglia, tumors of, 721 Basilar artery, embolism and thrombosis of, 691' Bathing in scarlatina, 226, 227 Baths in septicaemia, 326 in small-pox, 282 cold, in cerebro-spinal fever, 181 in ephemeral fever, 50 in erysipelas, 403 in relapsing fever, 161 in scarlatina, 228 in thermic fever, 649 in typhoid fever, 119 in typhus fever, 148 hot, in cholera, 447 in convulsions, 627 in simple insomnia, 661 in chronic myelitis, 761 mercurial, in liereditary sy[)hilis, 367 warm, in diphtheria, 395 in locomotor ataxia, 788 in measles, 251 in acute myelitis, 757 Bedding, 24 i disinfection of, 17 i Bed-rooms, proper dimensions of, 39 Bed-sores in cerebral lueniorrhage, 683 in cerebro-spinal fever, 175, 183 following cholera, 444 in myelitis, 755 in pva-mia, 327 in tyi)hoid h-v.-r, 89, 132 Belladonna in cerebro-spinal fever, 183 in scarhitiiia, 227 in typhoiil lever, 125 in whooping cough, 321 Cell's mania. See I'l'iiencep/i'i/ifix, Acute. palsv. See FacUtl Nn-rc I I'>eri-I)eri. See JVrnri/li*, A/uf/iji/r Enihmic. Bichloride of mercury. See Mrrrunj. Bilateral athetosis, 709 Bilharzia luvniatobia, 9 Bilious intermittent fever. See Malarial Fevers, Intermittent. remittent fever. See Malarial Fevers, Remittent. form of typhoid fever. 102 Birth-palsies, 706 Bismuth in influenza, 195 in measles, 252 in relapsing fever, 161 in scarlatina. 228 in typhoid fever, 12S, 129, 132 Black leg, cause of, 12 Blacksuiiths, mortality of, 26 lUack vomit, 456 Bladder, abscess of, in typhoid fever, 93 attention to, in myelitis, 758 distension of, in typhoid fever, 89 intiammation of, in locomotor ataxia, 788 in acute myelitis, 758 in chronic myelitis, 760 in typhoid fever, ^^^ paralvsis of See Sphincters, ParalysU o/.' Blindness in cerebro-spinal fever, 168, 173 following cerebro-spinal fever, 176 following typhoid fever, 91 See, also, Amb/yopia and Amaurosis. Blisters in cerebro-spinal fever, 181, 183 in typhoid fever, 128 Blood, bacillus of influenza in, 185, 187 changes of, in anthrax, 480 in cerebro-s]>inal fever, 175 in cholera, 440 in miliary fever. 202 in scarlatina, 225 in se])tica'mia, 325 in typhoid fever, 87 in typhus fever, 137 examination of, in malarial fever, 419 spirillum of relapsing fever in, 161, 152 Bloodletting. See I'enrsertion. Boiieriuakers, mortality of, 26 Boiling as a disinfectant, 17 Bone-marrow, changes in. in relapsing fever, 154 tubercles in, in acute miliary tubercu- losis, 332 Bones, atrophv of, in facial hemiatrophy, hypertroi>hv of in acromegaly, 863, .S(i4 ■ lesions of, in sirofula, 3-10 in hereditary syphilis, 364 Bookl)inders, iMortnlily of, 2<> !5orax in foot-and-mouth disease, 522 Boric acid in scarlatina, 229 in tvphoid fever, l.'{2 I'.nvinc lym])li. 202 Braciiial plexus, Icsidiis of, .S41 Brachycardia. See llradyrnrtlia. Bradycardia in tynlntid fever, 87 following typhns fever, 142 Brain, abscess ol, 714 diagnosis of, 715 874 INDEX. Brain, abscess of, etiology of, 714 morbid anatomy of, 715 symptomatology of, 715 in cerebro-spinal fever, 167 following influenza, 192 anaemia of, 677 atrophy and sclerosis of, 707 cancer of, 718 changes in, in cerebro-spinal fever, 167 cortical centres of, 696 cysts of, 718 glioma of, 717 hypersemia of, 676 inflammation of, 714 lesions of, in hereditary syphilis, 364 murmur in cerebral aneurism, 693 in hydrocephalus, 724 oedema of, 678 in erysipelas, 398 organic diseases of, 669 porencephalus of, 707 sarcoma of, 717 sclerosis of, diffuse, 713 insular, 711 miliary, 713 tuberous, 713 softening of, 552 red, yellow, and white, 689 syphilis of. See Syphilis of Brain. syphiloma of, 717 tubercle (tyroma) of, 717 * tumors of, 717 diagnosis of, 722 prognosis of, 723 symptoms, general and focal, 718, 719 topographical diagnosis of, 719 treatment of. medical and surgical, 723 Brand method, mortality after treatment by, 111 in treatment of typhoid fever, 119 of typhus fever, 148 Breakbone fever, 197 Breathing in laryngeal diphtheria, 382 in hereditary syphilis, 365 Brewers, mortality of, 26 Bright's disease. See Kidneys and Nephritis. Bromides in cerebro-spinal fever, 183 in convulsions, 627 in deliriuni tremens, 560 in dengue, 200 in epilepsy, 625 in measles, 252 in migraine, 659 in relapsing fever, 161 in typhoid fever, 127 in whooping cough, 321 Bromism, 625 Bromoform in whooping cough, 321 Bronchitis in actinomycosis, 476 in cerebro-spinal fever, 166, 176 in influenza, 189, 194 in measles, 238, 246 in relapsing fever, 155 Bronchitis in rubella, 258 in scrofula, 340 in small-pox, 277 in acute miliary tuberculosis, 333 in typhoid fever, 66, 88, 95, 98, 132 in typhus fever, 142, 144 in whooping cough, 317 Bronchitis, diagnosis of, from acute miliary tuberculosis, 334 Bronchitis, chronic, osteo-arthropathie pneumique in, 864 " Bronze liver," 423 Broths. See Diet. Bubo, parotid, 309 Buboes in typhus fever, 145 Bubonic plague, diagnosis of from typhus fever, 147 Builders, mortality of, 26 Bulbar paralysis, 803 Bullse in anaesthetic leprosy, 371 in erysipelas, 399 Butchers, mortality of, 26 CAB-DRIVERS, mortality of, 26 Cabinetmakers, mortality of, 26 Cachexia, malarial, 432 syphilitic, 353 Caffeine in diphtheria, 395 in typhoid fever, 132 Caisson disease, 650 Calabar bean in cerebro-spinal fever, 183 Calcification of muscles, 851 Calm stage in yellow fever, 455 Calomel in delirium tremens, 560 in influenza, 194 in malarial fever, 421 in acute spinal meningitis, 742 in milk sickness, 206 in acute poliomyelitis, 769 in relapsing fever, 161 in trichinosis, 511 in typhoid fever, 125, 127, 128, 130 in typhus fever, 149 Camphor in typhoid fever, 127 in typhus fever, 149 Calor mordax in scarlatina, 215 in typhus fever, 143 Cancer of brain, 718 Cancrum oris in typhoid fever, 91 tumors of, 721 Cannabis Indica in cerebro-spinal fever, 183 in migraine, 659 in typhus fever, 149 Capsule, internal, lesions'of, 700 Carbolic acid in anthrax, 483 in milk sickness, 206 in scarlatina, 229 in tetanus, 470 in typhoid fever, 125, 127 Carbonated water in typhoid fever, 116 Carbonic acid, proportions of, in air, 38 in soil air, 28 Carbuncle, diagnosis of, from anthrax, 482 Carbuncles, metastatic, in anthrax, 481 INDEX. 875 Cardiac crises in glosso-lubial paralysis, 804 in locomotor ataxia, 771* diagnosis of, from angina pectoris, 785 embolism, in typlioid fever, 93, 110 epilepsy. See Ep'depxij. failure in relapsing fever, 157 in typhoid fever, 110, 182 paralysis in diphtheria, 884 Cardinal's case (hydrocephalus), 724 Caries of bones in acquired syphilis, 352 Carotid artery, ligation and compression of, in cerebral luemorrhage, 092 internal, symptoms following oc- clusion of, 691 Carpenters, mortality of, 26 Carphalogia in acute miliarv tuberculosis, 332 in typhoid fever, 81, 113 Castor oil in typhoid fever, 130 Catalepsy in hysteria, 598 Catarrhal symptoms of measles, 238 Catheterization in hysteria, 609 in locomotor ataxia, 788 in acute myelitis, 758 in typhoid fever, 89 Cauda equina, disturbances caused by pres- sure upon, 849 Cemeteries, legislation regarding, 42 Centrum ovale, lesions of, 700 Cephalalgia. See Headache. Cerebellar ataxia, 722 vertigo, 722 Cerebellum, tumors of, 722 Cerebral ansemia, 677 symptoms and treatment of, 678 arteries, aneurism of, (593 embolism. See Embolism and Throm- bose. Cerebral contractures, diagnosis of, from spinal contractures, 792 Cerebral hamiorrhage, 679 conjugate deviation in, 685 convulsions in, 682 crossed hemiplegia in, 6X4 diagnosis of. 686 etioliigy of, 679 hemiaruesthesia in, 685 hemiplegia following, 683 locations of, 680 morbid anatomy of, 680 prognosis of, 687 secondary symptoms of, 685 .symptoms of, 6X2 treatment of, (Jttl Cerebral hemorrhage, diagnosis of, from acute alcoholism, 686 frf)m epilepsy, 686 I'rotii opium-poisoning, 686 Cerebral liyperaMiii;!. 676 forms, morl)id anatomy, and symp- toins of, 677 localization, 696 thrombosis. Sec Embollum and Throm- bOMlK. Cerebritis. See Encephalitix. Cerebro-spinal fever, 162 clinical description of, 167 complications of, 176 definition of, 162 diagnosis of, 177 duration of, 179 etiology of, 164 history of, 162 morl)id anatomy of, 166 mortality of, 179 prognosis of, 179 relapses in, 177 sequela^ of, 176 synonyms ot", 162 treatnient of, 180 Cerebro-spinal fever, diagnosis of, from in- fluenza, 178, 193 from malarial lever, 179 from meningitis, 179 from rheumatic fever, 179 from scarlatina, 179 from sniall-pox, 179 from tuberculous meninsritis, 177 from typhoid fever, 106. 178 from typhus fever, 146, 178 Cerebro-spinal form of typhoid fever, 82, 102 of typhus fever, 144 Cerium oxalate in iiiflueii/.a, 195 Cervical pachymeningitis, 743 plexus, affections of, 840 Champagne in tvjihoid fever, 116, 128 Chancre, 348 Character, significance of changes in the, 542 Charcot's joints, 782 Charcot-Marie type of progressive myo- pathic atrophy, 852 Chemical disinfectants, 19 Cheyne-Stokes respiration in cerebral luem- orrhage, 682 in cerebnil tumor, 719 in cerel)ro-siiinal lever, 175 in hiematuric intermittent fever, 427 in tuberculous meningitis, 672 Chiasma and tract, lesions of, 816 Chicken-pox. v^ee Varicrlla. Children, fatality of small-pox in, 280 typlioid fever in, 103 typhus fever in, 145 Chills, occurrence of, in anthrax, 481 in bilious intermittent fever, 427 in ctTcbro-spinal fever, 168 in dengue, 198 in (li])iitiieriji, 381 in erysipelas, 399 in foot-aMd-niouth disease, 521 in glanders, 513 in luematnric pernicious inliiniittent fever, 427 in liM'inoglobinuria, Xfil in iMlliienza, 1^7 in intermittent i'evir, ll.'} in measles. 23K 876 INDEX. Chills in mountain fever, 207 in multiple neuritis, 807 in mumps, 307 in pyaemia, 327 in rubella, 256 in scarlatina, 214 in septicaemia, 325 in small-pox, 266 in acute spinal meningitis, 742 in syphilis, 352 in acute miliary tuberculosis, 332 in typhoid fever, 68 in typho-malarial fever, 431 in typhus fever, 138 in yellow fever, 455 Chills and fever. See Malarial Fevers. Chin reflex, 525 in spastic bulbar paralysis, 795 Chloral in cerebro-spinal fever, 183 in delirium tremens, 561 in simple insomnia, 661 in measles, 252 in melancholia, 567 in relapsing fever, 161 in scarlatina, 228, 229 in small-pox, 282 in St. Vitus's dance, 632 in tetanus, 470 in typhoid fever, 127 in typhus fever, 149 in whooping cougli, 321 Chloride of iron in diphtheria, 392, 395 in erysipelas, 403 in brain syphilis, 732 in typhoid fever, 131 of lime as a disinfectant, 20 of zinc as a germicide, 20 Chlorine as a disinfectant, 19 Chlorine-water in typhoid fever, 125, 127 in typhus fever, 149 Chloroform in cerebro-spinal fever, 183 in relapsing fever, 161 in yellow fever, 4()1 Chloroform liniment in multiple neuritis, 816 in typhoid fever, 127 Chlorosis following typhoid fever, 95 Choked disk, 816 Cholera, 434 age, race, and sex in etiology of, 436 bacillus of, 436 cause of, 12, 436 of symptoms in, 438 climate and season in etiology of, 435 complications and sequelae of, 444 definition of, 434 diagnosis of, 445 , , disinfection after, 449 duration of, 445 recent epidemics of, 434 etiology of, 435 morbid anatomy of, 439 mortality and prognosis of, 446 period of incubation in, 440 prophylaxis of, 446 quarantine against, 450 Cholera, relation of, to miliary fever, 201 rigor mortis in, 439 sicca, 442 stages of, 440 stools, cholera bacillus in, 441 micro-organisms in, 441 symptomatology of, 440 synonyms of, 434 treatment of, 446 of convalescence from, 449 Cholera, diagnosis of, from acute mineral poisoning, 445 from cholera morbus, 445 from malarial fever, 429 from trichinosis, 509 from typhoid fever, 445 Cholera bacillus, 12, 436 cultivation of, 437 in soil, 29 in water, 30 Cholera infantum, cause of, 12 morbus, cause of, 12 diagnosis of, from cholera, 445 Cholerine, 434 Chorea, 526 general, 526 habit, 634 local, 526 senile, 634 following typhoid fever, 91 See, also, Aafomafic, Convulsive, Heredi- tary, and Reflex Chorea, St. Vitus's Dance, and footnote, p. 627 Choreic movements, causes of, 526 definition of, 526 Choreiform movements in cerebro-spinal fever, 173 in cerebral haemorrhage, 682 Choroid, tubercles in the, in tuberculous meningitis, 673 in acute miliary tuberculosis, 332 plexuses, sclerosis of, 724 Chronic periencephalitis. See Periencepha- litis, Chronic. Cimicifuga in St. Vitus's dance, 633 Circular insanity, 586 Circulation, effect of exercise upon the, 23 Circumcision, tuberculous infection in do- ing, 329 Circumflex nerve, affections of, 843 Clavus, 65(') Claw-hand in muscular atrophy, 8.56 in progressive muscular atrophy, 801 Clergymen, mortality of, 26 Clerks, mortality of, 26 Climate in etiology of dengue, 197 of malarial fevers, 410 Clothing, 24 color of, 25 disinfection of, 17 infection through, 25 Cocaine in cholera, 447 in influenza, 195 in sciatica, 849 in whooping cough, 322 Coccydynia, 847 I INDEX. 877 Codeine in dengue. 200 in influenza, 195 in typhoid fever, 127, 128 Cod-liver oil in scrofula, 84o iifter typhoid fever, 133 Coffee-ground vomit in locomotor ataxia, 779 Cold in hyperpyrexia, 118 etfect of, on poison of scarlatinu, 213 on poison of yellow fever, 452 pack, application of, US Colic in Raynaud's disease, 8(31 Collapse in relapsing fever. 158 in typhoid fever, 87, 110 stage of, in cholera, 442 Colles's law, 361 Coma, definition of, 659 Coma in cerebral abscess, 715 embolism and thrombosis, 690 haemorrhage, 682 syphilis, 72(), 728 sinus thrombosis, 694 tumor, 719 in cerebro-spinal fever. 172 in erysipelas, 400 in measles, 244 in pernicious malarial fever, 428 in Raynaud's disease, 861 in scarlatina, 219, 222 in small-j)0x, 267 in thermic fever, 646 in acute miliary tuberculosis, 834 in tuberculous meningitis, 672 in typhoid fever, 80 Coma vigil in typhoid fever, 80, 113 Comatose form of malarial fever, 428 Comma bacillus, 436 Commercial travellers, mortality of, 26 Complicating insanities, 546 Comj)ression of spinal cord, atrophy from, 852 Concussion of spinal cord, 744 Confluent small-pox, 273 Confusional insanity, 570 definition of, 570 diagnosis and prognosis of, 573 etiology of, 570 symptom.atology of, 570 synonyms of, 570 treatment of, 573 follcnving typhoid fever, 90 Congenital paramyotone, 857 syjihilis. See Siiphitix, Ifireditunj. Conjugate deviation in c(rel)ral lueuior- rhage, 685 tumor, 721 in tu"l)ercuh)us meningitis, 673 Conjun(;tivitis in msy, 612 in hysteria, 596 in infantile hemiplegia, 707 in malarial fever, 414 in measles, 244 in miliary fever. 202 in milk sickness, 2eraiiiia, 74'> Ergotin in typhoitomatoh)gy of, 797 svnonyms of, 795 ireatnient of, 799 Friedreich's ataxia, diagnosis of, from ataxic paraplegia, 794 from insular sclerosis, 7I.') Frontal convolutions, lesions of, 720 Fulminant cerebro-spinal fever, 169 Fulminant scarlatina, 220 Functional insanities, 547 Fungus haMuatodes, 718 Furuncles in dengue, 199 GAIT in antero-lateral sclerosis, 790 in ataxic jiaraplegia, 794 in lesions of the cerebellum, 722 in diphtheritic paralysis, 3S4 in Friedreich's ataxia, 797 in hemijilegia, 085 in insular sclerosis. 712 in locomotor ataxia, 780 in multi])le neuritis, 811 in chronic periencephalitis. 554 in ]>seudo-hvpertropliic muscular atro- piiy, 854 ' in Thomsen's disease, 856 Gait, steppage, in external popliteal paraly- sis, S47 in peripheral neuritis, 811 Gall-bladder, absce-ss of, in tvphoid fever, 93 Gallic acid in typhoid fever, 131 Ganglia, basal, tumors of, 721 ' Gangrene in cerebro-spinal fever. 174 in erysipelas, 400 in typhoid fever, 93 of intestine in typhoid fever, 80, 92,97 of lungs in relapsing fever. 157 in scarlatina, 224 in typhoid fever, iSiS, 95 in typhus fever, 144 symmetrical, 8()0 Garbage, cremation of, 16 Gardeners, mortality of, 26 Gastric crises, in locomotor ataxia, 779 fever. See IxniiUlint i]f(i/ariit/ Fever. form of typhoid fever, l(i2 Gastritis, diagnosis of, from influenza, 193 Gastro-enteric catarrh, diagnosis of from inthienza, 193 Gastro-intestinal form of inlhienza. 188 Gas-workers, diseases of, 27 Gelsemium in cerebro-spin^d fever. 1S3 General paralysis of the insane. See I'l ri- rnrtj)/i((/l/i.'<, ( '/irnnlr. Genitalia, alfection of, in angio-neurotic oedema. S62 gangrene of, following typhoid fever, 97 liy]>ertropliy of, in acromegaly, i^'^^t'^ Genito-urinarv crises in locomotor :itaxia, 779 German measles. See lliiliillti. Germicides, 16 Giant growth, diagnosis of, from acromeg- aly, .S64 urticaria. See Aiif/lo-inunific UCilnna. Giberl's syriiji in liercditiiry sypliilis, 36S (lilies de l:i Tourrette's disease. See Antn- VKitir C/iorcit and Fitv'ntl Sjkikih. fUngivitis in mercurialism. 358 (lirdie sensation in locomotor ataxia, 780 in acute myelitis, 754 Glanilers, 512 in aninnds, 512 884 INDEX. Glanders, bacillus of, 512 cause of, 11, 512 complications of, 515 definition of, 512 diagnosis of, 516 etiology of, 512 morbid anatomy of, 516 period of incubation in, 513 prognosis of, 517 prophylaxis of, 517 symptomatology of acute, 513 of chronic, 515 synonyms of, 512 treatment of, 518 Glanders bacillus, 512 results of inoculation of, 517 Glass-workers, mortality of, 26 Glioma of brain, 717 Gliosis in epilepsy, 622 Globus hystericus, 595 Glosso-labial paralysis, 803 symi)toniatology of, 803 Glosso-labio-laryngeal paralysis, 852 Glosso-pharyngeal nerve, lesions of, 834 Gluteal reflex, 524 Glycerin suppositories in typhoid fever, 130 in typhus fever, 149 Glycosuria in cerebral hsemorrhage, 682 in cerebro-spinal fever, 176 in cholera, 443 in the malarial paroxysm, 417 in relapsing fever, 158 in typhoid fever, 97 Gonococcus as cause of gonorrhoea, 11 Gout and food, 22 influence of, upon ty|)hoid fever. 111 Gouty insanity, 557 Grandeur, delusions of, 537 Granular degeneration of muscles in ty- phoid fever, 64 Gray degeneration of spinal cord, 759 Grisolle sign in small-pox, 279 Grocers, mortality of, 26 Gros mal, 615 Ground-water in relation to typhoid fever, 28, 54. Guinmata in acquired syphilis, 350 in hereditary syphilis, 365 of brain, 726 of kidney, 352 of liver, 352 of spinal cord, 734 Gunsmiths, mortality of, 26 Gurjun oil in leprosy, 372 Gustatory aurie in epilepsy, 615 paralysis, 825 HABIT chorea, 634 Habitations, 27 Habitus, apoplectic, 679 Haematemesis in dengue, 198 ■ in influenza, 190 in relapsing fever, 157 in typhoid fever, 84, 91 in typhus fever, 145 Haematidrosis in hysteria, 602 Hsematoidin in brain after haemorrhage, 681 Hsematoma of the dura mater, 669 Hsematomyelia. See Spinal Apoplexy. Hsematomyelitis, 755 Hsematorrhachis, 741 Heematuria in measles, 244 in relapsing fever, 155 in scarlatina, 220 in typhoid fever, 97 Hsematuric form of malarial fever, 427 Haemic murmurs in relapsing fever, 155 Haemoglobinuria and Raynaud's disease, 861 Haemoptysis in scarlatina, 224 in typhoid fever, 95 Haemorrhage in anthrax, 481 in congestive cardiac epilepsy, 618 in hsematuric intermittent fever, 427 in hysteria, 601 intracerebral, 681 in measles, 244 meningeal, 680 in typhoid fever, 67 in the retina, 815 in small-pox, 274 into spinal cord, 745 membranes, 741 in typhoid fever, 131 ventricular, 681 in yellow fever, 456 Hajmorrhagic diathesis in typhoid fever, 95 pachymeningitis. See Pachymeningitis, Hallucinations, definition of, 533 in delirium tremens, 559 in melancholia, 563 in paranoia, 582 sources of, 534 Hatters, mortality of, 26 Hay bacillus, 16 Headache, 654 classification of, 654 nervous, 656 organic, 654 sympathetic, 656 toxfemic, 655 Headache in acromegaly, 864 in brain syphilis, 727 in brain tumors, 718 in cerebro-spinal fever, 171 in influenza, 187-189 in relapsing fever, 155 in scarlatina, 224 in simple meningitis, 674 in small-pox, 267 in tuberculous meningitis, 671 in typhoid fever, 79 in typhus fever, 138 Health boards, duties of, 44 Heart, dilatation of, in typhoid fever, 93 disease, influence of influenza on, 192 influence of, in typhoid fever, 112 valvular, in locomotor ataxia, 784 in typhoid fever, 93 murmur in St. Vitus's dance, 631 INDEX. 885 Heart-muscle, typhoid bacilli in, 56 Heat as a disinfectant, 16 effect of, on poison of scarlatina, 213 exhaustion, 645 influence of, on typhoid bacillus, 57 moist, as a disinfectant, 17 Heating by direct method, 40 direct-indirect method, 39 indirect method, 39 Hebephrenia, 580 Hebetude in typhoid fever, 78 Hemeralopia, 815 Hemiachi'omatopia, 818 Heniianjesthesia in cerebral haemorrhage, 685 in hemiplegia, 685-708 in hysteria, 601 in lesion of the internal capsule, 721 in spinal tumor, 747 Hemianopia, 818 hemiopic pupillary inaction in, 819 heteronymous, 818 homonymous, 818 nasal, 818 significance of, 818 temporal, 818 Hemiplegia, following cerebral haemor- rhage, 683 in cerebro-spinal fever, 173 contractures in, 685 crossed, in cerebral hsemorrhage, 684 in hsemorrhagic pachymeningitis, 670 in hysteria, 599 infantile, 706 aphasia in, 707 contractures in, 707 convulsions in, 707 epilepsy in, 708 mental defects in, 708 morbid anatomy of, 706 post-hemiplegic movements in, 708 symptomatology of, 707 and Raynaud's disease, 861 spastica cerebralis, 708 Hemipl^gie fla'^que, 708 Hepatitis in typhoid fever, 92 Hereditary chorea, 637 definition of, 637 etiology of, 637 pathology of, 637 symptomatiijogy of, 637 treatment of, 638 immunity from disease, 13 tendency to disease, 8 Heredity in etiology of acromegaly, 863 of angio-iH'urotic fjedema, S62 of cerebral luemorrhage, 679 of epilepsy, 612 of l'"ri('(lreicirs ataxia, 795 of hysteria, 593 of idiopatliic muscular atro|)hy, 85-J of leprosy, 369 of muscular atrophy, 854 of peroneal type of muscular atro- phy, 856 Heredity in etiology of progressive muscu- lar atro])hy, 799 of scrofula, 33(5 of Thonisen's disease, 856 Herpes in cerebro-spinal fever, 174 in dengue, 198 in ephemeral fever, 47, 48 in paralysis of facial nerve, 830 of filth nerve, 825 labialis in malarial fever, 414 in typhoid fever, '^2 zoster in intercostal neuralgia, 845 in localized neuritis, 806 in chronic periencephalitis, 555 Hiccough, 841 in cholera, 442 in relapsing fever, 157, 161 treatment of, 841 in typhoid fever, 81 in tvphus fever, 143 Hippus,'824 Hog cholera, cause of, 12 Hospitals for contagious diseases, 21 Hot air as a disinfectant, 17 House sewerage, 35 Hucksters, mortality of, 26 Human lymph, objections to use of, in vac- cination, 294 Huntingdon's chorea. See Hereditary Chorea. Hutchinson's teeth, 364 Hyaline degeneration of muscle-fibres, 850 Hydatid of brain, 718 Hydrargyrum. See Afercurt/. Hydrocephalic cry in tuberculous menin- gitis. 672 Hydrocephalus, chronic, 723 acquired, 724 infantile, 723 morbid anatomy of, 723 symptomatology of, 725 treatment of, 725 Hydrocephalus following cerebro-spinal fever, 167 ex vacuo, 723 internal, in chronic periencephalitis, 551 Hydrocephalus, diagnosis of, from rachitis, 724 Hydrochloric acid as a disinfectant, 20 Hydrocyanic acid in milk-sickness, 206 " in typhoiil fever, 128 Hydrogen peroxide in diphtheria, 393 Hydro-pericardium in scarlatina, 219 Hydr()p!i<)l)ia, 4S5 Centaiiiii's metiujd in, 497 definition of, 485 diagnosis of", 494 ill the dog, 489 etiology of, 485 morbid anatomy of, 491 I'astcur's method in, 497 period of iiiciiltalioii in, 489 prognosis of, 495 j)ropliyla.\is of, 495 Hyiiiptiiiiiatology of, 492 886 INDEX. Hydrophobia, synonyms of, 485 treatment of, 496 Hydrophobia, diagnosis of, from lyssopho- bia, 495 from tetanus, 468, 494 Hydrophobia in the dog, 486 Hydrops. See (Edema. Hydrotherapy. See Baths. Hydrothorax in scarlatina, 219 Hygiene, 1 in diphtheria, 388 in scrofula, 342 in syphilis, 360 in typhus fever, 147 Hyoscine in delirium tremens, 560 in erysipelas, 403 in melancholia, 567 in acute periencephalitis, 550 in typhoid fever, 128 in typhus fever, 149 Hyperacusis, 833 in hysteria, 600 Hypersesthesia in cerebro-spinal fever, 172 in hysteria, 599 in relapsing fever, 155 of retina, 815 in typhoid fever, 81 in typhus fever, 140 Hyperbulia, 530 Hyperpyrexia in cerebro-spinal fever, 175 in cholera, 443 in dengue, 198 in diphtheria, 381 in ephemeral fever, 48 in epilepsy, 614 in erysipelas, 400 in hysteria, 602 in influenza, 188 in intermittent fever, 414 in measles, 241 in relapsing fever, 160 in rubella, 258 in scarlatina, 215 in small-pox. 266 in tetanus, 467 in thermic fever, 646 in acute miliary tuberculosis, 333 in tulaerculous meningitis, 672 in typhoid fever, 74-76, 118 in typho-malarial fever, 432 in typhus fever, 140, 144 as cause of degeneration of muscles, 64 treatment of, 118 Hypnotism in hysteria, 608 Hypochondria in Thomsen's disease, 857 Hypochondriacal delusions. See Delusions. Hypodermoclysis in cholera, 448 Hypoglossal nerve, paralysis of, 839 Hypomania, 569 Hypophosphites in scrofula, 343 Hypostatic congestion of lungs in typhoid fever, 66 Hysteria, 592 age, heredity, race, and sex in etiology of, 593 amblyopia in, 601 Hysteria, anjesthesia in, 600 anorexia in, 602 beast-mimicry in, 595 catalepsy in, 598 catheterization in, 609 convulsions in, 596 definition of, 592 diagnosis of, 603 disturbances of consciousness and mo- tion in, 595 of sensation in, 599 dyspnoea in, 602 etiology of, 592 in etiology of local syncope, 859 faecal vomiting in, 603 hemiplegia in, 599 hyperaestbesia in, 599 hypnotism in, 608 ischsemia in, 600 joint affections in, 603 mental symptoms in, 594 metallo-therapy in, note, 601 monoplegia in, 599 muscular atrophy in, 852 opisthotonos in, 596 paralysis in, 599 paraplegia in, 599 pathology of, 605 _ photophobia in, 600 prognosis of, 605 pseudo-angina pectoris in, 601 relation of, to paramyoclonus multi- plex, 858 respiration in, 602 rest-treatment in, 606 sweating in, 602 symptomatology of, 593 temperature in, 602 trance in, 598 treatment of, 606 urinary function in, 602 Hysteria, diagnosis of, from cerebro-spinal fever, 179 from epilepsy, 619 Hysterical breast, 604 contractures, diagnosis of, from spinal contractures, 792 dyspnoea, 602 insanity, 558 joints, peculiarities of, 603 diagnosis of, from arthritis, 603 paralyses, peculiarities of, 603 somnolence, 598 ICE in thermic fever, 648 typhoid bacilli in, 57 Ice-cap in erysipelas, 403 in meningitis, 676 Ichthyol in typhoid fever, 132 Icterus. See Jaundice. Idiocy in infantile hemiplegia, 708 and idiopathic muscular atrophy, 855 Idiopathic muscular atrophies, diagnosis of, from spinal atrophies, 855 Idiopathic muscular atrophy, 851 diagnosis of, 855 ! INDEX. 887 Idiopathic muscular atrophy, morbid anat- omy of, 855 prognosis of, 856 treatment of, ^bi!) Idiopathic pyaemia, 32G Ileum, changes in, in typhoid fever, 65 Ilium, periostitis of, following typhoid fever, 90 Illusions, definition of, 534 Immunity, 13 during epidemics, 13 transmitted by heredity, 8 from diphtheria, 375, 378 from scarlatina, 210 from tetanus, 470 from yellow fever, 453 Immunity conferred l)y measles, 235 by mumps, 307 by rubella, 259 by scarlatina. 221 by small-pox, 263 by vaccination, 289 Imperative act, 539 conce{)tion, 539 Incoherence, varieties of, 533 Incontinence of faeces in typhoid fevei', 113 of urine in cerebro-spinal fever 169, 176 in typhoid fever, 89 Indigestion as a cause of fever, 47 Infantile type of muscular atrophy, 854 Infantile paralysis. See Fo/iomi/elifis, Acute. Infants, fatality of smuU-pox in, 280 typhoid fever in, 103 Infection through clothing, 25 Influenza, 184 cause of, 12, 185 complications of, 189 definition of, 184 diagnosis of, 192 etiology of, 184 history of, 184 morbid anatomy of, 187 mortality of, 193 nature of, 184 prognosis of, 193 sequelae of, 189 symptomatology of, 187 synonyms of, 184 treatment of, 194 Influenza, diacrnosis of, from cerebro-spinal fever, 17H, 193 from dengue, 199 from typhoid fever, 108, 193 Influenza with typhoid fever, 97 Initial eruptions in small-pox, 267 Injections, sulicntaneous, of salines in cholera, 448 protective, in tetanus, 470 Injuries, remote effects of, 642 liuikeepers, mortality of, 26 Inoculation experiments in infhienza. 1.S5 in scarlatina, 213 against small-pox, 291 in typhoid fever, 57 Inoculation experiments in varicella, 299 Inoculations, protective, in hvdropliobia, 497 Insanity, I'lassitieation of, 546 definition of, 543 post-typhoidal, 90 See, also, Ah-ofio/ic, Circular, C'oniji/ica- ting, Con/usioiKi/, ( hns/itiitiondl, Doubfiiui, Funrfionnl, Goutij, Hijs- terical, Morul, yvuropathir, Or;/titiic, Periodical, Pure, Pcasouiii;/, and lox- (P)iiic InsanUji. Insects as conveyers of anthrax, 480 Insolation. See Thermic Fever. Insomnia, simjile, 6t)0 treatment of, 6<)0 Insomnia in brain syphilis, 728 in delirium tremens, 559 in influenza, 188 following influenza, 192 in mania, 568 in melancholia, 564 in acute periencej>halitis, 549 in trichinosis, 507 in typhoid fever, 79, 127 treatment of, 660 Inspiration, contraction of typhoid fever by, 54, 57, 58 Insula, tumors of, 721 Insular sclerosis, 711 diagnosis of, 712 etiology of, 711 morbid anatomy of, 711 prognosis of, 713 symptomatology of, 712 treatment of, 713 Insular sclerosis, diagnosis of, from Fried- reich's ataxia. 713 Intellectual aura* in epilepsy, (il5 Intellectual functions, general considera- tions on, 532 Intention tremors, 526 Intermittent fever. See Malarial Fcrrrs. Intermittent form of cerebro-spinal fever, 170 Internal ca])sule, lesions of, 7ro-spinal fever. 166 in influenza, 18!) in scarlatina, 224 in typhoid fever, (56, 95 splenization of, in typhoid fever, 66 tubercles in, in acute miliary tuberculo- sis, 331 Lymphatic glands, enlargement of, in scrof- ula, 338 inflammation of, in anthrax, 481 in scrofula, 3;'>9 involvement of, in acute ascend- ing paralysis, 749, 750 ill (lipli'tlifria, 380 III nibi'lla. .".8 in syphilis, 349 in hereditary sy|»hilis, 3(5(5 in ty|)lioid fever, (51, 63 tubercles in, in atiite miliary tuber- culosis, .'{.'tl Lymph-vaccine, 292 liVssa. See I/i/ifro/i/iohin. Lvssoplioi)ia, liiagiiosis of, from hydropho- bia. 495 M ACJilNlvMAKHllS, mortality of, 26 Main en grifl'c, 801 890 INDEX. Malaria, 405 Malarial cachexia, 432 treatment of, 433 Malarial fevers, 405 age, race, and sex in etiology of, 410 altitude and soil in etiology of, 411 in lower animals, 412 anticipating, 406 classification of, 412 climate, locality, and season in eti- ology of, 410 definition of, 405 duplicated forms of, 406 etiology of, 407 hsematozoon of, 407 mode of infection in, 409 micro-organisms in, 407 mortality of, 430 period of incubation in, 413 Plasmodium malarise in, 407 prophylaxis of, 419 quartan, 405 quinine in, 421 quotidian, 405 relation of, to phthisis, 412 retarding, 406 synomyms of, 405 tertian, 405 types of, 405 intermittent malarial fever, 412 diagnosis of, 418 exceptional cases of, 417 morbid anatomy of, 412 paroxysm of 413 period of incubation in, 413 prognosis of, 419 symptomatology of, 413 terminations of, 418 treatment of, 420 pernicious intermittent malarial fever, 425 algid type of, 427 asthenic type of, 427 bilious type of, 426 comatose type of, 428 complications of, 428 diagnosis of, 428 haematuric type of, 427 sequeke of, 428 symptomatology of, 426 synonyms of, 425 treatment of, 430 types of, 426 pernicious remittent malarial fever, 431 remittent malarial fever, 423 complications of, 425 diagnosis of, 425 duration of, 425 morbid anatomy of, 423 ' prognosis of, 425 symptomatology of, 424 treatment of, 425 typho-malarial fever, etiology of, 431 symptomatology of, 431 treatment of, 432 Malarial fevers, diagnosis of, from cerebro- spinal fever, 179 from cholera, 429 from ephemeral fever, 49 from meningitis, 429 from miliary fever, 203 from pneumonia, 419 from pyaemia, 328, 419, 429 from acute miliary tuberculosis, 334 from typhoid fever, 107, 429 from ulcerative endocarditis, 429 from yellow fever, 429, 458 Malarial typhoid, 97 Mai de montagne, 610 Malignant cerebro-spinal fever, 169 scarlatina, 220 typhoid fever, 102 typhus fever, 144 Malignant redema, cause of, 12 Malignant pustule. See Anthrax. Mallein, 513 action of, 517 Mammary glands in hysteria, 604 Mania, acute, 567 definition of, 567 symptomatology of, 567 Mania, chronic, 569 symptomatology of, 569 Mania in epilepsy, 617 following influenza, 192 Mania a potu. See Delirium Tremens. Maniacal epileptic automatism, 617 Marantic thrombi, 094 Marie's disease. See Acrornec/aly. Marriage, question of, in epilepsy, 624 in syphilis, 8, 367 Marrow of bones in hereditary syphilis, 364 tubercles in, in acute miliary tuberculosis, 332 Masked malarial fever, 417 Massage in idiopathic muscular atrophy, 856 in neurasthenia, 592 in acute poliomyelitis, 770 Mastication, spasm of the muscles of, 826 Mastodynia, 845 Matchmakers, diseases of, 26 Maxima of temjterature in typhoid fever, 76 Measles, 230 associated diseases in, 235 complications and sequelae of, 243 definition of, 230 diagnosis of, 249 etiologv of, 232 history of, 230 morbid anatomy of, 250 mortality of, 251 prognosis of, 251 prophylaxis of, 251 relations of, to tuberculosis, 249 symptomatology of, 237 synonyms of, 230 treatment of 251 INDEX. 891 Measles,diagno.sis of, from miliary fever, 202 from rubella, 259 from scarhitina, 221 from sin;ill-|>()x, 278 from syphilis, 355 from typhus fever, 147, 250 Meat, inspection of, 22 for tricliinse, 501 Median nerve, allections of, 844 paralysis of, 844 Medical experts, function of, in railway cases, (544 Medulla, tumors of, 721 Melsena. See Enterorrhaijia. Melansemia in malarial fever, 423 Melancholia, 562 agitata, 5(36 attonita, 565 classification of, 565 course of, 566 definition of, 562 periodical, 586 prognosis of, 566 simple forms of, 565 symptomatology of, 562 treatment of, 567 Melanosis in malarial fevers, 423 Membranous croup, relation of, to diph- theria, '.^m diagnosis of, from diphtheria, 386 Memory and consciousness, correlated dis- orders of, 664 Meniere's disease, 611 Mt'ningite foudroyante, 169 Meningitis, simple, 673 diagnosis of, 675 etiology of, 673 morbid anatomy of, 674 symptomatology of, 674 treatment of, 676 Meningitis in cerebro-spinal fever, 170 in erysipelas, 400 in scarlatina, 218, 223 in typhoid fever, 90 in typhus fcvcM-, 145 Meningitis, diagnosis of, from cerebro-spinal fever, 179 from malarial fever, 429 from small-pox, 278 from tetanus, 468 Meningitis, acute spinal, 741 symptomatology of, 742 treatment of, 742 Meningitis, chronic spinal, 743 treatment of, 743 Meningitis siderans, 169 Meningitis, tuberculous. See Tuberculous Mi'iiiiHiHiK and LfptonK'niiKjifis. Men.ilrual blood. s|iirilhim of relapsing fever in, 15] Menstruation in ty[>hoid fever, 97 in acromegaly, 863 Mental causes of diseases, 8 Mental changes in Tliomsen's (> in chronic periencephalitis, 556 in acute poliomyelitis, 769 in snuill-pox, 282 in syphilis, 356 in hereditary syphilis, 367 in typhoid fever, 127 Merismopedia gonorrho^ie, 11 Mesenteric glands, involvement of, in ty- phoid fever, 63 Metallic subacute poliomyelitis, 772 Metallo-therapy in hysteria, note on, 601 Metastasis in actinomycosis, 476 in mumps, 308 Metastatic abscesses in pytiemia, 327 carbuncles in anthrax, 481 Metastatic parotitis, 3(>9 symptomatology of, 310 Meteorism in hysteria, 602 in locomotor ataxia, 779 in ty])h()id fever, 83 in typhus fever, 141 Metschnikoff, vibrio of, 12 Micrococci. See Micro-orgnniHinx. Micro-organisms, diseases due to, 9 in actinomycosis, 475 in acute ascending paralysis, 750 in anthrax, 478 in cerebro-spinal fever, 165 in cholera sttiols, 441 in dengue, 197 in diplitheria, 373 in erysipelas, 3!»7, 398 in foot-and-mouth disease, 520 in malarial fevers, 407 in measles, 23(5 in metastatic parotitis, 309 in mumps, 305 in pya-mia, 326 in relapsing fever, 150 in niliella, 255 in scarlatina, 213 in septica'inia, 324, 325 in small-pox, 2(i4 in typiioid fever, 55 in varicelbi, 29i( in water, W in yellow fever, 451 Middle eereiiral artery, occlusion of, ()91 Mieseherian sac, 5(11 Migraine, 65() I diagnosis of, (559 ' ophllialmic type of, 658 892 INDEX. Migraine, symptomatology of, 656 treatment of, 659 Miliary fever, 201 definition of, 201 diagnosis of, 202 etiology of, 201 history of, 201 morbid anatomy of, 202 prognosis of, 203 symptomatology of, 202 synonyms of, 201 treatment of, 203 Miliary fever, diagnosis of, from malarial fever, 203 from measles, 202 from rheumatic fever, 202 Miliary tuberculosis, acute. See Tubercu- losis, Acute Miliary. Milk as convever of infection in diphtheria, 22," 376 in scarlatina, 22, 211 in tuberculosis, 22 in typhoid fever, 22, 59, 113 and disease, 22 as food, 22 sterilization of, 23 Milk in measles, 251 in relapsing fever, 160 in scarlatina, 227 in typhoid fever, 115 in typhus fever, 148 Milk sickness, 204 definition of, 204 diagnosis and relation to other diseases, 206 etiology of, 204 symptomatology of, 204 synonyms of, 204 treatment of, 206 Millers, mortality of, 26 Milzbrand bacillus, 478 Mind-blindness, 703 Mind-deafness, 704 Mineral poisoning, acute, diagnosis of, from cholera, 445 Miners, mortality of, 26 Minima of temperature in typhoid fever, 76 Miryachit. See Automatic Chorea. Mitchell, S. Weir, treatment. See Rest Treatment. Monoplegia, definition of, 523 in hysteria, 599 in spinal tumor, 747 in tuberculous meningitis, 673 Moral insanity, 578 Morbid desires, 542 fear, forms of, 539 impulse, 539 sleep, 661 Morbilli. See Measles. Morphine in delirium tremens, 561 in dengue, 200 in erysipelas, 403 in influenza, 195 in locomotor ataxia, 787 Morphine in pernicious intermittent fever, 430 in Raynaud's disease, 862 in relapsing fever, 161 in scarlatina, 229 in sciatica, 849 in St. Vitus's dance, 632 in trichinosis, 511 in typhus fever, 149 in yellow fever, 4(K) Morphoea. See Scleroderma. Mortality, calculation of, 4 in various occupations, 25 general, during epidemics of influenza, 192 Mortality of anthrax, 482 of cerebro-spinal fever, 179 of cholera, 446 of diphtheria, 388 of influenza, 193 of malarial fevers, 430 of measles, 251 of rubella, 259 of small-pox, 280 of typhoid fever, 109 of typhus fever, 145 of whooping cough, 319 of yellow fever, 458 Morvan's disease, 775 diagnosis of, from svringomvelia, 775 Motor area, tumors of, 719 Motor centres, 696 destructive lesions of, 698 irritative lesions of, 699 Motor centres and tracts, lesions of, 698 Mottling of surface in cerebro-spinal fever, 174 in typhoid fever, 72 in typhus fever, 138 Mountain fever, 207 Mouth-to-mouth breathing, tuberculous in- fection by, 329 Mucous form of typhoid fever, 102 Mucous membranes, lesions of, in scrofula, 339 Mucous patches in acquired syphilis, 353 in hereditary syphilis, 363 Mulberry tongue, 217 Multiple neuritis. See Neuritis, Multiple. Mumps, 304 age and sex in etiology of, 305 complications of, 308 contagiousness of, 305 definition of, 304 diagnosis of, 309 etiology of, 304 immunity conferred by, 307 morbid anatomy of, 306 period of incubation in, 307 symptomatology of, 307 synonyms of, 304 treatment of, 310 Murmurs, neurotic, in St. Vitus's dance, 631 Muscle callus in sterno-mastoid in infants, 838 lynEX. 893 Muscle symptoms in trichinosis, outi Muscles, diseases of, 850 changes in Thomson's disease, 857 in typhoid fever, 64 enlargement of, in pseudo-hypertrophic muscular atrophy, 853 rupture of, in tetanus, 407 Musrular crises in locomotor ataxia, 779 Muscular dystrophies, classification of 851 Muscular sense, testing of, 528 Musculo-sf)iral paralysis, 843 Myelitis, acute, 752 definition of 752 diagnosis of, 756 etiology of, 752 explosive, 755 foudroyant or central, 755 pathology of, 752 prognosis of, 755 symptomatology of, 753 treatment of, 756 trophic changes in, 755 Myelitis, acute, diagnosis of, from acute as- cending paralysis, 756 fn^n multiple peripheral neu- ritis, 756 Myelitis, chronic, 758 definition of, 758 diagnosis of, 760 etiology of, 758 patliology of, 759 prognosis of 760 .symptomatology of, 759 treatment of, 760 Myelitis, subacute, 755 Myocarditis in tvphoid fever, 65, 93 Myositis, 850 acute purulent, following typhoid fever, 850 Myositis ossificans progressiva, 851 Myotomy in torticollis, 839 Myotonia congenit;i. See Thomsen's Dis- ease. Mvotonic reaction in Thomsen's disease, 857 Myxoedema, relation of, to acromegaly, 864 diagnosis of, from acromegaly, 864 "VfAILS in acroniegaly, 863 J^\ in osteo-arthropatliic piiciiiiii(|ii('. 864 in sclerodactyle, S(J4 in small-pox, 271 in accjuircd sypliilis, 353 Naj)hthaiiii in typhoid fever, 125, 127, 130 Narcolepsy, 662 Nasal di[)htheria, 382 Necrosis from phosphorus, 26 in acfiuircd sy|)hilis, 352 of tibia following typhoid fever, 90 Negro, small -pox in the, 263 yellow fever in the, 453 Nelavan, symptomatology of, 661 Nephritis in cerebro-spitial fever, 166 in cholera, 441 in diphtheria, 383 in erysij)elas, 4t()r ataxia, 778 in multiple neuritis, 807 in mumps, 307 in acute myelitis, 754 in myositis, 850 in nerve syphilis, 736 in sciatica, 848 in small-pox, 267 in acute spinal meningitis, 742 in .spinal tumors, 748 in symmetrical gangrene, 860 in tetanus, 467 in tertiary syphilis, 353 in trichinosis, 506. 507 in typhoid fever, 81 in typhus fever, 140 Pain crises in locomotor ataxia, 778 Painters, mortality of, 26 Palate, paralysis of, in diphtheria, 384 in facial paralysis, 830 syphilitic scars of, 355 Palmar reflex, 525 Palpitation of the heart in cerebro-spinal fever, 175 in hysteria, 601 in typhoid fever, 85 Paludism. See Malarial Fcvera. Pancreas, changes in, in hereditarv svphilis, 364 Pancreatin in iliplitheria, 392 Panophthalmitis in scarlatina, 223 in snu\ll-pox, 277 Papayotin in diphtheria, 392 Paper-makers, mortal it v of, 2(5 Papillitis, 815 Paradoxical contractions, definition of, 525 Pariesthesia in antero-lateral sclero.sis, 791 in hysteria, 599 in locomotor ataxia, 780 in neuritis, 806, 807, 808 in syringomyelia, 773 in trichinosis, 5((6 Paragcnsis, 83.') Paralyses in acute miliary tuberculosis, 333 in tuberculosis meningitis, 673 Paralysis of abductors, 836 of adduction, .S36 in acute ascending paralysis, 749 atrophic, 772 of brachial olexus, 841 in brain sypliilis, 729 in iiriiin tumor, 720 in canine hydrophobia, 487 896 INDEX. Paralysis in cerebral embolism and throm- bosis, 690 in cerebral haemorrhage, 682 cerebral infantile, 706 treatment of, 710. See, also, Htmipleyia, Infantile, Diple- gia, Spastic, and Paraplegia, Infantile Spastic. in cerebro-spinal fever, 173 circumflex, 843 crutch, 843 of diaphragm, 840 in diphtheria, peculiarities of, 384 following dislocation of humerus, 841 facial, 827 of fifth nerve, 824 of fourth nerve, 821 in glosso-labial paralysis, 803 of glosso- pharyngeal nerve, 834 of heart in diphtheria, 384 of hypoglossal nerve, 839 in hysteria, 599 pecailiarities of, 603 infantile, 761 Landry's, 748 of long thoracic nerve, 843 of median nerve, 844 of motor nerves of eye, 822 diplopia in, 823 erroneous projection in, 823 ophthalmoplegia in, 823 secondary deviation in, 822 strabismus in, 822 treatment of, 824 in multiple neuritis, 807 in multiple alcoholic neuritis, 808 musculo-spiral, 843 in acute myelitis, 754 obstetrical, 842 olfactory, 813 of pneumogastric nerve, 835 in acute poliomyelitis, 764 in subacute poliomyelitis, 771 in progressive muscular atro])liv, 800 radial, 843 of recurrent laryngeal nerve, 836 sciatic, 846 serratus, 843 of sixth nerve, 821 of spinal accessory nerve, 837 in syringomyelia, 774 of third nerve, 819 in typhoid fever, 91 of ulnar nerve, 844 of vocal cords, 836 Paralysis agitans, 639 symptomatology of, 639 treatment of, 641 Paralysis, general, definition of, 523 local, definition of, 523 multiple, definition of, 523 Paramyoclonus multij)lex, 857 etiology of, 857 symptomatology of, 857 Paranoia, 579 definition of, 579 Paranoia, delusions in, 581 diagnosis of, 583 of early development, 580 etiology of, 579 hallucinations in, 582 of late development, 581 symptomatology of, 580 Paraphasia, 704 Paraplegia, definition of, 523 Paraplegia in acute ascending paralysis, 749 in antero-lateral sclerosis, 790 in hysteria, 599 in multiple neuritis, 809 in multiple alcoholic neuritis, 808 in acute myelitis, 754 in chronic myelitis, 760 in spinal ansemia, 744 in spinal apoplexy, 746 in spinal tumor, 747 in syringomyelia, 774 Paraplegia, infantile spastic, 710 Parietal lobe, tumors of, 720 Paronychise in small-pox, 271 Parosmia, etiologv of, 813 Parotid bubo, 309 Parotitis in cerebro-spinal fever, 176 in relapsing fever, 157 in typhoid i'ever, 66, 91 in typhus fever, 145 Parotitis, metastatic, 309 Paroxysm in hydrophobia, 493 in intermittent fever, 413 in melancholia, 564 in spinal neurasthenia, 643 in whooping cough, 315 in yellow fever, 455 Paroxysmal hsemoglobinuria and Ray- naud's disease, 861 Pasteur's method. See Hydrophnbia. Patellar reflex, 525. See, also. Knee-jerk. Pemphigus in cerebro-spinal fever, 174 in hereditary syphilis, 363 Pepsin in typhoid fever, 129 Peptonized milk in typhoid fever, 115 Peptonoids in typhoid fever, 128 Peptonuria in acute miliary tuberculosis, 332 Perforating ulcer in anaesthetic leprosy, 371 in locomotor ataxia, 783 Perforation of intestine in tvphoid fever, 92 Pericarditis in cerebro-spinal fever, 176 in dengue, 199 in influenza, 190 in scarlatina, 224 in typhoid fever, 93 Perichondritis in hereditary syphilis, 364 Periencephalitis, acute, 548 definition of, 548 diagnosis of, 549 etiology of, 548 pathology of, 548 jjrognosis of, 550 symptomatology of, 548 synonyms of, 548 treatment of, 550 IXDEX. 897 Periencephalitis, acute, diagnosis of, from pneumonia, 549 Periencephalitis, chronic, 550 definition of, 55(1 diagnosis of, 55G etiology of, 550 pathology of, 551 prognosis of, 556 symptomatology of, 551 synonyms of, 550 treatment of, 556 types of, 552 Period of incubation in tetanus, relation of, to prognosis, 469 Periodic amnesia, 667 Periodical insanity, 584 definition of, 5l Phosphoric acid in typhoid fever, 116, 126 in typhus fJver, 149 Phosphorus in confusioual insanity, 574 Phosphorus-j)oisoiiing, 211 IMiotophobia in hysteria, 600 in measles, 247 Phrenic nerve, affections of, 840 Phthisis from inhalation of dust, 26 following influenza, 190 relation of, to malarial fever, 412 following typhoid fever, 97 Physicians, mortality of, 26 Phvsiological test in diajrnosis of anthra.x, 482 Pia mater, diseases of, 670 Pigmentation of organs in remittent mala- rial fever, 423 of skin in scleroderma, .^65 Pitting in small-pox, prevention of, 282 Pituitary body, enlargement of, in acro- megaly, >^Q>\ Placenta, changes in, in syphilis, 362 Plantar rellex, 524 Plaques jaunes, 690 Plasmodium malaria", 407 in soil, 29 in water, 30 Pleurisy in cerebro-spinal fever. 176 in influenza, 190 osteo-arthro)iathie pneumiijue in puru- lent, 864 in relapsing fever, 157 in scarlatina, 224 in typhoid fever, 95, 99 in typhus fever, 137 Pieurosthotonos in tetanus, 467 Plexiform neuroma, 812 Plumbers, mortality of, 26 Pneumogastric nerve, cardiac branches 836 functions and lesions of, 835 gastric; and (esophageal bram of, 837 involvement of, in inlhienza, !;•: laryngeal branches of, 836 pharyngeal branches of, S.Sii pulmonary brani'hes of, 836 Pneumonia in (•ereliro-s))inal fever, 176 in inHut-nza. 1X9, 190 in measles, 246 in rehijising fever. 157 in .scarlatina, 224 in typhoid fever, 95, 98, 132 in typhus fever, 1 M Pneumonia, tliatrnosis of, from m;il;tii fever, 419 from acuti' perienei pliaiilis. 519 Pododynia, S47 Polio-eneeplialitis superior acuta. S2 t J'oliomyelitis, acute, 7<»1 (lefinitioti of, 761 diagnosis of. 767 elioir»gy of, 761 pathology of, 762 prognosis o(", 76M symplonnitology <»f, 76;{ of. les 898 INDEX. Poliomyelitis, acute, synonyms of, 761 treatment of, 769 Poliomyelitis, acute, diagnosis of, from acute ascending paralysis, 768 from multiple neuritis, 768, 810 Poliomyelitis, subacute, 771 treatment of, 771 Poliomyelitis, subacute, diagnosis of, from pseudo-hypertrophic muscular atro- phy, 855 from subacute metallic polio- myelitis, 772 Poliomyelitis, subacute metallic, 772 diagnosis of, 772 Polysesthesia in locomotor ataxia, 780 Polymyositis, diagnosis of, from trichinosis, 509 Polyneuritis. See Neuritis, Multiple. Polyuria in brain syphilis, 729 in cerebro-spinal fever, 176 in hysteria, 602 Pons, lesions of, 701 tumors of, 721 Popliteal nerve, external, atfections of, 847 internal, affections of, 847 Population, calculation of, 4 Porencephalus, 707 Position test, 527 Posterior meningitis. See Leptomeningitis. Posterior sclerosis. See Locomotor Ataxia. Post-febrile polyneuritis. See Neuritis, Multiple. Post-hemiplegic movements, 708 Post-mortem elevation of temperature in cholera, 443 in tetanus, 467 Post-mortem movements in cholera, 443 Potassium bromide. See Bromides. chlorate in diphtheria, 391 citrate in typhoid fever, 124 iodide. See Iodide of Potassium. Predisposing causes of disease, 7 Prefrontal area, tumors of, 720 Pregnancy and chorea, 633 Prehemiplegic chorea, 682 Pressure sense, testing of the, 528 Priapism in acute myelitis, 754 Primarv atrophic form of muscular atrophy, 854 Primary curable dementia. See Confusional Lisauitii. Printers, mortality of, 26 Prison-cells, dimensions of, 39 Progressive muscular atrophy, 799 definition of, 799 diagnosis of, 804 etiology of, 799 pathology of, 799 prognosis of, 804 symptomatology of, 800 synonyms of. 799 treatment of, 804 Progressive myopathic atrophy, 852 Propeptone in urine in measles, 247 Prophylaxis of actinomycosis, 477 of anthrax, 482 Prophylaxis of cerebro-spinal fever, 180 of cholera, 446 of diphtheria, 388 of erysipelas, 402 of foot-and-mouth disease, 622 of glanders, 517 of hydrophobia, 497 of leprosy, 372 of malarial fevers, 419 of measles, 251 of relapsing fever, 160 of scarlatina, 225 of scrofula, 342 of syphilis, 356 of tetanus, 469 of trichinosis, 510 of typhoid fever, 113 of typhus fever, 147 of varicella, 302 of yellow fever, 459 Prosopalgia, 826 Pseudo-angina pectoris in hysteria, 601 Pseudo-diphtheria, 376 Pseudo-hallucinations, 534 Pseudo-hypertrophic muscular atrophy, 853 symptomatology of, 853 Pseudo-hypertrophic muscular atrophy, diagnosis of, from subacute polio- myelitis, 855 Pseudo-paralytic rigidity, 710 Psychical antestliesia, 563 dysthesia, 563 hypersesthesia, 563 Ptomaines in diphtheria, 375 in typhoid fever, 58 Ptosis, causes of, 820 forms of, 820 hysterical, 820 in locomotor ataxia, 782 pseudo-, 820 Puerperal scarlatina, 210 Pulmonary form of typhoid fever, 98, 106 gangrene in typhoid fever, 95 haemorrhage in high altitudes, 27 veins, spread of tuberculosis from, 330 Pulse in cerebral haemorrhage, 682 in cerebral tumor, 719 in cerebro-spinal fever, 175 in cholera, 442, 443 in dengue, 198 in diphtheria, 381, 384 in epilepsy, 614 in hysteria, 601 in intermittent fever, 414 in meningitis, 675 in miliary fever, 202 in pneumogastric paralysis, 837 in relapsing fever, 155 in small-pox, 266 in tetanus, 467 in acute miliary tuberculosis, 332 in tuberculous meningitis, 672 in typhoid fever, 87 in typhus fever, 141 in yellow fever, 455, 456 Pupillary inaction, hemiopic, 818 IXDhX. 899 Pupils in cerebral hfcmorrhajre, 682 in cerebro-spinal lever, 173 in the epileptic paroxysm, 613 in hysteria, 594 in locomotor ataxia, 782 in chronic periencephalitis, 553 in typhoid fever, 80 in typhus fever, 139 Pupils, unequal, 821 in hysteria, 599 Pure insanities, 562 Purpura in cerebro-spinal fever, 109 in iueniaturic intermittent fever, 427 in relapsing fever, 155 variolosa, 274 Pustule maligiie. See Anthrar. Pytemia, 326" abscesses in, 327 definition of, 326 diagnosis of, 328 idiopathic, 326 micro-organisms in, 326 pathology of, 328 prognosis of, 328 pulmonary, following thrombosis of cerebral sinuses, 695 symptomatology of, 327 treatment of, 328 Pyaemia, diagnosis of, from malarial fever, 328, 419, 429 from scarlatina, 222 from typhoid fever, 328 Pysemic rheumatism, 328 Pyelitis in typhoid fever, 66, 97 Pyramidal tract, course of, 697 Pyromania, 585 QUARANTINE, 21 against cholera, 450 against yellow fever, 460 Quarrymen, mortality of, 26 (Quartan malarial fever, 405 Quinine in cerebro-spinal fever, 182 in dengue, 200 in ephemeral fever, 50 in influenza. 194 in malarial fevers, 421, 425, 430, 432 in miliary fever, 203 in mountain fever, 207 in pyu'inia, 328 in relapsJMir fever, 160 in typhoid fever, 123, 127, 132 in typhus fever, 149 f Quotidian malarial fever, 405 RAIUES. 8ee H;idrnphohiox, 264 Stajdiylococcus pyogenes albus, 11 aureus, 11 citreus, 11 Static ataxia in Friedreich's ataxia, 797 nystagmus in Friedreich's ataxia, 798 Status epilei)ticus. 614, 621 Steam in dijjhtheria, 392 effect of, upon poison of scarlatina. 213 superheated, as a disinfectant, 17 Steppage gait in external pojiliteal nerve paralysis, 847 in multiple neuritis, 811 Stercoraceous vomiting in hysteria. 603 Sterilization, 15 by steam, apparatus for, 17 Stertorous breatliing in cerebral hienior- rhage, 682 Stimulants in anthrax, 483 in cerel)ro-spinal fever, 182 in cholera, 449 in diphtheria, 395 in erysi])elas, 403 in milk sickness, 206 in pyjeniia, 328 in sei>tica?mia, 326 in tyjihoid fever. 130, 131 in tyjiiuis fever, 148 in yellow fever, 4(>1 Stomach, changes in, in yellow fever, 455 Stomatitis in measles, 243 in typhoid fever, 91 Stomatitis, diagnosis of, from hereditary sypiiilis, 366 Stools of cholera, 441 of typhoid fever, 84 Strabisiiius, 822 in eerebro-sjiinal lever, 173 in hysteria, 599 early, in locoinntor ataxia, 785 in tniierculciis meningitis, 672 Strawberry tongue in searlaliini, 217 Streptococci in diphllieria, 373 in etiology of pseudo-diphtheria, 876 in measles, 236 in pya'mia. 326 in ryfemia, 327 in relapsing fever, 156 in trichinosis, 507 in acute miliary tuberculosis, 332 in typhoid fever, 70, 102 in typho-malarial fever, 432 in typhus fever, 143 Swine erysipelas, cause of, 12 Symmetrical gangrene, 860 Syncope in diphtheria, 384 local, 859 Syphilides in acquired syphilis, secondary, 352 tertiary, 351 in hereditary syphilis, 363, 365 Syphilis, acquired, 345 bacillus of, 346 cachexia in, 353 cause of, 12, 346 contagiousness of, 345 course of, 354 definition of, 345 diagnosis of, 354 distribution of, 346 etiology of, 345 extra-genital sources of, 345 gumnuita in, 350 inoculability of, 347 latent period of, 347 lymphatic glands in, .349 morbid anatomy of, 348 periods of, 347 primary period, lesions of, 348 prognosis of, 355 prophylaxis of, 356 relation of, to other diseases, 356 secondary period, lesions of, 349 sequelte of, 355 symptomatology of, 352 synonyms of, 345 terminations of, 354 tertiary period, lesions of, 350 treatment of, 356 visceral lesions in, 351 Syphilis, acquired, diagnosis of, from measles, 355 from rubella, 259 from small-pox, 280 Syphilis of the brain, 726 diagnosis of, 729 pathology of, 726 prognosis of, 731 symptomatology of, 726 treatment of, 731 types of, 727 Syphilis of the cord, 734 diagnosis of, 734 pathology of, 734 prognosis of, 735 sym])tomatology of, 734 treatment of, 735 Syphilis in etiology of locomotor ataxia, 777 of chronic periencephalitis, 651 INDEX. 905 Syphilis, hereditary, 360 conceptional, 360 diagnosis of, 366 etiology of, 361 general morbid processes in, 362 morbid anatomy of, 363 placenta in, 362 prognosis of, 366 sequelfe of, 366 symptomatology of, 365 synonyms of, 361 three periods of, 365 treatment of, 367 Syphilis, hereditary, diagnosis of, from stomatitis, 366 from rachitis, 366 from scrofula, 342 Syphilis of nerves, 735 Syphilitic callus, 734 coma, 726 encephalopathies, 353 fever, 352 Syphilitics, question of marriage of, 8, 367 Syphilization, condition of, 362 Syphiloma of brain, 717 Syringomyelia, 772 diagnosis of, 775 pathology of, 772 symptomatology of, 773 treatment of, 775 Syringomyelia, diagnosis of, from cervical pachymeningitis, 775 from Morvan's disease, 775 from multiple alcoholic neuritis, 775 TABES, forms of, 811 Tabes dorsalis. See Locomotor Ataxia. Tabes ergotica, 778 Tache cerebrale in cerebro-spinal fever, 174 in tuberculous meningitis, 672 in typhoid fever, 72 Taches bleuatres in typhoid fever, 72 Tailors, mortality of, 26 Tannic acid in cpistaxis. 131 in typhoid fever, 129 Tartar emetic in typhus fever, 149 Taste, disturbances of the sense of, 835 tests for the sense of, 835 Teeth, anomalies of, in hereditary syphilis, 364 loss of, in facial hemiatrophy, 867 Telegrapher's cramj). See Occupation Neu- roses. Temperature in acute ascending |)aralysi.s, 74!) in bilious intermittent fever, 426 in cerebral li;einorrhage, 682 in cerebro-spinal fever, 175 in cholera, 443 in delirium tremens, 559 in dengue, 198 in (lij)htheria, 381 in ejMlepsy, 614 in erysioelas, 399 in glanders, 514 Temperature in hysteria, 602 ' in influenza, 187 in intermittent fever, 414 in measles, 238 in miliary fever, 202 in mountain fever, 207 in multiple neuritis. 807 in mumps, 307 in acute myelitis, 754 in acute periencephalitis, 549 in chronic periencephalitis, 555 in acute poliomyelitis, 763 in pya-mia, 327 in relapsing fever, 155 in remittent malarial fever, 424 in rubella, 258 in scarlatina, 215 in secondary syphilis, 352 in septicaemia, 324 in small-pox, 272 in St. Vitus's dance, 630 in tetanus, 467 in thermic fever, 646 in trichinosis, 507 in acute miliary tuberculosis. 332, 333 in tuberculous meningitis, 672 in tyj)hoid fever, 72 in ty])ho-malarial fever. 432 in typhus fever, 140 in whooping cough, 315 in yellow fever, 455, 456 Temperature, inverted, in typhoid fever, 76 Temperature, oscillating, in i)yiemia, 327 Temperature, subnornuil, in cerebral htem- orrhage, 682 in cliolera, 442 in confusional insanity. 571, 572 in heat-i'xhaustion, 645 in hysteria, 598 in intermittent fever, 416 in malarial cachexia, 432 in syneo|ial cardiac epilepsy, 618 in tuberculous meningitis, 672 Temporal lobe, auditory centre in, 699 tumors of, 721 Tender points in trifacial neuralgia, 826 Tendon reflexes. See Hrjicrex. Terminal dementia, 575 Tertian ague, 405 Test for typhoid fever in urine, 89 Tetai)ine,"465 Tetanus, 462 antitoxines in, 470 bacillus of, 463 cause of, 1 1. 4()3 definition of, 462 diagnosis of, 467 etiology of, 463 iniinuMity Ironi, 470 morbid anatomy of. 466 mortality of, Hi'.' period of incubation in, 466 prognosis of, 46S propliyia.xis of, 469 surgical measures in, 470 .synipfoMiatology of, 466 906 INDEX. Tetanus, treatment of, 469 Tetanus, diagnosis of, from hydrophobia, 468, 494 from hysteria, 468 from meningitis, 468 from strychnine-poisoning, 468 from tetany, 468, 639 Tetany, 688 etiology of, 638 symptomatology of, 638 following thyroidectomy, 638 treatment of, 639 Tetany, diagnosis of, from tetanus, 468, 639 Thalamus opticus, tumors of, 721 Thallin in rehipsing fever, 161 Therapeutic test in syphilis, 355 Thermic anaesthesia in hysteria, 600 in syringomyelia, 773 Thermic fever, 645 continued, 616 etiology of, 645 pathology of, 647 sequelse of, 649 symptomatology of, 646 treatment of, 648 Thermic sense, testing of, 528 Third nerve, paralysis of, 819 recurrent paralysis of, 820 Thirst in cerebro-spinal fever, 176 in cholera, 441 in hydrophobia, 493 in relapsing fever, 155 in typhoid fever, 82 in typhus fever, 141 Thomsen's disease, 856 definition of, 856 etiology of, 856 symptomatology of, 856 Thoracic form of typhoid fever, 102 Thoracic duct, spread of tuberculosis from, 329 Thrombosis in scleroderma, 865 in typhoid fever, 93 of femoral vein in typhoid fever, 133 Thrombosis of cerebral arteries. See Ern- bolism and Thrombosis of Cerebral Arteries. Thrombosis of cerebral sinuses, primary, 694 secondary, 694 symptoms of, 694 treatment of, 695 Thymol in scarlatina, 229 in trichinosis, 511 in typhoid fever, 127 Thymus gland in acromegaly, 863 in hereditary syphilis, 364 Thyroid gland in acromegaly, 863 Tic convulsif. See Aufomaiic Chorea. Tic douloureux, 826 Tinnitus aurium, 833 in cerebro-spinal fever, 174 Titubation, 722 Tongue in acromegaly, 863 in cerebro-spinal fever, 176 in dengue, 198 Tongue in erysipelas, 399 in milk sickness, 205 in relapsing fever, 155 in scarlatina, 217 in small-pox, 272 in syphilis, 352 in typhoid fever, 68, 82 in typhus fever, 138 Tongue, atrophy of, 803, .839 Tongue, spasm of, 840 Tongue, tremor of, in glosso-labial paralysis, 803 in insular sclerosis, 712 in chronic periencephalitis, 553 ulcer of, in typhoid fever, 91 in whooping cough, 317 Tonsillitis, diagnosis of. from diphtheria, 386 Torticollis, congenital, 838 facial asymmetry in, 838 spasmodic, 838 treatment of, 839 Toxa3mic epilepsies. See Epilepsy. Toxaemic insanities, 559 Toxalbumin in typhoid fever, 58 Toxines in diphtheria, 374 Tracheotomy in diphtheria, 393 in typhoid fever, 66, 95 Trance in hysteria, 598 Transfusion of blood in typhoid fever, 131 Traumatic neurasthenia, 642 treatment of, 642 Tremors in delirium tremens, 559 in Friedreich's ataxia, 797 in insular sclerosis, 712 in paralysis agitans, 639 in i)aramyoclonus multiplex, 857 in chronic periencephalitis, 553 in typhoid fever, 81 in writer's cramp, 652 Tremors, causes of, 526 definition of, 525. See, also, Intention Tremors. Trephining in brain abscess, 716 in brain tumor, 723 in epilepsy, 622, 626 in meningitis, 676 Trichina spiralis, 9, 22, 499 anatomy of, 501 distribution of, 507 Trichinosis, 499 definition of, 499 diagnosis of, 508 duration of, 508 historical note on, 499 morbid anatomy of, 507 mortality of, 510 prognosis of, 510 prophylaxis of, 510 symptomatology of, 505 treatment of, 510 Trichinosis, diagnosis of, from cholera, 509 from polymyositis, 509 from rheumatic fever, 509 from typhoid fever, 108, 509 Trigeminus nerve. See Fifth Nerve. INDEX. 907 Trismus, 826 in eerebro-spinal fever, 173 in tetanus, 46t) in trichinosis, ,")()() in typhoid fever, 82 Trophic changes in amyotrophic lateral sclerosis, 7i)4 in antpsthctic leprosy, 371 following cerebral haemorrhage, 683 in fifth-nerve paralysis, 825 in localized neuritis, 806 in locomotor ataxia, 782 in Morvan's disease, 775 in multiple neuritis, 807 in multiple alcoholic neuritis, 808 in acute myelitis, 755 in acute poliomyelitis, 764 in progressive muscular atrophy, 801 in spinal apoplexy, 746 in syringomyelia, 774 Trophic and vaso-motor disorders, 859 Trousseau's phenomenon in tetany, 468, 639 Tubercle of brain, 717 Tubercle bacilli in milk, 22 in soil, 29 in sputum in acute miliary tuber- culosis, 333 in tubercles in acute miliary tu- berculosis, 331 Tubercle*, distribution of, in lei)rosy, 370 in acute miliary tuberculosis, 331 in the choroid in acute miliary tuber- culosis, 332 in tuberculous meningitis, 673 Tubercula dolorosa, 812 Tuberculin, action of, in tuberculosis, 330 Tuberculosis following measles, 244, 249 following typiioid fever, 97 Tuberculosis, acute miliary, 329 course of, 333 definition of, 329 diagnosis of, 334 duration of, 334 eruptions in, 332 etiology of, 329 invasion in, 332 morbid anatomy of, 331 physical signs in, 333 j)rogn()sis > Water, bacteriological examination of, 30 contamination of, 30 by alga-, •". I filtration of. .''.1 Water, micro-organisms in, 29 purification of, 31 supply of, 29 tests of puritv of, 30 typhoid bacilli in, 30,31, 57 Water-bed in multijile neuritis, 811 in acute myelitis, 758 in tyi)hoid"fever, 130, ]82 Wernicke's te.st in hemianopia, 819 Westphal's symptom, 780 White softening of the brain, (389 of the spinal cord, 747 Whitlows in Morvan's disease, 775 Whooping cough, 311 age and sex in etiology of, 313 comf)licati(»ns of, 317 contagiousness of, 314 diagnosis of, 318 emphysema in, 317 etiology of, 312 historical note on, 311 lingual ulcer in, 317 paroxysm in, 315 prognosis of, 3 lit prophylaxis of, 320 symptomatology of, 314 synonvms of, 3il treatnient of, 320 vomiting in, 315 Will, conditions altering the, 530 qualities of the, 529 "Woods" in syphilis, 733 Wool-manufacturers, mortality of, 26 Word-blindness, 703 Word-deafness, 704 Wormian bones in hydrocephalus, 724 Wrist-drop in musculo-spinal i)aralysi.s, 844 in .symmetrical gangrene, 861 Writers' cramp. See Ocntpnfion Neuroses. Wry-neck. See Torticollis. YELLOW fever, 451 contagiousness (d', 452 definition of, 4.")1 distril)uii(»n of, 451 etiology of, 451 exceptional cases of, 456 imnuiiiity from, 453 morbid anatomy of, 454 mortality of, 458 prognosis of, 458 prophylaxis of, 459 quarantine against, 459 race in etiology of, 453 sym|)tomatology of, 455 synonyms of, 451 treatment of, 459 Yellow fever, diagnosis of, from acute yel- low atrophy, 458 from dengue, 199 from m.ilarial fevers, 429, 458 from relapsing fever, 15'.l, 458 Yellow softening of the brain, 6S9 ZI.M.M lOKLI.N' type of progressive myopa- thie atntphy, 852 i i v^. Mi Vx\i f^^ :l\^fi« -Til' fel» ^fVi^;' k ■ ','0*i.'fl iil' !»^ ^"•^ii! lit ^^:M mL ^:«;: l^il^ -W',W ,^liv)fl (;\(.; ^iUf 'M'^ i.i;ti ~\m:\ .\'-lf' Via? i W:'®^ .i;;)vi ■^Jl'-M':' ;'^&'.> 'imm