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BOOK BIHDER.
SH Camp Sirred^
up Rtttlf*,
New Orleans, Lonisiana.
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Medical >ND Surgical
CONTAINING
INVESTIGATIONS ON THE GEOGRAPHICAL DISTRIBUTION, CAUSES,
NATURE, RELATIONS AND TREATMENT
OF
VARIOUS DISEASES,
ie«50-i87e.
By J08EI*H JOISTES, Mi. D.,
rrofetscr ^ Ckemittryand CHnieal Medicine^ Medical Department University of Louisiana : Vistting Physician
^ Charity Hospital : Honorary MemSer qf the Medical Society o/ Virginia: Formerly
Surgeon in the PremsiotuU Army of the Confederate States.
VOLUME I.
IXTBODUrmON TO THK STUDY OT DISIASES OF THI NVBYOUS SYSTEM. INYBSTIQATIONS OK TRAU^
.MATir TKTANU8, EPILKP8Y, PARALYSIS, AND GBBKBBO-SPINAL MENINGITIS. CLINICAL
OBSERVATIONS ON DISEASES OF THE LYMPHATIC AND CIBCULATORY SYSTEMS, AND
OF THE LIVER AND KIDNEYS. INVESTIGATIONS AND RESEARCHES ON PNEU-
MONIA. OBSERVATIONS ON DISEASES OF THE OSSEOUS SYSTEM. ILLUS-
TRATED RY flOO CASES OF DISEASE, 400 PHYSIOLOGICAL EXPER-
IMENTS, 96 ANALYSES OF THE BLOOD AND URINE, AND
m TABLES, ILLUSTRATING THE SYMPTOMS AND
MORTALITY OF DISEASES UNDER DIFFER-
ENT MODES OF TREATMENT AND IN
DIFFERENT CLIMATES.
/>V
Vixxce SXalum S
B APR
\^.-
J 1 — *^
NE W ORLEANS :
PRINTED FOR THE AUTHOR, BY CLARK k HOFELINE, 112 GRAVIER STREET.
1©70.
KvTRRr.n AOt'OEDixo TO Act or ComiiinR, im tie trar lH7i'», iit
JOSKPH JONKH, M:. D.
Ih THE urricE or the Libhauam or ('ohgeeimi at Wadhikotox. I>. c.
OF
MY MOTHER,
MARY JONES,
AND OF
MY FATHER,
Rev. CHARI.es C. JONES, I). I>
TIUS VOLUMK
18
PREFj^OE.
Thb object of tbe Medical and Surgical Memoirs, is to place in an accessible form
for the use of Students and Practitioners of Medicine, tbe results of investigations and
researches, which tbe author has conducted during tbe past twenty years, and which
embrace tbe eTentiul period of the American Civil War, 1861-1865.
Situated at a distance from public libraries, and deprived of personal intercourse with
leauned men and original investigators, of congenial pursuits, whose counsel might have
removed doubts, and directed and stimulated exertion, the author has labored under
disadvantages, which necessitated the purchase of original works and monographs
relating to tbe subjects under investigation. The e£fort, therefore, has been made to
present such an analysis of the labors of others, in connection with the subjects exam-
ined, as might prove of value to Students and Practitioners of Medicine, more especially
in the Southern States.
The author has had no theories to maintain or destroy, and it has been his constant
aim to purify from error the observations which he has recorded.
The inductive method has been followed ; diseases have been carefully watched, and
tnopd through their different stages during life, and the vestiges left behind after death
have been noted ; the actual and relative mortality, under different modes of treatment,
and the relations of various diseases to food, habits, occupation, soil and climate, have
been observed ; and the facts thus gathered, have been interrogated, analyzed, separated
and classified ; and thus the effort has been made to eliminate or deduce fixed princi-
ples in pathology and therapeutics. Whilst facts are true and unalterable, in that they
exist, on the other hand, the deductions, or estimate of the value and relations of tbo
facts may be true or false, iu accordance with the mode of action of the mind which
interprets them ; the more thoroughly the mind lays hold of and determines the numer-
ous relations of facts, the nearer does it approach to the demonstration of fixed relations
or laws.
The cases reported have been drawn, to a large extent, from hospital and military
service, not because the experience gathered in private practice has been either less in
amount or value, but because in the Camp, and in the Civil and Military Hospital, it
has been possible to keep the patients more thoroughly under observation and control.
and in fatal cases, to command the necessary post-mortem examinations.
In the hot and almost tropical climate of the Southern States, it has been neces8<iry.
in the prosecution of investigations designed to illustrate the nature, causes, relations
and treatment of endemic and epidemic diseases, to encounter the hostile malarin of
VI
PBErACB.
swamps, marshes, crowded Hospitals and Military Prisons, and to endure the attacks of
disease.
The parsnit of these labors has necessitate the almost entire renunciation of that
repose which is so gratetul after laborious occupations ; and the time devoted to their
record and publication, has been snatched, as occasion offered, during the daily dis-
chaige of the duties of a laborious and exacting profession.
The volume now issued, relates chiefly to diseases which are more or less confined to
special anatomical divisions, of the human body, as the Nervous, Circulatory, Respiratory
and Osseous Systems.
The Introduction to the Stud^ of Di$ea9e$ of the Nervom Syttem^ should be regarded,
not so much as a general introduction to the first volume, as a distinct monograph, the
chief design of which is to aid Students and Practitioners of Medicine in the prosecu-
tion of original investigations and researches on the physiology and pathology of the
nervous system.
The effort has been made to illustrate all important conclusions, or laws in Pathology
and Therapeutics, by carefully recorded cases, and experiments on living animals ; and
in the present volume, the former, number about eight hundred, and the latter four hun-
dred. Many facta illustrating the symptoms and mortality of diseases under various
modes of treatment, and in different climates, have been condensed and consolidated in
tabular form, for purposes of reference and comparison.
In the Second Volume, will be grouped the monographs relating chiefly to
Endemic, Epidemic and Contagious Diseases, embracing Malarial Fever, Yellow Fever,
Typhoid Fever, Small Pox, Cow Pox, Syphilis, Measles, Cholera, Cholera Infantum,
and Dysentery.
The Third Volume will embrace, more especially, the consideration of the diseases
and accidents of armies, and such observations on the medical and surgical history of
the Confederate Army, as the author was able to make himself, or to obtain from the
Confederate Medical Officers.
The diseases of Military Prisons, as well as those diseases which supervene on gun-
shot wounds, and operations, as Erysipelas, Hospital Gangrene and PysDmia, will receive
extended consideration. The results of the investigations concerning the nature, rela-
tions and treatment of special diseases during the Civil War of 1861-1865, will also be
found under the appropriate divisions of each monograph, in the three volumes consti-
tuting the present series. Only those subjects will be embraced in this work which
have been elaborated to such a degree as to permit of practical and general conclusions.
The following extracts from official correspondence and orders, will serve as an intro-
duction to fhc various observations and statistics relating to the McMlical and Surgical
hbtory of the Confederate Army.
QENKRAL noSPITAL. AFOrSTA, GEORGIA, >
r»bniai7 Oth, 1H63. \
S. P. MooSKf
Surgton Qtneral C, S. A.^ Richmond, Va :
Sia :— Accompaoyiogf this, 1 have the honor to forward to the Surgeon General a small
manaficript volume containing obBrrvaiions on Traamatic Tetanns. I have endeavored care-
fully to investigate the phenomena presented bj a case of Tetwnus, which occurred in the
General Hospital in this place. Such an investigation as that now presented appeared to be
necessary, for I am unacquainted with the report of a single case of this disease, where
PRSFAGB. yil
ft cmrefol and foil record was kept of the pulfe, respiration, temperature, nerroiiB and muscu-
lar phenomena, and physical and chemical changes of the urine throughout the course of the
diseaae.
I hope that results worthj of the consideration of the Surgeon General have heen estab-
lished bj this laborious investigation. It appears to be not unphilosophic to draw general
conclosions from a single carefully considered case, of a characteristic and well defined dis-
eaae, for we must admit that if there be anything that can be called science in medicine, it
must be intimately connected with, if not absolutely dependent upon, the fixed character of
disease.
The Surgeon General will please excuse the liberty which I take in calling his attention to
the following conclusions, which I have attempted to establish from the results of the inves-
tigation of this ease.
The essential phenomena of inflammation were absent. The phenomena were exaggerated
manifestations of nervous and muscular action, rather than results of structural alterations.
The increased actions in the nervous and muscular systems were attended by corresponding
changes in the materials composing these structures, thus rendering it probable that the two
were intimately connected, and even dependent on each other, in the relation of cause and
effect.
The phenomena, during the active stages of Tetanus, point to a change in the electric con-
ditiona and relatioot of the nerves and muscles. In the discussion of the last proposition, I
have endeavored to present a clear and concise view of the remarkable investigHtions and
theory of the German philosopher, Dubois-Reymond, who, by a series of experiments of won-
derful delicacy, accuracy and variety, has established the important fact, that both nerves
aad muscles have their own electrical currents, which vary in direction and character, with
the various muscular and nervous actions ; and has clearly established, that the nervous and
muscular forces are either electricity or some modification of this force.
I have also presented the theory of De-la-Rive, which embraces that of Dubois-Reymond,
extends and perfects it, and is also based on the experiments and physiological labors of
Matteucci, Humboldt, Kobili, Marianini and others. This discussion will be found at the close
of the manuscript.
I am now engaged on the investigation of the Typhoid Fever of the camp. The investiga-
tion has been, and will be conducted in a manner similar to that pursued in this case of Tela-
DOS. In the course of three months, I hope to complete a manuscript volume of several hun-
dred pages on this disease, which will be tranmitted to the Surgeon General. The subject
ia of great importance, and worthy of the most careful study and investigation.
When this is complete, I will then turn my attention to Intermittent, Remittent, and Con-
gestive or Pernicious Fevers, which will be investigated and treated in a similar manner.
Any suggestions, with reference to the method and objects of the investigations, which the
Surgeon General may think proper to offer, will be carefully considered and acted upon. * *
Very respectfully, your obedient servant,
JOSEPH JONES,
Surgeon P. A. C. S.
CONFEDERATE STATES OF AMERICA, )
SUROKON GkNSSAL*! OVFfCK, j
Richmond, Ya., February 17th, 1863.
Svmaaov Josbpb Jonbs,
SiB : Your letter of the 10th inst., as well as the report in the case of Tetanus, have
been received.
The opportunities now offered of making a free and thorough investigation as to the nature,
history, and pathology of fevers caused by animal effluvia, contra-distinguished from those
produced by vegetable exhalations, or malaria, should not be permitted to pass unimproved.
Your attention, therefore, is especially called to this class of disease ; and you are
directed to make a thorough investigation. Besides the mere satisfaction in a scientific point
of view, the results are likely to be of the greatest practical beAefit tu the army.
If additional medical aid is deemed necessary for this purpose, you will communicate the
fact to this office.
Very respectfully, vour ob't serv't,
S. P. MOORE,
BurgtoH Oeiteral, C. S. A.
Augusta. Gioroia, June 28th, 1863.
S. P. MOORB,
Surpeon Cfeiurdl^ C. 8. A., Richmond^ Va.
SiB : Accompanying this, I send the Surgeon Gene ral, by express, the first manuscript
VUI PRXTACI
rolume of my Ubort, coaducied io accordftac« with th« order issaed from the Sargeon
Q«Qeral*8 office, Richmond, VirgtaU, Pebraarj 17tb, 1863.
Since the reception of this order, I hmrt deroted all the time not absolatelj demanded for
the discharge of mj duties as Surgeon, to the inrestigation of the class of diseases indicated ;
und this rolume contains a portion of the results of mj labors. In the prosecution of these
Investigations, the Inductire Method has been followed ; the phenomena and indiridnal facts
havf been observed and recorded, and general principles established bj the anal/sis, compar-
ison, classification, and combination of the facts and phenomena.
If the Sargeon General will furnish an order sufflcientlj definite and liberal, the present report
will be preliminary to a more eitended inrestigation of disease in the different dlrlslons of
the Army of the Confederate States of America, by which we hope to establish facts and prin-
ciples of unirersal application, and permanent ralne. By such an eitended stndr of the
diseases of armies under all the rariations of climate and soil, and under all the raried eirenm-
atances of toil, eiposure and changes of diet, to which the confederate soldiers are subject,
we may hope to settle definitely their true characters and modes of treatment.
Prom the complicated nature of the phenomena demanding inrestigation, as well as from
the peculiarities of the struggle in which we are now engaged with a powerful enemy, who
has blockaded our ports, and thus cut us off from Implements and materials of research so
valuable in modern inquiries in all the departments of physical, chemical, physiological, and
pathological science, many embarrassments have arisen, and will continue to arise, and
great expenditures of health and strengh, have been, and will continue to be necessary in the
prosecution of these investigations which have been conducted by the author in addition to
the full discharge of his duties as Surgeon. • • • • •
The cases presented, in the present report, were selected from more than one thousand
cases, treated and carefully observed by the author ; and, in addition to those treated imme-
diately by himself, in person, several hundred additional cases were examined in the various
hospitals and camps of the Military Department of Georgia and South Carolina, and confer-
ences held with the surgeons and other medical officers.
The attention of the Surgeon General is respectfully directed to the colored drawing of the
liver, intestines, and typhoid deposit in the so-called Camp Fever.
It is of the utmost importance to the accuracy and value of these Investigations, that the
post-mortem ezaminatidns should be extended as far as possible. • • •
I would still farther direct the attention of the Surgeon General, to the important fact estab-
lished by these researches, that the disease which has proved most fatal to our soldiers in the
Military District of Georgia and South Carolina, has been Typhoid Pever, and that no case
of true Typhus Fever has occurred in this department.
The importance of this fact, cannot be over-estimated in its bearings on treatment. * *
As the treatment of Typhus and Typhoid fever is different, purgatives being borne well in
the former, whilst they are destructive in the latter, it is of great moment to our Army, that
Typhus fever should be recognised and investigated.
• •••••
The perfection of such investigations will clearly depend in great measure, on the number
of cases subjected to analysis. It is well known that fevers arising from animal exhalations
are dependent on certain circumstances and causes, which are far more limited in their opera-
tion than those producing the various kinds of climatic fevers. As therefore the class of
•liseases indicated in the order of the Surgeon General, are necessarily circumscribed within
narrow limits, and dependent upon peculiar circumstances and causes, their full and free
investigation will necessitate occasional change on the part of the investigator. The true
characters of these diseases, as well as the great fact of their uniformity or diversity, of their
contagion or non-contagion, of their relations to climate and soil, as well as the circumstances
most favorable to their production or spread, can only be determined by an examination of
their various phenomena in different localities, and by the careful experience and testimony
of numerous intelligent observers widely separated.
• • • « • •
During the past seven years I have been conducting investigations similar to those now
indicated, upon the diseases of the climate of the Southern States, and have endeavored not
only to determine their true characters, and to illustrate their phenomena, but also to Investi-
gate their relations to climate, soil and waters, and their relations to well-known poisons ; at
the commencement of our present straggle I volunteered my services as a Private of Cavalry ;
my medical services were immediately required after my enlistment, and during a period of
six months active service, I was enabled to treat about six hundred cases of disease in one of
the most unhealthy regions of the Southern Cinfederacy ; and after entering the medical
service is a Sargeon, 1 have been engaged up to the present time in the investigation of the
> lass of diseases indicated in the Surgeon General's order ; the views therefore which I now
present in the accompanying manuscript volume, are the results of much labor.
PREFACE. IX
In conclusion, allow ine to ex|)rt'ss my high appreciation of the honor conferredf and to tes-
i\fy my orient desire tu fulfil the high and rcBponsible trust, by every means in my power.
Very respectfully, your obedient servant,
JOSEPH JONES,
Surgeon P, A. C. S.
'CONFEDERATE 8TATE8 OP AMERICA,)
Wj^R DkPABTMEXT, SvBOEON GENKRAL'e OrriCB, >
Riclimond, Virginia, July Idth, 1863.)
•"^CRCBOX Josspn Jones,
Sib : Your letter of 2d inst., is received, and also the 1st volume of your " Report on
Tetanus and Typhoid Fever."
The pressing importance of a vast variety of official engagements, has so far permitted only
a brief and desultory investigation of the contents of the latter ; but even with this, evidences
enongh are discovered, to justify the belief that much very valuable acquisition to the science
and art of medicine is contained therein.
For the seal, untiring energy, patient and laborious industry therein displayed, you are
entitled to, and are hereby tendered the thanks of this department.
* * * * « *
It would be well to visit the Hospitals in this department, (Virginia) at once ; although it
ii believed they offer, at the present time, but slight material on which to found a theory, in
connection with these investigations, still you might come and see for yourself.
******
Very respectfully, your obedient servant,
S. P. MOORE,
Surgeon General^ C, S, A,
BURGEON GENERAL'S OFFIOE, )
August 12th, 1863. j
The Surgeons in charge of the General Hospitals in Virginia, will give etery facility to
25ur^eon Jooes^ to carry out the within instructions.
S. P. MOORE, Surgeon General.
RICHMOND, VIRGINIA,}
Augnat 6tb, 1864. /
5. P. MooBs,
Surgeon (general C. S. A.^ War Department ^ Richmond, Va.:
Sir : — I have the honor to deliver to the Surgeon General, the Third Report on Typhoid
Fever, prepared in accordance with the order of September, 1863.
As the Report contains matter of importance to the enemies of the Confederate Government,
and as communication with Richmond has been seriously threatened, and even interrupted by
the Federal Forces, I deemed it to be my duty to deliver this Report, in person, to the Surgeon
General.
The attention of the Surgeon General is respectfully directed to the following facts, deveU
oped by the labors recorded in the present volume.
Daring 19 months, January, 1862 to July, 1863, the number of deaths from all causes, recorded
on the Field Reports, which relate to an average force of 160,231 officers and men, was
17,300; or 10.79 per cent, of the entire force. During the same period of time, the deaths
recorded in the General Hospitals, numbered 17,059; or 4.2 per cent, of the entire number of
cases treated. If we assume that the preceding forces represented only two-fifths ({ths) of
the actual number of men in the service of the Confederate States during this period, then
the deaths in the field during these 19 months amounted to 43,250; and if we assume that
the Hospital Records during this period, embrace two-thirds (}ds).of the actual number of
•ick and wonnded, then the deaths in the General Hospitals connected with all the Confede^
rate Forces, woald equal 25,588. According to this calculation the total deaths from all
caoses, in the Confederate Armies, during 19 months, Jan'y 1862 to July, 1863, were 66,838.
If we consider the Hospital Records as imperfect as the Field Records, then the total num-
ber of deaths would reach 85,807.
Alter earefol calculation, we have determined that it would be just to assume, that at least
25 per cent, of these deaths were caused by Typhoid Fever; that is, this disease caused during
\\* months, in the Confederate Forces, between 17,209 and 21,474 deaths.
It would be fair to assume, that Pneumonia and Typhoid Fever, together, have caused near
so per cent.; or between 34,419 and 42,048 deaths, in the Confederate Armies during 19 months,
January, 18C2 to July, 1863.
The great mortality of Typhoid Fever and Pneumonia, amongst the Confederate Forces^
X PftBFACB.
iiivesl0 those diseases with pecaliar interest and importance, and should lead to a thorouffk
^lamination of the different modes of treatment now before the Profession. Each medical officer
i^hniiM, AS far as possible^ test the ralue of the different modes of treatment, and carefully
ri'cord the results. The Sur^^eon General will find in the present volume, 3d Chapter, pp.
<i.'>7~ril4, a careful comparison of the results of the different modes of treatinp^ Pneumonia, in
Rurupean and Conffdernle Hospitals. The mortality from this disease, in a large number of
the (Confederate Hospitals lias been far greater, than what has occurred in this disease, under
different modes of treatment in European Hospitals.
In many of the Confederate Hospitals, the mortality from Pneumonia has been twice as prcut
as that in European Hospitals under Tartar Emetic, in large doses, and about four times as
great, as under the dietetic and and expectant systems, in which the powers of nature are
simply supported and drugs abandoned.
Extended researches have been conducted on Hospital Gangrene, Malarial Fever, Pyiemia
and Spurious Vaccination, and upon the relations and classification of fevers, and materials
are now in my possession, which will be elaborated and prepared, and delivered to the Surgeon
General at the earliest possible moment.
In the manual labor of copying the present Report, I have received valuable assistance
from Mr. Louis ManigauU, of Charleston, S. C, and I respectfully request the Surgeon General
to confirm his appointment as my Secretary.
Very respectfully, your obedient servant,
JOSEPH JONES,
Surgfn P. A, C. S,
tT, V
1,1874.)
CONFEDERATE STATES OF AMERICA.'
Sl'aOK03l QkKBIIAL*8 OrriOB, WaB DBrABTHKXT,
Bichmond, Tirvinl*! Augott Stb,
Surgeon Joseph Jones is directed to institute an extended investigation upon the Causes,
Pathology and Treatment of Fevers, and the Relations of Climate and Soil to Disease. Sur-
geon Joseph Jones will visit those parts of the Confederate States, and prosecute his investi-
gations in those Cities, Armies and Regimental and General Hospitals, which he may deem
necessary, as affording suitable fields for the establishment of the results indicated in tbts
order. Medical Directors of the Field and Hospital, and Chief Surgeons of Corps, Divisions,
Districts and Brigades, and burgeons and Assistant Surgeons of Regiments and General Hos-
pitals, will afford every facility to Surgeon Jones to carry out these instructions, and will
respond as far as possible to his inquiries by letter and circular, and will furnish him with
copies of all Field and Hospital Reports, which be may deem necessary for the illustration of
the various subjects of inqniry indicated in this order.
Officers of the Engineer Department are respectfully requested to furnish Surgeon Jones
with the neces&ary facilities for the examination and copying of such Maps, as illustrate tUe
Topography of important Posts and Districts occupied bv the Confederate Forces.
Surgeon Jones will embody the results of his labors relating to the diseases of the Confede-»
rate Army in suitable volumes, and will deposit them in the Surgeon General's Oflico, for th^
us? of the Medical Department of the Confederate Army.
S. P. MOORE, Surgeon General C S, A,
The surrender to the United States Forces April 27th, 18G5, by General Joseph £.
Johnston, of the Confederate Forces under his command, and of the country east of tho
Chattahoochee, necessarily terminated the labors embraced in the preceding order.
At the time of the evacuation of, and destruction by fire of the government buildings
in Richmond, Virginia, the manuscript volumes, containing about 1500 pages, prepared
by the author, were captured or burned.
Since the close of the war, the author has endeavored as time and occasion offered, to
^produee those portions aP his laborj, which appeared to be of chief interest to the
Medical Profession of America, and some portions of these labors which have been
brought to suoh a stage of completion as might admit of general conclusions, will bo
found in the present series of the Medical and Surfi;ical Memoirs.
JOSEPH JQNK9, M. P.
^''»- ¥95 St. Ckarhs Strftt, \
C^merif/'St. Andretu. j
2^IW QaLRANS, La., D^eemfter^ IMTfi
CO]::^TElS^T8,
OBSERVATIONS OX DISEASES OF THE NERVOUS SVSTRM 1-553
CHAPTER I.
IntrodactioQ lo the stady of the diseases of the Nervous System. Historical notes
reUtioj^ to the Aoatooiy and physiology of the Nervous System. Relations of the
Sympathetic and Cerebro-Spinal Nervous System. Views of Homer, Pythagoras,
Plato, Aristotle, Herophilus, Erasistratus, and other ancient writers, as to the
natare of nervoas action. As early as the days of Erasistratus, there was, appar-
ently, the commencement of that long series of observations, which ended in the
important discovery of Sir Charles Beil, that the Spinal nerves were the organs of
motion through their anterior roots, and of sensation through their posterior; and
the recognition, by physiologistSi that each ultimate nervous filament is distinct,
and rans isolated from its origin to its termination. Views of Galen. Rondeletius
and VaroUius. Results of the labors of the Anatomists of the sixteenth century.
Willis, in 1664, established the classification of the Cranial nerves, at present
received. The earlier anatomists examined the brain, only by slicing, so as to
obtain sections, bat VaroUius endeavored to unravel its parts, and in this impor-
tant method of investigation, he was followed by Willis, and, more recently, by
Vieusscns and Gall. Hypothesis advanced by Thomas Willis. Doctrines of the
saccesflors of Willis, and, more especially, of the school of Leyden (the school of
Boerhaave and bis disciples). Doctrines of the younger Albinus. Analysis of
the works and labors of Unzer Prochaska, Bichat, Cuvier, LeGallois, Wilson Philip,
Alexander Walker, Sir Charley Bell, J. Miiller, Magendie, Mayo, Bellingeri, George
Newport, and Marshall Hall. History of the development of the Doctrine of Reflex
action. Examination of the results of the Microscopical and Anatomical investiga-
tion of the minute structure of the Spinal Cord and Brain invertebrate animals.
Aoalvflis of the labors of Remak, Stilling, Volkmann, Kolliker, J. Lockhart Clarke,
Scbroeder Van der Kolk, and others. Theory of the Reflex action, as expounded
by Scbroeder Van der Kolk. Historical account of investigations, directed more
especially to the determination of the functions of the Cerebrum and Cerebellum.
Progressive development of the Neural axis in the animal kingdom. Analysis of
the labors and investigations of Desmoulin, Rolando, Flourens, Magendie, and other
phjsiolo^sts, upon the functions of the Cerebrum and Cerebellum. Recent experi-
ments of Fritsch, Hitzig, Ferrier, Nothnagel, and others, upon the functions of
circumscribed portions of the Cerebrum and Cerebellum. Analysis of the works
and labors of various observers, as Haller, Willis, Vieussens, Prochaska, Pofour
do Petit, Bichat, LeGallois, William Clift, Wilson Philip, Lobstein, Samuel Jackson,
J. Muller, and others. The laws of the action of the sympathetic and of its reflex
actions and relations to the Cerebro-Spinal Nervous System, and to secretion,
notrition and muscular motion as expounded by the eminent physiologist, J. Muller.
Analysis of the experiments on section of the Sympathetic, Pneumogastric, and
other nerves, by Cruickshank, Petit, Arnemann, Bracbet, John Reid, Mayo, Longet,
Claude Bernard, Brown-Sequard, and others. Relations of the Cerebro-Spinal and
Sympathetic Nervous Systems, to nutrition, secretion, and animal temperature.
Examination of the theories advanced as to the existence of vaso-motor, trophic
and iobibitory nerves. Relations of Chemical Changes and Animal Temperature.
Ancient and modern theories of animal heat. Examination of the progress of
Pagw.
• •
111 CONTENTS,
Pagw
modern diseorery, with reference to the physics and chemistry of animated beinj^.
Nature of mascalar force. Views of the Ancients and Moderns as to the nature of
the mechanical forces of animals. Relations of the muscnlar force, to the che-
mtcal changes of the food and blood. Mutnal relations of the muscular and ner-
vous forces. Relations of the Nervous force to Klectricity. Relations of the
Intellectual and Physical Forces. General Conclusionii 1-137
INVESTIGATIONS ON THE XATtTRE, CAUSES, RELATIO.VS AND TREATMENT
OF TRAUMATIC TETANUS, ILLUSTRATED BY OBSERVATION'S ON VA-
RIOUS DISEASES OF THE NERVOUS SYSTEM, AND BY EXPERIMENTS
ON LIVING ANIMALS WITH CERTAIN POISONS 141-40T
CHAPTER II.
Observations on Natural History of Traumatic Tetanus. Changes of the pulse, res-
piration and temperature. Characters and changes of the urinary excretion,
qualitative and quantitative. Cases illustrating the Natural History of Traumatic
Tetanus. The essential phenomena of fever and inflammation, absent in Traumatic
Tetanus; the symptoms exaggerated manifestations of nervous and muscular actions,
rather than of stractural alteration ; an irritation in a distinct nervous branch is
propagated to the spinal cord, and the disease arter its establishmeut, appears to
be dependent upon an undae excitability and increased action of the entire spinal
ganglia, as manifested in the greatly exaggerated reflex actions. Reflexion of the
increased activity of the ganglionic cells of the spinal cord, to the sympathetic
nervous system. Demonstration of increased chemical change in the muscular
and nervous systems in Traumatic Tetanus. Historical notes upon the condition
of the animal temperature in this disease. Observations of Hippocrates, Aretipus,
Paulus .£gineta. Celsus, John Brown, William Cullen, Lionel Chalmers, Benja-
min Rush, John Hunter, James Currie, Benjamin Travers, Robert Bently Todd, and
others, upon the Natural History, and more especially upon the condition of the
temperature in Traumatic Tetanus. The sudden and rapid rise of the temperature
in certain cases of Traumatic Tetanus near the futal issue, referred to several
causes, a* 1st, the effects of the violent muscular contractions and agitations ; 2d.
Impeded respiration ; 3d. The supervention of inflammation of some one or other
of the internal organs, but more especially of the lungs as in pneumonia: 4tb.
The translation or extension of the irritation of the gray matter into true inflam-
mation ; &th, The extention of the irritation from those portions of the spinal
cord especially connected with the reflex functions to those ganglionic centres
within the brain and spinal cord, which regulate the production of animal heat;
6th. The extension of the irritation to the sympathetic or vaso-motor system of
nerves ; 7th. Chemical and physical alterations of the blood. Portion of the ner-
vous system involved in Traumatic Tetanus, intellect unaffected. Cases. Tetanus
essentialy consists m such a state of exalted functional activity in the nerve cells,
as is attended with the constant generation of a larger supply of motor force, than
is necessary for the maintenance of the normal relations between the nerve and
muscles. Discussion of the mode in which the local irritation is conveyed by the
nerves to the ganglionic cells of the spinal axis. Examination of the views of
various anatomists and physiologists, as to the mode of termination and ultimate-
structure of nerves. Circulation and Respiration in Traumatic Tetanus. Inter-
mittent action of the heart — observations upon spasm of the heart in this diseafe.
Function of the skin actively performed ; bowels constipated. Mutual relations of
cerebro-spinal and sympathetic systems in this disease. Changes of the urine
during the various stages of Traumatic Tetanus. Hypothesis as to the nature of
the disease '. 141-1:»H
CIIAPTKR III.
Observations on the Patholoi^ical Anatomy of Traumatic Tetanus. Comparison of
Pathological changes in this disease, with tho^e of Insanity, Epilepsy, and Paraly-
sis. General conclusions as to the nature of Tetanus, and its relations to Climntc
and changes of Temperature. Cases illustrating the Pathological Anatomy of
Tftanus. Blood-vessels of gray matter of spinal cord congvsted and dilated.
Discussion of the cause of the congestion and dilation. Analysis of the invcjiii-
CONTENTS. xiii
Pages.
gations of yarioaa anatomists and physiologists, upon the effects of congestion of
the blood-Tessels of the spinal axis ; more especially of S. Weir Mitchell and
Benjamin Ward Richardson. Analysis of the labors of various pathologists,
with reference to the lesions of Traumatic Tetanus, as Morgagni, Rokitansky,
Larrey, Dupuytren, Pellitier, Hennen, Craigie, Curling, Copland, Parry, Travers,
Sandwitb, William Aitken, Lockhart Clarke, Dickinson, and others. Comparison
of the lesions, characteristic of Traumatic Tetanus, with those of insanity, para-
plegia, hemaplegia and epilepsy. Cases. Relations of Traumatic Tetanus to soil
and climate. Statistics of various Cities, as London, Philadelphia, New York,
Boston, Calcutta, Savannah, Charleston, Augusta, Nashville and New Orleans.
Relative prevalence and fatality of Tetanus, in White and Black races 199-270
CHAPTER IV.
Experimental investigations on the action of physical agents, and of certain poisons
upon living animals, instituted with the design of throwing light upon the nature
and mode of action of unknown fever poisons, and on the phenomena of convul-
sive diseases. Experiments illustrating the action of physical agents, abstraction
of blood, electricity, mechanical injuries of various portions of the cerebro-spinal
system, introduction of air into the blood-vessels. Experiments illustrating the
action of poisons, as Hydrocyanic Acid on living vegetables. Experiments illus-
trating the action of various poisons, as Prussic Acid, Cyanide of Potassium,
Strychnia, etc., upon living animals. General conclusions, drawn from 185 exper-
iments with poisons. Practical applications of the results to the Therapeutics of
TeUnus 271-334
CHAPTER V.
Treatment of Traumatic Tetanus. Historical Notes on the Treatment, illustrating
the methods advocated by Hippocrates, Aretaeus, Galeu, Celsus, Pelops, Paulus,
Aigineiti, and many ancient and modern writers. Tabulated cases illustrating the
results of treatment with various remedies. Discussion of the relative value of
the different remedies. Blood-letting. Section of Nerves. Amputation of affected
limbs. Local applications. Mercury. Antimony. Tobacco. Opium. Indian
Hemp, (Cannabis Indica). Woorara. Sulphuric Ether. Chloroform. Alcohol.
Chloral Hydrate. Cold Bath. Warm Bath. Nutritious Diet. Relative Mortality
from Traumatic Tetanus in Civil and Military Hospitals, and in Private Practice.
Relative Mortality in Traumatic Tetanus, under the different modes of treatment
and in the employment of various agents. Discussion of the modes of action of
thtf various agents employed in the treatment of Traumatic Tetanus 335-407
OBSERVATIONS ON CEREBRO-SPINAL MENINGITIS; AND MORE ESPECI-
ALLY AS IT APPEARED AMONGST THE SOLDIERS OF THE CONFEDER-
ATE STATES ARMY DURING THE CIVIL WAR OF 1861-18G5 411-553
CHAPTER VI.
Observations on the history of Cerebro-Spinal Meningitis in former periods. His-
torical notes on Cerebro-Spinal Meningitis as it occurred in the Armies of the
SoQthern Confederacy during the war of 1861-1805. Results of the examination
and classification of the sick and wounded, and mortuary records of the Confeder-
ate States Army. Observations of Confederate Surgeons on this disease. Reports
relating to a very fatal malady which occurred among some of the troops of the
Army of Northern Virginia, supposed to have been Cerebro-Spinal Meningitis.
" Report of sick and wounded in ten companies, Twenty-second North Carolina
Regiment, stationed at Camp Gregg, near Fredericksburg, April, 1803, by P. Ger-
vais Robinson, Surgeon P. A. C: S." "Report of W. D. Mitchell, M. D., Senior
SnrgeoD Rhodes' Brigade, Army of Northern Virginia." " Report of J. T. Banks,
M. D., Surgeon Thirteenth Regiment Georgia Volunteers, Army of Northern Vir-
ginia." '* Report on the preceding papers, by Surgeon R. J. Urctkenridge, M. I).,
Inspector of Camps and Hospitals, Army of Northern Virginia." "Epidemic of
Cerebro-Spinal Meningitis, by Surgeon G. A. Moses, of Mobile, Alabama.' Epi-
demic of Cerebro-Spinal Meningitis in New Orleans, 1872, 1873 41 1-43H
XIV CONTENTS.
CHAPTER VII.
Niitural History of Cerebro-Spinal MeniDj^ttis. GhaageB of temperature, pulse and
respiration. Pathoio^ical Anatomy of Cerebro-Spinal Meninf^itis 439-4sn
CHAPTER VIII.
Observations ou the relations of Cerebro-ISpinal Meningitis to Malarial Ke?cr. Cases
of Ccrebro-Spinal Meningitis, which occurred at Savannah, Georgia, February and
March, 1863. Effects of derangements of the blood, arising from defective circula-
tion and respiration, upon the organs and tissues. The derangements of the cir-
culation and respiration, and of the secretions and excretions, as well as of the
nervous functions in Cerebro-Spinal Meningitis, may all be referred to the local
inflammation, congestion and alteration of the meninges (especially the pta-mater)
and structures of the brain and spinal cord. Cerebro-Spinal Meningitis resembles,
111 its origin and progress, inflammatory diseases, and has frequently prevailed at
I he same time, and been intimately associated with Influenza, Catarrh and Pneu-
monia. The changes of temperature during the progress of Cerebro-Spinal Menin-
gitis, indicate the action of the agent producing the disease, directly on the
ccrebro-spinal system, rather than on the blood. The condition of many patients
(luring convalescence from Cerebro-Spinal Meningitis, indicates in the clearest
manner, that the cerebro-spinal nervous system has been inflamed, and parts of
structures permanently altered, rather than that there had been nothing more
than the action of a specific fever poison upon the blood. Experiments illustrating
the action of various poisons upon living animals, and designed to illustrate the
preceding propositions 48.1-541
CHAPTER IX.
Historical uotvs on the treatment of Cerebro-Spinal Meningitis. Table illustrating
the natural history and duration of Cerebro-Spinal Meningitis. Ratio of mortality.
Hclutive value of different remedial agents. Testimony of various physicians as
to the value of blood-letting, mercury, blisters, carbonate of potassa, hot bath,
opium, quinine, cold applications to head and spine, and other remedies 542-553
CMN'K^AL OBSERVATIONS OX CERTAIN DISEASES OF THE LYMPHATIC
AM) CIRCULATORY SYSTEMS, AND OF THE LIVER AND KIDNEYS,
ILLISTRATING THE RELATIONS OF DROPSY TO VARIOUS DISEASES... :»jR-6:t4
CHAPTER X.
Observations on 0«mosis. Preliminary remarks concerning the objects of the inves-
tigation. Defloiiion of the term Dropsy. Osmosis, endosmosis, eiosmosls, imiii-
liitiun, capillary attraction, absorption, diffusion, experiments on living animals,
iliiistrnting the phenomena of osmosis and the absorption and action of saline
piirgiitivus ».... 558-578
CHAPTER XI.
r>ropsy Arising from derangements in the nutrition of the tissues, IciKling eithtr in
nil increase of secretion, or diminution of absorption. Sudden accumulation of
fluid in the peritoneum. Researches ot Andral, Becquerel and Rudicr, on the
causes of .Vciite Dropsy. Constitution of the blood in Acute Dropsy. Treatment
of Acute Dropsy 57J»-5H3
CHAPTER XII.
l)rop«y arising from derangement.<i or altemtious of the blood, leading to deran;;'-
Diout ol the nutrition of the ti.«snrs, with an increase of secretion or a .liiuinulion
CONTENTS. XV
of absorption. Effects of the prolonged action of the malarial poison in deranging
the coDftitation of the blood, and in inducing Dropsy. Constitution of the blood
in malarial fever. Constitution of the blood in marsh cachexia. Treatment of
Dropsy arising from the action of malarial poison. 584-604
CHAPTER XIIL
Dropsy arising from derangements of the circulatory apparatus, attended with Tenous
obstrnctions and congestions, increased serous effusion from the distended blood-
ressels and diminished absorption. Ciirdiac Dropsy resulting from structural alter-
ations of the heart and large blood-vessels. Cardiac Dropsy ; dilatation of heart ;
death. Cardiac Dropsy ; dilatation of heart ; general anasarca ; death. Dilata-
ttoa of cavities of heart; universal dropsy. Articular rheumatism; valvular
disease. Aneurism of internal iliac. Aneurism of descending aorta. Aneurism of
ascending aorta. Aneurism of arch of aorta ; aneurism of arch of aorta and
asvcnding aorta ; dilatation of heart. Treatment of Cardiac Dropsy 605-620
CHAPTER XIV.
Hepatic Dropsy, arising from some obstruction to the circulation of the blood through
the liver. Cirrhosis, fatty degeneration and atrophy of the liver. Dropsy result-
ing from obstruction of the portal circulation in cirrhosis of the liver. Dropsy
resulting from cirrhosis of the liver and cardiac disease. Treatment of Hepatic
Dropsy 621-634
CHAPTER XV.
Dropsy arising from derangement or lesion of those organs which regulate the
amount of (be blood, as well as its constitution, by regulating the amount of the
watery element, and by the elimination of the excrementitious material. Dropsy
arising from diseases of the kidney. Dropsy resulting from Bright's Disease of the
Kidney, Bright's Disease of Kidney. Anasarca. Treatment of Dropsy arising
from disease of Kidney... 635-646
INVESTIGATIONS ON THK PREVALENCE AND FATALITY OF PNEUMONIA
IN THE CONFEDERATE ARMY DURING THE AMERICAN CIVIL WAR OF
1861.1865: WITH PRACTICAL OBSERVATIONS ON THE RELATIVE
VALVE OF THE DIFFERENT MODES OP TREATING PNEU.MONIA 610
CHAPTER XVI.
ON THE PRKYALKNr£ AND FATALITY OF PNKlMriNIA AND OK TYPHOID FEVEH IN THE rONFBD-
£KATE AKMY DURING THE WAR OF 1861-1865.
Importance of Pneumonia in view of its prevulencc and fatality. Table giving mean
streogtii, tbe total of sick and wounded, the cases of Pneumonia, and tlie Percent^
age of Pnenroonia in mean strength, etc., in the Confederate Army during nineteen
months, 1862-1863. Analysis of tliis table. Cases most numerous in tbe winter
find spring months. Table illustrating tbe prevalence of Pneumonia in tbe Armies
tarring in tilt diflferent s?ction8 of the Confederate States. Ca<ies in Virginia; in
the Army of tbe West, etc. Cases of, and deaths from, Piieunionia, Typhoid Fever
and other diseases, in the General Hospitals of the Army oC the Putumac, Nurtherii.
Virginia, and other Hospitals, during ^fteen months, in 18G2-l8G:i. roiiimo,n con-%
tinned and Typhoid Fever identical. Percenta;re of deaths from Pneumouia. Fa-,
tj&liiy from Pneumonia and Typhoid Fever. Fatality fiom other diseases. Cusca
of, and deaths from, Typhoid Fever, Pneumonia, and some other diseases, in the
General Hospitals in and around Richmond, during seven monthsi, in 18G2-186J.
r*ases of, and deaths from. Pneumonia, Typhoid Fever, and several other diseases:
io the general hospitals in Virginia. Cases of, and deatb-i from. Pneumonia, ami
fome other dis.ei^es, in the (>eneral Hospital at Charlottesville, Va.^ during twenty-
XVI CONTENW.
six months, from July, 1601, to August, 1603. Fatality in Hospitals at Savannali,
of PneniDonia and Typhoid Fever. Table showing the numerical relations of,
cases of, and deaths from, Typhoid Fever and Pneumonia, in the General Hospitals
in Virginia and Georgia. Prof^ressive diminution of the prevalence of Typhoid
Fever during the -^at. Table illustrating the numerical relations of Pneumonia
and Typhoid Fever in the Confederate Armies during nineteen months, 18U2-16C3.
Cases and death? from all causes, and cases of, and deaths from, Pneumonia and
Typhoid Fever in the General Hospitals of Charlottesville and Staunton, Va G49-GC8
CIIAPTKR XVII.
EXAMINAtloN OK THE DIFFERKXT yiOVVS OV TKEATIXti rNEl'MOXlA.
Objects and Importance of the Investigation, Dietetic System, which consists in
allowing the Disease to run its course, uninfluenced by drugs. Illustrative cases.
Observations by Drs. Dietl and Balfour. Rational Treatment designed to further
the natural progress of Pneumonia towards recovery. Method of Treatment
advocated by Dr. John Hughes Bennett. Views of Dr. Robert Bently Todd. Anti-
phlogistic System of Treatment. The lancet abandoned by Southern ph3'sicians in
the treatment of Pneumonia. The statistics to prove the wisdom of this step,
wanting. Examination of the data by which the relative merits of the An'tipblo*
gistic System of the treatment of Pneumonia may be determined with some
approach to accuracy. Investigations of Louis on Blood letting. Method and
results of the treatment of Pneumonia by Louis, Dr. James Jackson, Hughes Bennett,
Rasori, Laennec and others. Relations of Pneumonia to Malaria. Relations of
Pneumonia to Climate. Statistics of the treatment of Pneumonia by different
methods 6T0-694
(CHAPTER XVIII.
ANTIPERIODIC OB AIK)KTIVE MKTHuDtJK TRE\TIN(5 PNEUMONIA: RELATIONS OF I»NEl' MOM A TO
MALAHIA.
Use of Quinine in the treatment of Pneumonia, by Southern Physicians. Observa-
tions of Jean Senac, Oaleatius, (<eorgc (^leghorn, Morton, Lautter, Alibert, Laennec,
Ramizini, Lancisci, Sydenham, Huiham, Siiuvagcs and Broussais, upon the rela-
tions of Malaria and Pneumonia. Investigations of the author on the relations of
climate to Pneumonia. Mortunry statistics of Savannah, Georgia; Augustn,
(ieorgia; Charleston, South (^aroliiiii; New Orleans, Louisiana; New York and
Philadelphia. Cases illustrating the relations of Antecedent Malarial Paroxysmal
Fever to succeeding Pneumonia. Klfcets of the malarial poison upon the bioud.
Modifications of the phenomena of Pneumonia, induced by the action of the mnla>
rial poison on the blood, liver and spleen. Illustrative cases. Practical conclu-
sions deduced from these investi;;ations ()'J5-747
MOLLITIKS OSSllM-iMALAKOSTKON. tKSTEO-MALACIA, OSTEO-SARCORIS,
KNOCHENKUWEIClirNd, UArillTISMrS ADCLTORCM. RICKETS OR
SOFTENING OF THE I'.ONKS IN THE ADCLT) tSl-TUU
(ilAPTKli XIX.
Ul>tnlil(AL NOT>> ON MOLLITIKS OSSU'M.
No mention o! ihi« diiton^e in ttic works of Hippocrates, Paulns ^^^glncta, Arct.Tus,
iniil other nnvifiit writer'*. tHi^iTvatlons of Sachsiiis. Petra a Castro, Avicenna,
Mor^Miirtii. Fenu liu?, KiuUiu-?. llililiuui::^, (inbrit'lli, Courtialis, Bauda, Saviard,
VaUaUii. Pt'tit, r.oeihaav«»; and oilier.«J. Ucference to the literature of Mollilies
Os^ium 751-754
( IIAPTKU XX.
CASKS ILLl'.-^TRVTIX.i TIIK NATru;, |*lt ) iia^**, TERMINATION, AND AJIVTtiMlCAL LESIONS OF MOL-
LITIKS (i^vMl'.M.
Crtsc of Mi5< Bo/el, oli-fT\«d by thn author. The origin of the disease referred to
• •
CONTKNTfl. XVU
Pages.
«oDftttational derangeratots, rather than to a strictly local disease of the bones.
Cases reported by SyWanus Beran, Ambrose Hosty, John Pringle, J. W. Tenney,
Thomas R. Chambers, Samuel Solly, and others 755-772
CHAPTER XXI.
BKLATIONS OF MOLLITISS 0S3IUM TO FRAGILITAS OSSIUM.
Case of Marshall Lewis, obserred by the author. Illustration of the hereditary brittle-
oess of bones, recorded by Dr. Paull, of London. There is a state of the osseous
system, correctly indicated by the term Fragtlitas Ossinm, which cannot be referred
to the syphilitic, scrofulous, or cancerous cachexia, and which exists with health. 773-777
CHAPTER XXII.
KELATIUNS OF M0LLITIE8 OSiilUM TO 11I0KKT8 (KACUITIS.)
Deficiency of phosphate of lime characteristic of both Rickets and Mollities Ossium ;
the former confined to no sex ; a disease of childhood, and capable of cure : the
latter most commonly attacks adult females, and is almost universally fatal. Dis-
tinctions between the changes of the bones in these two diseases. Results of
microscopical iuTestigations : 778-782
CHAPTER XXIII.
BKLAT10M8 OF M0LLITIK8 OSSILM TO CANCEB.
The brittleness of the bones in cancer has long been observed — Cases recorded of
softening and alterations of the bones, by Lovisius, Pcrcival Pott, and Prof. R. W.
Smith 783-787
CHAPTER XXIV.
I-^IXOTITITION OF THK BLOOD, CX)XDITI(>N OF THK TEMPKRATIRE, PrLSE, AND REJ^PIRATION, AND
THK CHARACTERS OF THE TRINE. IX MOLMTIKS OS.**irM.
Observations of Dr. Bence Jones and Marchand. 788-700
CHAPTER XXV.
OMPARI.4IOX OF THE C^UEMICAL COMPOSITION OF THE BONE8 IN MOLLITIES OSSIL'M WITH THAT
OF HEALTH AND VARIOl'S DISEASED STATES— ilEKBRAL 0)NCLrSI(>NS.
Analysis of healthy bohes by various chemists, and of the bones in Mollities Ossium
and various diseased states, by Bostock, Prosch, Bogne, Ragsby, Lehmann, Von
Bibra, Marchand, Reese, Tuson, Barruel, Buisson, Valentin, and others — General
conclusions as to the nature of Mollities Ossium 791-799
IXDBX 801-816
IXTRODUCTrON TO THE STUDY
or
tseases p^errjittJJ ^ji^tcm*
MEDICAL MEMOIRS.
^ •.'»
OBSERVATIONS ON DISEASES OF THE ^^^f^E^^^mi^
i\''i 6 APR 77;^)
CHAPTER I . X V^/SEU"^^
INTBODCCnON TO THX STUDY OF DISEASES Or THE NraMC0n.9s3
HigTOBicu. notes, relating to the anatomy and physiology of the Nervous System. Belations of the sympathetic and
<>rdHD4^naI Nerrooa system. Views of Homer, Pythagoias, Plato, Aristotle, Herophilus, ErMistmtus and other
vneat writers, as to the natnre of nerroos action. As early as the days of ErMistiatns, there was apparently, the
aosuBeocemenl of that long series of obeenrations, which ended in the important discovery of Sir Charles Bell, that
the Spinal nerves were the oivans of motion through their anterior roots, and of sensation through their posterior ;
tad tk« reoognition by physioTogists, that each ultimate nervous filament Is distinct, and runs isolated from its origin
to its temiuation. Views of GaJen, Rondeletius, and Varollius. Results of the labors of the Anatomists of the six-
t««&tb c«oCary . Willis, in 16M, established the classification of the Cranial nerves, at present received. The earlier
watomistB examineil the brain, only by slicing, so as to obtain sections, but Varollius, endeavored to unravel its parts,
tad in this important method of investigation, he was followed by Willis, and more recentiy by VieuMens and Gall.
H7poth«aes advanced by Thomas Willis. Doctrines of the successors of Willis, and more especially of the school of
LrTfien (the school of Boerhaave and his disciples). Doctrines of the younger Albinus. Anis^ysis of the workji and
I bonof Unxer Prochaska, Bichat, Cuvier, Legallois, Wilson Philip, Alexander Walker, Sir Charles Bell, J. MUllei,
MiifeiMiie, Mayo, Bellingeri, George Tiewport, and Marshall Hall. History of the development of the Doctrine of
Brflex action. Examination of the results of the Microscopical and anatomical investigation uf the minute stricture
••f thf ^4Qal Cord, and brain in vertebrate animals. Analysis of the labors of Bemak, Stilling, Volkemann, Koliker,
J. Lockhart Clarke, 8chro«der Van der Kolk, and others. Theory of Reflex action, as expounded by Schroeder Van
4*1- Koik. Historical account of investigations, directed more especially to the determination of the fhnctions of the
<>ivbniBi and Cerebellum. Progressive development of the Neural axis in the animal Icingdom. Analysis of the
btiuni and investigations of Desmoulins, Rolando, Flunrens, Magendie, and other physiologists, upon the functions of
tb« Cerpbrom aa<l Cerebellum. Recent experiments of Fritsch, Hitcig, Ferrier, Nothuagel and others upon the fhnc'
tbM of circumscribed portions of the Cerebrum and Cerebellum. Analysis of the works and labors of various
'^«errtn, as Haller, Willis, Vieussens. PixKhaska, Polour de Petit, Bichat, Le. Gallois, William Clift, Wilson Philip,
U^otHn, Samuel Jackson, J. M tiller, and othen. The laws of the action of the sympatiketlc and of its reflex actions
•od relattoos to the Cerebro-Spinal nervous system and to secretion, nutrition and muscular motion as expounded by
Uip «Miiiftent physlO'Ogist J. Miiller. Analysis of the experiments, on section of the Sympathetic, Pneumonistric,
and iHh«r nerves, by Cruickshank, Petit, Amemann, Brachet, John Beid, Mayo, Longet, Claude Bernard, Brown-
S^urd and others. Belations of the Cerebro-Spinal and sympathetic nervous systems, to nutrition, secretion, and
■aioal temperatare. Examination of the theories advanced as to the existence^of vaso-motor trophic an#lnhibitory
i^rfot Religions of Chemical Changes and Animal Temperature. Ancient and modam theories of animal heat.
Ejuialaation of the pn>grefls of modem discovery, with reference to the physics and chemistry uf animated beings.
ni>u>Ty of the application of the thermometer, to the investigation of physiological and pauological phenomena.
Sntun of muscular force. Views of the Ancients and Modems as to the nature of the mechanical forces of animals.
S^l»tiun>i of the muscular force, to the chemical changes of the Food and Blood. Mutual relations of the muscular
«ad DTvous toTcn. Relations of the Nervous force to Electricity. Relations of the Intellectual and Physical Forces,
'"octml Concluidons.
HISTORICAL NOTES RELATING TO THE ANATOMY AND PHYSIOLOGY OF THE NERVOUS
SYSTEM.
(t wonld be a matter of much interest to trace the mod^ in which the human mind, in the
•tArliest periods of science, gradually distinguished between the nerves and muscles, and
unfolded the doctrines of physical, vital, nervous and intellectual forces ; but as the learning
'jf the Ancient Egyptians who were amongst the first and most successful cultivators of
Vedicine, and the first great teachers of the theory and practice, was lost at an early date,
iQcb an inquiry can proceed but little beyond the age of Hippocrates.
Homer who described the wounds inflicted in battle, does not employ the word muscle ; and
?Ten Hippocrates, is held to have had no correct conception of the difference between the
oerToas and muscular systems. For muscle, Hippocrates employs the word flesh, and he uses
iodiscrimiQately the tame terms, for nerves, sinews and ligaments, and he asserted that the
Qerres contract the limbs. Hippocrates, in his book, ^^de Insania." observes, that man is sane,
vbose brain is undisturbed, although in another work, referred however, by commentators to
ibe spurious works, be places the mind of man in the left ventricle of the heart.
Pjihtgoras, considered the Universe as a unit, animated by Divine intelligences, each
2 Introduction to the Study of Diseases of the Nervous System.
according to ita perfections, occupying its proper sphere : .absolute anttj or God, according to
his system, was considered the spiritual soul of the Universe — the essence of being — the
light of lights ; between the Supreme Being and man, an incalulable chain of intermediate
beings was conceiTed, whose perfections or attribnles were decreased in proportion to their
separation from the creative principle. Everything that appeared to have an existence proper,
was supposed to proceed from the union .of modalities. Thus, the Universe, the grand whole
or fnaerocotm^ included three secondary worlds ; and Man the little world, or nuerocosm, was
composed of a body, soul and spirit, manifested by three distinct faculties, viz : sensibility,
thought, and intelligence. Man is the point of union between divinity and matter, con-
necting heaven and earth ; the light of wisdom and intelligence that beams in his thoughts,
is reflected on nature, and he is the bond of communication between all things. Pytha-
goras taught, that the soul has a body, which is given to it in accordance to its good or bad
nature, by the interior labor of the faculties ; he called this body the subtle car of the soul
and said that the mortal body is only a gross envelope. Whilst Pythagoras, admitted,
eternal, uncreated essences, namely : spirit and matter ; and explained by the agency of these
two principles, the various phenomena of sensibility, intelligence and thought, it is not
known that he connected the exercise of the intelligence in man with the Brain or nervous
system, or with any special portion of the human body.
Plato the preceptor of Aristotle recognised three distinct faculties of the mind, having
three distinct seats, vis , the concupiscent whose seat was in the liver ; the irascible, seated
in the heart, and the rational seated in the brain. In this doctrine he was followed by Galen,
Tesalius, Femelins, and others, who acknowledged three spirits ; the natural which pass
from the liver with the blood ; the vital, which are carried from the heart to every part of the
body, through the arteries; and the animal which are transmitted from the brain, through the
whole body by means of the nerves. Plato appears to have held the doctrine that the intel-
lect, was distinct from the material body and capable of exercising itself, without any inter-
vention of the senses. Thus he says in the Phsedon :
** 1» Miythioff more ntSonal thMi to think by the thooghtM ftlone, dii«ng»g«d fkom all foroirn or wmlbte airttncy ; to
apply at once the pore enenca of thoacht In ItaeU; to the reMansh of the pure eannoe of each thing ia Iteelf, wlthoat
the minlitiy of the eyee and ears, withoot, in ihort, any intervention or the body, wboae elightOTt Influence only
tioablee the aonl and preTente It finding wlidom and tnith. If we are ever to attain the knowledge of the evencc
of things, mnat It not be in tliii manner.**
•
Plato held with Anaxagoras, that mind or intelligence is the first cause of all things, and is
the regulator and principle of all things.
Plato in common with Pythagoras, held the existence of different orders of created spirits.
He says that :
** The Bilpreme Intelllgenoe charged the eecondaiy gnda with the formation of mortal animal*. TheM> gods bar-
ing receired from the hands of the celestial Fkther the immaterial principle of the human muI, (hshlonod a body for
it, with the most regular and polished of the primitive triangles. This luminous and inwmipUble l«dy, which
envelopes the Immaterial soul, was placed in the bialn of man. The gods also endowed, the risible and gross body
of the animal with another, morul souL the seat of the riolont and fatal passion*. This occupied the length of the
spinal marrow, tearing between It and the dirine soul, the Interral of Che neck for fear that the two sutoUnces, of
a nature soilifferent, being too cloeely connected, the least pure, miffht tarnish or embarrsss the other by its contact.
** Ther«^f(ff^ the gods placed the mortal soul in the chMt and trunk ; and as this soul contains a good and n, bad
principle, they dirlded the entity of the trunk Into two departmenti. Just as is done with the apartments of males an4
female, by means of the diaphragm, placed In the middle as a iiartitliio. Nearer the head between the diaphragm and
the neck, they placed Uie manly and courageous, or bellici>se principle of the soul ; ma that being submitted to, an4
in concert with the riMson, It mar restrain the rorolts of the passions and desires, when these are unwilling to be
controlled by th^ influences which reason sends down from lU dtadol.
*• That portion of the soul which re<iuin«s food and drink, and all that the nature of our body rradeiw nccessarr,
is located between the diaphragm and the utubillcus. Thv gods hare extended it orer this entire region, like a nick,
where the body may find Its food. They have confined it there, Uke a ferocious boast, which it U nect^iary, nerer-
theless to feed, so that the mortal man may subsist.**
Aristotle is credited by some writers, with the discovery of the nerves of sensation, which
he is said to have called the canals of the brain ; but this great systematic writer ami loj^ician
attempted no analysis of motion and appeared to have no idea of the true functions of the
brain, although he appeared to have been better acquainted with the anatomy of this viscus,
than any of his predecessors.
Aristotle, described the brain as an inert viscus, cold and bloodless, an organ aui gmeri;
and not to be enumerated amongst the other organs of the body, as it bad no use except to
cool the heart. Aristotle thus explains how the brain, might be the refrigeratory of the heart ;
•* Inasmuch as raponn arise ftom the waten and earth, and when they r^ach the ci»ld middle reg{i»n of the air, arr
condensed into water, which flslllng upon the earth c^Ab It; so aU) the hot spirits carried fhom the heart t<i the
bnin, with the blood, and therv being cooled, ar» condensed into water, which again descends to the heart for the
poipose of cooling it.**
Aristotle placed the seat of the rational soul in the heart, where it can exercise all its func-
tions, and he therefore made the nerves (of the use of which in sensation and motion he
not ignorant,) to arise In the heart.
Introduction to the Study of Diseases of the Nervous System. 3
The Miatoinical and physiological views of Aristotle maj be gathered from the following
qaotations :
**That whidi to flrat fonnd In opening the head, to the brain, and it to placed in the anterior part. All animato pos-
•Milng a bnda, that to Co aay, all those which hare blood, aa well aa those of the older MoUosca, hare it generally
placed in the same position ; but the brain of man to mnch more oonslderable than that of other animato proportion-
ably to the sixe of hto body, and to also the most humid. The brain to enveloped in two membranes ; that nearest to
the cisalum to the strongest — the other, which resta immedtotely upon it, to weaker. The brain is always composed
at two lobeSjIi^dspeDdently of the cereMlIum, which lies beneath, and whose form and structure diifer from that of
the btain. There to nsoally a little cavity in the middle of the mass of the brain ; its substance to naturally cold to
the Umch, and nrtther Teins nor blood are ever fonnd in its interior; but the membrane which envelopes it to frill of
** Lst us speak now of the nerves, they proceed also from the heart, that viscus containing nerves in its structure-^
in Its lamst cavities ; and what is tenned the Aorta to a nervous vein, whose extremities are nothing else than
nerves. At the points where those extremeties terminate around the Joints of bones, they are not hollow, and are
soaosfHtble of the same tension as the active nerves. But the diiference between the nerves and the veins to, that the
nerves do only proceed without iutemiption fh>m one unique substance to all parts of the body, like tiie veins. The
oerrss oa the contrary, are distributed on all sides, and to the articulation of the bones. If tiiey proceed fiiom the
SBBM troDh, their continuity would be apparent in emadated animals.
The principle nerves are those of the brain, on which depend the power of leaping, then another double nerve-
called die tendon ; then the extensor and the nerve of the uioulder, which; contribute to the ;strength of the body.
Ho paiticalar name to given to the nerves, which belong to the articulations, because all articulations of the bones,
ai« booad together bv the nerves. In general, the nerves are found in great abundance around the bones, except
ttw booea of the head which are united by sutures.**
It is evident from the preceding qaotations, that Aristotle had no distinct notion of the
locomotive apparatus ; that he confounded the tendons and ligaments with the nerves, that
he placed the seat of the soul and sensation in the heart, and that he had no conception of the
elevated functions of the encephalic organ.
Herophilas of the Alexandrian School, who lived in Bgypt, in the time of the first
Ptolemjr, distinguished nerves as the organ of the will, and the channels of perception. He
maintained, that the Calamus Scriptorius, (the ventricle of the cerebellum,) is the chief of all
the ventricles of the brain, and that the nerves of volition spring from the brain and medulla
spinalis. Erasistratus, however, before Herophilus, taught when young, that the sensory nerves
anse from the meninges, and the motor from the cerebellum ; but when old, he taught that
both classes of nerves arise from the medullarj matter of the brain ; and that the animal spirit
was from the bead, and the vital from the heart.
It appears according to the most certain traditions, that Brasistratus and Herophilus were the
first, after the nervous system had been recognized as the ultimate organ of the animal and
vitai loDctions, and the brain ascertained to be its centre, who appropriated to different parts of
that organism, the functions of sensation and voluntary motion. Rufus, the Ephesian, who lived
under Tr^ao, says that Herophilus distinguished three sorts of nerves ; the first which serve
for senaation and voluntary movements, proceed from the brain and spinal marrow as
ranacles ; the second and third are destined to unite the bones and muscles. Although Hero-
philas had not entirely shaken off the prejudice which confounded tendons, ligaments and
membranes with the nervtss, nevertheless his doctrine was a decided advance upon that of
Hippocrates, Aristotle and the Asclepiadase.
Krasistratus placed the source of sensation in the meninges or membranes, and of voluntary
osotion in the substance of the brain, the nerves being mediately, or immediately the pro-
loogatioos of these membranes. According to this theory, then, the nervous membranes were
the vehicle of sensation, and the nervous substance the vehicle of motion. If we may credit
Kofus, Krasistratus did not derive the nerves from the membranes of the Encephalon to the
exclusion of its substance. This theory, which manifests the tendency, from an early
period, to refer the phenomenon of motion and sensation to distinct parts of the nervous
argaoijm, was again advanced by Fernelins. in 1&50, by Rosetti, in 1722,andby LeCat, in 1740,
and by each of these authors the hypothesis was regarded as original.
As early, therefore, as the days of Brasistratus, there was apparently the commencement of
that long series of observations which ended in the important discovery of Sir Charles Bell,
that the spinal nerves ere the organs of motion, through their anterior roots, and of sensation
through their posterior ; and the recognition, by physiologists, that each ultimate nervous
filament is distinct in function, and runs isolated from its origin to its termination.
It appears, also, that Brasistratus anticipated also many recent physiologists, in the doctrine
that the intelligence of man, and of animals in general, is always in proportion to the depth
And Dumber of the cerebral convolations ; that is, in the ratio of the extent of cerebral sur-
face, not of cerebral mass.
Those cases of nervous disease, in which either motion or sensation were exclusively lost,
as well as those cases of paralysis in which both motion and sensation and intelligence were
lost, mast, without doubt, have attracted attention at an early period in the history of medi-
cine, and at the same time necessitated the conclusion that sensation and motion are either
the foDcUons of different organs, or, if the same, that they were at least regulated by different
conditions. Between these alternatives, all opinions on the subject of nervons action have
been divided, and, as we have seen from the preceding examination of the views of Brasistra-
4 Introduction to the Study of Diseases of the Nervous System.
•
tuS| the conclusion that sensation and motion are the functions of different portions of the
nerTons system, was the first, ai it has heen the last to be adopted.
Oalen expressed in his writings manj clear and sonnd views with reference to the animal
mechanism -, he compared the office of the skeleton to that of the poles of a tent, or the walls
of a house ; be demonstrated, bj actual experiments, the action of Tarions mnscles, and his
Tiews as to the action of the muscles, were not only anatomically and mechanically correct,
but his discorenes and descriptions even of very minute parts of the muscular system have
been regarded with favor by modern anatomists. He proved experimentally, by sections of
the nerves, the dependence of all mnsular motion upon the nerves, which, according to his
view, all originated in the brun. Oalen says that in his time it was allowed by all, both
philosophers and physicians, that where the origin of nerve is, there the seat of the soul mnat
be ; and this, he adds, is in the brain, and not in the heart ; althongh be is not always con-
sistent in the shares which he assigns to the heart and to the brain, in the elaboration of the
animal spirita, nor is he uniform in maintaining a discrimination of origin between the ani-
mal spirits and the vital, holding, with Plato and Aristotle, that the human soul is eompoaed
of three faculties, or rather, of three parts; the vegetative, which resides in the liver, the
irascible, which has its seat in the heart, and the rational, which dwells in the brain. The
fact that when the brain of the living animal is uncovered by removing a portion of X\te vaolt
of the cranium, that viscus is seen rising and falling alternately, did not escape Galen, who
compared it to the pulmonary respiration, and attributed it to the same cause. He held that
the brain expanded like the Inngs, to draw in the air, and contracted to expel it ; the atmos-
pheric fluid penetrates the cavity of the cranium through the cribriform plate of the ethmoid
bone, and passes out by the same vent, carrying with it the excrementitial humors of the brain,
which run into the nasal fossae; nevertheless the air introduced into the cephalic cavity, by
inspiration, is not entirely rejected by expiration. A portion insinuates itself into the ante-
rior ventricles of the brain, and unites with the vital spirits, which are carried there by the
arterioles of the choroid plexus ; from this combination originate the animal spirits, the
immediate agents of the rational soul, and the most subtle of all the spirits ; these acquire
their last attenuation in the foorth ventricle, where they are instilled drop by drop, through
a round, narrow vermiform tube (acqueduct of sylvius); then the animal spirits are transferred
into the substance even of the brain, little brain and spinal marrow, where they are kept In
reserve to be distributed by the agency of the nerves to all parts of the body, and they give to
each region according to the direction and wants of the animal faculty, sensation, motion and
energy.
In opposition to Aristotle, who supposed the nerves to originate at the heart, Galen stated
that all the nerves are derived from the brain and spinal marrow. He enumerated seven pairs
of cerebral nerves, which comprise all that are admitted now, except the sympathetic, and
the external motor of the orbit; thirty pairs of spinal nerves, which he divides as follows:
Eight cervical, twelve dorsal, five lumbar, and five sacral. Galen pointed out two sorts of
nerves, one of which, those of sensation, he described as soft, and proceeding from the brain .
the other set, the nerves of motion, as harder, and originating in the spinal marrow.
Whilst Galen recognized, as others bad done before him, the contrast of the two phenomena
of sensibility and motion, and actually designated distinct nerves of sensation and motion,
be was ignorant of the fact, that each nerve by its double origin on the anterior and posieiior
parts of the spinal marrow, contained both sensory and motor filaments. (Considering the
membranes as mere envelopes, Galen limited the peculiar functions of the nervous system, tu
the enveloped substance of the cerebrum, cerebellum, spinal cord and iierTes; but as the ani-
mal faculty, according to his view is one, and its proximate vehicle, the animal spirits, is
homogeneous, and as the nervous, or cerebral substance, which conducts the^e spirits, is in
its own nature uniform and indifl^erently competent to either function, it therefore depended,
according to this theory, upon two accidental circdmstances, whether this substance conduce
to sensation, or to motion and sensation together.
The ganglions of the nervous system were well known to Galen, and he claimed their dis-
covery, and he appears to have had Fome notions of the great sympathetic; and so marvelous
was his minute knowledge of the distribution and functions of the several nerves, that it has
been asserted by competent authority, that, with the exception of a few minor particulars, hia
pathological anatomy of the nervous system was practically on a level with the pathological
anatomy of the early part of the nineteenth century.
The next important advance was made in the middle of the fourteenth century, after Galen's
death, by Rondeletius in 1550, who, reasoning from the phenomena of paralysis and stupor,
announced it as an observation not previously made, that all nerves, from their origin in the
brain, are even in the spinal marrow itself, isolated from each other. The cause of paralysis
is, therefore, not so much to be sought for in the spinal marrow as in the encephalic heads of
the nerves ; Galen himself having remarked that paralysis always supervenes when the origin
of the nerve is obstructed or diseased, f^aurentius, of Montpellier, a celebrated professor in
the same universitv with Rondeletiun. some thirty years later ( 1 5!»5), advanced the same doc-
Introduction to the Study of Diseases of the Nervous System, 5
trine, as a Dew and hitherto unheard of obserration. This anatomist and physiologist first
attempted a sensible demonstration of the fact, bj resolving under water, the spinal chord
into it« constituent filaments. He affirmed that this observation explained one of the obscurest
problems of nature, viz : Why it is thai from a lesion, say of the ceryical medulla, the motion of
the thigh may be lost, while the motions of the arms and thorax shall remain entire. Laa-
rentios, however, did not rise above the Galenic doctrine, that sensibility and motion may be
transmitted by the same fibre ; and, in fact, rejecting the discrimination of hard and soft
nerves, he abolishes even the accidental distinction that had been recognized by Galen.
Another important step in the anatomy of the cerebro-spinal nervous system, was accom-
plished by Varollius in 1572, when he showed that Galen was mistaken, in holding that the
spinal chord is a continuation of the cerebellum alone. Varollius demonstrated that this
chord is made up of four columns, severally arising from four encephalic roots ; two roots or
trunks from the brain proper, being prolonged into its anterior, and two from the cerebellum
into the posterior columns.
Contemporary anatomists (as Goiter, 1572, and Laurentius. 1595), recorded the tact, that
the spinal nerves arise by double roots, one set of filaments emerging from the anterior,
another from the posterior portion ef the chord. It was noticed also by Goiter, and Bauhi-
nos (1590), and others, that these filaments, in issuing from the spinal chord, passed into a
knot or ganglion ; but it was reserved for the second Monro, (1783), nearly two centuries after-
wards, to record the important observation, that the ganglion is limited to the fibres of the
posterior root alone.
The aostomista of the sixteenth century, described with more exactness than Galen, the
Tarioos branches of the nervous system. They distinguished more clearly each part, followed
farther the distribution of vessels and nerves, and corrected some material errors in this
branch of anatomy, which had existed from the time of GAlen. Whilst they assured themselves
that the nerves of the cerebrum, cerebellum and spinal marrow, served equally for sensation
and motion ; nevertheless, they still held most of the ancient prejudices concerning the
organs of sensibility and mobility, as well as the manner < in which they executed their func-
tions. It now seems almost marvellous, that, while the anatomists of the sixteenth century were
acquainted with the important facts of the independence of the motory and sensitive functions,
thatof these functions the cerebral nerves were in general limited to one, while the spinal
nerves were competent to both; that the spinal nerves, the nerves of double function,
emerged by double roots, and terminated in a two-fold distribution, and that each nervous
filament ran distinct from its peripheral extremity through the spinal chord to its origin,
should have stopped short of further inquiry and experimental demonstration, and should not
have surmised that in the spinal nerves difference of roots corresponds with difference of
function, and anticipated by actual demonstration, and by two centuries the most important
physiological discovery of the nineteenth century.
Galen described in succession seven pairs of nerves, making the optic nerves the first pair;
the second those distributed to the muscles of the eyes, and the third and fourth pairs those
distributed to the tongue and palate. Marinus is said to have established this division of the
cranial nerves into seven pairs, which Vesalius found to be incomplete; but Willis, in 1664,
established the classification of the cranial nerves at present recognized. Willis described
the olfactory nerves as the first pair, which previous to him were not recognized as a pair, and
he added the sixth and ninth pairs, which former anatomists had not recorded, and he whs the
first to describe in a distinct manner the '' Nervous Cmtre^^' the pyramidal eminences which con-
nect the brain with the spinal marrow. The earlier anatomists examined the bruiu only by
slicing, so as to obtain sections, but Varolius endeavored to unravel its parts, and in this
important method of investigation, he was followed by Willis, and more recently by Vieussens
and Gall. Thomas Willis advanced new hypotheses as to the uses of the nervous system, but
with these be commingled certain ancient doctrines, as for example, that serous effete matter,
in the ventricles, trickles partly through the olfactory nerves into the nostrils, partly through
the tnfundibulum to the pituitary gland, and thence by peculiar ducts to the veins, which
return the blood to the heart from the brain. Willis also agreed with Galen in regarding the
use of the fornix to consist in supporting the hemispheres. The peculiar doctrines of Willis
were that the cerebrum subserves the animal functions and the voluntary motions, the cere-
bellum subserves the involuntary motions ; that a perception of all the sensations, takes place
In the ascending fibres of the corpora striata, and that through the descending, voluntary
movements are excited ; that the understanding is seated in the corpus callosum, and memory
in the convolutions, which are its storehouses; that the animal spirits are generated in the
cortex of the cerebrum and cerebellum from the arterial blood, that they collect in the medulla
sre variously distributed and arranged to excite the animal actions and distill through the
fornix; that the animal spirits secreted in the cerebellum are ever flowing, equally and con-
tiouoDsiy into the nerves which regulate involuntary movements ; but those of the cerebjum
tQODJtooasly and irregularly according as the animal actions are vehemently performed or
fsfesrent. To excite sensation, the spirits flow along the nerves to the brain. Willis dis-
6 Introduction to the Study qf Diseases of the Nervous System.
tioguished between a thick nerTous fluid, suitable to notriUoD, and the extremely volatile
animal epiritg, snbserrient to sensation and raoTement. He explained the nnitj of the nervons
actionSi.by the communications or anastomosis of the nerves ; and he also held that the union
of the cerebrum and cerebellum is attained bj the tubercula quadrigemina, or nates and testes.
As to the loops of the nerves, with which the arteries are here and there encircled, he states
their use to be to relax and close the arteries, and thus during various emotions of the mind,
to admit the blood in greater or less quantity to certain parts. He decided that the pineal
gland is not the seat of the soul, but a lymphatic gland, having no relation with the substance
ot the brain, which absorbs lymph and carries it off again, through another vessel, and keeps
the plexus choroides expanded.
Ulisson, of the Univerity of Cambridge, in 1672, distinguished muscular irritability as a
peculiar power of the fibres of muscles, pointed out the differences of irritability in different
organs, and divided irritation into natural, vital and animal. In his attempts to explain the
mode in which the nerves operate on the irritability, Olisson assumed the existence of cer-
tain mild, sweet fiuids or vital spirits, which resided in the nerves ; the existence of a pecu-
liar nervous spirit like air, had been previously maintained by Brasistratus, Asclepiades,
Galen and others, and this theory found its most phiosophieal expression in the doctrine of
an ether or thin, elastic fluid, pervading all space, the vibrations of which give rise to the
phenomena of heat, light and nervous force. Thus Newton asks : ** Is not vision performed
chiefly by the vibrations of this medium excited in the bottom of the eye, by the rays of
light, and propagated through the solid, pellucid and uniform capiMamenta of the nerves
into the place of sensation ? Is not animal motion, performed by the vibrations of this medium,
excited in the brain by the power of the will, and propagated from thence through the capil-
lamenta of the nerves into the muscles for contracting and dilating them 7 " Haller also con-
ceived that the nervous spirit which was too fine to be perceived by the sense, was more
gross than fire, magnetism and electricity, as it was contained in vessels and confined by
boundaries.
The successors of Willis, especially of the school of Leyden (the school of Boerbaave and
bis disciples), embraced some of his doctrines, whilst others were abandoned or exploded.
For example, it was shown by anatomy, that all the nerves are not of involuntary motion,
which arise h-om the cerebellum, as the fifth pair of cerebral nerves, is wholly derived fh>m
the medulla of the cerebellum, the pons varolii.
Boerhaave held, with Willis, that the cerebrum is the organ of animality, a distinct pari
thereof being subservient to each of its own functions, sense and voluntary motion ; that the
cerebellum is the organ of vitality, or of the involuntary motions ; and that the cerebrum
and c^'rebellum are prolonged, the former into the anterior, and the latter into the posterior
columns of the spinal chord. Boerbaave held that all nerves are composite, being made up of
fibrils, of a tenuity, not only beyond our means of observation, but almost beyond the capacity
of the imagination. Some nerves are homogeneous, their constituent filaments being either
for a certain kind of motion alone, or for a certain kind of sensation alone ; others are hete-
rogeneous, their constituent fibrils being, some for motion others for sensation ; and of this
latter class are the nerves which arise from the spine. According to the doctrine of Boer-
haave, however, the spinal nerves, in so far as they arise from the anterior column, are nerves
both of sensation and voluntary motion (of animality) ; in so far as they arise from the pos-
terior column, are nerves of involuntary motion (of vitality). A homogeneous nerve does
not, as a totality, perform a single office ; for every elementary fibril of which it is composed,
runs, from first to last, isolated from every other, and has iu separate sphere of exercise ;
each distinct sphere of sensation and motion, has so many distinct nerves and terminations,
and all the different points of local termination in the body have corresponding points of local
origin in the brain. The centre of motion and sensation (the sensoriom commune), therefore,
is not an indivisible point, nor even an undivided space , but, on the contrary, it is the aggre-
gate of as many nervous terminations as there are encephalie origins of nervous fibrils. As
no nerve, therefore, gives off a branch, their sheaths of dura-mater alone ramifying, there is
no sympathy between the elementary fibrils, except through the sensorinm commune.
Van Swieten adopted, but did not advance the doctrine of Boerhaave, and Haller aban-
doned the opinion that sensation and motion are conveyed by different nervous fibrils. Haller
considered it to be a most improbable conjecture, that the same nerve may contain within its
•heath, both motory and sensitive tubules, distinct in their origin, transit and distribution,
but which, at their peripheral exremity communicated ; the latter, like veins, conveying the
spirits to the brain, which the former, like arteries, have carried out
The doctrine of the school of Leyden on this point was, however, still more articulately
evolved by the younger f Bernard Seigfried) AUnnus ; not in any of his published works, bat
in the prelections he delivered for many years in that university, on physiology. Prom a copy
in the possession of Sir William Hamilton, of the dicta of Albinns in this course, verv fully
taken, after the middle of the eighteenth century, by Dr. William Grant, compared with
another very accurate copy of the dicta, taken by an anonymous writer, in the year 1741, Sir
Introduction to the Study of Diseases of the Nervous System. 7
William Hamilton was enabled to present the following abstract of the doctrine taught by this
celebrated anatomist:
"Th* iMTTM have a triple destination, as they minister, (1) to roluntaiy motion, (2) to sensation, (3) to the rltal
ttttfgitMt secretion digestion, etc Albinus seems to acquiesce in the doctrine that the brain proper is the ultimate '
oina of the fifstand seoood Ainction, the After-Brain of the third. '
Ifenrss, acaia, are of two kinds. Tliey are either such, in which the ftinction of each ultimate fibril remains iso-
lated in ftinction from centre to periphery (the oerebro-splnal nerresX or such in which they are mutually oonfiuent
(tiie ganglionic nerves).
To spealr only of the cerebro-spinal nerres, and of these only in relation to the ftinctions of motion and sensation ;
they ai« to be distinguished into three classes, according as destined : (1) to sense, (2) to motion, (3) to both motion
and seasation. Szamples of the first class are the olihctoiy, the optic, the auditory, of which last he considen the
portio mollis and the portio^nra to be, in propriety, distinct nerres ; of the second class, are the large portion of
tbose pssrtng to muscles, ss the fourth and seventh pain ; of the third class are the three lingual nerves especially, the
ninth pair, flfarHs of which he had frequentiy traced, partiv to the muscles, partly to the gustalory papiUe of the
tpugne, aiMl the subcutaneous nerves, which are seen to give oflT branches, fint to the muscles, and thereafter to the
tactile papnisB of the skin. The nervous fibres which minister to motion, are distinct in origin, in transit, in termina-
tion, flnom those which minister to lensation. This is manifest in the case of those nerves which run from their origin
in eefaxate sheaths, either to an organ of sense (as the olfSactoxy and optic), or to an organ of motion (as the fourth
and sixth pain, which go to the muscles of the eye) ; but it is equally, though not so obtrusively true in the case
where a n«rve gives off branches, pully to muscles, partiy to the cutaneous paplllsa. In this latter case, the nervous
fibrils or flstnlse are, from their origin in the medulla oblongata, to their final termination in the Ain, perfectiy
disrinct The medulla oblongata is a continuation of the encephaios, made up of two columns, fh>m the After-Brain.
Imsaediately or mediately it u the origin, as it is the organ of all the nerves. As in both respects it is double, for
one part, the organ of sense affords an origin to the sensitive fibrils; whilst another, the oigan of motion, does the
ssme 1^ the motoxy. In their progress, indeed, after passing out, the several fibrils, whether homogeneous or not,
are so conjoined by the in vesting membnnes, ss to exhibit the appearance of a single nerve ; but when they approach
their dasUnatioB th^ sapamte, those for motion ramifying through the muscles, those for sensation going to the
rataaeous papilte or other orsans of sense. Examples of this are afTorded in the ninth pair, the fibres of which
(sgaiast mors modem anatomists), he holds to arise, by a double origin in the medulla, and which, i^er running in
the same aheaths, separate according to their different ftinctions and destinations ; and in the seventh pain, the hard
and soil portions of which ars respectively for motion and for sensation, though these portions, he elsewhere maintains,
ooght rather to be considered as two distinct nerves, than as the two-fold constituents of one.
"Ae pioof of this is of various kinds. In the first place, it is a theory forced upon us by the phenomena ; for only on
this snpposition can we account for the following fkcts: (1). That we have (Ustinct sensations transmitted to the
brain oiok different parts of the same sensitive organ (as the tongue) through which the same total nerve is diffused.
(2 J. That we can send out from the brain a motive influence to one,— nay, sometimes to a part of one muscle out of
a plvratity among which the same total berve (e. g. the ischiatic) is distributed. (3). That sometimes a part Is either
on the one hand paralysed without any loss of sensibility, or on the other, stupified without a dimunition of
lis mobaity.
In the SBcead place, we can demonstrate the doctrine, proceeding fh>m centre to periphery, and fh>m periphery to
centre. Though ultimately divldinic into filaments beyond our means of observation, we can still go finr, in following
<mt a oerve, botili in its general ramifications, and in the special distribution of Its filaments, for motion, to the mus-
cIm, and for sensation to the skin, etc.; and how fkr«o-ever we are able to carry out our investigation, we always
find the least fibrils into which we succeed in analysing a nerve, equally distinct and continuous as the chord of
vhlch they weiv constituent. And again, in following back the filaments of motion from the muscles, the filaments
of ssnsaftoD trom the skin, we find them ever collected into larger and smaller bundles, within the same sheath,
but never kwing their individualitv. never fbsed together to form the substance qf ti large chord. The nerves are
thus not analogous to arteries, wbtcn rise firom a common trunk, convey a common fiuid, divide into branches all
similar la action to each other, and to the primary trunk. For every larger nerve is only a complement of smaller
Bcrvea, and every smallest n«*rve is only a fssiculous of nervous fibrils; and these, not only numerically different, but
often lUfferinK from each other in the character of their fkinctlons.
** In the Aird place, that in the nerves for both motion and sensation, are enveloped distinct nerves or fibrils for
their srvcral functions — this is an inference, supported by the analogy of those nerves which are motive or sensitive
esHosively. And in regard to these latter, it becomes impiisstble. In some cased, to conceive why a plurality of nerves
■houUl have been fbond necsssaiy, ss In the case of the two portions of the seventh pair, in reality distinct nerves. If
We admit the snniositlon that eacti nerve, each nervous fibril is competent to the double office.
** In dft«/o«rA place, the two species of nerve are distinguished by a dlflerence of structure. For be maintains thi*
old Galenic doctrtna, that the nerres of motion are as compared with those of sensation, of a harder and more fibrous
textUTv;— a diveraity which he does not confine to the homogeneous nerves, but extends to tho counter filaments of
the heCpivgeneous. This opinion, in modtrm times, by the minority surrendered rather than reflated, has been also
s«bw"<|aeiitly maintained by a small number of the most accurate anatomists, as Malacame and Reil ; and to
this rwsolt the recent observations of Ehrenberg and othen seem to tend. (See Memoln of the Berlin Academy
t,T liWs p. €(i5.sqM Mueller's Phys., p. A9B).
** Finally, to the objection — Why has nature not, in all cases, as in some, enclosed the motive and sensitive fibrils
in dtsf inct slteaths ? As answer, snd If/tfc argument, be shows, with great Ingennity, that nature does precisely what
in the drcumstances. always affords the greatest security to both, more especially to the softer fibrils ; and he might
ha««« added as a sixth reason and second answer, with the smallest expenditure of means.
The svlitilty of the nervous fibres to much greater than is commonly 8aBpect«>d ; and there to prol«bly no point
of the bndy to which they are not distributed. What to the nature of their p<*ripherai terminations it to, however, diffl-
cult to dnmonstrate, and the doctrines of Ruyseh and Blalpdghl in this respect are, he shows, unsatisfactory. (The
W.>rks of Thomas Beld, D. D.; Notes and Supplementary Dissertations by 8ir William Hamilton, Edinburg, 1858, pp.
Varcelias Malpighi, held the ancient opinion of Plato, that the Brain is an appendage to
the Spinal Chord, in which medullary fibres collected together radiate towards the brain.
aotil thej end in the cortical portion, just as the fibres in the stem of a cauliflower, radiate
into the leases. Pracassatus, also adopted this opinion, and Thomas Batholin, afiBrmed, that
this was both new and peculiar, and that by it he could understand, how fishes, on account
of their small brain, are dull as to sensation, but agile aS to movement, from their large spi-
nal chord ; especially since in the incubated egg also, the anterior part of the brain is devel-
oped at a much latter period than that in which if the chick be touched it contracts. It i?
well known however, that Plato, had already stated that the spinal chord is first formed and
the brain is an appendix. Malpighi maintained that the cortical portion, secretes by means
8 Introduction to the Study of Diseases of the Nervous System.
of a gUnduUr structure, which be pretends it contains, a coagulable serum, from arterial
blood, and that it is necessary to sensation and movement, that this fluid be transmitted from
the cortical to the medullary matter. It did not seem possible to him that there could be a
reflux of this serum, in the nerves to the brain, so as to cause sensation, since the new serum
perpetually secreted, resists the retrograde movement. Ruysch, in opposition to Malpighi,
endeavored to prove by his injections, that the cortex of the brain is not glandular, but con-
sists of parallel vessels ; but Albinns clearly showed that the cortex of the brain was not
altogether vascular.
The doctrine of the Leyden school and especially of Boerhaave and Albinns, in regard to
the nervous system, and in particular touching the distinction and isolation of the ultimate
nervous filaments, does not seem to have been universally adopted, although in the works of
Unzer and Prochaska, similar views were advanced ; and it appears strange that Johann Muel-
ler, the most illustrious physiologist of the present century should have claimed as peculiarly
his own, the doctrine, " That the primitive fibres of all the cerebro-spinal nerves are to be
regarded as isolated and distinct from their origin to their termination, and as radii, issuing
from the axis of the nervous system.'* Mueller, even vindicates his right to this so-called dis-
covery, against other cotemporary observers, by stating that it had been privately communi-
cated by him to Van der Kolk, of Utrecht, so long ago as the year 1830.
John Augustus Unzer, gave to the world, his '* Principles of a Physiology of the proper Animal
Nature of Animal Organisms,'' in 1771, at the mature age of 44, and after he had been
virtually engaged for a quarter of a century in its preparation. His work therefore has been
justly considered, as the product of a powerful metaphysical intellect, in the prime of its
strength, and thoroughly informed on the subject to which it had been so long and so perse-
veringly and so assiduously directed.
It is probable, that his mind was directed to this subject, by his early associations at the
University of Halle, were both Hoffmann and Stahl had been professors for lengthened periods,
and when Unzer commenced his medical studies, the former was still professor at the venera-
ble age of 79. It was however, as the pupil of Juncker, an avowed Stahlian, that he directed
specially his attention to the metaphysics of vital action. At this time physiology, and
especially the physiology of the nervous system, was fast losing its purely hypothetical
character, and assuming the rank of a science. Mental philosophy had long taken cognisance
of the different kinds of motion in animals, of which every man is led to discriminate at least
three; namely : 1st, those dependent solely on the will ; 2d, those of which he '}» conscious,
but which are independent of the will as the exciting cause; 3d, those of which he is wholly
unconscious, and which can neither be excited nor restrained by volition. The first class of
actions could be readily ascribed to the soul ; but the second and third classed, although
independent of reason, volition, and even consciousness, were equally characterized by their
intelligent and exact adaptation to the wants of the animal. To explain the origin of these
adapted acts, and to determine their relations, to those of the reason and will, was a problem
%^hich bad occupied and baflBed the greatest intellects, from Plato downwards, and a satisfac-
tory solution had never been been given to the wcrld.
During the time that Unzer, was a student, and subsequently, general and histological
anatomy and experimental physiology were assiduously cultivated, and every year, some in-
teresting experiment or discovery was made: Lancisci, Valsalva, Pacchioni, Baglivi, Bantorini,
Morgsgni, and Spallanzani flourished in Italy, Winslow and Vicq d'Azyr, in France, — Albinns,
in Holland, — Lieberkiihn, Haller and SOmmerring, in Germany, — and Cowper Cheselden and
the .Monros in England ; whilst Krtiger, Wrisberg, Meckel, Lobstein, Walther, and others,
made the structure and functions of the nervous system their special study. The progress of
comparative anatomy, and experiments on living animals, during this period, cast vast light
on neurology. The vascular organization of the grey substance was known before the close
of the last century, and it was no longer a question, that the encephalon was the organ of
sensation and voluntary motion, and the seat of the mind. The researches of R. Vieussens,
Haller, T. F. Meckel, Vicq. d'Azyr, A. Scarpa, Th. Soromerrinf:. and of a great number of other
physiologists, had put this fact beyond que5tion. They had demonstrated thftt the dura-mater
receives no nerves, and that it is destitute of all sensibility, and could not be the source of
any movement. It was shown also by rigorous observation, that all the nerves coincide, and
are united at the base of the brain, in that part termed the protuberance annulare, from which
it was inferred with some probability, th::t this was the sensitive centre of the animal — the
place where all the sensations centred, and from which go forth all voluntary and retlex
actions.
Thus, during the preparation of his great work, new facts were brought before the intellect
of Unzer; it is nevertheless true, however, that he lived and wrote far in anticipation of
his age and his contemporaries, and that which he established hypothetically. but logically,
has since been demonstrated by dissection and experiment, and much (bat he advanced,
remains to he duly appreciated.
Uns&er endeavored to distinguish the physical forces, from the vital, nervous and intellect-
Introduction to the Study of Diseases qf the Nervous System, 9
ual forces of aniraalSi.and if his analysis was defectiTS in some respects, it was necessarily
40 from the imperfect state of those fundamental branches of knowledge upon which the
more restricted and complicated phenomena of living beings, depend for their proper eluci*
<lation and development.
The following is a brief outline of the work :
The priDutry seat of the animal forces, is in the so-called proper animal machines, namely,
the brain with its animal spirits, together with the nerves, through which the latter are com-
mooicated to the mechanical machines.
ADimal nature, is the aggregate of the proper animal forces, and the science of these
aocomplieated, is the pkynolo^ of aninuU nature. All animal forces act, when untrammeled,
either necessarily in connection with the mind of the animal or not ; and thus the science is
divided into two great divisions. The first treats of the animal nature in its connection with
mind, that is, in other words, with reference to the animal sentient forces ; but the second, in
reference to the nerve fortes^ independently of the mind; out of these a third division arises,
which describes the animal nature ae an independent whole, compounded of these two animal
forces.
The First Part, is devoted exclusively to the animal sentient forces of the auimal machines,
vbich are considered with reference to their action, in two ways ; namely, partly per se, as
ihey tbemselres act in the animal machines— the brain and nerves — and partly in reference to
their in/hience on the mechanical machines j with which the nerves are incorporated. In the con-
ciodiog chapter, the connection of the coneeptive force, and the animal moving forces, or in
other words, of mind and body is set forth.
Id the Second Part, the nerve forces are treated of, so far as they act independently of the
mind. It is shown that, besides, the animal sentient forces of the brain, there are only two
kiads of forces of the nerves which act in the body, as animal motiye forces, namely, the
Mose-tike impressions, which are divided into internal and external. These two kinds of
impressions are considered in the second and third chapters respectiv^ely ; and in the fourth,
their relations to the mental forces are elucidated. Modern physiologists, Haller, Zimmermann,
Whytt, and Oeder, had rendered much service to this department of physiology, by contri-
batiog materials thereto. E[aller, indeed, began to trace out the plan of this new department,
which certainly did not exist before him, but there he stopped : Dnser ventured to extend this
ostJine, with the hope of inducing able men to complete it. The most important progress
which Unzer accomplished in this matter^ consisted of the following : he defined the two
kiads of impressions, and the entirely different law by which they move the body without
having recourse to the hypothesis of rital spirits, as a motive power ; for these sense-like
impressions can be considered simply as phenomena, and their laws of action discovered
without a knowledge of their nature ; and he derived primarily from the nerves, that motive
force of the external impression, which Haller assigned to the muscular fibres, under the
4e2igoation of irritability^ but denied it to be a property of the nerves ; and finally, he demon-
«trated in advance of Le Gallois, Lobstein, Philip, Sir Charles Bell, and Marshall Hall, the
doctrine of reflex action, or the deflection and reflection of the impressions in the nerves,
whereby Uaxer affirmed, that many phenomena of the animal economy, hitherto inexplicable
can be understood, and he showed how the vis^neroosa is suflBcient of itself to develop these
movements in bodies, which were formerly attributed to the influence of the mind or soul,
«ad vite versA, Unzer details many facts to show that the spinal cord constitutes a separate
ceatre of aervoas influence not necessarily connected with the action of the brain, and he
clearly recognized the influence of the nerves over secretion and nutrition, and anticipated
b; Dearly a century the doctrine of the so-called Bxcito-Secretory functions of the nervous
srgtem, the discovery of which has been claimed by physiologists of the present day.
Id the Third Part, Unzer describes the economy of- animal forces in general, and traces as
it were, the course of life in animal nature, classifies the different genera of animals, from
the irrational to the rational, and treats of the origin of Ufe, maturity of the animal forces,
dfrbne and death of animal nature.
The following qnotations, which I have selected from various portions of bis work, will illus-
trate the views of Unzer, with reference to some of the more important questions and doctrine^
^f oearo-pfaysiology and pathology :
''Th« pnyper ■nlmml machines in animal organisms are the brain and neryes, in which the rital spirits (the nenrons
Md), Brepffodaeed and distributed, with the object of constituting the medium of the functions of these organs.
"^ fkt bratm m Oc aeal of Ike son/. We feel that we think in the head ; nowhere else are we conscious of our exist-
-■€< : ia BO other org»a is there a thought, or an idea or consciousnoM. Now, since the sentient faculty of animals
ii their sool, the aoal can have its seat nowhere else than in the brain, and it would be absurd to maintain that it Is
4iffand thrsoghovt the body. It Is snAcient to a physician to know, that the thinking faculty can hare no other
ofM thsn the madallsry matter of the brain.
* The Vnm i» tk* lahi>rotorg of the vital •piriU. It appears certoin that there is such a flaid essence secreted fkom
tk« T«ssels of the gray matter of the brai i into the hollow tubes of the medullary matter, which is carried into the
isbfs of the nerrea to their termination, and supplies the principle whereby the nerves are rendered capable of being
'k« ar|»as ot the eenaaa and of movements. (Haller's Physiology, Sec. 383). As the gray or cortical substance of the
^^a is the scrretin^ organ of the rital spirits, the medullary substance must be the seat of the animal sentient
fotws.
1() Introduction to the Study of Diseases of the Nervous System,
**Tlie bnin also giTM origin to all tb« nerrw, which «ra oontinuatfoD* of the oortloal whutanc*, gir^n off partly
from it directly in small bundles, termed the czaolal nerree, and partly flnom a thick cord of It termed the spinal
marrow, whi h paoaee through the spine, whence the nonres are distributed to all parts of the body.
** The oerres geneially are enclosed in an Inrestlng membrane, and, like the blood'^essela, diride and sob-divid*
in the greater part of the body, which they either penetrate or form loops in ; or, haying loet tbelr InYeettng mem-
brane, are so Incorporated with th • soft parts, that they can be no longer traoad. Their essential element is tbr
medullary nmtter of the brain, or the soft substance encloeeJ within the cortical substance of the brain ; whrres^
their investing membrane seems to have no share in the proper animal functions allotted to them. Ivery nerre b a
bundle of much smaller fibrils, each of whidi runs an independent course to and from the brain. ISrery nerve hs»
its special point of origin in the brain, and every fibril must have its special origin from that point, fma whence It
takes an entirely independent and separate couive through the medulla obfongata and the s|rfnal cord, to it>>
ttilnntt-st termination. According to ill pn>bability, the fibrils of the nerves are hollow canals.
** The nerves so terminate externally, that either they are incorporated with other machines of the organism appro-
priated to certain movements, or they are distributed over the skin or other parts of the body, aa the eyes, ean, etc.,
without excitlns; sncli machines to motion. If they be appropriated to certain movements, or at least without ou^per-
Htlng therein. The first are termed, in relation to their function, tnolor mrvm; the other are' soHlCtre aerset. Tue}
are, nowever, identical in structure and only differ in their local relation. Bach nerve may be either the one or tUr
uther, according to its distribution, and each motor nerve is at the same time endowed with the properties of tb«-
i«onsitive. The motor nerves have ganglia, composed partly of their own fibiils, and partly of other nervous twi|c»
and nervM which accompany them, whereby the direct course of the fibrils and nerves is interrupted. The nerri^
of the senses, which have no motive influence on the mechanical machines of the orsans, have no ganglia.
'*All the phenomena of motion and sensation manifested through the nerves, render probabl«« the existence of «
reiuarkabh subtle fluid essence, which is present invisibly in the medulla of the brain and nerves, and Is tb» mesn«
whereby all the functions of both are performed. It is termed the vital tpiriU or aemoM Jhud, Init It is not known
how and when it contributes to the animal ai tiona. It la not that fluid matter which Is seen in the medulla of thr
brain and nerves, but a much more subtle spirit, Imperceptible to the senses. It is inferred from the pbenomt<na
which betray Its existence, that this nervous fluid is a remarkably mobile flnid, a sjdrituous vaponr, which ca i be
neither aqueous, not glutinous, nor elastic, nor ethereal, nor electrical, pp. 17-18. • • e
" The scat of the soul is In the brain. Whenever the braiu is deftroyed, or its natural (hnctions intarmpted, thr
sentie.it force ceaaee to act So soon as It is restored to its natural functions, conceptions return. The whole brain if
not Immediately necessary to thought, since large portions of it may be lost or be defective, or be oompressed, or omi-
fled, or its functions otherwise interrupted, without any perceptible Influence on the mental powen, which, *» to thi*
cortical substance at least, is not remarkable, because it Is not the seat of mind ; but It cannot be deduced from any
observation whatever, that the whole brain may be wanting, (as, for example, when the heiwl is rem«ived, or the brain
entirely destroyed, or the functions of all Its parts generally Intorrupted), and the slightest trice of mental upera-
tions ever be perceived. Further, when a thought arises in the mind, a change must necessarily occur ooncnrreati;
therawith In the brain, and particularly In the medullary substanoe, without which the sentient force ournot art :
snd when this change occun in the brain, the sentient force is necessarily excited into action.
Whatever may be reasoned on the matter, a change In the bndn must consist in a morement, and the medrllary
matter must also be endowed with a motive force, which a^ in harmony with the sentient force. Bo that oadi dis-
tinct claas of perceptions is always connected with certain animal movements, and with the movements of a certain
claas of perceptions ; for it is ascertained from numerous observations, that after certain ii^uries of the mednllao
portion of the brain, especially of that part ftom which the nerves of sensation arise, certain kinds of perceptions, a«
ibr example, certain sensations, are prevented or disappear, and together with them all the ideas, deairas and instincti
dependent thereon, as well as other faculties of the mind. (Ualler.) This motive power of the brain, which is oon-
nected with the senti(*nt force (mind), is an animal-sentient force, and hence anses lk$ fimdammlal fftmm at primeiflt m
the doctrine of tke oomteelion between body and miiui, that the medMUari/ mtUlmr of As brofo pontmm <m ammnl sswli'wir forcA,
by vi^anjt of whieh^ at efDerg act of mmdy whether U bea isnteffoa, Jmagfaoltoa, (isrfpt, nj^lsetioa or eomebmiom, Asrs m pro-
dtKtd im U a eerlaim ammal moiwiMNl, wsoawary lAsrelo, isMomI MJbtofc Os oel e/ ttou^U am wsilfcsr oHm war eenlfasw, ami
with whieh U imfaOM^ arinee and oomtmnmt p.2i. • •
^ External impressions may be made on many nervea at the same time, and the mind can distinguish all and each
of the oxtomal sensations thence arising, although the Impressions come from the moat distinct nervea Into a com-
mon trunk (as, for example, the spinal oord), b^re they reach the brain, and there form the material ideaa of aa
fxtomal sensation. In the same nerve, and at the aame time, different impremlona may be made, yet the mind aoco-
mtely distinguishes them ; so that every external Impreaslon on each part of a nerve takes also an uninterrupted course
to the brain, and can there fonn the material sensation peculiar to itself, and distinct from all othen, without belnK
confounded or mingled, either on its way with other Impressions ascending at the)mme tima, along the nerve, or with
the material sensations which arise at the same time in the brain. The reason of this is, that the terminating flbrib
which receive the impressions, run a distinct ooune to their origin, and remain quite separate, however they may b«*
united with other fibrils to form an entire nerve, or however the latter may be united to form larger trunks, as the
spinal oord. Further, at the place of origin of the nerve in the brain, there ia a distinct point' where the material
Ideas must be developed frv>m the external impressions which it brings to the brain.** Chap. 11, pp. 36-37.
*' It is incontrovertible that many nerved, although sensitive, are mainly appropriated to certain special motr-
mente; and that the external impressions necessary thereto, are seldom or never transmitted to the brain, or ooly
those of a certoin kind ; but that, tor the most part, it Is their normal condition to remain In the nerve. The nenre»
of the stomach, intestines, and heart illustrate this point.
** What prevents the propagation of all these Impresnions to the brain ? There is nothing to be found in the nerre*
adapted to this end, except certain formations found scattered on the motor nerves, tormnd ganglia, and the point of
insertion of the smaller fibrils in the larger trunks, where also a sort of ganglionic formed. At those points the
direct course of the flbrib Is intermpted, and hero the external impression traversing the n can be deflected, and it»
transmission to the brain prevented ; the more especially, as the outer thick coat of the ganglion acto In some degnn-
as a muscle, and by a slight compresstion, can hinder the transmission (Monro). But Is it not pro lable that an exter-
nal impression on motor nerves of this kind. Is expressly intendud, when It reaches the ganglion, to be deflected u*
the trunk or branch of another nerve, or to another fibril of the name nerve interwoven In the ganglion ? For there-
by it wonld cacMea reflected or retrognuslve action In the fibril, as If an Impression were excited in it, and sent fium
above downwarda, or as if seat from the brain ; when thus deflected, it puts certain parte into movement. Just as an
impression really transmitted along the nerves from above downwards, and so Imltotes the latter by this reflected
«x>uno. If, however, thi" coixJeciure be groundless, still the fact remains, that external impressions on certain nerve*,
uot received directly, excite movements without reaching the brain, anl without being felt.** Chapter 11, pp. 41
and4Z. • *
Thus, it is Intelligible, how a nerve may retein ito eenslblllty and yet have lost motor power ; being aenslUve and yvt
paralysed, as it is often observed. If on the other band, the obstruction Involves those flbres only at the oer^bra)
origiu of the nerve which transmit the external impression to the brain, the latter will develop no material ides t»
the brain and no sensation in the mind ; but a sponteneous conception can excite a material Idea (an internal imprva-
«ion) at the origin of the nerve, and this may be transmitted along the flbres, and produce actions in the body, such a»
A volnntery movement for example. In other words, th«» same nerve may be insensible, and still the channel of th<-
Introduction to the Study of Diseases of the Nervous System, 1 1
wilL Bow eoold it be poafUe to ezpUin UkMe two cUmmv of phenomena, if the existence of this difference In the
flbrili of the mibo oerre be not edmlttod ? It to niAnifest to eTei7 one, that the nenrous fibrils are distinct, and ie|Mi>
rtmd tnm eofeb other at their origin. From theee and other consideratlotts, which will bo stated subsequently, this
doctrine of two dietiact dassei of nervo-fibrils exlsflnfc in the same nerre, and which are a|q>ropriated to the two
kinds of the internal and external impressions rsspectlTely, acquires an air of tmthfUIness which renders it worthy
of aeeeptaaoe. pw W. • •
** The nerres may hare an lafluenoe over the blood vemel, on the secretions, and on the whole circulation, In rarious
ways. Ib the flrst piaoe, through the kmrt, a compound hollow inusele, thionghoat which nerves from various sources
mn> diatrlbated se in other muscles. These nerves, like all othen, can receive external impressions, since an animiU
CMe when the heart to pricked or irritated. They oonseqaently transmit external Impressluns in such oases to the
hmin, aad prodoee therain at their origin external sensations, or cerebral impressions. When there to no impedi*
It, these are propagated downwanto along the same nerve, and, oonsequenly, may not only have an influence on
ch« movement of the hrart, but may excite sentient actions. In the same way, the sensational conceptions, dedroe,
aod avenlooa, sometimes excite cardiac movements, which are sentient actioiM produced through the nervee by
%Tsrieue mateilal external sensations ; examples of this kind are numwoue, as when ideas, foreseeing^ and emotlonf(
rhange the movementi, p. 90. * •
** 11i# nerves have anodier Influence ; namely, on the vaeoular qjrstem generally, since they are incorporated with
the eoalaof the arteries, and thereby probably supply animal force to the mnscnlar flbree which they surround. * *
* A thlid kind of Inflnenos possBieed by the nerves, is on the veoseto distributed to the mneoles. It almost neooe>
«aflly foUdWB, that the numerous blood vesseto distributed In them are affected by the contractions excited by tlie
•ervcs, ooaeequeatly the latter indirectly fhvor the circulation of the blood in the veins, and agitate and mix that in
thr arteries, hereby fevoring its conne towards the lungs. They regulate the secretions of the liver mesentoiy, etc.,
and dtoaiaii^ or retard thesn, they vrge on the b^ood, and the large muscles of the abdomen Impel the blood contained
in that cavity towarde the heart (Haller's Physialogy, }A16). Many of these acts are sentient, ni^, are even volition-
al ; and If to all theee aetions of the nerves on the blood veowto and the circulation, the direct action of the bninon ItH
aialtltodhMma t-apUlaries be added. It to dear that thto apparently simple mechanical motion of the heart to much
aader the tanportaiit Influence of the mind, and the still more Important influence of the nerves, p. 92. ** *
** The glands are a ttosae of vessek and nerves, and their function is to separate the secretions Arom the Mood. The
exercise the same Influence on these se on other vessels, and, consequently, secretion, which onllnarily
B to be simply physical, to not only animal, but to also sometimes a sentient action. The nerves have the most
lifcel iBflneoce oa thoee gtands which are surrounded by mnscnlar ttosue, or so placed between muscles that the
latter by their action, exprsm the fluid fh>m the glands when secreted ; so that it to ponred out. Sxamplee of thto
kind an the penU (CMIen), the urinaxy bladder, the bowels, the stomach ; atoo the parotid glands which are emptied
l»y thm actkm of the muscles of mastication. (Haller's Phystology, | St33). Many ghinds pour out their secretions
rraoa estenal srasalion, (tltilhition-^pain) ; many ftom imaginations, sensational antidpationB, desires, ete., as, for
•'xample, the salivary glands from the rfoolleotion or antldpation of an agreeable taste, or in hunger; many from
pa^«««» as the lachiyinal and sexnai glands; many even fnmi aeto of will, as when the saliva to stlmnlated to flow
by vwlwBtary masHnafimo, or weeping to Mened.
** The action of the nervee in the viscerals very complex, varying with the number of nervee distributed, or with
the vaxtovs impmssloas of which the latter are susceptible ; or they are influenced by the muscles, mus'-nlar ttosuee,
C&aad<*, etc, which sarronnd, or are in relation to them ; or as the nervee act directly or by sympathy, p. 94. * *
* Neveith**less external impressions on nerves oin proceed to the brain without exciting a vtoible movement in the
l»iiat touched,— "OUi be felt,— and can be reflected. by means of the internal impreasions of the sensation along the
priiKlpal nerve and ite branches, and If there be no hindrances, can excite movemento in the mechanical machines to
which the nerves are distributed, and, consequently, develop sentient actions in other parts by means of the external
— iimtien thos exdted on such sarlhoe. Thus titillatlon of the mucous membrane of the nostrils excttee sneeaing,
•ad a «oavnlsive movement of the diaphragm and resplrKtory rausdee, the nerves of which are in natural connection
with thoee of the nasal mucous membrane ; thus, also, many an external sensation of the cutaneous surface excites
l*y OMaas of the nerves, a tremor of the mnedes in relation to it, which is termed a Amddm: Thus, also, a tltlHs
ttoa of the aaaal mucous membrane exdtes efhision of mucous, which to a sentient action of tltlltotion In the capil-
laries or terminating tubuli of the minute glands. Thus, also, the cutaneous surfiice becomes inflamed, and swells
finm the stimulus of an arrid Irritant Thus, also, cold contmcts the respiratory pores by a sentient action on tht-
mioate terminations of the arteries, and Intermpts persplmtion." Chapter 111, pp. 108-109.
** Kateraal oeasations eadto the fhnctlona of the ptnadi, namely the ejKretum of/lmida ; and when they are enclosed
lo maociilar tissues, the evacnatlon takes place according to their mode of action on muscular timues; but when
ch'ire Is no muscular ttosue, they exdte an afllax of fluid. In virtue of their action on the terminating mouths of the
talmIL Thas a strong flavour excites the S(«retion and riisebanre of the saliva; irritation or pain in the eye,
•"tHtm the flow of tears; thus, also, titiHation causes parts to be Inbricated, by Irritating the nervee of the gtonda,
aad fisvoring a secretion nnd discharge of their fluids; and, also, irritation and pain of the bronchi cause a mucouK
dlediarge from the irritated glands— alt bcin^ manifestly sentient Hctlona In the glands, from exterual mnftations."*
<lM9tarll1,p.llO.
**rhe Sftwial I'lupi iiiiluii oa (fteasnm eaajwodaes fheioeie mo9emm$tM m <Ae hoitg m i/itwtrt f^i, aUkomgk iiknol felt, wnr
SrwasnMsdto As 5r«fo.
**If the nerve of a limb be Irratated with a needle, movemento take place exactly similar to those prudaeed in thf
natwfnl eoadftlon by the volitional conceptions; thus, the diaphragm renews ito motions, as in reepimtion, if the
trask of Itaaerve be inrftated; the body of a dog, or of an ox, (nay, even of a man, as to seen in executions bv
•leeapMatloa \ will be thrown into the most violent volitional movements when the spinal cord to cut through ; if
laeadi aa one the cord be irritated Inferiorly, the movemento Involve the feet only; if superioriy, panting, respire-
rioa, palpltatloa, degtatitfoa and vomiting result When an Irritation of the spinal cord produces spasmodic convul-
'osi of the whole body, bat a particniar nerve has been previonsly divided, the limb to which that nerve is distributed
aaaffected by spasnsodlc action, because the irritation cannot be transmitted to it ; thus, also, a decapitated frog
see up aad springs forward, and If thrown into water, begins to swim so soon as Ito spinal cord Is Irritoted with a
a«edle la the eervlcal regloa, Just as If It knew what it had to do. Bilguer relates a somewhat similar case. In which,
if a eartaia part of the aeck, where suppuration had teken place, was Irritated, the patient was obliged to stand
aprlght In spite of hIaMelf. ete. A great vsriety of well authenticated fiicto of this kind may be found In Haller's
rhjtlMogj'
** Tho Meanacato of the Kin&tdtoplay the influence of the tU nerrom strikingly, because ito adlon to greatest on the
asaeealar aortloa of the orgaatom. These, as a thousand experimento prove, may arise, as nerve actions, although
ihry aeaally occur aa sentient actions irom external sensations and sensational conceptions, instincto and passions, as
won as votitionallr. Thus a decapitated animal will stand, move forwsrd, raise iteelf up, leap, fly, or flutter ItK
wings, seek food, clean, defend or conceal itself, populate, etc. A decaplteted man. Immediately after decapitation,
etmgglee to free hto hsnds, attempt[^^) stand upright and to stamp with his feet ; if the head of a pigeon lie cut off
whilst It to raaaing. It continues to run on for some distance, until it knocks against something; a frog leaps for-
ward without Ito head, so, also, a headless fly flies, a snake, a fish, a worm, writhes and twisU about if touched.
•Ithoagh wholly deprived of sensation ; a fly makes the movement of brushing itn eyes, by a natural instinct.
elthotigh ito head be cut off; a headless snail seeks Ito food by its usual plan of feeling about ; a decapitated tortoise
dot* the same thing, and will live for half a year affer decap1tetion,and raise itself up, or endeavor to do ho, if placed on
Its back : an sar-wlg nips with the nippers of Its abdomen at Ito own separated head, when the head bites the hIm1i>-
12 Introduction to the Study qf Diseases of the Nervous System,
lueD ; the ftbdomen of a wmd will iting ; anloiAlB that fight with th«ir hiod feet, om then rlgoroualy wh«n deci4M-
tatad at erenr Irritation applitd Co the nerret; bvtterlliee, catteriiUlafi and lilk woma oopalate after decmfrftatlon,
and they and flies depodt tiielr oTa ; In ehort. all the inetlnctiTe actione of aoimale are eometliDee eeen to oocnr a»
nerre actione ; and It natnraily foUowa that tnej ooenr at flret in newW bom aaimale as each, and that it is only
after the perception of externa) sensations, that they iMeome sentient actions.** p. 213.
** The following irrafragable tmth fallows from these two leading principles: IrMIs Ike — iwinT mmehinm orv mdowttl
hf matHTt wtik Ike proptrtif of comdmitlmg ertwwl imjn ewtoiM to Ike hraim, lo Aat Ifcy wof fhsrw ensMt molwiaj idest. yMHT
rte to M— niioat, oad of leeetvimg faiw wiif imptimiomt eamted by oeaeiji«>ias, lh«|r obo ptnetet amolker and enUrelif mjfm
nroperlg^ and mnkdmded by malmre to ^eoi, by sniewt of Ike mrtmnal trnprmJomelk^ fscsirs, Ridker Ike laUer remek Ike
are/eU or mot, Ike aame mooememie leMeb mte igoBled wkem Aeif do rvodh Ike brain, oad are felt; amd lo ^eet^ bf
of am faiw mat im^ eetion, trfcfeJb Ikef reoetoeflvma tone* or ierUamt emued by w> eoaoqvMoa wbotoear, lb« mmm siere-
fnaili ae are Reeled h0 mteame of Ae cerebral foroee^ wkem Ike somA faiw mat Um^temion ie ftvdmoed by a eo$toeplio». pi IWL.
** In anImsL with a sentient brain, erery external ImprBSsion which is felt ossses directly to it, and excites therein
a material idea, and in the mind a oonoeftion. Having reached the brain, it Is turned back or reflected, ss it wen>.
and goce back as an Internal impTMsion of a conception. Into thoee nenre flbrils that move the limb, which th^
external impression is enabled to control by means of a sentient action of Its sensation. * * When a poly|M receivee
external ImpressionB, they pass onwards to the nearest ganglion whence they are reflected as if fh>m a brain, either
fntlrely, or In soch a way, tnat they only partly reach other ganglia, and thus they can be reflected many times. If
U snfllcient that at these points the external Impremions are transferred into Internal, and pass agsin from the
ganglia along the nerres to the mechanical machines, which they put In motion, no act of thought taking plac**
during the transformation, because there is no brain, (for in that only is the seat of the oonoeptive force), nor air
the internal Impressions adopted to excite a sentient action.*^ pp. 107-1 W.
** An external Impression is changed into or deTelons an internal impression, wheneror its ooone, which ie
naturally towards the brain fh>m the terminating fibrils, is so reflected or turned back, that it returns in the direr*
tlon from the brsln downwards to the branches and terminations of the nerres. * * In the nenres thera is no
place In which it can occur, except the ganglia of the motor nerres, and at their separation into branches and flbrils.
According to all probability, theee ganglia and points of diTisIon of the nenree, perform In the motor nerres the
ofllce of tte brain, In relation to the external Impressions, since they deflect theee from their course upwards, and
rommuniobte an internal impression, either to otner nenree aud their branchee, or to different flbrils in the same
nenre, conducting In the direction of the brain downwards, whereby theee twigs and flbrils are salli^>ly stimulated,
and such mnecular movements excited, es would have been caused if the external impreseion had reached the brain
and been tnmed back or reflected fVom thence by the intervention of an external senaition. p. 215. • •
** This explains what takes place in similar circumstances, when an impriwion Is made on the spinal cord, and
spasms and convulsive movements are excited In all parts below the point of inritatloo, except those, the nerves of
which are cut through. The reflected external Impression passes as an internal impression to, and only excite*
movements In those muscles to which It can be transmitted from the point of reflection, p. 224.
** Kxamples of this ctem of nerve-actions are to be met with daily, which sometimes are mistaken for sentient
actions (which they often aooompanvX sometlmee for special operations of nnfelt external imprasalons acting through
the brain, sometimes for inexplicable sympathies.** p. 224.
(The Principles of Physiology, by John Augustus Unaer; Translated and Mlted by Thomas Layeook, M. D.,
Sydenham Society, July, 1861).
George ProcbMka, born at Loapitz, in Moraria, April 10th» 1749 ( Professor of Anatomjand
Diaeaees of the Eje, at Prague, 1778, Professor of Anatomj, Physiologj and Diseases of the
fSje, at Vienna 1791), published his work, '*De Punctionibus Sjstematis Nerrosi," in 1784.
Prochaska adopted the principle of a general seusorium commune, but subdivided it
in accordance with the views of Willis, into a rational and corporeal soul in man ; thus, the
sensorium commune of the soul is seated in the brain only, and reflects the impressions of
which we are conscious; and the sensorium commune of the body, which is seated in the
brain, spinal cord, and ganglia and plexuses of the sympathetic system.
Thus Prochaska held that the brain only is the seat of the wul sensorium ; the seat of th^
body sensorium is the brain and spinal cord, and, as all obserTation shows, the ganglia and
plexuses of the nerves. That external impressions can also be reflected in the brain without
consciousness, is shown by the involuntary convulsions of voluntary muscles. Monsters born
without brain and spinal cord, and which live up to the moment of birth, show that the
consensus of the nerves, necessary to this form of life, imperfect though it be, may take place,
and that there may be a corporeal sensorium independently of the brain nod spinal cord,
and which consequently must be constituted by the plexus and ganglia of the nerves. The
movements observed to take place on irritating the nerves of a headless frog, and seen also in
decapitated men, prove the same thing. The sympathetic nerve appears likewise to reflect
it9 impressions in its ganglia and plexuses, without the consciousness of the sonl.
In accordance with this consensus of the nerves, as well in the brain as in the spinal cord,
ganglia and plexuses, the operation of a stimulus is not limited to the nerves immediately
irritated, but is extended to distant nerves, in known or unknown connexion with the irri-
tated nerves ; and this is demonstrated by innumerable examples of consensus of nerves, as.
for instance the irritation in the pregnant utera^i, often causes nausea, vomiting, headache,
toothache, etc.
Prochaska nsed the term, ** vis nerrosa,'* to designate that agent, by which the nervous sys*
tern \9 rendered fit for the performance of its functions. Prochaska illustrated the mutual
connection or law of ** self- conservation,'* between the "soul sensorium and body senso-
rium," by various facts :
** Por instance, the irrftation or Impression of too strong a light, goM to the optic nenrr, from whence It can onl>
get at the rfllary nerves through the brain, and induce oontracUon of the pupil, so an to <>xrlude the loo vivid light
from the eye, and obviate its unpleasant Impression.**
He gives the following examples of reflex actions
Introduction to the Study of Disectses of the Nervous Sj/stem. 1«^>
• • ** Tm7 many InstancM which might be adduced, uodoubtadljr prove thla general law of the reflections of
th* aaoaorioB eommane, of which it may be sufficient to mention a few. Irritation being made on the internal mem-
hraoe of the ooatriia excites sneesing, because the impression made on the olfactory nerves by the irritation is oon-
itnctod alcMig them to the sensorium rommune, there by a definite law is reflected upon motor nerves going to mus-
Hea employed in respiration, and through these produces a strong expiration through the nostrils, whereby the air
pawing with force, the cause of the irritation is removed and ^ected. In like manner it happens that when irrita-
lioa is caoaed io the trachea by the descent of a particle of food, or a drop of fluid, Uie irritation excited is oon-
dnctsd to the sensorium commune, and there reflected on the nerves devoted to the movement of res^ration, so that
a violenC ooogh is excited, a most suitable means for expelling the cause of irritation, which does not cease until
die irritaat be ^ected. If a fHend brings his finger near our eye, although we may be persuaded that no injury 1»
about to be done us, nevertheless the Impression carried along the optic nerve to the sensorium commune, is there so
feflerted upon the nerves devoted to the motion of the eyelids, tliat the eyelids are involuntarily cloeed, and prevent
th* offensive contact of the finger with the eye. These, aud innumerable other examples which might be brought
forward, manifestly show how much the reflection of sensorial impressions into motoriid, effected through the senso-
riwni commune, has reference to maintaining the conservation of the body.
* Mnce the principal Sanction of the sensorium commune thus consists in the reflection of sensorial tmpressloni*
into motor, it is to be noted tliat this reflection may take place, either with consciousness, or without oonaciousness.
Tbe movements of the heart, stomach and intestines, are certainly In nowise dependent on the consciousness of tho
•oal, for iriiilst no muscular movement can be excited, unless a stimulus applied to the sensorial nerves pssses, by u
P<>mKar raflectlon, to the motor nerves, and excites contractions of the muHcle, it is at the same time certain that
th* rdl«etfoo of the impressions suitable for exciting those movements, if it take place in the sensorium commune, in
HIectcd without consciousness. But it is a question whether these Impressions, in order that they may be reflected,
do raally timvel so for as the sensorium commune, or, without taking this long circuit, are reflected nearer in the
ieaaflia» ftom whence thdse parts derive many nerves ? But that reflection of sensational impressions into motor are
«<ffccted In the sensorium commune itself, while the mind is altogether unconscious, Is shown in certain acts remain-
tog Id apoplectics deprived entirely of consciousness; ^for they have a strong pulse, breathe strongly, and also raise
ch^ band, and very often unconsciously applv it to the affected part. The sensorium commune uso acts independ-
rntly of consdonsnem in producing the convulsive movements of epileptics, and also those which are sometimet*
utesrved In penons buried in profound sleep, namely, the retractions of pinched or irritated limbe, to say nothing
i»r the oiotion of the heart, and of tie respiratory acts. To this category also belong all those motions which remain
for aome time in the body of a decapitated man, or other animal, and are excited when the trunk, and particularly
the medulla spioalis, are irritated, which motions certainly take piece without consdousnesa, and are regulatod by
tbe remaining portion of the sensorium eommane existing in the medulla spinalis. All these actions flow from the
tifgaalam, and by physical laws pecnllar to the sensorium commune ; and are therefore spontaneous and automatic.
Tbe actions taking place in the animal body, with accompanying consciousness, are either snch as are independent of
voUtfoHior such as the mind can restrain and prohibit at pleasure ; the former being governed by the sensorium com-
mstte alooe Indi^ieodeotly of the mind, are ss much automatic as those of which the soul Is unconscious. Of this
ebaiacter are soeesing, flrom an irritant applied to the nostrils,cough, fh>m an irritant fallen Into the trachea, vomit-
ing, from a titlllatfon of the Ibnces, or after taking an emetic, the tremors and convulsions in St. Vitus* dance, and in
a paioxymn of Intermittant fever.
"Farther, it may be asked, whether the external impressions made on the terminations of the nerves and passed
unwaids Io the ganglia are extinguished In the ganglia themselves, or whether, being reflected by a fixed law, they
fHvm again along the nerves to tiie parts to be moved ? The celebrated Unser, and the eminent Winteri taught,
that axtemal impresakma are reflected in the ganglia, as they are reflected in the $emaorwm oommiNM, and that the
fT"g"* are special sensoria,— a doctrine which does not appear altogether destitute of probability. For if we con-
rider that the minute and invisible nerves disseminated over the internal membrane of the heart and auricles, per-
<>dv« the sttmalns of the inflowing venous blood, and although they cannot transmit the impression of that stimulus
to dM swspiniam eptwimn through the ganglia of the intercostal (great nrmpathetic) nerve, yet communicate it to
ibe motor nerves distributed through the substance of the heart (ventricles) and auricles, it follows that there is
neeeasarily a oonaensns between the sensory nerves distributed on the inner membrane of the heart and the motor
nerves dimsminated through the substanee of the heart (ventricles) and auricles, which must take place either in
^anclfo of the Intercostal nerve, or below them, in the communicating branches or plexuses of nerves. It seems
pfobaUa, therefore, that besides the Mnsorfom cofmmnM, which we conjecture to be in tbe flMdnIZa oMtrngata, mednOa
«MMiii, pern vutoUi and erara of the eenbntm and oerrbeOum, there are special tenaoria In the ganglia and plexuses of
the nervsn la which external imprsssions ascending along the nerves are reflected, that need not ascend all the way
to Iba siwrieiii eoiswaws, to be reflected thence.'*
ProchAska also thus noticei the important distioction between the two great classes of
iQToliiDtary and toI notary acts :
** Vevertbeless, this need for rest seems only to bo a characteristic of the nerves which are subordinate t>>
tbe will and not to the involuntary, which have to provide for the motion of the heart, respiration and digestion ;
and nbuas vis-nenrom is active, without intermission, during the whole of life, although It may be weaker or
•trooger ; though it cannot be doubted, that both kinds of vis have a similar origin, and are of the same natunv
«til1 observation shows that ths one belongs to the will, the other is involuntary ; that the former Is exhausted by
i*nasttorn and nMytlon, and requires rest and repose ; with the latter the contrary takes place ; and Anally, that the
r«o kinds of vis are Independent of each other. This distinctuew and Independence of the voluntary and involun-
tary vis-nervosa is shown, not only In sleep, but also In apoplexy, when the voluntary vis-nervosals quite arrested,but
tbv involantaiy performs its duty. So, also, in cases of fever, the voluntary vls-nervosa Is quite weakened, but tho
lotoluatary Is so much the more active."
Procfaaska records, in bis carefnl and coraprehensiTe description of the different parts ot
the nerrons system, tbe fact that fbe fifth pair of nerres, and all the spinal nerves, are
enlarged near their orii^in by ganglions. In like manner, with Unzer, he dwells upon the fact,
that oatare proceeds gradually from the most perfect and highly complex brain, to the sim*
pier and simplest ; and that^ at last, animals exist altogether devoid of brain.
Prochaska also noticed the influence of the nervous svstem over the blood vessels, and
enpecially tbe capillaries ; and refers the congestion and increased secretion induced by local
irritaotn and certain medicines, as purgatives, not merely to the irritation of the extreroitic <>
of tbe nerves, but also to a reflex action. Thus, he says :
phenomena take place if the nerves be stimulated locally ; but the same thing hsppens when the nerT«*»
«r» #xriiMl, not directly, but Indirectly through the brain. We know that thwt the (acr- h suflTuiMNi with tli»-
1 4 Introduction to the Study of Diseases qf the Nervous System,
bliuh of modmiy ; grief eaaaes a ooplovt flow of te&n, eoofwtloB of the Teaeeli of the ooi\JttBctiTa and iwelllog of the
whole face. The alglit of acreaable fbod proTukee the lallTa; itii not uniuiial for eoiDe penone to Tomit or he
pnrsM by only eeeing a medicine ; a iMdTioas Idea erecta the penle, etc.
*' The fkce ox a man etnick with raddea terror to pale, and eome men become pale when In a naroxyam of iage«
which pale neai la without doubt owing to a repulalon of the blood fhtm the cntaneone blood TeaMUf to thoee in Uu*
interior of the budy, Inasmuch aa the nerroua ayatem la affected in terror or rage, the queatlon ariiaea, whether the
cutaneona nerrea then affected completely repel the blood fh>m the rotaneoua veaaels, by contracting them to tbi*
inner veaaela of the body?
*' Other phenomena occurring in the natural atate, beaidea thoae mentioned In the preceding paiagiapha. are int«l-
ligible by thla oonceatlon ariaing in the Irritated part. And in diaeaaea there are frequently opportunitiea for ob>
Nerving the operanon of that nerroua influence on the Teaaela, In Tirtue of which fluida flow more eopioaaly and
Immediately to the irritated parta. Inflammation Itaelf la nothing elae than a powerftil attiactJon and derlation of
Mood from a atimulna, by which the Teaaela beoome filled, awell, are rendered tenae, red, painful, etc. If thia atimu*
lua be aufllcienUy powerrai, It dcawa the nenrea of the heart into aympathetlc action, and by increaalng the moT«^
menta of the latter, producca fever, the ooacommltant of Inflammation.**
■
Prochaska aUo discassed the question. " Have the nerves any influence on tecreUon f "
Boerfaaave, in cooBideriag the causea which operate in prodacing each varied secretions
from the blood, did not attribute anjdeBnite share to th*} nerves ; Haller conjectured that the
nerves operate in the secretion of the fluids, since they surround the vessels of the vlscerA
like sphincters, and thus either delajr or promote secretion ; Tissot also devoted an entire sec-
tion of his work on the functions and diseases of the nerres, to the secretions, for the purpose
of demonstrating how much the latter are dependent on nervous influence.
The observations of Prochaska on this subject, are of special interest when viewed in the
light of recent experiments upon section of the sympathetic, and injuries of certain parts of
the spinal chord. Thus he remarks :
** In tmth, aince it haa been ahown bow great la ttie Inflnence of the nerrea on the veaaela, in virtue of ahJcli
■timali can axcite a more oopioua flow of fluida to a part, we infar that the aame thing occurain the aecceting vl»-
oeia, which oonaiat almoat entirely of veaaela. 80 aoon, therefore, aa, by nenroua action, the fluida are more copi-
oualy attiacted to aecreting vlaoeia, the aecretiona are neceaaarlly increaaed. Moreover, aince the nerrea have tar
property of oanaing apaama, or contraction of the oaplUariea, it ia manifeat that the aecretiona may be dimlniabed, <ir
entirely Intenrupted by the influence of the nervea, the aecreting veaaela being entirely cloeed by oonatriction.'*
Prochaska adduces various examples, at the putrid and dissolved state of the blood in
fevers, the elTecis of section of the eighth pair of nerves in altering the character of the secre-
tions of the stomach; the vomiting of foetid, biliou.4 matter, excited by disease of the brain
and by irritation of calculi passing alon^ the ureters, diarrhcea, excited by mental emotion,
the effects of anger in producing jaundice, and in rendering the milk of the nurse unpleasant
in taste and injurious to the child, the effects of the bites of enraged animals, to prove that the
influence of the nerves on the fluids is so great, either at the time of secretion, or when
sfcreted, that it can modify or alter them, or entirely change their nature.*
Marie Francois Xavier Bichat, born November llth, at Thoirette, in thf present depart-
ment of the Ain, undertook his first course of Anatomy in 1797, and published his remarka-
ble work ** On Life and Death,"t In 1 799.
Bichat proposed to divide the nervous system into two distinct departments ; one, composed
of the enrepbalon and spinal marrow and their annexes, subserving the operations of th«*
iindersttinding and the will, and constituting the principal organ of the life of relation, or
animal life ; the other included the great sympathetic, with its ganglions and plexuses, giving
impulse to the acts of organic or individual life, or those functions, in virtue of which an
individual transforms into his own structure nutritive molecules, and casts off those which
are effete, or worn out, and injurious to the system.
Whilst Bichat formed distinct conceptions with reference to the influence of these grand
divisions of the nervous system, and urged with force and eloquence his views as to the differ-
ences between the animal and organic life, he failed to recognize fully the mutual connections
and relations of thecerebro spinal (system of animal life), with the sympathetic, (system of
organic life), and his physiology of the nervous system, as a whole, was inferior in accuracy
and completeness to the systems of Tnaer and Prochaska.
According to Bichat, the functions of the animal are of two very different classes : By the
one, (which is characterized by an habitual succession of assimilation and excretion) it lives
within itself, transforms into its proper substance the particles of other bodies, and after-
wards rejecta them when they have become heterogeneous in nature; by the other, it lives
externally, is the inhabitant of the world, and not, as a vegetable, of a spot only, it feels, it
perceives, it reflects on its sensations, it moves according to its influence, and frt>quently is
enabled to communicate by its voice, its desires, and iu fears, its pleasures and \i» pains.
The aggregate of the functions of the first order, Bichat named the nrganie U/e, because all
organized beings, whether animal or vegetable, enjoy it more or less, and organic texture is
the sole condition necessary to its existence : the sum of the Ainctionf of the second clas».
• ** DIaarrtatton on the rnnctlooa of the Nenroua Ayatem, by fieorge Prochaaka, M. D.** Tnuialated and Kdited by
Thomaa Layoock, M. P., etc., Sydenham flociety. IHAI. pp. :i<i3-4A<).
t ** PhvalolofHcal Reaearrhea on Ufe and Death, by XavUr Wchat** Tranalated fh>m the Prpnch. by B. r. Gold.
Introduction io the Study qf Diseases qf the Nervous System. 15
becAQse it U exclaBi?el>»the property of the aoimal, he denomiDated the animal life. He
rejrarded the Baogoiferous system as a middle system, the centre of the organic life, as the
braio is the centre of the animal life. In this system, the particles, which are about to be
uiimilated, are circulated and are intermixed with those, which, having been already assimi-
lated, are destined to be rejected ; so that the blood itself is a fluid composed of two part« ;
the ooe the pabulum of all parts of the body, and derived from the aliment, the other ezcre-
mentitions, composed of the wrecks and residue of the orgaus, and constituting the source of
(be exterior secretions and exhalations.
As defined by Bichat, the animal and organic life, are each of them composed of two orders
uf fanctions, which succeed each other, and are related and manifested in an inverse direc*
tioD. Thus, in the animal life the first order is established from the exterior of the body
towsrds the brain ; the second from the brain towards the organs of locomotion and the
voice. The impression of objects successively affect the senses, the nerves and the brain ; the
dnt receive, the second transmit, the third perceives ; the impression, in such way received,
transmitted and perceived, constitutes sensation. The animal, in the first order of their
faactions, is almost passive ; in the second, he becomes active. This second order is the
n^olt of the successive actions of the brain (where volition has been produced in consequence
of the previous sensation), and of the nerves which transmit such volition* and of the loco-
iQoiive organs and voice, which are the agents of volition. External bodies act on the
Mimsi by means of the first order of functions, the animal re-acts upon them by means of the
•iecoad. In general there exists between the two orders a rigorous proportion ; when the one
is very marked^ the other is put forth with energy ; in the series of living beings, the animal
vbieh feels the most, also moves the most.
A double movement is also exercised in the organic life; the one composes, the other
decomposes the animal. Such is the mode of existence in the living body, that what it was
«t one time, it ceases to be at another. Its organisation remains unaltered, but its elements
v&rr every moment. The molecules of its nutrition, by turns absorbed and rejected from
ibe EDimal, pass to the plant, from the plant to inorganic matter, return to the animal and so
proceed in an endless revolution.
Bichat endeavored to establish the following geueral differences between the two lives :
The organs ol the animal life are symmetrical, those of the organic life are irregular in their
cosformation and position ; the animal life is, as it were, double, its phenomena performed,
M tbey are, at the same time on the two sides of the body, compose a system in each of
'hem independent of the opposite system ; on the contrary, the organic life is a single system
in which everything is concatenated and concentrated where the functions on one side cannot
^K ioterrupted, and those on the other side subsist. Harmony is the character of the
•oimal, discord that of the organic functions ; the functions of the animal life intermit, the
fooctions of the organic life are performed with an uninterrupted continuity ; in the animal
life everything is modified by habit; the organic life is, on the other hand uninfluenced by
hsbit; whatever relates to the understanding belongs to the animal life, whatever relates to
tbe passions belongs to the organic life ; the organic life is the term in which the passions end,
Aod tbe centre from whence they originate ; the vital properties are only those of perception
tod motion, but in the two lives they possess a very different character ; in the organic life,
sensibility is the faculty of receiving an impression ; in the animal life it is the faculty of
receiving an impression, plus that of referring such impression to a common centre ; there is
usaimal eootractillty which has its principle in the brain, and is essentially subject to the
ioflaence of the will, and receives from the brain the irradiations which put in motion, and
(Cases to exist when the organs, in which it is observed communicate no longer with* the brain :
and there is an organic contractility, which is not dependent upon a common centre, has its
principle in the moving*organ itself, is a stranger to the influence 3f volition, and gives rise to
the phenomena of digestion, circulation, secretion, absorption and nutrition.
Notb withstanding the strong lines in which Bichat drew the apparent distinctions between
tbe animal and organic lives, he admitted that though at the first glance, the two sensibilities
prrgent a remarkable difference, their nature nevertheless was essentially the same — the one
being only the maximum of the other. Thus he says :
" It b erld^fit that the distinction Above eetsbllshed, with respect to M^nailrfllty consiatB In the different niodifica-
tiowof which thia power is snaceptible, and not In ita nature, which la everywhere the aame. This faculty la coni-
i»ra to til th« oTieami and forms their true and vital character; but an it is more or leas abundantly distrlbnted to each.
It c)t«« to meh a different mode of existence. No two parts e^oy it in the same proportion. Tn these varieties then^
us^rre above which the brain Is the term of it, beneath which the oriran alone is seneiltle of the impression. If
H> mufef my Idea* oa this head, tntellii:1ble, I am to use a vulgar expression, I should say that distributed in such a
^^■e to sa organ, odnsibility la animal ; In such another dose organic. Now that which varies the dose of sensibility,
««>iaMinMa the order of nature (in wbicli way the skin and the nerves are more sensible than the tendons and carti-
l*S^': at other time* disease ; thus in doubling the dose of sensibility to the cartilages, inflammation renders them
■^wil la this respect, and even snpeiior to the former, and as a thousand causes, may at every moment exalt or dimi-
*lifa tha power in any part of the Irady, it may be changing from the animal to the organic type.*''
Bichat labored strenuously to establish th(; entire indepcudeiicc uf tlio ccrebro-sftinal aiiil
16 Introduction to the Study of Diseases of the Nervous System.
sympathetic sjstemi ; and the fundamental proposition of his book, apon which the whole
chain of reasoning rests, as to the difference between the animal and organic life, rests on the
idea, that the ganglions cannot transmit the action of the brain to the different organs, because
the nervous system formed by the ganglions, is entirely independent of the nerToas system
of the brain. He af&rmed in the most decided manner, that the great sympathetic did not
derive its origin from the brain, nor from the spinal marrow, nor from the nerves of animal
life ; in fine, according to Bichat, this nerve does not exist, and the so-called sympathetic, it
only the aggregate of as many small nervous systems, as they are ganglions, which are the
particular centres of the organic life, just as in the same way, the brain is the great and
only centre of the animal life.
Notwithstanding this distinct and articulate enunciation of the absolute independence of
the animal and organic systems, Bichat was compelled by numerous facts, to admit that the
two systems were closely related, and could mutually act and re-act upon each other ; such
action and re-action being referred to the vague action of the sympath\<is. Thus he held, that:
** The moift numeroos sympathiM exitt between the internal vieoem and the brain, or ifei different parts. Kvei^
i*tep which we make in pnustloe, preeente ui with affections of the brain originating ^mpathetically, m»m tboee of
the liver, stomach and inteetinea. Mow, •• the effect of every kind of paarion is to produce a cliange of power in the
one or Uie other of theee viscera, such change will sjrmpathetically excite either the whole of the brain or mamt nf
its parts whose re-action upon the muscles, which rsMive from thence their nerves, will prodnoe the motions which
Are then observed. In the production of these motions the cerebral organ accordingly must be passive. It is acUvr
only when the will presides over its effects. The effects indeed of the passions, are similar to those diseases of ^r
internal oigans which by sympathy are the causes of atony, palsy and spsam. * *
** A manls informed by letter and In presence of company, ot a bad piece of news, which it is his Interaat to conceal :
Kuddenly his brows contrsct, he grows pile, and his features, are moulded acoprding to the nature of the pasajos
which has been excited. These are sympathetic phenomena produced by the abdominal viscera, which have been
affected by the passions, and which, in consequence, belong to the organic life. But in a short tinn. the man is capa-
ble of putting a restraint upon himself, hia countenance clears up, his color retuma Meanwhile the intMior seoti-
ment oonUnnes to subsist however, but the voluntary have overpowered the sympathetic motions, the action of the
brain has surmounted that of the stomach or liver; the animal life of the man has resumed the empire.**
CuTier in his Lectures on Comparative Anatomy, delivered in 1800, and translated and
published in English in 1802, presented an elaborate description of the cerebro-spinal and
^sympathetic neivous systems, in man and in vertebrate and invertebrate animals.
Cuvier regarded the ganglia^ when considerable, as each a l(ind of secondary brain, and
observes that they are larger and more numerous in proportion as the principal brain is less.
Cuvier gives the following observations upon reflex actions :
'* The general organ by which we exercise the fikculty of sensation, is the medullaiy substanoe. la all the *"*-*»'-^
in which we can distinguish it, that substance is divided into filaments, which, arising from certain centres, diatribntr
themselves over most parts of the body, whera they appear to serve other properties besides that of prDcuring sensa-
tions. The centres ttom which those nervous cords proceed, communicate with each other in a manner more or lew
intimate, and several of the filaments seem of no other use then to establish those communications. * *
'* The soft white substanoe which forms the essence of this system, is divided info filaments that approach each
other, and unite in bundles, which contain more filaments in proportion as they aro traced nearer to the comnuB
fasdculsB of all the nerves, called the spinal marrow, the anterior extremity of which is Joined to the brain, that is to
say, to a medullary mass of more or less magnitude, and differently formed according to the vavioos kinds of *«ii»^i« .
From the action of external bodies on our own, we peroelve that Uie nerves affected by that action communicate with
the common fMciculus, and that it communicates with the brain. Lecture 1, Animal Economy. Art. ii.
** There appears besides^ in the nervous system, certain phenomena which depend on the union of dlfferant nerrnk
whether that oommunicsJtion be produced by cords pasnng fh>m one to the other, or through the nediam of th*
brain. Those phenomena are called tfmpoOiAm ; they consist of involuntary motions, or rather of sensations, experi-
<*nced in places different flrom those that are affected. These sensations do not seem to depend upon the Inllneace of
the will, or the imagination, and frequently exist while we are ignorant of the place really affected, or the motion that
has occurred.
^ The sneesing which succeeds to irritations of the nostril, affords an example of the sympathy produced by th«-
union of nerves; the nerves of the nostrils, which come from the optbalmic branch of the fifth pair, are oonnect*!
I>y thesympatheticuB nia}or, with the nerves^f the diaphragm, and by this means theexdtement Is communicated. Th**
itneexing which takes place upon looking at a bright light, la to be ascribed to the unibn of the ciliaiy nerve with
the fifth pair; the irritation is communicated to the nose, and thence to the diaphragm.
" Another example of the same kind conHi«t4 in the great changes which the eyds present in different Internal
«ils eases of the body. These changes so important to the physician, are almost all produced by the union of thr
<«ympatheticus major with the fifth pair, and by that pair with the ciliary nerves.
^ Sympathetic affections occur still more frequently, where different parts of the body receive branches of the aani-
iienre which may communicate Irritation.
**Thns tears are excited by a strong smell. This is occasioned by the opthalmic nerve sending at the name Uok
branches to the nostrils and the ia'-hrymal gland.
'*The vomiting produced by pushing a finger into the throat. Is owing to the distribution of the eighth pair of
nerves, which gu both to the pliarynx and to the stomach.
** The eighth pair, or nervus vagus, and the groat Intercostal or trisplaiichnius, are the nerves which piodnoe th«
greatest number of this kind of phenomena, because they are distributed to a great number of parts, and form anton-
with a great many other nerves ; they have therefore been named nffmpaJOi^liaiM major^ and
LActures on Comparative Anatomy, etc., translated by Jamen Macartney, 1802, vol. II, pp. l2(>-ljl.'
The important experiments of Julian John Caesar Le Gallois, illustrating the action of th«
spinal cord, as an independent centre of influences, as well as the philosophical researches
of Lobsiein which anticipated by more than a quarter of a century, many so-called discoveritr 5
in the physiology and pathology of the nervous system, will be more fully considered when we
cxAmine the relations of the cerebro-spioal and sympathetic nerrous systems.
Introduction to the Study of Diseases of the Nervous System. 17
The 6rgi researehes of M. Le Gallois, were made on the foetus in 1806 ; two years after-
wards io 1808. he communiuated his first observations to the professors of the faculty of
mediciue of Paris, and illustrated the effects of decapitation and the functions of the
medulla spioalis; on the 2d and 16th of March, 1809, at the request of M. Thouret, dean of
the faculty of medicine of Paris, he demonstrated publicly before the same Society of
Professors, that the principle of the trunk resides in the medulla spinalis ; and the same
experiments were afterwHrds repeated on the I6th of April, before Messrs. ChH ussier and
Dumeril. whom the society had chosen a committee to examine them, and who made their
report on the 27th of the same month. The subject was far from being exhausted, and M.
LeGalloissoon after began his researches upon the motions of the heart. M. Magendie
proved 90on after by experiments, that it is by acting upon the medulla spinalis that the
poison of ttie Indians, known under the name of upas tieiM^ kills animals ; and about the
.lame time Mr. Brodie, of the Royal Society of London, instituted experiments to determine
the changes of temperature and the state of the secretions in animals kept alire after decapi-
tatioD. Mr. Brodie asserted, that the decapitated animals, which are kept alive, cool as
r«pidly, as if they were dead; but upon repeating these experiments, M. Le Gallois found that
whilst the temparature is considerably reduced, the reduction is less in these animals in whom
the life li preserved by artificial respiration after decapitation, and he pointed out that the
inflation of the lungs was one of the principle causes of the refrigeration, together with
•ierangeroents of the circulation. M. Le Gallois also endeavored to ascertain whether under
these circumstances, the formation of the carbonic acid in the lungs is diminished, and with
A corresponding alteration of temperature The labors of M. Le Gallois, finally appeared in
ttCODoected form in his work entitled '< Experiments on the Principle of Lift ^ and particular^ on
tke PrinapU of the Motions of the Heart and on the Seat of this Principle ;*' a translation of which
by Drs. N. G. and J. G. Nancrede, Appeared iu this country in 1813.
It was not the original object of M. Le Gallois, to explore the cause of the motions of the
beart, as he had adopted the theory of Haller on the subject ; experiments undertaken with
other views led bim to the conclusion, that it was impossible for him to understand his own
experiments, without determining, whether the nervous power influences the motions of the
heart; and if 80, in what way it has this effect. A peculiar case of labor excited in him the
'Jeiire to know bow long a full grown fcetus can live without breathing, after all communi-
cation between it and the mother has ceased. In order to solve this question by direct expe-
rimcnt, be placed the foetus of animals in various situations, similar to those in which the
boman foetus ie occasionally placed, when it ceases to communicate with the mother. When
tbe fcetus suffers decollation from artificial delivery by the feet, he found that the trunk
retains its life, and that if haemorrhage be prevented, by throwing a ligature round the ves-
sels of the neck, it dies in the same time, and with the same symptoms as if without taking
of the bead, respiration had been interrupted; and what completely demonstrated to him,
that a decapitated animal, is in fact suffocated, is that we may at pleasure prolong its existence
by inflating the lungs, to supply the place of the natural respiration. M. Le Gallois con-
ceded from these facts, that decollation, proves fatal by destroying the motions of inspiration,
Md that consequently, the power on which these motions depend is in the brain; but that
ibat on which tbe life of the trunk depends, is in the trunk itself. Endeavoring by destruction
of successive portions of the spinal marrow, to ascertain the precise seat of each of these
powers, be foond that, that on which the motions of inspiration depend, resides in that part
of tbe medulla oblongata, from which the eighth pair nf nerves^ take their rise ; and that on
which the life of tbe trunk depends, in the spinal marrow. By successive destruction of
varioos portions of the cerebro-spinal system, he sought to demonstrate, that it is not by all
the spinal marrovr. that every part of the body is animated, but only by that portion from
which it receives its nerves ; so that in destroying any particular part of the spinal marrow,
we only destroj life in those parts of the body which correspond to that part. His experi-
ments also illustrated the important fact, that if wc interrupt the circulation, in any particular
part of the spinal marrow, life is weakened and soon extinguished in all the parts which
receire nerves from it. There are therefore two ways of destroying life, in any part of an
40tma) ; the one by destroying that part of the spinal marrow from which it received its
aenres, the other by iuterrupting the circulation in that part of the spinal marrow. He
heoce concluded that two conditions are necessary to preserve the life of any part of the body ;
rii: the integrity of the corresponding part of the spinal marrow, and the- circulation of tbe
bloody and consequently that we may preserve the life in any part of the animal as long as
we can preserve in it these two conditions. We may, for example, preserve the life of the
xQterior parts, after that of the posterior parts is destroyed!, by destroying the corresponding
portions of the spinal marrow, or oice nersa. By numerous vivisections and by carefully des-
troying different portions of the cerebro-spinal axis, M. Le Gallois arrived at the conclusion.
*hat the power ou which the motion of the heart depends, resides in the whole of the spinal
marrow, since destruction of any one of its three portions is capable of stopping the circula-
'loa; and that each portion of the spinal marrow Influences life in two different ways ; by
3
1 8 Introduction to the Study of Diseases of the Nervous System,
the one it is essential to the existeoce of life in the parts which receive nerves from it : bj the
other, it preserves it throughout the body in general, by contributing to furnish to the organs
which receive nerves from the great sympathetic, and particularly to the heart, the life and
power (le principe de force et de vie), necessary to the performance of their functions.*
M. de Humboldt, M. Hall^, and M. Percy, in the report which they made to the class of
Physical and Mathematical Sciences, of the Impeiial Institute of'France, on the work of M.
Le Gallots, regarded the following points, as demonstrated by the experiments repeated
before the Committee of the Institute :
1st. That the cause of all the motions of inspiration, has its seat near the part of the
medulla oblongata which gives rise to the nerves of the eighth pair.
2d. That the cause which animates each part of the body, resides in that part of the spinal
marrow, from which the nerves of that part are derived.
3d. That in like manner it is from the spinal marrow, that the heart derives its life and its
powers; but from the whole spinal marrow^ and not merely from any particular part of it.
4th. That the great sympathetic nerve, takes its rise from the spinal marrow, and that the
particular character of that nerve is to bring every part to which it is distributed under the
immediate influence of the whole nervous power.
M. Procbaska placed the sensorium commune, in the brain and spinal marrow conjointly.
(Opera Minora, torn, ii, p. 51). Before bim, however, Marherr. Hartley, and others had been
of the same opinion. Prochaska held that the nervous power was generated throughout the
whole extent of the nervous system, so that every part derives from its own nerves, twkeo
alone, the cause of its life an<l of its movements. (Opera Minora, tom. ii, page 82). Prochaska
only regarded the sensorium as a central point, where the nerves of feeling as well as those of
motion meet and communicate, and which establishes the connection betweeu the diflTereni
parts of the body. (loc. cit. p. 152).
On the contrary, .M. Le Gallois demonstrated that the spinal marrow is not merely a means
of communication, between the different parts, but that from it, the cause of the life and thr
power or energy^ and of sensation and of motion of the whole body proceeds. And what
proves that M. Prochaska, in announcing his opinion, was far from suspecting the functions
of the spinal marrow as demonstrated by Le Gallois, is that he regarded it, with the older
physiologists, as a great buhdle of nerves, cratmsfuniM nerveus.
Up to the time of the labors of Le Gallois, the spinal marrow had been considered by most
physiologists, with the exception of Unzer, as a large nerve arising from the brain, in the
same manner, as all those which pass through the foramina o( the cranium, and which like
them are divided at intervals, in order to supply the intervertebral nerves; in short, this
spinal marrow was considered as a mere bunch of nerves supplying the trunk, as it was often
called. The brain therefore was considered as a centre of the nervous power, and consequently
as the only seat ot the principle of life. But Le Gallois clearly demonstrated, in advance of
Marshall Hall, and other physiologists, that the spinal cord constitutes a distinct system or
apparatus, with distinct functions and relations to the muscular sy»'tem and organs, and capa-
ble of receiving and exciting motor and sensitive and reflex acts.
Thus, with reference to the relations of the brain to the spinal cord, M. Le Gallois observes .
** When I move mj arm. the principle of thU motion emanates Trom the medulla spioalu, and not from the brain,
but it is the brain which determines and ilirects it, in the mode appropriated to the purpose for which I maJce it.
Cold-blooded animals furnish an evident proof of this assertion. If a salamander l>e decapitated, at the lint veitebrs,
it may continue to live for several days; but although it moves its body and limbs with as much force, as would br
to transiiort it from one place to another, it remains in the same place, and it may l>e left npun a plate, without fear
of its eecapiiig. If we examine all its motions, we perceive that they are all irregular and without design. It move»
its paws in o^xMiite directions, so that it cannot advance, or If it takes one step forward, it sooo takes another bark-
wanls. The «ame thing is observed in decapitated frogs; they no longer know how to leap, or if they do leap, it U
only when their hind legs meet with a particular support. If they are laid on their backs, they sometimee agitate
themselves, seemingly to change their situation, but they remain in the same position, becanse they no lunger know
how to make the motions noce»«ry to place themselves on their belly. But generally speaking, all these animal?
perform few motions, unless they are touched, and we conceive that it ought to l>e so since of all the senses, that of
touch alone can transmit impressiuns to them. * *
** Reptiles, as the tortoise and salamander, preserve life lor whole months after decapitation. The tortoise from which
Rodi removed the brain, by opening the cranium, survived the operation for several months. It is a well establishcil
fact that birds continue alive and even walk and run after their heads have heen cut off. The fact has fmquentl;
Ijeen quoted of the Emperor Commodus, vrho, whilst ostriches were runniug In the circus, amused liimmflf
by cutting off their heads with arrows, in the form uf a crescent. These animals were not prevented from running
tu* liefore, and only stopped at the end of the course. Several physiologists have obtained a like result, by decapitatinic
turkeys. (Lametrie CKuvres, Philusoph, ITal, p. Mi}. Cocks (Kaanw Boerhaave, impet. faciens, No. .Kl, p. 2«2, Trii
Tosctti, Mem. sur les part, sniisi, et irritab. tom. ii, p. V.H); ducks, (M.Cuvier, Lecuns Oralen), pigeons (Woodward, citf
par Haller). * * Desault relates in his Journal a case where the signal marrow had been cnt completely acrt>0» b.i a
gunshot, in which the palsy of the inferior extremities did not take place. A like case is found in the AMecto Mnlir*»
Franetmuiiana. .\uthors as!^.*rt, that h calf continued to walk a great ways after decapitation, (Biis quoted by ilal-
l«*r); that a woman walked a few steps, (Rzadskinski, Hist. Nat. Polon p. 3&3); that a man was able to hold hi>
swurd and brandish it at three different times; that another man struck his breast with iMth his hands. (Struvp.
.Vnthrop, Subliral.ir, 17.>», p :Wl. ♦ •
**Decapitatlcn it«elf is not necessary to prtKiuce thes*' phenomena, tliry are likewise obtained, and in a manner
* Kxpori(ft:(«« .«ui le princiiie de bt vie notamnient sur celui des mouvenienH du c«eur et sur le siege de c« prinri|<«\
Introduction to the Study of Diseases of the Nervous System. 19
otill won esrhms, •tber the ilmitle mcHod of th« medulla eplnAlls, performed at the oocipat. In this CMe the head
i< aliTe, u well aa ti&e rest of body, u is erinced by the motlone of the month and of the eyes. And neveithelem, the
uinel b exactly in the lame state, m If it had been decapitated, via : no longer able to goTem Its motions. A situa-
lioD, truly exttaordlnary. In which both the bead aud the body, poasees life sepaxately, without being able to exercise
aay iclioa orer tmiA other ; the head IWes, as if it were without a body, and the body as if it were without a head.**
M. Le Oallois, by making successive sections of the brain, from the anterior portion
backwards, concluded that the faculty which animals have of regulating their motions,
resides in the medulla oblongata.
With reference to the mode in which the brain regulates the motions of the body, without
furnishing its *' immtdiaU principle" Le Gallois held, that
" The brain appears to act upon the medulla spinalis, as the latter acts upon the parts which it animates. It la
thixHigh the nerrea that the medulla spinalis transmits its action, and the nenres appear to be formed of the same
mbsluoe wtth the white and medullary part of the brain, and medulla spinalis. I conceire, therefore, that the
«Jiite part of the mednlla epinalla, is compoaed of nervous filaments, having their origin or ternoination at one end
IB tli« bnia and at the other in every part of the medulla, and that it is In the clnerlnous part of the mednlla that
both the spinal aerves, and the principle that animates them arise."
lothis last supposition, that the spinal nerves were connected with the grey matter of the
cord, and tbut the gre^ matter of the brain is connected with that of the spinal cord, by
means of the nerve tubules, we have not only a philosophical explanation of the results of
decapitation and reflex acts, but also an enunciation of the general plan of the structure of
certain portions of the cerebro-spinal system, which has more recently been demonstrated to
be tme by the careful anatomical and physiological investigations of Shroeder^ Van der
Rolk, Loekhart Clarke and others.
Similar experiments to those of Le Gallois were performed by A. P. Wilson Philip,* and
3ir. William Clift,t the results of which differed chiefly in showing that the action of the
heart, although capable of being influenced thfough the brain and spinal cord, depended
rather apon its own ganglionic system, and that of the great sympathetic.
It wonld have been of interest also, to have traced, in connection with the preceding record,
the progress made by various observers, concerning the anatomy and physiology of the organs
ofMDse. Thus, Empedocles appears to have been the first who attempted to explain the
Qstare of sensitive impressions, by the supposition that an elemenlary affinity existed between
exterior objects and the organs of sense. He conceived that there exists in each of the
orirsos a force which governs and attracts from other bodies the molecules similar to their
own ; thus, the eye being of a resplendent nature, attracts the luminous molecules from
bodies ; the ear, which is of an airy nature, must attract sonorous particles ; the nose has a
raporons, the tongue a humid, and the organ of touch an earthy constitution. Aristotle,
Galen and their successors did not make any special modifications in the theory of Empedo-
dci, except to add the hypothesis of spirits, of which they made as many species as tbere
are different seoses. These invisible, impalpable .spirits were supposed to be secreted by the
brain, and to be transmitted to the external organs of sense by the nerves ; thus, the visual
ipirits connected themselves with the organ of sight, where they put themselves in communi-
cation with the luminous particles of bodies, and the auditive spirits were communicated to
the ear, where they were associated with sonorous particles.
The celebrated mathematician, Kepler, announced in the beginning of the seventeenth century,
that the crystalline lens was not. as had been supposed till that time, the seat of visiqn, but
(hat its function is to refract the rays uf light, the image of objects being painted on the
retina. Scheiner confirmed and extended these observations, and demonstrated that the
expansion of the optic nerve is the essential part of the organ of vision ; and many other
Anatomists snbnaitted the membranes and humors of the eye to careful dissection aud exam-
ination, and this complicated organ became to be one of the best understood in the organism,
'"^ir Isaac Xewtoo, also, by his researches on light and colors, contributed to the perfection of
the theory of the visual function. In like manuer, the organ of hearing was studied by Gas-
serins, Duverney and other anatomista; the osselets of the small muscles of the internal ear,
and the semi-circolar canals were described, the acoustic nerve was followed in its windings
and ramificatioos ; and R. Vieussens established the seat of audition in the membrane which
linei the drum of the labyrinth.
Mr. Alexander Walker, of Edingburgh, in 1809, first advanced in England the important idea
that in the spinal nerves the filatnents of sensation issue by one root, and the filaments of
motion by the other. Previous to this time, in Great Britain, the theory of Galen had, under
(be aathority of CuIIen and the Monroes, continued to prevail, notwithstanding the teachings
of Boerhaave. Albinus, ITnzer and Prochaska on the Continent.
* Expeifmeots^ made with a vlev to ascertain the principle on which the action of the heart depends, and the rela-
'ion vhldk sataelata between that ornan and the nenrous system, by A. P. Wllaon Philip, physician in Worcester. Phi-
l««iihical TnuMactiona, 1815, p. 6A.
t Experfm«nti to aacertain Uie action of the spinal marrow, on the action of the heart in flohes, by Mr. William
* Hit Philoaophtca] Tranaactions, IHl.*!. pp. 91-iKl.
'^0 Introduetion to the Study of Diseases qf the Nervous System.
Mr. Walker obaerTeti, in the ** Archiret of Unirertal Science," for Jn\j. 1809, pobliahed in
Edinbargh, p. 172 :
** MedullAiT actioD oommances lo the orgmiM of »eo«e, pawes to the sploal mamyw hr the aaterior faacicuU, of tb<-
•pioal nf nrn, which are, therefore the nertee of M^nnitioii— «0c<*nda through the RDterlur oolumM of the tpioal aukr-
row/* etc, and ** it datomida through the uunterior oolumoa of the epinal marrow, which are therefore it* deflceodiog
columiia, and expands through poeteriur UMcirull of all the nenret, which are therefore nenree of volition." * *
Ai in tome caaee, aeneatlon exiwtM without roUtion, and a* almoet all nonree arlao by distinct fliamenti, I am of opin*
ion that whenever a part having both Mnaation and volition. In eupplled from one nerrona trunk, that trunk envel-
opea, both a nerve of •enaatlon and one of volition.**
It is evident that the preceding statements inrolre the idea of double function with the
double origin of the spinal nerves; that each of these nerves has two roots and two functions,
one of these roots serving for sensation and the other for motion.
Mr. Alexander Walker attributed Mtwii/ion to the anterior^ and motion to the /H>«<«rior roote; and
this hypothesis appeared to be supported bj general analogy, and to be in copformitj with
the tenor of all previous observation. That the anterior column of the spinal marrow is con-
tinuous with the cerebrum, and the posterior with the cerebellum, had long been admitted
by anatomists ; and various physiologists, ad Willis, Boerhaave and Albinos, had referred the
automatic, and Pouteau the automatic and voluntary motions to the cerebellom ; and the
experiments of Plourens and other physiologists, performed after the enunciation of the
theory of Mr. Walker, showed that to the cerebellum belongs the power of co-ordinating or
regulating the voluntary movements. Sir William Hamilton also pointed out the parallelism
between the relative development of the cerebellum in young animals, and their command
over the action of their limbs. In contending, therefore, that the nervous filaments of sensa-
tion ascend in the anterior column of the spinal cord to the cerebrum, and the nervous fila-
ments of motion in the posterior to the cerebellum, Mr. Walker proposed the hypothesi.<*
which, independently of precisie experiment, had the greatest weight of probability in its
favor.
Sir Charles Bell, in 1811, in a treatise entitled '*.4fi Idea of n y*w Anatomy of the Brain,
Submittni for iV Obtervation of thf Author* m ^Friend* ^'* first propounded the counter doctrine
that the posterior roots of the spinal nerves, which have upon them a ganglion, are the
sources of sensation ; the anterior roots the source of motion ; and the primitive fibrils of
these roots, after their union, are mingled in one trunk, and thus distributed for the supply
of the skin and muscles.
Whilst Sir Charles Bell held the connexion of the cerebrum with the anterior, and of the
cerebellum with the posterior column of the spinal cord, he proceeded, however, not on
analogies and general probabilities, but by experiments expressly instituted on the roots
themselves of the spinal nerves, to establi.-ih that to the filaments ascending by the posterior
roots belong e'xclusively the function of sensation ; and afterwards, but before any other
physiologist, by an ingenious combination of special analogy and experiment, he established
the correlative fact, that the filaments descending by the anterior rootn are the sole vehicles
of Toloritary motion.
The same theory was advanced by M. Magendie eleven years later, and J. Mtiller ha«
claimed for the French physiologist the merit of having first subjected this doctrine to the
test of experiment in the case of the spinal nerves. This claim for Magendie is not, how-
ever, well founded, for Sir Charles Bell, in his first eiisay, in IHll, recorded the lollowing
experiment on the roots of the spinal nerves : ** On laying bare the roots of the spinal nerves.
I found that I could cut across the posterior fasciculus of nerves which took its origin from
the posterior portion of the spinal marrow, without convaUing the muscles of the back : but
that on touching the anterior fascicuius with the point of a knife, the mnscles of the back
were immediately convnlsed."
Sir Charles Bell supposed at first that the anterior roots contained nervous fibres for sensa-
tion a.4 well as for motion, while the posterior roots governed the operations of the viscera
and the secret operations of the frame, and united the body together. By careful dissec-
tions, by conclusive experiments upon living animals, and by a philosophical and wide induc-
tion of facts drawn from comparative anatomy, and by observing the modes of origin and
distribution of the cerebral nerves, and the effects of sections and pathological lesions upon
them. Sir Charles Bell was led to the more correct inference, that the single rodted nerves
were connected with the anterior columns of the spinal cord and corresponding partfi of the
brain, and the anterior roots of the double rooted nerves were exclusivelv motor, and that
the posterior roots of the spinal nerves connected with the posterior columns of the cord,
were sensitive. That Sir Charles Bell arrived at this conclusion before M. Magendie, Fodi-ra .
Bellibgeri or any other physiologist bad taken up the inquiry, rests upon the evidence con-
tained in the various papers which he published in the transanctions of the Royal Philo-
sophical Society of London, an analysis ol which we will give, and also upon the statements
contained in Mr. John Shaw's Manual of Anatomy, published September. 1821, and in several
l-apers by Mr. Shaw, (a pupil of Mr. Bell**) which appeared in the Quarterly Journal of Sci-
IrUroduetion to the Study of Diseases of the Nervous System. 21
eoce, December, 1821, and March, 1822, and ia the Medico-Ohirnrgical Transactions, April,
1822.
Majroand Magendie both published memoirs in August, 1822, upon the sensitive and motor
nerret, and these and subsequent works confirmed the doctrine of Mr. Bell.
The claims of Sir Charles Bell to the important discovery of the distinct seat of motion and
of sensation in the spinal nerves, have been acknowledged bj Sir William Hamilton, and by a
namber of English, French and German physiologists ; but the claims of Magendie to the
same discovery, which were advocated by a writer in the London Medical and Physical Jour-
nal, 1829, Vol. LXIL, p. 532. and by Elliotson, (Human Physiologj-*. 1840. p. 465), have been
recently ably supported by Bernard, (Rapport sur le Progres et la Marcbe de la Physiologie
Geoerale en France, Paris, 1867, pp. 12 and 154), and by Professor Austin Flint, Jr., (Histori-
cal Coosiderations Concerning the Properties of the Roots of the Spinal Nerves ; Quarterly
Joarnal of Psychological .Medicine, New York, Vol. II., p. 625 et seq ; Journal de 1' Anato-
mic, Paris, 1868, Tome V., p. 520 et seq., and p. 575 et seq).
However fully we may be disposed to admit the claims of Sir Charles Bell, at the same
time great credit must be accorded to Magendie for having independently and by well devised
and accurate experiments established the same doctrine. Magendie, in August. 1822, (Expe-
riences snr les Fonctlons des Raciues des Nerfs Rachidiens ; Journal de Physiologic, Paris, Tome
II, p. 376 et seq), published his first experiments on the functions of the roots of the nerves,
made upon living animals, and announced the conclusion '* that the anterior and the poste-
rior roots of the nerves which arise from the spinal cord have different functions : that the
posterior seem more particularly devoted to sensibility, while the anterior seem more especi-
aiUy connected with motion.*'
In a sab:»equent number of the same journal, Magendie states that when he published the
account of his experiments, he supposed that he was the first who had thought of cutting
the roots of the spinal nerves; but be was undeceived by a letter from Mr. Shaw, who slated
that Charles Bell had divided the roots thirteen years before. Having afterwards received
from Mr. Shaw a copy of Bell's Essay, ('* Idea of a New Anatomy of the Brain,") Magendie
observes :
** It b Meo bj thb quotation tram a work which I could not bo acquainted with, inasmuch, tut it had not bc>en puh*
lteh«d, that Mr. Bell, led hj his ingenious idoM concerning the nervous system, was very near discorering the func-
liona of the spinal roots ; rtill the Ihct that the anterior are devoted to movement, while the posterior belong more
fiartlcalarlj to aensaUon, seems to have escaped him ; it is then, to having established this fact in a positive manner
tliat I must limit my pretensions.'* Journal de Physiologie, Paris, 1822, tome, ii, p. 371
Magendie, in 1823, extended his researches to the cord itself, and demonstrated that the
anterior columns were motor, and the posterior columns sensitive, (Journal de Physiologie,
Paris, 1823, Tome III., p. 153, et seq.) ; and the name of this distinguished physiologist is
chiefly connected with the discovery of the seat of sensation and motion in the different col-
umns of the spinal cord.
Mr. Alexander Shaw, in his " Narrativt of the Ducoveriet of Sir Charles BeU in thf Xervow
SifMtem,'" pablisbed in 1639, states that a mistake of Sir Charles Bell's, in an experiment which
be had made to prove his doctrine, was discovered through the joint labors of M. .Magendie
aod Mr. Mayo.
M. Magendie, in 1822, asserted that the posterior column of the spinal cord, and the poste-
rior roots ot the nerves, supplied sensation principally ; the anterior principally motion ; but
that the latter were not wholly devoid of sensitive power. In the experiments of M. Magen-
die, the applii-aiion of galvanism to the posterior roots of the spinnl nerves, aftec their sepa ra-
tion from the spinal cord, excited contractions of the muscles, though they were but feeble:
while the same stimulus applied to the anterior roots, gave rise to violent muscular spasm
(J. de Physiologie, II , 276, Desmonlins et Magendie, Anat. Phj'siol. des Systems Nerveux.
Paris, 1826. p. 777),
Muller remarks that Fodera's experiments were accompanied with such contradictory symp-
toms, that it i» inconceivable how he could put them forth as confirmatory af M. Magendie's
otiservaiion. Neither can the claim of the Italian Physiologist, Belliogeri, be maintained,
althoogb both investigators appear to hare labored and achieved similar results without any
knowledge of each other's experiments and researches. The publications of Bellingeri were
made io 1818, 1823. 4. and ;\ and 1833.
Tl|e treatise of Professor Bellingeri, *^ De Medulla Spinaba,'* published in 1823, contains im-
portant observations on the structure and functions of the spinal cord. In this work he
aonouDced that the central part of the cord is composed of cineritious matter in the form of
two segments of circles convex towards each other, forming four projections, which are called
coroisa. The white, or medullary matter, is in the form of six cords or strands, two anterior,
•livided from each other by a deep furrow, and one on each side of the cineritious matter.
These cords or strands are supposed to be connected with different parts of the encephalon.
the anterior with the cerebrum, the posterior with the cerebellum, and the lateral cords wiih
the restiform process; these are termed respectively, the cerebral, the cerebellic, and the
22 Introduction to the Study qf Diseases of the Nervous System.
restiform parts of the cord. The white or medullary matter he described at fibrous, and the
graj, or cineritious matter, as globular. BlainTiUe. without apparently any knowledge of
Bellingeri's obserrations, adopted an opinion of the structure of the cord, in many respects
similar, although less minutely dereloped ; and the same appears to have been the case with
Rolando.
Bellingeri's experiments (Rxp. in NerT. Antigonismum, 1824; Exp. Physiol, in Med. 8pin.
1625), led him to conclude that the anterior pillars are more immediately connected with the
flexion of the limbs, and the posterior with their extension, and he applied this doctrine to the
cerebrum and cerebellum themselves, in consequence of their supposed connection with the
two parts of the column. Magendie had suggested the idea that the two portions of the
nervous system were connected respectively with the pillars of which the cord is com-
posed. It will be seen by a comparison of these views of Bellingeri with those of Sir
Charles Bell, that there is a material difference in some respects and marked coincidence in
others; and the conclusion is also Justified, that although Sir Charles Bell may have been
anticipated on some points, by th? Italian physiologist, yet wheu he performed his experi-
ments and published an account of them, he was entirely unacquainted with those of Bellin-
geri.
The experiments of Bell and Magendie, were carefully repeated in Germany by M. Schoeps,
on many animals, but the results obtained were doubtful and uncertain. Professor J. Muller,
of the University of Berlin, performed similar experiments in 1824, without success; subse-
quently whilst engaged in researches un the nervous system, he was induced to perform a
new series of experiments on rabbits, on a different plan. Professor Muller conceived that
the mode in which the investigation bad previously been conducted was deceptive, from the
circumstance thai many animals, especially rabbits, are so much frightened by the first steps
of the experiment, before they have suffered any considerable injury, that the most violent
irritmtion of the skin, not even pinching and cutting it, causes them to manifest any pain.
The slightest irritation of a nerve, when tense and stretched, with a needle, excites contrac-
tions in the muscles to which it is distributed. If then, the posterior roots of the spinal
nerves are merely sensitive, and not indued with motor power, they ought, when irritated
with the needle, fo excite no contractions of the muscles ; white these ought to ensue from
the irritation of the anterior roots. That he might perceive the most trifling twitchiogs.
Professor Mdller laid hare the muscles of* the posterior extremities ; experiments thus per-
formed yielded no certain results, since the shock produced in opening the spinal column bad
given rise to tremors of the muscles, which rendered the results of the further part of the
experiment unsatisfactory. After many unsuccessful attempts to verify M. Magendie's asser-
tion, Muller began to doubt the possibility of obtaining a decided and satisfactory result from
all such experiments. Desmoulins and Magendie themselves, bad merely said, in the one case
nearly all $enMntioH, in the other, nearbf aU power of motion it lott. The theory of Bell appeared
still to require demonstration ; even Magendie had not decided it satisfactorily ; and it seemed
to be impossible to decide it with certainty in the higher animals. Not only Muller, but Prof.
E. H. Weber, held the opinion, that the theory of Bell, had not been properly established by
experiment. The thought happily occurred to Professor 'Miiiler, of performing the experi-
ments upon frogs. These animals are very tenacious of life, and long survive the opening
of the vertebral canal ; their nerves also retain their excitability for a very considerable time,
and the large roots of the nerves of the posterior extremities run a long distance within the
cavity of the spine before uniting. The result was most satisfactory ; and the experiments
of Professor. .M tiller proved conclusively that it ur quite \mpo$$thle to excite mtucu^ar eontroetion*
in frogt bff irritating meehaniealtff, the f/OMterior roots of the apinai nen*ea : whi'e on the other hand, the
alightett irritation of th^ anterior roots, immetitotelif gives rine to verif strong actions ft/ the mturles. As
long as both roots of the nerves are in connection with the apinai cord, the traction experi-
enced by the cord itself, when the posterior roots are raised, may cause the production of
muscular twitches in the limbs ; such effects however, are quite independent of the action of
the posterior roots, and depend solely un the irritation communicated to the anterior roots,
by the spinal cord, in consequence of the mechanical violence which this has suffered. Hence.
if t.ie latter roots have lieen previoutily divided, no mechanical irritation of the spinal cord
itself, or of the posterior roots connected with it. excites the slighteitt muscular contractions.
The experiments of Professor MiiHer. with the galvanic stimulus of a single pair of sine
and copper plaie^ were equally conclus.ve. Thr^ apfUiratton of galvanism to tht anterior roots *»/
thf sptnat nerv**^ afifT thetr eonn^rUun wtth the c»trt{ is dtv.iied^ sx'tt t riolent mmacular twitchkngi :
the same stimulus applted to the ponfenor root*, is attended trtth no such ejf'fct. This result was
remarkable, for .Miiiler had imagined that, although the posterior root^ are endowed with
sensation merely, they might still conduct the irnlvitnic fluid to the muAclesi. and when a
powerful galvanic pile is employed, this is inevitably the case (as in Magendie's experiments),
the strong galvanic current l>rinj^ conducted by the posterior root of the nerve as by any
animal substance. Th«* stimulus of a pair of plates, however, while it causes the anterior
roots of thi" nervt>< to give rifie to muscular contractions, has no such influence when applied
Introduction to the Study of Diseases of the Nervous System. 23
to the posterior roots. Id this experiroent, it is necessary to be very cautious that the piatee
ttre brouirhi into contact with do other part than the nerves. When the experiments were
performed on frogs in the manner adopted by Sir Charles Bell, and M. Magendie, the results
were as decided as in those just detailed. If in the same frog, the three posterior roots of
the nerves going to the hinder extremity, be divided on th(i left side, and the three anterior
roots on the right side, the left extremity will be deprived of sensation, the right of motion.
If the foot of the right leg, which is still endowed with sensation but not with the power of
motion, be cut off, the frog will give evidence of feeling pain by movements of all parts of
the body, except the right leg itself, in which he teels the pain. If on the contrary, the foot
of the left side, which has the power of motion, but is deprived of sensation, is cut off, the
frog does not feel it. This experiment is the most striking of all, and the result is decisive,
hecause, on account of the small number and large size of the roots of the nerve going to
the posterior extremity in the frog, we can be certain that all are divided. (Elements of
Physiology by J. MuUer, M. D. vol. I, pp. 692-5). The foregoing experiments of Professor J.
Muller, ielt no doubt as to the correctness of the theory of Sir Charles Bell.
Sir Charles Bell, in his article " On the NeroeSy giving an account of some experiments on their
xtructuTf and functions^ which lead to a neuf arrangement of the system" communicated to the
Philosophical Society, by Sir Humphrey Davy, and read July 12, 1821,* limited the inquiry
to the nerves of respiration. According to the conception of Sir Charles Bell, the respiratory
nerves, form a system of great extent, comprehending all the nerves^ which serve to combine the
muscles en^loyedin the ad of hrealhing and speaking. He endeavored to show, that some hundred
moscles employed in the acts of breathing, coughing, sneezing, speaking and singing, are
associated, and brought into harmony by the respiratory nerves. Sir Charles Bell, announced
and sustained by experiments upon animals, the following propositions :
When we minutely and carefully examine the nerves of the human body, and compare them
with those of other animals, a very singular coincidence is observed between the number of
organs, the compound nature of their functions, and the number of nerves which are trans-
mitted to them. No organ which possesses only one property or endowment has more than
one oerve, however exquisite the sense or action may be; but if two nerves coming from
different sources are diiected to one part, this is a sign of a double function performed by it.
If a part or organ have many distinct nerves, we may be certain, that instead of having mere
accumulation of nervous power, it possesses distinct powers, or enters into different combina-
tions, in proportion to the number of its nerves.
The nerves of all creatures may be divided into two parts or systems ; the one siihple and
uniform, the other irregular and complex, in proportion to the complexity of organization.
Thas when an animal is endowed with mere sensation and locomotion, when there is no
central organ of circulation, and no organ of respiration but what is generally diffused over
the frame, the nerves are extremely simple ; they consist of two cords, running the length of
the body, with brMnches going off laterally to the several divisions of the frame. Here no
intricacy U to be seen, no double supply of nerves is to be observed, but each portion of the
frame has an equal supply ; and the central line of connection is sufficient to combine the
actions of Che muscles, and to give them the concatenation necessary to locomotion. There is
the same uniform and symmetrical system of nerves in the human bo(fy, as in the leech or
worm ; although obscured by a variety of superadded nerves. These additional nerves
belong to organs, which tracing the orders uf animals upwards, are observed gradually to
accomolaie until we arrive at the complication of the human frame. These nerves, additional
and superadded, to the original system, do not destroy, but only obscure that system ; and
accordingly, when we separate certain nerves, the original system of simple constitution is
presented even in the human body. According to Sir Charles Bell, the nerve of the spine^ the
(rntk or suh'oceipital nerve^ and the Hfth or trigemintts of the system of Willis, constituted this
nrtginat and symmetriral system. All these nerves agree in these essential circumstances; they
have all double origins; they have all ganglia in one of their roots: they go out laterally to
cert»iu divisions ot the body ; they do not interfere to unite the divisions of the frame ; they
are all muscular nerves, ordering the voluntary motions of the frame ; they are all exquisitely
sensitive; and the source of the common sensibility of the surfaces of the body; when
accurately represented on paper, they are seen to pervade every part ; no pnrt is without
iiiem: :ind yet they are symmetrical and simple, as the nerves of the lower animals. If
the nerves be exposed in a living animal, those of this class exhibit the highest degree of
Mfosibility ; while on the contrary nerves not of this original class or system, are compaia-
lively so little sensible, as to be immediately distinguished ; in so much that the quiescence
of the animal suggests a doubt whether they be sensible in auy degree whatever. If the fifth
H*rvr, and \\\e porUo dura of thf seventh, be both exposed, on the face of a living animal, there
will not remain the slightest doubt in the mind of the experimenter which of these nerves
footers sensibility. If the nerve of this originnl class be divided, the skin and common sub-
•PhllM»|rfilCMl TrmDMCtlont, 1K21, pp. 3M, 424.
A
24 Introduction to the Study of Diseases of the Nervous System.
stance ia deprived of sensibility ; and if a oerve not of this class be divided, it in no meaf ure
deprives the parts of their sensibility to external impressions.
The nerves which connect the internal ors-nns of respiration with the sensibilities of
remote parts, and with the respiratory muscles, are distinguished from those just described,
by many circumstances: thus, they do not arise by double roots ; they have no ganglia
in their origins; they come off from the mediMa oblongata and the upper part of the Sflinal
marrow ; and from this origin, they diverge to those small remote parts of the frame which
are combined in the motion oi respiration.
According to 5ir Charles Bell, the Par vayum^ (the eighth of Willis, the pneomogastic nerve
of the modern French physiologist,) which goes off from the common origin of the respiratory
nerves, at the lateral part of the meduUa obtoitgala^ associates the larynx, the lungs, the heart,
and the stomach. Th4*se organs, however, are at the same time supplied with nerves from
other sources. Comparative anatomy sustains the inference that this nerve is not essential tu
the stomach, as it does not exist but when there are hearts and lungs to associate with a
muscular apparatus of respiration. That the stomach must lie associated with the muscular
apparatus of respiration, as well as the lungs, is obvious, from the consideration of what
takes place in vomiting and hiccough, which are actions of the respiratory muscles excited by
irritation of the stomach. Sir Charles Bell, illustrated by a series of vivisections, the fact
that sneezing and coughing are entirely confined to the influence of the respiratory nerves,
and that the peculiar expression in sneezing, resolts from an impression on the respiratory
nerves, and that the muscles of the face are drawn iiito sympathy, solely by the influence T>f
the respiratory nerve of the face.
Sir Charles Bell complains of the loose manner in which the anatomy and physiology of the
sympathetic nervous system had been treated ; the connections of this oerve or system of
nerves, being universal, it had been supposed that it was the cord through which the relations
of the eye, nose, tace, throat, diaphragm, Ac, were established ; whereas this distinguished
anatomist and physiologist demonstrated that the combination is effected solely through these
nerves, which from their general or leading function are called the respiratory nerves.
Sir Charles Bell, in his Second Article (Phil. Trans. 1822, pp. 264, 312.) *'0n the nerves
which associate the muscles of the chest in the actions of breathing, speaking and expression,**
read before the Philosophical Society, May 2d, 1822, affirms that, whenever in examining the
comparative anatomy of animals, we find ribs rising and falling by respiratory muscles, we
ha 'e a medulla tpintths and the distinction of cerebrum and cerebellum ; and experiment and obser-
vation prove that the seat of that power which controls the extended act of respiration, is in
the lateral portions of the medulla oblongata^ from which it is combined through certain respira-
tory nerves which pass out from the neck, and also downwards by corresponding columns of the
spinal marrow, to the intercostal nerves. The medulla oblongata and tpintili*^ are composed of
columns of nervous matter, which from the different powers of the nerves, as they arise from
the one or the other of these columns, possess distinct properties. In animals that breathe
by ribs, and a numerous class of muscles, and which animals have a spinal marrow, a column
of nervous matter is embraced between the anterior and posterior virgae of that body, and
this portion may be traced downwards between the roots of the spinal nerves. Prom the
upper part of this column, where it begins in the medulla oblongata, the several nerves proceed
which form the respiratory system of Bell. The power of the regular succession of inter-
costal and lumbar nerves, as far us they regulate the respiratory actions, proceeds from the
connection of the roots of these nerres with this column wliich is continued downwards, and
which throughout can be distinguished from the rest of the spinal marrow.
Sir Charles Bell concludes this paper with valuable observutions upon the relations of the
respiratory system of nerves to certain diseased states, and dwells upon the fact that the res-
piratory nerves ure distinguished from the other nerves by retaining their power longer, that
they are alive to impression, and can be made to produce convulsions in the muscles they
supply, after the other muscles are dead to the application of stimuli. These facts sustain
the conclusion that the respiratory nerves have a centre and a source of power different from
that of the volunury nerves.
The respiratory nerves, so peculiar in relation and function, are differently influenced by
disease from the other division of the nervous system ; their functions are left enure when the
voluntary nerves have ceased to act, and they are sometimes strangely disordered, while the
mind is entire in all its offices, and the voluntary offices perfect. Thus in Tetanus, the volun-
tary nerves are under influence, and the voluntary motions locked up in convulsions ; in
Hydrophobia, the respiratory system is affected, and hence the convulsions of the throat, the
paroxysms of suffocation, the speechless agony, and the excess of expression in the whole
frame, while the voluntary motions are free.
Sir Charles Bell, in this paper, justly observes, that the confusion between vital and volun-
tary nerves, the combining, the par-vagum and sympathetic nerves together, and the exclusion
»»! i\\t portio d'tro of the st-veuih nerve, the spinal ufces^ory nerve, and the external thoracis-
Introduction to the Study of Diseases of the Nervous System. 25
nerve, from their natural classification with the diaphragmatic or phrenic, has given rise to
very vague theories, and occasioned very inaccurate statements of pathological facts.
Bv these experiments and researches of Sir Charles Bell, the respiratory system of nerves
has been extricated from the seeming confusion in which it lay encumbered, and he demon-
strated that it was superadded to the system of mere feeling and motion, which is common to
all animals. In man, through the respiratory system of nerves, is superadded to the original
nimal nature, higher powers or agency, corresponding to his condition of mental superiority.
These nerves are not the organs of breathing merely, but of natural and articulate language
also, and adapted to the expression of sentiments in the workings of the countenance, and of
the breast, that is by signs, as well as by words ; so that the breast becomes the organ of the
passions, and bears the same relation to the development of sentiments as the organs of the
senses do to the ideas of sense.
Sir Charles Bell * concludes the second part of his paper on the *' Nerves of the Orbit,''
read before the Philosophical Society, in 1823, with some general observations, on the views
held by the ancients relating to the functions of the nervous system, and at the same time he
took occasion to criticise adversely the work of Bichat and the experiments of M. Le Gallois ;
the following observations, however, appear to possess the most interest in their connection
with oar present introduction to the study of nervous diseases:
" Bo iv b it fttMD beinc tme that ganglia cut off senntion, that I have ascertained, and proved by ezperimenta,
that aU the oerrea, without a dogle excseption, which bestow aendbillty ftiom the top of the head to the toe, have
gM»gi«^ OB their roots; and those which have no ganglia are not nerves of sensation, but aro for the purpose of order-
ing the mvaealar fkame. * *
** nfa ootloB of a iluid moving backwards and forwards in the tubes of the nerv(>«, equally adopted to produce
BoCkMi aad sensation, has perpetuated the error, that, the different nervee of sensation aro appropriated to their
oflcce by the texture of their extremities, that then exists a certain relation between the softness of the nervous
^xtrooitiea, and the nature of the bodies which produce an impression on them. On the contraiy, every nerve of
<Miee 1* limited in its exerdae, and can minister to certain jierceptions only. Whatever may be the nature of an im-
poise eoouBBalcated to a nerve, premnre, vibration, heat, electricity, the perception excited in the mind, will have
rdfereoee to the oigan exercised, not to Uie Impremion mlade upon it"
In 1826, Sir Charles Bell published his paper '* On the yervout OircU, wMeh eonneeta the volun-
(toy museUt with the Brain.'*f The following analysis, presents the main points of his theory,
as well as the facts which he claims to have established.
In the preceding papers which Sir Charles Bell had addressed to the Philosophical Society
on the arrangement of the nerves of the human body, he had proceeded on a comparison of
the nerves of the spinal marrow with the nerves of the encephalon. It was shown that the
former were compounded of filaments possessing different powers, having several properties
or endowments, and proceeded to their destination without intricacy. Unless Sir Charles
Bell bad discovered the composition of the roots of these nerves, he would have continued
to suppose, that one nerve was simple in its structure, and yet capable of bestowing the very
different properties of motion and sensation ; but having satisfied himself that the roots
of the spinal nerves have distinct powers, he followed up the columns of the spinal mar-
row, and with a knowledge of the composition of these nerves as a key, he examined the
•iifferent properties of the nerves of the encephalon. In the head the nerves arise simply and
diverge to their destinations, without the close compact or union which the spinal nerves
form ; and, accordingly, the anatomy of the nerves of the brain offered satisfactory proof of
their uses or functions.
In the next place he demonstrates, that every muscle has two nerves of different properties
•applied to it. This fact coul not have been ascertained by an examination of the spinal
nerves alone, because of the intimate union of all their fibres, and consequently, he had
reconrse to the nerves of the head. By prosecuting these inquiries which led to the distinc-
tion of the different classes of nerves, he reached the conclusion, that, where neroea of different
fitnetioHs. take their origin apart and run a different couree, two nervea mtut unite in the mutdeiy in
ordrr to perfect the relations between the brain and muaelet. In his first paper, the difference bad
been shown in the nerves of the face ; by dividing one nerve, sensation was destroyed, whilst
motion remained ; and by dividing the other, motion was stopped, whilst sensibility remained
rntire. The muscles have no connection with each other, they are combined by the n rves ;
hut these nerves, instead of passing betwixt the muscles, interchange their fibres before their
distribntioD to them, and by this means, combine the muscle? into classes. The question,
therefore, may thus be stated ; why are nerves, whose office it is to convey sensation, pro-
fusely given to ronscles in addition to those motor nerves, which are given to excite their
motions? and why do both classes of muscular nerves form plexuses?
** Expose Uie two nerves of a muscle; irritate one of them, and the muscle will art; irritate the other, and the,
le remains at rest Cut across the nerve which had the power of exciting the muscle, and «timulate the other.
* cm ih** motion of the Eye by Sir Charles Bell, Phil. Tranii. 1(>2:), p. IGl;, p. 289. On the Nerves of the Orbit. Phil
TnuM. 1X21, p. 1M>1M.
♦ nUioMphicml Transactions, 1820, p. 163.
2G Introduction to the Study of Diseases of the Nervous System.
which to Qodirided — ^tbe animal will g1v« indication of pain; but although the nerre be injured m a* to oatue nni-
▼enod af itation, the muscle with which It ii directly connected, does not move. Both nenree being cut acroM, we
Hhall itlll find that by exciting one nerre the muscle is made to act, eren days after the nerre has been divided; but
the other nerre has no influence at all.
** Now it ^>pean the muscle has a nerve in addition to the motor nerve, which being necessary to its perfect ftinc-
tion, equally deeerves the name of muscular. This nerve, however, has no direct power over the mnscle, but clrcul*
tously thmngh the bialn, and by exciting sensation it may become a cause of action.
** BthMtn tk$ broM amd Ikt mmelet lker$ <■ a eirrU of nsress ; one tMrvs eoMMy* OMimftmmiM from the bntim to Ikt sniscIm
aitother gioot the mm$* of fk« eomdUiom of Ike wmtcte to the brain.
" If the circle be broken by the division of the motor nerve, motion ceases ; If it be broken by the division of the
other nerve, there Is no longer a sense of the condition of the muscle, and therefore, no regulation of Its activity.**
Sir Charles Belli in bis important article, *' On tke/unctiant of tome parts of the brain and on the
relations between the brain and nerves of motion and $ensation,^' received hj the Rojral Philotopbi-.
cal Societj, March 3d, and read May I5th, 1834, and published in the Philosophical Transac-
tions of 1834, pp. 471-483, extends the doctrine of a nervous circle cr reflex action, so clearly
announced in the preceding paper, to the spinal cord, thus announcing the doctrine claimed
and elaborated by Marshall tiall. Thus Sir Charles Bell, says :
** Tlie s|dnal marrow has much resemblance to the bialn, In the composition of its cineritious and medullary mai>
ter, and in the union of its parts. In short, its structure declares it to be more than a nerve, that is, it posaeasee
properties independent of the brain. Another consideration presses upon us. Where are the many relations existing
between the different parts of the fhune, and necessary to their combined actions established? There must be a
relation between the four quarters of an animal. If the muscles of the arm or of the lower extremities are combined
through the plexus of nerves in tlie axila, and in the loins, what combines the muscles of the trunk, and more
ea|)edally, what Joins the extremities together In sympathv? That their combined motions and relations are not
established in the brain, the phenomena exhibited In stimulating the nervous system of the decspitated animal suffi-
ciently evince. They must, therefore, depend on an arrangement of the fibres somewhere in the qiinal marrow.
Comparative Anatomy countenances this Idea, since the motions of the lower animals are concatenated independent
of a brain, and independently of the anterior ganglion which in some rrapects gives direction to the volition of these
animals.**
In the last article '* On the Nerrous System,'* published in the Philosophical Transactions in
1840, (p. 245), by Sir Charles Bell, he states that he was induced to commence the experi-
ments on the roots of the nerres of the spine in 1810, by the following considerations. Why
do six nerves pass into the orbits? Why should three nerves penetrate the coates of the eye?
Why should some of these nerves have ganglions on them and others none? If it be correct,
that the brain is the officina spiritum, and gives out a common influence through the nerves,
what is the meaning of the intricacy in the distribution of the nerves? He gives at length
the argument, drawn from anatomy, physiology, and pathology which led to his experiments
and discoveries.
From the preceding statement, it is evident, that the brilliant discoveries of Sir Charles
Bell, were not the results of accident. On the contrary his experiments on the spinal mar-
row and roots of the nerves, were not undertaken until after long consideration aud much
minute dissection. His lectures on the nervous system extended beyond what was customary
in the courses delivered in London, and not trusting to preparations, minute dissections were
made for each lecture ; and to afford time for these, discussions on the physiology and pa-
thology of the nervous system were thrown into the demonstration.
In making two distinct systems of the nerves arising from the spinal column, it was never
the intention of Sir Charles Bell, to convey the idea that they were cut off from the sen-
sorium.
The connection of the brain with the spinal marrow, formed a distinct subject of inquiry,
and Sir Charles Bell unfolded his views, on this important subject, most fully in the Philo-
sophical Transactions of 1834 and 1835, and we shall conclude this account of. his discoveries,
with an analysis of his papers * on the functions of some parts of the brain, and on the rela-
tions between the Brain and Xerves of Motion and Sensation.
The difficulties which attend the investigation of the structure and functions of the brain,
are manifested by the ineffective labors of two thousand years, and from the extraordinary
and contradictory results often ex|>erienced in experimenting upon an organ of such delicate
constitution as that which ministers to sensibility and motion, and which is subject to change
in every impression conveyed through the senses. This remarkable susceptibility, is exem-
plified by the extraordinary results, such as violent convulsions and excruciating pain,
arising from causes which appear quite inadequate ; the presence of a minute spicnla of bone
which has penetrated to the brain, will at one time be attended with no consequence at all. at
another it will occasion a deep coma, or loss of both sensibility and motion, and symptom*
apparently as formidable will be produced by slight irritation on remote nerves: — water in
the brain, which has free access to all the cavities of the brain, and which to all appearance
both presses equally, and if it irritate must irritate equally, will have the effect of render-
ing one side of the body paralytic and of convulsing the other with incessant motion. Another
source uf error, especially to the experimenter on the brain, is the disturbance of its circulation.
• PhiloMphlcal Trsosactions, iml, pp. 471-4M:t: 1h:i.>. pp. 2V»-'>«Ki.
Introduction to the Stiuiy of Diseases of the Nervous System. 27
for the brftin depends more directly than any other organ on the coodition of the circulation
within it ; by the mere raising of the skull, as a necessary prelimioary to most experiments,
there it an immediate disturbance of the circulation, which of itself may be attended with
insensibility or convulsions. Another source of error, was the obscurity which hangs orer
the whole subject, for although the brain be divided naturally into distinct masses, not one
of these grand divisions had yet been distinguished by its function, and there was not even
an opinion as to their relative importance. And if the enquirer be not critically guarded, he
is liable to erroneous conclusions, by the fact, that whole masses of the brain may be de-
stroyed by disease, or actually removed with impunity, that is to say, without any immediate
influence on the mind, or on the power of motion or sensibility ; yet the very slightest general
impression on the brain, will in the instant deprive the individual both of sense and motion.
The truth of Sir Charles Bell's discovery, that nerves have distinct functions, and not a
common quality, and that the sensitive and motor roots of the nerves spring from different
sources, being universally admitted, it appeared to him, in be a very rational mode of inquiry
to follow these nerves into the brain, and to observe the tracts of nervous matter from which
they take their origin. On this plan he proposed to demonstrate that termbUUy and motion
heling to the cerehrum^ — tkat two eolumnt descend from each hemisphere — that one of them^ (he anterior ^
yme* origin to the anterior roota of the spinal naves, and is dedicated to voluntarif motion — and that
the other (whieh from its internal position is less known) gives origin to the posterior roots of the spinal
neroet, amd to the sensitive roots qf the fifth nerve, — and is the column for sensation. And further,
that the columns of motion which come from different sides of the cerebrum join and decussate in the
medulla oblongata, — thai the columns of sensaidon also join and decussate in the medulla oblongata.
Finally, that these anterior and posterior columns bear in every circumstance a very close resemblance
to one another, — that is to say, the sensorial expansions of both are widely extended m the hemispheres :
lA«y pass through similar bodies towards the base of the brain, and both concentrate and decussate in the
mume manner. Vine agreeing m every respect, except in the nervous filaments, to which they give origin.
Of the Striated Septa in the Medulla Oblongata and Pons Varolii. Superior importance should
be given to these tracts of striated matter which descend from the brain to the spinal marrow,
since tbey are obviously the lines of communication, between the organ of the mind and the
frame of the body. But these longitudinal tracts are separated by certain plates of fibrous
matter which go directly transverse, are very regular, very easily demonstrated, and although
important in themselves, are particularly useful in establishing the natural distinctions or
boundariea between the columns, which descending from the en^phalon constitute the
medulla oblongata and the spinal marrow.
The pons varolii, or nodus cerebri, through which the filaments of the brain pass, from its
intricate structure may be taken as a key to the composition of the brain. By careful dissec-
tions, Sir Charles Bell traced these great tracts or courses of fibres into the crus cerebri, an
anterior one for motion, a posterior one for sensation, and a middle one, which he calls the
tract of the corpus oUvari. In the light of hia dissections, it was impossible for him to consider
the medulla oblongata as the mere commencement of the spinal marrow ; it has a peculiar struc-
ture and distinct functions ; it is the body formed by the convergence of the great tracts of the
cerebrnm, where these tracts respectively meet and decussate ; in it the tract of the corpus oli-
vari is joined to those of motion and sensation. Below the medulla oblongata, the spinal marrow
rommences, or rather is prolonged from it, but it is constituted with a distinct arrangement
of its columns. On each side it receives these columns from the. cerebrum, besides those
which come down from the cerebellum, under the name of corpora restiforma, to form its
posterior part, and these columns enter into relations which do not exist above. The
anatomist cannot fail to observe the remarkable correspondence in the structure and course
of the two grand tracts or divisions of the crus cerebri, which descending, form so large a
portion of the spinal marrow. Tracing them from the brain, we find both converging from
the periphery of the hemisphere ; both entering masses of cineritious matter, emerging alike
and approaching but not absolutely joining ; both contracting into narrow pyramidal columns ;
both having corresponding decussations, and only distinguished at last by one of them giving
origin to the motor nerves, and the other to the sensitive.
77k^ origin of the posterior roots of the spinal neroes — The posterior roots of the first, and conse-
quently of all the spinal nerves, are derived from that posterior column which descended
from the posterior division of the crus cerebri, and they are thus placed in the same relation
AS the anterior roots, with respect to the decussation of the prolonged medullary matter of
the cerebrum.
It has been observed by anatomists from time to time, that the nerves of the encephalon
come off in a direction ascending from the spinal marrow; according to Sir Charles Bell,
there can be no doubt that the sensitive root of the fifth ascends, and that it has its origin
10 the spinal marrow rather than in the brain.
Sir Charles Bell concludes his paper, published in 1834, with practical observations and
applications to pathological phenomena.
In his continuation of the preceding paper, published in the Philosophical Transactions of
28 Introduction to the Study of Diseases qf tf^e Nervous System.
1835, Sir Charles Bell gives the followiag addition to bis views as to the function of the
cerebellum.
As long as he entertained the belief that the nerves of sensation, that is to say the posterior
roots ol the spinal nerves, came from the posterior columns of the spinal marrow, and conse-
quentljr from the cerebellum, he found his progress barred, for it appeared incomprehensible
that motion could result from an organ like the cerebrum, and sensation from the cerebellum,
for there was no agreement between them. They conformed neither in size, shape, nor sub>
divisions. Sensation and volition are necessarily combined in every action of the frame.
Although these influences of whatever nature they be, are projected in different directions,
and belong to distinct filaments, they must be finally conjoined and in union. The anatomy
conforms to tliis idea ; the cords of communication between the seat of volition and the organs
of the body proceed from a centre, run parallel, undergo similar changes, and are blended in
their ultimate distribution as in their central or cerebral relations.
In his article published in the Philosophical Transactions of 1840, Sir Charles Bell records
the important fact, that since he bad reason to conclude that the columns of the spinal mar-
row, and the roots arising from them, were distinct in function, he had met with no instance
of disease, in the bodies of the vertebra, attended by paraplegia, in which the muscular
power of the limbs has not been the first affected: in all, the defects of motion has been
great«r than the diminution of sensibility; in some the motion of the limbs has been lost,
whilst the sensibility has been exquisitely acute. These facts he regarded, as accouiite . for.
by the motor roots of the spinal nerves being more directly exposed to the influence of the
inflammation seated in the bodies of the vertebra, than the posterior roots of sensation,
which arise more remote from the disease. Whilst expressing his unwillingness to enter on
so great a subject as the iuflaence of the cerebellum, and of the posterior column of the spinal
marrow which descends from it; Sir Charles Bell took occasion in the last of his papers
published by the Royal Society, to reiterate the opinion, that important as these parts must
be in the economy, there are no facts to countenance the belief, that they are directly con*
nected with the functions of motion and sensibility. Indeed he affirms, that the posterior
column of the spinal marrow has been softened to a degree, which we must suppose incon-
sistent with the continuance of its functions; and yet sensibility has been entire. But he
does not let this fact militate against his conclusions, for the column in the $pinal marrow which
givcM ri»f. to the senaitive roots ^ it posterior to that from which the motor roots arise : hut is not the pot*
tffrior portion of the spinal marrow
Mr. George Newport',* in an admirable series of investigations, upon the structure of the
nervous system in tiio lower animals, endeavored to demonstrate whether the discoveries of Sir
Charles Bell with reference to the nervous system in vertebrate animals, viz: the endowment
of different parts of the spinal column, with different properties ministering to different fnnc>
tions, volition, sensation, and involuntary potion, were applicable to the nervous system of
invertebrate animals.
The nervous system of Crustacea, according to Mr. Newport, consists of two longitudinal
cords, corresponding to the two halves of the body, united at certain distances ty ganglia;
thes^e cords are double, each being composed of two tracts, lying one over the other, analogous
to the motor and sensitive tracts in the spinal column of rertebrata.
Mr. Newport records the interesting observation, that while engaged upon the anatomy of
the lobster, he obuined a large living specimen, which although apparently vigorous and
healthy, appeared to suffer but little pain when pricked or pinched, and was of a much lighter
color than usual, its whole covering being quite blue, instead of the nsual blackish purple,
rpon killing the animal and examining its spinal cords, the motor columns and nerves were
of the usual size and appenrance, but all the ganglia of the sensitive columns, particularly
those in the post-abdominal region, were exceedingly small, and each enclosed only a very
small nodule of gray matter. Mr. Newport was led by this observation, to ask, ''whether we
may not infer that the degree of sensation in nerves belonging to the spiual column, very
much depends upon the size of the ganglia, and the quantity of gray matter they contain?"
Mr. Newport, in his paper, On the Respiration of Inserts, observes that the inverted posi-
tion of the nervous cords in insecU and other invertebraia has not a little confounded the
right understanding of the analogy which exists between the nervous cords of vertebrate and
invertebrate animals, and has given an appearance of probability to the opinion entertained
by some anatomists that the cords in the invertebrata are not analogous to the spinal cord of
virtebrata, but to the sympathetic system. Even some of those who now believe that these
cords are really analogous to the cerebro-spinal system of the higher animals, can hiirdly
•On thp Kerroan 8)»lfmof tbi* Sphynx liKU«tri, l.lnn : and on the chaiiKe which tt iind<>rKt>«w during a |»rt of th**
Mt-Umun'hoM* of the In^wt, tiy (Jw>ricr Ni-^purt, Tjh\. OoniwunlratiHl t»y P. M. KuKvt. M. I». Sec. K.«yal Sortrlj
Rf«il Jim«« 7th, IKVi. Phil. Trnnn. iKii. pp. liKi. 'Ji*H,
IVrt II, Phil. Trrnn*. IKU. pi.. »kV, 411.
Do the Bii*rrotti System of the 8phynx liffiiMrL Phil. Traiu. iKvli, p. 44Hi
On the Rivpirmtton of Inav^'U. Phil. Tram. 1K.V», pp :._*?». ■»«•.<..
Introduetion to the Study of Diseases of the Nervous System. 29
recoDcUe this opinion with the tAct of their being situnted along the ▼entral instead of the
dorsal aspect of the body. The reason for thi9 change of position of the cords in inver-
tebrata appears to be partly to protect the cords themselves and partly, that the nerves may
he supplied to the limbs withoat having to travel round the sides of the body, and thereby
be expored to the hazard of injury which they would be, were they situated along the dorsal
surface as in the vertebrata. But notwithstanding this change of position of the cords in
invertebrata, since we now find that they are composed each of two tracts, as in vertebrate
animals — it is important to observe that these two cords, and the tracts of which they are
composed bear the same relative position to the viscera, and to the exterior. of the body, as in
man and other vertebrata. Thus the cord which runs along the ventral surface in artrculata,
baa its motor tract nearest the viscera, or most internal, the same as in the human subject ;
while the sensitive tract, which possesses the ganglia, lies along the under surface of the
cord, and is nearest to the exterior of the body, just as the sensitive tract with its ganglia in
man. lies nearest to the cutaneous or external surface. It will thus be seen, that the two
tracts, maintain the same relative position with regard to each other, as well as to other parts
of tb\. body, in both divisions of the great kingdom of animated nature, whether the actual
situation of the cord be along the dorsal or ventral surface of the body. This being the case,
Mr. Newport, was led to consider the propriety of the terms anterior and posterior tracts or
rolwimw, as applied tn the motor and sensitive tracts of the nervous system, and whether it
would not be advisable entirely to ah mdon these terms, and designate the two columns external
and internal^ the sensitive the external, and the motor the internal column, since these terms
woald be strictly applicable to the situation or position of the columns in all classes of
aoimals.
With regard to the cords themselves, it was long ago suggested by Weber, that the ganglia,
which we now find to exist entirely in the sensitive tract in insects, are analogous to the
iovertebral ganglia of vertebrata. Hence the analogy between the spinal cord of the verte-
brata, and the abdominal cords in invertebrata, is very nearly proved. The very great
analogy, between the origin, course, and situation of the vagi nerves in man, and the corres-
ponding norves in insects, clearly demonstrates the identity of the structures.
Dr. Marshall Hall, in bis first paper on the Reflex Function of the Medulla Oblongata, and
Medtdla Spinalis^ which was read before the Royal Society of London, June 20th, 1833, and
published in the Philosophical Transactions of 1833, (pp. 635, 665,) gave an account of a
principle of action in the animal economy, which he conceived, had not before been distin-
guished with sufficient precision from the other vital and animal functions. The principle or
function which he endeavored to establish and illustrate by vivisections and pathological and
physiological facts, is connected in a peculiar manner with the medulla oblongata and the
medulla spinalis, being excited by causes in a situation which is eccentric in the nervous
system, that is distant from the nervous centres. •
' According to Dr Hall, whilst many of the phenomena of this principle of action, as they
occnr in the limbs had been observed, this function is by no means confined to the limbs, for,
whilst it imparts to each muscle its appropriate tone, and to each system of muscles its appro-
priate equilibrium or balance, it performs the still more important office of presiding over the
orifices and terminations of each of the internal canals in the animal economy, giving to them
their doe form and action ; and. in the second pi nee, in the instances in which the phenomena
of this faoction have been noticed, they have been confounded with those of sensation and
volition ; or if they have been distinguished from these, they have been too indefinitely
deaoniinated, instinctive or automatic. This property is characterized by being excited in its
action, and rtflex in its course ; in every instance in which it is exerted, an impression made
upon the extremities of certain nerves, is conveyed to the medulla oblongata, or the medulla
epiaalis, and is reflected along other nerves to parts adjacent to, or remote from that which
has received the impression. It is by this reflex character of the function, that Dr. Hall affirms
that it is to be distinguished from every other.
Thus, according to Dr. Hall, there are in the animal economy, four modes of muscular con-
traction. The firtt^ is that designated voluntary volition, originating in the cerebrum, ami
spontaneous in its acts, extends its influence along the spinal m<»rrow and the motor nerves,
in a direri line, to the voluntary muscles. The second^ is that of the respiration; like volition,
the motive influrnce in respiration passes in a direct line from one^point of the nervous system
to certain muscles ; but as voluntary motion seems to originate in the cerebrum, so the respi-
ratory motions originate in the medulla oblongata; like the voluntary motions, the motions of
respiration are spontaneous ; they continue at least, after the eighth pair of nerves has been
divided. The third kind of muscular action in the animal economy is that termed involuntary ;
It depends npon the principle of irritability, and requires the immediate application of a stimu-
lus to tbe nervo-muscular fibre iiself. These three kinds of muscular motions, Dr. Hall
regarded as being well known to physiologists, and he expressed the belief that they were all.
which had been up to the time of his investigation, pointed out. There is however, according
to Dr. Hall. % fourth, which subsists, in part after the voluntary and respiratory motions have
30 Introduction to the Study qf DisecLses of the Nervous System.
m
ceased, bj the removal of the cerebrum and medolla obloo^ta, aad which is attached to the
medulla spinalis, ceasing itself when this is removed, and leaving the irritability undiminished.
In this kind of muscnlar motion, the motive influence does not originate In any central part
of the nervous system, but at a distance from the centre ; it is neither spontaneous in its
action, nor direct in its course ; it is, on the contrary, excited hj the application of appropriate
stimuli, which are not, however, applied immediately to the muscular or nervo-muscular
fibre, but to certain membranous parts, whence the impression is carried to the medulla,
reJlfcUd, and reconducted to the part impressed, or conducted to a part remote from it, in
which muscular contraction is effected. The first three modes of muscular action are known
only by actual movements or muscular contractions ; but the rejifz functiony exists as a conti-
nuous muscular action, as a power presiding over organs not actually in a state of motion,
preserving in some, as the glottis, an open, in others, as the sphincters, a closed form, and in
the limbs, a due degree of equilibrium, or balanced muscular action — a function, in the
opinion of Dr. Hall, not previously recognised by physiologists.
The three kinds of muscnlar motion previously known, may be distinguished in another
way. The muscles of voluntary motion and of respiration, may be excited by stimulating the
nerves wh;ch supply them, in any part of their course, whether at their source, as a part of
the medulla oblongata or medulla spinalis, or exterior to the spinal canal ; the muscles of
involuntary motion are chiefly excited by the actual contact of stimuli. In the case of the
reflex function alone, the muscles are excited by a stimulus acting mediately and indirectly in
a curved and reflex course, along superflcial sub-cutaneous or sub-mucous nerves proceeding
to the medulla, and muscular nerves proceeding from the medulla. The first three of these
causes of muscular motion may act in detached limbs or muscles. The last, requires the
connection with the medulla to be preserved entire. All the kinds of muscular motion may
be unduly excited. But the reflex function is peculiar in being excitable into modes ot action
not previously subsisting in the animal economy, as in the cases of sneesing, coughing,
vomiting, etc. The reflex function also admits of being permanently diminished or augmented
and of taking on some other morbid forms. Marshall Hall, therefore treated of the reflex
function as the source of equilibrium in the muscular system ; as excitable into various
actions, which however familiar, are not constant ; and as assuming morbid forms.
Dr. Hall gives the following instances in illustration of the various modes of muscular action
just enumerated. Thus in the familiar act of swallowing, the apprehension of the food, by the
teeth, the tongue, etc., is voluntary, and cannot, therefore, take place in an animal from which
the cerebrum is removed. The transition of the food over the glottis, and along the middle
aud lower parts of the pharynx, depends npon the reflex function ; it can take place in
animals from which the cerebrum has been removed, as has been demonstrated by M. Plourens.
or the ninth pair of nerves divided, as in the experiment of Charles Bell ; but it requires as
Magendie has shown, the connection with the medulla oblongata, to be preserved entire, and
the actual contact of some substance which may act as a stimulus ; it is attended by the
accurate closure of the glottis, aud by the contraction of the pharynx. The completion of the
act of deglutition is dependent upon the stimulus immediately impressed upon the muscular
fibres, and is the result of excited irritability. This is an example of excited reflex function.
The condition of the glottis during respiration, and that of the pharynx and of the sphincters
at all times, except during the acts of deglutition,, or of excretion, afford equally interesting
and familiar examples of the permanent influence of that function. Whilst the nervous con-
nection between the larynx and the medulla oblongata is preserved entire, in the rabbit
{fjfpu» CanicaltUf) for example, the glottis is preserved open, being slightly dilated during each
act of inspiration ; but if the superior laryngeal nerves be divided, the aperture immediately
becomes so much diminished, that a state of excessive dyspnoea is induced. The sphincter
ani, on the other hand, remains closed in the decapitated turtle {chehma mydoM.) if the lower
part of the medulla spinalis be left in its canal ; but it becomes immediately relaxed and open,
if this pnrt of the nervous system be withdrawn. The action of this muscle depends
upon the medulla spinalis, and not upon the brain only.
Dr. Marshall Hall, enumerates the following inferences, as flowing from his facts and experi-
ments.
Physiologists, have hitherto enumerated only ihrtt sources or principles of muscular action :
volition, the motive influence of respiration, and irritability. There is hovever. a fourth
source of muscular motion distinct from any of them, though not hitherto distinguished, viz:
the reflex.
Volition and the motive influence of respiration are direct in their course, and spontaneous
in their action, the former proceeding from the cerebrum, the latter from the medulla ob-
longata; the movements of irritability are the result of the immediate application of a
sttmnlus to the nervo-muscular fibre itself: on the other hand the reHex /nnrtton^ which is
different from any of those, remains attached to the medulla spinalis, when the cerebrum and
medulla oblongata are removed, it is not direct like volition, or the motive power of respira-
tion; Its »eat is the mtMluMii g«>nerally, it ceases when the medulla is removed, leaving the
Introduction to the Stiuiy of Diseases of the Nervous System. 31
irriUbility entire } it is not excited immediately like the movements of iriitabUity, but
mediately in a reflex course, through the medulla, from the part stimulated to the part
moved.
In a state of health, the reflex function presides over the orifices and terminations of the
internal canals, such as the glottis and the sphincters, preserving the former open, the latter
closed; and it maintains the due tone of each muscle, and the due equilibrium of each system
of muscles ; when excited, it gives origin to the movements observed in deglutition or vomit-
ing, sneezing, tenesmus, etc., when morbidly augmented, it constitutes certain forms of
disease, as tetanus, hydrophobia, certain forms of tremor, paralysis agitans, chorea, stam-
mering, etc, ; when diminished, it induces those forms of tremor observed when the vital
powers are enfeebled ; when otherwise morbid, it occasions other forms of disease, as the
convulsion, the croup-like respiration, the affection of the sphincters, observed in dentition
the various effects of intestinal irritation, etc. The effects of the excited reflex function are
sometimes observed in a part near that irritated, as in the eyelids in winking, in the glottis
in iohaling a drop of water or particle of food, in the sphincters ani in dysentery, etc. ; some-
times in parts remote^ as in the irritation of bathing, when this induces strabismus, convulsion,
the croup-like respiration, relaxed sphincters, etc. All the functions of the muscular system
which remain after the sources of the motive influence of the voluntary and respiratory
motions are removed, with the exception of those of the heart, and other muscles which con-
tract upon the priuciple of excited irritability, depend upon the reflex function.
Dr. Hall thus enumerates the principles of the movements in the animal economy, viewed
in an anatomical and functional point of light.
1. The cerebrum, or the source of the voluntary motions.
'i. The medulla oblongata, or the source of the respiratory motions.
3. The medulla spinalis generally, the middle arc of the reflex function.
4. The nervo-muscular fibre, or the seat of the irritability.
5. The sympathetic, or the source of nutrition, of the secretions, etc.
The reflex function of the different portions of the medulla presides over their corres-
poodiog organs ; the medulla oblongata presides over the larynx and the pharynx ; the lum-
bar and sacral portion of the medulla spinalis presides over the sphincter ani, the cervix
vesicae ; and intervening portions of the medulla give tone and equilibrium to the corres-
ponding portions of the muscular system, and what LeGallois has designated *'&/«" to the
corresponding regions of the body. But the operation of the reflex function, is by no means,
confined to parts corresponding to distinct portions of the medulla. The irritation of a given
part may, on the contrary, induce contraction in a part very remote ; the irritation ot bathing
may induce spasmodic action or relaxation of the sphincters.
Dr. Marshall Hall made the following applications of his views, to the explanation of cer-
tain pathological phenomena ; affirming that the study of the reflex function revealed and
explained a totally new order of facts in pathology, and lead to a new division of diseases of
the nervous system, coinciding with the different modes of operation of their causes, into
tho»e of centric and those of eccentric origin :
** On* of tbe novt intarettiog medlcftl •objects, in reUtion to th« reflex (tmction, k that of deotition. Dentition
le A wm% of OAtvffml experiment npoo thle ftinction. The general convalaion, the stimbiamoi, the epaam of the flngen
and toae, the eronp^Uke aifection of the reapirHtlon, the repeated vomitings, the tenesmus, the stimngury, the iavol-
nnmrj dieefaarge of nrloe and of the fasces, fh>m its operation, denote the influence of irritation of the maxillary
aenree, throogh the medinm of the medulla oblongata^ upon the muscles of voluntary and respiratory motion of the
ry«, die larynx, the sphincters, etc, in the human sulyec^ and Indicate so many arcs of the reflex functions. * *
** With the effects of dentition in inlhnts, some affections of the adult may be compared as chorea, some forms of
rpllflpsy, and some forms of asthma. The diseases to which these designations have been given, vary exceedingly in
dtfemtt inctaacee ; iaasmveh as some oases are of centric and othen of eccentric origin. * *
** BpAlepsy Is plainly of two kinds : the flist has a centric origin in the medulla itself; the second is an affection of
tli« rriflfx ftinctioD, tne exciting cause being eccentric, and acting chiefly upon the nerves of the stomach or intee-
tiii««. which consequently form the flist part of the reflex are. * *
** Tr«e asthma, vis : that form of this disease which oocnrs in youth, and assumes a distinctly spasmodic form and
ro«ne, like so many other morbid conditions of the reflex ftinction, frequently arises from gastric or intestinal irri>
tatkm. • •
** With the effects of dentition, those of gastric or enteric irritation, in their multiplied forms may be compared.
** Teaesmns and strangniy are affections of other arcs of the reflex functions. * *
** Tetenos and hydropnobla appear equally to result from injuries inflicted upon the extremities of certain nerves,
t«y means of which the morbid influence is conveyed to the medulla, whence it Is reflected through the motor nervee
to tlM muscular system. As free lancing of the gnms In dentition, so the early division of the wounded nerve or
aaapntatloD In tetanns, has at once checked the morbid affection. * *
** Certain poisons as strychnine. Induce excem In the reflex ftinction ; other poisons as the hydrocyanic acid, dee-
tniy it altogether. In both eases the muscular Irritability remains perfect and undiminished. It Is probably through
the modlnm of the same functions, that many other poisons act upon the animal economy." * *
ft is evident from the preceding analysis of the first paper of Dr. Marshall Hall, on the
Rfjltx function of the nervous system, that Professor Trousseau is to a certain extent in error,
when be claims for Professor Graves the honor of having anticipated by many years the dis-
coveries of Dr. Hall.
In Profesnor Trousseau's criticism on the '* Clinical Leeturet an the Practice of Medicine by thf
lat^ Robert Jamea Oravee^ M, />. F. B. S.,'^ etc., he makes the following statement :
32 Introduction to the Study of Diseases qf the Nervous System.
**od thp othrr band, I cannot laflldently commend the pernaal of the lecturM, which treat of paimlvfles; they
contain a complete doctrine, and this doctrine hai decifdrely triumphed. The sympathetic panUysee of Whytt and
Prochaaka, have now their place assigned in science, under the much more physiological name of reflex paralyses,
and the Dnhlin professor b the first who has studied with exactness their etiological conditions, as he is the first who
has made known their pathogenic prooras. Anticpatlng by many rears the admirable works of Maraball Hall, he
has oomprphended, he has seen that tnomalons peripheric impressions may react upon any section of the medulla,
and determine at a distance dbturbance of movement or of sensibility ; he has in a word, created the class of peri-
phericor reflex panUysea, and has clearly established the relations existing between these paralyses and acute
diseases.*"
** Unhappily, these remarkabe lectures have remained a sealed letter for the midority of French practltionen ; bnt
it is time to render to the physicians of the Meath Hospital the Justice which Is due to them ; it ought to be known
that Graves is the rrrator of this new doctrine, which has profoundly moJifted within a few years, the pathitlogy of
f he nervous system ; it is right, in fine, to refer to Its tme author the suggestive theory of the paralysis and the oonvul-
sions of peripheric origin."
The claim thus advanced by Professor Trousseau, in behalf of Professor Graves, is whollj
untenable, as the first edition of the Clinical Lecturer of the latter, was published in 1843, ten
yeays after the publication by the Royal Soci ty of Dr. Hall's paper.
The views expressed in the first paper of Dr. Marshall Hall, were finally expanded into
his elaborate work On the Diseases and Derangements of (he yervous Su'tem^ published in 1841.
The following \fi a brief analysis of the matured views of this distinguished observer and phy-
siologist, as contained in the work just mentioned.
According to Dr. Marshall H.1II, the nervous system must be divided into
I. The Cerebral, or that of Sensation and Volition
II. The True Spinal, or that of the Movem;:nts of Ingestion and Egi'stion ; and
in. The Ganglionic, or that of the Movements of the Internal Muscular Organs, of Nutri-
tion, Secretion, etc.
TABLE OF THK NEBVOUtt SYSTEM.
I. Tks mUrt Nen^maS^tlem <s divlsJMs into
I. The Cerebral.
II. The True-Spinal.
III. The Ganglionic.
II. The Ctnbrai B§dem k
I. The seat of the Soul, and
II. The system of
1. Sensation and of the Senses.
2. Volition and of Spontaneous Motion.
3. Sleep and Fatigue.
III. TluTnM S/rimU S^tlem. Y ^**«** Fnnctiona.
I. The principle of Action is the Vi»>Nenrosa.
II. Its Modes of Action are excited, and reflex or
direct.
III. The Reflex Functions are thoee of
1. Ingestion and Betention.
2. Egestion and Exclusion.
IV. The Direct Functions are
1. The Tone ) of the Muscular
2. The Irritaldlity / Fibre.
I V . The Oam^iomk SgiSem.
I. The Principle of Action Is the Vis-Nervosa.
II. The Mode of .\ctlon excited, direct or imme-
diate.
III. The Functions those of
1. The Internal Muscular Organs.
1. The Heart and ArteriM.
2. The Stomach and Intestines.
2. Nutrition.
:S. Secretion, etc.
V. The St/i^em nf Emotioma^ tkmr art
I. I^ychical .\flectione, acting through
II. The True Spinal, and
III. The (Ganglionic Systems.
The r^rtitrnl M^sieni. •unipriM'* t-very part of the nervons system, which rvlates to v«»tfioM and r*diti*my the ner\-t'«
nf the wMWi— the ulfiu'tory, the upiic, the auditory, the gustatory, the nerves of touch, and the whole uf the nervM of
voluntary motion. Its centre is the cerebrum, includinir the Cfretwllum ; lt» sentient nerves run variously fW>m the
••nrnns of sen«e, and from the t'xlernal snrfitces. flrst without the rmnium or spine, and then within the rnuiiuni or
Hpine to itmt rt^ntn* ; it« volunlnry nerve pursue a siioilMrbut retrograde con me .Mnn that centrp to the muw-t<>s of vol-
untary motion. • •
The cfTe 'n^^pinal MUlNdivision of the nervous syvtem, or as It would lie more correctly ilesignated, the cerebral, is
tli«* system of w^tmtUfm and volition. It Is the system by which wi^ an* tonnecte«l imUUfctHoUfi with the external worid .
It l« that hy m««n« of whirh we fi*»l and iieneive t*xtenial 4>riJoet«. and by which wr approach them and appropriate
tbi»ra to our tim» <>ntirfly. My flnxers l»eing in nrntact with i»ny ol»j#H-t of moderate site, I f^el. I perrt'ive it, and by
HU art of volition, I raise it from titf table. This ap|mn*ntly «lm|<l<* up ration, re«|uire« thme portions of anatomy :
1. Ortaln nervf« must proceed continuously, uninterruptedly, /rosi the points of my Angers to the cerebrum, the
• ontre of tltiit «yst«>m ;
J. Tli*> nrv'brum moat lie in a state uf int4*grity ;
X Ortaiii nervfs most ptvceett fm m th** rervbnim to the muscles which are to be called into action.
Th»Te are, lh«*n, tvrt «ets of cfn«bral n^rr**^ ; at li-ast there are ren»bnil nvrves having two/WwVioaj.
Mixed in the OQsn-
ph gva: the Rec-
tum.
Introduction to the Study of Diseases of the Nervous System. 33
From the fxperlmenti of Sir Cli4rles Bell, snstained and extended bj thote of Profeflaor MUller, we maj conelode
ttet
1. Hie AgB&sUoiiic oenree are the volnntery or motor nerrce.
:L That the aanglla or general oolnmat are the oentret of the Incident andieflex nerree, and of the reflex actiens.
It remain* to oe aecertatued whether the aemtimU nerrei belong to the ffa$tgliomie colnmne ; bot this seeme moat prob-
abl#.
The tfiaetral, or mntimt or ftokaUary diTiilon of the nervooe system, eomprehends,
L Sentient nenree, leading to the posterior roots of the trifacial and spinal nerres^ and the posterior columns of
the ninal marrow.
IL The cerebmm, the centre of the system.
m. The Tolnntaiy herres imning from the anterior oolnmns of the spinal marrow and the anterior roots of the
trifedal and-spinal nerves.
The phmmahgg o/ tke ctrebnU §(fd$m, comprises sensation in all its fonna, perception, Judgment, Tolition, and Tolnn-
miiymolkm.
The aenses are the smell, the sight, the hearing, the taste, the touch : they oonTey to the mind all that we know of
the external world. Perception is derived from these. Judgment is a pnrely mental act. So Is Tolitlon ; and of this
TolsiBtary motion Is a frequent result. The motions which result from sensation generally <mpfjf wdiiiom ; but as toU-
tkm saaj exist without any previous sensation, the voluntary motions frequently are, and mojf be at any time upotUa-
Senaatlon or some effect of the Impression which produces it, must be conveyed by an appropriate nerve nnintero
rwpted to the cerebrum, — to the soul ; and thence the act of volition must act through a voluntary nerve, equally
uninterrupted in Its oourM, from the cerebrum to the muscle or muscles to lie moved. Thus we have a nervous aroh,
nf vrhldi the cerebrum is the keystone.
Many attempts have been made tu loeoIiM the function of the oerebmm ; that is, to prove certain functions to be
attached to certain parts of that organ ; without, however, much success. The lactt supplied by pathology certainly
|4MmI OS to the conclusion that the hemispheres of the cerebrum and cerebellum regulate the vohaUarp movements of
the opposite side of the botly ; whilst the medulla oblongata and spinalis oomaey the Inftnence of stimuli to the corres-
ponding aide. It has been asserted, from similar fiicts, that the anterior lobes of the brain govern speech ; the cor-
puim stnata, the Inferior extremities < and the thalarai, the superior extremities ; but these deductions are not suffi-
ciently subataatlated. The same remark must be made relative to the supposed connection befween the cortical por-
tion of the cerebrum and the Intellectual faculties, and the cinerltions portions and the movements.
r>irtnl<jj o/tkt Cerebral Sgelem. The cerebral system being the system of the sensations, of Judgment, of volition,
it Is to it that we mutt refer all morbid conditions of these mental acts or ftinctlons. Every derangement of the
o^naea, every form of dilerium or of coma, or of perverted imagination or Judgment, every act of violence must be
referred to tiie condition, primaiy or secondary, of the cerebrum or cerebellum.
THE TBUE SPINAL OB EXCITO-MOTOBY SYSTEM.
This ^jsteas, fbrmerly confounded with the cerebral, under the designation of cerebro<4plnal — this system as a
■jstfm. Dr. Hall considers as having been entirely elicited by his own laborious and persevering researehes.
Hi —a insie iavolen a spirfsm of imeideal, amd r(>4ex acrws eotmeded wilk tke bme-epitial marrow as their eeatre ; imftMOieN,
M tUe apenmtmmmeifHnu bi^ore;
tm fkfmologf eoasMf ia fmiedomM, ell 0/ vkiek are performed through (hie peetUlar amalamg. Theee ftmetione oompriee aU
cir it^e 0f UneMinm^ of rtiemtiom^ of ejejndeiom^ a»d of exdmtioiL, ia the aMimal eeomomg ; theg are (&om% therefore^ ou tehieh depend
I. TkePrmereatioaofthe /mdMdmal^amd
IL The roirfiMMMW of the Speeie*.
AM Ikiae fametiom are r^^ex-epUulfaaeUotu of which Ae Idea did notformerlg exid ; He principle of aetion in the sM-N«rro«a
.«f JVsBir, a motor power^ ofwhich^ there woe prerione^f no appiieatiom to phyuotogy whatever; ite patkologjf oomprime the
f^a^ rfiisr of i^aemtodie dieeaeee, amd ita etdhdieiekm ialo thoee of
I. Incident.
:L Cenrrlc
U. Bctfex Origin.
TABLE OF THE ANATOMY OF THE TRDE-SPINAL SYSTEM.
I. The Incident Motor Binnches. _ III. The Beflex, Motor Branches.
The Trochlearis 1 ^v^„,,
The Abdncens. /^""•
The Minor portion of the Fifth.
The Facial, distributed to
1. The Orblcuhuis.
2. The Levator Alse Nasi.
The Pneumogastrle or Its Accessory.
1. The Pharyngeal.
2. The (Xsophsigeal and Gardlac
3. The Laryngeal.
4. The Bronchial, etc
The Myo-gloeml.
The S|i4naT Accessory.
The Spinal, distributed to the
1. Diaphm^im, and to
2. The Intercostal and ) if.^i^.
3. The Abdominal |«n«:ic«.
The Sacral, distributed to
1. The Sphincters.
2. The Expnisors, the I^acnlators,
the fSUlopUn Tabes, the Ute-
rus, etc.
All the nerves represented on the left side of this table are imeUieiid motor nervee. Some of them are eemlieHt; but
whether sentient or not they are demonstnbly exeUo'motor^ and whilst they are motor, they are incident. Besplrii-
tlfun Ims its primlnm mobile In imcidewl eJKilo-moiofjf nerceii. By the cerebral system, we are placed in relation to the
external world pegthieattg or Ptemlattg; but by the true spinal system we are placed in a similar relation phgtUaOff. As
l<y the former w«> Imbibe all our Ideas, so by the latter we appropriate external ol^ects to our very snlMtance. On the
tme spinal system all Ingestlun, all retention, all expulsion, In res^rd to the animal frame and economy depend.
Rv«ry snch act is a i^imai act, a tme spinal act, reflex In its form and character, accomplished through the medium of
the incident and reflex nerves, and their connecting centre the true spinal marrow, and by the agtttcffot the tio-imromx.
The Incident Motor Binnches.
III. T
1. The Trifacial arising from—
■4
1.
1. The Bye-lashee.
2.
2. The Abe Nasi.
00 s
3.
3. The Nostril.
4.
4. The Fauces.
■a %
5. IheFace.
S 3
'1. The Pnenmogastric from
#
M
ft.
1. The Pharynx.
•" i«
2. The Larynx.
? i
3. The Bronchia.
I, s.
4. TheOardIa,— Kidney, and Liver.
l^
3. The Oloaso Pharyngeal?
1 0
e.
4. The Posterior Spinal, arising
from—
11.
7.
I. The Oenerel Surfsce.
8.
2. The Ohms Penis and aitoridls.
il
3. The Anns.
4. The Gervix Vesicie.
5. The Cervix Uteri
IS.
9.
•
s
34 Introduetion to the Study qf Diseases qf the Nervous System.
TABLE OF THX PHT8I0L0GT 07 THI TBUS gPIHAL STSTKM.
I. TlumelM
1.
or UM«jr«s» tiM I7«4ldi ; (and of tlM Iritf)
2.
Of u.. <«.«.. J\: S:Jfi^i.
8.
Of the iBgwtloo.
1. orSelMd.
1. Id BactloB ;
S. In Deglntftloii.
S. Of tlMAIr,or BanlmyoB.
S. Of tlia BMMn, or ConoeDtloii.
4.
Of Sxdiuloo.
6.
Of tb« IziNilBonL or of EgMtloii.
1. Of tbo Wmom;
%, OftUUriM;
8. Of tlM PnapirMioii ;
4. OftheBMuen;
6. Of tb« 7(Hii0, or Putoritton.
6.
Of tlM Sphlocton.
1. TboOuttlA.
S. ThtValTiilAOoUr
8. The 8plilDCt«r Aai.
4. The Sphinoter YeeicB.
II. The Dtttel Attkm or
The true epinel mftnow nwy be ooirectly rlewed ■• a dietlact n'y— , totally dlffereot in It* propertlee and ftmctioiui
from the oerehmm, and aa the centre of a dietlnct syetem of nerree, different ftom the eenttent and volantary, and
prmnriMfiil of a pecuUex and epedal motor power, which acte In incident ■■ well aa reflex dlrectiou for epedal pmpoeee
—Judging entirely flrom esperiment. It may be reoelTcd m a principle that eTevy part of the nerrooe eyetem, which
ie endowed with tne ezdto-motoiy pow«»r, beionge to thie lyitem, whether thii power he excited In the direction of
the nenrea/hDM or kmoHa the nenrone centrae. * * Sach nenre of the exdto-motoiy ayatem, with the exception
perhapa, of the pneamogaetric, la a oompoond nenre, harlnc a oerebnJ, aa well aa a true apuial origin. * * The
moat ueoal effect prodnMd by ellmnlating Incident nenrea, b a motion of the llmba. But In other inataneea we hare
acta of inqiiration, of deglntltloa. of expuMon, of doenre In the eye-Uda, lamyx, phamyx, and the aphlncten : —
interacting focta, whidi qwak a pnydologioal language, and aaaign diatlnctand apedal olBoee to oertdn exdlor^ienraa^
THS PAtHOLOOT OF THI TBUI SPIHAL 8T8TKM.
The ahnoraml and mofbid actlone of the wUmmtom or atttemeiBry power, obey the aame lawa aa in health.
The mortrfd etlmulua may act upon the incident, the central, the reflex part of the exclto-motory arc or ana, and
C Mince corresponding effecta-^coneaponding diaeaaea. To uae worda flunOlar to the phyaiologieta of Oerviany, we
TO a daea of centripetal, central and oentnnigal dlaaaaea. We may hare centripetal or centiml epilepqr, ai(d we may
hare anaamodlc tic, and other affectlona, from an affection of the rMex motor nerrea.
In thia manner, tk» dam tfmammodie dimatm Is aubnliTided Into fkra* snb-daaaas, a dlTlilon of the ntmost importaaee
In practice, and lllnsrated lo the Allowing table.
TABLE OF THE PATHOLOOT OF'.THE TBUE flPIirAL 8T8TEM.
I. Diseasas of the Inddent Nenres.
^ r I, The Crowing Inapimtlon.
I. 1. Dental. I InitatSoo \ i. BtfaMsmim, Spasm of the FIngen and
2. Gastric S. in y Toea; Strangniy; Tcoeamns; etc.
8. Intestinal, i Inftntai j 3. Gonyuldon.
) (.4. Plaralyali?
\ (I* Hyateria.
IL 1. GMtric. / Irrilatiott \ II. Aathma.
2. Intestinal. V in -< III. Vomiting; HIccnp; etc.
8. Uterine. i Adolts. i IV. Epilepsy.
J V. V. Pnerpeiml ConTulalon; etc.
ni. Timamatle Tetanaa ; Hydrophobia ; etc.
II. Bteeasas of the Spinal Harrow Itself.
I. Inflammation and other Diseases.
II. DIsaasM of the Vertebne and Membmnes.
III. Oe—tsrpfsmaro, etc, in DIssases wItUn the Cmrium.
IV. Geotrie BpUep^, Tetanns^etc.
V. ConTuMons from Loss of Blood ; etc
III. DIaeases of the Beflex or Motor Kenrcs.
L Spasm. • II. FhnlyalBL
1. Spasmodic Tic.
2. l^rticoUls.
8. Contncled Limbs ; etc.
Introduction to the Study of Disease$ of the Neroout System.
35
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TABLK or THK ACT OT VOMITIKO.
L Tk« Exelton and Moton which cIom the Lftryns.
n. Th« Ezdton and Moton which open the GftrdU.
in.
Kxcitvn,
III. The Moton,
1. Th«
1. Hm
«. Th«
IL The Centric
Oi^giui
«f Bxpiimtory Kffort.
fflMfaa hnach of the TrilhcUL j, l The SplMl aenree dletrlbiited
GMtric,B«Qftl, and Hepatie biaachee of the 8 § 1. To the latorooatal and
FaeaMocMliie. •2 . 2. To the aibdominal masclca
latectiaal «r Utariae bfaachea of the Spinal M ® &
• « &
Dr. Manhall
Hall that condodea his oheairatiani oa the nerroai fyitom la geaeiaL
tedlviidblelBlo
36 Introduction to the Study of Diseases qf the Nervous System.
I. The oerebrml, or phTalcnl, or that of our raUtton to the external world mmlaUp.
II. The tme-epf ml, or exdto-motonr, or that of the reflex action of the riMMreom, or of oar appropriation of
certain oWeeii of the external world pkumeaUg and In ma— ; and
III. The ganglionic^ or the qntem of iirfmiitiYiiiy, or ektmieal^ or atomic changes of nntrttlon, eecretlon, etc., alw>
under the immediate influence of the vitmtrwa.
IV. Intermediate between the >^ and meomd of theee !■ the inflnenoe of mmottom^ pomdom. tie.
Y. Intermediate between the mamd and third are the internal maecular organs, the neartf the etomach and
intestines, etc.; and these are nnder the tiiniMiliale Inllaence of the ffitmermaa and the irrUabOUif of the muscular flbrv.
VI. Lastly, the Ume and tnUabUUm of the general mnscular ijstem are eoMfaaC, and dirtei effects of the tme^nal
and ganglionic STStems, and of the ipm wsi suss. Om Ike tfiwwMt and Htmttptmemtt of the norwom ttfttem, <■ their prjmmrn
tarm» «ihi in Qtevr mod\fUxUiom*t bt Offt, ««r, eomdihttiem, horotlilmnf pre-ditpomtumf sgewei, ameref diitoriert tmd onfomic ditoam ;
by Manhall Hall, If . D., etc. London, 1841, p. 1 to 13u.
It would be foreign to the object of this Historical Ontline to extend tb* preceding analjiis
to the application by Dr. Hall of hit Tiewi to the varioas diaeasei of the nervous system anci
their modifications by age, sex, constitution and hereditary pre-disposition, with which this
physiologist and physician concludes his elaborate work.
With reference to the use of the terra reflex^ by Dr. Hall, it has been observed by certain
critics upon his labors, that the same expression occurs in the works of Haller, Tuser
Prochaska, Fred. Arnold, Treriranusand others. I have already endeavored to do full justice
to the labors of (Inzer, Prochaska, sir Charles Bell and others, quoting the passages of
greatest interest or of greatest concern with reference to the grand doctrines relating to the
structure and functions of the nervous system. Fred. Arnold, in his work entitled Kopf^tkeil
dtM vtgetaiivtn NervfnwyttemM, published in 1830, makes frequent use of the term reflexion ; thus
his experiments induced him to admit, that tlie action of light, does not take place immediately
upon the retina, but that it is refierUd through the nervous expansion in the eye to the iris,
and that this bringiug hack of the stimulus of light takes place through the brain. He also
distinguishes the motions of the tympanum which arise in consequence of an irritation
refiecUd from the auditory nerve to the moving apparatus of this nerve, from those which
immediately follow through the vibrations of the air.' The sympathy of the thoracic and
abdominal organs with the brain and organs of sense, be also accounts for on the principle
of reflexion. We fail to perceive in the views of Arnold any advance on the observations
of Prochaska, who alludes to ^rejiex action^ as seen in the act of sneezing, coughing, etc., and
dwells at length upon the influence of the nervous system upon the circulation of the blood ;
whilst they are far less explicit than the riews of Sir Charles Bell on the nervous circle which
connects the voluntary muscles with the brain, published in the Philosophical Transactions of
1826, a careful analysis of which we have already presented.*
The effort has been made also to show, that the facts, on which the reflex theory is founded,
possess still less of novelty than the theory itself.
Thus it was long knoirn that the life of certain animals may continue for some time without
a cerebrum and cerebellum, and that amphibious animals, after taking off their heads, are still
capable of making suitable movements; they seek to avoid injuries, and Hy from dangers.
We have already quoted Unzer and other physiologists who have recorded such facts. Robert
Whytt, who was born 1714 and died in 1766, and held the chair of medicine in the University
of Edinburgh, recorded the fact, that : if immediately after decapitating a frog, one of the
toes of the hind-foot be wounded, either very slight motion or none at all takes place in the
muscles of the foot. But if we pinch or wound this animal's toe, ten or fifteen minutes after
the bead has been cut off, then, not only the muscles of the leg and thigh, but those of the
entire body, are thrown into strong convulsions, and the trog sometimes springs up violently*.
'* In this case is not the irritation of the thigh, immediately after the head is cut off, ineffectual
in producing any motion in the muscles of the thigh and foot, on account of the great pain
occasioned by removing the head? Whereas the muscles are thrown into motion by wounding
the toe fifteen minutes after removing the head, because the pain is now so much diminished,
that it no longer prevents the animal from being sensible of the pain of his wounded toe."
Gilbert Blane, has quoted some facts, which show that instinctive actions, even in animals
possessing a brain and nerves, do not depend on sensation; that is. that instinctive or auto-
matic acts may be performed without the interventiou of the sensorium commune, and
therefore without sensation or consciousness. Trevirunus was induced by experiments snch
as these, to deny the assumption that the faculty uf associaiian is merely a property of the
brain. Le Gallols, states it as a well-known and proved lact, that birds, whose beads were cut
off, continued to live and even to run about for some time after : Mayo also ascertained the
fact that decapitated animals are capable of performing determinate and suitable acts under
the influence of irritants.
Le Gallois In bis memoir published in 1812, also sUtes that in the rabbit, after division of
the cord in the lumbar region, sensation and voluntary motion continued to take place, even
in the posterior extremities. But there is no longer any connection in sensation or novements
•PivfiMor BelUngvri*s doctrine of HsnyNM antagonism, discussed in his ''OMrPSsioaJ PMhohgitht,** bean sour
reseaiblancv to Dr. Marshall flairs raflrs Ainctloo.
Introduetum to the Study of Diseases of the Nervous System. 37
between tb« anierior parts posterior to the section of th« cord ; that is to saj that, if the
tail, or, indeed, one of the hind-feet be piocbed, the entire posterior parts are agitated^ but
the anterior parts seem to feel nothing and do not move. (Experiences sur le principe de la
Tie.) ^
Fod^ra, in 1822, stated, that, in wounds of the spinal cord, the aniDial snfTers pain and
convulsions ; if it be divided transversely, there is paralysis of the posterior parts, with loss
of sensation and motion. But irritation applied below the section produces agitation of the
muscles to which the nerves derived from it are distributed. The animal does not suffer pain,
for it haa no consciousness of what takes place in these parts. With regard to the spinal
cord, complete transverse section in birds does not in general entirely paralyze the posterior
extremities; if we pinch the foot they withdraw it, although they suffer no pain trom it, but
if the spinal cord be entirely destroyed in the interior of the vertebral canal, the paralysis is
perfect. (Recberches, exp^rimentalee, sur le eyst^roe nerveuz.) About the same time Mayo,
thus described the reflex function of the spinal cord.
•
** Oii the one luuid it !• clear that an Inflaence Independent of the will, occaaionally tbrowa voluntery niuaclee into
acttaB, aa apiiean in letanoi and other spamnodic diseaaee : and !■ shown remarkably in the physiological experiment
oC iniCatiBg the ekln on the lower extremitiea, after the divialon of the spinal cord in the back, when the occurrence
of acCioD llmltad to the masclea of the inferior extremitlea evincce that a connection exists independently of the will,
between aentieDt surfaces and the action of voluntary muscles. I have varied this experiment by dividing the spinal
coffd at onoe in the neck and in the back, upon which three unconnected nervous centres exist ; and the division of
tb«skiB of either nart (and especially at the soles of the feat, in the two hinder portions) produces a convulsive
action of the mttscica of that part alone. The same influence may, then, possibly regulate the nnconscions actions
to which these remarks relate.** Anat:and Phys. Comm., Mo. 11, 1S23.
It baa therefore with some reason, been affirmed, that the facts by which Marshall Hall
supports his theory, were well known long before his time, and were employed to throw light
upon tbe functions of the nervous system.
It mast be admitted however that great obscurity and confusion prevailed in the statements
of moat of the writers before his investigations, and the idea of an incident motor nerve did
not exist; and consequently, the system of such nerves, and the special physiology of this
system was totally unknown, and it must still farther be admitted that Dr. Hall has the merit
of having introduced a valuable anatomical, physiological and pathological classification, of
the parts and functions of the nervous system, based upon actual observ.ttion and experiment,
logically connected and to a great extent adapted to tbe wants of the physiologist, patholo-
giat and practitioner of medicine and surgery. The labors of Dr. Hall have thi'own a flood
of light upon many nervous diseases, and have teuded to introduce order and harmony into
this diiBcalt department of medical science.
Decided proofs that the reflex movements are independent of sensation have been afforded
by certnin phenomena of nervous diseases: thus in cases of paraplegia dependent on lesion
of the dorsal or cervical portion of the spinal cord, its lumbar portion remaining healthy,
slight irritation of the surface of the lower extremities as by tickling the sole of the foot, the
passage of a catheter, or the evacuation of the fteces, will produce convulsive movements of
the feet and legs, even though .tliey be perfectly devoid of voluntary power and sensation.
The first cases* of this kind adduced in illustration of the theory of reflex movemeut. were
observed by Mr. Barlow, Dr. Budd. and Mr. Barron. The same phenomena occur in cases of
hemiplegia ; an instance of which has been recorded by Dr. William Baly.f Dr. Reid remarks.
that tbe sensations which attend some of the reflex motions have been added for an ulterior
object— that it is necessary both for comfort and well-being, that these movements (such as
those by which the coutents of the bladder and rectum are expelled,) should be influenced by
volition, and that this of course, could only be accomplished by associating sensation with
tbe excitation of the impression.
Among tbe Germans the eminent physiologist J. MQIler was the first who advocated the
reflex theory of Marshall Hall, and by some writers tbe discovery of tbe mechanism of reflex
action, has been given to both these physiologists; but aside from the fact that the labor? of
tbe former were published one year after those of the latter had been presented to the Zoolo-
gical Society, it is evident from a careful examination of the works of Muller, that he maked
oo special claim to priority in this discovery, although conducting his researches indepen-
dently of. and differing on certain points from Dr. Hall. '
The views of Professor J. Miiller, may be thus staled, as finally matured and presented in
the second edition of his great work on physiology.^ and after he had (as is evi(knt from his
sutement) carefully examined the works of Dr. Hall.
Wken impresmont made by the action of external tttmuii on teneitive nervee give riee to motione in
other parte f theee are never the retult of the direct reaction of the eeneitive and motor ftbree of the nerves
• Batiks Memoirs, p. SJ, Mr. Oraiifer*s Observations on the Spinal Cord, p. 93, Dr. W. Budd, Med. Cbir., Tmns. vol.
xxH.
t KleaMiM of Physiology by J. MUtler. M. D. 1st Ed. Timns. by William Daly, M. D., Vol. I, p. 721.
t CUBaats of Fl^sloluiy, id Ed.. London lS4i>, Vol 1, pp. 7&4y 778.
38 Ifitroduetion to the Study qf lK$ease$ qf the Nervous Syetem.
on McA otktr; tU irriitition i$ eonMjfid hff tk€ 9gnmtwe Jihm to the hram and tpmal eord^ and it 5y
tk«m cawunmniealdd to iU motor Jihru, The ezperimenU detailed bj Professor Mailer, in support
of this proposition, render it erident that the ^neml spnsou excited in anlmnls bj tonebing
points of the sarftice, do not depend on a commnnication between the sensltire and motor
fibres in the nerret, bat apoo the fiMt, that the spioal cord is the esseotial link between the
centripetal impression conrejed bj the sensitire fibres, and the centrlfagal laflaence of the
motor nerves. The facts established experimentallj bj Mailer, proTe likewise, that the pheno«
mena of general spasms, thns excited, are not dependent on the sympathetic nerres, bat that
thej are owing to an Irritation of the spinal cord, bj rlrtne of which everj impression eon-
Tcjed to It bj the sensitlTe fibres, eren thoagh qaita local. Is propagated through the whole
spinal cord and brain, and thas necessarilj excites all the motor fibres giren off from them.
The stata of irritation of the spinal cord, here referred to, maj be prodnced bjr the following
canses : ibj the mere division and contnsion of the spinal cord ; bj the action of certain
poisons, as nnx-romica ; hj each causes as produce exhaustion of the brain and spinal mar-
row, hy excessivelj exciting them ; serere local irritation of a sensitive nerve maj, bj the
Intansit/ of the impression convejed to the brain and spinal marrow, give rise to twltchlnga
of the muscles and tremors, as In severe local burns, extraction of a tooth, 4c.; local Irrita-
tion of the nerves, from Infiammation or ganglionic enlargementa, frequentlj give rise to
general spasms and even to epilepsy ; irritation of the spinal cord, arising from local excltament
communicatad bj sensitive fibres, as in traumatic tatanus ; great irritation of the sympathetic
nerves in the intestinal canal, as in cholera and the intestinal aflbctlons of children. Sach
facta merely lead to the admission of the law, that whenever general spasms are excltad by
local impressions, the phenomena depend on no other commnnication between the sensitive
and motor fibres, than what exista in the spinal cord. In very many cases, however, local
irrTtation of the nerves gives rise, not to general, but to local muscular spasms ; In this oaae
again, according to Mfiller, the spinal cord is to be regarded as the band of communication
betwefin'the sensitive and motor fibres.* The cases of this kind are : local spasms, or spasms
only of those muscles, the motor fibres of which arise from the same part of the spinal cord
as the sensitive fibres that are irritated ; as in the case of burns, the contraction of the iris
under the Influence of light, the winking of the eyelids under the long continued infiaence of
light, the contractions of all the perineal muscles in the expulsion of the semen, which are
excited by irritation of the sensitive nerves of the penis, the spinal cord being the medium of
communication, between the sensorial impressions and the movements, the contraction of the
glottis and air passages excited by the contact of irrespirable gases, the movementa of degla-
tttion, and the contractions of the sphincter ani and sphinctervesicss ; in spasmodic movementa
of the organs of respiration, as sneexing, coughing, hiccough, vomiting, 4c., in contraction
of the diaphragm and abdominal muscles. Induced by irritation in the intestines or arinary
organs, and in the expulsion of the fcstus In some cases after the death of the mother, we
have examples that when the excitement of the sensitive nerve is entirely local, the reflected
influence from the brain, may be more extended.
In the second kind of cases, the reflex action affecta a large group of nerves-^the respiratory
nerves, and is excited most frequently by Irritation of a mucous membrane. When this irri«
tation, however Is more intense, the irritation of the spinal cord becomes extensive, and it
reflected upon almost all the nerves of the trunk.
The preceding is the view of J. Mailer as given in the first edition of his work, published
io 1833 and 1834, and it would appear that this theory was elaborated without any knowledge
of the labors of Marshall Hall.
Professor MQller agrees with Dr. Hall, as te the refiected motions which occar after the loaa
of the brain, being no proof that stimuli applied to the skin are still able to excite trae sen-
sations in the spinal cord ; the ordinary centripetal action of the nervous principle taken
place in these cases Just as when sensations are produced, but here it does not give rise to
sensation, since it is not communicated to the brain, the organ of consciousness. During lifb,
also, and In the state of health, many refiected motions are excited by Impressions, which ar«
not, as true sensations, communicated to the sensorium, but nevertheless exert a strong infla*
ence upon the spinal cord ; as for example, in the case of the irritation of the f«ces or arine,
exciting the contracticfus of the sphincters. But Professor MQller held that Dr. Hall goes
too far In admitting that, in the healthy state, every motion which follows true sensation la
voluntary, and that all irritations of sensitive parte which give rise to reflected motions am
unattended with sensation ; for the reflected motions of sneezing, coughing, and many others,
are consequent on true sensations. The reflected motions, and the involuntary not reflected
motions, most not be confounded with each other. If the glottis of an animal be tonchedy
says Dr. Hall, it contracte ; so likewise does the heart when touched. The removal of the
brain does not affect these phenomena ; but if the medulla oblongata be taken away, the
larynx can no longer be mtde to contract, while the action of the heart continues even after
the removal of the soinal cord. The he^rt Is affected immediately on the application of any
stimulus, by virtue of its irritihility ; the innpression mi le by a stimulus. applied to the larynx.
Introcbiction to the Study of Diseases of the Nervous System. 39
*
OB the eoatrarj, mutt be propagated to tbe medolla oblongata, and tbe contraction it effected
indlrectJy ibrongh tbe mediam of the latter part.
It reaiilta from tbe foregoing obserrations that epaemodic affections of tbe mnscles occurring
in dtseaiod statw, may bare rery different sources. There are spasmodic affections of which
the caiiao ia sealed In tbe motor nerves themseWes, or in the brain and spinal cord ; but con-
mlsiona mmj also arise from the reflex action of the nerTous system, their cause being
irtitatioo of tbe sensttiTo nerves. Of tbe muscular spasms of tbe latter kind we have instances
frequently occurring, In consequence of intestinal irritation, in dentition, odontalgia, and
from painfal affections of tbe nerves generally, whether these be dependent on organic lesions
or not.
All tba pbenomena hitheHo described, agree according to MWer in tbe circumstances of
the spinal cord being the medium of communication between the centripetal nervous action
produced by the exciting stimulus, and tbe subsequent motor action of the nerves ; but the
different "paths" of communication in tbe spinal cord may be more distinctly defined. Tbe
most common form of reflected motion is that, when violent impression on sensitive nerves
excites muscular contractions in the same limb ; this is observed when the skin is burned,
and in the first stage of narcotisation of an animal, a stimulus applied to the skin excites cou-
tractioBB most rapidly in the irritated parts ; thus also the stimulus of the food in tbe fauces,
excites tba act of deglutition ; dust on the conjunctiva, closure of tbe eyelids ; and irritation
of the urine and fseces, the contraction of tbe sphincters. Hence, irritation propagated to
the spinal cord must readily affect those motor nerves whi^b arise neateMtothe roots of
the exciting sensitive nerves ; in other words, that it is most prone to pass from tbe posterior
roots, or tbe individual fibres of these roots, to the anterior roots of the same nerve, like
electricity, leaping by the most direct course, from one pole to the other. When the motor
iafluence of tbe spinal cord is strongly excited by a sensitive nerve, that part only is affected
▼bicb la nearest to tbe root of the nerve; and the irritation of the cord, and of tbe motor
nerves ariaing from it, diminishes in proportion with the distance Irom that point. In the
lane way, in tbe brain the irritation is communicated from certain sensitive to certain motor
nerves. Tbna tbe optic and acoustic nerves, and the sensitive branches of tbe fifth nerve,
sre prone to excite reflex actions of the ciliary branches of the third pair and of the facial
nerve. The aensitive and motor nerves which thus react on each other through the medium
of tbe bimin and spinal cord, seem to stand in such a mutnal relation, that a change in the
eottdition of one produces a change in the other ; just as the scale of a balance rising causes
the other to descend, or as the sinking of tbe fluid in one branch of a bent tube makes it rise
in the other. Tbe form of reflex action next in frequency to that just described, is the pro-
daction of spasmodic contractions of the respiratory muscles from tbe irritation of tbe
macona membranes. Hence, there must pre-exist in the medulla oblongata and spinal cord
•oBw means of ready communication between tbe sensitive nerves of the mucous membrane,
(the filth nerve of the nostrils ; the vagus nerve in the trachea, lungs, pharynx, cesopbagus
Aod stomach ; tbe sympathetic nerve in the intestines and uterus; and branches of the sacral
plexus and the sympathetic nerve in the urinary bladder and rectum,) on the one hand, and
the motor nerves of the respiratory muscles (tbe facial accessory, and certain spinal nerves,)
OB the other ; while the spinal nerves that go to the extremities are excluded from this har-
mony of action. There are, however, certain states of irritation of tbe spinal cord and brain,
produced by tbe action of narcotic poisons, or other causes, in which every impression on a
•easitive nerve is capable of exciting the spinal marrow to a discharge of motor influence by
all the motor nerves, even by ttfose which are least prone to be affected by reflex action, —
namely, the motor nerves of the extremities. Volkmann has shown (hat even dividing the
spine longitudinally does not prevent the extension of the reflex motions to tbe muscles of
both ndea of the body, so long as the two halves of the spinal cord remain connected at any
one point.
With inference to tiie question, how far true sensation is engaged in tbe production of tbe
reflex motions, Yolkmann inclines to the opinion of Whytt, that tbe motions consequent on
impressions are tbe result of an appropriate voluntary reaction of the sensorium excited by
sensataon ; and Mfiller holds that this is indubitably the case in many instances, as in those
reflex phenomena which occur in an unimpaired state of tbe brain and spinal cord, viz : the
dosnre of the eyes under tbe stimulus of a strong light, and the action of tbe respiratory
muscles induced by irritation of the mucous membranes of the respiratory organs, intestinal
canal, or urinary system. But tbe continuance of reflex actions, after division of tbe spinal
cord into several portions, each part if it still contain a fragment of the spinal cord, still
evidenciag reflex motions, indicates that the preceding view is not applicable to all cases.
Tbe reflex phenomena are observed also to occur in parts withdrawn from the influence of the
will, aueb as the intestinal canal and heart. The spasms also, which are excited by the stimu-
lus of a sensitive nerve in animals in a state of narcotisation, do not in tbe slightest degree
resemble the phenomena of spontaneons reaction
JIfiller thos ezprMaes his view of the reflex actions : — InitatUm of unmiht fihret of a tpmal
40 Introduetim to the Study of Diseases ^ the Nervous System.
neroe exeUet primardjf a centripetal action of the nervoui principle^ eonveyinff the impreeeion to the
spinal cord; if this centripetal action can then be continued to the eenaorium commune, a true eeneation
is the reeult ; hut if, on account of divimon of the epinal cord, it cannot he communicated to the eenaorium,
it ttill exerts ite whole v^uenee tqxm the jpma/ cord. In both caeee, a reflex, motor action may be the
reeult. In the former eaae, the centripetal action excitee, at the eame time, eeneation ; in the latter case
it does not, but is still adequate to the production of reflex motion, or centrifugal reflection,
Miiller Affirms that Dr. Hall's theorr diffiBrs from that of Whjtt, as well as horn his own,
and is peculiar. In the first place Dr. Ball, limits the phenomena of reflex action to the
spinal nerres, and denies to the cerebral nerres of special sense the power of exciting them.
He supposes the reflex motor actions to be in no case excited bjr sensation, nor even bjr means
of the nerrons fibres. He maintains the existence of special nerres, or nervous fibres, endowed
with the " excito-motorj " function ; and the reflex action he supposes to be conreyed, not by
the nerTes of spontaneous motion, but by special fibres, which he calls ** reflecto-motory."
The posterior roots of the spinal nerres, and nerres of the mednlla oblongata, according to
Dr. Hall, contain sensitiTe and excito-motory fibres, ; the anterior roots spontano-motory and
reflecto-motory fibres ; the vagus, too, he regards, not as a nerve formed chiefiy of sensitive
fibres, but as an excito-motory nerve; for in an experiment performed by himself and Mr.
Brighton, its division gave rise to no pain, but affected the movement of respiration. Yolk-
mann disputes the validity of the views of Dr. Hall, and among other arguments states, that
Dr. Hall is incorrect in asserting the vagus to be insusceptible of painftil sensations.
Muller distinguishes two principal grounds of reflex motion :^
1. Reflex motions of the animal system, wherein he reckons the reflex motions of the
muscles supplied with cerebral and spinal nerves, the centripetal excitation may be produced
in the animal or.'organic nerves, in the external skin, or in the intestinal canal.
2. Reflex motions of the organic System. To them belong, according to him, the reflex
motions of the involuntary moving muscles ; the centripetal excitation may now be transferred,
first, to the brain Itnd spinal marrow from cerebral and spinal nerves, or may have proceeded
from organs, which are provided from the organic nervous system.
The laws of ireflexion, which were established in the case of the cerebro-spinal nerves, hold
good, according to Muller, likewise with respect to the sympathetic nerves ; that is, violent
impressions of sensation in parts supplied by the sympathetic may, when transferred to the
spinal marrow, produce motions in parts supplied by cerebro-spinal nerres. Reflexion from
impressions of • sensation in parts provided by the sympathetic to the spinal marrow, and
brain, and from' thence to the motory action of the sympathetic, takes place also, but in a less
degree, than, in the cerebro-spinal nerves'. The reflexion also of effects or actions, which
proceed from the cerebro-spinal nerves, are transferred to the spinal marrow, and from thence
to the sympathcttic nervous system. A reflecting power in the ganglia, in the case of sympa-
thetic sensations,' according to Milller, is not proven, and several facts are opposed to it. He
even assumes.it as probable, that the brain and spinal marrow are the connecting medium,
when secretions follow in distant parts after sensations through reflexion.
In order cleaely to understand MixUer's views, concerning reflex motion, it is necessary to
consider how, according to him, the voluntary motions take place; in connection with his
views of the physiology of the spinal cord. Thus the spinal nerves are capable of voluntary
determination, in this way ; the fibres of the spinal nerves ascend upwards in the spinal mar-
row, iMid are exposed to' the influence of the will in the medulla oblongata, the source of all
voluntary motion. On the other hand, the activity of the motory cerebral nerves receives the
impulse to voluntary motions iVom the medulla oblongata, ti may be supposed that, in this
part of the brain, the ^brea of all. the motory cerebral nerves and of the spinal nerves are
unfolded. The will puts these fibrllous origins into action, like the keys of a harpsichord.
To the voluntary motion, there is wanting, only the excitement of a vibration or an oscillation
in the origins of a certain quantity of the fibres of the medulla oblongata. All the rest is
mere mechanism. MAll^r designates the brain as the source of sensations and Tolnntary
motions, when he says : %h0 brain receives the impression of all the sensitive fibres of the entire
system, becomes conscious of them, and knows the place of the sensation, according to the
siTection of the various primitive fibres; the brain again excites the motory powers of all the
motory primiiive fibres and of the spinal marrow in the case of voluntary motion. So various
is the power, and still so similar is the action of the brain in exciting a certain part under the
immense number of primitive fibres to the playing of a many-stringed instrument, the strings
of which sound as the keys are touched. The mind is the performer, the primitive fibres of
all the. nerves, which are diffused over the brain, Are the strings, and the commencement of
these are the keys. In man and the higher animals, the spinal marrow, according U> Milller,
bears exactly the same relation to the brain, that sJI the cerebral nerves bear to it, and the
spinal marrow is to be considered as the common stock of all the nerves of the trunk, though
it stUl possesses peculiar powers over the nervous stems. The spinal marrow represents
not only all the nerves of the trunk in general in the brain, but also the individual primitive
H *res of tie K*rves of the trupk. The primitive fibres of the nervous stocks which enter
Introduction to the Study of Diseases of the Nervous System. 41
into the spinal marrow, proceed in a direetion parallel to each other, aa in the atoclc of a
nerre, to the brain, in order that thus isolated and separated, thej may impart to this organ
local sensations, and that in this isolated state also they may receire excitation for motion.
For according to Mfiller, if the primitive fibres of the nerves were bound together in the
spinal marrow, a local sensation in the trunlc would be jnst as little possible, as a separate
and isolated contraction of separate muscles in the trunk. The seat of the sensations, is
neither in the nerves, which bring to the brain the oscillations or vibrations of the nervous
principle, necessaiy thereto, nor in the spinal marrow, which conducts these effects or actions,
like nerves to the sensorium commune ; this takes place only through the action of the fibres
of the nerves and of the spinal marrow on the sensorium commune. But the spinal marrow
serves not only as a conductor of the fibres of the nerves to the brain, but appears also as
part of the central organ. As such it possesses the power of reflecting the sensorial irrita-
tions of its sensitive nerves to the motor nerves. It possesses also the property, whereby
motions, follow a sensation, without both kinds of nerves communicating by their primitive
fibres, a property potsessed by no nerve that is separated from the central parts. Tbe spinal
marrow is capable of reflexion from nerves of sensation to nerves of motion without itself
possessing sensation. »
Johaon Wilhelm Arnold,* in his masterly examination of the theory of the reflex function,
urges the following objections against the preceding theory of Miiller, concerning tbe
structure and function of the spinal marrow.
1. A careful anatomical examination shows no such structure of the spinal marrow, as
described by Mnller. In contradiction to his assertions, it may be stated, that the spinal
marrow does not diminish downwards in proportion as it gives off nerves which would be the
case, If it were tbe union of the primary fibres of tbe spinal nerves ; the fibres of the spinal
nerves cannot be traced far into the spinal marrow ; the fibres of the spinal marrow, which
can be demonstrated only in tbe white substance of the same, cannot be traced up to a certain
point of the central organ ; it is difficult therefore to determine the place where Muller's
harpsichord is to be found, whose chords are the primitive fibres, and whose keys the mind
sets in motion.
2. Lesions in the spinal marrow contradict Muller's theory: thus on injuring one-half ot
tbe spinal marrow, we do not always observe paralysis of the parts of the same side, which
lie below the seat of the lesion; softening of the spinal marrow does not always destroy sen-
sation in the parts which receive their nerves from it.
3. Experiments on animals according to Arnold, afford decisive proof that Muller's theory
concerning the conducting power of the spinal marrow is erroneous ; thus Volkmann's experi-
ments have ahown that a longitudinal diviaion of the spinal marrow does not prevent the
<fXtensiott of tbe reflex motions to all the muscles of both halves of the body, so long as any
line part of the proper spinal marrow remains connected in the middle line. Arnold has
repeatedly observed the following facts in his experiments on the action of nux vomica on
the spinal marrow, which he thinks peculiarly adapted to refute Muller's theory ; the cutting
out of a piece of the spinal marrow on one side, does not prevent the conducting power of
this part of the nervous system ; tbe same power still continues with respect to the impres-
•lons from without inwards, if the upper part of tbe spinal marrow is connected with the
lower only by means of a small bridge, or even when an irritation of the medulla oblongata
no longer readily communicates itself to tbe part of the spinal marrow lying below the section.
After catting out a piece of the spinal marrow on tbe one side, an Impression made on the
«oond side, is more rapidly and better conducted than on the injured side ; still, on the latter
side also, the conducting power is quite manifest, and not very much weakened. When after
cutting out tbe piece, nux vomica is applied, tetanus sometimes occurs about a moment
earlier on the uninjured side. The hind legs also are in several cases directed to tbis side.
This however, is by no means constant, and never of long duration.
With reference to the theory of reflex action, as expounded by Marshall Hall, John William
Arnold, remarks, that as Dr. Hall himself has declined to demonstrate anatomically his excito-
notory system, and even confesses his inability to do so, he finds it unnecessary to trouble
hioMelf with showing the impossibility of tbe existence of such a system, by the known
stmctnrc of the spinal cord. He therefore contents himself with an examination of the
experiments of Dr. Hall, in support of his theory, and concludes that these experiments prove
nothing farther than that the spinal marrow and medulla oblongata have a sensibility for
irritants, which act immediately on the same, that these irritants are capable of throwing
this into a condition which, being transferred to nerves of motion, dispose these to excite
motions; farther, that the irritants which affect the sensitive nerves belonging to the spinal
marrow, in like manner, occasion in tbis central portion of the nervous system, a state which
is followed by motions.
•IH* Lahiv voD der Eell«z— Fanction fur Pb jslologen nod Aente ; Duvwt«lU beortheilt, von Jolmnn Wlllielm
AffBoM. ]f«d. Chlr. Brr., Jul. 1843, pp. 33, 56L
42 Introduction to the Study of Diieases ^ the Nervous System.
According to Mr. Arnold, the fActt, and the conclntions immedUteljr to be drtwn from them,
were long known to physiologists, and only the consequences which Dr. Hall considered him-
self justified in drawing, are new and also unfounded. Mr. Arnold expresses the belief that all
the experiments of Marshall Hall, taken together, do not contain a single fact which can fairlj
be deemed a proof of the existence of an excito-motory system, and that the admission of such
a system is not supporud by any other kind of physiological proofs, and that it cannot as Dr.
Hall confesses, be demonstrated anatomically, and therefore that we are perfectly warranted
in rejecting the theory of an excito-motory system, as a system destitute of all experi-
mental and truly rational grounds. Having thus disposed of the substance or essence of the
system, Mr. Arnold thinks it unnecessary to treat of the consequences deduced from it, and
he proceeds to direct attention to some errors and contradictions inrolred in the theory, and
endeavors to demonstrate the groundlessness and untenability of the distinction of the nerves
on the one hand into sensitive and excitory, and on the other hand into such as serve for
voluntary motion and reflection.
The following facts disposed Mr. Arnold to admit against Dr. Hail, that both processes,
sensation and susceptibility of excitation on the one side, as well as voluntary motions and
reflex motions on the other, are ^ected by the same nerves :
1st. The skin, the organ from which sensations attain consciousness in so high a degree,
which as an organ of feeling, is the medium of so many sensations, is also the organ, whose
irritations call forth the so-called reflex motions, more than those of most other organs,
more, for instance, than those of the mnsdes. It is accordingly here the organ through which
conscious sensations are chiefly communicated, and that also through which the reflex
motions chiefly receive their excitations. The nerves which go to the skin are accordingly
sensitive and excitory nerves.
2d. In admitting special sensitive and excitory nerves, a general expansion of both nerves,
even to the most minute ramifications, must be allowed to exist in the skin, even the smallest
portion of which possesses sensibility and power of excitation. For as no portion of the
skin, however small, can be touched with the finest point of a needle, which does not excite
sensation, and at the same time the so-called reflex motions in decapitated frogs, it must be
admitted, as Volkmaon has well observed, that every part of the skin of the size of a needless
point contains two specifically difTerent nervous fibres, and to every muscular fibre, which
is subservient to voluntary and the so-called reflex motion, there belongs besides a cerebral
fibre, also a spinal fibre.
3d. After dividing the posterior roots of the nerves given to the posterior extremities, the
animals not only lose sensibility in these parts, so that no indications of pain are observed in
sticking or pinching the same, but also in irritating them none of the so-called reflex motions
follow, nor on the application of nux-vomica, does tetanus take place; whilst srfter touch-
ing those parts whose sensitive nervous fibres were not divided, this state immediately took
place.
4th. Nux-vomica exalts so very much the power of sensation, and increases also the
susceptibility to irritants after the removal of the head, that Dr. Hall numbers it among the
poisons which produce an excess of reflex function. This fact renders it so much more pro-
bable, that sensation and susceptibility to excitation are not effected by different nerves
and parts of the nervous system, more especially if the following points be kept in view :
After removing the head or brain, the susceptibility to excitation still exists, and nux-
vomiem also is still capable of producing exalted irritability and rigid spasm, a result very
striking in amphibious animals.
After injuring or partially removing the medulla oblongata, the so-called reflex motions
are weaker and of less duration than after mere decapitation of animals. The same thing
occurs with respect to the action of nux-vomica, if the process be carefully conducted.
The experiments of Mr. Arnold, on frogs, gave in general the following results : Removal of
one lateral half of the medulla oblongata does not suspend susceptibility to the action of
nux-vomica, if the process be carefully conducted. The action is merely of lesi duration :
cutting off a small portion at the upper extremity of the medulla oblongata does not pre-
vent the occurrence of the exalted irritability of the skin and the tetanic spasms ; it merely
seems to delay their occurrence, and to be the cause of these phenomena being less perma-
nent in the experiments in question, and also of their being less marked in the hinder
extremities. After the division of the medulla oblongata transversely, the tetanic spasms
either do not come on at all, or but very slightly or feebly. After removal of the medulla
oblongata, the reflex motions diminish more palpably in energy and duration than after their
mere lesion. This is also the case with tetanus occasioned by the application of nux-
vomica before cutting out the medulla oblongata.
According to Mr. Arnold, the medulla oblongata through which the sensations, at least of
very many parts of the body are effected, Is the great point of the nervous action of nux-
vomica, which increases the power of sensation in so high a degree, and also as the reflex
physiologists themselves admit, increases the susceptibility to excitation.
Introduction to the Study of Diseases qf the Nervous System. 43
From hit ezperimenis, m well u from the circnmstanoe that the tetanus occasioned by the
application of the nnz-Tomica still continues if the mednlla oblongata is not removed until
after the action has set in, the following conclusion maj be drawn : That the spinal marrow
is not active from its own intrinsic powers, and that it re-acts only so far as it is charged
from the medulla oblongata, and according to the manner in which this charging has talcen
place the so-called reflex motions still continuing after the removal of the medulla oblongata,
may be considered as charges of the nervous fluid accumulated from the spinal marrow, pre-
vioasly transferred from the mednlla oblongata. This view, however, is but partially cor-
rect ; for, besides the structure of the spinal marrow, aud many physiological facts, it is
opposed by the circumstance, that certain agents stiU act on it after the medulla oblongata
hat been removed ; Strychnine, for instance, is still capable of exciting rigid spasms under
favorable circumstances.
Mailer does not express himself very definitely as regards what takes place in the spinal
marrow in the reflex motion. According to his view, an irritation of a sensorial spinal nerve
next causes a centripetal action of the nervoui principle to the spinal marrow. ' If this can
reach the Mouornim commune^ a conscious sensation is produced. But if it does not reach the
sefMornim eoauniiiM, in consequence of a division of the spinal marrow, it still retains its entire
power as a centripetal action of the sensorial nerve to produce a reflex motion. In the first
case, the centripetal action would be at the same time a sensation, in the latter case not, but
it is snfllcient for the reflex motion, or for the centrifugal reflexion. But we are not here told
in what way the centripetal action, which does not reach to a conscious sensation, brings
about a centrifugal reflexion, and wherein the process effecting this in the spinal marrow dif-
fers from that in the brain in the motions attended by conscious sensations. From more than
one passage in Muller, it appears that he assumes that in the spinal marrow there is a
mechanical transference of the nervous fluid from the nerves of sensation to those of
motion. This assumption, however, according to Mr. Arnold, is contradicted, not only by all
the facts above adduced to disprove the isolated conducting property of the nervous fibres in
the spinal cord, but also, by the experiments which show that the motions of irritation of
decapitated animals evince the character of determinateness and harmonious accordance.
Prom the results of his experiments, Mr. 'Arnold drew the following conclusions:
1. A power to feel external irritants has its seat in the spinal marrow, in some degree
independently of the brain and medulla oblongata, the perceptive faeuUy of the epinal marrow,
2. This power in the spinal marrow regards not merely the Irritant in general, but also
the kind, the degree and the locality of it. But the property of perceptions connected with
consciousness is wanting.
3. Next to the perceptive faculty (the faculty of feeling), is the faculty of the spinal mar-
row to re-act correspondingly to excitement occasioned by impressions, and, in consequence
of this, to perform suitable, combined and harmonious motions, the re-active faculty of the
tpimal marrow.
4. These motions are no doubt suitable and harmonious, still they want the character of
freedom. They are not external manifestations of a will.
5. The spinal marrow possesses only in a slight degree the faculty of accomplishing
spontaneous motions. If, in decapitated animals, self-dependent motions follow, they are
principally the consequence of a disposition or excitation, which the spinal marrow has
received from the brain or mednlla oblongata previous to decapitation.
6. The degree of the perceptive faculty of the spinal marrow depends on a peculiar dispo-
sitioD of this organ, which is effected in it principally by the mednlla oblengata, and which
without it, can be produced in this organ only in a very slight degree. The same may be
said of the rapidity and violence of the motions occasioned by external irritants.
7. The disposition produced in the spinal marrow in this way, continues for some time in
It, if it be separated from the brain and medulla oblongata, and even In separate parts of the
same.
8. That which takes place in the spinal marrow, during the perception of external influ-
encea, and the determination of motions following thereon, is analogous to that which takes
place In the brain during conscious sensations and voluntary motions, only that clear con-
scioosnesa and freedom of the will are wanting to it, whilst the character of suitableness and
of barmooions accordance appertains to it in the highest degree.
9. The impressions which the central organs receive through the nerves, produce in them
a condition or disposition corresponding to their quality, depending both on the nature of the
impression, and the nerve by which it is taken up and conducted to the central organs of the
nervons system, whereupon these organs re-act in a corresponding manner.
10. A mere transference of the nervons principle from sensitive t<f motory fibres does not
take place in the spinal marrow. The term "reflex function,'' does not indicate what takes
place in this organ during the motion occasioned by external irritants.
11. With regard to the conducting faculty of the spinal marrow, observation goes to
show that it is In its total character, in its character as a whole, that it imparts the condition.
44 Introduction to the Study qf Diseases qf the Nervous System.
in which it is placed on the one band by the brain and the mednlla oblongata, and on the
other hand hj the nerres. After what haa already been eaid, it can no longer be admitted
that'the Sbres of tbetplnal marrow conduct impresaions aeparately and isolatedly, Jnst like
the nerrous fibres.
12. It is not the number of the muscles mored that the central organ determines, but the
end which is to be attained. A harpsichord theory, as it has been introduced of late years,
has no facts for and many facts against it. (Med. Chir. Rer., January, 1843, pp. 33-55.)
It is evident therefore that the theory of Dr. Hall, that the nervoul fibres engaged in the
production of the reflex or excited morements, are distinct from those which reach the centres
of sensibility and volition in the brain, was not established by the facts which he himself
adduced in its support. In fact Dr. Hall, himself, admited the impossibility of demonstrating
anatomically the existence of his excito motory system of nerves, and he inferred their exis-
tence from the results of physiological experiments, which as we have just seen by a review
of the experiments and arguments of Mr. Arnold, admitted of another explanation. Some
light however has been thrown upon the probable existence of reflex or excito-motor nerves,
by the observations and arguments of Mr. Grainger, Dr. Carpenter and Mr. Newport.
* Mr. Grainger (Observations on the Spinal Cord, London, 1837,) sought, first to prove that
gray matter is the source of all power in the nervous system, and that the white fibres are
merely conductors ; supporting this view by the fact that the nerves are rendered incapable
of performing their functions bj separation from the central organs : that the power of those
central organs is always proportionate to the quantity of gray matter which they contain :
that the abundance of gray matter in the brain, for example, bears a direct relation to the
development of the cerebral faculties, and its abundance in the spinal cord, to the motor
powers of the animal : and lastly, that even in particular parts of the cord where large nerves
enter and issue, a corresponding increased deposit of gray substance is found. In the next
place, Mr. Grainger directed attention to the roots of the spinal nerves, and showed that while
a portion of the fibres of each root is derived from the white fibrous substance of the cord,
another portion passes inwards, and is lost in the gray matter, as had been before stated by
Belltngeri and Weber. The latter fibres Mr. Grainger regarded as the true excito-motory.
and reflecto-motory fibres, the former he supposed to be the conductors of sensation and
volition ascending to or descending from the brain. These views he extended to the cerebral
nerves, and stated that they also may be traced to have origins both from deposits of gray
matter when the impressions conveyed by incident fibres are communicated to reflex motor
fibres, and also from the white substance which passes up to the hemispheres of the cerebrum
and cerebellum. Lastly Mr. Grainger pointed out the accordance of Dr. Hall's theory, with
the structure of the nervous system in the lower animals, and especially the invertebrata.
Dr. Carpenter, in his Inaugural Dissertation on the Nervous System of the Invertebrata.
(Edinburgh 1839,) expressed views essentially the same as those developed by Mr. Grainger.
The following are some of the most important physiological inferences, deduced by Dr
William B. Carpenter, from the structure of the nervous system in the invertebrate classes of
animals.
The actions performed by the lowest animals have almost entirely the character of reflex
movements, the manifestations of true sensibility and volition which they present being very
few. The earliest form of nervous system met with in these animals consists of ganglia with
nerves which convey to them the impressions made by external agents, and others which con-
duct ths reflex motor influence ; the principal sets of organs with which such ganglia are
conneeted being those which minister to the functions of the ingestion of food, respiration,
and locomotion. In proportion, however, as the development of organs of sense and the
character of the movements prove the participation of the faculties ot true sensation and
volition in the acts of the animal, particularly in those by which food is acquired, certain
ganglia, connected with the organs of sense, and like them, always seated near the month
acquire a larger size, and an evident predominance over the rest. Vet, even where this is the
case, as in the higher MoUnsca and Articulata, the organs by which the food is introduced into
the stomach, the organs of -respiration and those of locomotion, still remain under the imme-
diate influence of special ganglionic reflecting centres, while distinct fibres descend from the
cephalic ganglia and unite with nerves issuing from these local nervous centres, for the
purpose of conveying to the different organs the influence of the will, and receiving the
impressions destined to produce sensations. Thus the nervous cord in the arm of the Cuttle-
fish, is composed, according to Dr. Sharpey, of two fasciculi of fibres, in one of which ganglia
are formed at points corresponding to the prehensile suckers, while the other passes over the
ganglia without entering into their composition. The ganglia of this nervous cord are.
evidently centres of reflection ; for, when the arm is separated from the body of the animal,
each sucker may be stimulated to contract ; in order however that they mav act in unison,
these reflecting ganglia are connected by a fasciculus of commissural fibres, while at the same
time, the muscular apparatus of the suckers and of the whole arm is brought under the con-
trol of the will through the medium of the non-gangliated band, which descends from the
Introduction to the Study of Diseases of the Nervous System. 45
•
cephalic gmnglia. The same remarks appljr to the abdomioal nenroas cord of the Articnlata,
which has been shown bjr Mr. Newport (Phil. Trans., 1834) and Dr. Grant, (Lancet, Jnlj, 1834),
to consist of two pairs of fasciculi, one inferior, in which the ganglia are formed, and the
other superior, which passes over the ganglia of the cord apparently without entering into
their composition. The latter fasciculus, according to Dr. Carpenter, contains the true con-
ductors of sensation and yoluntary power, while the inferior fasciculus has the function of
connecting the diiferent locomotire ganglia, for consentaneous action. In like manner, a part
onlj of the fibres giren off bj the nervous cord is supposed to reach the cephalic ganglia
throagb the medium of the superior fasciculus, while another portion terminates in the local
jranglla which form their reflecting centres.
These riews respecting the nervous system of invertebrate animals appear to be confirmed
by the results of microscopic examination of the ganglia and by the results of certain experi-
ments. Thus Dr. Carpenter adduces the following microscopic observations by M. Leuret and
himself; in the ganglia of Mollusca, the fibres of the nerves according to Leuret (L'Anatomie
Compar^e du Syst^me Nerveux), terminate in the midst of the gray matter, in the Leech, he
deacribes and figures the fibres of the nerves which enter each ganglion of the ventral cord,
as being continuous in part with the longitudinal fibres of the cord, and in part with those
of the corresponding nerves entering the opposite side of the ganglion ; Dr. Carpenter states,
that in the Myriapoda, each nerve given off by a ganglion of the ventral cord has three series
of roots, one of which terminates in the gray matter of the ganglion ; another interlaces
with those of the opposite side; whilst the third is continuous with the fibrous portion of the
cord, which may be traced uninterruptedly to the cephalic ganglia. Valentin, some time before,
bad fonnd in the microscopic examination of the ganglia of the nervous cord of the Leech,
that while the longitudinal fibres of the cord were continued, in part, at least, uninterruptedly
over each ganglionic mass, those of the lateral nerves spread out in its substance and appeared
to terminate there. We have already examined at length the first papers of Mr. Newport, who
affirmed that he had distinctly seen commissural fibres passing between the nerves of opposite
sides in the ganglia of the cord of Insects. There appears, therefore, sufficient direct evidence,
to prore that many of the nervous fibres which enter the ganglia of the body of Invertebrate
animals, are not continued to the cephalic ganglia which represent the brain of the higher
classes.
That the vsntral cord of Articulate animals is a source of motor power, is sufficiently
proved by the well-known occurrence of automatic and reflex movements in these animals
after decapitation or division into several segments.
The elucidation of the properties of the different parts of the cord in these animals, still
remained an interesting subject for investigation. Dr. Hall stimulated one of the nerves
coming off solely from the superior non-gangliated column of the lobster ; the muscles to
which it was distributed, and they alone were contracted. He then stimulated one of the
nerves which arise from the ganglia ; muscles both anterior and posterior to the part stimu-
lated were excited into combined action. Valentin, in his experiments upon the Astacus
Finvitalis, found that irritation of the nerves arising from the ganglion itself, sometimes
produced motions, but not invariably, while irritation of the nerve given off by the superior
non-gangliated fasciculus of the cord always excited musular contractions. Valentin having
divided the abdominal cord Just below the thorax, irritaVed the superior fasciculus of its
lower portion ; muscular movements were very frequently excited. He irritated the infe-
rior fasciculus ; no such result followed. The strongest and most extensive motions were.
however, produced when the abdomioal surface of one of the ganglia was irritated : almost
all the muscles of the tail being thrown into action by stimulating one ganglia.
Dr. Wm. Baly, the learned and acomplished translator of MuUer's Elements of Physiology,
in conjunction with Mr. Newport, verified the preceding statement ; they found that lateral
compression of a ganglion, or irritation of its lower surface, in the tail of a Lobster, separated
from the body of the animal, caused contraction of muscles situated both before and behind
it, and violent movements of the whole tail. Dr. Baly drew from these experiments the fol-
lowing conclusions:
I. The superior fasciculi of the ventral cord of Articulata, and the nerves which arise
from It alone, contain motor fibres, — probably fibres subservient to volition. 2. The ganglia
of the cord are centres of motor influence, and give rise to movements through the medium
of efferent fibres, not only when subjected to direct irritation, but also, as Dr. Hall's experi-
ment seems to show, when an impression is conveyed to them by afferent or incident fibres
contained in the nerves which arise from them. 3. The effect of irritating a ganglion, or
the excito-motory nerves arising from it, is not necessarily confined to that ganglion ; but
may extend to other ganglia situated anteriorly or posteriorly, through the intervention of
the inferior fasciculus of the cord. Mechanical irritation of the inferior fasciculus itself,
after its division immediately behind a ganglion, does not, according to Valentin, excite
movements. Mr. Newport and Dr. Baly, however, found that lateral compress*ion of the
entire cord in the lobster, gave rise to muscular contractions in segments both anterior and
46 Introduction to the Study qf Diseases ef the Nervous System,
posterior to that in which the irritated part of the eord laj, though the coiiTulsioQS were in
this case not so energetic as when the ganglia tbemselres were compressed. Valentin state*
also, that the struggles of the animal, when the inferior fascicnlns, or the ganglia of the cord,
as yet in connection with the cerebral ganglia wern touched, evinced the true sensitive
endowments of these parts. (Blements of Physiology, by J. Mfiller, M. D., etc. Translated
by William Baly, M. D. Sec. Ed., Vol. 1, pp., 768-772).
To physiologists who regard the cephalic ganglia of the luTertebrata as the special seats of
▼olition and the perception of sensations, the small sise of the filaments connecting those
ganglia with the rest of the nerrous system in most of the Articulata, and many Mollusca,
must alone appear almost sufficient proof that a great part of the fibres entering and issuing
from the different nervous centres of the body, are distinct from the sensitive and volition
fibres. That the cephalic ganglia are the centres of sensibility and volition, is rendered pro-
bable, both by the history of their development in the animal series, where their size is
proportionate to the perfection of the sensorial and voluntary faculties, and by their special
structural relation to the other ganglia.
Mr. George Newport, President of the Entomological Society of London,' communicated to
the Royal Society, on the 6th of April, 1843, a paper *' On tke Structure, Reliuums and Dtvtlop-
ment of the Nervoue and CSrculatory Sytteme, and of the Bxkienee •/ a Oomplete Otrcutation of the
Blood in VetseUjin Mjfriapoda and Maerottrout Archnida^^^* which contained valuable additional
observations, bearing upon the reflex theory of Marshall Hall.
According to Mr. Newport, the formation of the great abdominal cord, in the Julidae, by
the lateral approximation of two distinct portions, is indicated in Its upper surface by a slight
median sulcus, and on its under surface by a slight longitudinal division, between the two
approximated ganglia, that form each of its enlargements. Bach of these lateral divisions
of the cord in Jnlns, as formerly shown in Scolopendra and other Articulata, is a compound
structure formed of two distinct longitudinal series or columns of fibres, which, notwith-
standing the different explanation that has been given of their function, since they were first
described by Mr. Newport (Philosophical Transactions 1834, Part 11., p. 408), are quite dis-
tinct from each other, although closely approximated together. By the aid of means, supe-
rior to those formerly employed in his investigations, Mr. Newport found that the abdominal
cord contained other structures besides those already described. In his former communica-
tion to the Royal Society, Mr. Newport indicated the existence of fibres that run transversely
through the ganglia of the cord, in the larva of the common butterfly ; and similar structures
have since been shown by Dr. Carpenter (Inauffwal DitBertation on yerooue Syttem of InperU-
brata), in other Articulata, and applied by him to explain some of the reflex phenomena of
the nervous sysum, in accordance with the theory promulgated by Dr. Marshall Hall. But
besides these two sets of longihtdinal fibree, and the series that pass trantoereefy through the
ffongUa, Mr. Newport discovered other structures in the cord that had hitherto been over-
looked. There are fibres that run longitudinally, in part of their course, at the tidee of the
cord, and enter into the composition of all the nerves from the ganglia, and are designated
by Mr. Newport nsjibret of reinforcement of the cord.
According to Mr. Newport, every nerve from a ganglionic enlargement of the cord is com-
posed of four sets of fibres, an upper and an under one, which communicate with the cephalic
ganglia ; a transverse or commissural, that communicate only with the corresponding nerves
on the opposite side of the body ; and a lateral set that communicate only with the nerves
from a ganglionic enlargement on the same side of the body, and form part of the cord In the
interspace between the roots of the nerves. It is by the successive addition of these lateral
portions of the cord, tbat Its size is maintained almost uniformly throughout its whole length
in the elongated bodies of the Myriapoda. With reference to the identification otihtjibrte of
reinforcement of the cord, Mr. Newport states, that their separate existence is indicated chiefly
at the postero-lateral margin of the ganglia, where they are seen to form part of the nerves
and cord, without passing towards the bnUn. In other part* of their course they are not
distinguishable by color, and very rarely by any longitudinal line of separation from the
fibres which form the inferior longitudinal series, or portion of the cord, to which they are
approximated ; but from which they are believed to be distinct, from the fact that they do
not ascend with them to the brain. Their function must be regarded only as rejie* ; entirely
independent of sensation, but capable of beioR excited into action by external causes. Mr.
Newport announced that the existence of the lateral fibres in the cord, fully explained the
reflected movements of parts anterior or posterior to an irritated limb, on the same side of
the body, as the commissural ones do the movement of the parts on the side opposite to that
which is IrriUted.
After a careful examination of the mode of development of the spinal cord, Mr. Newport con-
cluded that the cord, is elongated in the ganglia, by extension or growth longitudinally, and
that hence the ganglia must be regarded as performing a most important ofllce In the nervous
• Phil. Tnm^ 1M3, p. i4A-Xn,
Introduction to the Study qf Diseases qf the Nervous System. 47
sjrstem, that of being centres of growth and nutrition to the cords and nerves. The tirueture
of the ganglia confirms these conclusions, and shows that not only are these parts centres in
which the reflected motions of the limbs are effected, but that they are even of more import-
ance, being those in which the structures themselves are nourished.
Although Mr. Newport pointed out the existence of fibres in -the nervous cord of Myriapoda
and Arechnida, which lead to the conclusioui that the doctrine of the individuality, or special
function of each fibre is correct ; that there are fibres in every nerve derived from two dis-
tinct portions of the cord, which from their direct communication with the brain, from one end
of the body to the other, are believed to minister to volition and sensation ; and that other
fibre* also exist in the same nerves, that have no communication whatever, with that organ ;
and further, that some of these, which are extended transversely across the body, influence
both sides of those individual segments to which they are distributed, and those only, while
others combine in action two or more contiguous segments, but only by direct influence on
one side of the body : it yet remained to be shown by experiment, whether the assignment of
certain functions to these parts of the nervous system, in these inferior animals is correct ;
whether the results of experiments on these worm-like beings agree in principle with the experi-
ment already made by many physiologists on the vertebrated classes, and those which the patho-
logy of disease has afforded in man himself; whether, as leading to these important results they
coincide with the first experiment made on one of the Crustacea, conjointly by Dr. Hall and
SCr. Newport, in the spring of 1834, (Lectures, Lancet, February 3d, 1838, p. 650, idemoirs on
the Nervous System, p. 67,) and with others subsequently performed by Valentin (De Function
Nervorum, Bun. 1839, also Baly's HiiUer) on the same animal, and afterwards repeated by Dr.
Balj and Mr. Newport, in 1840 (Muller's Physiology, by Dr. Baly, Sec. Ed. Vol. 1, 1840, p.
771 ; ) and lastly, whether the seat of sensation and volition is confined entirely to the supra-
oesopbageal ganglia, the brain in these Articulata. ^
No experiments had as yet been made on any of the Myriapoda with reference to these
inquiries, save only one, imperfectly described by Dug6s (Traite de Physiologie Gomparee,
torn. 1, p. 162 ;) hence it became especially necessary, that with this object the inquiries of
Mr. Newport should be extended to these lower forms of life, so fsr removed from those on
which experiments had already been made, and in which from their low organization, the
phenomena may be well studied. With this object Mr. Newport made careful experiments on
one of the lowest of the Chilognatha (Julus terrettriSy) and one of the highest of the Chilopoda,
( LiikoiriuM fof^atua. )
The questions which Mr. Newport proposed for examination, were :
1st. Whether sensation and volition are confined to the supra-oesophageal ganglia, the
brain, or whether they exist also in the first sub-oesophageal ganglion, or in the other ganglia
of the cord ?
2d. Whether these functions are destroyed by partial destruction of the brain?
3d. Whether there is any direct evidence of sensation in a portion of the cord that is
Insulated from the brain ?
4th. Whether the movements in these animals, when deprived of the brain, are identical
with those of the Crustacea and Vertebrau ?
These experiments lead Mr. Newport to the conclusion, that the seat of volition is solely in
the snpra-ossophageal ganglia or brain of these animals, since all direction of purpose, all
avoidance of danger, all control over the movements of the body, either of speed or change
of direction, are lost when they are much injured or removed. Volition ceases quickly yr)^
they are severely wounded, and is greatly diminished even when only one is slightly affected.
This latter fact is indicated by the loss or diminution of purpose, and by the gyratory move-
meota of the body.
These experiments also lead to the conclusion, that all the phenomena which occur in the
posterior parts of the body, after the brain and cord have been separated, are refiez or excited,
and that tbeae are most intense in the two extremities of the cord — the medulla oblongata
aod the terminal ganglion ; and further, that the reflex phenomena are always excited, and do
Bot occur spontaneously, and that their intensity is greater in proportion to the stimulus
applied, and gradually diminishes until they entirely cease or are re-ezcited precisely as
already shown by Dr. Hall in the vertebrata.
The experimenu, both on the Julus and Lithobius seem further to show, that the reflected
movements cease first in the anterior part of the cord and its ganglia, and that they are
retained longest in the posterior ; that the movements are more powerful and continue longest
when the cord is entire, the brain alone being separated from it ; and that they entirely cease
sooner in proportion to the greater number of parts into which the cord is separated ; further
also, that the reflex phenomena are less readily excited in the anterior part of the cord, while
it is still in connection with the brain, and that they cease entirely soon after the cessation of
volition in that organ ; and in those experiments in which only a very short portion of cord
was removed with it from the body. ^
Many of the phenomena are precisely similar to those which have hitherto been observed in
48 Introduction to the Study ^ DUeaset of the Nervous System.
the Crustacea. Thej agree in the cireamttanee that xiolent contractions of the segments and
limbs, both anterior and posterior to a ganglion, are induced by irritation of that ganglion,
both when connected with the brain, and when isolated from it, thus pforing these move-
ments in the latter instance to be reflex ; but there Is as jret no direct proof that sensation
does not also exists in these ganglia.
The general results of these experiments, tend to conflrm the belief, that the fibres pointed
out by Mr. Newport, in the composition of the cord and ganglia, and which cannot be traced
to the brain, are those by which the reflex morements are instituted indepeudentlj of this
organ. Mr. Newport, confirmed the correctness of these conclusions, by subseqhent and still
more extended experiments upon the Goleoptera, Ortboptera, Hymenoptera, Xeuroptera, Dip-
tera, and other Hexapod Insects. (Phil. Trans. 1843, pp. 243, 302.)
It has been long recognised that the spinal cord of the higher animals, might be regarded
as containing a succession of independent reflecting centres : but the reflecting action of the
centres or segments of the cord seemed explicable without admitting Dr. Hairs theory of the
existence of special incident and reflex fibres. Even when Mr. Grainger pointed out the
accordance of that theory with the mode of origin of the spinal nerves, it still appeared pos-
sible that the fibres which entered the gray substance of the cord might, through the medium
of it, act on each other, and nevertheless be afterwards continued upwards to the brain. When
however the existence of two distinct classes of fibres, those for sensation and volition, and
the fibres which are engaged in the production of the reflex movements, appeared to be demon-
strated in the invertebrate classes, and Dr. Hairs theory might therefore be regarded as appli-
cable to these animals, there appeared to be no reason for the adoption of a different expUna-
tion of the phenomena in the vertebrata, when the function and intimate structure of the
nervous system are in all other essential points the same.
It remains, therefore, that we should in the next place examiue carefully, the results of
the microscopical and anatomical investigation of the minute structure of the spinal cord and
brain in vertebrate animals, not merely with reference to the verification of the theories of
Sir Charles Bell and Dr. Marshall Hall, but also as affording the best anatomical and physio-
logical basis for the investigation of certain pathological phenomena manifested by the ner-
vous system in diseased states.
«
RESULTS OF THE MICBOSOOPIOAL AND ANATOMICAL INVESTIGATION OF THE MINUTE
STRUCTURE OF THE BRAIN AND SPINAL CORD IN VERTEBRATE ANIMALS.
When the investigation was transferred to the spinal cord of man and of the vertebrata
generally, the dlfflcolties were greatly increased, on account of the greater sise and more com-
plex structure of the nervous masses to be investigated ; and such researches were not possi-
ble until a comparative recent period, when both the instruments for, and the methods of pre-
paration and investigation of the nervous structures, had been brought to a high degree of
perfection.
It has been well said by Schroeder Van der Kolk, that the examination of the intimate
structure of the brain and spinal cord, is undoubtedly, one of the most difficult Investigations
in minute anatomy. The peculiar softness of these parts, the fact that they are destroyed by
slight pressure, the extraordinary minuteness and delicacy of their tissue, (their primitive
filaments being quite imperceptible to the naked eye, while it Is with difliculty that, onder a
tolerably strong magnifying power, a single thread can be followed even for a very short
space) — ^lastly, the infinite number of the primary filaments (which in many places interlace
in the most varying manner, forming a net-work incapable of being unravelled) — are so many
reasons why the most persevering efforts of very distinguished anatomists have led to such
varying results, and why great difference of opinion still exists in reference to the most isn*
portant questions.
The communication of sensation through the spinal column to the brain, and the convey-
ance from thence of the orders of the mind with Inconceivable rapidity to the different
muscles, led to the almost universal acceptance of the doctrine, that the nerve filaments ran
from their ultimate distribution directly through the spinal column to the brain ; and after
the brain and spinal cord had been shown by Ehrenbcrg to consist in their intimate structure
of minute tubes, the immediate connection of the nerves through the latter with the former
appeared to have been demonstrated beyond all doubt by Valentin. Remak, who subse-
quently engaged in the microscopical examination of the gray substance and carefully inves-
tigated the ganglionic cells with their efferent filaments, was one of the first who seems to
have had some doubt as to the direct course of the nerves through the spinal cord Into the
brain ; and Hannover, two years after, in 1840, by the employment of a solution of chromic
acid, detected the transverse fibres (commissures), in the spinal cord, in birds, frogs and
fishes, and expressed the belief that the cerebral fibres took their origin from ganglionic cells.
In his work (Recherthft Microscopiques sur le Systems Nerveux, 1844), he shows the origin of
Introduction to the Study qf Diseases of the Nervous System. 49
ibe nerre 6bret from the ganglionic cells in the cortical substance, and states that the fibres
of the spinal cord descend perpendicularly, and curving at obtuse angles pass over into the
roota of the nerves, the cerebral fibre and the nerve fibre having thus direct connection with
each other. The transverse fibres he describes anew, without, however, having been able to
trace them to the peripherj of the medulla ; a few of these would sometimes appear to bend
round into the nerve roots, and portions of them he described as passing from one to the
other side of the cord. He was not able to detect these transverse fibres plainly in any of
the mammalia ; and with the exception of isolated instances in fish; he did not observe
nerve fibres arising distinctly from the ganglionic cells in the spinal cord. Stilling and Wai-
lach on the other band, inferred that the roots of the nerves ran transversely between the
white colamns of the spinal cord and the gray matter, and were merely direct prolongations
of the transverse fibres of the latter, the anterior roots decussating in the middle with the
posterior roots from the other side of the spinal cord. They considered that the will acted
chiefly through the gray matter. In their first essay ( Ueber die TexUir det Ruckenmarks, 1842)
these observers appeared to confound the ganglionic cells with dilated blood-vessels ; but
the sabsequent investigations of Stilling, (Ueber die Textur der Medulla Oblong, 1843), were
much more complete and are regarded by competent anatomists to be correct. Stilling des-
cribes the mnltt-polar ganglionic cells, but the connection between the nerve roots and the
spinal corpuscles, as he calls them, or ganglionic cells, was still unknown to him, although
he expressed the opinion that they are closely connected with the motor power. Although
StiUing represents with the greatest accuracy, the origin of the nerve roots from the gray
substance, his investigations were on accoant of the low magnifying powers employed,
insufficient to show the more minute connection between the nerve roots and the other fibres
of the medulla oblongata ; while his experiments by partial transverse sections of the spinal
cord showing that refiex movement is not prevented, and that even voluntary motion remains
beneath the divided part, described in an earlier essay, have had much influence in suggesting
the idea of a local cross origin and decussation of the spinal nerves.
Volkmann arigued that if the nerves ran uninterruptedly through the spinal cord to the
brain, all the filaments which are distributed as nerves throughout the body, must be present
in the upper part of the cord, and the medulla spinalis should bear resemblance to a cone,
that is, the medullary matter or white columns ought to be so much thicker in the cervical
portion, as would be necessary to enable it to contain all the nerve filaments ; which is by no
means the case. He sustained this inference, by his investigations on the spinal cord of a
serpent {Orotahu mutut^) in which he reckoned not fewer than two hundred and twenty-one
pairs of nerves, whose united thickness exceeded the circumference of the spinal marrow at
the second cervical nerve more than eleven times.
The nerve roots therefore, according to Volkmann arise in the spinal cord, and do not run
directly through to the brain : and he further shows, that the motor filaments at their origin
in ths spinal cord are so adapted, that every stimulation applied to them must produce a
corresponding combination of movements. Since, he says, the application of a stimulus to
the roots of the frog is sufiicient to bring into motion all the corresponding motor fibres, there
is no dottbt that this effect may be produced by a single cerebral fibre, penetrating to the
point of insertion of the allied crural motor nerves. Still less reason is there, he adds, to
donbt, that a single cerebral fibre is sufficient to bring into action all the motor fibres which
work simaltaneously, as for example, the nerves of one and the same muscle, and which,
therefore, are in all probability so arranged, as to be incapable of acting independently of one
another. These observations contain the foundation of the true explanation of the course
and relation of the nerve roots and the spinal cord, and had this observer been better acquainted
with the relation of the ganglionic cells, their efferent filaments, and their connection with
the nerve roots sod other fibres of the spinal cord, he would certainly have left little for his
successors to add : but circumstanced as Volkmann then was, he could explain these and other
phenomena only by the hypothesis of a decussating conduction in the spinal cord, a theory
incapable of satisfactorily accounting for the great regularity and steadiness of either the
voluntary motions, or of the natural phenomena of refiexion, swallowing, and other such like
movements.
KolUker, endeavored, by fresh investigations and calculations, to refute the arguments of
Volkmann, and to re-establish the old opinion that all nerves arise directly from the brain.
That all the nerve filaments proceeding from the spinal cord may be comprised in its upper
part, Kulliker endeavored to prove by fresh measurements of the thickness of the nerve roots,
compared with the constant increment of medullary matter as we proceed upwards in the cord.
The probability of this was, he thought, much increased, by the j^reater tenuity of the nerve
fiiaaonts in the spinal marrow than in the nerves. With the main question, whether all the
spinal nerves arise from the brain, is most intimately connected that of the use of the multi-
polar ganglionic cells. KoIIiker assumes that these ganglionic cells are no where connected
with the nerves ; he found that the filaments derived from them constantly subdivide into
progressively finer branches, so that if a connection with the nerves must take place, this
50 Introduction to the Study qf Diseasei qf the Nervous System.
can be the emse onlj with the most miniite ramifications. He considers it to be impossible,
that a prolongation of a central ganglionic cell should pass as cjlinder axis into the donbly.
outlined nerre fibre, although Wagner positiTelj states that he has undonbtedlj seen such io
be the case, and the careful and learned obserrer Schroeder Van der Kolk, has more than onoe
decidedlj confirmed Wagner's obserTation.
It would extend this introductory chapter into the magnitnde of a large Tolnme, if we were
to enter into a minute and critical examination of the labors of the various obserrers as R.
Wagner, Budge, Stilling, KolUker and others, and we will best serve the interests of the
physiological and pathological student and practitioner of medicine by presenting the outline
of the labors of those observers as Clarke and Schroeder Van der Kolk, who have made the
spinal cord a careful study during a series of years, and whose ability and methods of research
have been universally acknowledged.
Mr. J. Lockhart Clarke, investigated carefhlly during the period of several years, and em-
ployed much time and labor in endeavoring to arrive at some well grounded and settled conclu-
sion with reference to the difllcult and intricate subject of the anatomical structure of the
spinal cord ; and his investigations were especially directed to a question of great interest and
pny Biological importance, vis : whether the roots of the spinal nerves belong exclusively to
the spinal cord, or whether part of them ascend within either the white or gray columns, and
form the channels by which impressions are transmitted to and from the brain. At the time
these inquiries were begun and nearly up to the period of their completion, Mr. Clarke had
not seen any of the works of Dr. Stilling, and knew no more of his investigations into the
structure of the spinal cord, than what he had gathered from the anatomical and physiological
works published in England. However, nearly, therefore, a few of the facts brought forward
by Mr. Clarke, in his papers, published by the Royal Philosophical Society of London, may
correspond to the results of Dr. Still lug's inquiries, it is but Just to sute that the investiga-
tions were made without any knowledge of Dr. Stilling's views, excepting only those with
regard to the origin of the spinal nerves. The observations of Mr. Clarke, were made by
means of one of Mr. Ross's finest microscopes, on many thousand preparations of the spinal
cord of man, of the calf, sheep, pig, dog, cat, rabbit, Guinea pig and frog, reptiles and fish.
In his first paper, (Rueardu9 into tlu Simciwt of the S^rinal Cord^ Phil, TVimj. 1851, pp. 607,
621), Mr J. Lockhart Clarke illustrated and esublished the following facts, with reference to
the structure of the spinal cord.
The posterior gray substance, at the lower extremity and in the dorsal region of the spinal
cord, consists only of a single mass ; and the iubttanHa ffttatinata^ there extends uninterrupt-
edly across from one side to the other. The nerve fibres of the gray substance, including
those of the MuhttanUa gtlatmomi, are not gray fibres bearing nuclei, like those of the sympa-
thetic, but fine tubules. Two considerable columns of caudate vesicles, which Mr. Clarke
named the poHerior v$tieular eoUmuUf in, intimate connection with the posterior roots of the
nerves, extend through the whole length of the cord ; commencing small at its lower extremity
increasing in size in the lumbar and cervical enlargements, and terminating at the upper part
of the medulla oblongata. The number of caudate vesicles, particularly in the anterior gray
substance, is in direct proportion to the sise of the nerves. The column of vesicles into
which, in the cervical region, the spinal accessory nerve may be traced, exunds down the cord
as far as the lumbar enlargement. A considerable branch of the spinal accessory nerve, aAer
entering the giay substance through the lateral column, may be easily traced to the caudato
vesicles of the anterior cornu. The spinal accessory is the only nerve immediately attached
to the lateral column. The posterior roots of the spinal nerves, are immediately attached to
the posterior white colnmns only ; and the anterior roots to the anterior colnmns only ; bat
fibres fh>m both these roots, after traversing certain portions of the gray substance pass oat
again, into the white columns. Neither the anterior nor posterior colnmns are connected by
a transverse commissure.
The central portion of the gray substance, immediately surronnding the spinal canal, in
not a commissural structure, but a layer of fine fibrous tissue for supporting the walls of tho
canal, which is lined with a layer of columnar epltbellam. Phil. Trans. 1851. p. 607.
Mr. Clarke In his second paper '* On etritrim J^meOtnu of the S^fmal Oord^ wUhfirther /neMfye^
thiu mto iti Sintetyrt," Phil. Trsns. 1853, pp. 347-356, examined more fully the question, whether
the roots of the spinal nerves belong exclusively to the spinal cord, or whether part of them
ascend within the white or gray colnmns, and form the channels by which impressions ara
transmitted to and from the brain, and also, endeavored to apply the resnlts of his diseoverlea
to the explanation of the functions of the spinal cord.
Many physiologists and anatomlsu maintain the opinion, that part of the fibres comprising
the anterior and posterior roots of the spinal nerves, ascend longitudinally with the whiu
columns, without entering the gray substance of the cord, and transmit to and ttom the brain,
impressions which give rise to sensation and voluntary motion ; and In support of this doctrine,
Mr. Grainger, {Sj^miU Gbnl), Mr. Solly, (Human Brom), and Dr. J. Budge (Mailer's Archiv,
Introduction to the Study qf Diseases qf the Nervous System. 51
1844,) iMTe Addnced tbe fact of having traced these fibres in the tpinnl cord of the Vertebrata,
and Mr. Newport and Dr. Carpenter, (Phil. Trans. 1843), in the InTertebrata.
On the other hand, Todd and Bowman, (Physiological Anatomj, vol. 1, 1845), Stilling
(Utttersnchangen uber die Textar des Buckenmarks, 1842), Volkmann (NervenphysiQlogie,
in Wagner), and others, hold the opinion that all the fibres of the spinal nerve enter the gray
en balance, and belong exclusively to the spinal cord.
In his first paper, Mr. Clarke showed unquestionably that to the posterior white columns,
the posterior roots, and to the anterior white columns, the anterior roots of the spinal nerves
arc exclnsively attached ; while the lateral oolumns, to which both these roots were formerly
supposed to be connected, are in immediate conuection only with the spinal accessory nerve
(Philosophical Transactions, 1851, Part II, p. 608). Mr. Clarke has shown that the bundles
which form the posterior roots, consist of three kinds, which differ from each other partly in
direction and partly in the sise of their component filaments. The first kind enter the cord
transversely and pursue a very remarkable course. Bach bundle, after traversing the longi-
tudinal fibres of the posterior columns in a compact form, and at right angles, continues in
the same direction to a considerable but variable depth within the grey substance, dilating
and again contracting, so as to assume a fusiform appearauce. It then beuds round upon
itself at a right or more obtuse angle, and running for a considerable distance in a longitudi-
nal direction down the cord, sends forwards, at short intervals, into the anterior gray sub-
stanoe, a series of fibres like those from the roots of plants. In this longitudinal course, it is
Joined by corresponding fibres from bundles above and below it, which thus contribute to
form a continuous band. The fibres projecting from this band into the anterior gray sub-
stance, have the following distribution : Part of them form loops with each other within the
gray substance, particularly near its border ; others extend directly into the anterior white
columns, etc., and bending round, both upwardt and downwardM^ are seen sometimes to re-enter
the gray substance, and form with each other a series of loops, and sometimes to continue a
longltndinal course within the white anterior columns, amongst the fibres of which they
become lost. Whether the latter also ultimately form broader loops, with corresponding
fibrca from the gray substance, it is impossible to ascertain. But even if those which
m»emd in the anterior columns are continued upwards to the brain, one can scarcely avoid
inferring that those which descend re-enter the gray substance, either to form loops or to
bccouM continuous with the fibres of the anterior roots, since the whole of the latter proceed
directly to the gray substance. Mr. Clarke has sometimes felt almost persuaded, that a great
number of the fibres of these posterior roots are directly continuous, in the gray substance
with those of the anterior roots; but he is unable to make this statement with absolute cer-
l*inty, and reserves the question for future investigation. The second kind of bundles which
form the posterior roots, and traverse the posterior columns transversely, and with different
degrees of obliquity from without inwards, extend nearly as far as the posterior median
fissure. Their component filaments are finer than those of the other kind of bundles, meas-
uring in a recent state about the l-7000th of an inch in diameter. They enter and pass
Ibrongh the posterior gray substance at various angles, and in compact bundles, which decus-
■aie and interlace each other in the most complicated manner. Some of their fibres cross
over to the opposite side through the posterior commissure, behind the spinal cord ; others
extend into the posterior and lateral white columns ; and the rest may be traced deeply into
the anterior gray substance, where they separate in various directions and are ultimately lost
to view.
Tft« bundles which compose the third kind of posterior roots, enter the cord obliquely. A
few of their fibres proceed near the surface, both upwards and downwards, and pass out
again with the roots above and below them. The rest cross the posterior white columns
obliquely, and chiefiy upwardt^ a small number only passing downwards. Interlacing at the
same tine with each other and the roots already described, they diverge, and for the most
part reach the gray substance at points successively more distant from their entrance, in
proportion to the obliquity of their course ; the remainder, or most divergent, taking a
longitudinal course with the fibres of the posterior white columns amongst which they are
lost. It is impossible to say whether any of these longitudinal fibres are continued as far as
the braiu, or whether they ultimately reach the gray substance of the cord. It is also
extremely difilcult to trace the other fibres of these roots, after they have reached the pos-
terior gray substance. In some of the finest preparations, however, they may be seen to
iaierlaee each other in a kind of net^work. A large proportion diverge abruptly in various
directions, so that in any section they are divided. Many of them, both singly and in small
bundles, may be observed to form loops by returning to the white columns.
The mmUrior rooU of the spinal nerves, as Mr. Clarke formerly described them, traverse the
anterior part of the antero-lateral columns in distinct and nearly straight bundles. They
form no interlacement with each other, like the posterior roots, until they reach the gray
sabstance. Here their fibres diverge in every direction, like the ezpunded hairs of a brush.
Some near the margin, are easily seen to form loops with those of continuous bundles \ others
52 Introduetion to the Study qf Diseases qf the Nervous System-
ran outwards to the lateral colamos, and inwards to the anterior columns after decussating
in the anterior commissure with corresponding fibres from the opposite side. A large number
diverge equallj downwardt and upwardt for some distance m the gray substance, while the
remainder pass more deeplj backwards and are lost. In no single instance has Mr. Clarke
seen anj portion of these roots, take a longitudinal course, on directly entering the anterior
white columns.
But besides the transverse bundles which form the anterior roots, a continuous system of
exceedingly fine transverse fibres may be seen to issue from the anterior gray substance.
Thev pass through, nearly all, at right angles to, the anterior white columns, and disappear
as they proceed towards the surface of the cord ; but as many of them may be observed to
turn round and take a longitudinal direction, it is probable that at the points where they
disappear, they all follow the same course. Within the gray substance they wind about and
are gradually lost, mingling with the fibres of the anterior roots, and with those proceeding
f^om the fine bundles of the posterior roots, which perhaps are continuous with them.
It may then, according to Mr. J. Lockhart Clarke, be fairly laid down as a well-established
fact, that nearly all, if not the whole of the fibres composing the roots of the spinal nerves,
after passing through the anterior and posterior white columns of the cord, proceed at once
to its gray substance : and that if any of them ascend direeiiy to the brain, it must be iho9e
<mly of the ^Mlmor roots which run longitudinally in the posterior columns.
Professor J. L. C. Schroeder Van Der Kolk, in the year 1847, detected a close connection
between the peripheric distribution of the sensitive and motor nerves, by the discovery of the
law of the course and distribution of sensitive nerves in the skin, namely, that throughout
the body the sensitive branches of a mixed nerve run to the part of the skin, which is moved
by the muscles receiving motor filaments from the same nerve*trnnk, so that, the action of
the muscles being known, we can according to this law, even d priori^ define the distribution
of the sensitive nerves in the skin.
This law may be announced thus : WhiU the nerve givee off motor braneket to ike wuttelet, iu
wentUhe branehee run to the part of the thin which i$ moved by the eame mueeiee^ or^ in other worda^ a
epmal nerve gwee ita motor hranehiu to the mutelee a$ vnatrumenta of motion^ and tie eeneiUve branehee
to the pari moved.
Several phenomena led this accurate observer and distinguished physiologist, to suspect
that a closer central connection, must exist between the sensitive and motor nerves of the
same trunk; and for these reaions, he endeavored to ascertain whether a more accurate
investigation of the structure of the spinal cord would enable him to trace out this connection,
and elucidate most questions as to the structure and functions of the spioal cord, especially, aa
the numerous vivisections which bad been performed, had led rather to greater perplexity
than to the eatablishment of fixed truths. Schroeder Van der Kolk, communicated the reaulta
of his investigations first provisionally in the Reports of the transactions of the section for
Physical and Medical Science of the Provincial Society of Utrecht, on the 26th of Jnne, 1648,
and subsequently brought them more in detail, and illustrated by various preparationa, In
the autumn of the same year, before the Royal Netherland Institute. Professor Schroeder
Van Der Kolk, continued the investigations on the minute structure of the spinal cord, and
laid their results before the Dutch Academy of Sciences on the 24th of December, 1653 ; the
communication was, however, not read until the subsequent meeting on the 27th of January,
1854, and was printed in the second volume of the '* Transactions of the Academy." In
presenting the matured views of Professor Schroeder Van der Kolk, I shall quote from the
valuable translation of the works of this anatomist and physiologist, ** on the Minute Struc-
ture and /VrfM<um« of the Spinal Oord and MedtMa Oblongata,*' by William Daniel Moore, publiabed
by the New Sydenham Society 1659, and which must not be considered as a mere translation
of the Essays, originally published by the Royal Academy of Sciences, at Amsterdam, la
1854 and 1856, but on account of the large amount of additional matter and alterations fur-
nished the translator by the distinguished author, should be regarded as a second and reviaed
edition of the original works.
The following conclusions were drawn by Profassor Schroeder Van der Kolk, ttom hit inves-
tigations on the anatomical structure of the spinal cord.
1. The ganglionic ceHs, especially in the anterior horn, are connected with one another by
more or less ramified fibres of communication, and thus form more or less distinct groupa.
2. From the ganglionic cells, especially in the middle and anterior parts of the anterior
horn, arise the motor nerves, which unite at the margin of the gray matter into one, or com-
monly two or more nerve-roota close to one another, and now leave the spinal cord in a
transrerse direction in order to compose the roots of the motor nerves.
3. Along the outer edge of the anterior horn run marginal fibres or filaments, which take
their origin from the rays dividing among the longitudinal columns, and are connected with
the ganglionic cells, situated In great number along the outer edge of the anterior born.
These cells are again connected with others more deeply placed, and so eventually with the
group of ganglionic cells, whence the motor nerve arises.
Introduction to the Study qf Diseases qf the Nervous System. 53
4. The Anterior longitudinal columns consist of white, mostlj parallel, meduUarj fibres
whieh pass into the transverse rays just mentioned, and so convey the orders of the will to
the ganglionic cells in the gray matter; the loogitudinal fibres, which are situated next the
gray bom, curve directly, in order to pass into a ganglionic cell.
5. The posterior nerve-roots contain two sorts of filaments, those for proper sensation and
those for reflex action. Hence the posterior nerve-roots are also much thicker than the
anterior.
6. The nerve-roots for sensation pass, immediately after their entrance into the spinal cord,
upwards along the posterior columns, in order to repair to the brain, or the seat of perception.
They do not penetrate the gray matter. It is, however, not improbable that the sensitive
nerves are lost towards the posterior horns in the gray matter in ganglionic cells ; whence
fibres arise, which cross through the posterior commissures, and on the opposite side as pos-
terior rays, repair in the medulla oblongata upwards as sensitive filaments to the brain.
7. The other filaments for reflex action, pass across towards the posterior horn, and
amooK the longitudinal fibres or columns form several plexuses ; in part they press through
the scattered gelatinous substance of the posterior born, to the mildle of the gray matter,
where they appear to pass into ganglionic groups ; perhaps they also give some filaments to
the marginal fibres, which everywhere as a band surround the gray posterior horn. The
reflex filaments are in this case at least in part, the ascending fibres which at different heights
again repair through the posterior horns to the ganglionic cells of the anterior horns.
8. These marginal fibres arise in great part from the nerve rays, which from the posterior-
bom spread in the medulla; they surround the horn, and at its basis curve from either side
towards the centre of the group of ganglionic cells, in which also the reflex nerves terminate.
Among these marginal fibres, several, for the most part oblong, ganglionic cells are scattered;
some ganglionic cells are met with also in the gelatinous substance, especially nearer to the
centre.
9. The posterior horns of the gray matter consist chiefly of very fine longitudinal fibres.
Now, as the former in the cervical and lumbar bulbs are at least five or six times thicker than
in the dorsal portion of the spinal cord, it follows that the latter are in these parts present in
mach greater number; whence it would appear that they do not run through the whole
spinal cord, bnt for the most part terminate in the cervical and lumbar expansions, where the
najority of reflex actions and movements are excited and combioed ; they appear, therefore,
throogb their longitudinal direction, more or less to unite several groups of cells, placed above
one another, and thus to form longitudinal filaments of communication.
10. The posterior commissure, consisting of white fibres, passes in part into adjoining
ganglionic cells, partly into the cells which are present in the centre of the gray matter, while
again some fibres are connected with the marginal fibres around the posterior horn
1 1. Ttte anterior commissure forms a decussatioo ; its fibres push forward in order in purt
to terminate directly as rays among the inner and anterior longitudinal columns ; in part they
proeeed towards the inner edge of the anterior horn, when they pass into the marginal fibres,
which take, as we have above seen, their origin from the rays.
12. The fibres of both the anterior and posterior commissures are not directly connected
with ibe nerve roots, though they are probably connected with the anterior ones by means of
the vnitlag filaments from the several ganglionic groups, and both commissures consist of
white fibres.
13. In the spinal cord a central canal may always be found, lined internally with epi-
tbaliAl cells, and sometimes appearing to contain an albuminous fluid; in man it seems to be
narrower than in most animals.
Tbe principal points in the physiological inferences, with reference to the spinal cord, may
be collated In the following propositions :
1. The several primitive fibres, which are lost as a motor nerve in a muscle or system of
mntcles, appear to arise from a group of mutually connected ganglionic cells ; they receive
tbe Impression of our will along the anterior white columns and the transverse fibres or rays
connected therewith, passing into such a group; which stimulation, being uniformly dis-
triboted over all the cells of the group, produces in all the motor filaments of the nerve
arising from it an uniform and simultaneous sction.
3. The number of these anterior conducting filaments of volition must thus be proportionate
to the aamber of groups of cells, and the several combinations of which they are capable,
and mnsi therefore be much less than the number of medullary filaments for the sensitive
nerves in the posterior columns ; so that, by the constant accession of new sensitive nerves,
the white medullary matter increases more in thickness upwards posteriorly than anteriorly,
as Is confirmed by the form of tbe spinal cord in transverse sections.
3. Where numerous muscular nerves spring from the spinal cord, as for the extremities,
more nnmerons groups of cells, whence they arise, must be present ; hence it is, that the
anterior gray horns in the lumbar and cervical bulbs are so much thicker than in the dorsal
region, or the more highly situated portion of the cervical region.
54 Introduetion to the Study iff Diseases of the Nervous System.
4. In aoiniAls whose maBcnlar morementa are more simple, *s in fiah, tbe spinal eord is
slighter, and the gray matter, as well as the ganglionic cells, is mnch more scant/, as fewer
combinations of movements are required.
5. Reflex movements take place, not by over-leaping or transverse connection, bnt the
reflex nerves appear to terminate, partly in a central group of ganglionic nerves, which are
more or less directly connected with the small groups of motor cells, and partly seem to pass
into the minute longitudinal fibres of the posterior horns. Therefore', as the posterior nerve-
roots contain at the same time sensitive and reflex nerves, it is easily explained why they are
nearly twice as thick as the anterior roots.
6. The posterior hornf of the gray matter, through which, probably, the small groups of
ganglionic cells are mutually connected, appear to serve especially for the co-ordination of
movements which take place In reflex action ; the latter are more general in proportion to
the more irritated condition of the gray matter or of the ganglionic cells.
7. Through their connecting filaments the groups of motor cells appear to be so united,
that as a stimulus applied to one of the toes is sufficient to excite in a frog, by reflex action,
a harmonised movement, or a Jump, so, also, perhaps, only one impression is required to pro-
duce a co-ordinate movement (for example, a step), which may then again be modified,
according to circumstances, by special impressions on each of these groups of cells. The
cause of the co-ordination of movements is situated In the spinal cord, and not in the cere-
bellum.
' 8. The transverse commissures appear to be designed to preserve the harmony of move-
ments between the two sides ^ the anterior, which seems to be more coiffnected with the fila-
ments conducting the orders of our will, for the harmony of the voluntary movements, and
of the muscles acting simultaneously on each side of the body ; the posterior for the involun-
tary harmony in reflex action, the equilibrium of the body, etc.
9. The two horns of gray matter appear to stand in tbe closest relation to motion ; the
anterior are the direct sources of motion, the postesior serve rather for reflex action and
co-ordination. After the administration of strychnia, conjestion or effusion of blood takes
place in both horns. The latter do not seem to be sensitive.
10. The medulla oblongata appears to be the common central point, where reflex action
comes to either side, and on the irritated state of which general spasms, as convulsions and
epilepsy seem to depend.
Professor Schroeder Van der Kolk, thus sums up the principal results of his investigations
n the structure and functions of the Medulla Oblongata:
or THB MIDULbA OSLOMOATA.
1. In the medulla oblongata, a perfectly unique organisation commences. The nuclei, or
ganglionic groups, whence the nerves arise, are here more distinct from one another. The
nuclei for motion, as those of the hypoglossus, the accessory facial and the small branch of
the trigeminus, lie near the raphe or septum ; tbe nucleus of the abducent is still uncertain ;
the nuclei for the nerves of sensation, which are first distinctly seen in the mednHa oblongata,
as the portio major trigemini, the vagus, glosso-pharyngens and auditory, lie more to tbe
outside, and further removed from the raphe. In addition, auxiliary ganglia, or aceesaory
nuclei, each of which has its own function, occnr in the medulla oblongata.
3. Of the spinal cord, only the anterior columns pass, in the corpora pyramidalia, as con-
ductors of the orders of our will for the movemtnt of the extremities upwards towards the
brain. The lateral columns of the cord terminate on a level with the vagus, which is inti-
mately connected with and exercises a reflex action on them. Consequently, in hemiplegia,
we never have paralysis of the half of tbe trunk, bnt only of the iace, tbe tongue and tbe
extremities.
3. At the Inferior boondary of the medulla oblongata, and above tbe termination of tbo
lateral columns just mentioned, a new system of fibres begins in tbe medulla oblongata,
descending fh>m tbe brain (the thalami, and especially tbe corpora striata), and here dividing
into an infinite number of fine longitudinal bundles, separated by transverse fibres. These
longitudinal bundles, at least for the most part, curve to penetrate into tbe raphe, to decus-
sate there, and so to pass over into the nuclei of the nerves of the opposite side, as ooo-
ductors of the orilers of our will, or for tbe communication of the impression of sensatioa
to the brain. Tbe accessory ganglia also receive tbe eondnctiog filaments by which the/
communicate with the brain, from tbe same fasciculi.
4. The uerves of tbe medulla oblongata do not participate in the decussation of tbe corpor*
pyramidiilia, as ther are situated higher up. They themselves do not decussate; but in tho
manner described in tbe pn-cediog paragraph, tbe conductors of the orders of our will
decussate here also, aaln tbe corpora pyramidalia, for the movement of the extremities. Id
the mednlla oblongata the decussation is in the situation of the nucleus ; for the nerves of
the f xiremitirs is situated above the nuclei, in the known decussation of the corpora pyra-
Introduction to the Study of Diseases of the Nervous System. 55
midalw ; in both parU, therefore, there is perfect correspondence. In like manner filaments
arise from the nuclei of the sensitire nerves, which decussate and conrey the received
inpreaaion to parts situated higher up. Now, as sensation appears to decussate, and the
naclei of tbtf sensitive nerves lie on the same side as their termination, these nuclei cannot be
the scat of the perception of sensation.
5. Betides this, there exists in the medulla oblongata a system of transverse fibres {fibr«
orrvMte), some of which arise externally, surround the medulla^ and pass into the raphe, while
others, in part, arise internallj from the corpora restiforma and the root of the trigeminus, in
part from the nuclei of the nerves, and from the corpora olivaria. These transverse fibres
seem to unite the two halves most intimately, and to produce a bilateral action so eminently
characteristic of most nerves of the medulla oblongata, and such as occurs in no other part
of the body, being seen in the bilateral action of the face, the tongue, the voice and respira-
tion.
OF TBI VIBTKB OF TBI MBDtTLLA OBLONGATA.
6. In addition to the above bilateral connexion, the nuclei, particularly of the facial,
stccassory and hypoglossal nerves, are in part connected from behind near the fourth ventri-
cle, by a transverse commissure, which appears to increase the bilateral action of the nerves.
T. Of all the nerves the auditory has in its central nucleus, the largest ganglionic cells,
and \m it the connexion of the latter with the nerve filaments, and with one another, is very
easily Men. Prom this central nucleus fibres radiate in the direction of the nucleus of the
facial ncrre, probably for reflex action of the stapedius muscle and of the tensor tympani, and
for the partly involuntary reflex movements in the erection of the ears in animals. This nucleus
of the anditorr nerve is also closely connected with the sensory root of the trigeminus, and
the two nuclei of the auditory, are intimately united by many fibrse arciformes, radiating
from this point. The so-called roots of the auditory nerve in the fourth ventricle, do not
aerTO for hearing ; but appear to be reflex filaments, which are connected by means of gan-
glionic cells with the auditory nerve, and in terror caused by an unexoected sound, reflect
apoB the whole muscular system, and place the body in an attitude of dSbnce.
8. The glosao-pharyngeal nerve has this peculiarity ; that it passes through the middle of
the great root of the trigeminus, thereby perhaps creating a closer connexion between nerves
of taato and sensation.
9. The abducent nerve differs from all other nerves of the medulla oblongata in this, that
its root, Instead of curving inwards to the raphe, bends outwards. In this way it perforates
In aa outward direction, the fibres of the facial nerve and a poftion of the facial nucleus. It
does not aa Stilling thinks arise from the latter, but merely perforates it, to pass posteriorly
and saperlorly to the facial nerve, apparently into a nucleus. This nucleus does not appear
to be In close connexion with the raphe ; that is, no filaments seem to run from the nucleus
to tbo decussation. Perhaps it is more or less intimately united with the higher situated cere-
bral £brea, passing to the opposite nucleus of the oculo-motor, an arrangement which would
aflbrd a simple explanation of the antagonism between the oculo-motor of the one side, and
the intemas of the opposite side.
10. The nervus trigeminus is one of the most remarkable nerves of the medulla oblongata.
While iu minor portion, as a muscular nerve, finds its nucleus very near the raphe, the major
portion perforates, in an obliquely descending direction, the whole medulla oblongata, to the
iaferior border of the corpora olivaria. In this course it passes all the other nerves of the
■edttila oblongata and their nuclei, and gives off fibres to every nerve, except the abducent;
cooeequeatly, it Is connected with, and can act on all the other nerves and their nuclei, as the
facial and glosso-pharyngeal, and it is particularly intimately connected with the vagus and
aceeeeory. and also with the hypoglossal nerves. In the same manner it is closely connected
with the corpora olivaria. Hence the nervus trigeminus is a reflex nerve par exeeUenee, whose
x%A%% fliaaents convey the impression they have received either directly to these different
aenre-Diiclel, or indirectly give it np again to the aaxiliary ganglia.
11. In every situation, where reflex filaments proceed from the roots of the trigeminus to
the aerre-nnclei, fresh groups of ganglionic celU arise in this root. It is even probable, that
in geaeraly when a nerve filament determines a special action, the latter is communicated to it
throagh gaaglionlo cells.
OB TBB AUXILIABT OABOLIA.
13. Several nerves of the medulla oblongata have their auxiliary or accessory ganglia,
which endow them with peculiar and most complicated functions. The principal of these
aaxiliary ganglia are the corpora olivaria.
13. Almost all these auxiliary ganglia act bilaterally, and are at the same time con-
nected by special radiating fibres with the nuclei of the nerves on which they act.
14. The corpora olivaria, as the largest and most important of the accessory ganglia, are
distiagaiahed from other ganglloale groups by their peculiar structure and very small mnlti-
56 Introduction to the Study of Diseases qf the Nervous System.
polar gADgHonic cells, whence fibres pASS outwArds And inwArds, to unite as mArginal fibres,
into fAScicnli of different degrees of strength. Of these fAScicali, some run to the centrAl
nuclei of the nerTes, And others to the rAphe, to unite with the corpus olivAre of the opposite
side. Besides these, there are Appendages, or Accessory corporA oUtaHa, which AppeAr to Agree
with the former in structure Aod function.
16. The corporA olirariA Are more intimAtely And closely connected with the nuclei of the
hypoglossos, than with the nucleus of any other nerve. This connection is Accoraplisbad bj
A spcciAl trAct pAssing out from the hilus of the corpus oliTAre, And termiuAting in the nucleus
of the hypoglossus. The corporA olivAriA Are also united by other fibres with the nuclei of
the accessory nerre. Besides these connexions, the upper part of the corpus olivare it
further united with the nucleus of the fAciAl nerre.
16. Through these connexions, the corpus olivAre seems to serve as au Auxiliary gAuglion
for the faypoglossAl And Accessory nerves, for the purpose of regulating the InnnmerAble com-
binations of movements by the tongue, which, as AppcArs from pAthologicAl observAtlons, take
plAce in the ArticnlAtioo of the voice during speech, And in deglutition. All these movements
require a bi-Uteral action, which Appears to be effected through the corpora oHvariA. It would
AppeAr thAt different pArts of the corporA olirAriA exercise different functions, according to the
nerves with whose nuclei thev are connected by rAdiAting fibres, for these severAl ftmctions,
as expression, articulation of the voice, and swallowing, mAy be sepAmtely lost in disease.
17. Besides these corporA oHvaHa, another group of larger ganglionic cells occurs Also ia
man and AuimAls as AUxiliAry gAugliA, on a level with the fAcial nerve, being very closely con*
nected on the one side with the nucleus of the facial nerve, and on the other with the root of
the trigeminus. This group appeArs to serre for the reflex Action of the trigeminus, in wink-
ing of the eyelids, which, as is well known, depends especiAlly on irritation of the fifth pair.
18. The connexion of the nervus vagus and its nucleus with a bundle of longitudinal fibre*,
which is situated on the outside, and appears to constitute the upper part or summit of the
lateral columns of the spinal cord, is of great imporUnce. From the nervus vagus fibres past
into this lonptudii^I fasciculus, where agAin gAuglionic cells Are situAted at the seat of tran-
sition. This connAion appears to be subservient to respiration. Hence it follows, that a
very strong centripetAl Acting stimulus to the vAgus, brings a11 the muscles of the chest And
Abdomen into a state of tension. One not so strong seems to ACt, in the first place, by means
of these longitudinal fasciculi on the phrenic nerve and the muscles of Inspiration, causing the
descent of the diaphragm and the enlargement of the chest. As the lateral columns act on the
muscles of the trunk, these irritations of the vagus are not followed by convulsions in the
extremities, nor have we, in hemiplegia, paralysis of one half of the trunk.
19. Both longitudinal columns *are connected with one another, as well posteriorly at the
fourth rentriele, as anteriorly by transverse fibres or commissures And fibrs Arcifomes
through the raphe, rendenng respirAtion bi-lAterAl. A puncture or wound In the middle line
or raphe, destroys this connexion in Action, respirAtion ceAses, And deAth is instAntaneous.
20. Besides these, there Are Also proper marginal fibres which run parallel with the con-
ductors of the orders of our will round the hypoglossal and accessory nuclei, and in the laose
manner decussate, and then curve upwards ; they terminate in the lateral loagitudioal col-
umns, with which they appear to be connected by multi-polar ganglionic cells. Through
these fibres, our will acts on the lateral columns of the spinal cord, and so on the respiratory
organs.
21. With these longitudiuAl columns, And especiAlly the nucleus of the vAgus, the greAt
root of the tngeminns enters into very intlmAte connexion, so thAt la some pUces thej aeom
to be coherent. This stAte of things is Apparently closely related to the known reflex aetloa
of the trigeminus on respiration, exemplified in sneeslag, etc.
22. Swallowing, when voluntarily excited, is also a reflex action, which is alwaya accom-
plished with rapidity, but Is very complicated. The exciting stimulus appears to proceod
from the second branch of the trigeminus, namely the palatine nerve ; for division of the
lingual or glosso-pharyngeal nerve does not prevent swallowing. But the irritation teesas to
be conveyed to the corpora oHvaria Inferiora ia animals and to the correspoadiag porta in
man, whence it is reflected oa the hypoglossal and accessory nerves, with which thaaa cor-
pora olivaria are closelv connected, and throngh which the act of deglutition is occasioaod by
the simultaneous excitation of many muscles into bi-lateral action. Perhaps, also, the sasall
root of the trigeminus, by closing the month, participates is the act. The aaclei of the gloaao-
pharyngeal also appears to be united with an auxiliary ganglion similar to that of the facial
nerve, nrhlch auxiliary ganglion is also closely connected with the trigeniaua. Schrooder
Van der Kolk affirms that he is aaacquaiated with its action. (Professor Scbroeder Vaa dar
Kolk, Minute Structure and Functions of the Spinal Cord and Medalla Oblongata. New
Sydenham Society, London. 1859).
According to the view of Scbroeder Van der Kolk and Wagner, the brain and spinal cord
are nothing else than massive accumnlations of primitive fibres, and multi-polar ganglionic
cells ; combinations of primitive fibres do not occar except through the latcrpositioB of
Introiuetkn to the Study qf Diseases qf the Nervous System. 57
pwglioaie cells ; cooMqaentlj all phenomenA of innerration depend on combinations with
one another, and with central and peripheric nerre paths, of indiTidnal ganglionic cells and
larger aggregates of the same, as special seats of innerration of rarions physiological import-
anee. For erery separate morenent, a special gronp of ganglionic cells must be present,
whence all the nerre filaments arise, which go to a mnscle or system of muscles, always act-
ing siofeiiltaneoosly. The sensitire roots divide, after their entrance into the spinal cord, into
aseendiBg bundles, passing upwards with the longitudinal columns ; and into transTerse,
which diriding into different fasciculi, proceed towards the posterior horn of the gray matter,
and after haTiag perforated the latter, appear to be in great part gradually lost in the group
of ganglionic cells, situated in the middle of the gray matter between the horns, and in these
last has been recognised by Scbroeder Yan der Kolk reflex nerres. This obserrer cannot,
boweTer, wholly agree with Marshall Hall, who assumes excito-motor nerres, that is, special
nerree, said to accomplish the motions caused bj reflexion. This, according to the riews of
the 1e«nied professor of the UniTersity of Utrecht, being an hypothesis which is based on no
certain foundation; as it is sufficient that the roots of the motor nerves receive the stimulus
to aeUoB fW>m- the group of ganglionic cells, whether this be communicated through the will
from before, or through the reflex morements from behind. According to this idea, there-
fere, the groups of ganglionic cells, may be considered as constituting a battery with two
poIcA, or, rather, capable of being charged from two sides ; the one pole is connected by
oseans of the lateral rays, with the filaments which conduct the orders of our will, the other
pole, by means of different combinations of ganglionic cells, with the reflex nerves, so that a
gronp is capable of receiving both psychical and physical stimuli. As, however, the posterior
roois, in thie case, contain two kinds of nerves, those for sensation and those for reflex action,
it is not surprising that they should be thicker than the anterior roots, as Is universally
admitted. According to this view, therefore, reflexion takes place, not by springing over, or
tranaverse conduction, but along fixed routes, whereby the reflex action is regulated. Wag-
ner differs from this opinion in assuming the existence of sensitive fibres passing transversely
in the posterior boms into ganglionic cells. There appears to be little probability in this
Idea, as it is impossible to discover anv difference in these posterior transverse roots, and as
they perfectly resemble one another, it would naturally follow that they must all be classed
either among reflex or among sensitive nerves. The existence among them of two so differ-
ent kinds of nerve filaments as those for sensation and for reflex action, can hardly be admit-
ted ; and the connection of proper sensitive fibres with the posterior boms, may be doubted,
becanse irritation of the gray matter in the spinal cord by strychnia, which gives rise to great
congestion In the posterior horns, excites no pain. Lastly, it has been shown that the
ascending gray fibres in the posterior horns, at least for by far the greater part, do not run
tbroQgb to the brain, as the posterior horns become so slight in the middle of the back, that
Boet of the ascending fibres have In this situation disappeared. However it must be admitted
that the question is still wholly undecided, whether, when reflex sensation or sympathetic
sensation tskes place, the proper sensitive filaments first communicate their action to one
aaotber in the seat of perception in the medulla oblongata, by means of ganglionic cells, as
appears to be the most probable supposition, or whether they stand in more intimate con-
nexion with the posterior gray horns and the spinal cord. The assumption appears to be
more probable, that the transverse rays which spread from the posterior horns into the pos-
terior white columns, are capable of accomplishing some closer connection between these
parta, although, on account of the insensitive nature of reflex action, this is not entirely
clear; perhaps they give the knowledge of reflex action. The very large number of slender
ascending fibres In the posterior horns does not appear to render this explanation of the
phenomena of reflex action improbable. It must be remembered that in a somewhat irritated
condition of the spinal cord every sensitive point of the skin conveys its stimulus to all parts
of the cord, and for this an infinite number of fibres is required adequately to produce a pro-
portionate connexion with the several ganglionic cells. Wagner, with Scbroeder Van der
Kolky admits, by the same reasoning, the presence of reflex fibres in the posterior roots,
whereby the thickness of the latter is increased, and he therefore also admits the reflex motor
Derres of Marshall Hall. Wagner puts It forward as doubtftil, whether the fibres conveying
voluntary stimulation to the muscles, and arising from the brain, unite with a peculiar system
of ganglionic cells in the spinal cord and medulla oblongata, or whether the ganglionic cells,
with the reflex motor fibres, serve this purpose, of which he holds the latter opinion to be
the more probable, inasmuch as the will can suppress the reflex phenomena. By the dis-
covery of the connexion of the transverse fibres radiating from the anterior horns, with the
longitudinal anterior columns, Scbroeder Van der Kolk anatomically decided this question.
Most probably the longitudinal slender fibres of the posterior horns consist of filaments of com-
■nnication, connecting the several groups of ganglionic cells with each other ; and in this
manner the difficult theory of reflex action is simplified, as the reflex nerves pass between
these longitudinal filaments, perhaps partly pass into them, and the latter are probably con-
nected with the same ganglionic groups In which the reflex nerves terminate : for otherwise.
58 Introduetion to the Study qf DUeases qf the Nervous System.
M hM beeo «lr«adj obterred, It UditBcnlttonndentand how the posterior horas should be so
maeh slighter and smeller in the dorsAl thmn in the lumbar region, and contain fewer longi-
tadinal fibres, which applies also to the enlarged cenrical tract and higher part of the neck.
Bjr reflex action the muscles are now first brought into motion, the nerres of which arise
nearest to the reflex nerves, where, therefore, the eicitation of the reflex UArre, or of some
of its filaments, has the shortest way to run from the posterior horn and the centre of the
gray matter to the motor cells of the anterior root, both the anterior and posterior roots
uniting to form a mixed nerve.
To illustrate his theory of reflex action Schroeder Tan der Koik, supposes the following
illustration. I^et us suppose a simple case ; for example, that a person unexpectedly bums
his flnger ; so soon as he perceiTes it he will draw his hand quickly back ; this Is not altogether
voluntary ; he would do the same, if in an unconscious state, for example, when under the
influence of chloroform, or even in sleep. Now what takes place in this case? The forearm is
flexed, and at the same time the humerus is drawn back, that is, the biceps and branchialis
antious enter into action for the first, the latissimus dorsi and teres mijor for the second
movement. But there is now no difficulty in supposing that the reflex nerves, which are given
off with the sensitive nerves of the finger, through their combination in the spinal cord",
irritate the group of ganglionic cells whence the nerves are derived which excite the biceps
and branchialis anticns, and at the same time the group of cells,' from which the nerves for
the latissimus dorsi and tsres mijor arise. Thus through a combination of connecting fila-
ments by means of ganglionic cells, wherein the reflex nerves terminate, both groups ar«
simultaneously stimulated, and so both movements are combined. If the irritation is severe,
or if the spinal cord be more than ordinarily sensitive, the stimulus may bring several muscles
Into action ; for example, when a decapitated frog takes a jump on the application ot a stimu*
lus to the hind foot or toe, several groups of ganglionic cells are brought into action through
the reflex nerves, which groups are more or less connected with one another, and the move-
ment becomes a combined or harmonised one, a Jump. Here it must be borne in mind, that
a certain amount of irritation is necessary before reflex motion takes place ; that is, the cells,
wherein the reflex nerves appear to terminate, must be excited to a certain extent before they
communicate the action which has been developed to the neighboring group of cells, whence
the muscular movement is immediately accomplished ; they are like Leyden Jers which must
be charged before the spark passes. Remote or higher situated reflex cells, which probably
are connected by means of longitudinal filaments of communication in the posterior horns
with those which are directly stimulated, shall therefore, not be so rapidly excited to action,
or to keep to the simile, become charged, as those which receive the stimulus directly from
the reflex nerves ; and hence it is that almost always, as Volkmann remarks, the next adjoining
muscles are the first to be moved. But If the whole spinal cord be in a more highly irritated
condition, and if the reflex cells be, as It were more highly charged, only a slight stimulus is
necessary to produce a universal discharge, and more general reflex movements take place, as
in convulsions, epilepsy, or after the administration of strychnia. This excitation occurs
almost always in consequence of a greater determination of blood (congestion,) or as a result
of the blood being poisoned, for example, by strychnia. Now if strychnia be given to a dog,
this drug as is well-known, is taken up into the blood, and the blood so poisoned is in contact
with the gray matter of the spinal cord, which is so rich in vessels, and still the convulsions
which take place are intermittent. Suddenly, without any previous symptomf, the dog falls,
becomes convulsed, or makes involuntary movements ; but these cease after some time, and
now the animal appears to be perfectly well. In such a case Professor Schroeder Van der
Kolk, has seen intervals of even more than an hour, in which he could touch and stroke the
dog, while he ran round without any appearance of injury, until the sensibility had again
become so great, that even the simple blowing of air upon him excited convulsions. Thus
notwithstanding that the gray matter was incessantly in a state of interchange with the
poisoned blood, the convulsions were not constant, and it was not until after a tolerably long
interval that the susceptibility was sufllciently restored to reproduce them. The same phe«
nomenon is observed in epilepsy : if a severe attack has taken place, the patient is usually
free for a long time, if a slight attack ensues, a second often occurs after a short interval ; io
the latter case only a partial discharge had, as it were, occurred, so that It was not until a
second rapidly followed that the equilibrium could be restored. And it is perhaps to this
cause that we should attribute the periodicity of so many phenomena which appear to stand
in close connexion with the spinal cord, as agues, febris larvata, etc. If the excitability Is
exalted, as in children, only a slight stimulus is often required to produce general reflex
phenomena, that is, convulsions ; if a more remote group of ganglionic cells is eicited to a
higher degree, a remote stimulus through a reflex nerve, distantly connected with this group
by means of fllaments of communication, will be able to produce reflex movements in it, as is
sometimes the case in hysterial affections. According then to the reflex theory as expounded
by Schroeder Van der Kolk, the groups of motor cells, which he designates as such for dis-
tinction's sake — whence the motor nerves arise, possess as it were two poles, that is they are
Introduction to the Study qf Diseases of t}ye Nervous System. 59
ooiiB«eled on the one tide with the condnctinn^ fiUmenta of the will (anterior eolnmnt),
poeleriorly with the reflex nerres by meant of other ganglionic cells. Now if these reflex
oerres are eonnected through communicating filaments with sereral groups of motor cellSj so
that hy reflex action a harmonised movement, for example, a Jump, takes place, it may be
asenmed that by means of the .anterior conducting filaments of TolUion, the groups are most
easily brooght harmoniously into action, whereby a combined or co-ordinated movement is
produeed. We have indeed the power of Tolnntarily moving a separate muscle, for which
separate condocting filaments may exist, but we can with equally little exertion or conside-
ratioQ bring into action sereral groups of muscles, of which a step, a co-ordinated movement
is the result, and this is probably produced by a pre-arranged connexion, by means of the
eommnnicatlag filaments of several groups, which are affected as by reflex action. That the
prodnetion of harmonised movements, for example, taking a step, is referable to the organiza-
ttcHi and action of the spinal cord, that is to different intimate connexions of certain groups
of ganglionic cells, and therefore may be said to be pre-arranged in the structure of the cord,
will appear extremely probable, if we watch a very young child, which when the mother takes
it np In her lap, very easily beirins to make the regular movement of a step, alternately with
the right and left foot; and this is seen more clearly in a young chicken, which runs off
immediately after leaving the shell. Different combinations of muscular action are necessary
for the taking a step, which are not learned by study and practice, ending after many failures
in a soccessfol election ; but the combination which is required for the purpose must already
exist, organized, and, as it were, pre-arranged in the spinal cord, so that a single impress is
snfident to bring this combination into action. Our mind knows neither the muscles or the
instmasents, nor their number or situation, through whose combined action it produces a
step. What study it would require, if out of all the possible irregular muscular movements
of whieh the leg is capable, we were obliged, by practice, to learn to combine those which
produce a step. The cause of the co-ordination of muscular movement is therefore situated,
as Yolkmann correctly supposed, in the spinal cord, and Schroeder Van der Kolk, considers
it to be incomprehensible bow any one could ever have referred it to the cerebellum ; for if
the cause of this co-ordination lay in the cerebellum no harmonized reflex movements could
take place in a decapitated ftog. In the opiuion of Schroeder Van der Kolk, the experiments
of Flonrena, Hertwitch, and others are easily explained ; the motor fibres pass from the cor-
pora pyransidalia through the pons varolii to the crura cerebri ; they here decussate with the
transverse fibres of the pons, and between both lies a thin layer of gray matter, containing
small mnltipolar cells. If a part of the cerebellum be taken awi^, the violent irritation so
prodoeed ia reflected by means of the transverse fibres on the corpora pyramidalla and irre-
gular movements are the result. If the cerebellum was the seat of co-ordination, regular
movementa would of necessity ensue on irritation of that organ. But in ulceration of the
cerebeliam, when the irritation is more chronic and not so violent, Schroeder Van der Kolk,
has never seen irregular movements arise. He thinks therefore, that the difficult phenomena
of reflex action may be satisfactorily explained by the theory of specisJ groups of motor cells
and of reflex cells, and the varying degrees of connection in which these are placed with one
another by means of their communicating filaments. This view also supplies an explanation
of Schilling's singular observation, that of the transverse roots of the posterior nerves in the
gray natter, some bundles curve upwards but others downwards. Were these sensitive
nerves, there could be no possible reason for these curving downwards ; whereas if they are
reflex aervea, it follows from the nature of the case that some bundles may and even must be
in connection with cell groups situated above, and others with cell groups placed beneath
them, and consequently they must curve towards the latter.
The commissures, connecting the right and left sides of the ipinai cord, appear to parti-
cipate more or less in the production of the reflex phenomena ; and it has in fact been shown
tlml the fibres fh)m the posterior commissures run for by far the greatest part transversely,
aad im the middle between the two gray horns are lost partly in the same ganglionic groups,
ia which the reflex fllaments also disappear, and seem partly to terminate in the small group
of gaaglionie cells situated at the side of the central canal : there is, therefore, every proba-
bilitytbat the fibres of the posterior commissures serve for lateral reflex action, and are con-
sequently capable of transferring to the opposite side the impression received in the groups
of reflex cella, while those of the anterior serve to produce in one voluntary movement har-
BBony and agreement between tbe two sides, and so to preserve equilibrium. But, as the
decussated fibres of the anterior commissure pass either directly as transverse rays into the
anterior medullary columns, or by means of the marginal fibres and cells are more directly
eonnected on the Inside of the anterior horn and the rays proceeding thence, with these lon-
gitudinal columns, which Schroeder Van der Kolk recognizes as conductors of the orders of
the will — ^the will most exercise more influence on the anterior commissure, and by this route
mast tbe given impression be conveyed to the other side. We can thus see, not only how the
harmony of the movements of both sides is maintained, as has been already observed, but
tkat this arrangement may also influence the muscles, which either always or almost always
60 Introiuetion to the Study qf Digeoies qf the Nervwu Syetem.
art la the hMlthjr fUte moTed fii^Urljr on both lidM ; for ezftanploy the mntelet •itiwted in
the middle, the sphincters »nd levatores Mii, the ischio*c*Temosi, as well as the abdominal
and ioteroostali and in great part the dorsal muscles, which hold the bodjr in the erect or
straight position ; also the muscles for deglutition, those for the development of the Toice, and
others which always act sjmmetricallj. The posterior commissure seems to serre for the
more involuntary lateral reflex actions, because its fibres appear to end in the middle of the
gray matter, where Schroeder Van der Kolk, thinks that he has also found the termination of
the reflex nerves. However, the connexion of the reflex nerves with the next anterior aM>Kor
root is much closer, than with the fibres of these transverse commissures, since, as Pfifiger has
shown, In extension of reflex movements, the latter ascend exclusively on the one side, until
the Irritation, having reached the medulla oblongata, passes over and produces general con*
volsions. The posterior commissure may also serve for involuntarily preserving the equUi«
brium between the two lateral portions of the body. These reflex movements bear so very
much the character of cdordinate,or. If we will, of voluntary movements, that they often
cannot be entirely distinguished from them; for example, rubbing or scratching where itching
is felt, which takes place likewise In sleep, and to avoid which in case of violent itching, even
a powerful exertion of the will is necessary, just as a decapitated frog endeavors to remove
with itii foot the irritation of acetic acid applied to the side of its body, or if this is prevented,
sometimes with the foot of the other side. Some, as E. Pfluger, observing such phenomena,
have been misled Into assuming a sort of voluntary power or mind in the spinal cord, an error
which Van der Kolk, considers as attributable solely to want of examination of the ingenious
arrangement of the tissue and of the structure of the cord, in which all these harmonised move-
ments appear to lie hidden, pre-arranged in the several combinations of the groups of gan-
glionic cells, and ready to be excited by any stimulus, whether voluntary or reflex, so that they
are produced Just as the harmonic tones of a piano under the Angers of a player. Schroeder
Van der Kolk, justly observes, that <*8uch a view is sufficient to excite amazement at the inge-
nious nature of all these arrangements and wonderful combinations, but it Is conceivable, and
in my opinion not so dlfllcnlt to imagine ; while the idea of volition in the spinal cord, without
consciousness, with the entire rejection of the existence of a soul, as Pfldger suggests, is an
absurdity not to be thought of. On the contrary, the deeper we penetrate into the knowledge
of the mechanism of our body, the more shall we be convinced that the whole is arranged as
a perfect minister of our spirit and of our will. In which both the amasingly correct insertion,
siie and combination of the muscles, and certainly not less the combination of the ganglionic
groups, whereby these muscles are harmoniously and suitably moved, are calculati^ with
incomprehensible wisdom and fulness of purpose."
There has been a great deal of controversy, as to whether the gray matter, the antero*
lateral or posterior columns are at all sensitive or not, and on this subject the most conflicting
opinions have been broached ; in the opinion of Professor Schroeder Van der Kolk, the gray
matter In the spinal cord serves solely for motion, the posterior rather for reflex action and
the cdordination of movement, whilst sensation is transmitted upwards exclusively through
the posterior and lateral medullary columns. That such is the case, Schroeder Van der Kolk,
inferred especially from the phenomena produced by strychnia in dogs ; it would appear that
after administration of strychnia, great congestion and irritation take place in the gray osattor
which In the situations where they are most folly developed, as in the loins, amy pass Into eflia-
sion or dilatation of the blood vessels, and still all this occurs without any sensation, without
any pain. Were the gray matter in the spinal cord sensitive, or did the sensitive nerves
penetrate into the gray matter, such congestion and irritation as excites in a sensitive nerve
itself the most intense pain, could not be considered to exist without occasioning some sea*
sation. Hence It follows also, that reflex movements cause no pain, nor sensation In the
spinal cord, so that by this observation the direct ascent of the sensitive nerves in the spinal
cord, is physiologically, or pathologically confirmed. A difficulty, however, still remains,
namely : that if the sensitive nerves proceed directly upwards, along the posterior columns,
into the medulla oblongata, the nerves of sensation of the right side should be situated above
the decussation, next the motor filaments of the left, which as is well known decussate
beneath the corpora pyramidalia, and thus the perceptions of the right arm should fall at the
side of the Incitement to motion of the left, which must cause confusion. But Poville*s
observations have shown, that on tbe posterior surface of the medulla oblongata, behind
and above tbe anterior decussation for motion, a decussation of fibres also takes place, through
which probably the nerves of sensation are likewise conveyed to the opposite side. But as to the
use of these decussations, and why the motor and sensitive filassents do not remain on the same
side, Schroeder Van der Kolk confesses that we are not yet in a position even to form a prob-
able conjecture. He admits also, that the situation, where the impression of the sensation is
observed, can scarcely be determined with any cerutnty ; probably however. It is in tho
medulla oblongata, whither the fifth pair runs, while in fish, where the proper hemlspberee
of the brain are wanting, there is no higher sitnation to which the seat or sensation can with
JntroduetUm to thB Study of DUeases qf the Nervous System. 61
«a/ nmaou be r«f«md MoreoTer, it is w^H knowo, lh»t i^jurj of the more hifl^hly situated
parts, espMAlly of the eerebram, oooaiions no pain, and the cerebram is insensible to pain.
If from tbo preeedin^ facts it is laid down, that both horns of f^raj matter in the spinal cord
serre for moUoii, the anterior for more direct motion, the posterior for reflex action, and
coordinaiicn, it becomes intelligible wbj ▼ivisections performed on animals, in which it has
been aUenplod to cat through only the posterior or the anterior columns, have lead to such
diseordaoi results. It is indeed, erident that it is absolutelj impossible to cut through these
edunaa, without wounding the graj horns, which project across them, the necessarj result
whereof will be that different movements must be produced by this injurj, whether of the
anterior or of the posterior horns, according to the different groups of ganglionic cells, reflex
nerves, or fUsunents of communication which are wounded ; so that this question can never
be solved in this way, and confusion, rather than light and knowledge, will have resulted to
phjsiology from such experiments.
B. Pfloger, from a great number of observations has shown, that reflex action is at first
strictlj nailatcral ; furthermore, that if reflex action arises from a stimulus in the brain or
cerebral nerres, the reflex movements in their farther progress .extend to the nerves situ-
ated inferiorlj, and thus to the medulla oblongata; that, on the contrary, if reflex action
arises from a spinal nerve, it extends in its further progress firom below upwards towards the
medulla oblongata, and not vice versa ; but that if the affection has reached the medulla
oblongata the reflex movement may again extend in an inverse order to the lower parts, or
pass into general convulsions ; that lastly, if a reflex movement arises in motor neryes which
are very remote from the insertion of the sensitive nerve primarily affected, these remote
motor nervea are always such as arise from the medulla oblongata^ Hence it appears that
the medalla oblongata is the principal centre, whence the more general reflex movements and
convulsions take their origin ; and Schroeder Van der Kolk has shown, by his masterly
investigationa, that the medulla oblongata is the starting point from which epileptic fits arise,
and to which the attention of the physician should be principally directed ; and that though
the primary irritation may be remote, for example, in the bowels, a morbidly exalted sensi-
bility and irritation in the medulla oblongata will always exist, rendering it more capable of
discharging itself, as it were, in involuntary reflex movements.
The preceding theory of reflex action, as expounded by Schroeder Van der Kolk, ahd based
upon hia extended and accurate microscopical, anatomical and physiological researches and
investigations, must bo accepted as the last and most perfect expression of this doctrine,
which, as we have seen, had its origin more especially with Unser and Prochaska.
Brown-Sdquard* concluded, from his numerous experiments, that the posterior columns of
the spinal cord, are sensitive, and that they do not conduct directly to the brain ; but convey
impresaions to the gray matter of the cord, which transmits them inwards ; that the con-
ductors of sensitive impressions, whatever they may be on their entrance into the cord, for
the moot part pass downwards and join the gray substance above the point of entrance ; and
that a still amaller number at once lose themselves in the center of the cord. All these fibres
effect their crossing from side to side in the spinal cord, and no crossing of sensitive fibres
takes place in the brain or medulla oblongata. •
The anterior and lateral columns are motor and centrifugal, their fibres pass directly onwards
from the cerebrum, and effect their crossing in the lower part of the medulla oblongata.
The gmy matter of the cord receives sensitive impressions from the posterior roots of the
nerres, conducts them onwards to the brain, or reflects them to the motor nerves. It is
itself insensible to mechanical or galvanic stimulus.
Brown-Seqnard supports these propositions by numerous physiological experiments and
pathological observaUons.
We have thus endeavored to present the history of the doctrine of the reflex function of the
cerebro-spinal system, and to examine impartially the facts upon which it rests, by means of
analysis of the labors of original observers, and whilst striving to render impartial justice,
we have at the same time made an effort to aid the student of medicine in his inquiries, by
bringing him in contact with the original sources of our knowledge upon this difficult, com-
plex and important subiect.
We propose to examine in a similar but briefer manner the results of investigations
directed more especially to the determination of the functions of the cerebrum and cerebel-
Inm. Much relating to this subject has already been presented in the preceding pages, and
Applied to Phyilology and Pathology. By X. Bvown-Mqnard, M. D., etc Kew York,
1S&3.
8v let >imlUto do la Seetlon et de la GalTaniiatlon da Nerf Oraad Sympath^Uque aa Goa. Paris, 1864.
lippem ear qaelqnea BspMoaees de If . Btrown-Mquard. Par If . Paal Broca. Paris, 1856.
Bnz flitf^rina ear la Fhyslologle de la If Oelle RplnlAre. 1866.
Inrfciiirhw bpfaimentUee sar la Tianfinissloii Crois^e dca Impnealons sensitiTee daos la If oSUe l^plDlftre. Bails,
■KMfteMrtal aad CUnieal Bewarohee on the PhjrioloffT and Fnthologr of the Spinal Oord and some other part* of
t^imwOinCraa. Blchasoad, 1866. >»»/■" r-
62 Introduction to the Study of Di$ea$e$ of iko Nenwug Sgitem.
we hare recorded the riews of Tftrions writere, m Galen, Albinns, Boerhaare, Willii, Unser.
Prochaika, Sir Charles Bell, Martball Hall, Schroeder Yac der Kolk, Remak, Tolkmann and
others, with reference to the relations of the cerebmm and cerebellnm to sensation and
motion, and the reflex ftinetion of the spinal cord, and cranial and spinid nerres.
RESULTS OF INVS8TIOATION8, DIRBCTKD MORS SSPBGIALLT TO THS DITXRXINATI09
or THE FUNCTIONS OF THE OEREBRUM AND CEREBELLUM.
In man the intellectual faculties appear to be ezclnsiTcly confined to the brain, but as we
descend in the scale of Tertebrate beings to those whose functions, and especiallj whose
nervous functions are less perfect, it would appear that the spinal cord partakes with the
brain of certain of its faculties ; and in animals of the simplest organisation the brain
entirelj disappears, and the spinal cord seems to be substituted in its place. It has been
doubted, with reason, whether the animal without a brain possesses anj degree of what can
properlj be called perception ; and in this case it has been conjectured that the sole object of
Its nerrous system maj be to conTcy impressions from one part to another, which are necet*
sary for the functions of the animal, but which do not excite any ideas of consciousness.
As the nerTOus centres, and their gray or Tesicular constituent more especialljr, appear to
originate the nerrous force, and as certain nerves, termed motorj and efferent, conduct it to
the tissues principally muscular, on which it acts by producing contraction, and other nenres
termed sensory and afferent, carry the impressions receiTcd at their distal ends to the centres ;
it is evident that sensation, or the appreciation of the impression by the individual, follows
only when the afferent nerve conveys its impression to the brain ; when it stops short in the
spinal cord, or ends in a ganglion, it may excite a corresponding or connected efferent nenre
to produce motion or a reflex action, which nmy then take place without sensation or voU*
Uon. In the Lancelot ( Branch lostoma) which presents the simplest form of vertebrate exist*
ence, the neural axis shows no distinction between brain and spinal cord ; it is a slender tract
of nucleated cells, inclosed in a delicate pia mater, constituting a continuous cord of opaline
8ub*transparency, ductile and elastic. It is depressed or band-like along its middle third,
which i^ slightly grooved along the median Hue of the dorsal surface, and tapering to both
ends, but more gradually to the binder one, the fore-end being less acute. A streak of pig-
ment cells marks the middle of the upper surface ; darker cells mark the origins of the nerves.
These number from fifty to sixty pairs, and appear to come off as simple chords. They per-
forate the membraneous neural canal, and accompany the inter-muscular septa, dividing Into
two principal branches — one to the neural or dorsal, the other to the haemal or ventral mus-
cular segments. The first pair of nerves, which Professor Ooodsir thinks might correspond
to the trifacial, passes to the membranous parts above the mouth ; the second pair is much
larger, it passes out of the neural canal, and sends the branch upward and backward toward
tbe front edge of that segment, which communicates with the dorsal branches of several suc-
cessive nerves of its own side, the main trunk curves downward and backward, communicating
with the corresponding parts of the succeeding nerves of its own side, to some way beyond
the vent. From the principal function of the second conspicuous pairs of nerves In tbe
Lancelet, as a nerve of association, it probably answers to both the trigeminal and vagal,
which in most blgher fishes combine to form the lateral nerve, with the same relations to the
spinal nerves and median fins as the nerves in the Lancelet. The succeeding nerves divide,
soon after emerging, into dorsal and ventral branches, as in higher fishes, corresponding In
number with the muscular segments. This is the most simple persistent condition of tho
central organs of the nervous system known In the vertebrate snb-ktngdom. In all other
fishes, tbe fore part of the neural axis, receives tbe vagal, trigeminal and spinal sense nervee,
and develops and supports ganglionic masses, principally disposed in a linear series parallel
with the axis; this part is the brain (encephaloo) ; the rest of the axis retains its columnar
or cord-like character, and is lodged in the canal of tbe spinal column. (Anatomy of the
Vertebrates. By Richard Owen. Vol. 1, pp. 368-271.)
According to Professor Richard Owen, the average proportional weight of the br^n to the
rest of the body in fish, is as 1 to 3000 ; a certain sise being essential to the performance
of its functions, as a recipient of the impressions from the organs of sense, it does not, there*
fore vary in different species, so as to accord precisely with the general bulk of the body.
The sise of the optic lobes has a more constant and direct relation to that of the eyes, which
soon acquire their full development. As the brachial respiration is a peculiarly active and
important function in Fish, the peculiar development and complexity of the medulla
oblongata may be associated therewith, as tbe centre of the vagal or respiratory nerves.
Professor Owen has recorded the following interesting observations, upon the comparative
anatomy and physiology of the cerebellum in fishes :^
** Tk« •stoiidTt gndation of tbe Mrebelliiai between tbe eztreoMa of etnictore prteeoted by tbe Myvlae tad th«
Sbaffc, me aigbt be expected, tbrowe more dlrvct llf bt apoa its f^uKtlM. WItb ragmrd lo tbie, two vlewe bave '
taken. According to one, it it tbe orfaa of naMttTene« ; acoording to tbe otber it ie tbe etat of tbe mwacmUt i
ion to the Study qf Diseases qf the Nervous System. 63
•r lh« TCipdBtor of tolwitefy moiloD. MuijazMrinwnti In which th« eenlMUiiiD hai bMB niiitllAtod or reihoTod
Ihni wambloodod ^***"**», rapport the idoa or iU Intimate relation with the looomotiTe powera. Bat to the con-
dMiiNB ftom these experlaente, hae been ol^eeted the potsiUli^ of the eonTuldTe muecular phenomena having
eriMB ttum tho ffp**'— of the remaining eentree, oocaiioned by the mntilatlon or deetroctlon of the one in qneetion ;
•ad It mey w«ll ba dovbCed whether nature ever aaewen eo tni& when put to the torture, as she doee when epeaklng
Tolaaluilj thnmch her own experiments, if we maj to call the ablatton and addition of parti which eomparatlTe
taetMBj eifew to oar contemplatloa.
If ia wfawKia to tho sexoal hypothecs of the cerebellum, we oontrut the lAmprej with the Bhark, we shall be
bd by the moch laii«r proportional slae of the generative organs in the lower oartllagiBoas fish, and fh>m the
otaRTcd fcct of tho male waA femal<) Lampreys, entwining or wreathing themselves entirely about each other,
■stmHy aiding In the expulsion of their reipeetive generative products, and lo abeorbed in the pamion as to permit
ttomselves to bo taken oat of the water and replaced there, without interruption of the act, to expect a larger oere-
bdlsm in tho lAMprey than in the Shark. But the veiy reverse of this is the fact : the Lamprey has the smallest,
sad the flhaik tbe lancost, cerebellum in the clam of Ashes. If on the other hand, we compare the Qyclostome and
nigiostomo Ohrtflaginbus Ashes, in refbrence to their modes and powers of locomotion, we shall find a contrast which
Aaictly aoBOfda with that in their oerebellar development. The Myxine commonly passss its life as the internal
pMirile of soma higher oiguiiaed Ash ; the I«mprey adberm by its suctorial mouth to a stone, and seldom moves
hrtom iti placo; aoither fish pomesiei pectoral or ventral fins. The Shark on the contraiy, unaided by an air
Usddir, nslBlna Itaelf at tho surfhee of the sea, by vigorous muscular exertion of well developed pectoial and
fsuihl Ah^ ■OBia, aa It wars. In Om upper regions of its atmoqiherv, Is proverbial A>r the lapidlty of its coune, and
nMrts Uha Aa sBg^ ^J pnisaing and devouring a living prey ; it Is the fish In which the Instruments of vulun*
tvy molioa ■« host developed, and In which the cerebellum presents its laigest sise and most complete structure.
And this structava uannot be the mere concomitant of a genexal advance of the organisation to a higher type for the
doggtah Bsya, that po^^ «t the bottom, thoo|[h they copulate, and have In most other respects the ssme gnde and
type of stnctara aa the more active Squaloid Plagiostomee, yet have a muoh smaller oerebellum, with a mere orucial
iadeatetion Inataad of tmaivene laminm. A more decisive Instance of the relation of the cerebellum to the power
ef loeomotioo Is given by ttia Lepldoslren In which with a more marked general advance of organisation than in the
f tha eoreballnm has not risen above the simple commlmuru condition which It preeento in the Isui-
sny : the genacatlva qrslem, how«vir,of the LepMoeiren Is as complex as in the Plagfostomes, and Is more extensive ;
Mt a« fins sre nduoed to mere filsmanti, and the fish Is known to pass half the year In a stete of torpid Inactivity.
The ocRbelfasm la large in the OhlmsBm. In the heavy laden ganoid fishes, the cerebellum is smaller than In the
ocdiaary osseoaa Aahes; the Imbricated aitoour of dense enamelled bony scales must limit the latorsl Inflections of
tte tril ; so wo flnd In Folyptems the oerebeihmi hardly more developed than in Lepidosiren, whilst in the somewhat
setlve and predaceons Lepidosteus It is the smallest of all the segmento of the brain. In the grovelling Stur-
the oarebeltam oflen a gnde of development shove that In the Lepidosiren. Finally, amongst the nomal
the largest and highest organised oerebelitito has been found In the Tunny, whose muscular system
mceoache^ la aooia <^ Ite physical characters, most neariy that of the warm-blooded dam.
uve could enter the sensorinm of the ibh and experience the kind of sensations and idess derived from the Inlet
ef their pacaUariy developed and enormous eyes, we iplght be enabled to understend the oflloe of the peculiar com-
pkxMm of thoir large optic lobes ; without mo^ experience, we can at best only Indulge in vsgue oo^jectare ftom
iht esslngj of oar own sensations. We find, when nature reduces tbe organs of sight to such minute specks and
eon give bat a ftoUo Idea of the presence of light, sufllclent perhaps, to warn the Amblyopsii to retreat to the darker
noMKO oftfM oabtananean abode, that the optic lobee are not reduced in the nane proportion, but retain a form and
riw, which aa oompared with Uieir homologies In other animals, are suflklently remaricable to suggest a fhnction over
•ad sbove that of raeslving tbe impresiions of visual roectia, and forming the Ideas ooasequent thereon.
The aaalooalcal condition of the proeenoephalon, and its homology with the hemispheres of the binl*e braiu ex peri-
"lead to til " ' "
itsd oa by Floareas, would lead to the belief that it was In this division of the fish's brain that Impressions become
isHBCkmak and that hare was the ssat of distinct and tenable Ideas ; of such for example as teadi the fish Ito safest
Isifcing piaraa, and givs it that degree of caution and discernment which reqniree the skill of the prMticed angler to
wiiSMiih If diffsrent parts of the prosencephalon were special seats or organs of diiferent psychical phenomena, such
phfrniMMna ara sattdcntly diverrtfled In the clam of fishes, and are so energetically and exciuelvely manifested si to
jestiiy tbe axpoctaUon on that physiological hypothesis of corresponding modiflcatione in the form and development
d lh« hoaMlocaas of the oerebrsl hemlqiheres. Some spedes, as for example the Shark and the Pike are predatory
•ad fencloas; some, as the Angler and tike ftate, are crafty ; some, as the Sword-fish and Stickleback, are combative;
■ome, as the uup aad Barbel, are peacefol, timid browsers; many iishee are social, especially at the season of oviposi-
tioa ; a Ibw aia saoaogamus aad copulative ; still fewer, nidificate and Incubate their ova.
Sow, If wa eoonpare the prosencephnla of the Shark and Pike, fishes equally sanguinary and Insatiable, alike
aneDdaUe, th# ^jTfante respectfhlly of the sea and lake, we flnd that theee parte of the brain differ mors in shape, in
ulsttie siaa, aad In structars, than In any two fishes. The prosencephalon of the Pike, Is lem than the cerebellum,
■ach Ivas than tho optie lobeo; in the Shark, it exeeeds In siie all the rest of the brain; In the Pike the proeen-
nriphslna coaaiits of two distinct lobes brought into communication only by a slender transverse oommimnre ; In the
Aark, tiie hMBh^eres are Indlstlngulshab^ blended into one large sub-globular mam. If we compare the prosen-
cefhafe of the Pike wiUi those of the Oarp, we flnd them narrow In the devonrer, broad in the prey.
The liBphlaa Intfcs at the boCtoss, hidden In the sand, waiting like the Skate for Ite prey to come within reach of
its JawB^tfia dififiMnsnce In the shape, slae and structars of their proeenoephala, Is hardly lem than between the Shark
and the Pfko. The combative Stiwleback has longer and narrower prosencephala than the cowardly Oudgeon. The
BidfAeatlve aad phllo-progenltive OilWc>%s has neither the antero-latorai, nor the posterior regions of the cerebellum
I dsvatopad tlbaa to the boay flahes geaemlly.** Anatomy of Vertebratee— London, 1866, Vol. 1 pp. 289-290.
Ib tbe Brain of the Crocodile a marked adTance is seen in the relatire size of the cerebral
lobct, especial] jr in regard to 'their breadth and height posteriorly, giring a pyriform
•hape to the prosencephalon; the optic lobes, also, are not inferior in bulk to the cerebellnm.
The brain of the Bird differs from that of the reptile in the superior size of the cerebrum
sad oerebellom, together with the folding of the latter, which relates probably to the higher
loeomotiTe powers of the bird ; it differs from the brain of the Mammal in the absence or
mall begioniog of the fornix, and of the lateral lobes of tbe cerebellnm ; it differs from the
bram of erery other class in the lateral and inferior position of the optic lobes.
In mammalia, the brain has a cerebellnm, with large lateral lobes, and the gray superflces
Bneh folded ; ibe commissnral fibres form, as they cross the under surface of the brain, a
defined track or prominence, called pons yaroUi ; the optic lobes are medial in position, and
<liTided by a transverse furrow; tbe cerebral lobes, are not only united by a round commis-
•sre, hot by a '* lyra " and hypocampal commissure, from which is developed in the majority
of the class, a '' corpns callosnm/' or greet commissure. In the lowest types of mammals the
64 Introduetwn to the Study qf Diseases qf the Nervous System.
cerebral hemispheree are withont folds, and leave the oerebellnm, olfactory lobet , and part
of the optic lobes exposed. In man the brain presents an ascension step in deTelopment,
higher and more strongly marked than that by which the varions lover classes are dlstio-
gnished from each other. Althongh in the highest mammalia, the cerebmm maj extend oTer
the cerebellum, in man not only do the cerebral hemispheres overlap the olfactory lobes and
cerebellnm, but they extend In advance of the one, and farther back than the other ; and
their posterior development is so marked that anatomists have assigned to that part the char-
acter of a third lobe ; it is peculiar, with Its proportionally developed posterior ventricular
horn and ** hippocampus " minor, to the genus Homo, Concomitantly with the correspond*
ingly developed anterior lobes of the cerebrum, the ventricle Is in like manner produced, into
a hom-Uke form, in advance of the corpus striatum. The superficial gray matter of the cere*
brum through the number and depth of the convolutions, attains its maximum extent in
man. Peculiar mental powers are associated with this highest form of brain ; and their coo*
sequence strikingly illustrate the value of the cerebral character, and sustain the position
that the OmMt Homo, is not merely a representative of a distinct order, but of a distinct sub-
class of the mammalia. While the human brain is exceeded in weight by that of the Blephaat
and Whale, it is absolutely heavier than In all other animals ; on the other hand, in the pro-
portionate sise of the cerebrum to the cerebellnm, the human brain surpasses that of all
mammalia, being as 8 to 1.
In proportion as intelligence advances, the surfkce of the cerebral hemispheres becona
more extensive and are thrown into more numerous convolutions, separated by deep sulci ;
thus indicating that there is a relationship not mereiv between the bnlk of the brain and the
iutellei'tual iaculties, but also with the amount and distribution of the ganglionic cells of the
gray matter.
Professor Tiedemann, in his work on the Anatomy of the Foetal Brain, has discussed the
question, whether, according to the common opinion, the spinal cord be a production of the
brain ; or whether, according to the doctrine which has been supported by Qall, the brain
should not rather be considered as an appendage to the cord, and as a production of it.
He conceived that he had clearly proved this last to be the correct view of the subject, resting
his opinion principally upon the progressive development of the parts. With respect to the
progressive formation of the cerebrum, by tracing its development in the foetus, and compar-
ing this with its structure In the different classes of animals, Professor Tiedemann has shown
that as we advance from the foetal to the more perfect state of the brain in the human subject,
or from the inferior animals to those that possess a more complete organisatiou of the nervous
system, the cerebral lobes become gradually more elevated and arched, and that their convo*
Intions and sinuosities are progressively developed, so as to give. In man, its elliptical and
almost globular form. It is thus shown by Embryology, as well ashy Comparative Anatomy,
that the human brain is distinguished from that of all animals, both by the site and elevation
of the hemispheres, and by the greater number of convolutions.
The vast superiority of man over all other animals, in the facnltles of the mind, which
may be considered as a generic distinction of the human subject, led physiologists at a very
early period to seek for some corresponding difference in the brains of man and animals.
They naturally investigated the subject in the first instance, by comparing the proportion,
which the mass of the brain bears to the whole body; and the result of this comparison, in
the more common and domestic animals, was so satisfactory that they prosecuted the inquiry
no further, but laid down the general proposition, which had been universally received since
the time of Ari$toUe^ that man has the largest brain in proportion to his body. Some more
modern physiologists, however, in following up this comparative view in a greater number of
animals, discovered several exceptions to the general position. They found that the propor-
tion of the brain in some birds exceeds that of man ; and that small mammalia (some quadm-
mana, and some animals of the mouse kind) equal the human subject in this respect. As
these latter observations entirely overturned the conclusion, which had been before generally
admitted. Simmering furnished another point of comparison, vis : That of the ratio which
the mass of the brain bears to the nerves arising fh>m It.
The fact has been long known, that when the spinal cord is compressed or divided in any
part, the limbs that are supplied with nerves which branch off below the Injury are paralysed ;
and the nearer to the head the injury is situated, so much more extensive is the derangement
of the different functions ; and there are cases upon record, where, after dislocation or frac-
ture of some of the cervical vertebratae, all power has been lost over the voluntary muscles,
and the functions of the abdominal and thoracic viscera, have been nearly suspended, yet for
the time that life was capable of being continued under these circumstances, the cerebral
functions and the mental faculties have remained in a sound state. If the brain, therefore be
considered as the centre of perception, it follows that an Injury to this organ, is attended with
a loss of sensation of the whole system, though each of the organs of sense and motion may
be individually In a sound state, as has been so often witnessed In the effiects of external
violence upon the brain, and In various diseased states either of nervous matter iuelf, or of
Introduction to the Study of Diseases qf the Nervous System. 65
other bodiM io iu yicinity, saeh as tumors of the skull, thickening of its membranes, or
effnsed liquids of anj kind pressing upon the sarface of the brain, or contained within its
cavities. Pressure is undoubtedly, one of the most frequent causes of the loss of nervous
power ; and this maj take place, without anj permanent injury to the part compressed, for
when the pressure is removed, the organ frequently resumes its ordinary functions.
The qoeslion was early raised by physiologists, whether when volition is exercised and mus-
calar contractioa is produced, the first effect consists in some change in the brain itself, or
whether the will acts immediately upon the muscles ? This question cannot be regarded as a
oicrely rerbal one, involving more of a metaphysical than a physical inquiry, for analogy as
well as the results of direct inquiries into the anatomy and functions of the cerebro-spinal
system, strongly &vors the opinion, that in volition, some change first takes place in the
brain itself, and the results of such change are communicated to the special and spinal nerves
sad gaagliooic centres connected with the organs. Although this view has been generally
adopted hj modern physiologists and sustained by anatomical research and physiological ez-
perimenta, a contrary doctrine was maintained by many of the writers of the last century, and
espeelallj bj the Stablians, who conceived that the Soul is co-existent with the different parts
of the bodj, and is extended through all the organs of sense and the parts subservient to
motion. According to Stahl and his disciples, the soul, is immediately concerned in every
vital function, and acts directly upon every part of the body. Whilst the opponents of this
doctrine, coocladed that the brain is the common centre of the nervous system, to which all
the impressions of exterior bodies on the extremities of the nerves are referred, and from which
originate all actions that are executed by the organs under the control of the will, they were not
satisfied with assigning the brain generally as the sensorlum oommune, but they sought to find
out some particular portion, which might be regarded as the more essential organ to which
all the rest are subservient. However curious the investigation, and however whimsical the
opinions to which it has given rise, and however connected with the discussion, which occu-
pied so much of the attention of the older metaphysicians and physiologists respecting the
teat of the soul, or the material organ of perception and volition, the entire enquiry resulted
in developing accurate views as to the anatomical structure of the brain, and also led to many
important discoveries ss to the use of its individual parts. The doctrine was evolved from
saeh discussions coupled with anatomical research and physiological experiments, that not
only the rarioas parts of the brain, must each of them exercise some peculiar function, but
also, that certain portions of it possess the specific powers of the nervous system in a much
greater d^ree than others.
It would be foreign to our purpose, and perhaps unprofitable, to examine the various
notions that have prevailed at different times, such as the supposition, evidently derived from
the ancients, that the immediate seat of perception, is not in the brain itself, but in the in-
vesting membrane, or the idea of DesGartes, that iht pineal ffland^ is the peculiar organ of the
nervous function, and theteat of the aotd.
Those physiologists proceeded upon true inductive principles, who examined the brain after
It had been injured by accident or disease, and noted the effects produced upon its faculties
by the injury or destruction of special parts. The general results of these inquiries were that
the medullary matter in general, possesses the appropriate fiicolties of the nervous system, in
a higher degree than the cortical, and that the sensibility of the medullary part increases as
we proceed nearer to the centre of the brain, where was also found a much more elaborate
system of organisation, and a much greater variety of separate parts, all of which it was fairly
concluded serve some appropriate purpose connected with the nervous powers.
An examination of the brain, after it had been injured or diseased* established the remark-
able result, that it is capable of undergoing a much greater degree of disorganization, in its
mechanical structure, than could previously have been supposed compatible with the main-
tenance of its functions, without their being materially affected. With respect to the more
external portions of the brain, it was well established by the experiments of M. LeGallois, Dr.
Philip, and more particularly of M. Flourens, that it may be sliced or cut, or even that large
masses of it may be removed. without any very considerable effect being produced upon the
perceptiTe faculties. These results corresponded with those pathological observations, in
which abscesses have formed iu the brain, and tumors and excrescences of various kinds,
which when not compressing the remaining parts of the brain, seemed to produce little injury
to its functions ; snd in which different parts of the medulla of the brain have been destroyed
by mechanical means. From such facts, Dr. Alison, concluded that it is satisfactorily ascer-
tained that no point of the brain, higher than the corpora quadrigemina nor of the cerebellum
is essentially concerned in sensation.'' Physiol, p. 16.
Anatomists have also attempted to trace up the nerves of the different organs of sense, to
particular portions of the brain, which might be considered as their origin. Although maoy
of the nerves may be traced to certain parts of the brain and to the medulla oblongata, no
tpectal anatomical centre has been discovered, and the difficulties which were encountered by
the physiologists of the last century, were evident from the fact that Soemraering, fixed a pen
66 Introduction to the Study qf Diseaus of the Nervous System.
the halitnf, or flaid io the Tentriolefli as the prlmarj seat of sensibility. Such considerations,
led manj physiologists, to conclude that although the brain is to be regarded as the common
sensorium, yet this expression can only be employed in a general way, when we speak of the
cerebrum and cerebellum, as contrasted with the neryes and spinal cord.
Willis was amongst the first, to distinctly point oqt certain phenomena sustaining the yiew,
that different portions of the brain are subservient to different offices, as for example, thai
some are more particularly connected with the organs of sense, some with the voluntary
motion, and others with the different vital functions. According to Willis, the cerebrum or
proper brain, is the organ of the perception derived f^om the external senses, and of voluntary
motion, while the cerebellum is the source of the involuntary and vital fhnctions ; and as we
have seen, this opinion was entertained by Boerhaave and others with certain additions and
modifications. Although this opinion was partly derived from observations and experiments
upon the effects of injuries to the two parts of the cerebral mass respectively, and partly from
the disclosures of comparative anatomy, the objections urged by Haller and other physiologists
against this hypothesis appeared so weighty, that it was abandoned as untenable.
The French physiologists, have during the present century, been particularly active in the
investigation of the functions of the cerebrum and cerebellum, both in the way of direct ex-
periments on living animals, and of pathological observations.
Flourens, especially distinguished himself among the French experimentalists, although
in some respects he had been anticipated by the labors of professor Rolando, performed twelve
years before. The experiments of the latter, were very similar in the mode of their execution,
to those of the former, and in the conclusions deduced from them. The conclusion of Rolando
differs from that of Flourens, chiefly in that whereas the latter physiologist, considers the
cerebellum to be the regulator, as he he terms it, of the voluntary motions ; Rolando regards
it as the origin of them, thus more completely separating the primary seat of perception frons
that of volition.
There is every reason however, to believe that Flourens, was ignorant of the experiments
of Rolando, while he was pursuing his investigations, and their coincidence has tended io
establish confidence in the accuracy of the results ; and they have been also confirmed, in
some of their leading points by the subsequent experiments of Serres and Desmonlins, and
they moreover obtained to a certain extent the sanction of Cuvier. The observations of M.
Flourens, were contained in memoirs read before the Royal Academy of Science during the
course of the years 1822 and 1823, (Recherches Expirimen tales sur les Propri6ies et les Func-
tions du Systems dans Animaux Vert^brSs). The object of the experiments of Flourens, was
to ascertain the properties of the nervous system, and the functions which its different parts
respectively exercise in voluntary motion.
The nervous system consists of the nerves, the spinal cord and the brain, and the brain may
be considered as made up of the cerebrum, the cerebellum, the corpora quadrigemina, and
the medulla oblongata. Flourens conceives that the nervous system possesses three distinct
properties ; that of volition and perception, which he regards as the same function, and terms
sensibility ; excitability or the power of directly producing muscular contraction, and coor-
dination : these three functions are exercised respectively by the lobes of the cerebrum, by the
nerves of the spinal cord, and by the cerebellum. The method which Flourens adopted to
prove his hypothesis, consisted in removing the different parts of the nervous system, or
mechanically irritating them, and carefully noticing the effect produced upon the animal ; and
the chief value of the experiments, consists in the gradual manner in which he proceeded
from one part to another, and the corresponding observations which he made upon the state
of the animal in each step of the process, by which as least, he was enabled to fix the limit of
the seat of the different functions with considerable accuracy. It was thus shown that
mechanical injury of the cerebral lobes does not cause pain, or excite muscular contraction,
but these effects always ensue from injury of the nerves, the spinal cord, the medulla oblon-
gata and the corpora quadrigemina. The cerebellum agrees with the cerebrum in the absence
of pain or muscular contraction, when it is subjected to mechanical injury. The senses of
sight and hearing seem to be destroyed by the mutilation or removal of the cerebrum, and a
general state of stupor is induced, which renders the animal incapable of voluntary motion.
When the cerebellum is mutilated or irritated, a variety of very singular and irregular motions
were produced, which did not appear to be properly convulsive, and which seemed to con-
sist in a loss of the power of connecting and regulating the contractions of the muscles, so as
to produce the natural and appropriate actions of the animal. The especial result of the
removal of the corpora quadrigemina, appears to be the loss of sight ; the contractile power
of the iris is also destroyed, which it is said still remains after the removal of both the cere-
brum and cerebellum. Voluntary motion, or the external senses, except that of sight appear
to be necessarily destroyed by the removal of the tubercles. It was well known that an iignrj
of the cerebrum or the cerebellum, is manifested by a loss of the functions of the oppoeite
side of the body ; but with respect to the spinal cord, the medulla oblongata and the tubercles,
the point was still undecided ; the experiments of Flourens, seem to prove that the tubercles
Introduction to the Study of Diseases qf the Nervous System. 6?
•et like the cerebrom end cerebellam, while the spine and the medalla oblongata, produce
their effeet on the same side with that on which tbej have been i^jnred. One of the most
important points which Flonrens attempted to establish, was that the lobes of the cerebrum
are the ezclasiye seat of sensation and volition ; and jet it is evident ft'om the result of the
experiment, that after the removal of these lobes, sensation, although rendered feeble or
obtnse, was bj no means extinguished, while the functions which depended upon volition,
such aa the various kinds of looomotioo, were still executed by the animal, although it was
difficult to excite them into action. The experiments performed upon the cerebellum, whilst
leading their author to the conclusion that this portion of the brain, is the organ through
which the animal exercises its voluntary power over the muscles, and combines and regulates
their actions, so as to produce all the complicated varieties of voluntary motion, may also
be equally well explained, without referring them to the action of a distinct or specific
nerronB function, but rather to the existence of the cerebellum, as a centre of the sympa-
thatie or associated actions of the nerves that are concerned in voluntary motion.
The results of the experiments of Bouillaud, were opposed to those of Flourens, with res-
pect to the functions of the cerebrom, for he found that animals, in whom this part has been
entirelj removed, still gave evident marks of perception, and performed certain motions, which
hmve been regarded as depending on habit or instinct; he agrees, however, with Flourens, in
regard to the Amotions of the cerebrum. The view of the functions of the cerebrum advanced
by Plonreos, are confirmed in the main by the experiments of Magendie and Fod6ra, whilst the
experiments of Desmoulins, which appear to have been equally direct with those of Flourens,
were attended with different results.
K. DesHioulinB (Anatomic des Systimes Nerveaux des Animaux k Vert6br6s), observes that
tliere are three modes of becoming acquainted with the functions of the nervous system, and
aoaignlng to each part of it, its specific oflBce.
The first is that of experiment : by removing successively the several parts of the brain
aad ita appendages, and by observing what effect is produced by these successive removals,
we attempt to gain the knowledge of the specific uses, both of the parts that are removed,
and of those that are left. The two other modes proceed upon the principles of induction.
They consist of duly appreciating the facts which are to be obtained by the study of compa-
rative aaatomy and pathology.
Desmoulins remarks, that there are three distinct orders of nervous phenomena ; those
which produce mu9cular contraction, that which produces sensation ; and those which pro-
dace thought. The two first are seated both in the cerebral-spinal system and in the nerves ;
and ID each of these systems every nervous function hMS its appropriate seat and conductor.
The third, which is confined to the cerebro-spinal system, gives rise to a variety of faculties.
The phenomena of consciousness, being very different from those of feeling and thought,
ought probably to be regarded as a fourth power, and it is further suggested that vdlition
nay constitute a fifth distinct nervous function. According to Desmoulins, if we successively
remove the whole of the cerebrum, then the optic tbalami, and lastly the whole of the cere-
bellem, so as to leave the insertion of the fifth pair of nerves uninjured, the animal retains
the eonacloasness of all the sensations which have their seat in the face, except those of sight ;
he ia said to manifest the perception of sounds, odours, tastes, and mechanical irritation ; he
criea oat when the organs of the external senses are stimulated ; the respiration and the cir-
culation proceed ; the muscular motions are no more affected than when the cerebellum alone
is removed ; aad even the power of volition would appear to be not altogetber destroyed.
But by the division of the spine below the lobe, all the functions are suspended, so as to indi-
cate thai this is the place of the gathering and reunion of the sensations of the entire body.
And it farther appears thai the different parts of this lobe have their specific functions ; one
part being more intimately connected with the sensations of the face, and another with the
digestive organs.
With respect to the specific properties of the cerebellum, Desmoulins endeavors to show,
thai there is no foundation, for the opinion that has been embraced by Gall and others, that the
development of this part of the nervous system bears a relation to the generative faculty. Nor
does he agree with Rolando and Flourens, that the cerebellum is the great agent in produ-
cing or regulating muscular motion. The opinion which Desmoulins entertained with respect
to tbe specific use of this part was, that the mutilation and destruction of the cerebellum
** neairalisent une force qui faisait ^uilibrS avec une autre force produisant la tendance li
recaler. Ce n'est done pas le cervelet lui-m^me qui est le si6ge de cette derui^re force, il
parait I'Mre au contraire d'une force impulsion en avant, comme nous le verrons plus tard."
He quotes certain experiments which were performed by Magendie, and which consisted in
diriding one of the pedicles of the cerebellum, the effect of which was a rapid rotatory
motion of the animal on its axis, which continues incessantly for a considerable time, snd is
only prevented by a mechanical obstacle. The conclusion which Desmoulins draws from the
experinsents of Magendie, is ''que deux forces antagonistes circulent par lesdeux demi-cercles
lat^mux que ferment le cervelet et sa commissure." A no less remarkable effect, is stated as
68 Introduetion to the Study qf Diseases qf the Nervous System.
beings the resalt of an injury of one of Ihe optic thaUmi ; thii, it is said *' entraine imsitii-
blement I'animal dans one conrss on dans on vol circalaire oo de manege, snr le c6t^ dont on
a bless^ le lobe ; " and it is also stated that frogs and serpents <*toornent sur le e6t£ oppose
an lobe bless^/'
According to Detmontins, the volome of the brain is not the measure of the intellect, and
the interna] contour of the cranium is frequently not parallel to the external surface, so that
the relative sise of the different parts of these lobes cannot be ascertained bj an ezaminatioo
of the skull. There is, however, a mechanical structure which appears to bear a regular
ratio to the perfection of the intellectual faculties, vis : the number and character of the con-
volutions of the hemispheres. Magendie is stated to have been the 6r6t to suggest the idea,
that there is a connexion between the number of these convolutions and the state of the
intellectual faculties. This position is supported bj various facts in comparative anatomj,
by the comparative state of the fcetal and adult brain in the same kind of animal, as well as
by the brains of idiots. Hence is deduced the general principle that the number and perfec-
tion of the intellectual facnlties, both in a series of species, and in the individuals of the
same species, are in proportion to the extent of the cerebral sur&ces. With reference to the
hypothesis of Oall and Spureheim, that particular faculties have their seat in particular parts
of the brain, whilst admitting that the doctrine is plausible, Desmoulins held that the argu-
ments brought forward by these anatomists were inconclusive, because they were derived
only from the external form of the cranium ; and he conceived that it is by the examination
of the brain, after the partial or total loss of certain faculties, that we are to gain accurate
information on this point.
Desmoulins also describes some singular varieties of muscular motions produced by the
mutilation or removal of certain parts of the cerebrum. " Se I'on retranche k un mammtftre
la route de rhemisphere cerebral et le corps stri^ ; aussit6t Tanimal s'ilance droit en avant
et court sans se d^tourner Jusqu'li ce qu'il choque un obstacle." This peculiar motion is said
to depend upon the destruction of the medullary matter, while the destruction of the cine-
ritious part has no immediate effect upon the motions of the animal, but appears to destroy
its volition and intelligence.
Magendie, who, in conjunction with Desmoulins, composed the physiological part of the
work to which we have just referred, is entitled to the credit of the various important physio-
logical experiments with which it is illustrated.
In the experiments of Magendie, (Magendie's Jonrnal, t. iii., p. 157), the removal or
destruction of the cerebellum produced an irresistible tendency to retrograde motion, and
when one of the crura cerebelll was divided, the animal began to rotate with great rapidity,
and continued to do so without interruption, as long as it survived the operation. A similar
kind of rotation was observed by Serres in a man, in whom, after death a disease of the same
part df the brain was detected ; and Fod^ra also witnessed the same irresistible tendency to
retrograde motion after the removal or mutilation of the cerek>ellum.
Bonillaud, (Mageodie*s Journal, t. x., p. 36 et seq.)« found that the removal of the cerebral
lobes of a fowl produced drowsiness and want of perception; but although the intelletual
powers were destroyed, the animal still appeared to retain sensation ; hence he inferred that
these lobes are the more immediate seat of the intellect. He dissented from the eooclusioB
of PoviUe, that they are **'the sole seat of the instincts* intelligence and volition/* because
some sensations and instincts certainly remain after their removal. He supposes that the
different portions of the cerebral lobes possess distinct functions, as some of them may be
destroyed, while others continue. Bonillaud details a number of experiments, in which the
lobes of various animals, birds, rabbits aud dogs were removed, cauterised or laid bare ; tlie
general results were that the sensations were not destroyed, but that the intellectual power*
were either destroyed or disordered. The removal of the cerebrum destroyed the power of
recognising external objects and intellectual acts depending on this power, bnt the animal
still retained the power of motion and the use of the external senses ; the dee tmction of the
anterior part of the cerebrum produced very nearly the same effect with the destmctioa of
the whole. The experiments of Bonillaud were supposed to afford clear proof of the dlfllbrent
seats of the sensations and the intellectual faculties *, the anterior lobes appearing to be more
especially the seat of the intellectual faculties.
The observations of Plourens were confirmed by Hertwig, who found that the eerebellum
itself was insensible; that irritation of It excited no conrnlsions; and that though lesion of
it interfered with the combination of movements, the senses of all the other functions were
not thereby affected. Hertwig, however, remarked, that if the mutilation of the cerebellam
bad been partial only, its function was restored. He also found that removal of one side of
the cerebellum affected the movements of the opposite side of the body. The experiments of
Plourens were also repeated with similar results by Bodge and Looget. The comparative
vIKtcts of removal of the cerebrnm and cerebellum, were well shown by Longet, who says :
** Take two pigeons, from one remove completely the cerebral lobes, and fkom the other only
Introduction to the Study qf Diseases qf the Nervous System. 69
bmlf the cersbellom ; the next day the first will be firm upon Mb feet, the second will exhibit
the ttiuteady and uncertain gait of drunkenness.''
Longet demonstrated the fact that both sight and hearing are retained after extirpation of
the hemispheres, even more clearly than Bouillaud, by the following experiments : The hem-
ispheres were removed from a pigeon, and the animal survived the operation eighteen days ;
when placed in a dark room, the iris contracted and the eyes winked when a light was sud-
denly broaht near the eyes, and the bird even followed with its head the motions of a lighted
caodle. The report of a pistol caused an animal to open the eyes, after the removal of the
hemispheres ; and it gave other evidences that the sense of hearing was not destroyed by the
severe operation. (Traite de Phynologie),
The weight of testimony based upon actual experiment, appears therefore to favor the
conclusion of Floorens, that the cerebellum possesses the power of co-ordinating the volun-
tary movements which originate in other parts of the cerebro-spinal centre, whether these
movenents have reference to locomotion or to other objects. Dr. R. B. Todd, in his elabo-
rate and valuable article on the Physiology of the Nervous System, published originally in
the third volume of the Cyclopedia of Anatomy and Phvsiology, (pp. 720 -723 ), and repro-
duced in the ** Phytiologieal Anatomy and Phynology of Man" advocates the view that this
power is mental, or dependent ior its excitation and exercise. In support of this proposition,
be appeals to the experience of our own sensations, and to the fact that the perfection of it
rconires practice. Thus, .he says, that the voluntary movements of a new-born infant,
althoagh perfectly controllable by the will, are far from being co-ordinate ; they are, on the
contrary, remarkable for their vagueness and want of definition. Yet all the parts of the
cerebro-spinal centre are well developed, except the cerebellum, and the convolutions of the
ccrebrnm. Kow, the power of co-ordination improves earlier and more rapidly than the
iotellectual faculties ; and we find, according to Dr. Todd, that the cerebellum reaches its
dcTelopment of form and structure at a much earlier period than the hemispheres of the cere-
brum. It may also be stated as sustaining this view of the mental nature of the power by
which voluntary motions are co-ordinated, that in the first moments of life, provision is made
for the perfect performance of all those acts which are of the physical kind. Thus, respira-
tion and deglntition are as perfect in the new-born infant as in the full grown-man ; and the
excitability of the nervous centres to physical impressions is much greater at the early age,
partly perhaps, in consequence of the little interference which is received at that period from
the will. That the cerebellum is an organ favorably disposed for regulating and co-ordinating
all the voluntary movements of the frame is very apparent, according to Dr. Todd, from
anatomical facts. Thus, no other part of the encephalon has such extensive connections with
the cerebro-spinal axis : it is connected slightly with the hemispheres of the brain, by the
processtts cerebelli ad testes, but most extensively with the mesocephali, the medulla oblon-
gata and the spinal cord. Dr. Todd calls especial attention to the fact that its connection
with the brain proper is more immediately with that part which may be regarded as the centre
of sensation, namely : with the optic thalami. And he suggests, that this connection of the
cerebellum with the centre of sensation, may probably have for its object, to bring the mus-
cular sense to bear upon the co-ordination of movements, in which the individual experience
of every one shows tbat, that sense must materially assist^ The cerebellum is brought into
union with each segment of the great nervous centre upon which all the movements and sen-
aations of the body depend ; through the restiform bodies it is connected with the medulla
oblongata and the spinal cord ; by the fibres of the pons, with the mesocephale, and thus with
the anterior pyramids and corpora striata ; and through the processus e cerebello ad testes
with the optic thalami. With reference to the object of these extensive connections. Dr.
Todd afirms that it would be difficult to conceive auy function for which so elaborate a pro-
vision would be more necessary, than that of regulating and co-ordinating the infinitely Com-
dex movenents which the muscular system is capable of effecting ; more especially, when it
seems highly probable that the antero-Iateral columns of the cord, and the anterior pyramids
and olivary columns supply all the anatomical conditions necessary for the development of
acts of sensation and volition.
Whilst therefore, Flonren's views respecting the office of the cerebellum, derive support,
both from experiments and anatomy ; on the other hand, the evidence furnished by the effects
of disease, has not been of that satisfactory and decided character as to convince pathologists
of the correctness of the physiological theory. A superficial lesion of either cerebellar hemi-
sphere, or of the median lobe does not cause paralysis, but may producs delirium or convul-
sions, as a superficial lesion of either cerebral hemisphere may ; but a deep seated lesion
of the cerebellum involving the central white substance which is continued from th«» crus
oerebelli causes hemiplegia on the opposite side. This similarity between the effects ol
cerebellar and of cerebral disease, considerably increases the difficulty of obtaiuing from
pathological phenomena any contribution to the solution of physiological questions. Dr.
Tood thus explains this similarity : — the transverse fibres of the pons passing through the
(pbale would propagate to this segment the morbid influence of any deep seated lesion
70 Introduction to the Study qf Diseases qf the Nervous System.
of the cerebellam, and thus Affect the adjacent pjramid, which again would affect the oppo-
site half of the body jatt at if the morbid inflnence originated in the cerebral hemisphere. It
is then, this secondarj affection of either pyramidal body which obscures the proper signa
referable to cerebellar disease.
Some cases of disease of the cerebellnm have howerer been recorded by M. Combette,
{Revue MedieaU Avrilf 1831) ; Magendie and CmTeilhier, (Anat. Physiologique, Liy.. 15, fl. v.)
Dr. Todd, (Cydopmdia of Anatotuff and Phftiology, p. 722, 8.); Andrai, (Glinique M^dicale,
1834 tome V.) ; Gnyot, Delaroare, Oall (Sur les functions dn Cenreau, Paris, 1823, tome III,
p. 341); Petiet, (Journal de Physiologic, Paris, 1826, tome VI, p. 162 et seq); Larrey,
(Memoirt on Military Surgery^ Baltimore^ 1814 ; Ob»ervationi on VFoiindif, etc, If^furuB^ of the Oert"
helium^ Philadelphia, 1823, p, 199, et $eq)\ Wagner and Laborde, (Journal de la Physiologie,
Paris, 1861, tome IV, p. 386, p. 637); Fiedler, (Bio Fall too Verk&mmerung d%9 CertUUum.
ZeiUekrift fur rationaU Median, Leiptig und Haddherg, 1861, Bd, XL S, 250 et »eq) ; Vulpian,
(Systime Nenreux, Paris 1866, p. 629) ; Bonvler, Hammond, (The Physiology and Pathology
of the Cerebellum — Quarterly Journal of Psychological Medicine, New York, 1869, toL III,
p. 237), in which were observed great muscular debility of the extremities, a loitering gait
like that of a drunken man, and defective power of coordination.
Professor Austin Flint, Jr., in his recent work on the Nervous System, (New York, 1673),
after a careful analysis of the 93 cases of disease of the cerebellum reported by Andrai, and
of 16 additional cases, collected from various sources by himself, draws the following conclu-
sions :
** W» OOBI0 BOW to th« m»in qvoitioo, whethor or not In viow of Kho raMilli of ozporimonti oo intmah mmI tho
>f r
phenoBMB* ofaMrTttd In 0M«t of dtowiw or injury of the oerebollam, tbia nerre centre preeidee over coordination of
■ctioa of the nuclee. which la certainly neoeaaaiy to the equiUbtntlon, except the mnadea of the liMe and thooe
concerned In apeech. Thia queatkm aeema to na to be capable of n definite anawer.
Krery earaAilljr obaerred oaae that we h«Te been able to fln«l, in which there waa aa onoompllcnted dlaeaaw or In-
Jury of the cerebellnm, proTlded the diaeaaa or injary InTolred more than half of the oignn, praaented grmt diaorder
in Uie general moTementt, particularly thoae of ptogreaalon, • a a
We do not make the laaeivatlon that mors thain half of the cerebellnm mnat be deatioyed in order ancofaaftilly to
prodnce difleulty in mnacalnr coordination, on purely theoretloal groanda, but refMd thb point aa poaltlvely domiMi-
atrated by experimenta on animala. Theae experlmentt ahow that ono-hnlf of the organ la capabte of performing tb«>
function of the whole. We hare un analogy to thia In the action of the kidn«>ys» one of whldi ia aaflkient Ibr tbo
elimination of the effete oonalituontt of the urine, alter the other haa been raomTed.
Notwithataoding the contrary Tiewa of many phyalologicnl writera, we are flnnly oouTlnoed from experlmenli and
a careful atndy of pathological ftcta, that there ia no one point in the phyaiologr of the nenre-contree more definitely
aettled than that the cerebellum prealdea over equilibration and the ooOrdinaoon of the muacular moTemeafei, par-
tieularly thoee of progriwaton. In thia atatemant we make axcapdona in IhTor of the moveaaenta of reapirmtlon d«g-
lutltloB, of the fiMe, and of thoae oonoeraed in apeech, aa well aa the involuutaiy moTementi generally. Aa another
example of a nerre-oentra preakUng orer muacular coordination, we have the Inatanoe of the portion of the left
anterior lobe of the cerebrum, which coOrdinatea the action of the mnadea concerned in apeech.
The theory that the diaordered moTomentt which follow li^ufy of the cerebellam, la almply due to Tortigo ta not
tenable. In only three of the oaaaa dtedf la vertigo mnntionod ; and In two. the word rertlgo aeema to be need rather
aa an explanation of the phenomena obarrred, uan in their rimple deacrlption. There fa a diaeaaa loTolTing tho
aeniidrcular caoala,aad other parte of the lutemal ear, called ]l4nMre*a dtoraae, in which there la aaarfced want of
equillbimtlon and muacular coordination, attended with, and probably dependent upon vertigo. The rertlgo fa alwnta
Teiy diatinct, and fa mentioned In all the oaaaa ; and though It fa Um In the recumbent pnitlon, it fa never entirely
abaent.** ppu 38&-iiS8.
Povllle supposed that the cerebellum Is the centre of sensation. This hypothesis has been
opposed upon both anatomical and pathological grounds. Thus the cerebellum, wants that
general connection, both direct and indirect with ientient nervety which might be inferred if it
performed the oflHce in question, not one of the nerves of pore sense having any connection
with it ; and diseased states of the cerebellum do not give rise to any loss of sensibility, such
as might be expected where the centre of sensation Is involved.
Oall was the author of the theory that the cerebellum was the central organ of the sexual
appetite, and he has been followed in this view by many crantologbts or phrenologists. Pre*
cise facts, however, have not confirmed, and pathological data seems rather opposed to thia
view. Baron Larrey was led by his extensive experience to conclude that ** the cerebelluni
exerted a strongly marked vital influence on the genital organs.*' {Ctimque CUrurgteaie, tome
1, p. 297, 1829) ; and he cites the following cases to sustain this view:
**A yoaag aoldlorof IS, received a blow upon tho nape of the neck. He became alarmingly ill In oonaeqneooe.
and only quitted the hoapltal aAer three mo itha* aai|oum there. Fourteen yean afterwaida thfa man preaented
himaelf for diachaige. He waa then pale and beardleas, and hfa voice waa piping and feminine. Hfa genital oqpaa
were reduced to the alae of thoee of a child of a few montha old ; — the teatea were not larger than haricot bcana. Be
•lated that aince hfa aocldent, he had been without any aexaal deaire, although he had formerlv been like the net of
the comradea In thfa raapect ; that hfa beard, which waa well grown at the age of 18, had flulen out. Hfa IntoUeo*
tual f^nltiea had never been affected.
** An artilleryman received a muaket ahot In the neck, the ball tiaveraiug the nane and graiing the oodpltal pio*
tttbefmncua. The eight and hearlug were much affected; the teatea fell Into a aort or atrophy, and the pMila ahrunk
in the aame degree, and waa altogether inactive.** CSKWfue WemrfkaU, tome 1, p. 306.
Oall's view rests on two assumptions ; first, that the instinct of generation or of reprodnc*
tion is the moH inditpentahle and mott powerful of all the inetincU ; and secondly that great width
ol the occipital region of the skull, and thickness of the back of the neck indicate great
Introduction to the Study of Diseases of the Nervous System. 7 1
derelopment of the eerebeUam. It is by reason of the Msumed transcendent importance of
the generative instinct that so large a portion of the brain (an eighth or ninth part of the
whole) was assigned bj Gall to exercise an exclusive interest over it. The following objec-
tions have been urged against the hypothesis of Qall : The sexual instinct cannot be separated
from the emotions, and especiallj from ihose which are clearly instinctive in their nature ;
the same part of the brain would probably exercise its influence upon all the emotional
actions. Bnt even if the sexual instincts were separable from the other instincts, it seems
very questionable whether it is of that paramount importance as to need a separate organ of
great magnitude, of complex structure, and of extensive connections with the rest of the
cerebro-spinal centre ; and if we compare it with the instinct of self-preservation, as mani-
fested either in providing for the wants of the body or for defence against assault, it certainly
cannot be admitted to have a superior influence to this the most pressing of all, to which, as
iSu- as is known, a separate seat has not been assigned in the brain. Great width of the occi-
pital region, and thickness of the back of the neck, does not necessarily indicate a great
development of the cerebellum.
If Gairs doctrine be correct, the great size of the cerebellum in the human subject would
warrant the belief that the sexual instinct in man far exceeded that of other auimeJs ; but
this it bj BO means the case.
In fiab, the sexual instinct appears to be strong, and yet the cerebellum is by no means
large; and in the kangaroo, which is described as being most solacious, the cerebellum is one
of the niiallest to be found in the class Mammalia. The solacity of Monkeys is well known,
and yet in them the cerebellum is much smaller than in man, in whom the sexual impulse is
Bach less violent. Against the statement of Gall and most of his followers, that mutilation
of the genital organs, or their decay in the advance of age, is attended by marked effects on
the oerebellnm, may be opposed the results of the researches of M. Leuret, who took the
weight of the cerebellum both absolutely, and as compared with that of the cerebrum in ten
Blalliona, twelve mares, and twenty*one geldings, and obtained the remarkable result, that
castration tends to mtffment^ and tun to reduce the weight of the cerebellum.
The few cases quoted by Gall, in which the injury in the neighborhood of the cere-
bellum seemed to affect sexual instinct have been considered as far from exclusive, for they
might equally apply, if it were assumed that the seat of the instincts were in the posterior
lobes of the cerebrum, in the medulla oblongata, or in the spinal cord: Burdach has collected
the facts which bear upon this question. He has calculated that affection of the sexual pas-
sion is observed once in every seventeen cases of lesion of the cerebellum, and once in three
hundred and thirty-two cases of lesion of the cerebrum. In apoplectic cases attended with
erection of the penis, there has been found effusion of blood in the cerebellum : (Serres, in
Magendie's Jour., iii, p. 114). Donglison observed priapism in a case of inflammation of the
cerebetlnm with serous effusion ; bnt destruction or irritation of the spinal cord in animaU
also gives rise occasionally to erection of the penis j the coincidence of disease of the spinal
cord with alfoetion of the genital organs is much more frequent. Cases have been recorded
in which the cerebellum had been injured or destroyed by disease, in which the sexual pas-
sion had been strong. The various cases cited by Gall, Larrey, Cruveilhier and others, in
which disease of the cerebellum was attended with loss of the sexual appetite, do not really
prove any direct connexion betwen the two ; although certain facts observed by Budge and
Hammond, as well as those cases in which irritation of this part has been followed by per-
listent erection and manifest exaggeration of the sexual appetite, would seem to imply that
the cerebellnm may have other fhnctions besides the equilibration and c&ordination of certain
DQscnlar movements. M. Budge (Muller's Archiv., 1839, p. 390), states, as the result of
repeated experiments, that irritation of the cerebellum with the point of a knife, in a cat just
killed, eanses the testicle of the same side to move, so as to place itself more at right angles
with the vas deferens. Budge also observed movements in the cornua of the uterus and the
Fallopian tubes, in females, following irritatiou of the cerebellum. (Lehrbuch der Sped"
fJlem Pkytiologie dee Memohn, Leipzig^ 1862, 788). Hammond (Phytioloffy and Pathology ^ of the
CerebeUmm; Quarterlg Journal of Peychological Medicine, New York, 1869, vol. iii, p. 223,) also
noted similar movements in cats just killed, and also movements of the intestines and of the
msicles of the abdomen, thigh and back.
It most be admitted however, that the physiological and pathological facts, are not suffi-
ciently namerons and definite, to sustain the doctrine of Gall, that the cerebellum in the seat
of the sexual instinct.
Physiologists now regard the brain as a collection of ganglia connected by commissures or
nerve fibres with each other, and with the different columns of the motor and' sensitive nerves.
The gray matter of the cerebrum and cerebellum, the olfactory ganglia, the gray matter
of the corpora striata, and of the optic tbalami, the tubercula quadrigemina and the gray
matter of the tuber annulare, or pons varolii, and the ganglion of the medulla oblongata,
•re generally recognised as distinct ganglia, having separate and distinct functions, which are
■lore or less completely understood.
72 Introduction to the Study of Disoases qf the Nervous Syttem.
Accord tog to J. Luys, (iUchercKea tur U Sytthite Nervtvx (Xribrc^Spimal 9a Struebtrt^ m» /Wne-
thnt et tet Maladiet, firia, 1866), the gray niAtter of the cerebral hemitpheree it compoied of
a mass of mere cells, connected together by their prolongations into a plexus, which in its
turn is connected with the fibres of the white snbstance. From this cortical cellolar plems,
white fibres arise, which maj be divided according to their direction and destination into two
classes. The first class consists of cnryed commissural fibres, which pass into the whito sob-
stance to a certain depth and return to the gray matter, connecting thus the gray substance
of adjacent convolutions. The second class consists of fibres, which arising from the gray
substance of the convolutions, connect them with the corpora striata and optic thalami :
these have been called converging fibres, and their general direction, as far as it has been
ascertained, is as follows : arising from the internal, concave surface of the cortical substance
of the cerebrum, at first running side by side with the curved commissural fibres, they sepa-
rate from the latter as they curve backward to pass again to the cortical substance, and are
directed toward the corpora striata and the optic thalami. The limits of the irregular planes
of separation of the commissural and the converging fibres contriboto to form the boundaries
of the ventricles of the brain. The converging fibres arising from all points in the concave
surface of the cerebral gray matter, take various directions ; those from the anterior regioa
of the cerebrum pass backward, and form distinct fasciculi which converge to the gray tub-
stance of the corpora striata ; those from the middle portion converge regularly to the mid-
dle region of the external portion of the thalami ; the fibres f^om the posterior portion pats
from behind forward, and distributo themselves in the posterior portion of the optic thalami ;
the fibres from the convolutions of the hippocampi and the fascia dentata, are lost in the
gray substance lining the internal borders of the optic thalami. In addition to these con-
verging fibres and the curved commissural fibres connecting the different convolutions of
each hemisphere with each other, are commissural fibres, which connect the two hemispheres,
as well as fibres connecting together the corpora striata and the optic thalami of the two
sides. Certain of the fibres converging f^om the gray snbstance of the hemispheres to the
corpora striata and optic thalami are probably connected with the cells in the gray matter of
these parts ; other fibres pass through the corpora striata and optic thalami to become finally
connected with the fibres of the medulla oblongata, and, through the medulla oblongata,
with the columns of the spinal cord ; following the antero-lateral columns of the cord from
below upward they aacend to the medulla oblongata, decussate in the median line, and from
the medulla pass to the brain. Certain of these ascending fibres, which are nearly all conti-
nuations of the antero-lateral columns of the cord, ascend to the brain by passing deeply
through the pons Varolii ; other fibres ascend in the cerebral peduncles, of crura cerebri ;
and other fibres pass to the tobercula quadrigemina. As the bundles of fibres ascend firom the
medulla oblongata, they become more and more numerous by reinforcements of fibres, pro-
bably derived from the cells of the collections of gray matter in their course.
The marked difference in the appearance of the cells In the most superficial and in the
deepest portions of the gray substance ; the former being small and presenting a delicate
network of anastomosing fibres, resembling the cells of the posterior eornua of the gray
substance of the cord ; while the latter are large and resemble the so-called motor cells of
the cord, has led to the suppositiun that the larger cells are for the generation of the motor
stimulus, while the smaller are for the reception of sensory impressions.
The gray substance of the cerebellum, is divided distinctly into an internal and external
layer. The internal layer presents an exceedingly delicate network of fine nerve fibres, la
which are found numerous bodies like free nuclei, called by Robin, Myelocytes* The external
layer, resembles that of the gray substonce of the posterior lobes of the cerebrum, and is
divided into two or more secondary layers ; the most external portion conUins a few small
nerve-cells and fine filaments of connective tissue, and the rest of the layer contains a great
number of large cells, rounded or ovoid, with two or three, and sometimes, though rarely,
four prolongations.
From the gray substence of the convolutions and their prolongations, the fibres of the cer-
ebellum converge to form the crura, or peduncles on each side. The superior peduncles paaa
forward and upward to the crura cerebri and optic thalami. These connect the cerebrum and
cerebellum. Beneath the tubercula quadrigemina, some of these fibres decussate with the
corresponding fibres upon the opposite side ; so that certein of the fibres of the superior pedun-
cles pass to the corresponding side of the cerebrum, and others pass to the cerebral hemisphere
of the opposite side. The middle peduncles arise from the lateral hemispheres of the cerebellumf
pass to the pons varolii, where they decussate, connecting together the two sides of the cere-
bellum. The inferior peduncles pass to the medulla oblongate, and are continuous with the
restiform bodies, which, in turn, are continuations chiefly of the posterior columns of the
spinal cord. According to Luys, the fibres fVom the cortical substonce of the cerebellum all
pass to the corpora dentate and there terminate, being connected with the cells. Prom the
corpora denteto, new fibres arise, which go to form the cerebellar peduncles. Lnys does not
admit the existence of commisnural fibres connecting the two lateral halves of the cerebel-
Introduction to the Study of Disecues qf the Nervous System. 73
lorn, and Mtames th»t the decauation between the two tides, takes place through a special
system of deenssatiog prolongations from the cells of the cortical substance, which he
calls intereortical commissural fibres. Bj the superior peduncles, the cerebellum is con-
nected as are all of the cephalic ganglia, with the cerebrum ; bjr the middle peduncles, the
two lateral haUes of the cerebellum are intimatelj connected with each other ; and by the
inferior peduncles, the cerebrum is connected with the posterior columns of the spinnl
cord.*
It is aow uniTersally admitted that an animal deprived of the cerebral hemispheres, is in-
c^Mble of a spontaneous roluntary effort. Thus Vulpian sajs with regard to a rabbit from
which he had removed the cerebral hemispheres and the corpora striata, that it was com-
plelelj deprived of spontsMieous yolition ; all its movements, which are, indeed, much less
varied than those of a bird operated on in the same manner, are exclusively and directly due
to a stimulation produced by exterior excitations or by interior inclinations, such as fatigue,
etc., {S^hm Ntrveuz^ Ptrit, 1866, p. 680.)
The observation of Pourfour du Petit^ in 1766, connecting the loss of speech with disease of
the left side of the cerebrum, the observation of Dr. Marc Dax, in 1836. who concluded from
the lose of speech in one hundred and forty cases of right hemiplegia, that the faculty of lan-
guage occupies the left anterior lobe, the reports of cases of aphasia, with lesion of the left
anterior lobe by Broca, Aubertin, Charcot, Falret, Perroud and Trousseau, and the limitation
of the lesion, by M . O. Dax, in 1863, to the anterior and middle part of the U/t anterior lobe, and
the eabeeqnent observations of Broca, Huglings- Jackson, Sanders, Moxon, Ogle, Bateman,
Bastian, Von Benedict, Brannwart, Austin Flint, Wilbur, Seguin and others, indicating that
the most frequent lesion, in apkaeiaf is in the parts supplied by the left middle cerebral artery,
particularly the lobe of the insula, or the island of Reil, have not only rendered it probable
that the organ of articulate language is restricted to these parts, but has sustained the view
so long held by certain physiologists, that special portions of the cerebral substance, are con-
nected with the exercise of special intellectual faculties.
As we have seen, various physiological and pathological writers, and more especially
RolaodOy Flourens, Desmoulins, Magendie, Longet and Vulpian, have held that a great part
of the cerebral substance is neither excitable, nor sensible to direct stimulation : but the
more recent experiments of Pristch and Hitsig, appear to have opened a new field of physio-
logical investigation, and indicate that certain portions of the cerebrum possess excitability,
and that their action Is confined to particular sets of muscles, Fritsch and Hitsig, after ex-
poesog the cerebral hemispheres of dogs, found that certain parts of the anterior portion
responded to a feeble galvanic current. They applied the stimulation by means of two needles,
conducting a feeble galvanic current, introduced through the grey into the white substances.
Bach galvanisation produced movements restricted to particular sets of muscles ; but it was
dificttit to say whether the contractions were due to stimalation of the white or of the gray
sabetance. These observers claim to have determined different centres for the different mus-
cles ; the centre for the muscles of the neck was located in the middle of the frontal convolu-
tion ; external to that, was a centre for the extensor and abductor muscles of the fore legs ;
and so on, other centres for sets of muscles being found in the anterior portion of the hemi-
spheres« By pasting an' interrupted current through these parts, tetanus of particular mus-
cles was produced. In other observations, when the gray substance wss removed at the
points mentioned, there was partial loss of power, but not paralysis, of the sets of muscles
correapondiag to the centres operated upon. The experimenters regarded this as due to a loss
of mmeadar eenee. In these experiments the action was alwayt crossed. It was also found that
after severe hsemorrhage, the excitability of the cerebrum quickly disappeared, which may
account for the negative results obtained by previous observers. No motor properties were
found in the posterior portions of the cerebrum.
These experiments of Fritsch and Hitcig, throw a new light upon the cerebral substance,
for it has heretofore, always been found difficult to experiment upon the great encephalic
centres without disturbing the physiological conditions so seriously, as to render the result of
direct observation of this kind more or less indefinite.
Now that it is ascertained, that in all probability, these centres readily lose their normal
properties, as a simple consequence of hemorrhage and exposure of the parts, the results of
the older experiments, in which the cerebral tissue was apparently shown to be incapable of
receiving direct artificial impressions, must be received with doubt, and should be re-examined
by these new methods of research.f
In the London Lancet, October 21st, 1871, No. xvii, p. 581, it is stated that the experiments
of Fritsch and Hitsig, have been confirmed by Schiff. Schiff is of the opinion however, that
the movements produced by stimulation of the brain*s substance do not depend upon direct
•TW PkjiMo^ of ]Ua>Nerroiu SyiteBi, bj AiuUb Floret, Jr., M. D^ pp. 317. 310, S60, 862.
t FilSnn ead HItric, Vber dl« •l«6tviieb« bi«gbeik«lt 6m Gnmhlnu :— Arcliiv fUr Anatomle, PT^iolocle, iiii<l
WlMvarlMlUich* Madedn, LHpKif , 1870, 8. 300 et Mq. The PbjiJolosy of lUa— VerroiM BpUm, by AMtin FUst,
Jr^ If . D. Hcv Toffe, 1S7JI, pp. 323-3Ml
le
74 Introdueticn to the Study of Diseases qf the Nervous System.
eicitability of the brftin, but are reflex, the reialt of irritation of parte eoocerned in tactile
seneiblHtj.
More reeentljf Dr Bdward Hitiig,* hai poblithed an aeeoont of the electrical exploration
of the brain of'an ape, with the constant and indnctive cnrrent, with the following general
reenlte : The anterior central convolntion is the general centre for the mnscles of the bodj :
and the special centres for the different seta of mnscles were found distributed in it as follows :
close to the great longitudinal fissure, separated from it about three millimetres, was the centre
for the hinder extremities; that for the anterior limbs was found about three millimetres more
to one side ; and still seven millimetres farther in the same direction was the centre for the
parte inneryated by the fkcial nerre. Finally, close to the sylrian fissures, he found the
centre of the muscles of the tongue, month and jaws. This last obserTation is interesting
from the fact that lesions in the same neighborhood are so f^nentlj connected with aphasia
in the human subject.
Professor David Ferrier, f of King's College. London, has repeated the experimente of
Hitsig and Fritech, with the following general resulte :
The research was commenced with a view to test the accuracy of the views entertained by
Dr. Hughlings-Jackson on the Pathology of Bpilepsy and Ghorea. As is well known, Or.
Jackson regards localized and unilateral epilepsies as depending on irritating or discharging
lesions of the convolutions about the corpus striatum. In order to put this theory to the
proof, Professor Ferrier, determined to eipose the brain In various animals, and apply irrita-
tion to the surface after the method of Fritech and Hitsig, who as we have seen, had shown
that contractions of definite groups of muscles could be caused in dogs by passing galvanic
cnrrente through certain portions of the anterior regions of the brain. The progress of the
research ultimately led to the endeavor to establish the localisation of cerebral fh actions,
not merely as regards motion, but also as regards sensation, and the other faculties of the
mind. The experimente were repeated before the British Medical Association, at Bradford, in
1873 ; an account of the experimente were first published in the third volume of the ** West
Riding Lunatic Asylum Reporte," for by the kindness of Dr. Grichton Brown, the superin-
tendent of the Asylum, Dr. Ferrier was able to conduct his experimente there. An abetract
by the author of bis researches has also appeared in the Journal of Anatomy and Physiology,
November, 1873, and it is from the preceding sources that we condense the following general
conclusions of Dr. Ferrier.
The method of experimentation which Dr. Ferrier adopted, is to place the animal under
chloroform, and gradually expose the surface of the brain by successive trephinings and
removal of the skull by the bone forceps. In this way he has been able to expose the whole
hemisphere. After removal of the dura mater, the points of blunted electrodes, in connection
with Dubois Reyraond's induction coil, are applied to the surface of the brain, without injury
to the cortical substance.
1. The anterior portions of the cerebral hemispheres are the chief centres of voluntary
motion and the active outward manifestation of intelligence.
2. The individual convolutions are separate and distinct centres ; and in certain defined
groups of convolutions, (to some extent indicated by the researches of Fritech and Hlulg),
and in corresponding regions of non-convoluted brains, are localised the centres for the vari-
ous movemente of the eyelids, the face, the mouth and tongue, the ear, the neck, the hand,
foot and tail. Striking differences; corresponding with the habite of the animal are to be
found in the differentiation of the centres. Thus the centres for the tail in dogs, the paw in
cate, and the lips and mouth in rabbite, are highly differentiated and pronounced.
3. The resulte were such as to indicate with a degree of exactitude the localisation in
certain definite and easily defined regions the cerebral centres for various apparently pur-
posive combined movemente of the mnscles of the limbs, as well as of the tail, the facial mus-
cles and the muscles of the Jaws and tongue. These are all situated in the anterior parte of
the brain in advance of the fissure of Silvius, and the individual centres are marked off In tbo
various external convolutions. The general plan is that in the superior external convolution,
anterior and posterior to the crucial sulcus, the various movements of the paws, legs and tail
are centralized ; and it is shown that the differentiation of these centres is to a great oxtent
characteristic of the animal's habits ; the centre for the fore-paw in cate being much more
highly differentiated than in dogs and rabbits.
The middle esternal convolutions govern movemente of the eyelids, face and eyes, while the
inferior and the Sylvian gorern various movements of the whiskers, angle of the mouth,
depressors of the lower Jaw and tongue. In the convolutions posterior to the Fissure of
Silvias, certain movemente are described as resulting from irritation, vis : of the ears, eyes,
• Berliner Ktla, WocheuKhrift, No. 6, Feb. S, 1874. Alto Chicaso Jonraal of NerroiM ftod MooUl Ptowwa, Vol. t.
Mo. % PH** ^^
t BridA Modloftl JovnuU, ISTS, Medled Tlmat ud GMotto, AvgiMt SOIb, 1873, ■». 0S, Wcit BIdiag LaUttlSc
Aaylam MwUcaI Reporti, Vol. III. 1879.
iooniAl of Anatomy and Plijaloiosy. Norenbor, 1873, p. 15S.
Introduction to the Study qf Diseases qf the Nervous System. 75
•tc There are indieatiooB of the situation in those regions of the centres of special sense,
sight, bearing and saell.
4. The action of the hemisphere is in general crossed ; bat certain moTements of the mouth,
toagne, and neck are bilaterallj co-ordinated from each cerebral hemisphere.
One of the most important conclusions drawn from the experiments, is, that the region
which governs the movements of the month and tongue in cats and dogs, is the homologne
of what is known as Broca*s eonrolution in map, viz : the posterior part of the inferior fron-
tal. This is farther borne oat bjr experiments on monkeys. The pathology of Aphasia is
thns rendered comparatiyelj simple. The memory of words is situated in that part of the
braiu which governs the movements of articnlatioo. It is shown, however, by the experi-
ments, that the brain is symmetrical, and that the corresponding part of each hemisphere
prodacee exactly the same effects on opposite sides of the body. Generally the action is
unilateral and crossed ; but, as regards the mouth, the action is almost bilateral ; and hence
disease of one or the other side alone does not cause paralysis of the articulating muscles,
beeaase the other side is able to govern as before. The occurrence of loss of speech, with
lesion of the left side, is attributed to the fact that most people are left-brained, and that,
therefore, a lesion of the left side causes such an interference with the voluntary recalling of
words, that the person is speechless, not because memory of words is utterly lost, as this
exists in the undamaged side, but because he is unable to lay hold of the word which he
wiabee to express. With the edacation of the other side, however, the individual recovers
the power of speech. Daring the interval of recovery of speech, only automatic expressions
or iaterjections are uttered, which are evoked by a sort of reflex action, and unconnected
with volition. The experiments indicate not an anatomical, but a physiological co-ordination
through the media of the lower ganglia.
5. The proximate causes of the dilTerent epilepsies are, as Dr. Hugblings-Jacksoa supposes,
discharging lesions of the different centres in the cerebral hemispheres. The affection may
be limited artificially to one muscle or group of muscles, or may be made to involve all the
Bsnecles represented in the cerebral hemispheres, with foaming at the mouth, biting of the
toagae, and loss of consciousness. When induced artificially in animals, the affection as a
rale first invades the muscles most {n voluntary use, in striking harmony with the clinical
obeervatioos of Dr. Hughlings-Jackson.
It was found that in rabbits, eats and dogs, the application of the electrodes for a few
seconds, induced almost immediately, on some occasions after the lapse of a distinct interval,
violent onilateral epileptic convulsions. When the electrodes were applied, one at the ante-
rior, and the other at the posterior part of the hemispheres, the convulsions were complete
and violent in the whole of the opposite side of the body. As a rule, they commenced in the
face, spread to the neck and upper extremity, and then invaded the hind leg and tail. Dila-
tatioo of the pupil, clonic spasms of the jaws, foaming at the mouth, and loss of oooseious-
nesa, were induced when the fits were at their greatest intensity. Occasionally, spasmodic con-
vnlaions remained localized in one or other limb, or in some one muscle or group of muscles ;
and frequently, instead of a hasty epileptic attack, a series of choreic twitches alone were
manifested, without aoy affection of sensibility or consciousness.
6. Chorea is of the same nature as epilepsy, dependent on momentary and successive
discharging lesions ot the individual centres. In this respect Dr. Hughlings-Jackson's views
are again experimentally confirmed.
7. The corpora striata have crossed action and are centres for the muscles of the opposite
side of the body. Powerful irritation of one causes rigid pleurostho tones, the flexors pre-
dominating over the extensors.
8. The optic thalamus, fornix, hippocampus major, and convolutions grouped around it,
have no motor signification, and are probably connected with sensation.
9. The optic lobes or corpora quadrigemina, besides being concerned with vision and the
movements of the iris, are centres for the extensor muscles of the head, trunk, and legs.
irrltatioa of these centres causes rigid opisthotonos and trismus.
10. The cerebellom is the codrdlnating centre for the muscles of the eye-ball. Rach sepa-
rate lobole (in rabbits) is a distinct centre for special alterations of the optic axes. These
cerebellar ocalo-motorial centres are brought into relation with the cerebellum as a eo-ordi-
nallag centre for the muscles concerned In the maintenance of the equilibrium ; and these
functions are indicated as mutually depending on each other.
11. On the integrity of those centres depends the maintenance of the equilibrium of the
body.
12. Nyttagmus, or oscillation of the eye-balls, is an epileptiform affection of the cere-
bellar oculo-motorial centres.
13. Irritation of the nates causes great dilatation of the pupils. The action is crossed,
bat powerful irrtution easily acts on both sides of the body. Trismus and opisthotonos ar*
induced when the ganglia are powerfully stimulated.
76 Ifitroduetian to the Study qf IHsea$e$ qf the Nervous Syetem.
At the Berlin Medieo-Piycbologieal Society in Norember, 1873, Dr. Hitsig,* the author of
the method of the examination of the brain by electricity, made some remarks on the prece*
ding experiment! of Dr. Ferrier, and called attention to the important discrepancy, that whilst
he and Fritscb had found only one part of the conTexity of the hemisphere capable of elec-
trical excitation, Ferrier extends this property to nearly the whole of it. This Hittig,
explains by saying that Ferrier has in his experiments used too strong cnrrents, (the second-
ary coil of StOhrar's battery being pushed in to eight and even four centimetres), and has thus
excited the ganglia at the bisse of the brain, so that It Is to them, and not to centres localised
in the cortex, that the morements noted most be referred. Another reason why Hitsig doubts
some of the elTects of irritation in Dr. Ferrier's eases, is because, although, there is such a
remarkable anatomical similarity between the brains of the dog and the cat, the latter found
that electrisation of the spot on the cat's brain corresponding to the centre of morement for
the tail In the doggare no result. Hitiig has repeated scTeral of the experiments In which
Ferrier's results differed from his own, and declares that his own Tiews are re*aiBrmed. M.
Carrillet presented on behalf of himself and M. Dnret, at the teanee of the Soe, d§ BMo^^
Jan. 3, (Report in Oas, Med. de Paris, Jan. 24), a communication relatiTC to the excitability
of the cerebral hemispheres by faradie currents, in which be criticised the recent iuTesUga*
tions of Dr. Ferrier, in regard to the location of th e functions of the brain. The eflTort Is
made to show that the phenomena described by Ferrier and others, are not due to localised
excitation of cortical centres, but to translkiltted irritation of the cerebral ganglia and pedun-
cles. M. Garrille and M. Do ret, repeated the experiments of Dr. Ferrier, and then afterwards,
endearored to obtain the same results when the animal was completely under the inflnenoe of
anesthetics, but found them altogether different. Thus, when the ansesthesia was imperfect,
it was possible by applying the electrodes successi?ely to the surftice of the conyolu tions, to
reproduce some of the movements described by Ferrier. For example, the excitation of the
anterior portion of the external superior cooTolution, caused the raising of the fore paw, the
flexion of the toes, the elevation of the shoulder, etc., of the opposite side ; while on the
other hand, the excitation of the second and third external couTolutions produced a rota-
tion of the head towards the opposite side. Some of these moTements, the experimenters
attributed to electric excitation of the muscles by the liquids which bathe the surface ;
others to the direct diffusion of the excitation through the substance of the cerebrum ; and
test experiments appeared to demonstrate the correctness of both of these suppositions.
When ansBsthesia was complete, no effects were obtained by the exciution of the conrola-
tions with any intensity of the current. Neither the centres described by Ferrier as regula-
tors of the associated movements of the fore-paw, in those of the posterior paw, or the lips,
or the eye-lids, were manifested by electric Irritation.
These results are explained by the hypothesis, that the currents applied to the surface, net
only by exciting the corpus striatum and the peduncles ; or, in short, those portions of the cere-
brum which are known to be excitable. Anesthetics affect the medulla, and through It gradually
suppress the excitability of the various organs. When, therefore, the animal experimented
npon is under their influence, the diminished excitability requires stronger stimulus, until,
when the loss of sensibility is complete, the reaction ceases altogether.
The following are the conclusions of M. Carville:
The peripheral layer of the hemisphere, Is nnexcitable, insensible, and contains no motor
centres.
The effects obtained by faradisation, which penetrates to the corpora striata and peduncles,
are due to the direct excitation of these organs.
These effects cannot be attributed to any reflex action. Complete anesthesia, which hin-
ders these effects, does not at all change the conditions of the peripheral stratum of the heoi-
ispheres, but acts merely by more or less diminishing the excitability of those parts of ibe
hemisphere which are nniversally recognised as excitable.
M. Dupuy} in a note presented to the Soc. de Biologic, Jannary 3d, 1874, holds that:
The conclusions of M. Ferrier cannot be accepted because that observer did not atteaspt
to find out whether the electric currents (faradie, as he terms them), which he used in his
experiments, diffuse themselves, or not, through the encephalon. By the aid of a galvano-
scopic frog, M. Dupuy has been able to prove that in fact they are so diffused ; and that we
cannot, consequently, claim, any more than before, that the cortical layer of the brain is
excitable by electricity.
We cannot localise the nutritive or functional centre of any nervous conductor in a par-
ticular cerebral convolution, as Ferrier supposes, because, when the animal operated on is
completely anesthetised, electrical irritation of the cortex causes no contractions ; while in
the same animal, and with the same electrical current, the direct irritation of the seiaiao
nerve, previously laid bare, causes a contraction of the muscle to which it is distributed.
• M«liMl TloM* Mid GMvtto, Jumary Mlh. Iir74, p. 101.
t (liloAso Joiinua of Kerroiu and Meatftl iNmam, Vol. I, No. 2, April, 1874,* p. 23 1.
X Cliloaco Joorattl, Kmtow ud Mratal DImmc, Vol. 1, Ko. % p. :ct2.
IfUroduetion to the Study qf Diseases qf the Nervous System. 77
Dr. Roberta Bartbolow,* of CincinnAti, hiiB had the boldaess^to apply thii method of cierebral
ezpIormUon lo the bttman snbjeet.
A woman thirtj«two jean old and of feeble iatelleet, was admitted to the Good Samaritan
Hoepttal in Cincinnati, on accoant of an epethelioma which had destroyed some two inches of
the top of the sknll, leaving the dnra mater exposed.
Dr. Bartboiow, anxions to repeat in the human subject the experiments of recent investi-
gaiora of the function of the brain, proceeded to apply powerful galvanic and faradic cur-
rents to the dura mater, and to the substance of the brain, by needles of various lengths
insalated to near the points. The needles, during the three weeks of experimenting, were
iotrodaced about ten times in each hemisphere, to the depth of from a twelfth part of an
inch to an ineh and a half, and at distances varying from a quarter of an inch to an inch.
The first point demonstrated was the insensibility of the dura mater and the brain sub-
stance itself; the patient was absolutely unconscious of the presence of the needle when
introdaced, though in the entire possession of her faculties. The presence of the needle
itself, when it penetrated a certain depth, was felt by the patient, not where the needle was,
hot in the extremities on the side of the body opposite to that of the hemisphere of the brain
penetrated, chiefly in the hand and arm. When the needles were connected with the galvanic
battery, distinct muscular movements occurred on the side opposite to the hemisphere of the
brain in which the needles were. The pain experienced in the extremities was also much
more decided. Choreic movements were excited on the side of the body opposite to that of
the brain in which the needles were plunged. A stronger electric current applied to the right
hemisphere, cansed the unilateral epilepsy of the opposite side, of great violence.
Tho following experiment was made to test faradic re-action of the posterior lobes :
AB latnlAtod needle into the left poeterior lobe, to that the' non-lninUted portion rested entirely in the
of tile brain. The other in«tn1ntea needle wm pUeed in eontnet with the dncm mater, within one-loarth of
aa tech of the lint. When the drenit wae cloeei, mnecnlar oontiactioB of the right upper and lower extremitiaB
m in tho MMeding obeonratiotti. IWint bnt Tidble eontraotlon of the left orbicuiaiti palpebarnm, and dila-
llialaoe
tatloB of the pnplii also enmied. Karj complained of a rery itrong and unpleaaant feeling of tingling in both rijcht
iltiea, eapodalbr in the right arm, which the eeiied with the opposite arm and mbbed Tigorouely. Notwlth-
^ Ike very evident pain fkea which the enflBred, ehe imiled m If mnch amneed.
Th« Doodle wne now withdmwn fkom the left lobe and pamed in the lame way into the lubstance of the right.
tho cnrrent pamed^precieely the lame phonomena enaned in the left extremitlee and in the right orbienlaria
vm and pnpile. when the needle entered the brain inbttance, ehe ooniplained of acnte pain in the neck.
to derolop mora decided re^ottone, the strength of the current was increased by dcawing out the wooden
cvUader ono tech. When communication was made with the needlta, her countenance exhibited great distress, and
Jtm bngan to cry ; Tery soon, the left hand was extended, ss if In the act of taking hold of some ottJect in fh>nt of
her; tto arm presently was agitated with clonic spasms ; her eyes became fixed, with puplis widely dilated ; lins
warn tium, and she ftothed at the mouth : her breathing became stertorous ; she lost coDScionsness, and was violently
OB the left sida. The oonTulaloBS lasted flTe minutes, and were succeeded by coma. She returned to oon>
In twenty minutes ftom the beginning of the attack, and complained of eomo weaknem and Tertlgo.
Two days later the patient was brought down for similar experiments with the galvanic
corrent : " She was pale and depressed, her lips were blue, and she had evident difBcnIty in
locomotion." The electrical excitement caused rhythmical convulsions of the right side of
the neck and right arm. The experiment was discontinued. The next day she died. The
aetopay showed great congestion of the brain, and purulent exudation on the left side.
There was a thrombus in the longitudinal sinus, which lay nearly in the centre of the ulcer.
The inflammation was greatest at the points not at all touched by the needles, but their tracks
were marked by lines of *' diffluent eerAral maUer,^*
It is evident that precisely the samu objections which have been urged against the experi-
ments of Dr. Ferrier hold good against those of Dr. Bartholow upon this poor, defenceless,
miserable patient of the Oood Samaritan HotpiUU! of Cincinnati, vis : That the currents
affected simultaneously all the ganglia at the base of the brain, being diffued to regions far
distant from those included between the points of the needles.
Prvfeesor Qndden,t of Zurich, has instituted imporunt researches upon the nervous sys-
tem, which consist In taking young animals immediately after birth, and removing or wound-
ing portions of the nervous system, and then permitting the animal to grow up, the effects of
the lesion upon the subsequent development of the animal being carefully watched. By this
uMthod of experimenting he has fixed the cenire for voluntary motion in the anterior lobes of
the cerebral hemispheres, and in this respect reaching a result similar to that obtained in the
preceding experiments with electrical excitation of the various portions of the brain.
MM. Pournie and Beaunis,} in France and Nothnagel|| in Germany, have endeavored to
determine the functions of the brain by destroying circumscribed portions. Thus the
• flnfinnart Koquirer, March 24, 1874.
Cblcago Journal Nerrous and Mental Disease^ Vol. 1, No. 2, p. 233.
Assetfaan Journal Medical Seiences, April, 1874.
Boston Medical and Surgical Journal, April 30, 1874, p. 433.
t Afchlv. ftir Psychlarie und Nenrenkran kheiton. Band II, 1870, page 803.
1 ItechfiThiW KxpeflmenUlee sur le Vonctlonnement d*n Gerreau, per le Dr. Idouard Foumle, Paris, 1873.
I Tlicbow*! Arafalv. f Path. Anat. u £ Klin. Med., Band. 67, ad heft., pp. 1K^214.
78 hitroduetion to the Study qf Diseases nf the Nervous SysUm.
unimal to be operated upon wm geoeralljr put under the influence of obloroform, Mid a small
bole was made tbroagb the skull, down to tbe dura mater ; a small but definite quantity of a
eoneentrated caustic solution was introduced, bj means of a syringe, into tbat part of tbe
brain selected for tbe operation. A solution of cbromic acid was need by Notbnagel, and
one of cbloride t>f sine, deeply tinged with analine, by Fonmie. Such injectioni caused
complete destruction of comparatiTely limited portions of tbe nerrous enbstanee.
Acoording to M. Fournie, injection of many parts of the cortical substance led, apparently,
to loss of memory and of tbe cognitive faculties, and to disturbance In diflbrent groups of
muscles. Nothnagel found tbat destruction of a small portion of the rabbit's brain, at a
point corresponding to tbe outer end of the last frontal convolution, on tbe anterior lobe of
the brain, destroyed tbe muscular sense in tbe fore limb of tbe opposite side* He also found
a definite locality in the cortex of the cerebrum, near that for the muscular sense, but a little
anterior to it, and on the lateral surface of tbe hemisphere, the iojeetion of which to some
little depth led to paralysis of the extremities of the opposite half of tbe body. This gener*
ally disappeared at tbe end of two or three weeks, and the animal regained the use of its
limbs. Nothnagel does not look upon this point as the centre for motion to tbe affected
extremities, but believes that the point of lesion lies in tbe direct path of transit of tbe motor
impulse, tbe ultimate seat of which must be sought elsewhere, and tbat there are other, but
less direct routes fh>m it to the nervous apparatuses, that are immediately instrumental in
exciting the muscles of tbe limbs to contraction, which routes are gradually opened in pro-
portion as the animal regains the use of the paralysed limbs. Another mode of explaining
the gradual restoration of the use of the limbs, is by supposing that the corresponding part of
the opposite' hemisphere assumes slowly the function of the part destroyed. Both Nottanaffel
and Fournie, found that Injury done to particular parts of the white substance in the interior
of the hemispheres, led to muscular paralysis on the opposite side of the body. Fournie
found that iujeotion of tbe cerebellum led to lack of precision In aim, or lack of co-ordinating
power. In some Instances a lesion of the cerebellum in dogs, led to a peculiar movement of
the eyes, in the perpendicular plane.
When tbe optic thalamus was tbe seat of lesion, various phenomena were noted, according
to tbe seat and extent of the lesion ; in case of toul destruction of one of these bodies, there
was total loss of sensibility on both sides of the body ; vision was lost in two cases, in which
the posterior half of the optic thalami was the seat of the lesion ; another effect of lesion of
tbe optic lobes was a sort of galloping motion of the limbs, which was often continued until
terminated by paralysis or death.
Professor Nothnagel has published in Yircbow's Archiv., Iviii, 420, Nov., 1873, a contiuoa-
tloo of his researches into certain parts of the brain : in this series of experiments, numbering
over a hundred, he has modified bis former method of Investigation, namely: the Injection of
a Hw drops of a concentrated solution of cbromic acid into the particular region selected,
because so many animals died from escape of the acid into the fourth vontricle. He now
simply pricks the brain with an ordinary microscopic needle. Rabbits wero the animals used
in these experiments. He describes a remarkable series of '* exquisite, conrulsive, springing
movements," produced by irritating a well defined spot of the hemispheres. In sixty experi^
ments he succeeded in hitting this spot twenty- three times ; in these- cases the animal was
seised with convulsive movements of such frlghtfiil intensity, that Nothnagel believes tbat
ihey cannot be compared with any known phenomenon of experimental nerve- physiology,
not even with the general convulsions occurring in ii^urles of the pons. Tbe animal,
immediately after the prick, or, at latest, one or two minutes afterwards, is Impelled either
fbrwards, sideways, or occasionally backwards in a series of leaps, in which it Is sometimes
shot up two or three feet into the air, 9Mif bjfa tprm^^ and even strikes itself against the wall
of the room in which the experiments are made. These symptoms rapidly disappear, and tbe
animals often appear quite boalthy a few minutes after tbe operation. The exact spot in the
hemisphere (tbe prick was always made on the left side) which must be penetrated to pro-
duce these convulsive movements, is in the binder part of its apex. The spot lies over the
corpora quadrlgemina, which would be reached if the needle were introduced too far.
Rxperiments made in paru of the hemispheres further backwards, so as to irritate tbe
region surrounding tbe hippocampus maior in its lower half, gave absolutely negative results,
although tbe needles were pushed from side to side, so as to lacerate tbe cerebral snbstanees
In experiments upon the Optic Thalami t—lf the puncture only entered tbe superficial layer,
of the thalamus, little or no effect was produced ; but if it went deeper towards the baso, dis-
turbances of movements appeared, consisting of a deviation of the opposite extremities, often
only the anterior ones, towards the median line : small extravasations produced by pricking
the posterior half of the thalamus cause the animals immediately to turn tbelr head to the
opposite side : if the thalamus were transversely divided, tbe deviation of tbe fore legs was
found lo persist a long time : in tbe case of the prick it soon passed off*.
Nothnagel, therefore concludes, that the paths, whether fibrous or ganglionic, whose de-
struction produces this phenomenon do not lie in a compact mass, but are scattered tbrottgb
Introduetian to (he Study qf Diseases qf the Nervous System, 79
Uw tabstaoce of the thaUmas, so that iqjary to a part of them by the simple pancture U
compenaaied for bj the others which remalo intact.
Notfaaagel's resalts with regard to the bippooampas major and optic thalamus, thas agree
ifl aaaj points, with those of Dr. Ferrier on the same parts, bj the method of electrical irri-
tatioB, but the latter found no motor disturbances on stimulating the thalamus.
I have thas endearored to present the general histor/ of results of the following methods
of research which have been employed for the determination of the functions of the cerebrum
and cerebellum.
1. Minute Stivcliire and A.natomical Relations of the Brain and Spinal Cord.
3. Comparative Anatomy and Physiology of the Cerebro-Spinal NerTous System.
3. Effects of Diseais and Pathological lesions upon the component parts of the Cerebro-
spinal System.
4. Disturbances of nerrons functions by sections of the different ganglionic masses.
5. Irritation or excitation of definite portions of the brain, by means of electric currents.
6. l>estrQction of definite portions of the brain in young animals, and observations npon
the effects of such lesions upon the nutrition and growth.
7. Destruction of small portions of the brain, by the injection of corrosiTC solutions, and
by small needles introduced into its substaoee.
RSLATION8 OF THE OBBSBBO-8PINAL AND SYMPATHETIC NERVOUS SYSTEMS.
«
Whilst eadeaToring to present a general yiew of the adTance of knowledge with reference
to the fnactlons of the Sympathetic Nerrons System and its relations to the Cerebro-Spinal
System, we shall also record the facts illustrating the relations of the neryous system to
Kutritiott, Secretion, Circulation, Respiration and Inflammation.
As fisr aa possible the plan of the preceding portions of this Chapter will be carried out
sod the more important facts and researches presented in the order of their discoyery and
execution.
The obscurations and experiments of Rnfus Ephesns,^ Galen,' Piccolhomini,* Riolan,^
Plcmpina,*^Fills,* Chirac, Bohn,' Duverney, Yieussens,* Schrader, Valsalya, Morgagni,
Bagliyi, Berger,* Ens, Senac, Heuermann, Haller,^^ Brunn,ii Molinelli, Petit, ^* Fontana,'*
Cmikabaak, Haighton, Meyer, Bichat,^* Oupuytren,^^' Dumas, ^^ Blainrille, Provencal,^*
Vesalina, Colnmbus,' Riolan,^' Bidloo,>* Muralto, Courten, Drelincoort,^* Martin,'^ Emmet.
Portal, Prochaska,*! Winslow,» Le Gallois," Philip, Lobstein,>« Reid," Krimer, Arne-
aann, Lollge^>« Brodie,>' Chossat,** McCartney,*' Nasse,*o Bernard,st Hall,** Brown-
Seqnard,** and others, haye demonstrated that to the nerrons system is delegated the pro-
1 ApMUasloaac, PiMt. Hum. Oon. Qneo«. PuWJa, 166i» p. 32.
t Gifini Opem. T«ietiit« ft|md JiiBtaa, 1676, de Hlppocr. et Plat decntti, lib. U. c»p. tI. p. 239.
S liwlnrmt*ff Pnelcctlonat Ardiang. PleoolhomlBi, BonuB, IM6.
4 OpM» AaAloaileiL Latatia PMMoniBS IMS.
A rwniamnntB Madklas. LorukU, 1M4.
5 Opatm Omnia, edento Blaalo. 1682, torn. i. Hvnroram DetcripUo.
7 CucahM Anatom. Phytiol. LIpito, 1697.
8 Tiualtai OB the Heart, TobIobm, 171A.
9 F^yaiolofte Madlca, FiBBOofnrtl, 1737.
10 MSboIim for Im paitiat lensililat et initablas, torn. 1.
11 ObBB«Btaril de nbat is Sdent. Nat. et Medic. Llpelv, tonL It.
U H^Molna de rAoad^aie del Sdeaeea, aa. 1727.
13 Traits ear le ¥«aiB de la Tip»re.
U Be^Mclu Fhy*. ear la Tie et la Mort
Ite iMtee daiik> Biblioth.*MMie., tam. sriL p. 1. Phyrtologioal Beaearehei.
ea Ufc aad Dcatii, by Xavler Blchat, tvaas. hy f. Qold, LoadoB.
15 i««mal Ote^ral de MMedae, par M . SMUllot, torn. zxziU.
16 Bnlletln dee Sciencee Mftdicales, torn. t.
17 BaehelrldliuB Aaatom Pteriaiie, 1668. Opera Aaatomi.
18 aiiiiHiltoBie ABatom. Ohinug. Logd. BMar., 1706.
19 Kxpcefmenta ABaton. Lngd. Batar., 1681.
» bnto et OfaMir. de MMadae de la 8od«t« d*BdimboorK, Paris, 1742.
21 Open MiBOia. TieBoa, 1800, torn. ii.
23 bpaeitfcm Aaaiiiia. Tnlt4 dee Neift.
23 Bspcefmenli on the Priadple of Life, aad PaitiGalarlT on the Prindplee of the Motione of the Heart, and the
iUoie. Timnilated by M. C. aad J. O. Nanexede, Philadelphia, 1813. .
of thfi Principle, by M. Le Oal
1A Stnetnre, FOnetioBs aad Dieeaaee of the HnaiaB Sympathetic Metre, by John Fred. Lobetein. ' TraBslated by
Joeevh fteeoaet, M. D., Phihwl., 1831.
2S *Ab Bxperimeatal InyeetigatioB iato the FaactioBft of the Eighth Pair of NeiTefe,*" by John Beid, H. D.
EdiBbug Medical aad Surgical Joanal, 1838.
2B Trait« de Pbyilologie, Pnrto, 1860, t li.
i7 Medloo-Chiniiv. Traae., 1837, toI. xx, p. 132
» M4im»ii« ear iTaflneBce dn mt aerr. aar le ehal. anim. Thtee de Paris, No. 126, 1820.
29 Trmfhi on laflunmatlon, 1SS8. p. 18.
30 ITatefaaclinngen snr Phyiiol. and Pethol., 1830, Til.
31 Gai. M4die. de Fltfis. toI. TiL No. 14.
3x Phil. Tnas., 1833. Ob the Diseasea and Derangementa of the Nerrons (System, by Manhall Hall, M. D., Loadon,
IMl.
33 Izperimeotal Beaearehes applied to Physiology aad Patholc^y, by B. Bfown-S4qnard, Mew York, 1863.
80 Introduction to the Study of Diseases of ike Nervous System.
perty of regnlMing the action of tbc orgmas and AppAratnt, and thnt regnUting the uboont
of oijgen and blood supplied to the organs and tissues and apparatus.
The blood sappljing tbe notritive elements of tbe tissues and organs, and the materials for
the secretions and dcTelopment of the forces, and oxygen being the active agent in all the
chemical actions of liTing bodies, It, is evident that whatever disturbs the constitution of
the nervous system, necessarily disturbs the ftinctions of the apparatus and organs, and
produces corresponding alterations In their secretions and excretions.
As the integrity of the nervoas system depends upon the integrity of the blood, in llko
manner whatever alters the constitution of that fluid will produce aberrated action in tbe
nervous system and in turn, this disturbance may extend Itself indefinitely.
Disease, then, whether arising in the organs, or in the blood, or originally in the nervous
system, will always be attended by aberrated nervous action. The most prominent symptoms
of disease will be manifested by the nervous system.
In investigations into the causes and effects of disease, we should considor the distinction
between the offices and phenomena of the two systems of nerves, the cerebro-spinal and
sympathetic.
Lfong before Haller, the intellectual fhnctlons, sensation, and voluntary motions, had been
distinguished from those which are exercised without our knowledge, and over which oar
will has no command, such at circulation, nutrition, and secretion. The former were distin-
guished under the name of external animal functions, and the latter under the name of
internal natural ninctions, and both orders of functions were known to be equally under tho
control of the nervous power. Willis* asserted the distinction between the nerves destined
to voluntary motions and those which preside over the internal natural functions which aro
independent of the will. He placed the origin of the nerves of the external animal ftinctlons
in the cerebrum, and that of the nerves of the internal natural fhnctions in the cerebellum,
and contended that if the motions of the heart as well as the other vital functions do not
undergo any interruption, it is because the action of the cerebellum continues without ceas-
ing ; whilst on the contrary the voluntary motions require repose, because the action of tbe
brain is intermittent. ^
Boerhaavef adopted the opinions of Willis, and in the action of the heart, in udditlon to
nervous sction, be admits two other causes of its motions, and their harmony : the action of
the blood of tbe coronary arteries upon the fibres of the heart, and of the venous blood in
the internal surfaces of tbe cavities of the heart. Recent experiments} have rendered this
opinion of Boerhaave more than probable.
In 1762, Hailer published his experiments upon Irritability, which tended to establish tbe
existence of an internal life independent of the nervous power, and demonstrated that the
cause of animal motion resided in the muscular fibre itself. The opinion Is now gaining
ground with physiologists that the contraction of the muscles and all animal motions result
from the chemical changes of the elements of the muscles and blood. Haller admitted that
whilst the irritability of the muscles is the cause of all animal motions, it cannot produce
them without a stimulus, and that the nervous power is the natural stimulus of idl those
which are submitted to the will, whilst the involuntary muscles acknowledge stimuli of
various sorts, which are appropriate to their functions, and wholly abstracted from tbe ner-
vous power. According to Haller, the blood is the natural stimulus of the irritability of
the heart ; and alimentary substances the natural stimuli of the intestinal canal : and tbe
motions of these organs are not submitted to the will because they are independent of tbe
nervous power. This theory of Haller, although imperfect, and in some respects erroneous,
nevertheless expressed great truths which are now being demonstrated. Careful experiments
demonstrate that Haller was in error when he asserted tbe independence of the heart
and the intestines of the nervous system ; and ProchaskaJ in 1784, admitted the nervous
power as one of the conditions necessary to the manifestation of irritability, and accounted
for the fact that the motions of the heart were not stopped by the entire suppression of all
communication between the brain and the heart, by the abandonment of the Uien geneHdIy
received opinion that the brain was the centre and only source of the nervous power, and by
the adoption of tbe opinion that the nervous power is produced In tbe whole extent of tbe
nervous system, even in the smallest nerves, and that It can exist independently of the brain,
for a certain time.
Willis' and Vienssens* acknowledged the general relations of the sympetbetic system with
the cerobro- spinal, and considered the sympathetic as the medium by which the sympathetic
relation is tendered so remarkable between the cerebrum and the viscera of the middle and
• Tho. Wlllto opwm OBttJa, adcnto Oct. Baldo. AmftolodMd, 16S2. Tom. L 4« C«ntei AnMoaMi «ip^ xv.
iH«r. BoOTliMTe Inrt. M «dk», 1 40e. TuitwlctMi in Aphpil^MM, etc Lafewil Bela% t74A. Tom. U.
Bn>wii*MqiMrd.
OoBOMatallo d« ruMHoollMW toUa— th N«rrori, tTM.
I N«rranim DvarripCio •! Vam. Qip. zxvl. Opera Omnia. G«D«vm, lOM, Iocm f.
t MeoioffiaplL UdIvmb., UK 3 d« Ntffvia, cip. v.
Introduction to the Study of Diseases of the Nervous System. 81
lower pftrtf of the abdomen, and noticed the important physiological and pathological facts
thflt not only do the Tarioni conditions of the brain affect the Titcera, but the affections of
the Tiicera effect the brain as well as the mind itself.
Dr. Robert Whyti of Edinbnrg, to whose important ** Essay on the Vital and other InTol-
nnlary Xotions of Aaimals/' published in 1751, we hare alluded In the discussion of the
history of the doctrine of reflex aetion, promulgated fourteen years afterwards in 1765, his
'* Obserrations on the Nature, Causes and Cure of those Disorders which have been commonly
called Kerrons Hypochondriac or Hysteric," a work which abounds with ralnable clinical
(tcts Ulastrating the " Sympaiky^^ of the nerves . ^
In the first chapter, in which he discusses the <* Structure, Use, and Sympathy of the NerTcs,"
Dr. Wbytt enumerates yarlous instances of sympathetic actions and discusses the mode of
tbeir production. Thus he says :
"Otr bodleiaiv, Xtj neantof the Mnraf, not only •ndowed with fealiiig »od » power of motion, bvt with a
RBtitiM* tjoipftthj, which laoither gonend and extended thronghthe whole vyetem or confined in a great a meae-
mt to eeilBin pacta.
That vnxf eenMble pait of the body hae a eympathy with the whole, will •uflltilently appear from the following
GUd water thrown on any part of the budy that is warm, producea a aiidden oontnction of the whole TemeU and
poni of the riiin, and by that raeani frequently pate a itop to imall h«raorrhageo. * *
Wbm the biain ia wonnded, inflamed, enpparated, or otherwlia hnit, almoat every part of the body la liable to
■ifer,Mid fomittnfi^ tramoca, convulaioBa, palaiea, Ac, often enane. In anlmala newW dead, the whole moaclei of
the tiuk and ezCntmitiea are atrongly oonTolaed, when a probe ia puahed down throngb the aplnal marrow. * *
A IbTtf, MHmi, and violent oonvnlaiona, have been produced by a pin aticking in the coata of the atomach :(a)
lad wonaa, affecting either tkiii part or the inteatinea, oocaaton a aurpriaing varied of aymploma.
i^ileplk flta hava pioeaedad tnm a loqgh bone or oartihiglnoua anbatanca, irritating the nerrea of the great toe,
or the caif of the leg; and the wound of a tendon or nerve haa been the cauae of a fever, dtUrfmrn^ tremora, violent
eoavalrieQai a Maana and death. ^ ^
BMidaa tiila gaaaial eewwai which prevaila thronghont the whole body, there la a particQhir and very reuailMbia
iTBpMtkj batwaea aaveial <d itt oigana, by meaoa of whidi many opeiationa are carried on in a ao.und atate ; and
(■to, ooovvlaive motlona, and otiier morbid aymptoma are often produced in each parte, aa have no near connexion
vfth thoaa that are immediately affected. * * Grief; vexation or fear, leaeen the aecretion of the mOwk, deatroy the
ifPitiie, and aometiBaaa oecaalon a tooeeaeaa. The great oonaent between the bmin and the heart appean tnmk the
mddca aad rrmarkaNa eflacta of the paaaiona on the latter. MThea one eye ia affected with an inJIammation, a cata^
fad, or the fWHa aBrnia, the other ia often aoon after attacked with the aame diaeaae. The contraction of the pupil la
aot ovlog to ll|^t acting aa a MtmOm on the irit, but aolely to the «ympathy between thia membrane and the retina,
* * The aoiae of n file and other hanh aonnda affect the teeth with an nneaay aenaatlon. The whetting of a kailh
haa eaaaad the goam to Meed. • a The effluvia of Hangaiy water, or apiri^ of wine drawn atrongly into the
Katrih, iacxeaae Che derivation of the aallval Juice into the mouth, and aometimea atop a tickling cough. The amell
of (tatefal fbod makea the mliwa flow when one ia hungrv. Stemutatortea not only increaee the aecretion fh>m the
aoee, bat alao tnm the lachrjrmal veaaela. a a a pain in the teeth often affecta the cheek bone, one aide of the head,
tha thraat, and the corcaapondlng ear. Childiah, tnm the irritation of the guma in teething, are liable to vomiting,
paniag, a coogh, n fever and oonvulaiona. * a A diaordered atate of the atomach and inteatinea, with wind or
aoxlcMu haaoan lodging in diem, will aometimea ao affect the brain, aa to deprive people of their reaaon. At other
ttaca, the aame eanaea will produce a vertigo, oephofaw, Aem<eraaki, elaeM hyiCirtaw, palpitatlona, intermlaaiona of the
paJaa, diflealty of br«»thing, audden flnahea of neat and aweating. * *
A ■ lainn or dlaagree«ble aenaation in the atomach makea the pulae quicker and amaller, ralaea a aweat. and aome-
iia«i graatly incrcnaee the aecretion of the mUm or urine. When the atomach ia empty and affected with a aenae of
haocer, the aalival Juice flowi much more ooploualy into the mouth, than after a full meal, or when the natural
•ntttite for faod ia waunting. * *
Aa hifaaamaHon of the inteatinea ia frequently attended with vomiting and a auppremion of urine. An ofmChofoaoa
oraMiMMi la often oecaaioned in hot climatee, by a retention of the faeooaiam, or other acrid humoora, in the bowela
of iobata. That itching of the nooe, which ia a common aign of worma, aeema to indicate a peculiar aympathy
Utvcen thia part and the Inteatittea; and the many other aymptoma produced by wonna, which I ahall have oocaalon
te aeatioa afterwude, ahow a remarkable and extenaive oonaent between the flrat oaaaagea, and many other parte of
the body. Stoaea i nit ting the biliary ducta, frequently oecaalon a namma and vomiting. * * A aonMo, vomiting,
aadveecaa aad Inflammation of the bowela, are often produced by an inflammation in the kidneya, or atonea in the
■rathim. a a An irritation of the neck of the bladder, or extremity of the rectum, ia the cauae of a conatant con-
taeiioa of the diaphragm and abdominal muadea. A atrangury and iatmmm mutually oecaalon each other. * *
At the time of paberty, not only the voice, but the whole body undergoea a aenalble change, which ia probably
««lBg to the tfmaiaa communicated to the nervea of the genital parte by the Miaea ; for we certainly know that other
ain£ appttad to the nervea of the noae or atomach according to their nature, will either inatanUneoualv impart new
*ifor to the whole body, or aoon oocaaion a general «tapor and debility. It la owing to a aympathy with the ^Ioim,
that the vafaaloe mminkoSm are contracted in time of ooiuon ; and, when the membmne which llnea the lower part of
the OTCira la atlmalated by the eeman, the aopalaratonn writm are excited intS oonvuMve motlona.
The gnat variety of aymptoma in the hyateric diaeaae ia the reaaon, why a more extenaive avmpathy haa been
■Kribed to the womb, than to any other part, except the brain. * The vomiting which generaUy accompaniea an
leSaaunation of that organ, the naaeea, and depraved appetite after conception, the violent contraction of the
ibfhiagm and abdominal mnaclea in delivery, the headach, and the heat and pain in the back and bowela about the
tUae of BMBBtraation, are aufllcient proof of ttie conmmt between the atenu and aeveral other parte of the bodv. But
there to ao part ao much affected by the different statea of the womb aa the breaati. which become more turgid before
■■7 afiMaraaca of the mewMa, aad aufaaide after the period la over. The chaogea that happen to the breaaui in time
«C pregma^, and after delivery, are atill more remarkable.** pp. ^39.
The ohserrations and researches of Winslow,^ Oirardiand Fontana,' Jacobson,' Lobttein,*
u; RiMM. Ctatar. U.. Otoerrat. M.
1 bporitloa Anatomlque, Traits dea Nerfh.
'« Journal de 1|Mecine, Chir. et Pharm., par Bacher, torn, xcill.
:» Ada regies flocfetatia Hafbienaia Medion, voL v. HafhiflB.
4 fltnictare, Fnnctionf, and Diaeaaea of the Sympathetic Nerve, by J. F. LoUteia . Irxm. by J. Pancoaet. Phila-
Mphia.1831.
II
82 Introduction to the Study qf Diseases qf the Nervous Sj/Uem.
Ribes,^ KilliftB,' LAiimonior,* Cloqoet,^ Scarpa, Hmm, and others, ettabUshad the itmctare
and diftribation and communications of the sympathetic system of nerTes, and laid thefonn-
dation for the philosophical generalisations of the physiological and pathological phenomena.
Scarpa demonstrated by actual experiments, that the sympathetic system receives nenrcs
from all parts of the nerrons system, the brain and spinal marrow, and that all the Tiscera
receiTe nerves composed of many separate filaments from different sources.
Wartsel divided all the ganglia of the sympathetic system into three orders, the cerebral,
spinal, and vegetative, and affirmed that they differed essentially from each other in their
structure, and in their behavior under the action of chemical agents.
Proehaska distinguished the nerves of motion from those of sensation, and affirmed that,
the heart cannot contract itself, unless the inpression of the stimulus upon its cavities is
transmitted to the ganglions of the system of vegetative life, through the nerves of sensation,
and thence reflected to the fibres of the heart, through the nerves of motion. Whilst admit-
ting the connection of the sympathetic system with the action of the heart, he is confused
and uncertain in his account of the functions of the ganglions, which he appeared to consider
as knots and ligatures, tight enough to intercept all communication in the calm and quiet
state, but not sufficiently tight to prevent the action of the nervous force, generated in the
brain during the agitation of the passions. He asserted that it is through the nerves of the
eighth pair that the effect of the passions is felt upon the heart.
In common with Winslow, Winterl, Johnstone, and others, Proehaska believed that the
ganglia of the sympathetic system were so many little brains capable of supplying the neces-
sary force to the viscera.
We have already presented an extended analysis of the views of Proehaska and Unser, and
directed attention to the fact, that the former writer, noticed the influence of the nerrons
iyttem over the blood vessels, and especially the capillaries, and referred the congestion
and increased secretion Induced by local irritants, and certain medicines, as purgatives, not
merely to the irritation of the extremities of the nerves, but to a reflex action.
Ponrfour du Petit [1712 and 1726, Mimoiirt dom Uquel U ui dimtnUrioue te$ ntrft mtereoUaur
fommumt dtt ramaaa qui porteni du apriU dam lea yeux. MSmoirea ae Paead^mie roffcie det
teUneu, Annie^ 1727, Faritf 1729,^. 6 e( teqJ] demonstrated that the division of the trunk of the
sympathetic nerve, which he termed nervuM mitrtoitaUsj opposite the fourth or fifth cervical
TertebrsB in dogs, was rapidly followed by great disturbance in the circulation of the eyeball,
and attended with inflammation, flattening of the cornea, retraction of the eyeball, with pro-
trusion of a fold of the conjunctiva, a flow of tears, and ultimately with ulceration and destruc-
tion of the entire organ. These experiments appeared to demonstrate that the influence of the
sympathetic was propagated from below, upward toward the head, and not from the brain down-
ward ; and are Justly regarded as the starting point of our deflnite knowledge of the functions
of the sympathetic system, although they illustrated only the influence of the cervical portion
upon the eye. The investigations of Ponrfour dn Petit, were subsequently repeated and extended
by various observers, as William Gruikshank,* Ameman,* Dupuy,' Dr. John Reid,' Magea-
die,* MoUnelli,!* Ifayerof Brun,!^ Braschet,i> Brown-86quard,is Claude Bernard,*^ and
other physiologists.
William Gruikshank, in 1776, performed important experiments upon the par-vagnm, and
Intercostal or sympathetic nerves, [Phil. Trans. 1796, p. 177], with the following resmlts
Section of the right par-vagum and right intercostal [sympathetic], was followed In a dog.
by heaviness, slight inflammation of the right eye, difficulty of respiration, suUenness, and a
disposition to keep quiet. The unfavorable symptoms did not continue above a day or two ;
and on the eighth day, the dog seemed to be perfectly recovered. The experiment was then
repeated upon the left side, of the same dog, but instead of a mere section, about one Inch of
the lett poT'-paffym and intercostal nerves were removed. The eyes of the dog became Instantly
red and heavy, his breathing was more difficult than in the former experiment ; the salira.
was ropy, increased in quantity* and flowed from the mouth, the pnlse was increased to IGo
1 DicCionAlre d«i SdcooM MMioAles, ton. Irt.
2 Anfttomtoch* UDteirocbanc uber 4m Nemito Hinin«rren|»ar, Pefth, 1SS2.
9 Joarnd d« MMedne, Chlmrgio at Phftrmade, par Bttcher, torn. zcUL
4 TmltS d*ABAtoiDi« DMcriptire, torn. U.
5 Ksperiin«Dti oo the Nerrca, pMtkvlariy oa their RepiXMiactioo ; mhI on the SdIimI Marrow mf LiTiag AalHale.
by WIlliABi CraikebAQk. Phil. I^e. 17M p. 177.
e Oottenceo, 1787
7 JowMlde MMrcine, Ckintnie, eCe., Daembie, 1816, tome x»U, p. 510.
S RdlDbargh MedlcftI aod Snrflfml Joanial. Aagiut, 1839.
9 Aofttomledei Syvlemat Merreax* etc, tome zl, p. 716.
10 Oommeot BuTDoleoel, tone 111, 1706.
It JontiMl dn rhimrsle, 1K27.
IS Becherchei Cxperlinentalea, rar lea Faoctlone/le Byet^me Kenrevs GhiQ|(lloaaIri.
IS ExperimeDtal Rteorchea, applied to Physiology aod Pfttholofy-.lf edioel Buailiier« PhiU. Jtrngau, IBit^ Ke«
geriem Tol. S» p. 487.
14 Gssptee Bendwde U floctoa de Blotoffl*, Pwie, ISSl, teae iU, p. 163.
I
Introduction to the Study of DUeases of the Nervous System. 83
per minote. NotvithatAnding these BymptomSf the dog ate and drank even roracioaslj at
times. In breathing, the inspirations were low and deep, the expirations were attended with
repeated jerks of the abdominal muscles. The sSTenth day after this second operation, the
dog was fotrnd dead, and upon post-mortem examination, eTerjthing seemed to be normal, bat
the loDgt, which contained little or no air, were of a red-brown color and resembled more
the substance of liver than of inflamed lungs, and sank to the bottom when thrown into water
The ioner aarface of the trachea and its branches, appeared to be exceedingly inflamed, and
coTered with white fluid, in some places resembling pus, and in others ropy, and more of
the nature of mocus.
In another experiment, in which the par-vagi and intercostals of both sides were simnltane-
oosly divided, the eyes of the dog became instantly dull and heavy ; he tottered as he walked j
foamed at the mouth; vomited; breathed with excessive difficulty, and his inspirations being
long and deep, and his expirations short and sudden, attended with a loud bark. Next morn-
iog, Mr. Crnlkshank, found the dog apparently dead ; but on examining more attentively,
found that he breathed still, though exceedingly slow, bis pulse was gone, he felt cold, and
his limbs were stretched out. When placed before a warm fire, the dog revived to a son-
tiderable extent, and manifested phenomena similar to those exhibited Just after the operation.
In the afternoon the dog died, having survived the operation twenty-eight hours. The lungs
in the dead body, were loaded with blood, but not to such an extent as to cause them to sink
in water.
Mr. Craikshank, repeated the experiments upon other animals, with similar results. In
his experiments upon the division of the spinal marrow in the eervieal region, Mr. Oruikshank
observed that there was a decided fall of temperature.
The idea that the sympathetic was a distinct nerve, apoears to have been originally
broached by Soemmering ; who said, "it is a nerve that exists independently, and Is only
connected with the cerebral and spinal nerves." The older anatomists, considered the sym-
pathetic with Haller sSb a cerebral nerve, or with Petit as a spinal nerve.
Bichat, aa we have shown by an analysis of his works on Life and Death, was the originator
of the doctrine of an organic system of nerves, and however erroneous and confused many of
kis statements and doctrines may now appear, it Is without doubt true that the clearness and
eloquence with which he presented his theories, stimulated careful investigation, as well as
decided opposition.
Bichat acknowledged an animal and organic life distinct from each other, and affirmed that
the sytem of ganglions (sympathetic system) belonged entirely to the organic life, and that
the cerebral system belonged entirely to the animal.
Whilst Bichat understood the influence of the several parts of the nervous systems, he failed
to recognise their mutual connections. The mutual relations of these systems were estab-
lished by the experiments of Le Oallois.
Le Oallois, by an extensive series of experiments, arrived at the following conclusions : —
** Life ta pnwiocad by an ImprMaion of the mrtarial blood nutde npon the bxmln and mednlla iplnaUi, or bj a prinei-
|4« re— Woi^ fhMD Ihle InmreMon.
* TIm prelonsatlon of life depends npon the oontinned renewal of thli ImpraMion. * *
" It ie thii impreMien, tiifa principle formed In the brain and spinal marrow, which, nnder the name of nenroni
power, aad tkrovch the medium of the nenres, animates all the rest of the bodj, and presides oTer all its ftinctlons.
** This heart denTss all its powen ftom this principle, as do all the other parti, the sensation and motion with which
thflj arc anduwd^ with this dilference, that the heart derlTes its power fh>m •rvty point of the spinal marrow, without
exeepdoB, whikrt erary part of the body is only animated by a portion of that medulla (by that by which it is supplied
with aerrea) ; a differMice which may serve to explain the intensity of the power of the heart, and its nninternipted
Qoatinaaaee ftom the moment of conception, till the hour of death.
** Fkom th« grant sympathetic nerre, the heart reoelTes its prlndpsl nerroos fllamenti ; and it is only through that
ascre that It can reeoiTs its eneigy fkom evexy part of Uie spinal marrow. The great sympathetic must, thersfbra,
haw iSi oflglB is this medulla.
** Tram the same principle, we can no loncer admit the assertion of Bichat. though pretty generally adopted, that
tbeic is in the same ladiTidoal two distinct liTea one animal, the other orsanlc; th£t the bnln is the only centre of
sal ami life ; aad thai the heart, independent oAhe biain, and of the nerrous power, is the centre of life.
** It must» howoTar, be obsenred, that there is a real and Tery important distinction to be made between the organs
that rseelvo th«ir nenres ftom the great sympathetic, and those which recelTe theirs Immediately ftx>m the medulla
esvOBBKfeaaBO spinal maviow.
** The fermar laoeiTe their principle of action fkom the whole uerrons power ; their functions ars not submitted to
th« will ; they are exareised in erery instant of life, and, st most, suffer only remissions.
**The latter, on the contrary, have their principle of action In a limited portion of the nenroos power; their fhno-
tMMBs are sabsritted to the will; they are temporary, and can only be repeated after complete intermissioas of longer
«r ahofftn' daiation.
** This distinctioii comptlses nearly the same oigaas as that of the two lives; but it Is evident that it rests upon a
lasis entirely dtflinant, since the organs of organic life, which, in the system of the two lives, is considered as inde-
ppndeat of tha bnUn and of the spinal marrow, are precisely those which receive the most powerful Influence
horn tt.
"* Somenras anatomical, phyriological, and pathological feets can only be conceived and accounted for by this dis-
tinctkm. For Instance, It is known that certain pains In the bowels cause debility, prostration of strength, and great
4iaoTder OinMighont tha animal economy. This Ihct, which Is unaoooontable in the system of the two lives, is
readily uademlood, from the moment we reflect that the Intestines derive their principle of action fh>m all parts of
tK# nervous power, through the great sympathetic, ftom which they receive their nerves ; and that consequently,
th«Ir aflfMtk>Bs ought to react Immediately npon every part of this same power.
** Kxperimenti on the Principle of Life, and particularly on the Principle of the Motions of the Heart, and af the
84 Introduction to the Study ((f Diseoies qf the Nervous System.
Smi of the priadpl<* I7 M. Lc QtUoif, M. D. P. Tnaatotod bj N. C. ud 4. 0. SMcnd«, M. P., PhUadolphiA, 1811.
pp. IM-U*. ^^
Mr. WiUiam Clift, from a tcriea of •zperinenti upon the braiD, «ptnal cord and heart of the
Carp, (Pbiloeopbical Trans., 1815, pp. 91-96), ■imilar to those performed bj M. Le Gallois,
drew the following condasions :
1. That the muscles of the bodj of a Carp, four hours after the brain and heart are
removed, can be thrown into powerful action.
2. That the moment that the spinal marrow is destrojed, the muscles lose all power of
action.
3. That when water is admitted into the pericardium, and the fish allowed to swim about,
the action of the heart ceases sooner than when the organ is exposed to the air, and the fish
kept quiet.
4. That whether the heart is exposed or not, its action continues long after the spinal
marrow and brain are destrojed, and still longer when the brain is removed without injury
to its substance.
6. That the action of the heart is accelerated for a few beats bj exposure of that organ ;
bj exposure of the brain ; injury of the brain ; destruction of the spinal marrow, while con-
nected with the brain ; by the connection between the brain and spinal marrow being cut
off; while remoring the whole brain produces no sensible effect upon the heart's action, and
destroying the spinal marrow after it is separated from the brain, renders the action of the
heart slower by a few beats.
Up to the time of Haller, the opinion prevailed, that the muscles derive their power from
the nervous system. Haller, on the contrary, taught that the power of the muscles depeods
on their mechanism ; that the nervous influence is merely a stimulus which calls it into action,
and consequently those muscles, the heart, for example, which act apparently only by the
application of one peculiar stimulus, unconnected with the nervous system, are wholly inde*
pendent of it. This opinion seemed confirmed by Its being generally admitted, that the
action of the heart continues after its removal from the body, and that it cannot be influenced
by stimulating the brain or spinal marrow, or the nerves which terminate in it. Haller and
his followers maintained that there were two distinct vital powers, one of the nerves, and
another of the blood-vessel system. Certain objections, however, were raised against the
doctrine of Haller, such as, that the heart is influenced by affections of the mind and dis-
turbances of the cerebro-spinal system, and that it is supplied with nerves. Various hypothe-
ses were formed to remove these difficulties. Several writers maintained, that although the
heart is independent of the brain and spinal marrow, it may l>e subject to some peculiar
action of its own nerves ; others, that the ganglia through which its nerves pass, have a
power independent of the sensorium commune. Fontana and others maintained that the
nerves of the heart are useless: others, that the nerves are distributed in its vessels, and do
not enter the substance of the heart ; Scarpa, however, proved that the nerves are distributed
to the heart, in the same way as to similar parts. The experiments of Le Gallois tended to
establish the absolute dependence of the heart upon the force derived f^om the cerebro-
spinal system, and more especially from the spinal marrow.
Dr. A. P. Wilson Philip* of Worcester, England, instituted in 1815, an important series of
experiments, similar to those of Le Gallois, which while confirming the important result that
the spinal marrow is capable of performing its functions independently of the brain, tended to
overthrow the conclusion of Le Gallois, ** that by the destruction of the whole or cervical
part of the spinal marrow, the action of the heart is immediately so debilitated, that it is no
longer capable of supporting the circulation ; while by the destruction of the bniin, on tho
contrary, its acfion is unimpaired : from which he iofiBrred, that it is from the spinal marrow,
that the heart derives the principle of its life and of its motions." M. Le Gallois considered
those motions of the heart which remain after the destruction of the spinal marrow, or th.r
interruption of the nervous influence upon the heart in any otner way, and which in hia
opinion misled Haller and his followers, as movements without force, incapable of supporting
the circulation, and analogous to the motions of other irritable parts on the application of a
stimulus, which in this case is the arterial blood contained in the heart.
The following experiments will illustrate the mode in which Dr. Wilson Philip, successfully
combatted the views advanced by Le Gallois.
A imbUt wan d^Hred of MOMtioo uid Tolootaiy powvr by a ttroke on the oodpnt. WImq * mbMt b kUI«d la thfe
«i^, tb« rwplration ImnwIUtely ccmbi ; bat the actloo of the haut and of the clrcnlatloii CDBtlaae, aad m^ b»
•vpported for a ooneidenble length of time, by nrtlflcini reaplmttonf na pnetfeed Am by Fontnnn, nod Aftamnraa by
ChlrnC|Brodlf> !<• Onllote, nod otheia. In the prceent experiment, the drcnlntion waa aupported by aitUclnl ivaplin-
tlon. The apionl marrow «m laid fanrp, ftom the ocdpnt to the beclnning of tha donnl vertahra». The cheat w«e
then opened and the hmrt fovnd beating regnlariy, nnd with oouMeimble force. The aplnnl mnivow aa Su* na It
* Kxperimenta made with a «iew to aaoertaJn the principle on which the action of the heart dependa, and tho
relation which aubaiau between thnt otsaa and the nonrooa ayaum. Phlloaufthkal Tfnaaactiona, IS1&, p. Sw-SU.
Introduction to the Study af Diuases of the fhrvous System. 85
hU ton taM bara, «m bow wholly nmoTfld, but witiiout in tho l«Mt ftffnellDg the wtloii of the licort. After this,
the tfdldtl ntpiimtloa boing frequently ditooDtinaetL Dr. Wilaon Phillm repeatedly mw the action of the heart
bseoBM kagnid, and increaae on renewing It. The aknll waa then opened, and the whole of the brain removed, ao
ftol B« part of th« neiTona •yatem remained above the domal Tertebim, but without any abatement of the action of
the h«rt, vhleh atlll eoatinned to be more or lem powerftU, aa the artifldal reaptratlon waa diaoontlnned or renewed.
Xhk bfliaf for a oonaiderable time diaoontlnued, the ventricle ceaaed to beat about half an honr after the rrmoval of
(b« bniB. On renewing the raapiimtion however, the action of the ventricleo waa reatored. The raapiratlon waa
agiia diaoontinned and renewed with the lame effeeta.
In other ezperiments in wblcb opium aod other poif ons were applied to the exposed brain
tod tpiotl marrow, and in otbera still, in which the sadden and complete destrnction of the
brain and spinal marrow, were effected bj hot rods of iron, the action of the heart was not
arrested, if artificial respiration was maintained. ^
From various trials, Dr. Wilson Philip, found that the circulation ceases quite as soon with,
u withoot the destruction of the spinal marrow. Loss of blood seemed to be the chief cause
of arrest of the circulation.
Dr. Wilson Philip, found however, that oertain applications, to the exposed brain and
•pinal narrow, as spirit of wine, tintctnre of opium and tobacco, caused an acceleration of
ths aetioa of the heart. Dr. Philip attributed this increase in the nnmber and force of the
kcart beats, to the transmission of the excitement, from the nerrons centres of the brain and
ipintl cord to the central organ of circulation. Bnt the fact that in the series of experiments,
the tame results followed, wherever the stimulus was applied, whether to the brain, the cer-
rieal, dorsal or lumbar portions of the spinal cord, would rather lead to the conclusion, that
the spirit of wine, and solutions of opium and tobacco, were absorbed, and entering the blood
acted as direct stimulants upon the ganglia and mnscuiar fibres of the heart. Dr. Wilson
Philip, concluded from these experiments, that the peristaltic motion ot the intestines, obeys
the tame laws as the action of the heart.
According to this obserrer, his first set of experiments proved that the power of the heart,
ii independent of the brain and spinal marrow, for it continues to perform its functions after
they are destroyed or removed, and the removal is not attended with any immediate effect
spon its motions ; the second set proved, that the action of the heart may be influenced by
•gents applied to any considerable portion, either of the brain or spinal marrow.
From another aeries of experiments. Dr. Philip concluded, ** That the nervous influence, so
far from having a power of preserving the excitability of the muscles, exhausts it like other
stimnlL" The excitability therefore is a property of the muscle itself.
By these experiments, Dr. Wilson Philip, arrived at the conclusion of Haller, that the heart
•nd other muscles possess an excitability independent of the nervous system ; but he was
carried a step farther, that they are all equally capable of being stimulated through this system,
bj which, the great objections to Haller's doctrine are removed. His views are still farther sus-
tiised by certain epperiments which showed that if either the brain or spinal marrow be
instantly crushed, the heart immediately (eels the shock, the action of the heart and circula-
tion becoming very feeble for a time, but, if artificial respiration be continued, the organ
fndually regains its lost power ; *' precisely as a muscle of voluntary motion, will by rest
recover iu excitability, although all its nerves are divided, if its circulation continues."
Dr. Wilson Philip,* subsequently performed various experiments, illustrating the effects of
division of the eighth pair of nerves, upon the functions of the lungs and stomach : and be
fonnd from repeated trials, that both the oppressed breathing and the collection of phlegm,
cMsed by this operation, may be prevented by sending a stream of galvanism through the
longs: and he was thus led to the successful application of ^alvanum in the treatment of habitual
tsthma. Soon after the operation, the animal begins to breathe with difficulty, and this
synpton gradually increases, and is at length evidently the cause of death. On inspecting
the langs after death, the air cells and tubes, as far as they can still be traced, are found
filled with a viscid fluid ; and in a considerable proportion of the lungs, generally more or
lest according to the time the animal has survived the operation, ever^ trace of both tubes
snd cells is obliterated, the lungs both in color and consistence, assuming much the appear-
ence of liver. The portions of lungs thus changed, sink in water. Dr. Wilson Philip ascer-
tained by repeated experiments, performed in the presence of various gentlemen, that after
* Ob the effeeta at Galvaaiam ia Beatoring the dae action of the Langa. FhlL Trana., 1817, pp. 22-31. An Expert-
■eatat laqniiy into tbe Lawa of the Vital rnnctloni, etc PhiladelphU, 1818.
SooM pQcltiooa, rrapectioig the inHaence of the Voltaic Battery, in obTlating the elTecta of diriaion of the Eighth
Hir of Servca. FhiL Truu., 1822, pp. 22-23.
Soaw ohienrationa on the effeeta of dividing the nenrei of the langa, and 8ul]Jecting the latter to the inHnence of
Vateie aleetiteibr. PhlL Trana., 1827, pp. 207-300.
mo
Sone o)i!i lanona relating to the Function of Digeation. Phil. Trans., part 1, 1829, p. 137. Some obaerrationa on
^ TaacUoaa of the Herrona Sjratem, and the relation which they bear to the other Tital ftinctiona. PhiL TnnC,
lait II, 1829, pi 28L On the Nature of Sleep. Phil. Tmna., 1833, p. Td. On the Belatlon which anfaeiato between
^ Kerrone and M nacolar Syatems in the more perfect animals, and the nature of the influence by which it ia main-
Waad. Phil. Trana^ 1833, pp. 53-73. On the Katum of Death. Phil. Trans^ 1834, p. 167. On the Sourcea and
itrtan of the Pmraiv on whldi the Orenlation of the Blood depends. Phil. Trana., 1831, p. 488.
86 Introduction to the Study qf Diseases of the Nervous System.
the oerTti mppljinj^ the langa Are divided and the ends separated, If the proper degree of
Voltaic electricitj was tranamitted continuoagly ihroagh the luDgt, bj those portions of the
nerves, which remained attached to them, no affection of the breathing supervened, and the
lungs after death were found quite healthj, provided that the current of electricitjr had been
properljr applied. When the electrical current was too powerful, or has continued for such a
length of time as to excite inflammation, the appearances were entirely different from those
produced bj simple division, without the galvanic current. In the same manner it was found
that when the nerres supplying the stomach were divided, digestion was altered and finallly
arrested; but when the electrical and galvanic current of proper intensitr was pasted through
the nerves attached to the stomach, digestion was performed as in a healthy organ.
From raeh experimvnti Dr. Wilaon Philip ooiiclod«d, *^ that Um tilNiti of dividing the nerres of m vltel owkmi, and
•epumUng the dirided ende, !• not merely that of demncinc iti eecreting power, but oJUftof* Mwere en wkiek ik knUkg
ttntaimn itpmd$; amdtkailht •jftdL of VaUaic d»dbici»$, U thai ofpimmtUig Mtkmtfowtn, • «
The nerrone power Is esiential to the Amotions of secretion, sad the other aerfmilntlnf prooesses of the nalnal
body ; sad that VoUalo electricltr applied in the sum wnj, ns te ns pomihls, Is onpnble of snpfriyiaff its forao la
these procesMS.** PhlL Timos., 1827, p. 300.
By a series of experiments, Dr. Wilson Philip demonstrated that the circulation in the
capillary vessels is independent of the heart ; and that the vessels bore the same relation to
the nervous system, that the heart does, ** their power being independent of this system, bat
equally with the heart capable of being influenced by either stimulants or sedatives applied
either to the bn^n or spinal marrow, and that even to the instantaneous destruction of their
power. They in all respects bear the same relation to the nervous system with the heart,
which affords the strongest argument for believing that their power is of the same nature.
The circulation is maintained by the combined power of the heart and blood vessels ; and the
power of both, is a muscular power." Phil. Trans. 1831, pp. 489-496.
For the purpose of determining whether the action of the heart is affected by impressions
made upon the ganglia of the sympathetic system, Dr. Wilson Philip caused the performance
of the following experiment :
** Mr. Field partially dlTided the spinal marrow near the head In an ass, In such a manner as to destroy the eeo-
riMlity, as Ihr as the experiment was ooooemed, bat not to Interrupt the respiration, thus bringing the animal into the
best possible state for the experiments. It lay as still, and suffered as little during itj as an animal ouite dead in the
usual sense of the word, while the circulation was mora perfsct than It could be nnoer any artlfldal Inflation of the
lungs. In another respect, the state of the animal was particularly Ihvorable, for Mr. Field succeeded la exposing
ifllnsl* " — -
the semilunar ganglion and Its plexuses with a Tory trifling lorn of blood, not, I believe, four ounces. The heart
then found to pulsate sixteen times In ten seconds, as aeeertained by the pulaatloa of the arteries in the neighboritood
of the gangUon. The ganglion and the plexusss wars then Inrltated bj the point of a eoalpel. and at length cat
acrom in Tarioos directions; but, althouj^i, the beats of the heart were repeatedly counted during theee operetions.
they continued unlfonnly of the same ftuquency. Spirit of wine was then imtled to the wounded ganglion
plexuses, but without the least change In the beats of the heail A strong Initeloa of tobacco la water was now
saplled, tmt with the same reeoit, the beattngs of the heart being still sixteen In ten seconds; aor eoald aay vnih^
tion In the force of the beats be obsenred In any part of the expurlBMnt.
■^The conduslou was dnwn fhim the experiment, that we cannot Influeaoe the onaas snnilied liy tfm gaagllonlr
aerrco by causes affecting the ganglions and plexusss. Independently of the brsln ana spinal ssarrow ; and the lafor>
encee fkom this and the preceding focts are unaToldable. that the former oigans SMke only part of the ohaanel
through which the Influence of the latter is conveyed ; and that the pecaUar oflloe of the gangflous aad alexases is
to combine the Influence of the nerree which terminate and are blended In them, and send off nenree endowed with
their combined lidluenee. In consequence of which the parts which rscelve the nerres proceeding ftom theas bename
sttldect to eveiy part of the biain aad splnsi marrow.** Phil. Tna., 1833, p. SI.
Dr. Wilson Philip thus recapitulates the more important results, which had been established
by his experiments and researches, which had been proscuted for near thirty years :
' ** That the power of the muscles both of Toluatary and iavohinmiy Bsotloa Is Independent of the nervous Mslum ;
but that both are su^ected to its Influence, this influence being the cooelant etimulant in the Aioetlone of the for-
mer, but only an occasional stimulant lu those of the latter, which. In their ordinary Ainctlons are excited by stUnn-
lantepecuflar to themeelves.
** That to the mnedes of Toluntaiy motion It Is suppled from thoee parts of the bnln aad epinal marrow, tnm
which the nerre of the particular muscle takes Its rise; to sach of the muades of Inrolnamiy aiotioa, ftosi every
part, both of the brein aa#q>inal marrow.
** that thete oigans are the only actire parts of the nerroue system, and that the oerebrel aad epinal nerres on the
iMidplexui
one hand, and the ganglionic nerres with their ganglloas and plexuam oa the other, are only the channels through
which their Influence b cooreyed. the power of both systems of nerree being at all timee proportloaed to the exdte>
ment of the brein and spinal marrow, and aoon AMsIng, and not to be reTlved when th<*lr influence is wlthdrewa,
sod being unlnflnenred l>y canses acting Independently of theee orgaae on either set of the nerree theraselree or oa
the ganglions and f4exuees.
** That the ganglionic system of nerres, with their gaagtlons aad nlexuses, If the means of combining the Inflaeace
of ererr part of the brein and spinal marrow, and bestowing It on tae muscles of luToluntary motion, as well as on
the Tarioos secreting and other asrimlbiting organs, theee mnedee being subserrlent to the functlone of theee organs,
which It appears, (h>m direct experiment, require for their due performance the combined Influence of every part of
the brain and spinal marrow.
** That the manner In which the nenrous Influence affects the muecutar flbre Is not essentlaUy different tnm that la
which It to affected by other stimulants and sedatlTos.
**That this Influence Is not an agent peca>lar to the nerroue eystem, but capable of existing elsewhere, aad eooer>
^ueotly not a Tltal power property eo called; which further appears from an agent which operelee in Inanimate na-
ture being capable of all Itsftaoctlons.
**That th» brain and spinal marrow therefore, so for from bestowlog on the mnecular flbre. Its power, only supply
an inanimate agent which, like all other such agents, capable of affecting It, acts on it either as a stiasuhuit or
Introduction to the Study af Diseases qf the Nervous System. 87
tin,aoeofdiur to the dagTM in which It ia ftppUed ; and that the whole of the fkctf relating to this agent, prorce lt«
i^UXj with voltaic elei trid^ which haa heen found ezpertmentally to be capable of all its fiinctione.
** We cannot RTlew the phenomena of the aulmal eoonomj without being struck with the extent and variety of
tk» Berroof Infnence. We not only find the Interoonne between the animal and the external worid maintained by it,
tke hcezt and vemels snl^ected to its control, and secretion and the other assimilating processes immediately depen-
tot oa It, but that by its means the animal body is formed into a whole, every part of it being capable of influencing
•f «7 other.** Phil. Tnas., 1833, p. 70.
Doring more than a baadred jears, the import of the ndmerous braDchet connecting tbe
sjmp*thetic witb tbe cerebral and spinal nerves, has been made tbe subject of a number of
coaflictiDg theories. Hanj physiologists with Haller and his school, have supposed that tbe
primitive fibres contained in their connecting cords arise from the cerebro-spinal nerves, pass
throsgh the ganglion, and subsequently radiate into its branches. According to this view
tbe lympatbetic is essentially a cerebro-spinal nerve ; — presided over by the brain and spinal
conl,jast as the peripheric organs are by the other nerves. Hence, the physilogical pecu-
liarities of its branches, would depend solely on the numerous ganglia that are interposed in
tbeir coarse. Other physiologists have followed the theory started by Petit, and developed
bj Bichat, according to which the sympathetic or ganglionic system constitutes a nervous
tyitem independent of the brain and spinal cord, its peculiar fibres supplying the intestines,
tbe blood-?es8els, the glands, and in general terms — all those tissues, which are destined to
nbeerve the phenomena of nutrition, and the unconseioQS and involuntary functions. Ac-
cording to this theory, the sympathetic is a special visceral, vegetative, or organic nervous
•ystem ; which has an authority independent of, and co-equal with its animal counterpart,
composed of the cerebro-spinal nerves, which effect the conscious feelings of sensation and
paia, tod the voluntary movement. This question has been examined anatomically, physio-
iogietlly and pathologically by Prof. John Fred. Lobstein, who appears to have anticipated
maoy of the results of recent experiments and research, and advanced doctrines which have
sisee been claimed as original by others.
The following quotations from the elaborate work of Lobstein upon tbe Slrueture^ Function,
md Dittatei of the S^mpaihetie Nerve embody the most important results and generalisations
ettablieked by this author, and illustrate in a forcible manner the relations between the cere-
bro-ipinal and sympathetic systems. The author sums up in the following manner the theo-
riei of Beil amd others : —
"The eenbcal a«fTo«s vysAsm is fonned differently ftom that of the sympathetic system. The bran^es of tbe
hoMrconvfligs fimn tte oeriphevy of the body towuds the oenbmm, and are inserted into it by their roots, as the
noto of vsgetaMes aro In tae soil ; that system, therefore, has bat one centre, which is in the enoc^ahalon. The latter,
ss At contmiy, is not eoUoded Into any centre ; It has no Ibens of action, but exercises Its fhnctions over a wide
'The qmpatihatie system connectB the oigaas together in three dUferent modes : 1. It fbrms netwoilu around the
■tli, vhi^ emhmeo the arteriss with Umt slender and minute braachleti (as the Ivy clasps the stem of a tree),
tad pwetmtss with them to the orgaas. These networks are known under the name of plexuses, twelve of which
m casflMnlcd, appevtsining to different parts. * * 2. These plexuses are connected to the brain and me-
4tlhqteslis by hnsnchss which Bell calls conductors. * • 8. These breaches, the conducton of the piex-
Ma, ai^ssr to framapeffect connection between the animal and vegetable systems; every commotion which the
few Tiiceia suffer would be conveyed to the seasorlum commune, and efas ssrw the will would exercise a perfect
cDBtiel over the oigana of the thorax and abdomen, were not theee movements intercepted by enlsurgements in the
ceadectoB called ganslia."— pp. 72, 73.
" Whea the two nervous systems by which the animal is rendered more perfect are considered physiologically, each
■»T ^ wteemed a sphere of activity In which the vital actions are differently performed. In the animal sphere,
(tbsl Is, in tbe cenbram, the medulla qiinalls, and their nerves), the determination of the will and senses, when
tniMftiieii to the oommon sensorlum, become impressions tastanter, and, as it were, at a single impulse. In the
v«g«tMiT» sphere, the nervous energy is slowly, steiMiily, but obscurely dispersed inio the organs. Thess are con-
Bcetod together, act aocordlng to their peculiar laws, and compose a qrstem separate ftom the animal sphere, over
*Uch spptofriale laws preside. This qrstem also possesses the Ihcul^ of perception— namely, it receives impres-
riflee, sad naets upoD them ; but this perception abides In its own n^on, and is not communicated to the brain. In
sbeslthy slate, the system of ganglia exerte no maalfiold influence npon the cerebral system, ftom which it is divided
^ the iMamtoiy or Isolating appaiatua, ths series of ganglia in the sympathetic nerve. But the esse is different in a
Msie of ifiwnsB, iar when the vital energy i> increased in the communicating nerves of the plexuses, the condition of
Dm gsaiila Is diaaged ; th^ transmit^ impressions which ths extrsmities of the nerves in the visceim receive, and
kamse cendnetota, whilst befbre they were non-conducton or Isolators." * * pp. 74, 76.
" la the ftatua, none but the sympaUietIc nerve Is in vigorous action : it exists previous to the secretory and nutrl-
mtoifaBs; ftsnatains the energy of the heart; and breaks In sometimes upon the cerebral sphere, and determines
<^satemslli motfams which the infhnt, when doeed in the uterus, performs with its muscles. Acephalous fioetuses,
^•MitBCs flf earsbral and spinal medulla, and hence wanting the nervous centre from which emanates the principle of
Bunlsr eoutractioDa, perform, nevertheless, muscular movements which can be In no other way excited than by the
vital iaSasBce of the sympathetic nerve, which Is Joined Iqr an anastomosis with the spinal nerves.**— p. 77.
"Dsriaf tbe extraniterine life of man, when there exists some immediate internal sense inherent to the
Mbbs^ this nerve forms a remarkable iotercoilrse between the cerebrum and the viscera of the thorax and abdo>
ao, M h proved by nnmberlea phenomena. Then, as In the embryo and fcetns, it governs the svstem of capillaty
vMd^ sad dirscts the fVittotions of ssstmilation and nutrition, through the Influence of the vital plastic power,
vUehhRMaiaiB calls vital chemistry.** • • p. 77.
AAer this general statement of the facts established, and theories broached by others.
Ubfteio proceeds to give the results of his own investigations :
"AoeonUag to a corollary of the greatest Importance, there exists a relation between the sympathetic nerve and
wpar vsgum to wit, that one may take upon it the functions of the other ; for in the inferior vertebrated anima s
«• pw vsgum appoacs to be more prolific la branches distributed to the intestines, as the sympathetic nerve Is leas;
88 Introduction to the Study qf Diseases of the Nervous System.
Mid It it foand that la mbm T«ft«bimtMl miIiimIs no ■ympfttlMtJc n«rre Mtliti at all, and fa wbldi Ha teadfaofl art
performad by the par ragam only. Whence it Ibllowv tnat the par vaipim eboald be chuMd aader the mudo law ae
the ■ympathetlc iteelf, with the nerreeot Tegetative life. In fine, in all orden of aalmala, the qrmpatlietlc nerve te
always foand, in ivgard to Its deTalopmeat, to oorreepond with the pre-exleting vaicnlar apparatae; whicti pr>Tta
that it owee iti delicate oonstmction to the wants of the veeMla.
*' A nenroaa •ystem which ezieti in the loweet ecale of animals Is peculiar to the nutrient organs, and patutwm
especial flinctions of Its own. which, prior to the appearance of the binin, constitntiMl a nerrons eratre, aod which,
when the cerebral oeatre Is fonned ia animals, is Inter^connected only, and nerer composes with it one nadlvlded
apparatus, but always retains its pristine fona aad habit that su<di a system is endowed with the grsateei ftuMtloaal
Importance, is seif^evldent.** — p. 81.
** As to the forces, the brau^es of the sympathetic nenre are undoubtedly endowed with the same power as oerrea
in general ; that is, ftom the Tital principle by which tone, strength and enerig^ art maiatelned In tike offgaas over
which they preside. It does not seem improbable that the ganglia whidi dlTenify the tmnk onght to be uiustdiiud
as the laboimtories of that principle, which the Intenml or egredlent branches ooadnct to the vlseera, and oC the
aature of which we are entirely unacquainted. In the cerebial voluntary nerves, as well as in the sympathetic aeme,
the nervous principal traverses In both dlrsctions ; to-wit, fh>m the trunk Into tibe bimncfaes, and agsia from the
biaaches into thetrnnk.**— p. 82.
** But the branches of the sympathetic briong principally to the arteries which thay envelop, while the ftacst la-
ments which follow the arterial branches into the oigaas are termiaated in the external coat. Heaoe it la amniftiat
that the vessels are primitively coastltuted uader the government of the nerves, and that from them the force aad
aneigy are bonowed with which they cweiate In the fhnctions of nutrition and seoretfoa.** — p 83.
** Fiom all that has beea hitherto produced, we are at liberty to ooaclude that there Is no Bssenflei differeaos be>
tween the sympathetic nerve and the encephalic mam andspin^ nerves, but that the two nervous systessa are so §^
distinct that both are peculiarly «ituated aooording to the different condltiont In which they exist In body.
** In the anatoinioal part of tbli treatise It was first demoostrsted that the trunk, brandies and filamenta of the
sympathetic nerve have the same structure as the cerebml and spinal nervesi the sauM plexllbrm dlvMoa, aod, ahea
examined with the microscope, the mme composition ; to-wit, medulbi and neurilemma. On the other hand, I know,
ftom attentlTe observatton, that the sympathetic nerve transmits the Impressions it receives to the comaioa seaaoriam
ia the saaia aiaaaer as the oeiabral aad splaal nerves. Tbas aa irritant aflRctlhg the priaue Titm Is perDsived taiaM>
diatelyby thebraia, aathefoUowlagdamoiistnaes: 1. The tormina ooenrriag in varhms dkeaica. S.Aealcalws
lodging In the biliary dacti, thepelvis of the kidaaQ or the ureters. 3. An Irritant near the hepatic plexna, froea
which an animal was seen to suffer, by Haller. 4. The galvanic agent produdng intense peristaltic amtioo, and
sacrstioo of latostlasl flaid, aooordiag to the exparimeats of OnHpeagelser.'*— p. 87.
** The sympathetic aerve presides over the foactioa of natritioa, not only bacauae It l8^lartB many ncrvca to dhe
chylopoietic oigaas, and suataiat their energy aad iafluanoer bat bacauae It Is also dlstilbated to the arteiiea, which
carry the aatrieat blood.
** Let as sappose the aervoas power destroyed la the abdondnal plexasss; the tone of the stomach, gaalrtc, and
latestinal digestion, and the fnactioas of the llTer aad sple«i woald be Impaired.
*' That this iadeed amy take place, is taught by aamberiem iaslaaoss of mental disease, which, whaa thrown apoa
the solar plexus, saddealy disturbs the whole fhactloa of digestion.
** The abnormal action of the abdominal nerves exerdses an influence over the organa, in rsgioiii varv dlstairt fhim
eadi other, flrom which it is aianifost that the ftinctlons of assimilation and nutrition are under Itssot^ertion.
Beceatly one af aiy Intimate friends, who Is about thirty yean of sge, tt^^w bdng suddenly terrified by the bamlag
of his house, had his hair to tarn white In the course of a fow days, was it not the mentil saflSBriag he expertaacad^
which, by the aaaaiamns ooasent of physiologists, deranges the abdominal nerves, that la this esse pcadncwl the
ehaage by disordering the force aad functions of theee nerves f aad did not this dlsoraersd aetfcm affect the aatiiitua
of thecspillariesr
** PhyslologlBtB haTe loag daoe acfcaowledged the great lafluaaoe of the aerves over the oaplllaiy aad aatrteat
vessels. Thas, if It is eahaaoed, the actloa of the latter is iaereased ; If dimlaished, weakeaed ; if atteriy defideot,
destroyed; heace it Is aa they are aiaintained to supply this olBce, that they have not any control beyood it. Ia it
not then evident, that when the nerves are injured, nutrition would be frequently destroyed 7 The experimaats oC
Dupuy apoa horses, la which the saperior cervical ganglia were cat away from dther side, fhrnlih good pcooT of
this: coatractloa of the papll, rsdaem of the coi^unctiva (phenomena dnoe observed by P. PMlt), emaclatkn of tke
whole body, odema of the feet, and an' universal cutaneous infiammation followed the opemtion.**— pp. 89, 90.
** What I have said of nutrition in general, holds good in the secretions of tne fluids, beoanse the saaia msrhanlsM
supports secretion.**— p. 91.
"As we are coaslderiBg phydological aad pathological phenomena, we will ask if there be any isaotaat that the
secretloa of the fluids in the glands may be Increased by the effects of the imagination alone.
** Who cen deny that the maternal milk, the bland aad sweet nutriment of infhnts, has been suddenly rtianged by
mental affections to an atrodous poison? No other instmmeats certalaly exist bat the nerves, by wboaa aid the
psychological irritant caa act apoa the orgaas.
** The sympathetic nerve governs the action of the heart and the drenlatlon of the blood.
** The cardiac nerves have the same relation to the fibres of the heart, as the cerebral and spinal nerves with tke
voluntary muscles."-~pp. 02. m.
** The sympathetic nerve forms an admirable dialn of connection between the prindpal organs of the hnama bo4y.**
This proved aaatomicallv and physiologically and pathologically. **The sympathetic action is by no msana drewm-
scribed to the cavity of the abdomen ; on the contrwy, It spreads itself wider, aad cuanects the separate parts of the
body la doee aafoa with Itselt
" Mo«i o/ Ike pfceaow g, iwdeed, iway 6e eomBJdtnd ateommmmnlf im wUch th$ y wipsrty <• proeed is arise >»ewi i
end Ji^kHaeimg of lk$ tmrtm. lit. TitOatitm of tknnm prodmim meetiwy, 6«oaiii» lk$ maai ittrvm of lk$ tf
gamgliom an commtdad tkrotigk Iko werfiam of IJho dmp mnt«d amd mtprnfUAal vidioa nercaii, wiA Ike iyipirtfcsh't ;
Ck«dMvJbra^«Ml<eplenMaHMi,wUdbMioM«ibyiuMii«o^^ 2d. il a Msnee UgM aha an
for 1k» iieprmrfwi bmmg pomkfed by Ou retfao, and tram^mrrod JNilMlljy to Ike eUiarff Merrw, U Mmtjfod le Ifce _ ,
end be tike aoeof braiM*, awl the remainimg namd nerves of Ike fi/lh pair. M. The aaaatomodi of CUe aeree (■lapiilfcrfii >
wiA Ouj^/tkpair^ areomaU for Ike griUmg of Ikt feaO, amd itching of Ike aoee, <a the rermimoee disswest a/ cMUrva ; remal
ealeeU, or aepkriiie, prodmee eonutia^, or other dieordere of the elemaeh, whOel the etimmtatimg eaaee, {f eot^fbted la the htmdder,
rarejb rrritm ^osHc deroMgememL For the nervous comma nicatlooe are more conspicuous and more nnmeroaa beaweea
the kidneys and stomach, than between the stomach and urinary bladder. A. The observations of aeithmted
praetitioneie Instruct us, that many laboring under diseases of the abdominal rieoera, saffer doudlaem of Tlsioa, that
the retina Is also drawn Into consent** — pp. 96, 07.
'* Bmtthe medimm thromgh which Ike oomuxlUm of the nerree m ekieflff made^ m Ike par eoyaM, Ike priaeipal saemBwnm «/
trhick wilk Ike iaiereoelai nerer, in Ike nerit, CAorox, and abdomen^ fonn mamff plemees, apoa wkitk Ike aOHem ^Ike epaepeAaltc
nerre drpende^ and tkromgh tke mediam of tehicky dkie/^r, tkat admiraUe inlercoaree exiele betiMea tkekead and nhdosiea, Hnm
to phi/9iciane in aU agee.''^—p. 07.
^* In this respect the fiwcia oommunlcans of Wrisberg Is of great Importance, and which, in mv Judgnieat. nd^t be
more aptly named, the great abdomino-cephallc anaatomotlr branch, for by It the animal life is connected witt the
nutrient or vegeutlve, ao that the mnUtiuns of one may be Immediately felt within the domalas of the other, per^
Introduction to the Study qf Diseases qf the Nervous System^ 89
cdTdl by ttte aijid, tad vioc mtm. I th*!! aXim ioiim caam of •Momlnal lUnwo in the third Motion of this work,
is vUeh tiiii MjmpklQa is nililGientlT manlfott u the morhid itate.**— p. 96.
'*Thenmte by which Qie deecending or aaeending Impreision goes and retama, li none other than the abdominal
hidft, or tlie abdomino-cephaUc anastomotic branch. Thli alone, and nnlntermpted by ganglia, forme the immediate
{Btoiwuw between the oerebma and abdomen«**'~p. 99.
"Inreflectiag npon the natnre of intermittent reTeri, I have thought that it might, perhajMLbe fbund in the
dhndereiid penrected action of tiie abdominal nerrone eyetem. Mid there appear, indeed, to be suiBcient gronnde to
raadtrtUsoptefen pn»baUe.** • «— p. lil. .
''The fUQTfwna of Intennlttent fever are tied down to a regular rhTthmm, in ooneeqnenoe of th^ being ntdlcated
ia the Bcrtonefyiteni, npon which natnre haa Impreesed a law, according to which they most perfonn their AinctionB
pMfadlaUy.'*— lip. 121, 122.
" bd nerrooa eyntmn, themfbre, le ohnoxiooi to it> own diieaoee . Bnt the mode In which the cerebral and spinal
aenei,Bod the oerret of the ahdominal plezneet and ganglia are affected by ditioaae, li the eame. As in the tsxIous
UiMh of eoQTnlaionfl, epUepqr, tetanus, etc, there is disorder in the Toluntaiy nerres, even when no organic lesion can
b« dteoTsrod la them; so the nerres of ttie thoracic and abdominal visceim may be affected without any altemtion
pcfcesAk lo the laiisss. As the perrerted action of the cephalio bmin is r^ected with great force upon the abdo-
aittl teaia, so in tarn does the latter re-act npon and overwhelm the fonner ; and finally as the cerebral «vstem,
vheo it ti etapefled, as It were, by the violence of disease, destroys life, in like manner, I believe, an analogous
cflacttskeo ^aoe In certain dlsesses in the solar plexus.** — ^p. 122. Oonnectlon of the simpathetic and cerebnHiplnal
^jiUau, Qhistialed by aomenms pathologioal conditions. Effect of blow upon epigastrium, p. 122. Effects of the
nifiw*ni of miliaiy tȴanfhiWMita In producing abdominal paralysiB or apoplexy, nemicrania excited by hypochon-
dris md hTSleris, p. 128. Relations of affections of the head to the state of the ganglionic system and die bowels, pp.
in, US. Explanation of delirium and of the action of cathartics in modiiying tne phenomena of fever, pp- 128,
U5-C. ** Sympathy between the teeth and abdominal nerves,** p. 187.
Tkiftnmiti matim of Che hrsia if hy TMmemM ciinmmarib«d lo As oae% «/<h« eranMim; ii U edMdid to dkkmt regiom
9f 9u H*h twhaiet off amc dimatm an nrodmoBd,
'4/hr Mow af Cm ftroia tktn ia mooiMiadty a difmamie dimirdmr of (he nereow uppofYilM of lh« Uoor, miteeedaU io Ihe
mikmaik!t§iittm,nomitfwkkk kamoafi^hefmotoU aaiitfofioni. J mey lellh UUtr reasow, nfmr ft to a co wnwiifofllioa of
A« r^ Mr wij—i wUh the mikar plenu, 6« whieh £he cei ehram <• cowaerted to (he righi mmitmuar gamgUomy from lohaiee
'MMit intSg am poMoHor aorMk*v-pp. l$l, 182.
Ufeitefai niitratad the relations of the qrmpathetlc and cerebral systam of nerves, and also the oonneotlon of the
wrrooi ifjstem with dIsessM, by numerous pa&ologloal Ihcts. The notes added by Dr. Joe^ph Fanooast ^so contain
isteieMlag oorroboratlTe Ihcts.
"A Trn^ise on the Structure, Vunctions, and Diseases of the Human Bynpathetlc Kerve," by John Trad. Lofasteln.
Tnaiktod ihnn the lAthi, with notes, by Joseph Punooast, M . D., Phlkdelphla, 1881.
lo the 7%M(Paibologicftl) Seeiion of hie work, Lobtte'm giret rarions obserrations, illus-
intiog the conDeetioa of certain fhTcri and iaflanftmations, with difeased states of the sjmpa-
thetie ganglia and nerves. Thus he aitribates the oppression of the chesti shortness of breath,
sirictsre of the pnecordia, and sensation of anxiety which precede the appearance of the
enplion in Tarioni diseases, as scarlatina and smallpox, to the action of the poison upon the
gtogliooic systen. He susuins the Tiew that intermittent ferers are caused by the disorder
ud perverted action of the abdominal nervous system, on the following grounds : let. The
cuei of this diseaae are very rare, in which the fnnotions of the abdominal organs continue
ni(oroBS and entirely unaffected. 2d, The commencement of the paroxysms is often marked
vith vomiting. . 3d. We experience daily that this disease is mitigated, and very often en-
tinij removed by the use of cathartics. 4th. A single emetic, when given previously, some-
times suppresses the paroxysm, and not unusually removes the whole disease ; from which it
eppceri that this remedy makes an impression upon the solar plexus, of an opposite nature to
tltat which has produced the fever. 5th. When the disease is either maltreated, or left to
itieir, congestions are produced in the abdominal viscera, induration of the liver, intumescence
oftbe spleen, etc., and the general morbid state is changed into a topical affection. This
■cttDorphosis appears to prove that the morbid action prevails at first in all the plexuses, and
■fterwirds migrates from one to another. For it is ficst apparently disseminated in the whole
^tory of the ganglionic system, before it runs with much impetus into a single plexus,
which is commonly the splenic; and as the vessels are under the influence of the nerves, it
oanot be otherwise than that congestions should be produced in the vessels. 6th. The
ptroxysms of intermittent fever are tied down to a regular rythmns, in consequence of their
^isf radicated in the nervous system, upon which nature has impressed a law, according to
which they must perform their Kinotions periodically. According, therefore, to Lobstein, the
Dorbid cause of intermittent apoplectic fevers (pernicious intermittent of Alibert), is seated in
tbc gaoglionic system of the abdomen, for be found no mention made by authors of any
reasrksble ditordar of the cerebrum, as being the idiopathic cause of this disease. Although
it had been said that there is nothing in the affections of the sympathetic nerve to be detected
by the lenses, yet Lobstein affirmed that he was convinced, by attentive autopsic researches,
that phlegmasise positively occur in that nerve, corresponding to various diseases ; and he
txprened himself as fully convinced, that other organic changes might be found in this nerve,
if the caltivators of anatomy would sedulously investigate the subject. To Lobstein, should,
therefore, be awarded the credit of having first directed the attention of the profession to the
ftractoral alterations of the sympathetic, and their connection with diseased states of the
o^Cut, and of the general system. This was not a mere matter of conjecture, but his opinion
vu bated upon his own direct pathological observations. Thus, in a careful autopsy of a
PRfDut woman, who died apparently from obstinate vomiting, distressing pain in theback,
Md rapid emaciation, the stomach discharging black vomit towards the end of the disease, the
90 Introduction to the Study of Diseases of the Nervous System,
brain and organs, and the uterni, which was in the fifth month of pregnancy, and the foeta^
which it contained, were found to be normal ; the only lesions were obserTed in semilaaar
ganglia, which were intensely red and inflamed.
In the body of a girl six years of age, who had been seised with epidemic pertassis, which
was first converted by metastasis into a spasmodic vomiting of three days' continuance, and
finally degenerated into an incurable form of clonic convulsions from which she died. Lob-
stein found the whole left part of the solar plexus inflamed, whilst the right appeared to b«
in a natural condition. He also quotes the testimony of Autenrieth, the celebrated Profesior
at Tubingen, who, on examining the body of a girl who had died from pertussis, found the par
vagum inflamed in the whole of its course through the thorax. The cardiac nerves and the
thoracic portion of the sympathetic nerve, had likewise suffered some alteration. Profesior
Autenrieth also asserted that he had seen the abdominal nerves (sympathetic) a little changed
in subfeets who had died from 7)fphtu Fever,
Dr. Aronssohu, an able surgeon of the Strasburg Hospital, communicated the history of
two cases of disease, which plainly denoted the existence of inflammation of the semilunar
ganglia. Death in the first case resulted from the removal of a fibro-cartiUginoas tumor,
loosely attached to the dorsal spine. The second case was that of a woman thirty -six year»
old, who, in her second pregnancy, was subjected to vomiting, which continued tbrougbont
the whole period of gestation, and after parturition, but was rendered milder by the appear-
ance of a furfuraceous eruption upon the breast and arms. To these morbid symptoms were
afterwards added inflammation and swelling of the left knee, and diarrhoea ; but after the
supervention of the latter, the vomiting which had been so obstinate and continual for almost
three years, was brought to a close. Finally, hectic fever was developed, which, by exhaust-
ing the strength, gradually terminated life. On examination, after death, the villoae coat of
the stomach appeared to be inflamed, and thicker than usual, especially towards the pylorus,
and the semilunar ganglia were found in a state of general inflammation.
In the body of a girl ten years of age, who had died from the retrocession of a miliarr
eruption attended with symptoms of great anxiety, oppression of the chest, and distention of
the epigastrium, Lobstein found a place in the left trunk of the intercostal nerve highU
inflamed between the eighth and tenth ribs, with a phlogosisof the ninth and tenth thoracic
ganglia, and their two anastomatic branches from the costal nerve. Lobstein records alto
various alterations of the sympathetic nerve, iu diseases of the lungs and heart, and givrs
instances to show that the sympathetic nerves have been enlarged in various diseases. Thus
A. Duncan has noticed a case of diabetes, in which the urinary bladder was very mach dilated,
and the sympathetic nerve three or four times larger than usual fkt>m its ingress into the
abdomen, and its termination in the pelvis.
Lobstein observed the nerves forming the suprarenal plexus, much thicker and enlarged in
disease, where the renal capsules, which were more than twice as large as usual, hail degen-
erated into tubercular substance. Lobstein proved, by observations nndertaken for the pur-
pose, that the nerves may not only be increased in thickness, but likewise in nuosber, as in
cases of hydrosarcocele, in the spermatic cord, organic disease of the epididymus, sod hyper-
trophy of the thyroid gland ; and he also showed that in certain diseased states, the reverse
condition may exist, vii : decrease in the number and siseof the nerves supplying the diseased
organ.
The physiological and pathological relations of the sympathetic and cerebro-spinal nervosa
systems have also been subjects of investigHtion by the late Dr. Samuel Jackson, formerU
Professor of the Institutes of Medicine in the University of Pennsylvania.
The following quotations from his work on the Principles of Medicine, published naore than
forty years ago, will show that his views were expressions of those relations of the nerrous
system, which are now being recognixed by the profession :
** OoncldemUoiw, bMad on the anatomical stnictur»« l«ad to Ihe followliif InreraiiGM aa to tbe ftonctloiM of ^o
saagUonlc tftU'n :—
a. ** It la not indepondent of the cerebn>-«plnal nenroua vjstem, but derires Ita nenruns actlrlty from iU conii«MSiiMi
with that ijatein.
6. ** It ia connected throoghoot ito whole extent by the nuueroua nerrons fllamenta paealiig tfom one saa^lkm i»
another, and uniting together the different plexueee.
c. ** The oigane of the head, neck, thorax, and abdomen, with the genital organs, which rooeive n^rvotie fll«mc>fit»
fh>m thia ajatein, are placed in a communion of actiorn and ImpnHibionw, which are tran«mitt#<d from one to th* othrr.
and it b thna the nrindpal instrument of the aympathlee between thoee organ*.
d. **8u|n>ljing the thoracic and abdominal vlaoera and genital organs with nervee, and communicBtliic with th<
cerebit>«pfnal nenrona ayatem. It ia the medium of oommnnlcation l>etween theao org%nti and the nervooa •j9i»rm of
relation.
«. "Supplying the abdominal and thondc Tiacera and genital oigana with numeroua nerrea, thb •yat«« mnat l»
the chief agent in maintaining the vxerciae of their fuuctiona.
/. ''From the quantity of nenrea which It diatributea to the arteries, the cloeenem with which theee vnam^k ai>
inTeetad with thoae nerrons fliamenta, and which are lost in their coats, it must exercise an active agency 0T9r tk<4r
circulation, and in this manner influence the secretions and nutrition.
f . ** The muscles that receive nenroua fllaments ftom this system hare this pi<cullarity, that they act without volitkm
or even ron«cionsneas. They mnst,mnse4|uently, receive the nei-vous stimulation (or this purpose fn>m tike giuiglftunk
system.**— p. :J7.
IfUroduetion to the Study of Diseases qf the Nervous System, 91
pkjnkdogkftl and pfttbologioAl fkcts we d«riTe » oonflniifttion of theve priociplei, and obtain additional light
to aniilng at a knowledge of tho fanctionf of tlili ijatem.'* * ^*-p> 87.
** Tho gaoglioale fjslam famiahing th« principal n«nroiui supply to the •arCkces, whera are Mated the InstinctiTe
want* at the or^uilam, we have in the above &ct8: let, Uiat the ganglionic ■jrstem ie the nerroiM appantue of the
ioettnfti and internal eenaee ; 2d, that it oommonicatee to the nerrona syetem of animal life or relation the wants of
the eovDonj ; and 3d, is capable of eompelling that ijsteui to command the acts neoessaiy to supply these wants.
" Th« ftntenogation of pathological phenomena will furnish additional elncidation to this subject.
* Irrilatloiis exdted In the macons tusue of the stomach and small intestines by the impressions of Irritating agents,
«iU excite Irritations in the biain, and sometimes soinal marrow.
"The acvte inflammations of the gsstro-lnteetinal mucous tissue Fan»ly, it may be asserted never, fiUl to occasion
rerrbral or epAnal inflammation. Hence, they are inTarlably attended with headache and delirium, pains In the bacJc,
and often neunlgic pains in the exteemities; they frequently occasion coma, apoplexy, hydrocephalus, conTuIsions,
•od paralysis. The chronic inflammations of the same tissue are also productive of chronic inflammatiions of the
rrrabcnl ofgans» and hence we And mania, monomania, catalepsy, and hysteria, are flrequently counected with that
■tale oC the digestive oigana. The connection between the cerebnnipinal organs and the mucous tissue of tiie
■toaftcb and small intestines, by which the actions of the one are transmitted to the other, is most probably effected
ihroogh the nerves of the ganglionic system, and the inosculation of the solar plexus with the par vagum.** * * —
p. 4a
" None of the viscera that are placed under the influence of the ganglionic system of nerves, exercise so decisive
•ad pr»miBent an action over the cerebro^inal nervous organs as the stomach and small intestines, especially the
** With lev promptness and lees constancy the other organs in this connection respond to the morbid irritation of
the gastrlr mucous surfiue. An example is afforded in acute gastritis, in which the eye is always injected wiUi blood,
ihe iuieas aod tongue are arid and inflamed, the lungs often partake of the disorder, and respiration is impaired or
«>fmag«L The liver, the kidneys, the genital organs, all display moro or less of disturbance in their ftinctlons, cor-
tespotMUng to the degree of the gastric disease. The acute Irritation of these organs are attended, in a like mode,
witii disorder and distnrtiance of the stomach and its functions. Thus, inflammation of the kidneys, uterus, Uver,
and eoasotimes of the eye, Is^irodnctive of an irritable state of the stomach, producing nausea and vomiting.
"The above pathological phenomena exhibit: flrBt,a close connection between the stomach and the brain, by
«hkh they mutually reflect their irritatlous on each other: and second, that the different organs to which the gang-
>t<«iiic system sends nerves, possess a free communion in their actions, which is taost extensive and active between
iho«« otgnne most abondantly supplied with nerves.
** TUe ffsagHwsic qrstem, from these Ihcts, would appear to be the medium of the qrmpathies that bind together
the vierera of the s|4ianchnic cavities— the cranium, thorax, abdomen and the genital organs.** * • pp. 40-42.
** While It cannot he duubted that the oi^^ans of the moral fkcultiee and passions are situuted in the brain, neither
ran it be deomd that the viscera aro not entirely passive in their exercise.
" Wluit is the exact part they peilbrm, it Is not easy to divine ; but eveiy one Is conscious of sensations of a peculiar
kind, having either a pleasurable or painfiil character, experienced in ^e epigastrium, in the chest, and sometimes
lo uther pMts, while under the influence of moral emotions of an agreeable or distreeslng nature.
"* MymfsOhy Is the medium connecting the organic actions of the different organs, and consists in the transmission
w a remote organ, aod the repetition in that organ, of the same mode of action which had been previously excited in
Mioie other organ. One organ is In this manner an excitor or stimulant to the actions of other organs, and ooncuri by
ikls means to the maintenance of the vital activity of the whole orgHuism.** * * p. 590.
** In ik« aenapa, we have the podtive demonstration of the transmimion of impnsalons from one organ to another
<lksiaat ocvan. • * A rsdpfocity aod identity of action, it Is apparenL prevails between the organs of the senses
<>n the extf^mal surf!M:e, the recipients of external impressions, and the internal cerobral organs ; an action excited
in the one being transmitted to and repeated in the other. * * In this example of the senses we have presented a
wri«« at pbeaomona corresponding exactly with thoee constituting the sympataies, an action excited in one organ
iraaamltfed t*i and reiterated In another.
'* Illoetrations of a yet stronger character are fUmlshed by the phenomena of the nervous apparatus, exemplifying
in a mnrv vivid light the character and mode of production of the sympathies.
^ A meolMl impression, an Idea, the exdCatlon of a moral emotion, excites or modifies the nmvements of the ca|dl-
Ury eitr«lnlion, or disturl* the regular function of some important «>rgan. Tho deep suffusion of the mantling
> I hmI la the flice of the modest feaiale, the eloquent langu ige of the unuttered thought. Is a striking exempliflca*
tk«o of the influence of cerebral excitement over the capillary circulation. The efl^scts of the passions on the heart,
«• rre<iiieatly disturbed in Its mode of action liy moral emotions ; the disortlera of the biliary secretion, and derange-
ment of the digestive action of the stomach, induced by profound mental operations, are strong evidences of tae
ir»napvrt of impreasiuns by the nervous qrstom. A still more impressive example m found in the erotic ideas in
«ir»«me, so stimulating the genital organs as to provoke in them the actual sensations of the venereal act, and the
•-|er«hrtl«n of the seminal llQUor.
-* In thcee examples is manifested an excitement transmitted by nervous communication from one organ, in which
It Is 4evek»p«d, to another organ, to which It Is transported, and to which It is imparted.** * * p. 502.
" TKe power of transmission Is common to all the nervous apparatus, and Is the means connecting its different
l«irtk*aa. Bnt Ibr tlie transmission of the excitement of the oiganic actions a spedflc nervous apparatois is provided ;
ii Is tlM ipuigllonic system, or the sympathetic— the nervous system of the viscera and organic life. By the arrange-
RMtat and dlirtribntlon of this system a nervous appartus Is provided, independent of, yet most intimately connected
with the cerebrD-epinal nervous ^stem. It is endowed with the same force, nervous activity, fluid, or whatever
Hsme It may be known by. It possesses an analogous mechanism; nervous oryaus, or centrm (the ganglia), nervous
• oris of mmmnnicatioB or of transmission and receptive expansions in the viscera. Its actions and influences are
i« a sfaiifcir mode-^impressions received, excitement of nervous activity, and transmission of exdtement; audit
''X^rcises a oontrolling and governing inflnence over nil the splanchnic viscera, to which it is distributed, similar to
that «>xdt«4 by the cerebrospinal apparatus over the organs of locomotion, expresdon, sensation, the intellectual
•ad mural Csraltiea. • • pp. Aft2, 503.
** The two important centres which have been indicated as exidting in the nervous system are Immediately oon-
nxtffd til each other, and by this connection th<* two apparatnsen are placed in communication, and direct relations
■laMMbnd between them. This oommunioation is establbhed by the eighth pair, par vagum, or pneumogastric
VrMag ttam the medalla oblongata, it sends branches to the ganglia of the neck and thoimx, but Is princip^ly ex-
p^-odeo in aoas<om<isee with the solnr plexus and semilunar ganglia; so that it may be either described as proceeding
fnem three ganglia and terminating in the medulla oblongata, or, arising from this last, it terminates in the ganglia.
' The oommnnication formed by the par vagum or pneumogastric between the centres— the medulla oblongata and
•cmiJnanr gaaglia^--aalablishes the intimate relation and immediate oonnectioo uniting the two apparatuses of tlie
•i^nrtms vrgans — the cerebro^nal and ganglionic or organic. By this connection impressions are mutually reflected
frtm the one apparatus Into the other; and consequently the impressions of the viscera, especially those of the alido-
B*n, which have no dirset oommunicatlon with the brain, reach that organ, while thoee viscera experience themselves
fmo>Uhemiio9» from the inflnence of cerebral excitement.** • * — pp. o94, iWt.
' fn the natural state of the organism the correlation and mutual play of the organs on each other, tliniu;;h the
M^4inm of the nervons system, and by the radiation of Its ingenerated nervous activity, are not chnmotcriKod by
features m striking aa lo be readily seised on and established. They nevertheless do exist, and are whnt \n to be un-
92 IfUroduetion to the Study of Diseases qf the Nervous System,
dMitood iNvpnlyliy the •jBergi* of wittmi. la fli« palholoftoal •teto (he wiiA&nom of thla wodo of oomMctlon and
inflaenoc are too apparent to be mbviidefetood. The pafhoMfloal phefioBMoa an, howarer, no awf* thaa eocagtar-
atloBfl of the phjelologlaAl pheaomaoa. Whan* aa ocgaa, in a state of aotlTe Irritation or acnte lalaauMMlon, acte
OB another and dtataat orcan, affeoH It la the iaae manner, comaivBieatee Iti owa oonditloo. U li aot that a eoaaee-
tion to eetabUehed whloh dM not belbfa preTail, or a mode of aotkm and Inflaeaoe to bnragnt Into Play which pre-
vloaily had ao extoteaoe. The eoaneellon vae already there : the aetioo and iaflaeaoe already had belac ; aad aa
fkom Uito natand or phyilolofleal eoaneetlon aad iaflaeaoe tae orgaoe harmonlae aad eoireepoad to eaoh other In
healtti, eo ftom the eame oaaae are tbay parttetaaate of ttie eame condition in dieeaee. It in ftvan thie aataral, flaed
oonnectioa and inflnenoe that aa onaa pathologioeliir eseited, caaerattng in llmlf; by the aerroae eiemente of He
■troetare, aa eaeem of nerroas aeHnty. beooaee a momd or pataoloflcal esdtant to the other orseae eoBbraeed in
the laage of Iti nervone drele, or with which it to in moat lattmata narrone condition.** * *— 1PP« M9t eoik.
Th< views of the emiaeat phjsiologiit, J. MQIlar, coacerniog the Laws of Action of the
sympathetic nerve and the propagation of imprestions in it, may be gathered from the fol-
lowing propositions, consolidated from the Second Edition of bis Elements of Physiology.
or TBI ACTIOVS or TBI iTMPATBITlO VBBVB III IMTOLUVTABT BOTIOMi.
'I. All the parts sal^ect to the influence of the sympathetic nerve are incapable of volnn-
tary motion.
II. The parts which are supplied with motor power by the sympathetic nerve still continue
to move though more feebljr than before, wbtiB^hey are separated from their natural connee>
tions with the rest of the sympathetic system, and wholly removed from the body.
III. Hence all the parts endowed with motion, and supplied with nerves from the sympa-
thetic, are, in a certain degree independent of the brain, and spinal cord.
lY. The central organs of the nervous system can, however, exert an active influence on
the sympathetic nerves and their motor power.
V. The ezperimentd of Dr. Philip tend to show, also, that distinct parts of the sympathetic,
and the movements depending on them (those of the heart, for example,) do not derive their
nervous influence exclusively from distinct regions of the brain and spinal cord ; but, on the
contrary, that the brain and the whole spinal cord, or every part of it, can exert an influence
on the motions of the heart.
YI. The movements excited in organs which are under the influence of the sympathetic
nerve, hj irritation applied to them or to their nerves, are not transitory and momentarj con-
tractions ; they are either enduring contractions, or they consist of a long-contlnaed modifi-
cation of the ordinary rythmic action of the organ : hence, in these organs, the reaction con-
sequent on the irritation is decidedljr of longer duration than the action of the sUmolus.
The motion of the nervous principle in the sympathetic nerve then is slow, and its rate
capable of being measured.
YII. The immediate cause of the involuntary motions, and the cause of their type, lies
neither in the brain, nor in the spinal cord, but in the sympathetic nerve itself; even the
influence of the ganglia is not neeeasary ; the branches of the sympathetic going to an organ
mar be entirely removed, the twigs distributed to the substance of the organ only being lef^.
and the motions will be continued as before, the reciprocal action between the muscular flbres
and these ultimate nervous twigs being apparently adequate to their production.
YIIl. Although from the fbregoing observations, It is certain that the extreme minute
branches of the sympathetic have still the p3wer of regulating the movements of the parts
not subject to the will, yet it is not less true that both the brain and spinal cord, and the gan-
glia themselves when in a state of Irritation, exert an influence on these movements as long
as the contractile organs are connected with them through the medium of the nerves. The
brain aad spinal cord, are however, also to be regarded as the source of the power of the
syiapathetic itself, which would without them, become exhausted.
Ia. It results from the facts already stated, that the sympathetic n#rve Is charged as it
were with nervous power by the braaa aad spiaal cord, which may be regarded as the soar«ae
of nerrous influence ; but that, when once charged, it continues to emit this influence in the
osanner peculiar to itself, even when the further supply Is for a tiose diminished. This aflbrds
an explanation of a part of the phenosnenon of sleep.
X. The influence of narcotics locally applied to the sympathetic nerve does not extend to
the distant organs which the nenre supplies ; but these organs may be'paralysed by the direct
narcotisation of the minute nervous fibrils which are distributed In them. In this raspect
the sympathetic resembles the cerebro-splnal nerves, which are deprived of their excitability
by a narcotic substance only in the part where it has actually touched them. But with refer-
ence to the action of narcotics on the organs, under the influence of the sympathetic, there is
observed In the case of the heart a remarkable, and at present inexplicable difl^rence between
the external and internal surface of the organ. If a narcotic, such as pure opium, or extract
of nux vomica, is applied to the external surface of the heart, it produces little or co effect.
or, at all events, a very slow one ; the rythmic motions of the heart of the ftog, removed fnm
the body and thus treated, continue for a very long time; but if a small quantity of opium or
extract of nux vomica be brought into contact with the inner wall of the ventricle, its move-
Iniroduetian to the Study of Diseases qf the Nervms System. 93
DMBts art p«niuuieatly amited, freqnemly in • few geconds after the applieatton. Of this
fact, fint obterred br Dr. Henry', (Bdlnbargh, Med. and Sarg. Jonr., 1832,) Professor Huller,
hae aatislled himself by repeated experiments on frogs. This observation explains the rapidity
of narcotic poisoning, when the poison has once entered the blood and reached the heart.
XI. The laws of reflexion, previousiy aafolded, prevail likewise in the actions of the
sympathetic nerte ; strong impressions on parts supplied by the sympathetic nerve may be
propagated to the spinal cord, and give rise to motions of parts which derive their nerves
from the cerebro-spinal system.
XII. Impressions on parts of which the nerves are derived from the sympathetic are com-
annicated to the spinal cord and brain, and excite the motor inflaeoce of the sympathetic
nerve by reflexion, although the reflex action is here less marked than in the case of the
cerebro-iplnal nerves. Whea we compare the reflex phenomena presented by the cerebro-
apinal nerves, with those in which both the original excitation and reflected action are seated
in parts nndar the influence of the sympathetic, we find that the former are much more ener-
getic and readily excited than the latter : for how frequent, rapid, and easily indeed, are the
reflex motions of coughing, sneexing, vomiting, etc., how much more numerous are the reflex
phenomena in the cerebro-spinal system, compared with those presented by the organs
govaraed hj the sympathetic t The circumstance, also, that inflammations of the intestinal
canal do not affect the pulse — that is the heyVs action, — so quickly nor to fto great a degree,
as inflammation of other parts supplied with cerebro-spinal nerves, seems to favor the opinion
that reflex motor action of the sympathetic nerve Is less readily excited by irritation of the
sympathetic itself than through the medium of the cerebro-spinal nerves ; or rather perhaps,
that circumstance is elucidated by the latter fact.
XIII. Reflected action of the sympathetic, from an impression communicated to the spinal
cord by cerebro-spinal nerves, is a more frequent occurrence. As instances of this we may
mention the effects on the heart's action of strong pleasurable or painful sensations of the
skin ; the movements of the iris from impressions on the optic, auditory and fifth nerves ;
and the contraction of the seminal vesicles from irritation of the sensitive nerves of the
penis.
XIV. Can reflex phenomena be produced in the sympathetic nerve through the influence
of the ganglia, and independently of the brain and spinal cord? This interesting question in
the opinion of Professor Muller cannot at present be decided. If such a mode of reflex action
existed, it would constitute a remarkable difference between the sympathetic and thecerebro-
apinal nerves ; it would show that the primitive fibres of the sympathetic are enabled by
means of their ganglia to act on each other, which in the cerebro-spinal system never occurs,
except through the medium of the brain and spinal cord. If muscles which derive their
nerves from the cerebro-spinal system, and which are separated from the trunk of the body
be Irritated, neither the whole muscle, nor even the entire length of the muscular fibre, con-
tracta, but merely the part directly affected by the irritation. The question is, therefore,
whether on irritating a single point of the Intestines removed from the living animal, together
with the mesentery and ganglionic plexuses, contractions of some extent, as for example, in
an entire loop of intestine, will take place. According to Professor Multer they will not ; on
the contrary, the irritated parts only will contract; indeed, on pinching the intestine with
forceps, there does not even follow a circular contraction of the whole tabe, bnt merely a
limited contraction at the part pinched, while the opposite side of the canal remains quite
flat and nndtsturbed. Yolkmann obtained the same result from similar experiments. Benle
obtained a different result, from that of the experiments of Muller and Yolkmann, which
•aemed to prove that the reflex movements of tha intestines can be excited only through the
madiam of the spinal cord. Even in intestines separated from the body of the animal, (a frog,
rabbH or gninea-pig), he was able to excite circnlar contractions, which extended progres-
stvel/ in one or both directions, and sometimes were accompanied by contraction of the
laagUadiaal masoalar baads. Henle therefore, admits that the ganglia are centres of reflex-
ioa, which is also the opinion of Mr. Granger, (On the Spinal Cord, p. 133). Valentin, (De
Faaction : ffervor, pp. 92-96), denies that the ganglia of the sympathetic can reflaat the im-
preeaiofts of contripatal fibres upon cenlffifii^ motor fibres, hut he believee that they in
•ooM wajr render the centripetal fibres more prone to excite reflex motor action in the spinal
cord. Reflex movements are excited, he says, with the greater facility, tlie more numeroufi
the ganglia which tlia nervons fibres irritated, traverse in their course to the central organs.
This latter observation would accord with the theory of the ganglia being centres of reflex
aeiiofi.
XV. We are at present entirely ignorant as to whether irritation can, through the medium
of the sympathetic nerve, give rise to movemants in another ; since all the sympathetic phe-
aoveaa of this kiad can he explained on the principle of reflection firom the brain and spinal
OOTv.
XVI. It is not proved (and several facts have been observed which are opposed to the be-
lief,) that the ganglia can exert aa insnlatiag action so as to impede the transmission of motor
1)4 Introduction to the Study qf Diseases of the Nervous System.
influence from the brftin and tpinAi cord. It is not volantarf influence, but motor inflnence
generally, which is here referred to ; for CTerj one is aware how readilj and qnickly an im-
preMion on the brain and spinal cord influences the whole sympathetic system ; how quickly
a mental emotion alters the heart's action, and gi^es rise to movements of the intestines, to-
gether with borborygmi ; bow a hysterical fit, in which the central organs of the nervous
system are affected, terminates with a rumbling of air in the intestines.
XVII. It is not certain that the ganglia are the cause of the parts supplied by the sympa-
thetic uerve being withdrawn from the influence of the will.
XVIIL In certain organs, which are subject to the influence of the sympathetic and of the
spinal nerres at the same time, a voluntary influence seems to be exerted only after the long
continuance of a centripetal or sensitive impression.
XIX. Many parts which are supplied by the sympathetic nerve, are indeed capable of in-
voluntary motion only, but become associated with the motions of parts subject to volition,
a part of the voluntary motor influence being commanicated involuntarily to them, Just as in
the associate motions of voluntary muscles.
XX. The motions of organs which derive their nerves from the sympathetic system, have
a peristaltic type. The motions are progressive in a certain direction, and the course which
they take is dependent not merely upon the brain and spinal cord, but likewise on the nerves
of the organs themselves.
or THB 8IN8ITIVI rVNOTlOMS OF TBB SYMPATHBTIC IIBRVB8.
I. The sensations in parts, the nerves of which belong to the sympsthetic system, are faint,
indistinct and undefined ; distinct and defined sensations being excited in them only by violent
causes of irritation.
II. The sensitive impressions received by the sympathetic nerve, although conveyed to the
spinal cord, may not be perceived by the sensorinm, the organ of consciousness. The action
of a sensitive nerve continued to the spinal cord, may give rise tn sensation, or it may not ; to
produce a sensation it must be propagated with some degree of force to the brain ; when
It does not produce sensation, its influence is confined to the spinal cord, but it may give
evidence of its affecting the cord by other signs than sensation, namely, bv reflex motion.
III. The impressions which give rise to reflex motions, when conveye<i to the spinal coni
by the sympathetic nerve, are in most instances, not productive of sensations ; while those
impressions which are received by cerebro-spinal nerves always give rise to sensation.
lY. The ganglia of the sympathetic nerve do not prevent the transmission of centripetal
actions in that nerve to the spinal cord ; they have not an Insulating power over its centri-
petal currents.
V. The ganglia are likewise not the cause of the impressions on the syippathetic nerve
being unattended with true sensation.
VI. In many cases, irritation of a violent nature in organs supplied by the sympathetic
nerve, f(irtB rise to sensations in those parts ; in other cases, the irritation being less violent,
the sensations in the parts affected are indistinct, while distinct sens.*ition8 are present in other
parts supplied with cerebro-sploal nerves.
VII. The secondary sensation in the cerebro-spinal nerves consequent on irritation of
branches of the sympathetic, occur especially at the extreme parts of the organs affected.
VIII. That the ganglia exert a reflex action in the production of the sympathetic sensa-
tion, is not proved, and many facts are opposed to the idea of their having such a function.
OP TUe OBOAVIC PUNOTIOKI OF TBI SYMPATHITIC IIBBVB.
** We are most unac^oidiited with tlie lawi of the or(Miic adioB vi di« •vaiMUMtic tt«rv«; for w« h«T« l»iit Jim
\Mani that there are io all nanrra, evea in the c<«rebn>-^aal, pecnilu- frav iMclcali, or organic ftbrea, on whicli d«*
|t6iid the organic actiona of the n#rv«s In tecretlon and in nntrltion. We hare now to enqvire whether In Iheee
nerrea the motion or oecillatlon of tha narruua prindpla can be propagatid only In the canttUugnl dtrectloa tnm the
tninkn and ganglia to the bnuirhee, or in the contrary dlrvctWn aleo ; or whether the action of the nenrone ptinc^ie
in them can be excited In all directtone, a particular fibre of theee nervee being capable both of tnnamitting a tItI-
Tying inflnenoe Io a gland, and of exereiMng a reflex action eo as to oommunieate the Irritation in one gland to other
urganio nervee. It would be deeiimhie aleo to know whothar the organic narvea aia, by virtna of their anaatomoeee,
foabled to re-act on each other in euch a manner that iacreaaed eecretioo from a whole eurttta may be azdted by
irritating one point, or whether all 9iich reflex actlone are affected through the medium of the spinal cord. The (act*
known relatire to thia enldect admit of two explanations, and It cannot be delennlned with certainty which Is the
(-umirt one. There are certain casta, however. In which either one or the otiicr theory ie more pcolmhla.**
I. When in consequence of impressions on sensitive nerves, secretions take place in distant
parts, the brain and spinal cord are probably the medium of communication.
'* The Irritation may here be eommanloated tn the oncaalr Mum by the ganglia of the roots of the sensltlre nervee.
Hhlch are traveiMd by fibres of the sympathetic ; or It may be reflected on the organic filitas by the spinal ootd. The
latter Is evidently the most probable view, since the reflex action of the epinal cord in the reflected motions Is a de-
inonstmted flu:t, bat the reciprocal action of the different fibres io the ganglia of the nensltlYe nerves on each oth^r
a mere hypothnels. The cases of sympathetic affections of organic nerves here alluded to are very ftraqaenL fmpre*-
Mions on Internal mucus memlmnea,— for example, by drinks, — freqnently give rise imaaedlalely tu a general sweat.
Introduction to the Study of Diseases of the Nervous System. 95
tMmiC tmpraMloM oo MnsttlTe nerret ftre lomeUmM followed by lyncope, and with » cold aweat Th« latter pbeno-
oMna mn «Tfcl«Dtlj the reeolt of an infloence reflected by the spinAl cord, Bince the ■ymptoms Id syncope sometimes
•JliBct aa exteat of the ayetem lo great ae to be explicable only in that way. In lonie other caiee of this kind, it iit
more doabcftal whether the f^eoomeoa ouor be explained in the wme manner. Irritation of the oo^jnctiTa of the
ryeaad ey»4ide, attfioded with eeniatlooe, giree rise to a flow of tears ; etiinall applied directly to the mucue membmne of
the Boae, or Tolatile etimnlant* nifecting the aame muoiu membrane, when taken into the mouth, producing violent
•enaatlolu la the noee, likewiee give iIm to an effusion of tears. Mustard and horse-raddish have this effect sonie-
Tiflice even when taken in the mouth. It is usual to explain these phenomena by supposing the irritation to be com-
BaaJcated by the ethmoidal nerre to the trunk of the first division of the fifth nerve, and to be thence reflected upon
the ••rriie lachvymaUs: the secretion of tears fh>i9 irritation of the conjunctiva has been explained in the same mati-
aer; the irritation of the oo^Junctiva being communicated to the first division of the fifth nerve, has been imagined
to be thenee again reflected upon the lachrymal branch ; in both these cases however, the explanation is defective ;
for, inawinnh as the ftbrss of a cerebrospinal nerve are wholly distinct la their entire extent, an impression on one
portioa of Its ftbras cannot be reflected upon others. Again, the same phenomena have been sui^iosed to be the
rtaatt <rf syoinathy of the Schneiderian membrane with the lachrymal gland through the medium of the ganglion of
the s|iheDO-pMatine, which has been stated by some anatomists to be connected mth the ciliary ganglion bv meann
of syaipathetic flbrss. Now, since the ciliary or lenticular ganglion, by Its long roots, is connected with the nasal
nerve, and thus with the trunk of the first division of the fifUi, which g|ives off the lachrymal nerve, an Ijnmedlatp
omoectioo was thus found to exist between the spheno-palatine ganglion and the latter nerve. But the same oljec-
tioD must be made to this explanation as to the former ; for, unless the fibres In the fifth nerve communicated with
each othar, an initation ocmveyed through the ciliary ganglion and nasal nerve to the fint division of the nervui*
trigvmfnoB covid not be reflected upon the lachrymal branch. There are other physiologists who imagine the Im-
prei^bn la the noee to be communicated to the Gasserian ganglion on the trunk of the fifth nerve, and to be thence
reflfecCed apoa Um first division of the nerve and Its lachrymal branch. No objection could be made to this explana-
cioa at the phenomena, provided that we knew that the Gasserian ganglion, the ganglion of a sensitive nerve, were
capable of giving rise to sympathy and reflex action ; if it were proved that centrifugal nervous currents can take
place io eeultive nerves, such as the Ischrymal nerve ; and if it were demonstrated that the lachrymal nerve nmlly
•appllss the facfaryroal gland which regulates its sei^retlon. Since the secretion of tears, like other secretions, In
drtcmiaed prohaUy 1^ flbres of the sympathetic nerve, the most simple explanation would still be that which
•appoasa the Irrltatloa tu bo conveyed fh>m the nose backwards to the spheno-psJatine ganglion, and, by means of the
0D«B«clloB of all the organic nerves with each other, to be reflected in some way or other through the medium of
ufganle flhsaa upon the lachrymal gland. But whether snch a reflex action from sensitive nerves directly upon
orgaaic narvea, without the Intervention of the brain and spinal cord, can occur, is a questionable point; and I know
Bo other argument in fovor of Its possibility than the impoeaibllity of proving that it cannot occur. A very ftnequent
inataaee of reflex action of the secreting function from IrritMtion of a sensitive nerve is the increased flow of saliva
oftra ooaaing on quickly when food Is taken into the mouth. The mode of explaining the phenomenon Is equally
as oaeeitaln here as In the former ease. The assumption that the brain and spinal oora form the medium by which
Che IrrltatloB of the sensitive nerve Is enabled to excite the organic action is at least fhvored by the analogy of simi-
hr r«0ected actiooa of sensitive or motor nerves, through the Intervention of the central organs."
II. There prevaili a concert of action between the different parts of a secreting^ mem-
brane; thus the itate of one spot ioflaencea the condition uf the whole extent of .a serous
membrane. Here it is more simple to explain the phenomena bj communication of the
orffAnic fibres with each other.
III. A particular state of one organ, such as inflammation, or a secretiuf; action in it.
sometimes causes the production of a similar state in other parts. In this case we hare an
instance of reflected action of the orj^anic fibres of one part upon those of another.
laflaiiaaHnw of the testiele may be replaced by Inflammation of the parotid; erysipelatous inflammation of the
dlia May ha tmaafenad to the membraaes of the brain; suppression of the secretion of one organ Blay give rise to
laciaanad siw'fiitlun In aoother. All snch phenomena are probably attended with changes in the organic flbrfw
bplooglng to the sympathetic system, which sccompany the blood-vessels. And here, again, the question arises,
•bHker soch reflexions are produced through the medium of the sympathetic alone, or whether the brain and spinal
noni mn the medium uf reflexion between the centripetal and centrifugal actions. There are no fi^ts which enable
II* to deckle this question; but in many cases it is probable that the sympathetic nerve alone Is engaged In the
pwidartion of the phenomena. In llayer*s experiments, l'g<iturp of the sympathetic nerve between Uie first and
•eeoad oervfeal gaJaflia, was sometimes followed by an affection of parts which appear to be under the influence of
th^ flfst cmricargaaglion, namely, by Inflammation of the eye. The peculiarity of the organic nerves, namely, the
dlMcalty of diatioguishing eltiier origin or termination in them, their want of arrangement Into trunks and bianchee,
aatf Che lucieaaa which they firequently undergo in their course, is certainly in favor of the possibility uf their actionn
l«4ngpopagated la all directions from the eentral points of the ganglia, and not confined to centripetal and centrifu-
gal camata. This view is also favored by the circumstance, that when an organ ceases to be supfilied with ui^nir
flliras tnm one sooree, the supply may be furnished by another. Ligature of an arterial trunk, without doubt in-
iaiaa tlie ocgaalr nerves whidi aooomnany It ; nevertheless, no death of the pari, atrophy, or cessation of Mecretion in
It taeax; so that it appeam as If the nerves accompanying the collateral veasels were able to supply the lost
iaflaaaca, or that the new supply Is fUmished by the organic fibres in the spinal nerves. On the other liand, the
ifrtlaence of the »pinal nerves may be lost without atrophy ensuing. In V. Pommer's experiments, too, it was ol»-
e»rved that dlvMoa of the sympathetic nerve on both sides of the neck, gave rise to no i^jurious oonsef|uences, su,
rhat ifefhaps the iaflnooce of the divided portions of the nerve had been supplleil from other sources, as, for instauce ,
Ky fhe flbres accompanying the vertebial arteries. The metastasis of a morbid process, however, takes pUkce In all
emmm towanls the organ which Is predisposed to it ; thus, in poisons, with tendency to pulmonic affei'tions, the metuH-
taeis takes place fn>m the skin to the lunp; In patients liat»le to hepatic disease, from the skin to the liver ; and in
t«hef«, with Irritable bowels, from the skFn to the Intestinal canal, and so on. In considering the laws of equllib-
rtaas, to whlsh the secretions are sut{|«ct, not only the nervous system, but the nature of the different secretions, and
Iheir relalions tu the components of the blood, and to one another, are to be attended to.
IV. The i^anKlia appear to be the central parts from which the vegetative influerice U dis-
tribotetl to the different organs. Inflammation of the eye and even the general phenomena of
impaired nutrition, have been obserred to follow injury of the first cervical ganglion.
V. This radiating influence of the ganglia appears to be in a certain degree independent
of the brain and spinal cord, since the embryo may be developed while the bnitn and spinal
marrow are destroyed.
VI. It appears, however, that the brain and spinal cunl are the main source whence the
96 Introduction to the Study qf DiseasoM of the Nervous Syetem-
•
power of the ornate nerres is grftdaallj renoTftted, ■inoa certain aflfeoltoni of the brain and
spinal cordf attended with paraljsig, are likewise prodnctiTe of atrophj. — Elements of Physi-
ology, Vol. 1, Sec. Ed., pp. 778-803, 1840-1842.
Professor J. Mdller illustrated many of the preceding propositions by experiments, and he
is entitled to the credit of hating first systematically and philosophically applied the laws
governing the action of cerebro-spinal nerTes to the sympathetic. Even Magendie seemed to
think that so little was known of the properties of the sympathetic, that he hesitated to
regard It as a nerre. Mfiller not only applied the doctrine of reflex nervous action, as devel-
oped by Marshall Hall and himself, to the phenomena of secretion, nutrition and inflamma-
tion, and to the actions of the sympathetic or organic system of nerves, but be also accom-
plished much for Physiological and Pathological Science, in showing in a clear and philo-
sophic manner how investigations on the subject must be prosecuted.
If the labors of Lobstein and MuUer had been properly studied and recognised, there would
have been no subsequent controversy as to the priority of discovery of the reflex actions of
the sympathetic system and of the ao^eaUed exeUo^ucrekny tyMtemof nervu.
Dr. Henry F. Campbell, of Augusta, Georgia, published in June, 1850, ^^ An Buoy omtke
fnjifienee of Dentition in Fridueing Di$eaieJ*^ in which he endeavored to sustain, not by experi-
ment, but by references to well known anatomical, physiological and pathological facta, and
more especially by the experimenta of Pourfour du Petit, Dupuy and J. Reid, on the sympa-
thetic, the proposition
**Th*tintheBafttoni7«iid pbyriolQK7,M mU m In the 4«pflBd«nt ftwriTrif of tte pwof of dcotitloa, «• lad
«Bpl« nonnd for the vginlon, tMt th* illimm iMrtAinlBg to this period, noy be depeadeat, and lo mumjf
ore ODttrely lo, npon the kwol inltatAon ottendlnc the procwi boiag tnoMBltted thmgh either the
^yetem of nerree, prodvdiic oonTubiTe dtowoeii is the Botoiy ^ipoialM, or thioagh the tympathetiG, cauiiig
imaffemeDt in the eecretoiy otrmm, portioalMly the tlinentMy oumI, by the ewoy whkh it exendeae orer the arterial
ftooi which thoM eeerelloiM are etiaUaated.**
A similar theory was applied by Dr. Campbell, to Typhoid and Typhus fevers, in a paper
presentad to the American Medical Association at iu session of May, 18&3.* Thus be says:
** After the meet oarsftil and laboriooe oourideratioD of the phenomena, rrlatlonehip and erentt of thia tmly ntyete-
lioiie diecaee, keeolnff in riew at the mmt time aa well aa we were able, the mtUn nhyiftologloal dapendeoeke of each
an intricate qneaUon, wp are indnoed to regard the tyi^ioidal atate, mantfeeted both in the typhoid and typhnafeTon,
aa a moiMd affection of the whole or portlona of the ganglionic qntema of nenrea, known alao aa the great eympa-
ihetie nerve, Irat of Che exaet nalnraof wtikh,aDd how prodoeed, we know not**
Dr. Campbell admitted, however, that the preceding hypothesis retted upon no pathologi-
cal observations of his own :
**,We are tally aware that our riewa of the pathology of typhoid feren wonld be greatly corroborated, oonld therr
be diMOTerad any appealable larian In the gang llonto narNini eaatraa. la aaMicia who nave died daring their pro-
gnm; hot, like the pathologloal aaalomy of all the aervona qrriem, Ihia woiild be aa
ly diflealtiea. • • Theae changea, then, are piabably Biolafiilar and Inapprec labia with oar
Invaetlgatloa***
Dr. Campbell's riews with reference to the reflex' relation subsisting t^etween the cerebro-
spinal and sympathetic system of nerves, were fiarther expanded and illnatrated by the snore
recent experimenta of Claude Bernard and Brown-S^uard, la his *' Prise Bssay, The Bxcito-
Secretory System of Nerves ; Us Relation to Physiology and Pathology,''" and in his elaborate
Report on the Nervous System in Febrile Diseases, and the Classification of Fevers by the
Nervous System.^
Dr. Marshall Hall published in the London Lancet, 1857, an article, in which he announced
the discovery of a system or sub-system of Sseito^Stentorp Nerves, which he regarded as
not less extensive than the Bxcito-Motory System of Nerves, which he had preTionsly
announced to the Royal Society, in February, 1837.
Dr. Campbell is certainly entitled to the credit of having first applied the term, Bxcito-
Secretory, to the sympathetic nervous system ; but neither Dr. Marshall Hall nor Dr. Henry
F. Campbell demonstrated the reflex relation existing between the cerebro-spinal and sympa-
thetic svstem of nerves.
1 Sontheni Medical and Safgkal Joaraal. Jane, 1SAQ, w^ 811-1
2 An Inqairy into the Nature of Typhoidal Ferera. Trana. Am. Med. Aaao., May, 186S. Sympathetic Nerve In
Relies PheMmena. Traae. Am. Mad. Aim. ^oL ri, IS5S.
:i Tiaaa. Am. Med. Aaao^ IWT.
4 Timaa. Am. Med. Aaao., ISM. Claim of Priority In the Diacovery and Naming of the Exdtory*8ecretory Syetea
of Nerrea, 1^ R. J. CampbeU. 1SA9.
Introduction to the Study of Diseases of the Nervous System. 97
KXPER1MENT8 ON SECTION OF THE NERVES, ILLUSTRATING THE RELATIONS OF THE
SYMPATHfrlC TO NUTRITION, SECRETION, CIRCULATION, RESPIRATION AND ANI-
MAL TEMPERATURE.
The effects of sectioa of the j>ar vo^um upon the conjanctWal membrAne of the eye, when
practiced apon those animaU where the sympathetic is so closely connected with th|s nerre, that
the one cannot be divided without the other, hare been noticed by various phyisologists. At
a longer or shorter period after the trunks of the par vagum and the accompanying sympa-
thetic nerves were divided, the conjunctiva became red, swollen, and projected over the
cornea. The pupil was contracted, and only a small part of the ball of the eye was
seen between the half closed eyelids. This inflammation frequently went on to the secre-
tion of purulent matter, and after lasting some time began gradually to abate. Petit, as we
hire SAid, was the first who observed these effects upon the eye after the section of the par
Fd^vM, and justly attributed them to division of the trunk of the sympathetic : for he was per-
fecUj aware of the connexion of this nerve with the sixth pair, and first branch of the fifth
pair within the cavernous sinus, and of the intimate relation of the trunk of this nerve with
that of thenar 9<^wm in the neck in quadrupeds. We have also shown that Gruiksbank in
like manner noticed this inflammation of the conjunctiva in his experiments upon the par
Tagom.
That Petit was right in supposing this inflammation of the eye to arise from section of the
sjmpaihetic and not of the pear vugum^ was fully demonstrated by the experiments of Dupuy,
Jonmal de M6d6cine, Chirurgie, etc., Decembre, 1816, tom. xxxvii, p. 340), upon the effects
of the removal of the superior cervical ganglia of the sympathetic. These experiments of
Dopny were confirmed by those of Brachet (Functions du Syst^me Nerveux, Ganglionaire,
•'hap. ix. 1830.)
This inflammation of the eye frequently takes place with great rapidity after section of the
>5mpatbetic ; in one case Dr. J,ohn Reid observed the conjunctiva reddened a very few min-
ates after the operation ; in two of Petit's experiments it is mentioned that in a quarter of an
boar after the section of the nerves, the cartilaginous membrane at the inferior angle of the
eje had encroached uponthe cornea ; and in the fourth experiment of Dupuy upon the horse,
it u stated, *' Ausaitot ^tpr^s reparation," the eyelids were swelled and the eyes watery.
This inflammation appears to be confined to the conjunctiva — the contracted pupil and half
closed eyelids probably dependiuf; upon the impatience of light generally accompanying this
condition. Petit mentions that he killed a dog on the third day after the operation, and on
'lissectioQ found the inflammation apparently restricted to the conjunctiva.
Dr. John Reid did not, however, consider it fairly ascertained that the inflammation is con-
tiaed merely to the surface of the eye. In the experiments of Dupuy and Brachet upon the
tffdcttof the removal of the superior ganglion of the sympathetic, the same phenomena pre-
^etited themselves as far as the eye was concerned, as when the par vagum is cut in the neck.
\>f. John Reid held that this inflammation of tho conjunctiva from section of the sympathetic
to the neck, CHnnot, in all probability, be referred to the same cause as that produced by sec-
tion or disease of the fifth pair — the former occurring almost instantaneously without arrest-
ment of the usual secretion, and apparently from some direct effect upon the blood-vessels
or their contents; the latter coming on more slowly, and apparently arising, as has been inge-
lionilj ioggested, from the arrestment of the usual secretions which protect the conjunctiva
Tom the irritating effects of the external atmosphere, as seen in various cases when the nerves
ofieereting surfaces are cut. (Alison's Outlines of Physiology, p. 148. 1833).
Dr. John Reid,* who has enriched physiological science with several valuable memoirsf in
*bieh nnmerons experiments upon the nervous system are detailed ; after having frequently
verified the observations of Petit, Gruiksbank, Dupuy, Brachet and others, carefully exam-
ined the question, whether after section of the sympathetic the contraction of the pupil and
partial closure of the eyelids, might probably depend upon the impatience of light, which
* On tile Efleets of Lesion of the Trunk of the Ganglionic Syntem of Nerves in the Neclc upon the Eyeball and it»
^PP«i»daf«i BdinlmrYh Medical and Surgical Journal, A.ugUMt, IH39.
t Oa the R^atiooa between MiMcolar Contiaetility and the Nervous system— Kd. Monthly Journal Med. Science,
May. imi. Order of SitoocMlon in which the Vital Actions are arrested in Asphyxia— Ed. Medical and Surgical
J-'unkil, 11141. Effects of Venesection in renewing and increasing the Heart's Action, under certain circum-
•uncBi Ed. Medical and SaT^ical Journal, April, 18:)6. An experimental Investigation Into the Functions of tho
i^jflith Pair of Merres, or the Glosso-Pharyof eal, Pneumo-Gastric, and Spinal Accessory— Ed. Medical and Surgical
ionnMl, Jasuary, IKiS, April, 1839. On some Points in the Anatomy of the Medulla Oblonnta^Ed. Medical and
^rriealJoanial, Jan asjy, 1841. On the Anatomical Relations of the Blood-Voesela of the Mother to those of the
Miv to Roman ftpedes — ^Ed. Medical and Surgical Journal, No. 146, January, 1841. Infection of the Vessels of the
ptftiM, to show some of the pscnUariCles of the Circulation— Gd. Medical and Surgical Joamal, Januory and April,
'■^•V SpUMtiooal and Smotional Reflex Actions. On some Points in the Anatomy and Physiology of the Heart—
!<bpiedla of .inatomy and Physiology. Tables of the Weights of some of the most Impoitant Organs of the Body
u 4ilen«t periods of Life — London Ed. Journal Medical Science, April, 1843. ObeervMtions on Phlebolites— Ed .
^t^aaX aad Saxgical Journal, April, 183.5. Physiological, Anntomlrat and Pathological Researches, by John Ri'id,
X ^•, eUL, Edinburgh, 18M.
13
98 Introduction to the Study of Diseases of the Nervous System.
freqoentlj ftccompaoies inflammation of the conjonctiya. Bj a series of experiments per-
formed daring the summer of 1839, Dr. John Reid satisfied himself that the contraction of the
pupil, the projection of the cartilaginous membrane or third ejelid, situated at the inner
angle of the eje, orer the cornea, and the partial approximation of the eyelids to each otber«
take place immediately after the injury of the sympathetic, and before the inflammation of the
conjunctiva presents itself, and that they continue after it has disappeared. From the experi-
ments of Dr. Reid, it would appear that in rabbits the superior ganglion of the sympathetic,
and a considerable portion of the trunk of that nerve, as it lies in the neck, may be generally
remored without affecting any change upon the iris ; while the compression or section of the
trunk of the sympathetic in the neck in dogs and cats, is instantly followed by contraction of
the pupil, the forcing of the cartilaginous membraneorer theinner part of the anterior surface of
the eyeball, the retraction of the eyeball deeper into the socket, and a slight approximation of
the eyelids. In dogs this also is followed — sometimes after a rery few minutes, but generally
after a longer interTal, by inflammation of the conj'uncUva^ which is occasionally so severe
that this membrane presents an almost uniform redness, and is covered by puritorm mucua,
and the cornea becomes dim. As far as Dr. Reid was able to observe this phenomenon, the
inflammation is confined to the conjunctiva. On the other band, in the experiments which be
made upon cats and rabbits, the inflammation of the conjunctiva in the former was trifling, if
present at all ; and in the latter it was entirely absent. Dr. Reid was at first inclined to
believe that the outward projection of the third eyelid — for in the dog and cat it has no maa-
cles attached to it — was dependent upon the rolling inwards of the eyeball ; but subsequent
observations nearly satisfied him that this depended upon the retrahent oruli muscle drawing
the eyeball deeper into the orbit, by which the fat is pressed forwards, and the third eyelid
pushed over the anterior surface of the eyeball. This would also explain the approximation
of the eyelids. Dr. Reid found it impossible to ^ive anything like a plausible explanation of
the effects of injury of the sympathetic upon the eyeball and its appendages, and the cause of
their dissimilarity in different animals; he regarded it as evident, however, that this is to be
sought for in the connexion of the branches of the sympathetic with the encephalic nerves of
the orbit, and especially with the sixth pair, and those branches forming the ciliary nerves.
He expressed his intention of executing extensive minute dissections of the ascending branches
of the superior sympathetic ganglion in various animals, to give some i^auaible solution of this
que8tion,and,if possible, to throw light upon the question, whether an injury of the cervical por-
tion of the sympathetic in man,such as may occur in certain diseases and operations on the neck,
would be followed by contractions of the iris, and inflammation of the conjunctiva.
In a case described in the Medical Gazette, (September 29th, 1838, p. 16, Vol. zxiii), when the
right carotid, the ragus and the surrounding parts were described as being entirely enveloped
in a large morbid tumor, and where, consequently, the sympathetic could hardly be supposed to
escape, the pupil of that side was described as becoming smaller during the course of the
disease.
During the late American civil war, after the battle of Fort Donelson, while in
charge of a hospital steamer on the Ohio river, a case came under the observation of Pro-
fessor J. S. Jewell,* M. D., of Chicago, in which there was a gun-shot wound in the left side
of the neck, about two inches below the angle of the jaw, entering at the anterior edge of the
sterno-mastoid muscle, and ranging backward and slightly inward, and issuiug behind on the
same side, close to the spinous process of the sixth cervical vertebra. At the time Dr. Jewell
first saw the patient, and while under his observation, there was reddening of the corres-
ponding side of the face, with a bluish tint, reddening, and watery condition of the eye on
the same side, much heat, and a feeling of fullness and disziness In the head, and swelling of,
and discharge from the mucus membrane of the left nostril. From the direction the shot bad
taken. Dr. Jewell was certain that it had injured, if not divided both the sympathetic and
pnea mo-gastric nerves on the left side. Dr. Jewell also reports the case of a gentlensao
who came under his eare, with severe erysipelas of the right side of the face and neck, com-
plicated with marked malarial disorder. On the right side of the neck, midway between the
lower jaw and clavicle, a large abscess was developed, which finally occupied all the space
between the two points named. There was extensive sloughing and erosion of all subcatane-
ous structures, leading, finally to fatal haemorrhage. But during the latter halfof his illness,
the phenomena, such as follow division or destruction of the sympathetic were developed ;
there was extreme redness ot the corresponding side of the face and head ; increased heat as
compared with the other side ; reddening of the eye ; contraction of the pupil, ete. There was
also at times, rerj irregular action of the heart. The patient died from hemorrhage and
blood poisoning (Chicago Journal of Nervous and Mental Disease, Vol. I, p. 16). WUlebandt,
Oairdner, Coates, Ogle. Heineke, Verneoll, Ruleaberg, Poiteau and others, have reported cases
of compression of the sympathetic by means of tumors, aneurlsmal, glandular and otherwise.
* Chkttgn Jovnwl of Kenroiui and Mental I>tef«M. Vol. I, No. 1, Jui., 1874, p. 14.
Introduction to the Study of Diseases of the Nervous System, 99
in vbieh similar phenomeoa have been obseryed. Dr. William Ogle, (Medico. Ghir. Trans.,
Vol. iii, p. 151), has reported an instance of probable deetrnction of the right ceryical sympa-
thetic ij abscess, in which the eyeball was retracted, the palpebral fissure narrowed, the
papil contracted, the right side of the lace redder and hotter than the left during repose, but
ifter Tiolent exercise or fever, colder ; the left side of the face alone sweated, and the right
side of the month and tongue were complained of es being drj. Dr. S. Weir Mitchell, in his
recent valuable work on the Ii^urie* of Nerve%^ Phila., 1872, pp. 318-321. (Also, Gunshot
Wounds and Other Injuries of Nerves, 1864, pp. 39-44), gives the following as the only
koowD cases of direct mechanical violence to the sympathetic nerve reported by the staff of
the U. S. A. Hospital for injuries of Nerves, etc.
WoMd o/ n^ iffMpalMie iwrv0 ; womud htaltd fa >te waefa ; oare6rai «|fiN|)tom« ; conlrtutel piipti; fU)ri»; lackryma-
EAfori M0«mt§., aged twenty-foar ; wounded at ChaDceHorarille, May 3d, 1863 ; was standing erect, and looking
tovudi tiM left ftde, when a ball entered hie right neck, one and half inchee behind the ramni of the Jaw at the
ast^nor edge of the itemo-cleldo-mastoid muede, paaeed acroee the neck, rising a little, and emeiged immediately
t«k»v, sad a half inch In front of the angle of the Jaw on the left side. He fell senseless, and may have remained so
doing belfsa hour. On awaking, he found his month full of clotted blood, which he pulled out; the bleeding had
ceised. After a short reat he was able to walk nearly three miles to the rear, where his wounds were dressed witii
cold wUsr. On his way he discovered that his speech had become hoiuse, difficult and pttinful, and that d^lutition
jSsvcriw to great uneasinees and to burning pains. * * Aiter fire days of great suffering and utter iniUrflity to
svdlow.he obtained some relief; but for a month or more was forced to take a little water after erery mouthful of
fbcd. the poww to swallow gradually improved, and is now as good as it ever was. A week after he was wounded
)m vss able to artlcsilate without pain, although hoarsely. This difficulty also lessened by slow degrees. * * During
U* reoorety, which was rapid the wounds healing within six weeks, he had a good deal of pain in the back of the
Btck. He says that he had headache, whenever, aAer the ii^ury, he attempted to walk flur, or exert himself. About
««e omith after he was hurt, a comrade noticed the peculiar appearance of his right eye, and called his attention to it.
A littl« later it began to be troublesome in bright lights, and has rsmained so ever since, with of late some change
fer tbe better.
JbIj 15th, 1863. — Pupil of the right eye Is Tory small, that of the leit unusually large. There is a slight but very
fitinct pto^ of the right eye, and its outer angle appears as though it were droppmi a little lower than the inner
angle. The ball of the right eye looks smaller than that of the left. These appearances existed whether the eye was
'ipra or closed, and gave to tinat organ the look of being tilted out of the usual position. The coi\JunctiTa of the
lifht eye is somewhat redder than that of the left, and the pupil of the right eye is a little deformed, oval rather than
nmnl * • The left eye waters a good deal, but has the better vision, the right eye having become myopic. In
^aligtkt he sees well at flist, but after a time, observes red flashes of light in the right eye, and finally, after long
eipoesre, sees ttie same appearance with the left eye also. * * Has lost flesh and strength since he was wounded .
About Aogust 30th, the patient rode to the office of Dr. Dyer, who examined his eyes with the opthalmosoope, but
^ad DO abnormal external appeaiances. Mooney walked fh>m Dr. Dyer's office to the hospital, an unusual exertion,
af hf «B8 weak, and avoided exercise, on account of thelieadache it caused. An orderiy who was with him on this
'CcarioB, raoiarked to one of the hospital staff upon the singular appearance which his uce presented after walking
la ih« heat. It becsune distinctly flushed on the right side, and pale on the left. This fi^ct was afterwards observed
«aev by one of us. The patient had used exercise and had Just come in. The right half of the fsce was very red.
Tli^fluh extended to the middle line, but was less definite as to ito limit on the chin and lips than above these
pDion. He complained of pain over tne right eye, and red flashes in that oigan.
A ccrrfQl thermometric examination, mi^e diring rtpote^ showed no difference in the heat of the two sides within
tbe month or ear. * * Under a tonic ooune of treatment he gained ground rapidly. Tbe eyes became less sensi-
tive the popUs sDore neariy alike, the line of the lid stralghtor. * * He was at last able to return to duty October,
Eslfoberg and Guttman*, refer to two cases of injury of the sympathetic of similar kind.
Whilst in the preceding cases, injaries of the sympathetic nerve were attended with con-
traction of the papil and congestion of the conjunctiva, as in the experiments, upon* certain
taimals, detailed by Reid and others, it is worthy of note that the changes did not result in
tbe destruction of the eyes hy inflammation as occurred in some of the experiments of Petit,
t)opiiy and Btachet, but indicated rather marked circulatory disorder in the muscular struc-
tares of the blood-vessels supplied by the sympathetic. Brachet relates several experiments
U) ibow that injury of the sympathetic or destruction of its superior cervical ganglion is
attended by great vascular congestion of the anterior and middle lobes of the brain, producing
drowsiness and stupor ; the experiments of Dr. John Reid, however, did not confirm those of
X. Brachet. It ie worthy of note however, that pain in the head and stupor and loss of memory
were observed in the case of section of the sympathetic reported by Dr. S. Weir Mitchell.
CoQtractioB of the pupil, consequent upon lesion of the sympathetic in tbe neck, is not
noticed in the experiments of Cruikshank,^ Arnemann,' Mayer' of Bonn, and Brachet, whilst
this eftct is described by Petit, '^ Molinelli,^ Longet* Valentin^ and others. In tbe experi-
nenlsof Gamerer,' and Pommer,* detailed in the treatise of Stilling^^ on spinal irritation,
* Me Patholflgle dea Bympathetlcua anf Fhysiologischer Orundlage. Beriin, 1873. Pages 8-4),
1 PbiL TiaiML, 1796. Part 1.
t Tcfvnche fiber die B^eneration der Kerven, 8. 09-102. Gottingen, 1787.
3 Jounial dcr Chtmrgfie, Von Graefeund WalUier, Zehnter Band, S. 418, 1827 ; and Functions du Systeme Nerreaux
<isa|lkmsire. Oiapter U, 1830.
i a^BMrfre dans leqnel 11 est IMmontr6 que les Nerfs Intorcosteux Foumlssent des Rameaux, qui se Portent dcs
'«Viti ks Tenx ; dana V Historic de *1 AoadAmie Boyale des Sciences, AnnA, 1727.
d (V«iBeat BoDOBtenai, torn, iii, 1766, p. 280.
4 Aaalomle et Phyafologie dn Systdme Nervenz, etc, tom. 11. p. 363, Paris, 1842.
7 D« FuBctionfbaa Kervomm Oerebrallum et Nervl Sympathetlcl. pp. 109, 114, Bemso, 1839.
* Tomche fiber die Katur dn Krankhaften llagenerweichnng, 1828.
'> Betoage xar Katar, nnd Heilknnde. 1831.
^ PhTrioiogisclie, PaUiologiache una Medidnisch-Practische Untonuchungen tlber die Spinal Irritetlon, S. 1^9,
]«. Leiprig, 184a
100 Introduction to the Study of Diseases of the Nervous System.
uo change was observed upon the eyeball in the rabbit after section of the sympathetic and
▼agus in the neck ; similar results were obtained by Arnold, in bis experiments npon hens and
pigeons, and he concludes that the effects upon the eye, which follow lesion of the Tagas in
the dog, depend upon the injury of the sympathetic and not of the vagus, as had been con-
clusiTely established by the experiments of Reid on the cat. Longet also determined that in
the rabbit, the contraction of the pupil was dependent upon section of the sympathetic and
not upon that of the ragus. From his careful and extensire experiments, Valentin concluded,
that the iris derives its motor filaments from two sources — from cerebral and from spinel
nerves ; its cerebral motor filaments come from the inferior branch of the motor oculi nerre :
its spinal motor filaments from the spinal cervical nerves ;^ these latter in the rabbit come from
the superior cervical nerves, and enter on their passage upwards, the superior cervical gan-
glion of the sympathetic and the ganglion of the trunk of the vagus (ganglion inferius. t
In the dog, on the other hand, they come also from the lower spinal cervical nerves, and join
the united trunk of the vagus and sympathetic in the lower part of the neck. The cerebral
filaments move the circular muscular fibres of the iris or the contractor muscle of the pupil :
the spinal filaments move the radiating muscular fibres of the iris, or the dilator muscle of the
pupil. When therefore the spinal motor filaments are cut in the neck, the dilator muscle is para-
jyzed, while the contractor muscle, no longer antagonized by the extensor muscle, is perma-
nently contracted, and the pupil is consequently diminished in size. Valentin infers, that the
arrangement of the spical motor filaments of the iris in the human species, resembles that of
the rabbit ; and he also expressed the belief that this view of the motor nerves of the iris,
being derived from two different sources, and supplying antagonist muscles, will not only
explain the effects of lesion of the sympathetic and vagus In the neck upon the iris, bat
enable us to understand the variety in the condition of the pupil as to contraction and dilatation
in certain diseases, which have hitherto puzzled medical men, and also clear up some ana-
tomical anomalies in the origin of the ciliary nerves which have been recorded. Mr. Paget,**
mention* several cases of injuries of the brachial plexus at the base of the neck, in which the
pupil of the eye on the side injured, was altered In size. Dr. Hugh lings -Jackson suggested to
Mr. Paget that the change in the pupil, in injuries of the brachial plexus, might be due to the
relations of this plexus to the cllio-spinal portion of the spinal cord. This region, as we have
just seen, was first indicated by Valentin, and subsequently more fully investigated by Badge
and Waller and extends from the first cervical to the sixth dorsal vertebra, or even so low aa the
tenth, according to Brown-Sequard. Within these limits irritations of the cord act on the
pupil, precisely as do similar agencies addressed to the sympathetic nerve itself.
M. Claude Bernard, in 1852, laid before the French Academy his remarkable experiments
on the sympathetic system. (Comptes Rendus, vol. xxxiv., p. 471 ; Premiere Semestre.
Pevrier, 1852.) Having divided the sympathetic in the neck of a rabbit, this distingaished
French Physiologist observed an elevation of temperature in the tissues on that side of the
head, ranging between 5^ and 7" Fahrenheit. When contrasted with the uninjured side, this
increase of heat was plainly perceptible by the hand, and admitted of accurate measurement
by the introduction of the bulb of the thermometer within the nares, or into the external audi-
tory meatus. While however, this development of heat was most evident on the side of the
neck where the sympathetic had been divided, and least so in the opposite corresponding
region, where It had been left uninjured, the whole body shared, to a certain extent, in its pro-
duction, and exhibited evidences of a temperature exceeding the nstural standard ; indeed,
not much difference was apparent between the warmth of the abdomen and rectum and that
of the side of the head which had undergone mutilation. This elevation was not a transitory
phenomenon, bat persisted with remarkable steadiness till the animals were killed ; and even
after death, Bernard found the side of the neck, on which the experiment had been practiced, the «
last part of the body to lose its vitnl heat — the last in fact to die. No signs of inflasimation
or of any other disorder exhibited themselves, to which this aagmentation of temperatare
might be reasonably referred ; for although, in the first instance, it was accompaaiad by
increased vigor of the circulation and vascular turgescence, yet these conditions subsided in
a few days, while the temperature itself, showed no symptoms of diminution. When the sjm-
pathetic nerve in the neck was divided, or the superior cervical ganglion extirpated, the tem-
perature of the side operated on increased rapidly, and in some cases in a quarter of an hour
had risen 11^ F.; the arteries and smaH vessels dilated, and became much more full of blood
than those of the opposite side ; the pupil contracted, as well as the palpebral open-
ing, while the globe of the eye appeared depressed in the orbit ; the hyperaemia, which is
the immediate result of the operation, subsides considerably in a day or two; but the eleva-
tion uf temperature is much more persistent, lasting in rabbits 16 to 18 days, in dogs 6 week»
to 2 months. Bernard has shown, that not only the superficial parts, but the deep*seated.
and even the blood returning by the jugular vein, is hotter than the corresponding parts 1»f
the healthy side, or than they themselves were previously. Both Bernard and Brown-Sfquani
Introduetion to the Study of Diseases of the Nervous System. 101
hare obserred thai the temperature on the sonnd side falls below its 'prer ions figure, the
difference in one experiment amounting to 6^ F.
The important circumstance has also been noted, that the phenomena just described are
more prominentlj marked in healthy and vigorous animals than in those that are weakly,
and in those that are digesting food, than in those that are fasting. When an animal whose
cerrical sympathetic has been divided on one side is exposed to a temperature above that of
its own body, the side where the nerve is entire gains heat, while the other remains almost
unchanged ; and before long no difference can be detected between them ; on the other hand,
when the animal is placed in a medium considerably colder than its own body, the difference
between the normal and the operated side becomes more prominently nAirked ; the former
losing heat much faster than the latter, and the thermometer showing that it may become as
much as 21° F. colder than its fellow.
Brown-S^qnard,* found that the phenomena which follow section of the cervical part of the
sympathetic, are mere consequences of the paralysis and therefore of the dilatation of the blood-
vessels ; the blood finding a larger way than nsual, arrives there in greater quantity, there-
fore, nntrttion is more active, and the sensibility is increased, because the vital properties of the
nerves are augmented when their nutrition is augmented. As to the elevation of temperature.
Brown-S^qnard, has seen as M. Claude Bernard has, that the ear exhibits sometimes, one or
two degrees Fahr. more than the rectum ; but the temperature of the rectum is a little lower
than that of the blood ; and as the ear is full of blood, it is very easy to understand why it
has the temperature of the blood. Brown-S6quard based his opinion in part upon the fol-
lowing important experiments: If galvanism be applied to the superior portion of the sym-
pathetic after it has been cut in the neck, the vessels of the face and of the ear after a certain
time begin to contract ; their contraction increases slowly, but at last it is evident that they
resume their normal condition, if they are not even smaller. Then the temperature and sen-
sibility diminish in the face and the ear, and they become in the palsied side the same as in
the soand side: Brown-S6quard concludes, that the only distinct effect of the section of the
cervical parts of the sympathetic, is the paralysis and consequent dilatation of the blood-ves-
sels ; that the cervical sympathetic sends motor nerve fibres to many of the blood-vessels of
the heart ; and that the blood-vessels are contractile, and that the nerves are able to put
them In action.
It wac long known that certain injuries of the nervoos system might be followed by a par-
tial or even general elevation of heat. Chossat found a considerable diminution in the tem-
perature of dogs, after the section of the inferior portion of the spinal cord ; but in two cases,
where the spinal cord was divided at about the level of the last dorsal vertebra, he found an
increase in the animal heat. In one of these experiments the increase was from 105^.98 F.
to 106*. 7 P.; in the other from 105^.98 F. to 109<'.6 F. {Uhm. sur Tinfluence du Syst. Nerv.
Sur la Chal. Anim : Th^se de Paris, No 126, 1820, p. 35, Exps. xxiii and xxiv.) An increase
in the temperature of parts paralyzed in consequence of the division of their nerves, was also
noticed by Dr. Macartney, (Treatise on Inflammation, 1838, p. 13.) H. Nasse, who made
many experiments on this subject, sometimes observed an elevation in the temperature of the
paralysed parts after the division of the sciatic nerve, or after the partial destruction of the
•pioal cord, (Vutersnrchunger Zur Physiol, und Pathol., 1839, v. ii, p. 190.)
Brown-S^quard has seen several cases, in which an accidental injury of the spinal cord was
attended with marked elevation of temperature. The most remarkable of them, was that of
a man who was admitted into St. Oeorge^s Hospital, In whom there was a forcible separation
of the fifth and sixth cervical vertebrae, attended with an effusion of blood within the theca
vertebralis, and laceration of the lower part of the cervical portion of the spinal cord. Res-
piration was performed by the diaphragm only, and, of course in a very imperfect manner.
The patient died at the end of twenty-two hoars ; and for some time previous to his death,
be breathed at very long intervals, the pulse being weak and the countenance livid. At last
there were not more than five or six inspirations in a minute. Nevertheless, when the ball of
a thermometer was placed between the scrotom and the thigh, the mercury rose to 111^ of
Fahrenheit scale. Immediately after death, the temperature was examined in the same man-
ner, and foond to be the same. In more than twenty experiments, Brown-Siqnard, only
once found an increase of temperature of the leg of a guinea-pig, after the section of the
sciatic nerve. This increase lasted about two or three days after the operation, and amounted
to 3* F. After a complete transversal section of the spinal cord in the lumbar region, in birds
and mammals, Brown*S6qnard, found repeatedly, an increase of one, two or three degrees Fahr,
in the temperature of the paralyzed part; and he ascertained that it is not in consequence of
an increase of the general temperature of the animal, that such an increase exists — it is to be
foand only in the paralyzed part. Brown S^quard never found any increase of temperature
after a complete transversal section of the spinal cord, either in the cervical or the dorsal
* Medical KzamiiMr, AngiMt, ISM. 8«« •!«> ExperUn^ntml RcMarcfaM, ftppUed to Pbjmloluicy and Puthulogy, liv
K. nrown-Mqpfd, New Yorii, lSft3, p. 9, p. 7.^.
102 Introduction to the Study of Diseases of the Nervous System.
regioD. After a lectioa of a lateral half of the spinal cord, at the leyel of one of the three or
four last dorsal Yertebrse, he almost constantlj found an increase in the temperature of the
posterior limb on the side of the section, the eleyation varying from one to four degrees Fahr.
but on the contrary, there was a diminution of from one to fire degrees Fahr., in the temper-
ature of the other leg. In some cases, in consequence of the increase of temperature on one
side and its diminution on the other side, the difference in the temperature of the two limbs,
amounted to from six to seven degrees, Fahr. ; and together with the increase of temperature
in one limb, there is an augmentation of sensibility, and with the diminution of temperature
in the other limb, there is also a diminution of sensibility.
From the preceding facts, Brown-Sequard drew the following conclusions :
1st. An injury of the nerTous system may produce in the parts, which then become par-
alyzed, either an increahe or dimiuutiou of temperature.
2d. The sympathetic nerre and the cerebro-tpinal nervous system appear not to be differ-
ent one from the other, in this respect.
3d. The degree of temperature of paralyzed parts, depends on the quantity of blood they
receive ; and this quantity varies according to the size of the arteries and capillaries of these
parts.
4th. Ii is a fact hitherto unexplained, that the arteries and capillaries may be either
dilated, normal or contracted in paralysed parts. (Experimental Researches applied to Phy-
siology and Pathology, pp. 73-77.)
More latterly, Bernard has discovered that section of the lumbro-sacral plexus, or of the
sciatic nerve was followed by an elevation of temperature in the posterior limbs thus treated,
and also that section of the brachial plexus about the first rib, was followed by a rise of tem-
perature in the corresponding anterior extremity. By recent investigations, Bernard has
found that there are two sets of nerves in the cervical sympathetic, one oculo-pupillary,
arising in the dog from the anterior roots of the two first dorsal ; and the other, vascular and
calorifice, arising from the sympathetic ganglia. He also states that division of the anterior
and posterior roots of the nerves proceeding to the posterior extremity, in dogs causes para-
lysis of motion and sensation, but no change of temperature or vascularity ; division of the
sciatic nerve, however, raises the temperature 6^ to 8° G. (11° to 14° F.). and increases the vas-
cularity. Division of the sympathetic nerves has the same effect, but causes no paralysis.
Bernard attributes from these observations, more importance to the proper fibres of the sym-
pathetic, than to those which it receives from the spinal nerves in controlling the local circu-
lation. Bernard has also recorded the important observation, which has been confirmed by
C. Hanfield Jones,* Weber, S. Wier Mitchell,f and others, that oedema or inflammatory action
do not supervene after division of the cervical sympathetic, in the abnormally hot parts, so long
as the animals continued in good health ; but if they fell aick, either spontaneously or from
the effbcts of other operations, the mucus membranes of the eye, and nose on the operated
side onfy became very red, swelled, and poured out purulent matter abundantly. If the ani-
mal's health improved, these inflammatory phenomena ceased
Upon the results of his experiments upon the sympathetic, Bernard built the theory of a
special influence of the sympathetic upon the blood-vessels, and upon calorification, and -dis-
tinguished the sympathetic system from the motor and sensory nerves, as being voM-motor
and calorific nerves.
Bernard} thus formulated his ideas : —
1. Division of nerves of sensation, besides producing ansesthesia, diminishes the temper-
ature of the parts supplied.
2. Division of the motor nerves, besides causing paralysis, g^ves rise also to eoldnem m tht
parafyted partM.
3. Destruction of the sympathetic nerve, which neither produces muscular paralysis nor
loss of sensation, is accompanied with a constant and very considerable elevation of temper-
ature.
The most important questions which arose from the results of these experiments were :
First. When the sympathetic is divided, is the increased heat in exact proportion to the
excess of blood in the part ?
Second. Does the increment of heat remain within the range of temperature which is pro-
per to the internal organs of animals 7
Third. Is the regulation of the calibre of the blood-vessels and the rate of circulation in
a part dependent upon the proper fibres of the sympathetic, or upon those which al though
mixed with this system are derived from the spinal cord?
If the two first questions be answered in the affirmative, the phenomena following section
of the sympathetic have only a subordinate and comparatively insignificant relation to the
* 8tiidi«a on Functional Nerrous Dlaoiden, London, 1870, p. 30.
t I^JuriM of Ni'nre* and their cottMNin^noes, Flifladelphia, 1872, p. S2.
; L«voiw rar la Ptiydologle et U Fkthologle, dM BymoM Nenrenz, Vol. U, p. 490, (1858).
IiUroduction to the Study of Diseases of the Nervous System. 1(^3
prodactton of beat ; the section of the nerre merely causing hypersmia, the consequence of
which is, that the normal blood-heat is more perfectly attained and exhibited by the parts
thos more richly supplied with blood.
With reference to the third question, if the movements of the ressels depend upon the
eerebro-spinal system, then the tympatheUe ia not the tpedal vato-motor nerve.
Brown-S6quard* has shown by snbsequent experiments that the result of section of the
sympathetic is not so constant as Claude Bernard and himself had- at first admitted. Thus,
in some rabbits, in which the two ears were warm and Tascnlar before the operation, there
was no decided increase in the rascularization and in the temperature of the face, and in
▼ery cold weather the extremity of the ear of rabbits, on the side of the section of the sym-
pathetic nerve, remains cold. And as we have seen, it results from the experiments of Brown-
S^nard, and from the observations and experiments of Brodie, Chossat, H. Nasse, Macartney
and others, that the following opinion of M. Claude Bernard is incorrect. He says : ** It is
known that injuries of the cerebro-spinal nervous system, constantly produce a total or a
partial diminution in the temperature of animals, either when a nerve has been divided, or
when the injury is made on the nervous centres.''! He says also, that an injury of the sym-
pathetic nerve produces a very rapid increase of temperature ,* so that the sympathetic nerve
and the cerebro-spinal nervous system are completely different, one from the other, as to
the influence on animal heat when they are injured ; the one increasing, the other diminish-
ing animal heat. Brown-S6quard has shown, however, that these two effects, vis : increase
and dimtnatioa of animal temperature, may follow an injury of either the sympathetic or
the cerebro-spinal nervous system ; and in both cases, the increase may exist, at first, and be
followed by a diminution.
Bndge| found, that the elevation of temperature is not only produced by division of the
sympathetic, but also that injuries of that part of the spinal marrow which lies between the
seventh cervical and the third dorsal vertebra, which thus includes the eighth cervical and
the first and second dorsal nerves, has the same effect on the temperature of the head.
Waller] attributes the rise of temperature simply to the paralysis of the circular fibres of
the smaller arteries, and the increased supply of blood thus induced by the section of the
sympathetic : De Buy ter,JI noticed no alteration of temperature which could not be explained
by the increased accessor blood: andDondersf remarks, that in these experiments the temper-
ature of the ears very seldom exceeds that of the rectum, that it is high just in proportion to
the amount of blood sent to the ears — that ii diminishes wheif they are congested — and that
after ligature of the carotid, the temperature of the ear on the side of the section is not higher
than that of the other side, and that if the ears are forcibly rubbed the temperature in both
is alike. Kn numerous experiments Schiff** observed that the difference of temperature
of the two sides of the head (of the ears), may be very considerable and amount to even
21.^6 to 28.8* Fahr ; that the difference of temperature was proportionate to the diffierence in
the quantity of blood in the parts, and that when (as exceptionally occurs), the section of
the cervical sympathetic has no effect on the vessels of the ear, there is also no elevation of
temperature. Schiff refers the increased fulness of the vessels to paralysis of the blood-
vessals, and the increased local temperature to the larger quantity of blood circulating
through the part. He also propounds the theory that the sympathetic is not the sole and
exclaaive vascular nerve of the head, but that the cervical, auricular, the facial, and the tri-
gemioas nerve have a similar function ; and that the part of the vaso-motor nerves of the
bead, which is actually contained in the sympathetic consists entirely of the spinal nerve
fibres coouined in it ; that the vaso-motor nerves pass through the spinal cord, and that a
part of the medulla oblongata must be regarded as the centre for the vaso-motor nerves,
becaase those of the head and trunk both meet there, fie maintains that in complete spinal
paralysis of a part, the temperature of this must be elevated, whilst in incomplete, (i. e.
paralysis of motion only), the temperature must be diminished. Schiff claims to have esub-
lished by experiments, that the vaso-motor nerves of the face, and of the distal portions of
the extremities on the one hand ; and those of the trunk, the arm (above the elbow), and the
upper part of the thigh, on the other hand, form two distinct groups which keep perfectly
separate In their course through the spinal cord, so that the latter group of vascular nerves
decussates laterally, as does the corresponding group of the other half of the body, which
those of the first group fail to do ; and further, that when a section is made of the left half
of the spinal cord near the medulla oblongata, the vascular nerves of the skin of the face, of
tbe hands and feet, and of the lower part of the fore-arm, and of the leg (below the knee) of
* Kzpefiamital BM—rehet iwpU«d to Phvslologjr uid Piktholog}', pp. 76-7C.
f Gai, Mad. d« Puli, Vol. 7, jlo. 14, p. 287 .
t* Goaptai B«odM, szXTi, 377.
OompUm B«odva, xxxrl, S7S, 1S53.
PtMirt, tfe AcHoM, Atropn Belladoonc, ISftil.
r AaatM KIngMi Tu bet Cb, Oetr., 18fi3.
** UatewochaDgto war Fhyaiolosief <!«• H^nrM Systenui, i, IM.
104 Introduction to the Study of Diseases of the Nervous System.
the left side, and on the other side (the right), those of the trunk, the arm (above the elbow),
and the upper part of the thigh are paralyzed. In subsequent experiments, Sehiff,* excited
fever, by the injection of pus into the pleura, or into the vascular system in animals, in whom
be had previously divided the left cervical sympathetic, or resected the nerves of one extrem-
ity. As soon as the fever set in, the parts unaffected by the section of the nerves, began to
rise in temperature, whilst in the parts suffering from the vaso-motor paralysis, which were
previously warmer, the temperature either did not rise at all, or only very slowly ; and when
the febrile temperature was fully established, the organs which before were warmest (the
nerves of which were divided), were colder than the corresponding parts of the other nnio*
jured side. He concluded from this, that the paralytic hyperaemia, induced by the nerve
section, and that induced by fever, (and congestion), do not depend on the same process ; that
the latter is of a much more Active nature, and that therefore, there must exist in the nerves
of the blood-vessels, such elements as, when stimulated, cause an active dilatation ; bot
after section of the nerves, this is no longer possible.
Kussmaul and Tenner,* reduced the increased warmth of the ear, of the side on which the
sympathetic was divided, below that of the other ear, and even lower than that of its own
temperature, before the section, as soon as in addition to ligating or compressing the carotid
on the same side, they also ligated the two subclavians at their origin, and thus prevented
the establishment of the collateral circulation : on the other hand, they procured an elevation
of temperature, if they only ligated the subclavians, and thus increased the lateral pressure
of the blood in the carotid. Compression of the carotid on one side, after previous ligature
of the subclavians, produced parallel results, whether the sympathetic was previously divided
or not, and the section of the sympathetic produced no greater increase of heat than the in-
creased pressure of the blood. On the other hand, Lussana and Ambro8oli,f after suspending
animals by their hind legs, did not find so great an increase of temperature in the ears, as
they did after division of the sympathetic; and they express the view that a local pathologi-
cal process of blood dissolution, induced by the section of the sympathetic, causes the
elevation of temperature, and not mere hyper«mia,or increased functional activity. Sehiff |
confirmed the observation of Brown-S^quard, that complete division of one lateral half of the
spinal cord in the dorsal region, was followed by a rise in temperature in the hinder extremity
of the corresponding side, and a fall of temperature in the opposite limbs.
Tscheschichim,} after complete section of the spinal cord, in a variety of situations, oh.
served uniformly, a suppressioh of the active operation of the vessels, and a falling of the
general temperature, in addition to the loss of voluntary movements ; and he considers the
primary cause of this diminished warmth, to consist in the paralytic dilatation of the vessels,
their overfnlness of blood, (and especially in the veins,) in the hindrance of the free circula-
tion of the blood, and consequently in the increased radiation, or loss of heat. He found that
the rapid sinking of the internal temperature after division of the cord, might be diminished,
or even prevented, by enveloping the body in bad conductors of heat, (wool, cotton, etc..)
thus hindering the loss of heat from the surface of the body. When however, be divided the
meduUa-oblongata in a rabbit, near to its Junction with the pons, he found that immediately
after the operation, the general temperature began to rise, and the pulse and respirations
were greatly quickened ; after half an hour the temperature was from 102**. 92 to 104^. 18 F. :
after an hour, it rose to 106^. 16 F., while the respiration ranged from 78 to 90, and it was
impossible to count the pulse. Immediately after the operation, the reflex phenomena became
unusually evident^ and the least touch excited convulsive movements of the whole body of the
animal. After an hour and a half, the temperature reached 107^. 96, P. : after two hours, 108*'.
68 F. ; more rapid breathing and convulsions set in, under which, in half an hour more the
animal died. Tscheschichim, connects these facts with the theory of centres of control, which
have their seat in the brain, and regulate the activity of the spinal cord. By the eeaaeless
activity of these, the intense activity of the spinal cord is diminished ; when they are destroyed
or isolated, the activity of the spinal cord is morbidly increased, and for some time exhibits
in excess of functional activity, (increased reflex action, quickened respiration, acceleration
of the cardiac systole and increased animal heat.
Naunyn and Quincke,|| asserted, that after crushing of the upper part of the spinal cord,
remarkable elevations of temperature were only met with, when the animal was prevented
from losing heat, otherwise there was always a rapid sinking of temperature lasting till
death ; and they conclude that injuries of the cord have a two-fold operation,— an increase
of warmth production, and an increase in the amount of heat given off. The contradictory
results obtained by different observers, are explained by these contrary forces. They also
observed that the rise of temperature was more rapid when the cervical portion of the medulla
" Allftra Wi<>ni»r, M«l. ZHtg., IH.VJ, p. :\}k
t Molc«chutts Untcmui'liqiiirva Zur Nmnn'ltiu *\*'-* M4*ii«-h«'n itn-l <l«'rThmni. lK.'>«i, p.!iiw|:l2.
* (!iijM>ttl I^inilMinU. 1M4;7. Nm. i-WU.
f Untt'ninrhiingcn, p. Hiti.
tUiclirrt'* Anhlv., Iw^;, p. V'i.
Introduction to the Study of Diseases of the Nervous System. 105
WAS divided, than when the section wm in the dorsal portion. These observers have also
shown, bj experiments, that after division of the spinal cord, the temperature can be kept at
a low degree bj means of quinine, which limits the production of heat.
Orig Mitlheil, believes that he has met with cases, which justify him in concluding that
there is a centre in the cervical portion of the cord, for limiting the temperature, by irritating
which, there is a decrease of temperature ; by paralyzing it, there is an increase of heat ; and
that this centre is to be looked for in the anterior fibres of the cervical portion of the spinal
cord. Brener and Chrobok,* have investigated the question, whether the nerves of a part
supply the stimulus which causes the febrile elevation of temperature in an infiamed part, by
means of experiments on animals, in whom they have as far as possible divided all the nerves
of one part of the body. After the injuries caused by the operation have healed, they have
set op local inflammations in the nerveless part ; and they think themselves justified in con-
cluding that the fever of the traumatic inflammation is independent of the nervous connections
of the inflamed part with thee nerv centres.
Clinical observations furnish only a few cases exactly analogous to the results of experi-
ments on the relations of the nervous system to the temperature of the body ; but Wunder«
lich, alter an elaborate review of many of the facts Just recorded, considers the following as
analogoas spontaneous coiAitions :
1. The local alteraUons of temperature in neuralgias during the paroxysm of pain.
2. Observations of temperature in paralyzed parts.*
3. Observations on variations of temperature in those forms of disease which are con-
sidered as vaso-motor neuroses.
4. The effect* of mental exertion or excitation in elevating the temperature in cases of
disease, the eflSects of different kinds of delirium, and the moderation of febrile temperature,
which is sometimes observed after a quiet sleep.
5. The great elevation of temperature in acute (rapid) inflammation of the brain.
6. The more enormous elevation of temperature in injuries destructive of the spinal
cord.
7. The very disproportionate rise of temperature at the end of tetanus and other fatal
nenroses.
According to Wonderlich, these facts are favorable to the theory, that a large share in the
regnlalion of heat, belongs at least in complex cases to the nervous system ; the influence of
certain nerve tracts on the activity of the heart on the one side, and on the circulation on the
other, is indeed indisputable ; and on this account it may be safely assumed, that alterations
in the assonnt of blood in the peripheral vessels, influence in more ways than one, the warmth
of the places concerned, and of the general temperature also. A great part of the pathologi-
cal phenomena of warmth, may be only the expression of the action of the vaso-motor nerves ;
and perhaps, even in actual diseases of the nervous system, the fluctuations of temperature,
partiealarly if slight, must be attributed to an alteration in the circulation. But it appears
from the lesions of the nervous system which are attended with enormous elevations of tem-
perature, that some hitherto unknown power has sway over animal heat, since the most
reaaarkable alterations of temperature occur with profound disturbances of the nervous
system, withont corresponding anomalies of circulation, and according to Wonderlich, it is
perhaps not too much to affirm, that the integrity of certain parts of the central nervous
apparatns is more necessary for the regulation of animal heat, than that of any other part of
the body.
Sanoelf has advanced the hypothesis of the existence of fibres, distinct from the motor
nerves of mascles and vessels, as well as from the sensory, whose office is to preside over
natrition, and which are divisible into a centrifugal and centripetal set ; the centrifugal when
excited, incrcM^ nntrition, when paralysed, decrease it; on the other hand, paralysis of the
centripetal fibres, is the cause of the diminished resisting power of anaesthetic parts to injuries.
Samnel, regards fever and inflammation as states of excitement of the trophic nerves; and
atrophies as the reverse. Samuel, records various experiments in which irritation of sensory
and compound nerves caused intense inflammation of the parts to which they were distrib-
oted. Weber has strongly controverted the views of Samuel, and concludes thet the influence
of nerves upon inflammation is nothing else but the influence exercised by them upon the
blood-vessels, and that inflamosation cannot be caused either by paralysis or irritation of
nerves. Whilst it most be admitted from the various facts recorded by different observers
coadoctiag independent investigations, that certain nerves, when stimulated, do excite an
ioflneace in the districts to which they are distributed, in the way of increasing the amount
of blood cireolatiog through the tissues, by antagonizing the ordinary vaso-motor nerves
accompanying the arteries, whose activity induces the opposite condition ; at the same time it
«
• WIeacr Madk, Jahrtrflckw, XIT, p. 3, 1S67.
t Dl« TlophiiM N«rT«o, Letpdg, WigMid, ISSa Oust Jahr., ▼•!. 11. p. 63-«7, ISSl.
14
106 Introduction to the Study qf Diseases of the Nervous System.
is doubtfal whether the 80'C«Ued trf>pkit Denres are indeed « gpecial set, or whether the tame
effecte maj not be produced through ordinarj motor and lentorj nervee.
Againit the doctrine, that the cerebro-spinal and sympathetic oenrons tjttem, may direcUj,
bj means of special systems of nerreS| as the viuo-moUtr^ trophic and inhibiiory direetlj increase
or diminish animal heat, and directly increase, diminish or alter nntritioo and secretion, the
following facts and arguments may be opposed.
The well known and almost nniTersally acknowledged facts, that no nerrj cells or nerre
fibres are found in the entire vegetable kingdom, in which the processes of secretion, excre-
tion, and progressive development of complicated structures and organs, are manifested in
perfection ; that in the lowest or most simply constituted aoimals, in which development,
digestion, nutrition and secretion take place, as in the more complicated animals, no nervea
have been detected ; that abnormal products, as the various forms of tumors and cancers, are
developed from special germs, without any special nervous intervention, and present nniform
products, no matter whether the tissue in which they arise, be well or illy supplied with
nerves ; as well as the possibility of cutting out and transplanting organs, as the testicle,
from one tissue to another, without interfering with the process of growth and secretion ; and
the independent vitality of the cells everywhere, throughout the most complicated animala,
and the apparent impossibility of reproducing the more highly organized tissues in the most
highly organized animals, when destroyed : may be regarded as satisfactory proofo, that in
animals, the process of development, nutrition and excretion, may go on without the inter-
vention of a- nervous system, and that even in the most complicated animals, the proceaa
stands in no such relation as that of cause and effect to the nervous force.
The nervous system makes its appearance at a certain stage of development, and is so to
speak, a product of preceding Tital action. The fact is true of the animal kingdom in ita
successive stages of development from the most simple organism, to the most complicated,
and also of the development of the solids and fluids of each highly organized animal, that
there is a simultaneous development of the rarious organs and apparatus, without the de-
pendence of the one upon the other. Thus in the case of the human foetus, the most com-
plicated forms of apparatus, as the respiratory organs and accompanying respiratory muscles,
are developed and perfected, whilst the system destined to preside over these functions after
the birth of the animal, is without any known or demonstrable influence upon the develop-
ment and perfection and action of the respiratory organs and muscles. The entire brain and
spinal cord may even be absent in the fcetus, without any arrest of development of the mus-
cles and thoracic and. abdominal organs. In the foetus, the development and perfection of the
entire muscular system appears to be wholly beyond the sphere of the cerebro-spinal system.
The entire organic life of animals, or everything which goes on in them, without the interven-
tion of sensation or any other mental act, may go on without the intervention of a nervous
system. Chemical change In the organs and apparatus, and chemical change in the nervous
system, is the source not only of heat, but of muscular and nervous force, and of all the
forces generated in the animal economy. All the acts called vital, and nervous, and masea-
lar, by many physiologists, such as the contraction of the muscles and the transmission of
impressions, to and from the nervous sensitive centres, along the nerves, are doe to the chem-
ical cbsnges of those elements which have been separated from ozygen and elevated into a
state of force (capable of chemical change,) by the forces of the sun, acting throngh special
organs, in the vegetable kingdom. There is a change of force in direction and mode of
action, but there is no creation of force. Physical and chemical actions take place in a simi-
lar manner in all animals, simple or complex ; they differ only in intensity. The higher the
animal, the more complicated its parts, the more rapid the chemical changes, and consequent
generation of the forces, and the greater is the necessity for some special apparatus, which will
bring all the complex organs and apparatu.^, and actions into harmonious relations. Unless
the actions of different organs can be telegraphed (so to speak) to each other, contusion iu a
complex organism will necessarily rennlt. Thus if the amount of blood circuUtlng throngh
any organ be too great or too little, there must be some medium of communication, and some
means of regulatiog chemical and physical actions, through that special apparatus by which
the circulation of the blood which furnisher the elements of chemical change may be increased
or diminished. The nervous system forms the medium of communication between the iotel-
leeiual faculties and the exterior world, it connects together and influences the various organs
and apparatus, it regulates secretion and excretion, and the consequent development of thr
animal forces, br regulating the circulation and respiration, and it excites and controls the
dynamic mur^cnlar apparatus, not by the possession or emission of a peculiar force generated
de noro^ but rather by a modification of physical force generated by the mutual reactions of
the blood and nervous system. To the nervous system is delegated the property of regulating
the action of the circulatory and respiratory apparatus, and thus it controls the amount of
oxygen and blood supplied to the orgsns. The blood supplying the nutritive elements of the
tissues and organs, and the materials for the secretions and excretions, and development of
the forces, and oxygen being the active agent in all the chemical actions of living beings, it is
Introduction to the Study qf Diseases qf the Nervous System, 107
•rident ibftt whaUver diiiarbs Uie constitation of the nerToas system, necessarilj disturbs
ib« fancUona of the «pp»ratas and orgaoSi «nd prodooes correspooding alterations in the
ecerttilons and excretions. As the iaiegrity of the nerrous system, depends upon the integrity
of tbe blood, in like manner, wbaiever alters the constitution of that fluid, will produce
aberratad action in the nerrons system, and in turn, this disturbance may extend indefinitely.
The view which has been held by some physiologists, that the production of animal heat,
is e$9entiaUjf dependent on nervout agency^ independent of chemical change, is evidently errone-
OQs, for the following reasons : Heat is generated in the Tegetable kingdom during the
chemical changes of the nutrition and growth of the cells, without the intervention of neryes;
so also to certain diseases, a large amount of heat is generated after death, and the cessation
of all nerTOQS i^enoy. The eteyated temperature of inflammations and fevers, is attended
with a corresponding increase of chemical change in the blood and organs, as is evidenced
by the greatly increased amounts of urea, phosphorie acid, sulphuric acid, and extractive and
coloring matters in the urine, and carbonic acid in the expired air. Certain agents, as pus
and putrid blood, are capable of inducing decomposition and rapid chemical change of
the blood when introduced into the circulation. We cannot in the living body, any more
than in the exterior organic world, derive physical force and motion from nothing ; it must
arise from pre-existing motion or force. The chemical changes of the human body, have been
sbowo by careful experiments, to be sufficient in amount and character to develop and main-
tain animal temperature. When the true calorific equivalents of carbon and hydrogen, are
used io the calcnlatioa, and the relatively minute quantities of phosphorus and sulphur, are
also iaeloded, the heat produced by the various chemical changes in the animal body, is
adeqoale to maintain a definite degree, corresponding to the normal temperature, and to com-
pensate for the heat dissipated by radiation, and by the evaporation of the fluid transpired
through the skin and lungs. The nervous system may influence the amount of heat, by
inflaencing the respiration and circulation, and possibly also by the conversion or transmuta-
tion of its peculiar physical, nervous or electrical force into heat. Depressions aad elevations
of the animal temperature, may also be due to chemical changes of an abnormal character in
the blood and iu the nervous and muscular structures, excited by morbific agents, which act
chemically upon the organic constituents; whilst at the same time, they may produce such
deraagemeat in the actions of the muscular and nervous systems, as to lead to a state of actual
proftralion and depression.
The view held by certain physiologists, based upon the results of the old experiments of
Petitf Cruikshank, Dnpuy and Bracket, upon the sympathetic, that the nervous system pre-
fides absolutely and wholly over secretion, and is capable of producing all the phenomena of
inflammation, and even the absolute derangement and destruction of complex apparatus,
has been greatly modified by the results of more recent and careful experiments ; and the
inflaeace of the nervous system and especially of the sympathetic, has been gradually nar-
rowed down within definite bounds. As we have shown by a careful exammation of the
labors of various physiologists, the marked tendency of the more careful experiments, is to
reduce the phenomena to tne action of well-known physical and chemical laws.
It has been well established that in the lower animals, the action of the heart, as well as of
the circulation and digestion, may continue for weeks after the destruction of the central
oiaas of the* nervous system. Thus Bidder carefully removed the arches of the cervical ver-
tebrm of frogs, so that little blood was lost during the operation, and then completely de-
slfojed the spinal cord. Frogs treated in this way often lived six weeks, and sometimes ten,
the cirealatioo in the web of the foot remaining at the same time active and not differing
from that of aninjured frogs. The heart beat powerfully and quickly ; in a freshly killed
frog, IB wialer, the^beart pulsated thirty-five times in the minute ; while in a frog, the spinal
cord of which had been destroyed twenty-six days previously, the pulsations were forty per
miaate. When the brain and spinal cord were destroyed, the medulla oblongata being left,
frogs were retained in life until the sixth day; and when the entire central 'organs of the
nerrons system were removed, they lived until the second day ; the rapid ensuing death in
the latter case being doe according to Volkmann, to the effects produced upon the respiration.
Witbio a 'ew weeks after the destruction of the spinal cord, the muscles of animal life were
found to have lost their irritability in a marked degree, and still later no contraction could be
prodaeed in them by application of chemical or mechanical stimuli ; the heart, however, in
4ach cases still continuedr to pulsate eleven times in a minute, and retained its property of
rcepoading to external stimuli. The intestinal canal, in like manner, retained its irritability ;
applieation of stimuli giving rise to contractions which were sometimes of a local nature, at
other times extended for a considerable distance on either side of the part stimulated. Diges-
tion in like manner, suffers but little from destruction of the central parts of the nervous
system : healthy frogs, and others, which had been operated upon, were, after being starved
for a considerable time, fed with worms, and kept in separate glasses. In the one, as well as
in the other, the worms, were found after twenty-four hours, to be fully digested, and the
stomach and duodenum, were filled with colored mucus; such was observed to be the case,
108 Introduction to the Study qf Diseases of the Nervous System.
aTen in aniiiials when the spinal cord bad been destrojed twentj-siz d«ji preyionilj. The
secretion of urine also continues ; when in animals in which the brain or spinal cord has
been remoTed, the bladder was emptied bj external pressure upon the walls of the abdomen,
in a short time it again became filled and distended to an enormous sise, unless emptied in the
way Just mentioned. It had been obserred bj Valentin and Stilling, that after destmction
of the spinal cord in the frog, different derangements in the nutritive processes ensued ; there
were frequently obserred dropsical swellings, especially of the limbs. On these also soras
formed, which often penetrated as far as the bones. In reference to these results, Yolkmann
states, they are, as shown bj Bidder, chiefly accidental. Bidder found that when the bottom
of the vessels in which the frogs were kept, was covered, not with water, but with moist graas.
or moss, no such degenerations ensued. The rapid death which ensues in warm-blooded
animals, when operated upon in the above manner, depends according to Yolkmann, upon
the difficulty of sufficiently keeping up the respiration by artificial means, as well as upon the
loss of blood and diminution of animal heat, (Gycloposdia of Anatomy and Physiology, Vol.
V. p. 467.)
The fV'equent occurrence of certain pathological changes, after section of the sciatic nerve
in mammals, has been cited as a proof of the dependence of the nutritive operations upon
nervous agency. In order to test this doctrine, the distinguished physiologist, Dr. R. Brown-
S^quard, about the year 1849, performed the following experiments : He divided the sciatic
nerve in a number of rsbbits and Quinea-pigs, and placed some of them at liberty in a room
with a paved floor, whilst he confined others in a box, the bottom of which was thickly cov-
ered with bran, bay and old clothes. In a fortnight, the former set exhibited an obviously die-
ordered action in the paralysed limbs ; the claws were entirely lost ; the extremities of the
feet were swollen, and the exposed tissues were red, engorged and covered with fleshy granu-
lations. At the end of a month these alterations were more decided, and necrosis had sopor-
vened in the denuded bones. On the other hand, in the animals confined in the boxes,
no such injuries had occurred ; and although some of them bad been kept living for four, five,
and even six months after the division of the sciatic nerve, no alteration whatever appeared
in the palsied limbs except atrophy. In these cases a portion of the nerve had been cat off,
so that reunion was nearly Impossible, and did not take place. Bxperiments made opon
pigeons gave the same results. It is obvious, from these experiments, that the pathological
changes which occur after the section of the sciatic nerve, do not proceed directly f^om the
absence of nervous action, but that they are consequent upon the friction and continoed com-
pression to whi ch the paralyzed limbs are subject, against a hard soil, owing to the inability
of the animal to feel and avoid it. In similar experiments made on frogs. Dr. Brown-S^nard
found that no alteration took place, except when water penetrated through the wound, under
the skin and between the muscles. With the help of an eminent micrographer, (Dr. Lebert),
Dr. Brown-S6quard made researches on the influences produced on the capillary circQlation
in consequence of the section of all the nerves (sympathetic and cerebro-spinal nerves), in
the legs of a number of frogs. They found no appearance of disturbance in the capillary
circulation, neither in an hour, nor in three or four days after the division of the nervee.
Brown-Sequard states that when resection of a long portion of one of the sciatic and cervical
nerves is made in a very young rabbit, Ouinea-pig or pigeon, the palsied limb eontinoee to
grow in length, but It grows only very little, if at all, in thickness. When the experiment is
made on all the nerves of the wing in a very young pigeon, It is al^o fbnod that the wing
grows in length, but very little in breadth or thickness. The secretion of quills takes place
equally as well in the palsied limb as in the other. Brown-Sequard ha^ also found that boms,
wounds and ulcerations existing in parts palsied In consequence of the section of their
cerebro-spioal nerves, are cured as quickly and as well as those in sound parts. Aceortling
to this observer, the transformation of the arterial blood into venous, is not so complete In
the palsied, as in the sound limb, but it always takes place, even in a great measure. When blood
was injected into the arms and fore-arms of two decapitated men, thirteen or fourteen hours after
death, and when cadavaic rigidity existed, the blood, which was of a bright red color when
injected, came out nearly black from the veins. From these facts, Brown-Sequard concluded
that the nervous action, (that of the sympathetic, as well as of the cerebro-spinal nervee), is
not necessary for the change of color of the blood in the capillaries, and that the aervoo*
system of animal life has an influence upon nutrition, by which it takes a share in the trans-
formation of arterial into venous blood.
Brown-Sequard found, by careful experiments, that the remarkable phenomena which fbl-
low section of the cervical sympathetic, in the celebrated experiment of Claude Bernard, are
mere consequences of the paralysis, and therefore of the dilatation of the blood-vessels ; the
blood finding a larger way than usual, arrives there in greater quantity, therefore the nutri-
tion is more active ; the sensibility Is increased, because the vital properties are augmented
when their nutrition is augmented; and the temperature, although elevated above that of
the sound ear, does not rise above that of the blood, the ear being fhll of blood, it Is very
easy to understand why It has the temperature of the blood. A great many fiscts prove that
Introduction to the Study of Diseases of the Nervous System. 109
the degree of temperetore and of sensibility of « part is in close relation with the quantity of
hlood ctrcalating in that part. We have already dwelt apon tbe great importance of the fact,
diseprered by this obserTer, that If gaWanism be applied to the superior portion of the sympa-
thetic after it has been cut in the neck, the Tessels of the face and of the ear after a certain
tine begin to contract ; their contraction increases slowly, but at last It is evident that they
resume their normal cunditioui if they are not eyen smaller. Then the temperature and the
sensibility diminish in the face and the eaf , and they become in the palsied side the same as
in tbe sound side. When the galyanic current ceases to act, the vessels begin to dilate again,
and ail the phenomena described by Dr. Bernard re-appear. Dr. Brown-S6quard concludes
from these experiments, that the only direct effect of the section of the cervical part of tbe
sympatbetiCi is the paralysis, and consequent dilatation of the blood-vessels. Another evi-
dent conclusion is that the cervical sympathetic sends motor nerve fibres to many of the
blood* vessels of the head. Certain experiments prove that tbe blood-vessels are contractile,
and that the nerves are able to put them in action. It has been established by Budge and
Waller, that the cervical sympathetic is one of the motor nerves of the iris, and that the
spinal cord is the origin of the nerve fibres going from the sympathetic to the iris. On the
other hand, Bernard doubts that the effect of dividing the sympathetic is to paralyze the
arteries, and so cause their dilatation ; and regards it as an anomaly that arterial paralysis
should promote greater activity of the circulation. That paralysis of the arteries should
proaotie a greater activity of the circulation, is, however, evident, when it is established
that arterial contraction has necessarily the opposite effect, and diminishes tbe afl9nx of blood
to tbe part. Thus, when the arteries in the frog's web are made to contract by the applica-
tion of cold, the capillaries appear empty and devoid of red particles ; on the contrary, when
the web is warmed, the arteries immediately pour in blood abundantly. The recent observa-
tions of Bernard (La. Clin. Burop., 1859, No. 29, p. 262 ; Syd. Soc. Qen. Book, 1861, p. 29),
demonstrate very clearly that paralysis of the sympathetic nerves increases and accelerates
the arterial current. When a manometer was inserted into the right coronary artery of the
lip of a horse, and another into the left, both instruments showed a pressure of 160 to 180
milUm ; the pressure of blood increased 40 millim on the left side after division of the cor-
responding cervical sympathetic ; in the coronary veins of the lip, the instrument showed a
pressure of 30 or 40 millim, which increased to 50 or 60 after section of the sympathetic,
while the pressure again fell 20 millim when the nerve was galvanized. Pulsation of the
veins and a brighter color of the venous blood, were also noticed as results of division of the
same nerve. Dr. G. Handfield Jones, in his valuable and profound " StiuUei on Functional
yierwoma Duorders^'* has well observed, that ** the old and oft-used phrase, * great arterial
action,' descriptive of a larger and bounding pulse, when translated into correct physiologi-
cal language, means, of course, great cardiae action, with a want of arterial."
Ackermann and Bergson (Syd. Soc. Year-Book, 1860, p. 131, Vircbow's Arch., Vol. xv. p.
401); made an opening in the skull of rabbits, removed a portion of bone, and of the corres-
ponding dura mater, and closed the aperture with a glass plate and collodion ; they were
tbns enabled to observe tbe varying state of the vessels of the brain : section of the right
cervical nerve was found to sause injection of the diploS, and of the cerebrum of that side ;
and three hours afterwards when the left nerve was divided, the injection of tbe correspond-
ing eerebral vein became equal to that of the right side. Jachkowitz has shown that sec-
tion of the sympathetic plexus of the splenic artery causes congestion of blood, softening
and disintegration of the capsule : if part only of the plexus is divided, the corresponding
pan only of the spleen is affected. In the experiments of Samuel upon rabbits, dogs and
cats, the bypersemia of tbe intestinal mucous membrane produced by extirpation of tbe
emliae plexus was so great that it exceeded all pathological hypersemias hitherto known. The
secretion of the mucous membrane is increased by the operation, but not to tbe same deg^e
as in a violent diarrhoea. After removal of the lower part of the spinal cord and the roots
of tbe nerves in a frog, Wharton Jones found that the arteries of the webs retain all their
contractility, or are even more than usually disposed to be constricted : if now tbe ischiatic
nerve be divided on one side, the result is, that the skin of the extremity subjected to tbe
experiment becomes, even to the naked eye, redder from vascular congestion than that of the
opposite extremity ; and on examination of the web under the microscope, the arteries are
fooad to be considerably dilated — in the web of the opposite extremity, on the contrary, the
arteries are seen still much contracted, some even to closure. Such facts illustrate in a clear
maoaer the control of the sympathetic nerves accompanying the arteries over the circula-
tion, and through the circulation upon the nutritive actions.
Tbe vaso-motor system of nervf s is without doubt concerned in the phenomena of Fever,
and especially in the chill and cold stage of malarial Fever : it is nevertheless probable that
specific fevers are caused by the action of specific poisons, which derange the constitution of
the blood primarily, and secondarily induce disturbed nervous action. Whilst there is an un-
doubted contraction of the smaller arteries in the cold stage of malarial fever by which the
blood is forced as it were into the more vascular and less resisting organs, at the sAme time
1 10 IrUroduetion to the Study qf Diseases qf the Nervous System.
there is a marked eleration of temperature in the central organi. The great redaction of the
temperature of the surface and extremities is eTidently due to the withdrawal of the blood
bj the contraction of the minute arteries ; but it is not clear, that the eleration of the blood
in the central organs, is due to the nervous influence, for it maj be the result of the increased
frequency of the respiration and heart beats and the action of a specific poison, indttcing
destruction of the fibrin and blood corpuscles.
In those cases of Traumatic Tetanus, in which a 'Sudden and great rise of temperature pre*
cedes death, other causes as actual inflammation of the spinal marrow, the generation of
pyogenic compounds, and the retention of carbonic acid from impeded respiration, may be
active in producing this remarkable phenomenon. The same obiervation applies to the ele»
vation of temperature following injuries of certain portions of the nervous system and espe*
cially of the spinal cord. Until thorough investigations are instituted into the changes of
the blood, the force and frequency of the pulse and circulation ; the amount of oxygen con-
sumed and the carbonic acid exhaled and the amounts and characters of the renal and cuta-
neous excretions in the t'arioos conditions characterized by sadden and great elevation of
temperature, the doctrine of special nervous centres of control of heat and nutrition, most
rest only upon a hypothetical basis. The. tendency of recent investigations is to re-establish
the so-called HumoriU Pathology, and locate the origin of inflammation and even of Ganeer,
Phthisis and Scrofula in certain changes of the blood. The migration of the colorless blood
corpuscles, through the walls of the capillaries have been shown by Conheim and others to
be of prime importance in the phenomena of inflammatory diseases.
The experiments of Ludwig and Bernard, have shown conclusively that the sympathetic or
vaso-motor system of nerves are not the only organs which act upon the circulation, but
that stimulation of the fifth pair and of the facial produces a greatly increaaed flow of saliva,
while at the same time the circulation of the gland is accelerated.
The essential idea of the inhibitorp tkeorjf^ is that a peculiar kind of impression made on a
centre may disorder or paralyze its action and prove directly depressing. Thus Weber and
Bernard, long ago, demonstrated the possibility of arresting or diminishing the action of the
heart by galvanising the medulla oblongata or the pneumogastric nerve. (Lemons sur le
Systime Nerveux, tome ii, p. 392). The subsequent experiments of Pfluger and Lister, have
shown that galvanization of the spinal cord may induce complete relaxation and quiescence
of the small intestines, which had been previously in active movement, while the mnsclt-s of
the limbs were thrown into spasmodic movement Such experimenu prove that slight elec-
tric irritation of the medulla oblongata augments, while more powerful irritation diminishes,
or even arrests the heart's action. Powerful mechanical irritation of the medulla oblongata
diminishes the frequency of the heart's action. Slight irritation of the spinal cord increases,
while powerful irritation diminishes the frequency of the heart's action. We are scarcaly
justified from such experiments to conclude that the dilation of the vessels is an active phe*
nomenon and dependent upon a special system of nerves, the so-called mmo dUaion and wmm
contractors : neither can the view of Eulenburg and Landois be adopted as proved, that there
are four systems of so-called inhibitory nerves, viz : the cardiac, the respiratory, the'iutosti-
tinal, and those which restrain the reflex movements. The conclusion of Lister, appears to
be more in accordance with the facts, that one and the same afferent nerve may, according as
it is operating mildly or energetically, either exalt or depress the functions of the nervous centre
on which it acts. The phenomena may be explained by referring the contraction of the ves-
sels and the consequent diminution of blood supply and of nutrition and calorific and mus-
cular actions, when the nerve is irritated, to an influence conveyed along the nerves to the
muscular tissue ; and by referring the reverse phenomena characterized by dilatation of the
vessels, increased blood supply, increased chemical and nutritive and secretory changes aad
elevation of temperature, to simple paralysis or loss of vascular tonus. It must be clearly
borne in mind that, relaxation of the muscular fibres of the arteries of such an organ as the
heart accompanied with increased supplies of oxygen and blood, would necessarily be attended
by increased nutrition and incr«as<*d action in the muscular structures proper to the heart
itself. A complete investigation of the so-called InkthUorff actions, should embrace a minute
qualitative determination of the amounts and changes of the blood and of the structures of
the various organs subjected to experiment, as well as of the so-called regulating and inhi-
bitory ganglia and nerves.
Brown-S^quard has shown, that the view held by many physiologists, that the secretion of
the gastric juice is stopped after the section of the two pneumogastric nerves is erroneous.
It is difficult to solve the question by experimenu on warm-blooded animals, because they
die too quickly aAer the section of the vagi ; but not so with frogs, they are able to live per-
fectly well, either after the extirpation of the medulla oblongata, or after the extirpation of
the ganglia of the par vagum. In both these cases, the digestion continues to be performed.
This observer repeated the experiments of J. Reid, with similar results, viz : when all the
nerves, both cerebro-spinal and sympathetic of the posterior limb in frogs are divided, and if
the gaWanic current bt applied every day to the palsied limbs on one side, these galvan-
Introduction to the Study of Diseases of the Nervous System. Ill
iied limbt retain their natural dimeosioni, whilst the palsied limbs not galvanized become
atrophied. Moreover, if the application of galvanism in made on the palsied limbs of very
joang animals, and continued every day until they arrived at adult age, the limbs are then
foand to have grown as much in every respect as the sound limb. In these experiments,
galvanism appears to act in two ways ; in the one by exercising the muscles and increasing
in consequence their nutrition ; in the other by producing directly some of the chemical
changes which constitute nutrition. The atrophy which happens in paralysed muscles,
takes place mostly, because they remain without exercise, and partly, because when nervous
action is deficient the respiration of the muscles Is not carried on as well as when the nervous
system acts upon them. Galvanism applied to a palsied limb acts partly in producing the
transforvsation of arterial blood into venous blood, i. e. what Gustav Liebig calls the respi-
ration of the muscles. Brown-S6quard has seen frequently, the venous blood, in palsied
limba, becoming as black as normal venous blood, after the application of galvanism, and he
attribates this change of circulation, not to a direct chemical influence, exerted by galvanism
on the blood, for if galvanism be applied to blood in a vase, no change of color is produced,
but to an interchange between blood and the living tissues. From the preceding facts, Brown-
S^nard conclades, that N^rvout Action w not neeeuary for Nutrition, (Experimental Re-
searches, applied to Physiology and Patholbgy, pp. 6-12).
The researches made before those of Brown-S^quard, as to the influence of the spinal cord
vn the aniary secretion, could not give a decided result, because no physiologist, had been ,
able to keep any warm-blooded animal living a sufficient time, after the destruction of a
large part of the spinal cord. This observer kept living, nearly three months, a young cat,
on which the spinal cord had been compleUijf dettroyed from the eleventh to the twelfth costal
vertebra to its termination. This cat lived all that time in apparently good health, and its
nrioe was always perfectly normal. It was acid, as is the case constantly in cats fed on meat,
milk and bread. The bladder was paralysed, but the sphincter vesicae generally contracted,
so that it was necessary every day to compress the abdomen, and the bladder to empty this
pouch. When this operation was neglected for two days, the bladder contracted in conse-
quence of the excitation produced on its muscular fibres by their distension. This fact clearly
proves, that the urinary secretion is not under the dependence of the spinal cord. Brown-
:^oard has also shown that the opinion of Krimer, that the urinary secretion depends upon
the neduUa oblongata, is incorrect. Thus, after destruction of the medulla oblongata, in frogs,
the secretion of urine continues as long as the animals had lived, i. e., three or four months:
and when the medulla oblongata is extirpated in hybernatiug animals, after having emptied
the bladder, with proper attention to the respiration, these animals have lived a little more
than a day, and after death, the bladder was found full of urine, apparently normal. The
medulla oblongata, therefore is not a centre on which the urinary s/cretlon depends.
Browa-S4qnard has in like manner shown that the opinions of Segalas, W. Philip, Krimer,
Chossat, Longet and others, about the influence of the spinal cord on the functions of organic
life, are qnite erroneous. Birds are able to live for months, after the destruction of the spi-
nal cord, from the fifth vertebra to its termination. This fact proves not only that the func-
tions of organic life may continue to exist in such a case, but that they appear to be executed
then as in healthy birds ; for if the operation has been made on a young bird, it will afterwards
grow very well. This physiologist succeeded in keeping alive, from the 8th of April, until the
4th of July, a young cat, in which the spinal cord had been destroyed to a similar extent; the
palsied parts grew in length proportionally as much as the sound parts, and acquired more
than double the length they had at the time of the experiment, the nutritive reparation was
so powerful that the pieces of the vertebral column, which bad been cut off. were reproduced,
the fnnetions of organic life existed without any apparent disturbance, the temperature
remained at the ordinary degree in the rectum, the secretion of the hair and nails took place
as in healthy cats. In birds, the temperature remained normal after the destruction of a
great part of the spinal cord, and the secretion of quills and nails continued to take place.
As to ihe influence of the medulla oblongata on the functions of organic life, Browo-S^quard's
experimeuts on cold-blooded animals, have proved, that the functions, (except, of course,
pulmonary respiration), may continue to exist, without any appearance of disturbance.
r Experimental Researches, pp. 13-15). After the complete transverse section of the spinal
cord in mitmmals or birds, it has also been shown, that the ulcerations which take place
arotind the genital organs do not result directly from the absence of nervous action, but from
continued pressure, and the continued presence of altered urine and fseces.
M. CI. Bernard, by his wisely devised and carefully executed experiments, has shown, that
in creriain glands, the chemical conditions which cause the venous blood to appear at one
time red, and at another black, are determined by the influence of two nerves, which have
distinrt origins and possess powers apparently antagonistic to each other. Each of these
nerves, in order to produce a chemical action on the blood, modifies the mechanical phenom-
ena of the capillary circulation, so that there is established a correlation, both necessary and
ea«y to be understood, between the chemical changes which the blood in the organic tissue?
112 Introduction to the Study of Diseases qf the Nervous System.
andergoes, and the mecbanicftl condilioot of the capUUrj ciroulation, whiob are under the
immediate inflaeoce of the nerret. The experimente irhieb led to these resaltti were made
upon the sabmaxillary gland of the dog, which it partieal:irljr adapted to this kind of research,
on account of the intermittence in its act of secretion, exhibiting rery clearlj the rariations
in the color of the renoas blood. The nerre which causes the renons blood to appear red in
the reins of the submaxillary gland, is a small branch which arises from the posterior portion of
the lingual branch of the fifth pair ; bat it is only in contact with the fifth pair, coming reallj from
the seventh, and is principallj formed bj the chorda- tympani ; whilst the nenre which renders
the Tenons blood in the sobmaxillarj gland, black, is deriTed from the great sjmpatbeUc,
and accompanies the arterial branches of the carotid. When the rein and nerres of the gland
are exposed, and an impression upon the nerre of taste is produced hj dropping a little rino*
gar in the mouth, the blood rapidly reddens in the rein, because the impression of taste pro-
duced upon the tongue and carried to the nerrous centres, has been transmitted bj reflex
action thtough the corda-trmpani. The proof of the truth of this interpretation of the pho-
nomena, is immediately furnished, for when this nerTous filament is cut at the point where it
separates from the lingual nerTe, the Tenons blood of the gland remains black, and from thai
moment, notwithstanding the application of Tinegar upon the tongue, and the impression upon
the nerTe of taste, the red color of the blood does not appear, because the nerTous medium by
which the modifying influence of the blood was conducted baa been interrupted. But if the eat
extremity of the nerTe next the gland, be irritated by means of galTanism, the blood In tho
glandular Teins becomes red, and resumes its black color when this excitement ceases. If all
the filaments of nerres which go fkx>m the great sympathetic to the gland be out, the Tenoas
blood loses its black color, and takes a russet color, which becomes permanent* because the
influence of the great sympathetic nerre has been Interrupted and does not rvach the gland.
But if the action of this nerre be re*established, by applying galTanism to its glandular ex-
tremity, the Tenons blood becomes Tery black, and again resumes its red color, as soon as the
galTanic influence, ceases to act upon the nerre. Thus the rariations in the color of the
Tenons blood in the gland, are due to two nerrous influences, well marked and perfectly die-
tioct. In endearoring to understand the mechanism of the influence orer the blood, it Is
erident that there in no anatomical continnity between the nerres and the globules of the
blood, and that It is necessary that there should be other phenomena intermediate between
the nerrous action and the chemical change, in the globules of the blood ; and these Inter-
mediate conditions do exist, and consist in the different mechanical changes, which each
nerre produces in the capillary circulation of the gland. The mechanical conditions of tho
capillary circolation, produced in the sobmaxillary gland, by the tympanico-lingual, and the
great sympathetic nerres, are exactly the opposite of each other. When the tympanico-lin-
gual nerre is ei cited, the renons blood appears of a red color, and at the same time, there
comes on a considerable actirity in the rapidity of the circulation ; in proportion as tha
renoos blood becomes redder, it flows more and more rapidly, and the quantity which flows
through the rein is much increased. When the influence of the great sympathetic predom-
inates, the renous blood Is blackened In color, and at the same time its circulation becomes
sluggish, the ^lood flows through the rein, with a current slow in proportion to the intensity
of its color, and eren if the action of the sympathetic nerre, is sufllciently excited, the current
of the blood may entirely cease, to re-appear the moment the excitement of the nerre eeases,
and again accelerated if the tympanico-lingual nerre is irritated. The i^d and black color
of the venous blood is a fixed relation to the actirity of the circolation in the snbmaxillaiy
gland. But this rapidity in the circulation of the blood cannot be produced directly by the
nerres, for ther hare no direct and intimate action on the blood itself. The contraction and
eipansion of the blood-ressels of the gland, can also eiplain the modifications in the proper-
ties of the blood. Bernard has prored by experiments, that one of the two nerres of the
sobmaxillary gland dilates the vessels, while the other contracts them. When the action of the
tympanico-lingual nerre is intense, the increase in the calibre of the capillary ressels is so
marked, that the blood passes from the arteiy Into the rein without losing the impulse of the
heart, and makes its exit from the rein of the gland, with an interrupted Jet as of a true
artery. This renoos pulsation disappears, as soon as the action of the tympanico-lingttal
nerre diminishes or entirely ceases. The sympathetic nerre, on the contrary, contracts and
narrows the calibre of the glandular ressels, in the most marked manner.
These experiments of Bernard, established the important fact, that the nerres act only as
agents of the dilation and contraction of the blood-ressels ; and although the nerrous Influ-
ence in secretion does not differ from that of the moior ntrvet m gfntral cvtr wuuemi&r Utmt,
nerertheless, by a rery natural connection of phenomena, it produces a series of pbysieo
chemical changes in the blood. When the sympathetic nerre. the constrictor of the ressels
is actire, the contact between the blood and the glandular elements Is prolonged, the chemi-
cal phenomena, which results from the organic changes between the blood and the tissues
has time to take place, and the blood flows of a black color. When on the contrary, the
tympanico-lingual nerre which dilates the ressels is actire, the passage of the blood through
Introduetian to the Study qf Diseases qf the Nervous System. 113
the giMid becomet very npid, the modificAtioDS of the blood which take place in the contact
of the blood-globnles with glandular tlMue are accomplished with a different result, and the
blood comes from the Tein with a rtrj red color and preserres the appearance of arterial
blood.
Tbos has this physiologist shown, that eren secretion may be referred to chemical
and physical laws; and that the special nerrons system, which snimates each capil-
lary system and each organic tissue, regulates ereywhere the current of blood in its relation
to the special physiological acts of the organs ; these nerrous modifications of the capillary
cireuUtion take place, in situ and without the least disturbance, to the neighboring organs,
stlU lees to the general circulation ; each part is connected with the whole, by the common
stales of the general circulation^ also by means of the nerrons system, and each part may thus
hare ita appropriate circulation and physiology.
Whilst the experimental researches of Bernard, on the* Great Sympathetic, instituted to
determine the relations of this nerre .to the organic changes taking place in liring tissues.
establish that section of the nerres of sensation is attended with abolition of sensation ana
diminution of temperature, that of the nerres of motion with paralysis and cooling, section of
the sympathetic with no loss of motion or sensation, but with an increased afflux of blood,
into the dilated Tessels, and with an augmentation of temperature, section of the spinal mar-
row and nerrons tracts enclosing the commissures of the nerres of sensation and motion and
of the sympathetic, paralysis of moTcments, and sensation and dilatation of Yessels, and
aagoientatiou of heat; at the same time a careful comparison of the results of these experi-
iMuta, hare shown that in no case was the section attended with the cessation of nutrition
and secretion and the essential phenomena of inflammation. In section of the cerrical sym-
pathetic, the dilatation of the arteries and afflux of blood accompanied by elcTation of tempera-
tore aad oorrespondiog congestion and redness, resembling in all respects similar manifesta-
tions in inflammation, may exist for days and weeks and eren months, without any apparent
change in the tissues, or the inoreaSe of the parts by inflammatory exudation, or through the
eflbsed serum. By its distribution to the arteries, the sympathetic, as a compound nerre of
sensation and motion, exerts a power oTcr the passage of the blood through the ressels by
ittflneaclng the contractility of their muscular fibres. It thereby affects the rapidity of cir-
culation, and also regulates the entire rate of secretion. The entire digestire tract and its
dependencies, as the salirary glands, (Esophagus, Stomach, Pancreas, Lirer and Intestines,
are thus brought under its influence. The influence of the sympathetic in secretion therefore,
does not differ essentially from that of the cerebro-spinal system, and it is therefore necessary
to modify the old riews which prcTailed for nearly a century with reference to the so-called
nerro-pathological inflammations and nerTo-secretory (excito-secretory) actions.
If the statement of Jacnbowitsch be accepted, tiz : that sympathetic cells exist in certain
parts of the spinal cord ; and if the obserTStions of If. Luys, indicating the existence of a con-
tinaoas column of sympathetic cells extending along the inner face of the posterior horn of
gray matter in the cord for its whole length up to the brain, be regarded as correct : the raso
motor centres in the cerebro-spinal system, indicated by the experiments of Budge, Waller, Claude
Bernard, Brown-S^nard, Schiff, Masius, Salskowsky, Ludwig, Thiry and Kronecker, and others,
may be regarded as belonging to the sympathetic system, and similar in all respects to the organic
ganglia found outside of the cavity of the cranium and spinal column. The raso-motor phe-
nomena, woold be simplified by such a Tiew ; and certain pathological phenomena, as the
increase of heat and increase of the capillary and general circulation might find a ready ex-
ptanattoo. Tbas the introdnction of a poison, or of the product of inflammation into the
blood, might induce paralysis of the Taso-motor centres of the sympathetic system within and
without the cerebro-spinal axis. The central organ of the circulation, that is, its muscular
stmetnree l»eing excited to increased action, by the Increased supply of blood, and the blood
being driYen more rapidly through the entire course of the circulation ; and the muscular
apparatus of respiration, being at the same time excited to increased action ; all the essential
conditions of fever, tIs : the rapid introduction of oxygen and its rapid distribution through
the dilated vessels ; rapid chemical change and elevated temperature, may thus be established
by the aetion of a morbific agent upon the vaso-motor system of nerves. According to this
view, tbo increase in certain excrementltious products, result from increased chemical changes
resniting fh>m the establishment of those conditions of the respiration and circulation favor-
ablo C* tbo rapid transformation of the elements of the blood and tissues into crystalloid pro-
dneU : and the relations of the nervous system to these changes is indirect, that is, by its
aetion npon the apparatus devoted to the ssration (oxidation oxygenation) and circulation of
the blood.
Whilst admitting that the ganglia of the sympathetic constitute centres of nervous excita-
tion, ftom whence the organic muscles and other contractile tissues receive the motor im-
polaeSf and the heart and. circulation generally their regular actions, Just as the coordinated
contractions of the voluntary muscles are dependent upon motor impulses from the central
eerebro -spinal ganglionic masses ; we are not Justified by the experiments of physiologists
U
114 Inh^oduetion to the Study qf Diseases of the Nervous System.
upon the cerebro-spinal nerTefi oor bj those directly upon the organie tjeteiD, in adopting
that qualification of the nenro-patbological doctrine, which regards the sympathetic as pre-
siding overi exciting, directing, controlling, and actually generating, as it were, the entire
ensemble of phenomena, designated as secretion. Thus, if we take the most noted and ex-
treme examples, as quoted by the most strenuous advocates of the neuro-pathology, and
consider them carefully in connection with the facts and principles already established, we
will find that there is no broad line of demarcation between the cerebro-spinal and sympa-
thetic nerrous systems in their relations to secretion. The relationship of muscular motion,
secretion, nutrition and excretion to the cerebro-spinal system, is fully admitted ; and as wo
hare shown the tendency of the more recent experiments is to establish a close relationship
between the sympathetic nervous system and nutritive actions, secretion and excretion and of
the muscular apparatus of the circulatory system, and of the alimentary canal and its associ*ted
organs, and to limit the action of the sympathetic nervous system chiefly to the excitation
and control of the movement of the muscular apparatus jvhicb directly ministers to the organic
functions, and to the control of the movements of >he heart and of the blood-vessels.
The phenomena following Bernard's celebrated experiment, of irritating the mesial lina of
the floor of the fourth ventricle, in the centre of the space, between the origin of the auditory
and pneurao-gastric nerves, may result, in great part at least, from conditions other than a
direct influence of the nerve force on the secretion of grape sugar in the liver, as from excited
action of the heart, deranged respiration and aflSux of blood into the capillaries of the liver
and spleen, in consequence of the irritation of the vaso-motor centres of the nerves supplying
the blood-vessel system. The fact that diabetes may be induced artificially, not only by the
puncture of the middle of the calamus scriptorius of the fourth ventricle, but also by punc*
ture of the olivary bodies, and of the cervical portion of the spinal cord, shows that the
hepatic tissne is not excited to a more energetic discharge of its functions by a stimulus con-
veyed by the fibres of the pneumo-gastric nerve ; but that the increased formation of sagar
is due to the result of the irritation of the general rasso-motor centre of the whole body,
which Kronecker, of Leipsio, has definitely fixed in the fioor of the fourth ventricle, or of one
or more of the vasso-motor centres of the cerebro-spinal axis. According to this view, the
sympathetic is the agent of transmission, and the phenomena is referable to the same class
as those observed when this nerve is divided in the neck.
In section of the fifth pair of nerves, if the various disturbing influences affecting the eye
be removed, we have but little else produced by this section than the same injection of the
blood-vessels, and increased heat, observed when the sympathetic is divided in the neck.
, Snellen discovered that if the ears of the rabbit be sewed before the eyes of the animal in
which he had cut the fifth pair, destructive ulceration was prevented.
It has also been observed, that in section of the pneumo-gastric, the resnlting changes
denominated Huumania and JMeumomc Inflammation^ are due to the entrance of irritating buc-
cal mucus through the paralysed rima-glotttdis, and a great part of that which had beoD
called pneumonia, was nothing more than such an obstruction of the air cells, and hyper-
aemia of the blood-vessels, as prevented the proper introduction of oxygen, and eliminatioD
of carbonic acid, and ensured the slow poisoning and final death of the animals. Such inves-
tigations are not complete without the full consideration and elimination of the poisonous
effects of the carbonic acid gas retained in the lungs and blood. In section of the pneumo-
gastrics, pneumonia may be avoided, if foreiga bodies be prevented from penetrating into the
bronchia.
The effects of injuries or sections, therefore, of the vaso-motor system of nerves, appear to
be chiefly the contraction or dilatation of vessels, and the arrest of the pulsatile movemeata
which have been seen in minnte vessels in many parts of the animal economy, and to the
existence of which some physiologists have been inclined to attach much importance, in the
regulation of the capillary circulation. These alterations, with the consequent changes in
blood supply, which they bring about, may be the direct results of nerve lesions, or of reflex
influences originating in the periphery and transmitted to the central ganglionic centres, and
reflected from thence to distant organs, or of the action of poisons introduced into the blood.
However caused, the influence of the vaso-motor and so-called trophic nerves appear to be
limited to the increased or diminished supply of blood, and the alterations of these condi-
tions.
If it be true, that the nervous force is the direct result of the chemical changes of the
nervous structures, and is a physical force capable of being transmuted into other modes of
force ; if it be probable that the nervous force is electricity, or a modified form or state of
this physical force; and if it be true that all the chemical actions in the body develop this
force, together with heat, it follows as n necessary consequence that the nerves may be capa-
ble of influencing secretion, in virtue of the power which this active physical force has of
exciting chemical change. Thus an impulse originating in the central masses of nervoos
matter, or reflected from the circumference, may be propagated by changes of the molecnles
of the nerves, and reprodace its original effects, by transmission to distant organs. The
Introduetim to the Study of Diseases qf the Nervous System. 115
•Acta of this traotmiMion would tafj accordiDg m the nerreB termioate in. or are connected
directly with the am scalar apparatas of the respiratory- and circulatory and dynamic appa-
ratus of the liTing organisoii or with the excretory and secretory cells of the rarious organs.
We would thus hare an example of chemical change in the periphery of the nerres, and in
the TarioQS organs, whether muscular or secretory, to which they are distributed, analogous
to that which takes place at the terminals of the galvanic battery. Thus in Traumatic teta-
nus, where there is an exaltation of the acts or force of the ganglionic cells of the gray matter
of the spinal axis, constant impulses are sent out to the roluntary muscles and to the sympa-
thetic. In Tirtue of the nerrous connections between the two systems ; and thus the ganglt-
ooic cells of the sympathetic become In turn excited, and the organs to which this system is
distributed, as the kidney, lirer and alimentary canal and heart, are in turn affected.
According to this riew the function of a nerve would be limited by the nature of the struc-
ture to which it originates, and that of the ganglionic centre in which it terminates; bnt all
oervous action would consist essentially In molecular changes of the afferent and efferent
oerres. The nerTOUs force being in all nerves the same form of physical force, the functions
of each nerTous fibre would be determined on the one hand by the functions of the struc-
tures to which it is dsitributed, and its relations with the central ganglionic cells.
The tendency of such a theory appears to be the subjection of physical and pathological
phenomena to the domain of physical science.
After we hare given full force to the arguments commonly urged against the identity of
electricity and nervous force, such as the fact that crushing the nerve destroys its power to
coDvef impressions, while it may still conduct electricity, and the difference in the speed
with which the galvanic and the nerve currents are propagated, (thus it has been estimated
that in the fVog's nerves, at a temperature of 52 to TO* P., nerve force moves at a rate of 81
to 126 feet per second, in man in motor nerves, 300 feet per second, in sensory nerves, 110
feet per second, while electricity travels at a rate of 462,000,000 feet per second) ; it must be
admitted that electricity in passing through moistened threads has so low a rate of move-
ment as to render the argument against the identity of the two forces doubtful, and in need
of a series of elaborate experiments upon the rates at which the nerves themselves act as
electrical conductors ; and it must still farther be admitted that nerve force, like magnetism,
depends, for its manifestations, upon peculiar physical conditions, and chemical combina-
lioos of onranic matter, and that at least it may be correlated with electricity, heat, and
other modes of physical force.
HrPOTHETICAL DISCUSSIONS AND INVKSTIQATIONS CONCERNING THE NATURE OF THE
NERVOUS FORCE.
Threo hypotheses have been invented to account for the power of the nerves to transmit
sensitive and motor impulses and excite secretions : the one which is the oldest and has
been the most generally received, is that the brain and nerves are provided with a certain
fluid called the animal spirits, which serve as the medium of communication between the
different parts of the nervous system ; the second supposes that this transmission is effbcted
by flseana of the vibrations or oscillations of the particles of the nervous matter itself; while
the third ascribes the action of the nerves to the operation of electricity.
The hypothesis that the brain and nerves are provided with a certain fluid called the ani-
mal spirits, which serve as the medium of communication between the diffsrent parts of the
oervous system has generally beed ascribed to Descartes,* who reduced it to a regular form,
sod contributed by his authority to its general reception, although traces of this supposition
maybe found in the writings of the older physicians.
Plato, the preceptor of Aristotle, as we have seen, held that the animal spirits are trans-
mitted from the brain through the whole body by means of the nerves, and in this dootrine
he was followed by Galen, Vesalius, Feroelius, and others.
Galeo, who refuted the doctrines of Aristotle, as to the functions of the brain, held that
the aniflsal spirits are not contained in the ventricles only, but are dtifhsed throughout the
whole tobstance of the cerebrum and cerebellum ; he bad, however, originally advanced the
opinon that they are transmitted from the anterior ventricles to the fourth, through the
opening now termed the aqueduct of Sylvius. Although Galen asserted that the function of
the oerres consists in transmitting the animal spirits from the brain to the other parts of the
body, for the purpose of sensation and motion, still, he does not appear to have been quite
ccruio as to the correctness of his doctrine, as be propounds the following questions : Firstly,
whether the nerves contain animal spirits like the cavities of the brain? Secondly, whether
this spirit is innate In the nerves, and when a limb is to be moved, is excited only when acted
upon by the spirit contained in the cerebrum ? Thirdly, whether this spirit be innate in the
* Daarmrtc* Tractatm d« Homloe. Amat, 1677, See 14.
116 Introduction to the Study qf DUeases qf the Nervous Syetem.
nerr^t at all| bat nth^ri when we Mok to more « limb, whether it does not flow from the
brain into the nerre ? Fonrthlj, whether the matter of the ipirits flowe into the nenret from
the braio in any way 7 or it it not rather its force, rirtne or faeultj, jaat aa the inbitanoe of
the tan remaining motionlett, its light-giWng property is poured forth into the ambient air ?
He obaerres that he only proposes these qnestioas for general discussion, as he was nnabia to
decide absolutely on them.
Caspar Bauhin was amongst the first who denied that the rentrides are the laboratory and
storehouse of the animal spirits, and who taught that they are generated in the snbstanee of
the brain, and dispensed directly from thence through the nerres to the organs of sensation
and motion. Caspar Hoffman opposed the ancient doctrine as to the use of the Teatrides in
preparing and retaining the animal spirits, on the ground, that all the nerres of the body and
cerebrum arise from the spinal cord, either within or eiternal to the cerebrum ; that the
rentrioles are lined internally with the pia-mater, which prerents ingress and egress ; that
since the two superior Tentricles open into the third, and the third into the inftiadibiiliim,
and this into the palate, there is no reason why the spirits might not pass out this way ;
that the Tentrides are not continuous with the nerTCS, but with the body ; and that if it be
necessary to the action of the spirits that they be under the control of the mind in the ressels,
no force is known which compels them into the straits of the nerres after baring entered into
the ocean of the Tentricles ; and finally, that the Tentricles hare already a function incom-
patible with that of the spirits, namely, to collect and excrete the effete matters.
These arguments were sufficient to lead many from the doctrines of Galen, and to eouTinee
them that the Tentricles of the brain are not the factories and storehouses of the spirits, but
only established for the collection and expulsion of the effete matters.
Des-Cartes* maintained that the animal spirits were secreted from the brain, by pores
opening into the Tentricles, and that there accumulating, the slightest disturbance of them
excites the soul seated in the pineal gland ; and contrarily that the animal spirits in the Ten*
tricles are moved by the will acting through the pineal gland, and distributed thence tbroagfa
the nerres to all parts of the body.
The principal ground of this hypothesis, seems to hare been the idea that the brain is •
secretory organ, an idea which wss snggesed by the great quantity of blood sent to it, and
by some supposed resemblance In its structure to other secreting glands. Tet, as nothing
cognisable by the senses is produced by it, it was concluded that it must secrete something
of a subtle or ethereal nature, particularly suited to the performance of the functions which
belong to the brain, and which are so unlike those of other material substances. At the
time Uiat Des-Cartes wrote, CTerything that could not be otherwise explained, was referred
to the agency of some kind of refined spirit, an idea which appears to have been originally
derired from the alchemists, and after ^being incorporated with the metaphysics of the age,
gare rise to a long train of mysticism.
The doctrine of the uerTons fluid, or animal spirits, not only became a subject of popular
belief, but their existence was assumed by many medical writers as an ascertained fact^ and
their different diseases and affections were spoken of with as much confidence as if the
authors had been treating upon something which was the immediate object of their senses,
and with which they were perfectly fsmiliar.
Haller derotes no less than ten pages of his great work. El. Pbys., x, 8, 1 1, 16, to learned
discussions respecting the nature of this imaginary agent ; inquiries whether it be albumin-
ous, spirituous, acid, sulphurous aeriform, or ethereal, and concludes that it bears a resem-
blance to what has been termed the ^ptntait netm of plants, a substance nearly as little under-
stood as the one which it is intended to illnstrate.
Riolanns, the son, tried to weaken and explode the arguments of Hofhaan, and, while be
defended the doctrine of Galen, in some measure adopted that of Aristotle ; but Wepfer fully
refuted Riolan, and duly Interred the doctrines as to the use of the Tentricles in produdng
end retaining the animal spirits.
The animal spirits, being ejecud from the rentrides, were placed in the cerebral substance ;
and Ifarcellus If alpighi, Thomas Willis, Sylrius de le Boi and many other writers, were unani-
mous in the belief that they are secreted in the cortical substance of the brain ; that when
•ecreted they are receired into the medullary substance, and distributed thence throbgh the
nerres to the whole body; and this doctrine is maintained by many physiologists and
pathologists to the present day. The faculties of the mind, such as perception, imagioation
and memory, were banished from the rentrides, together with the rital spirits, and were
• BmmU Dw-ChrlM TiMtitM &• Heida* ct d« FoimatloBe Fvlw. Qeofva Prior Motlt Ftipolnlt LeAovM 4*
La rori«, M. D^ lUwtntw. AMtrioteMi, Amad Dul«l«a ItMrtrivm. l<m, siv, m. i4-Se.
Tkvetetot D« ifento HnmaiiA, t^vM racttltattlMW •! Fanctionlbua, Nm Nob D« iQiudein Cnloao Ciub Ciirpoff*:
ftecmidiiin Prindpto Ronatl DM-Oarteo, Autorv, Lttdovlcv d« lo For(«, MoSldaii, Apad MmaTtoDon Doctor*. Ab»-
leludunl, Apvd DonUleBi EUoTMoa. 1069.
Introduction to the Study of Diseases of the Nervous System, 117
located by some in tbe solid maMet of the brain; bj othen were affirmed to be properties of
the iflnnaterlal, rational lonl alonei and in no wife dependent on the bodjr*.
It would ioTolre a ueeleM expenditure of time to enter into a detailed account of the vari-
ont hypotheeet propounded and earneitlj adrocated by Malpighi, Willis, Boerbare, Ruysch,
Albiaus, Mayow, Mayer, Whytt, Kaauw, Aitruo, Haller, Meckel and others, as to the nature
of the aaiaal spirits.
The hypothesis of Wbration had been imperfectly stated by many of the earlier physiolo-
gists, but it was so much detailed and embellished by Hartley, as to be by common consent
connoctad with his name. The hypothesis of Tibrations, was laid down by N. Robison, in
his treatise on the Spleen, several years before, and by Gondillac, in his work on Human
Knowledge, two years before Hartley's observations.
Aecording to this doctrine, the action of the nerves consist in a ribration of the particles
of which they are composed, by which impressions are transmitted along them, and conveyed
to aad from the brain, in perception adA volition respectively.
Thin hypothesis embraces two suppositions, viz : either that the particles of the medullary
matter itself are the agent, or else, that there is diffused or dispersed through them, a subtle
fiMtr^ which acts the sole or principal part.
Hardey adopted the supposition of the intermediate action of the ether ; Dr. Young on the
other hand, substituted the electric fluid for the hypothetical ether. Blumeobach i^mitted
the plaasibility of the doctrine of a nervous fluid, which is thrown into oscillatory vibrations
by the action of stimulants, and argues in favor of the similarity of Nervous Action and the
electric influence. Blumenbach even went so far as to say, that by the oscillations of this
Btber, Hartley, ** very ingeniously explains the association of ideas, and again by the sssist-
anoe of this, most of the functions of the animal faculties.'* (Physiol, { 226).
It baa been urged in support of the opinion, that nervous action essentially consists in
vibrations, that besides light, which is the specific and appropriate cause of vision, the sensa-
tion of sight, may under certain circumstances, be produced by other causes, which may all
of them te ultimately referred to motion. A smart blow on the eye, friction and pressure
upon the ball, and electricity, all produce this elTect.
Sir laaac Kewton, concludes his Principia with the following remarkable hypothesis :
** And now we might add something concerning a certain most subtle spirit which pervades
and ilea hid in all gross bodies; by the force and action of which spirit, the particles of bodies
mutually attract one another at near distances, and cohere, if contiguous ; and electric bodies
operate at greater distances, as well repelling as attracting the neighboring corpuscles ; and
light is emitted, reflected, refWicted, inflected, and heats bodies ; and all sensation is excited,
and the members of animals move at the command of the will, namely, by the vibrations of
this spirit, mutually propagated along the solid filaments of the nerves, f^om the outward
orgaas of sease to the brain, and from the brain into the muscles." (Principia, Book iii,
G«ncrml Scholium).
We have in the preceding hypothesis not only a statement of the doctrine of vibrations as
applied to the nervous system, but also a comprehensive enunciation of the modern doctrine
of the correlation of the physical and vital forces.
The Third or Electric Hypothesis of nervous action, is of modern origin, and rests princi-
pally upon the observations of Oaivani, Aldini, Von Humboldt, Philip, Matteucci, Nobili,
Dubois Raymond, and other Continental and Bnglish physiologists.
It has been well known from remote antiquity, that certain fish, possess the property of
comsaonicating shocks and a benumbing sensation to persons who have incautiously grasped
them. It was also observed at an early day that certain affections of the nervous system
were benefitted by these shocks, as well as by the force emitted by the load stone and magnets.
The remarkable effects of certain fish, have been satisfactorily traced to Electricity, and it is
now well established that no real difference eiists between the electric fluid thus secreted or
excited by these animals, and any of the other modifications of Blectricity.f When electric
pheoomeoa began to excite attention, it was supposed that the fibres of the muscle might be
disposed in such a manner as to form a kind of battery, which should produce contractions
by iu explosions; and after the discovery of galvanism, an elaborate attempt was made by
Valli^J of Pisa, to account for musqolar action by supposing that the muscles consisted of
aa arraogemeot of parts, analogous to that of the elements of the galvanic pile. Valli's
speeulations on the action of the two metals upon the parts of living animals, led him to as-
OB ttk9 Feactioiii of th« Nerroiu Syit^n, by Geone ProcbMka.
• ll«Bt«r, Pbil. TnuM. 177S. Dr. John Dmry, Phil. Tnu». 1838, 1834. Oay-Liunc, Abb. do Chtm., Izt^ p. 16, Joint
paptr wlia BmboUl. Coltedea, 8tenoM del* AomI. do Selonoei, Ootob. 1836. Maltooeci, Muoet de TAcnd. do ScIobm,
IKM. Badelpbi, Abbaad, du AomI. t. Boriln, 1S80, 182t Walrii, Phil. Timai., IHi. IngonhouM, Vormiichto,
MchrtfttB, p. Z72, TlonnA, 178S. Humboldt. BonpUnd and Fandi^, Phil. Trmnt., 1839. Rudolph!, Abhand Acm].,
Bortta, ISM. MOllor, Hnndbueh dor Ptayilologlo do Menchono, 1, p. 60, Cobloni, 1837.
f IxpoHBODta OB Animal Bloctrieltj, with tboir application to Phyiiology, by K. Valli, Brit Crit: March, 1704
do Pky*. t. xU, paarim.
118 Introduetion to the Study of DiieoMSs of the Neruoue Syttem.
sert the ideniity of f lectrieity and of the nerTont fluid, and the same opinioii wm to a certain
extent countenaDced bj Dr. Young,* Dr. Abemethy, and others. Valli belieyed the nearo
electric fluid to be secreted by the capillary arteries supplying the nerres, by which it became
conveyed to the muscles, which be belicTed to be always in an electric condition, the interior
being negative, the exterior positive. He also noticed the curious fact, that in experiments
on frogs, the nerves lose their irritability to the stimulus of electricity at their origin flrst,
retaining it longest at their extremities ; and on this haaarded an opinion that probably the
distal extremities are really the origin of these structures.
Galvani really discovered, not only the fundamental physiological experiment of Galvanism
properly so-called, (the contraction of the muscles of the frog when touched with dissimilar
metals) but also that of the electricity inherent in the nerves and muscles.
According to Galvani's theory, the muscles chiefly contain the animal electricity. Thej
represent a Leyden Jar, their outer surface being charged with negative, their inner with pos-
itive electricity. The nerve is the conductor of the ji^, and together with the blood-vesseU,
it supplies the muscles with electricity. The experiments of Galvani, although commenced
in the Summer of 1786, were not published until 1791. Yolta, in order to determine whether
the positive electricity existed in the nerve or in the muscle, discharged through a frog a
very slightly charged Jar, at first from the spiue to the muscles, then in the contrary direc-
tion, and finding that contractions resulted in the former case, and not in the latter, be
concluded that the current from the slightly charged Jar, and that in the frog's limb passed
in the same direction, in the first case, and in the opposite direction in the second, and hence,
contrary to Galvani's opinion, that the nerve is endured with negative, and the outer surface
of the muscle with positive electricity. Subsequent observations by Du Bois Reymond, and
others, have established the correctness of this conclnsion. Volta, however, abandoned the
view of an animal electricity, and instituted those remarkable experiments upon the effecta
of the contact of heterogeneous metals, which finally led to the discovery of the Voltaic pile
in 1799.
Galvani, aided by his nephew, Aldini, produced contractions without the aid of any metal
whatever, and performed what may be regarded as the fundamental experiment on the elec-
tricity of muscles and nerves. Thus the limb of a frog, prepared according to Gal vaults
method, is taken, and the nerves are cut off close to their exit from the spine. Then without
dipping them into any fluid, and without exposing them to any agent, that could afford any
change in them, they are brought in contact with the outer surface of one thigh. This may
be done, either by lifting them with a non-eonductor and letting them Ikll again, or by pres-
sing them gently on the surface, so that if possible they touch only a single point of the
muscle. On so doing the limb will be immediately convulsed. Galvini even caused the limb
to contract, by simply bringing the nerve in contact with the masde, of another animal, in-
sulated from the limb. Without taking off the skin from the limb, he allowed its nerve
to fall upon a piece of abdominal muscle which was lying on a plate of glass, and had
no connexion with the frog : the limb was convulsed. Volta explained these contractions
by referring them to the action of the electricity generated by the contact of heteroge-
neous tissues, as in the case of heterogeneous metals. Alexander Humboldt, next inves-
tigated this subject, and demonstrated, that muscular contractions may be excited, 1st,
by bending the thigh of an animal upon its ischiatic nerve, when the parts were in or-
ganic connexion ; 2d, by touching simultaneously the crural nerve and the muscles of
the thigh with a portion of the crural nerve which had been cut off; 3d. by establishing
a circuit between one point of the nerve and some other point of the same nerve by means of
some animal tissue Galvani died December 4th, 1796, and Aldini alone exerted himself for
the lost cause of Animal Electricity, and in 1804, published a work of experiments ; and
animal electricity was neglected for twenty-three years, when in 1827, Nohili demonstrated
the Electro- Magnetic Current of the Frog. (Ersted, in 1822, discovered the deflection of the
needle by the galv^tnic current ; this led to the construction of the OahanomtUr, By the
judicious application of Amp^r^s astatic double needle, Nobill discovered that deflections of
the needle when present, always indicate that a positive current was passing fri>m the muscle
to the nerve, or from the feet to the head in the frog. The current was increased, whenever
several frogs were included in the circuit. Nobili referred the current to thermic inflnenees,
and to the effects of evaporation, and hence his discoveries did not excite the attention which
their importance demanded. In 1836, Becquerel proposed a theory of the Blectric fishes, and
discovered that at the moment of the shock, the electricity was developed in the brain, and
was thence conveyed to the electric organ, to charge the little cylinders of which it is com-
posed. Matteucci seized upon this idea, and still farther elaborated the theory. In 1637 and
i 838, Matteucci published experiments with a galvanometer of 2500 coils, and attempted to
decompose Iodide of Potassium by animal electricity. These experiments showing that a
current may be obtained from any part of the frog, formed the startling point of the delicate
• L*c. V. I p. 740.
Introduction to the Study of Diseases qf the Nervous System. 119
Aod remftrkftble inTeiUgations of the dittingniahed philosopher, DnBoie Reymood, in 1842,
who has thowo that both the nerves and muscles of liTiog animals are endowed with electficity;
which obeys definite laws and relates the two systems to each other. In the Galvanometer
employed by DoBois Reymood, in the investigations upon the muscular current, the wire is
3280 feet long and 67-lOOOths of an inch in diameter, and coiled 4650 times around the frame.
In the more delicate instrument employed in investigations on the nervous current, the cop-
per wire measures 5684 yards, or 3.17 Bnglish miles, and is about 55-lOOOth of an inch in
diameter, and is coiled around the frame 24,160 times. Matteucci published his first experi-
ments on the frog current together with those on the Torpedo in the year 1837.
In 1838, he published another p^per on the frog-current alone. Matteucci's merit is that
he showed that the electro-motive action in the frog, upon which the frog-current depends,
is independent of the contact of the muscle and nerve, external to the limb, so that by con-
necting any two parts of the frog, the back and the eye for instance, a current is obtained.
Tkis discovery entirely overthrew the oAd Voltaic doctrine, and Nobili's theory of thermo-elec-
tricity, as well as the idea of any electro-chemical action ; moreover, the method of observation
described by Matteucci, but afterwards abandoned, contains the germ, the further develop-
ment of which gave the means of searching deeper into the laws of the electric current in the
muscles. This paper, which was reprinted in Paris in 1840, unchanged and without any ad-
dition in llalttncei*s **Essai sur les Ph^nomenes electriques des Animaux," as the sixth chap-
ter of the second part X>( that book, forms the starting point for the researches which Du
Hois Reymond has made in animal electricity. He obtained his first results in the Spring
of IMS.
The following conclnsioBs have been drawn from the researches of DuBois Reymond.
1. The muscles and nerves, including the brain and the spinal cord, are endowed during
life with an electro- motive power, which acts according to a definite law, both in the nerves
and muscles, and which may l^e briefly stated as the law of the antagonism of the longitudinal
and transverse section ; the longitudinal surface being positive, and the transverse section
negative. As the nerves have no natural transverse section, their electro-motive power,
when they are in a state of rest, cannot be made apparent unless they have been previously
divided. The muscles having two natnral transverse tections, may show their electro-motive
power without being divided.
2. Bvery minute particle of the nerves and muscles act according to the same law as the
whole oerve or muscle.
3. The currents which the nerves and muscles produce in circuits of which they form part,
mast be considered only as derived portions of incomparably more intense currents circulat-
ing in the interior of the nerves and muscles around their ultimate particles.
4. The electro-motive power lasts after death, or in dissected nerves and muscles after
separation from the body of the animal, as long as the excitability of the nervous and muscu-
lar fibre ; whether these fibres are permitted to die gradually from the cessation of the condi-
tions necessary to the support of life, or whether they are suddenly deprived of their vital
properties, by heat, chemical means, etc.
5. In the different contractile tissues, the electro-motive power, is always proportioned to
the mochaaical power of the tissue. Other animal tissues may, indeed produce electro-motive
action ; bnt it is neither so strong as the action of the nerves and muscles nor so regular ; nor
does ii vanish with the vital properties of the tissues ; nor does it undergo those sudden
variations of intensity or direction, which may be thus stated : —
6. The current in muscles when in the act of contraction, and in nerves when conveying
motion or sensation, undergoes a sudden and great negative variation of its intensity. The
negative variation of the muscular current is not a permanent one during permanent con-
tractions. It consists rather of a rapidly following succession ot single and sudden variations
of the intensity. If any part of a nerve is submitted to the action of a permanent current,
the nerve in its whole extent suddenly undergoes a material change in its internal constitution,
which disappears on breaking the circuit, as suddenly as it came on. This change, which is
called the electrotonic state, is evidenced by a new electro-motive power, which every point of
the whole length of the nerve acquires during the passage of the current, so as to produce, in
addition to the usual current, a current in the direction of the extrinsic current. As regards
this new mode of action, the nerve may be compared to a Voltaic pile, and the transverse
section loses Its essential import. Hence the electric effects of the nerve, when in the electro-
tonic fftate, may also be observed in nerves without previously dividing them.
7. The electro-tonic state of a nerve is the commencement of its electrolysis. The con-
traction on making the circuit is caused by the nerve passing into the electrotonic state, and
that on breaking the circuit by the nerve passing out of this state.
8. Approaching death, and severe injuries of thp muscular and nervous tissue, cause other
modlflcations of the electro-motive power of the nerves and muscles, of which some are per-
maoeot, and connected with the total extinction of that power, others are only transitory.
120 Introduction to the Study qf Diteases qf the Nervous Syetem.
9. Tht electric pheBomena of motor and leoeitiTe nerret are identical. Both claesei of
nerTCt tranfmit irritation in both directione.
If a nerve or mnscle be brought into a state of fonotional actiTitj, (either by mechanical,
chemical or electrical stimalation), it ie foand that the current paseinf through the gaWaao-
meter is diminished in intensity, i. e., the difference between the electrical conditions of the
longitadinal and transverse sections becomes less. This is known as the neffotint panatiom
of the nerve or muscle-cnrrent. Bj means of extremely delicate instruments, it has been
shown that the negative variation is first felt in those parts of the nerve or muscle which are
in the immediate neighborhood of the point where the stimulus is applied, and that it
afterwards makes its appearance at points successively more and more distant, while disap-
earing at the points where it had first appeared. In other words, the negative variation in
transmitted with a wave-like motion along the nerve or muscle in both directions from the
point stimulated.
The nature of this wave-like motion has been recently carefully investigated by Bernsuin,
who has determined, both for muscles and nerves, the rate of transmission, the length and
duration of the wave. When a muscle is stimulated at any one point, the electrical condi-
tion of the muscle at that point is changed, and this changed electrical condition is propa*
gated wave-like in both directions at a rate of 2.927 metres in 1^^, and each portion of the
muscle requires 0.0039^^ to go through this changed condition and return to its normal stato,
and Che distance measured on the muscle between a point which is Just entering upon, and
one which is just leaving this changed condition, is 10 mm. The rapidity of the wave of
negative variaHim in nervetf agrees quite closely with the value found by Helmholts for the
rapidity of nerve force, vii : 26.4 metres in U^, This valne was obtained by noting how the
time elapsing between the irritation of a nerve and the consequent contraction of the muscle
attached to it varied according as the stimulus was applied at a distance from or close to the
muscle. This close correspondence of the two phenomena in regard to rapidity, together
with the fact that the height of the wave of negative variation, i. e., the amount of the
electrical change, increases with the intensity of the stimalation, clearlv indicates that a very
close relation exists between the manifestation of nerve force and the change in the electriciU
condition of the nerve, and may even be considered as furnishing a sufficient reaioo for
regarding the latter as a measure of the former.
It has thus been finally established by the labors of many observers, that the phenomena
of atmospheric, machine, Voltaic, and animal electricity, are one ; are governed by the same
laws ; have the same origin, and produce the same results ; and are doe to the same force :
and it has been shown by philosophers, that electricity may be produced by motion ; motion
by electricity ; electricity by magnetism ; chemical action by electricity ; electricity by chem-
ical action ; electricity by heat ; heat by electricity ; and nervous excitation and muscular
motion by electricity.
MUTUAL RELATIONS OF THE MUSCULAR AND NERVOUS FORCES.
The discussion of this subject is necessarily difficult and to a certain extent, in the present
sute of physiological science^ unsatisfactory. Thus at so late a date as 1837, the physiol-
ogist, J. M&ller, after an extended and elaborate examination of the facts and experiments,
bearing upon the question of the nature of the nervous foree, arrived at the following
conclusions :
ItL ** Thai the tIM Mtkmi of th* nemee en nol Att«ad«d wtth thm d«T9lop««nt of aaj geXyealc cemati wkfcb
oar laatniaiooti cen deCoet
M. ■*ThfttUMle««oraetloaorih«Mrfoeiltai»,«i«tolillydiftf«atfh»llMiMoroloctr«aHy.
Sd. ** To epeek tli«ff«f6i«, of ab oioetrie oirriDt In tho bottm, !• to om qollo m efwboUeeX aa ospnHloe, m If «•
ooaqMurad the actton of the Beiroos principle with light or metniillwii Of the luitare of the aenrooe prtDdpIo, we %tm
M Ifiioimat, M of the oatvie of Iff ht and electridtx : while with tta piopertlee we aiv nearly aa well aoqwlatad m
with thoee of light and othor latpofiideraMe ageoln Howerer mooh. thoM Tarlow priadplea diiiw ftom each other,
the aaiM qeeaHoa appilea to all ; aamtly, en their eiKeam prodaeed bgr eomati of aa Jipoedaimhle iMtler tiavettng
throogh apaee, or ^ the aadatetlooa of a fluid 7 The dlerwioa aa to which theory it eorract. Id the caae of the*
irrooi prinelple, to at pieaeat a flutter oot afRMUng the etody of the lawe crfT Ha actfon ; Joat m the tawe of oetka,
Mt Maaln the laiae, whieherer theory of the natvra of Mght be adopted.**
aerro'
The doctrine of the unity and correlation of forces, propounded by Dr. J. R. M^yer, shortly
afterwards, in 1S42, not only led to the recognition of the essential unity of the ao-called
imponderables, vii : the chemical forces, heat, light and electricity, and moUon, but also slowly
but sorely revolutionised the theories of physiologists, and led to the reference of all ohemi-
cal physical and vital forces, or processes, to a single force or power, which originally appeared
as light from the son, and excited in inopganie matter and living organisms, heat, mechanical
motion, chemical change, electricity and nervous and muscular force. The labors of Mayer
and Helmholts, Orove, Faraday, Joule and others, have led to the annunciation of the
theory, thst there is in reality, but one single force which runs through an eternally changing
Introduction to the Study of Diseases qf the Nervous System. 121
roaod, ii dead or inorganic, m in organic liTing nature. As far a« the knowledge of man
extendi, matter and force, are indestrnctible ; Force changes its form ; heat is changed into
motion ; chemical action developes force in accordance with the amount and character of the
Btttter altered, and in all chemical and physical changes, the resulting power maintains aeon-
sttnt magnitude : — animal heat is dependent upon chemical changes, and the resulting forces,
beet ind motion, and muscular and nerTOus force, are dependent upon, and are equiTalent to
the som of the power of the simultaneously produced chemical processes.
Professor Owen, in his recent work on Oon^araUve Anaton^ and Phytiology, thus applies
thcu Tiews :
"yenikUj it not eleetxid^. anv mora fbaii maconldty ; both ai« pacaliar modca of polar foroe. Any point of
tk« nxflke of a narre, is podtiTe u> relation to any point of the tnuurene section of the eama nanre, Jnat aa any
point of the iQiftcc of a mnade ia poaitiTe in relation to any point of the traniTene section of the same muscle.
Ugatira of % nerre aireata the nerrona enirent, not the electric cnrrent : a dlrided nenre connected by an electric
ooBdnrtor, tmnanltsthe electric cnrient ; bat tiie nerroos cnnrent excited 07 stimuloos aboTa the section, is arrested by
th« elMSrie cMKlQctor. Nenrid^ ia oonrertible into myonidty and Into other forms of polar force, Jnat aa myonid^
or the moaralar force, may be dispoaed of by conyexsion into heat, electrid^ and chemidty, the latter shown by the
•Tolntioa of cubonic add. Molecular change in nerrons and In muscular fibre attends the exerdse of their respect-
he fuvsi.'*
One of the most striking facts, with reference to the true nature of the muscular and ner-
Tont forces, has been furnished by Comparative Anatomy, viz : that the peculiar instrumenti
foood in certain of the lower animals, have the property of accuoaulating and concentrating
tbe fobtle mode of force, applicable to the communication of electric shocks. The currents
geaented in the electric organs of certain fishes, besides their effects upon the living body,
exercise all the other known powers of electricity ; they render the needle magnetic ; and
tbej decompose chemical compoundii and emit electric sparks. Pacini, from a minute com-
parison of the organs, deduces, that the electricity in the Torpedo, is produced by the dyna-
mic conflict between the two polarities inherent in two sets or degrees of innervation, as it
ii evolved in the thermo-electric pile, by the conflict of two polarities inherent in two differ-
ent degrees of temperature ; whilst in the Qymnotus, it is produced, as in the Voltaic pile, by
tbe chemical conflict, between the materials of the elements excited by the nervous influence.
In the experiments performed by Professor Faraday, on a large living Gymnotus, it was de-
nonitrated by the galvanometer, that the direction of the electric current, was from the
interior parts of tbe animal, to the posterior parts, and that the person touching the fish,
vith both hands, received only the discharge of the parts of the organs included between the
points of contact. Needles were converted into magnets ; iodine was obtained by polar de-
composition of Iodide of Potassium ; and avaiiing himself of this test. Professor Faraday
kfaowed that any giren point of the organ, is negative, to other parts, before it, and positive
to such as are behind it. Finally in those experiments, heat was evolved by the electric
iptrk obtained.
An analogy has been pointed out by comparative anatomists, between the row of compressed
celU, constituting the electric prism of tbe Torpedo, and the row of microscopic discs of
whick the elementary muscular filaments appear to consist ; the looped termination of the
exciting nerve, is common to muscular tissue, and that of the electric organ : and the electric
like the motory nerves, rise from the anterior myclonal tracts, and though they have a spe-
risl lobe at their origin, beyond that origin. In the Torpedo, they have no ganglion. An im-
preasioo on any part of the body of tbe Torpedo, is carried by the sensory nerves, either directly,
or through the posterior myclonal tracts to the brain, excites there the act of volition, which
ii conveyed along tbe electric nerves to the organs, and produces the shock ; in muscular
contraction, tbe impression and rolition take tbe same course to the muscular fibres. If the
electric nerves are divided at their origin, from the brain, the course of the stimulus is inter-
mpted, and no irritant to the body has ai.y effect on the electric organs, any more than it
would have under the like circumstances 00 the muscles. But if the ends of the nerves in
connection with the Organ be irritated, the discharge of electricity takes place, just as irrita-
ting tbe end of tbe divided motor nerve, in connection with the muscle would induce its
contraction. If part of the electric nerves be left in connection with the brain, the stimulus
of volition, cannot, through them, excite the discharge of the whole organ, but only of that
part of the organ, to which the undivided nerves are distributed. So likewise the irritation
of the end of a divided nerve in connection with the electric apparatus excites the discharge
of only that part, to which such nerve is distributed. The power of exciting the electric
Motion, like that of exciting the muscular contraction, is exhausted by exercise, and recovered
^7 repose ; it is also augmented by energetic circulation and respiration ; and what is more
iignificant, of tbeir close analogy, both powers are exalted by the direct action, on the nerv-
oni centres, of the drug strychnine ; its application causes simultaneously a tetanic state of
the mnscles of tbe fiab, and a rapid succession of involuntary electric discharges.
We propose in tbe next place, briefly to examine some of tbe most Important facts, illus-
trating tbe nature and relations of the muscular and nervous force, without any special refer-
ence to tbeir chronological arrangement, in the history of physiological science.
16
122 Introduction to the Study of Diseases of the Nervous System.
It ifl DOW well established that animal life, if not possible witbont constant chemical and phy-
sical changes in the molecnles of the bodj ; and since such disturbances are alwajs accompanied
with the liberation of electricity, it would not be unphitosophical upon this general riew, to
infer that electrical currents exist in all living animal structures, and that the intensitj of
their electrical actions, varies with the amount and character of the chemical and physical
actions of the tissues.
The experiments of Brown-S6quard upon the effects of the injection of arterial blood, into
the blood-vessels of the arm of a criminal who had been guillotined, and into the vessels of vari-
ous animals after rigor-mortis had been established, as well as the similar experiment bj Pro-
fessor Stannius, upon the power of arterial blood, not only to overcome rigor-mortis, but alto
to restore muicular contractility and nervous excitability, prove conclusively that the power of
the nerves to transmit impressions, and of the muscles to contract, is due to the chemical actions
and reactions between the oxygen of the blood, and the elements of the muscles and nerves.
The Italian philosopher Matteucci, has shown that during muscular contraction, the con-
sumption of oxygen, and the exhalation of carbonic acid are increased, in accordance with the
amount and length of the muscular actions. It is reasonable therefore, to refer the muscular
force to the chemical actions established within the muscular structure ; and it appears to be
probable that the chemical actions, are first transformed into electricity, or some modification
of the force, to produce this contraction.
Helmholtz, in like manner has shown, that muscular action is always accompanied by a
chemical change in the composition of the acting muscle.
Physiological experiments of the greatest delicacy and accuracy, have established the fact,
that electrical currents, circulate in all tissues in which active nutrition is carried on, and
that the alectro-motive force, is strongest, and at the same time, is capable of the greatest
and most sudden variations in intensity and direction in the nerves and muscles ; that there
exists, both In the muscles and in the nerves of all animals a natural electricity, which is
manifested under the form of closed currents, circulating along the muscles or the nerves of
the animals, and of which we can collect a very small derived portion by the assistance of
delicate intruments, and the presence of this free electricity is subordinate to the state of life
of the animal, and disappears with the loss of vitality in the tissues.
DuBois Reymond, by a series of experiments ot wonderful delicacy and accuracy, and
variety, has established the following important physiological facts and principles: the mus-
cles and nerves, including the brain and spinal cord, are endowed during life with an eKctro-
motive power, which in both, acts according to the same definite law, the longitudinal sur-
face being positive, and the transverse section negative ; every particle of the nerves and
muscles, act according to the same law as the whole nerve or muscle : the electric currents
in the nerves and muscles show in some instances, variations of intensity and direction, so
sudden, that it appears impossible to account for them by any change of large heterogeneous
elements, or In any other way than by assuming corresponding changes of position in almost
infinitely small centres of action, hence, nervous and muscular electrical currents manifested
and measnred by the instruments of the experimenter, must be considered only as derived
portions of incomparably more intense currents circulating in the interior of the nerves and
muscles around their ultimate particles ; the electric state of both nerves and muscles, must
therefore be compared to that of closed circuits : in the different contractile tissues, the
electro-motive power is proportional to the mechanical power of the tissues, and whilst other
animal tissues may produce electro-motive action, it is neither so strong nor so regular as
the action of the nerves and muscles, nor does it vanish with the vital properties of the tissues,
nor does it undergo the sudden variations of intensity and direction which characterise the
electro-motive force of the muscles in the act of contraction, and of the nerves when convey-
ing motion and sensation ; when the nerves are no longer able to cause sensation or motion,
or secretion, the electric current appears very feeble, or its normal direction becomes inverted,
the negative surfaces being now positive, and the positive surfaces negative, and finally, the
electric phenomena in the nerves disappears at the same time with the vitality ; the muscular
current continually decreases aAer the death of the animal, and after the separation of the
muscle from the body ; the electric power of a nnscle is always proportioned to its contract-
ility, inasmuch as those agents which do not influence its contractility also exert no influence
on its current ; the diminution of the muscular current after death, is proportional to the
diminution of the exeitabitity of the muscle ; both the electro-motive force, and excitability
have the same termination, that is, the rigKn-'mortiSf caused as Briicke has proved, by the^co-
agttlation of the fibrin contained in the muscles, external to the blood-vessels ; the current
when once it has gone In consequence of the rigor-mortis, never returns; limbs in a state of
decomposition after the relaxation of the rigor-mortis, no longer possess any electro- motive
force: DuBois Reymond, considers therefore, that the phenomena of muscalar and nervous
currents, can only take place in the living tissues.
Another electro-physiological law of great interest, and especially in its relations to certain
diseases of the nervous system, as Tetanus, has been established by DuBois Reymond, for the
Introduetion to the Study qf Diseases qf the Nervous System, 123
motor Deires, and maj be expressed thai : the motor nerrei are not excited by the Absolute
amoant or density of the carrent, but merely by the variaHoru which occur in the density of
ttie corrent, from one ifutant to the other, and the more considerable the Tariations in the
density of the current, the greaier the physiological effects. It results from this, that unsta-
ble cooditiooB of the closed muscular and nervous currents depeodent upon derangement of
the chemical and physical properties and actions of the molecules of the muscles and nerres
voald be necessarily attended by deranged muscular and nervovs actions ; Fariations in the
density of the currents circulating in the motor nerves, may be attended with either exaltation
or depression, or alternate exaltation and depression of muscular action.
We iril! examine, in the next place, the important question, whether corUraetililyt be inhe-
rent io the muscles, or whether it be entirely the result of a force communicated to the mus-
cles bj the nerres.
The cootroTersy with reference to the inherent contractility of muscle, independent alto-
gether of nerrous influence, carried on from the time of Haller to the present day, may now
be considered as settled in the affirmatire.
The experiments of Bernard, Kdllilcer, Althus and other physiologists with woorara,
demonstrating that this poison kills the motor nerres without destroying the power of the
mnsdes to contract; the microscpical observations of Dr. Wundt, showing a difference
between the contractions of muscular fibres when the electrodes are directly applied to the
mascles or to the nerres ; and lastly the important microscopical observations of Mr. Bo wen,
ihoving that the fragments of the elementary fasciculi of voluntary muscle, which he had
isoUted from every extraneous tissue, whether nerve or vessel, contract when excited by
mechanical irritation, establish the existence of inherent muscular contractility, independent
of nervous excitability.
Thtt muscles do not derive their state of tone or power of contractility from the cerebro-
spinal and sympathetic nervous systems, and especially from the spinal cord, but possess
vitbin themselves all the conditions necessary for the generation of their proper force, is
manifest from the following considerations : In chemical composition, the muscles resemble
more nearly the contractile element of the blood, viz : fibrin ; the anatomical and mechanical
arrangement of mnscles adapts them for contraction and expansion, whilst the large supply
of blood which they receive furnishes the essential elements and conditions for the continuous
munteoance of those chemical changes which develop the muscular force ; the mechanism
of mascolar contraction may be seen by the microscope, even in detached portions of muscu-
lar fibre entirely deprived of nerves ; muscles dissociated from the nervous centres by the
section of all the nerves distributed to them, retain their power of contraction for a consid-
erable period, long after the nerves which sink in them have lost their excitability ; the irri-
tabilitj of tue nerves and muscles may be destroyed or suspended, independently of each
other, by the action of certain poisonous substances, which have the power of destroying the
irritability of the nauscles and nerves by a direct action upon their tissue.
The results obtained by Dr. E. Harless, (Muller's Archiv., 1847, p. 228); fi*om experiments
undertaken for the purpose of determining the relation in which the nervous influence stands
towards the irritability of muscular tissue, establish that the functional integrity of the nerves
ramifying in the mascles, is not necessary for the excitement of muscular contractions, and
that the mnscles themselves are susceptible of the direct action of stimuli. Having exposed
rabbits to the influence of the vapor of ether, until they were so far overpowered by it that no
morements of their bodies could be excited even by means of galvanism, they were killed by
opening the carotid arteries, and the brain and spinal cord exposed. On galvanizing these
BcrTOQs centres, not the slightest movement of the body resulted, but when the galvanic
stimulas was applied to the muscles of the trunk, violent contractions at once ensued. Gal-
raoiiing the crural nerve, produced not the slightest action of the muscles of the corresponding •
1^, bot these muscles were thrown into immediate contraction when the stimulus was appiied
directly to themselves. Similar results were obtained by galvanizing the nerves and then the
Boscles of other parts of the body. The result in all cases appeared to point to the conclusion
that the muscular tissue possesses within itself an inherent power of contraction independent
of the influence of the nerves distributed to it; for, in these experiments, the nervous system
vas so far overpowered by the ether that no amount of irritation of it could excite muscular
contractions, while these contractions, were at once induced when the irritation was applied
to the muscular tissue itself.
M. Bernard has demonstrated that the irritability of the muscles may be destroyed, while
that of the nerves remains unaltered, and that the sensitive and motor filaments may each be
ptraljied independently of each other. Thus, when the frog's leg has been prepared and
separated from the body, with the sciatic nerve attached, the muscles contract whenever the
Qcrre is irritated, the irritability being manifested in this experiment only through that of the
aoicle, and that of the muscle being called into action through the nerve. If a frog's leg be
prepared as above, and the animal be poisoned by woorara, the poles of a galvanic battery
Applied to the nerve will produce no effect, showing that the nervous irritability has ceased
124 Introduction to the Study qf Diseases of the Nervous System.
to exist, bat if the galTAoic discharge be passed directly through the muscles, contraction at
once takes place; the mnscnlar irritability has BarTived that of the nerres.
Salphocjanide of Potassium produces paralysis of the muscular tissue, while the nerves of
the same part retain their irritability ; woorara destroys the irritabilitv of the motor nerves
without affecting that of the mnscleS| and at the same time the sensitiTC fibres retain their
power of transmitting impressions ; in poisoning by strychnine the sensitire filaments of the
nerres are paralyzed, while the motor filaments and muscles retain their irritability.
The researches of Bernard have been confirmed by a series of experiments with woorara
and conilne, undertaken by Kolliker. According to Kdlliker. the action of confine is nearly
equal to that of woorara.
Dr. J. Althns has obtained similar results with woorara, and be gives the following as the
experiment which best shows that it is only the motor nerves which are killed by the poison.
The crural artery and veins are closely tied up on one side, so that the circulation of the
blood in the limb is stopped. The animal is then poisoned by inserting a small quantity of
woorara under the skin. If galvanization of the motor nerve be practiced, a short time
afterwards, it becomes evident that all the nerves have lost their integrity, with the excep-
tion only of the crural nerve of that side where the vessels have been tied ; this nervci when
galvanized, sets the muscles in play. But if the electric stimulus be directed to the muscular
substance itself, contractions may be obtained in all the muscles ; and the contractile power
of those muscles, the nerves of which have been poisoned, will last even longer in those
which have not been, in consequence of the stoppage of the circulation of the blood in the
latter.
The following are the experiments with Sulphocyanide of Potassium and Strychnine, as
detailed by Dr. John G. Dalton, in his valuable Treatise on Human Physiology :
In a living frog, the sciatic nerve is exposed in the back part of the thigh, afler which a
ligature is passed underneath it and drawn tight around the bone and the remaining soft
parts. In this way the circulation is entirely cut off from the limb, which remains in con-
nection with the trunk only by means of the sciatic nerve. A solution of sulphocyanide of
potassium is then introduced beneath the skin of the back in sufficient quantity to produce
its specific effect. The poison is then absorbed, and is carried by the circulation throughout
the trunk, and the three extremities, while it is prevented from entering the limb by the liga-
ture which has been placed around the thigh. Sulphocyanide of potassium produces paraly-
sis, by acting directly upon the muscular tissue. Accordingly a galvanic discharge passed
through the limbs, which received the poison by absorption, produces no contraction in them,
while the same stimulus applied to the limb, the blood-vessels of which had been tied, bat
which communicated freely with the sciatic nerve, is followed by a strong and healthy reac-
tion. But at the moment when the irritation is applied to the poisoned limbs, though bo
risible effect is produced in them, an active movement takes place in the healthy limb. This
can only be owing to a reflex action of the spinal cord, originating in the integument of the
poisoned limbs, and transmitted through sensitive and motor filaments through the cord to
the sound, unpoisoned leg. WhiUf there/ore^ the muteUi of iht poUoned limbt hare been directly
paralyzed, the nervei of the tame parts have retained their irritability. If a frog be prepared in a
similar manner and poisoned by the introduction of woorara beneath the skin of the back,
when the limb, which has been separated by the ligature around the blood-vessels, is irri-
tated, its own muscles react, while no movement takes pUce in the poisonc^d limbs ; but if
the irritation be applied to the poisoned limbs, reflex movements are immediately produced.
In the poisoned limbs, therefore, while the motor nerves have been paralyzed, the sensitive
filaments have retained their irritability.
If a frog be poisoned with strychnine, introduced underneath the skin in s a flicient quantity,
death takes place after general convulsions, which are due to an unnatural excitability of the
reflex action. Tetanus and poisoning by strychnine, both act in the same way, by heighten-
ing the irritability of the spinal cord, and causing it to produce convulsive movements on the
application of external stimulus. It has been observed that the convulsions of Tetanus are
rarely, if ever, spontaneous, but they always require to be excited by some external caase,
such as accidental movement of the bed-clothes, the shutting of a door, or the sudden pas-
sage of a current of air. Such slight causes of irritation, which would be entirely inadequate
to excite involuntary movements In the healthy condition, act upon the spinal cord when its
irritability is heightened by disease in such a manner as to produce violent convalsioas.
Similar appearances are to be seen in animals poisoned by strychnine. This substance acts
upon the spinal cord, and increases its irritability without materially affecting the fbnctioos
of the brain. Its effects will show themselves, consequently, without essential modification,
afler the head has been removed. If a decapitated frog be poisoned with a moderate dose of
stryebniae, the body and limbs will remain quiescent so long as there is no external sonrce of
excitement; but the limbs are at once thrown into convulsions br the slightest Irritation
applied to the skin, as, for example, the conuct of a hair, or a feather, or even the jarring of
the table on which the animal is placed. That the convulsions in cases of poisoning by
Introduction to the Study of Diseases of the Nervous System. 125
strjehaine are alwajB of a reflex character, and nerer spontaneous, is shown bj the following
fact, 0rst noticed bj Bernard, riz : That if a frog be poisoned after division of the posterior
roots of all the spinal nerves, while the anterior roots are left antouched, death takes place,
as asnal, bat is not preceded by any convulsions. In this instance the convulsions are
absent, timplj because, owing to the division of the posterior roots, external irritations can-
not be communicated to the cord. In poisoning by strychnine, however, the unnatural
excitation of the reflex action is followed by a paralysis of sensibility, so that after death no
reflex movements can be produced by irritating the skin, or even the posterior roots of the
spinal nerves. Bnt if the anterior roots, or the motor nerves themselves be galvanized, con-
tractions invmediately take place in the corresponding muscles. In this case, therefore,
the aeaaitire filaments have been paralyzed, while the motor filaments and the muscles have
retained their irritability.
Soch facts justify the conclusion, that there is no direct dependence of the muscles upon the
nerToas system for the development of their proper force ; and that this force results from the
chemical changes involved in the healthy nutrition of the muscles ; the chief influence of the
Dervoas system therefore upon the muscular system is by the disturbance of the electrical
condition, and by an influence upon the nutrition of the muscle through the variation of the
amounts of blood circulating through the muscular structures. It has been shown by numer-
ous experiments, that if the nerves of a muscle be divided, and it be left to itself, its nutrition
fails gradoally, and with this change in the chemical actions, the contractility diminishes ; but,
if on the other band, the muscle be daily exercised by galvanic stimulus, both its nutrition
and Its contractility remain unimpaired. Longet found that when a motor nerve is separated
from the nervous centres, in a living animal, it will lose all trace of excitability on the fourth
day after its connection has been severed. After the fourth day, mechanical, chemical or
electrical stimuli, will fail to produce muscular contractions, if they be applied to the free
extremity, or the branches of the nerve ; on the contrary, a muscle, the motor nerve of which
has lost its excitability, will visibly vibrate under the influence of a stimnlus, even twelve
weeks after the section of the nerve has been made. From this Longet inferred, that the
motor nerves are not the only exciters of muscular motion : that muscular irritability is inde-
pendent of the motor nerves ; and depends essentially upon the supply of arterial blood, a
condition necessary not to impart or communicate to the muscles the property in question,
bat only to maintain in the muscular tissue, the nutrition which keeps up the vital properties
of all the tissues of the animal body. Dr. John Reid, obtained similar results, by insulating
the hinder extremities of frogs, from their nervous connections with the spinal cord ; and then
daily exercising the ronscles of one of the paralyzed limbs, by a weak galvanic current, while
the mnseles of the other limb were allowed to remain quiescent. At the end of two months,
the muscles of the galvanized limb retained their original size and firmness, and contracted
vigorously, while those of the quiescent limb had shrunk at least, one-half of their former
balk, and presented a marked contrast to those of the galvanized limb. But even at the end
of two months, the muscles of the quiescent limb had not lost their contractility.
Whilst such experiments therefore, demonstrate on the one hand, that the muscles develope
their own mechanical force, on the other hand, they demonstrate, the close analogy, if not
absolute identity between nervous force and electricity.
Tb» nerve possesses of itself a certain electric state, which is modified by long excitation
exercised upon the nerve; tlte muscle has likewise a natural electric state, which is modified
•very time there is a contraction ; in the absence of excitation exercised upon the nerve, and
of contmction produced upon the muscle, there must necessarily be established a certain
electric eqoilibrium. which consists in the circulation of internal electric currents, in relation
with the chemical phenomena that are accomplished in living muscle.
M. Amici, by means of his compound microscope, has succeeded in forming an idea of the
stmctore of elementary muscular fibre, and of the mechanism of muscular contraction.
According to this observer, a simple muscular filament, is composed of a series of discs, ex-
cessively thin and near together, connected with each other by means of a great number of
infinitely small threads, going from the circumference of one of the discs, to that of the other ;
the discs themselves, are as it were, rings, the circumference of which being more compact
and resisting, serve as the attaching point to the threads, whilst their central point is filled
with a soft matter, analogous to that which is found in infusoria, and which seems to be the
matter of which the muscle is formed. When contraction takes place, the threads are seen
to enter inwardly, forming a broken line, so as to bring about the approximation of the discs.
which instead of remaining the two bases of a cylinder, seem to be the bases of two truncated
cones, opposed by their smaller bases. There follows from this change, a shortening of the
entire fibre. De La Rive, reasoning upon these facts, thus explains the cause and mode of
conirmctions : — In the state of rest, and under the influence of vital force, the particles of
each disc, or ring, have their negative poles turned interiorly, and their positive poles exte-
riorly, but under the action of any cause whatever, the particles makes a demi revolution,
which eanses their negative poles to turn downward, and their positive upward, or recipro-
126 Introduction to the Study qf Diseases of the Nervous System.
cally; it foUoKS then from this, that these particles, having their contrary poles placed all
near the others, in the same rectilinear direction, which is the direction of the length of the
fibre, they matually attract each other, which causes the discs to approach, as actually takea
place in contraction.
In endeavoring to explain the mode ot action, and nature of nervous and muscular force,
and the relations of the nervous to the muscular system, by the aid of the facts and laws
already recorded, and which as we have before stated, have be 'U established by actual experi-
ments of the greatest delicacy and accuracy, we shall avail ourselves of the formnlaliony
extension and perfection of the theory of DuBois Reymond, by the philosopher De La Rive,
as presented in various parts of his great work on Electricity. ,
In order to explain the electric state of the muscle, it must be admitted that each organic
molecule of which the muscular bundle is composed, is naturally electric, and that it possenses
the two electricities in a free state. M. DuBois Reymond conceives, that these molecules,
which may be of any form, but which he supposes to be spherical, have each a positive
equatorial zone, and two negative polar zones. He supposes, moreover, that they are so
arranged, that the diameters which pass through the negative poles of each are parallel to
each other, and to the axis of the muscular bundle ; he terms the molecules peripolar. De La
Rive, is disposed to believe that the phenomena may be very well explained by assuming thfti
the organic molecules have but two electric poles, one positive and the other negative, an
hypothesis which De La Rive, has already set forth for inorganic molecules; only on the
other hand, this philosopher is led to suppose, as indeed M. DuBois Reymond is obliged to do,
in order to explain the electrical phenomena of the muscle, that by the effect of life, these
molecules assume a peculiar arrangement. They are not indeed, arranged as in an inorganic
substance abandoned to itself, so that there is established an electric equilibrium, by the
effect of the mutual neutralization of all the molecular electricities, but so that in each trans-
verse section of the muscular bundle, the positive poles of the molecules are turned outward,
and the negative poles inward. The positive and negative electncities of the molecules of
each section, which radiate from the centre to the circumference, neutralise each other, ex-
cept the positive, of those which are at the circumference, and the negative of those which are
at the centre. But these two free electricities are reunited by the exterior surface of the
muscle, forming currents of which we collect only a derived portion in the experiments in
which we cause the transverse and longitudinal sections of a muscle to communicate together,
or two dis-symmetrical points of the same section. Such then, would be the arrangement of
the molecules in each elementary muscular bundle, whence would naturally result a negative
electric state to all the points of the two bases or extremities of the complete muscular bun-
dle, and a positive state to all the points of the longitudinal surface. The electrical state of
the artficial sections, whether transverse or longitudinal, would evidently be also, the conse-
quence of the same distribution of the particles.
The nervous current is subject to the same laws as the muscular current ; we may there-
fore assimilate these two currents, and consider the former as being, as well as the latter, a
derivation of the current that is established in the nerves, and in the conductors with which
it is surrounded, bf the effect of the electric polarity of the nervous polarity of the nervous
particles, and of the arrangement which they assume under the influence of the vital force.
With regard'to the electro-motive power of the nervous particles, it is difficult to appreciate
it ; but we 'may affirm that, under equal circumstances, the nervous current is in no way
inferior in force to the muscular current. The electro-tonic state which the nerve aseames,
which renders it fitted for conveying to the muscles, or to the nervous centres, those modifi-
cations that we recognize under the form of motion or sensation, is due to a molecular polarisation
of the nerve, analogous to that which is determined in all conducting bodies, by the effect of the
passage of an electric current. This polarization consists in the fact, that the nervous mole-
cules, endowed naturally, like those of the muscle, with two electric poles, turn all their
positive poles on the side towards which the current is directed, and their negative on the
side whence it comes. This explanation, which De La Rive borrows from Bn Bois Reymond,
does not require that wo should admit, with the latter philosopher, in the nerve, any more
than in the muscle, the existence of peripolar molecules, which he supposes to be formed io
the nerve, each from the juxtaposition of two bipolar molecules. De La Rive considers that
tt*is enough to suppose that these molecules are bipolar ; and that nnder the influence of the
vital principle, they are in the nerve, as in the muscle, arranged in such a manner thai their
positive poles are turned exteriorly, and their negative interiorly. This arrangement explains
fpr the nerve, in the same manner as for the muscle, the manifestation of the current proper,
called in this case nervous current.
A nerve excited by any mehns whatever, and an electric current applied directly, acts in
the fame manner upon a muscle. It is therefore probable that it is by a modification in it#
natural electric state, that the nerve acts, when, by virtue of an excitation arising from the
brain, or from the muscle, or from an exterior cause, it produces motion or sensation.
The following explanation has been given of this mode of action : The nerve possesses n
Introduction to the Study of Diseases of the Nervous System. 127
certAin electrical state^ which physiologists ha^e succeeded io detennining ; moreover, this
electric state is modified bj every excitation exercised upon the nerve. The muscle has,
likewise, a natural electric state, which is modified every time there is a contraction. In the
absence of excitation exercised upon the nerve, and of contraction produced upon the mus-
cle, there must necessarily be established a certain electric equilibrium, which consists in the
circnIatioB of internal electric currents, in relation with the chemical phenomena that are
accomplished in the living muscle. De La Rive does not aflSrm by this that these phenomena
are the cause of the electric currents ; their cause is in the vital force, which gives to organic
molecules, naturally bipolar, the arrangement necessary for the establishment of this current ;
but this arrangement once established, the current is sustained by the chemical actions that
accompany it, and which it probably determines itself in part. Vital force, according to De
La Rive, here plays a part analogous to that of the force which polarizes the molecules of an
electrolytic liquid, when a metal susceptible of being attacked by it is plunged into it; then,
when the circuit is closed, the current itself is sustained by the chemfical actions that result
from the closing of the circuit; the latter at the same time increases in intensity. This takes
place likewise for the chemical actions that constitute muscular respiration, since, as M.
Matteacci has observed, they are more powerful when the muscle is contracted than when it
is not. Thus, life is transmitted by the nerve, by means of the electric state that it possesses
in the normal condition of vitality ; and from this there results for the muscle an analogous
electric state, with certain differences to which we have directed attention, and which are
due to the different nature of these two parts of the animal body.
Now, if by any cause whatever, the electric state of the nerve is modified, equilibrium is
destroyed ; and from this there results a contraction of the muscle or a sensation. Before
studying the consequences of this modification, we may remark that it consists in the fact
that the organic molecules of which the nerve is formed, are not polarized transversely from
within outwards, but longitudinally from one extremity to the other, as in every conducting
body traversed by an electric current. When the modification arises from the immediate
action of the nervous centre, it appears that the polarization is brought about always in such
a manner that the negative poles of the molecules are turned on the side of this centre, and
the positive on the side of the muscle, as would result from the action of an electric current
that might be travelling in the direction of the nervous ramifications. It is thus explained
why an electric current which travels in this direction favors the contraction much more than
when it travels in the contrary direction. This is equally a natural consequence of the fact
that the particles of the nerves upon which the immediate action of the brain must be exerted,
being the interior which penetrate into it more deeply, have their negative poles free.
ff, instead of coming from the brain, the action exerted upon the nerve comes from the
muscle, the polarization of the nerve must take place in a contrary direction, namely, so that
the positive poles are all turned towards the side of the nervous centre, and the negative
towards the side of the muscle whence the excitation comes. This reversion in the polarity
of the molecules of the nervous filament that abuts on the brain, must affect it, and produce
in it a sensation. This is confirmed by the effect of a foreign electric current, which, when
it circulates in the nerves in a direction opposite to that of their ramifications, produces a
sensation, and not contraction. De La Rive conceives, therefore, from this, that polarization
is established in a contrary direction in a nerve of motion, and in a nerve of sensation ; and
that the same nerve cannot at the same time, in the normal state, transmit motion and sensa-
tion. There is only the case in which it is excited in a part of its length ; it may then trans-
rait motion towards the periphery, and sensation to the nervous centre, its two portions being
polarized in directions contrary to each other. The effect of ligature, which, in altering the
molecular constitution of the nerve, arrests the transmission of the cause of motion, if it is
made below the irritated point, and that of the cause of sensation, if it is above, are equally
well explained ; for the polarization of the nervous molecules, under the action of the excit-
ing cause, cau'uo longer operate. The objection, therefore, which has been so often urged
against the identity of the nervous force and electricity founded upon the fact that a ligature
arreets the passage of the nervous force, but not that of an electrical current, is shown in the
light of the preceding theory to be fallacious, and to be based upon incorrect views of the
intimate molecular constitution of the nervous and muscular systems.
Now, how does the excitation of the nerve bring about the contraction of the muscular
fibre ? Since we may bring about this contraction by the immediate application to the mus-
cle of an exterior electric current, it is evident that the nerve brings it about by modifying
the electric state of the muscle. We have seen that when the muscle is contracted its current
proper diminishes, which appears to be evidently due to the fact that its particles change their
place, and arrange themselves in respect to each other, so that their negative and posi-
tive poles are turned In the direction of their length, as in a conductor traversed by a
current, and no longer in a transverse direction. This change of place must produce an
approximation of the particles in a longitudinal direction, and, consequently, shortening of
the fibre, which is the characteristic of contraction. But this shortening, and the approxima-
128 Introduction to the Study of Diteases of the Nervous System.
tion, which is tht came of it, last only an instant, on account of the electricitj proper of the
fibre, and the particles replace themselTes at their former disunce. However, there is an
important difference to be noted. When muscular fibre is contracted bj the effect of a con-
tinuous electric current applied either to its nerye, or immediately to itself, the contraction
endures, it is true, but for an instant ; but the particles of the muscle, while still regaining,
by yirtue of elasticity, their former relative distance, preserve their electric poles turned in
the direction of the length of the fibre ; it is only at the moment when the electric current
ceases to circulate, that the electric poles of the particles replace themselves in their normal
position, and this return is accomplished by a new displacement of the particles, and eonee-
quently by a new contraction. The reason why there is contraction only at the establish-
ment and at the rupture of the current, is because it is only at these two moments that there
is a semi-revolution of the particles of the muscle. When the current, instead of being con-
tinuous, is discontinuous, then there is so rapid a succession of displacements, and returns to
their primitive position of the particles of the muscle, that the contraction seems to be per-
manent, which cofuiUuUa Utanui ; however, as may be seen by the galvanoscopic frog, the eon-
traction is really intermittent.
It remains to know, how it may result from a modification in the electric state of the nerves,
that any particular muscle is modified so as to produce contraction. It would be necessary
in order to solve this question, in a somewhat satisfactory manner, to know better than we do
now, the manner in which the nerves terminate, and in which they are ramified in the mns-
cles.
It appears to De La Rive, as probable, that each elementary nervous filament abuu upon
an elemeatary fibre ; then it is not astonishing, that if this nerve is polarised by a cause of
ezciution, it brings about the polarization of the muscular fibre upon which it abuts ; in this
case the fibre enters into the circuit of the nerve, and it must suflTer contraction; as when it
is traversed immediately by an artificial electric current. We shall find then the same phe-
nomena ; in particular, that the contraction lasts but an instant, providing the nerve is not
tetanised, wliich causes the muscle itself to be so also. In sensation, it is the muscle whose
normal electric state is disturbed, which polarises the nerve, so as to act upon the braiu. [q
both cases equally, it is not astonishing that everything that alters the molecular constitution
of the nerve prevents its polarity being established, and consequently arrests the transmission
of motion and sensation. De La Rive, conceives it to be very important, in order to found
these explanations upon more solid bases, and in order to be able to give them more precision,
that we should succeed in determining better than has been done, the mode of communication
of the nerve and the muscle. What appears to this observer, to be eminently probable is.
that in muscular contraction, as in the transmission of sensation, the reciprocsl action of the
nerve and the muscle is brought into operation at the very extremity of the nerve itself, and
not all along its course through the muscle.
* De La Rive, concludes from the detailed study just given, that the body of a living abimal
may be regarded as theseat of an innumerable multitude of electric currents, the greater por-
tion of them having only local circuits ; it is the derived portion of these currents that we
succeed in collecting by expenment. But when by the effect of the will, or of another cause
acting directly upon the nerve, its electric state is modified, the corresponding local current
is transformed, if not entirely, at least in part, into a current, tbe more considerable circuit of
which comprehends then, the nerve and tbe corresponding muscle ; and the effects that we
have been pointing out result from it.
De La Rive, is led to assume that the agent, by means of which all nervous action is excited
is electricity ; not an electricity created at the very moment when the nerve acts, but pre-
existing in all the organic particles, as it pre-exists in hII the particles of inorganic and organic
matter. This philosopher, is moreover, forced to admit, that, under the influence of life, these
particles are arranged in an altogether special manner, and which permits of the accomplishment
of the organic functions; so that life cannot be considered as a consequence of the electric
nature, and of the arrangement of the particles, but must, on the contrary, be regarded as the
cause of their mode of grouping, and consequently indirectly of the phenomena that results
from it. Let lire indeed be taken away, and the particles, still preserving their electric pro-
perties— that is to say, their polarity — are grouped quite differently, so as to obey tbe condi-
tions of equilibrium of the forces that are proper to them, and no longer present aoght, bnt
the ordinary phenomena that inorganic matter offers us.
M. Uatteucci, while still recognizing that organic currents sre not due to any exterior
chemical action whatever, considers that we must attribute them to the chemical actions of
the living organism. It would be according to him, in the chemical action that must exist be-
tween muscular fibre, properly so-can«»d, and arterial blood in contact with it, and eonse-
qutttly in the nutritive life of the tissues, that we ought to seek for the cause of these currents.
It would be thus inherent in the state of the life of the organic tissues, and constantly con-
Introduction to the Study qf DiMoases qf the Nervous System. 129
neeted with a difference in the state and in the nntritiTe power of these tieauei, bo that the posi-
ttre element of the organic pair woald be alwaji represented bj the part of the tissne whose
ontritiTe power is the stronger. As is apparent, M. Mattencci, agrees with De La Rire, in
this reepect, that it is from the Tital force that he makes animal electricity depend in the first
iDStance ; only according to himi it is onlj indirectly in compelling natrition to operate that
the nerves, intermediate between Tital' force and the muscles, would deyelope electricity,
whilst according to De La Rire, the action would be more direct ; the transmission of Tital
action from the nenres to the muscles being brought about by the yery electricity with which
the neryes are primarily endowed.
De La Biye, does no way contest the part of chemical action in the production of animal
electricity ; but it is from it that he makes the first origin of this electrici^ to proceed, which
appears to be pre-existent to the causes that determine its manifestation, as well in the liying
orsanisa as when inorganic matter is in question.
If tb«n the propagation of neryous action, be due to a natural and progressiye modification
in the arrangements of the particles by yirtne of their electric polarity and the closed circuits
of electricity in the quiescent state ; the two most formidable objections to the identity of
nerroas force and electricity, Tic : the arrest of the neryous current by a ligature, and the
slow rate of the transmission of nerrous force, as shown by the ingenious experiments of M.
Helmholtz and DuBois Reymond, receiTe an easy explanation. The ligature destroys the
natural arrangement of the molecules of the nerTes, upon which the transmission of the weak
uerTons current depends, and transmission of nerTous excitation through the neryes neces-
sarily requires a sensible duration longer than that of a simple and more powerful extraneous
electric current, because of the progressiTe alteration and re-arrangement of the molecules
composing the nerTous and muscular structures, during the transmission of sensation and
motion and the performance of mechanical acts.
We haye thus presented, from yarious portions of his great work on Electricity, and in the
yery language of its learned author, the theory of De La Riye, which embraces with slight
modifications, the theory of DvBois Reymond, and rests for its truth upon the extensiye re-
searches of this accurate and skillful obseryer, and also upon the results of the labors and
experiments of Oalyani, Volta, Aldini. Humboldt, Mattencci, Nobili, Marianini and others.
If this theory be true, it results, that the neryous and muscular phenomena of certain dis-
eases, as tetanus, must be due to disturbances in the electric condition and relations of the
Bsolecnles of the neryes and muscles.
If in the state of health, the molecules of the neryes and muscles are restrained in a par-
licolar arrangement by the yital force, and if under the action of the will, or of other causes
determinining muscular contraction or relaxation, this arrangement is modified so as to
become similar to the condition of a conductor transmitting an electric current, it is most prob -
able that when the derangement of the molecules is caused by almost eyery cause howeyer
slight, capable of disturbing the electric equilibrium, and eyen beyond all control of the will,
and eyen so powerful in its effects, as to rend asunder the muscular structure, there is either
a want of proper action of the yital force in preserying the mutual and definite relations of
the molecular forces, or an undue aotiyity in the molecular changes in the neryes and mus-
cles.
We will demonstrate in the Medical Memoirs, that during the active stages of Traumatic
Tetanus and Fever, there is an increased chemical change of the nerves and muscles ; we must
eoDclade, that teunus is due not only to a disturbance in the electrical conditions and rela-
tions of the neryes and muscles, but chiefly to a great augmentation of the intensity of* the
electrical actions in both nerTCs and muscles. This Tiew is farther sustained by the fkct, that
the contractions of the muscles in tetanus, are far more Tiolent and prolonged than those of
health, excited by any cause whateTer, internal or external, by the will or by mechanical
stiamli, so rioleot in fact that the muscles are frequently ruptured, and that too, against no
otWr points of action than the long bones, and in no other action than in that of simple in-
Tolaatary contractions ; and by the equally striking fact that a continuous current of elec-
tricity, may when passed in a certain direction, relicTe the spasm of tetanus. Nobili discoT-
erod that frogs affected with Tiolent tetanus, became quiet if a continuous current was sent
throagh their limbs in a giTen direction, while the tetanus continued undisturbed if the cur-
reat moved in a contrary direction. M. Mattencci, observed similar effects of continued
currents upon frogs tetanised by strychnia, when they were subjected t6 the action of a
contlnQoas galvanic current, the tetanus disappeared very soon, and did not return, although
the frogs died afterwards from the effects of the strychnia. M. Nobili concluded from his
electro'physiological researches upon tetanus in the frog, that it might be possible that the
action of an electric current guided in a given direction might serve to calm if not to cure
ietnans in man. Mattencci, actually tested the therapeutic effect of the continuous current
in iraomatic tetanus. In conjunction with M. Farina, he caused a continuous current from
thirty to forty pair of plates, to pass along the spinal marrow of a patient suffering with trau-
matic tetanus, tn consequence of gun-shot wound of leg, in the direction from the sacrum to
17
130 Introduction to the Study of Diseases qf the Nervous System.
the nape of the neck. The effectB were marked| the maicolar contractioDS and conTuUions
were greatly diminished, the patient wae enabled to open hie month, the circulation and tran-
ipiration were re-established, and the relief appeared to be great. The patient died however,
afterwards, in consequence of the irritation kept np by foreign bodies in the wounded limb.
DuBois Rejmond, has remarked, that in a tetanized limb of a frog, the gastrocnemius mus-
cle became quiet, as soon as the sciatic nerve was laid upon the tendon of the mnscle ; that
is, if the inveru current proper of the muscle was made to pass through the nerre ; but that
tetanus continued unchanged, when the nerre touched the flesh of the muscle, that is, when
the direet current proper of the muscle traversed the nerve.
Professor Ecklard, of Oiessen, has been led hj an important research to the conclusion,
that if a constant continuous current of a certain intensity and direction be made to pass
through a nerve, the excitabilitj of this nerve will be so much diminished that any mechani-
cal, chemical or electrical stimulus, which would otherwise bring about a contraction of the
muscle, will no longer be able to induce such contraction, so long as the galvanic current
continues to traverse the nerve ; but that as soon as the circuit has been opened again, con-
tractions will be brought about if the nerve be excited anew. We have also In experiments
upon the lower animals, produced powerful tetanic spasms and even death by passing a
strong interrupted current, both from the magneto-electric and galvano-electric machines,
along the course of the spinal cord. The interrupted current passed in sofficient Intensity up
and down the spine, produces effects similar to those of tetanus and of strychnia in poisonous
doses.
In Traumatic Tetanus, the mind Is unaffected, and as a general rule the temperature is not
elevated as in fever, and the sudden and violent muscular contractions cannot be controlled
by any force of the will; and in this state, we have a complete demonstration at the hand of
nature, that the nervous and muscular systems constitute peculiar physical apparatus,
worked by physical force. In tetanus we have such an exaltation of the functions of the
spinal system of nerves, that the reflex actions are performed with great intehsity and entirely
beyond the control of the will ; and the theory appears to be reasonable, that the nervous
and muscular phenomena are due to disturbances in the electric condition and relations of
the molecules of the nerves and muscles. It is clear from the phenomena manifested In
tetanus, that sensation and motion, and the force by which they are excited, are wholly dis-
tinct from mental or intellectual acts. Ordinarily in health, the mind acts through the
nervous system, receiving inpressions and transmitting impulses, by means of the nervous
force which depends for its manifestation upon the molecalar arrangement and forces of the
nervous system ; in such a state as that of Traumatic Tetanus, or as that produced by certain
drugs, as strychnia, the physical force of the nervous system, is developed in far larger amount
than necessary, and the actions become like those of a machine heavily charged with elec-
tricity. If the nervous and muscular forces, were not, purely physical forces, we could have
no soch manifestations as that of tetanus.
We conclude this introduction by some general observations upon the
PHYSICAL AND INTKLLEOTUAL CONSTITUTION AND RELATIONS OF MAN.
The progressive study of the phenomena of the universe known to the human mind
finds the last most comprehensive, complicated and typical work in man, governed by the
mechanical, astronomical, physical and chemical laws of inorganic bodies, and comprehend-
ing within himself all organic nature— composed of inorganic elements, prepared and grouped
inlo definite compounds in the vegetable kingdom, by the combined actions of the forces of
matter and of the sun, under the guidance of the vital principle— endowed with a body per-
fect in its mechanical structure, and in the arrangement of its parts, with the sise of its orgaos,
the strength of its muscles and bones, and the vigor of its forces constructed and arranged
with exact reference to the force of gravity, the sise of our globe, and Its relations with the
sun and all other worlds in the universe ; worked by forces the resultants of the chemical
changes of those substances, which in the vegetable kingdom have been elevated into a state
offeree by the action of the sun ; unable to create or annihilate any force, any more than to
create or annihilate matter; endowed In common with all vegetables and animals with vital
force, and arising from the same common origin, the cell, and like plants and animals passing
through various st!ages of development ; possessing In common with all animals, and in con-
tradistinction to vegeubles, a nervous system, endowed with special sensibilities relating the
various organs and apparatus to each other, in soch a manner, that amidst an innumerable
number of complex actions, unity and harmony result ; and relating the mind with the ex-
terior world in snch a manner, that it is capable of obtaining a view of its ever-changing
relations — endowed with intellectual and moral faculties capable of receiving impretsioBa
through the nervons system, and of exciting the forces by which they are snrroanded, asd
of directing and controlling them, so as to act upon the exterior universe — formed by the
Eternal In His own image, for purposes stretching into Infinite ages.
IiUroduetion to the Study qf Diseoies of the Nervous System. 131
It ia a anirertal Uw, that the component parts of the Uniyeree hare not in themselYes
th« entire atm or reanon of their existence — every form of matter is, definitelj related to
«Tei7 other form of matter apon the face of the globe, and the combinations of these varions
relftUons and actions and re-actions of terrestrial masses, form the essential conditions for the
Bsatlbitation of the designs of the Creator. ^
Ai a nan is composed of inorganic elements, and governed by all the laws, physical, chemi-
cftl ud sstronomical, which govern the exterior world, it follows as a necessary consequence,
thftt the peculiar constitution and relations of the inorganic elements of the crust of our
globe, Biiist affect the physical and mental endowments of man.
The solid portion of the globe has been constructed for man, just as the body has been
nude for the ioal. The mutual relations of the solid and fluid portions of our globe, and
the distribution of the forces of the sun, have exerted no small influence upon the physical
ud mental derelopment of the human race. .
The endless eireulation of matter resulting from the combined actions of the forces of the
IDD, sad the forces of the matter of our globe — every earthquake which, in past or present
times, has fractured and dislocated the solid strata of the earth, elevated the bed of the
occao, or depressed the level of the continents — every volcano which has poured forth the
liqoid ooDtenta of the interior of the earth — every flood which has swept over the ancient
coDtineDts — has contributed, more or less, to the formation of a suitable soil for the mainte-
nsoee of plant* and animals, and the development of the human race.
The examination of the mutual relations of celestial and terrestrial bodies, and animated
beiags, demonstrates that the existence of man is absolutely dependent upon the relations of
the component members of the universe — that a single alteration in the chain of phenomena
woald destroy the conditions necessary for the existence and manifestation of the phenomena
of Diaii — that the forces of man are resultants of the forces of the sun and fixed stars,
vhieh keep up a never-ending circulation and change of matter upon the surface of our
globe^-that man cannot create or annihilate force, any more than he can create or annihilate
matter — that the great law of the Indestructibility of force, of action and reaction, applies to
the phenomena of man, and Consequently the intellectual and moral faculties are limited
to the guidance and direction of the forces with which the Creator has endowed the universe
—that man comprehends within himself all phenomena, astronomical, physical, chemical,
phjiiologieal, and psychological, and is therefore a type of the universe— that the knowledge
of the structure, phenomena and relations of man, includes a knowledge of science,
whether relating to matter or mind.
The phenomena of man are complicated and restricted, and depend for their existence and
manifestation, ultimately upon the general phenomena which affect all bodies ; and if we
vish thoroughly to undertand, medical, (physiological, pathological and therapeutical) phe-
Bom«na» we most analyze the component phenomena of man, and commence the study with
the most general, anrestrictted and simple phenomena, and then rise gradually to the knowl-
edge uf the more complicated and restricted phenomena, and finally attempt to gain an emi-
oeoce of thought, from which we may survey the phenomena of man in their mutual rela-
Uoti, and in their rel.itioos with the exterior universe.
As the material part of man has been constructed with exact reference to the exterior uni-
verse, «o the intellect of man has been constructed with exact reference to the exterior uni-
Terae. The material part of man has also been constructed with exact reference to the
itractare of the intellectnal and moral natures ; it stands between the exterior world and
the mind, and as a portion of the exterior world, a machine governed by the laws of
exterior bodies, typical of the great mechanism of the surrounding universe, it forms a fit
instruBient for the manifestation of the Spirit breathed into it by the Creator of the
rsirerse. The material body of man, with its complicated machinery, appears to have
been constructed with exact reference to the action of the intellectual and moral nature.
Thns, the complicated apparatus of the nervous system relates the mind of man, through the
senses, with the exterior world; and the complicated muscular apparatus obeys the volitions
of the mind through the nervous system, and accomplishes various mechanical actions, by
vhicb matter is moulded, and its forces controlled and directed according to the interior
ideal creations of the intellectual faculties. The forces which work the muscular locomotive
fjiiem, are developed by the chemical changes of the elements of the muscles and nutritive
flnids. The office of the digestive and circulatory and respiratory systems, is to prepare
materials which will readily enter into chemical change, and thus generate the forces by which
ander the guidance of the mind the locomotive apparatus of the body may be moved, and the
barriers and obstacles in nature overcome, and the forces of matter controlled and directed,
10 as to accomplish definite effects.
In whaterer manner the intellect of man be regarded, whether as an indivisible immaterial
•gent, or as a product or secretion of the brain, many metaphysicians have found it conve-
Bient, if not absolutely indispensable, to divide and classify its powers or faculties. Thus,
for purposes of systematic study, analysis and comparison, metaphysicians have designated :
1H2 Introduction to the Study qf Diseases qf the Nervous Sf/stem.
I. The Simple GognitiTe Facnltiet, b/ which we •ttain the knowledge of individual obj^cu
in the concrete, *■, (1.) Sense*Perccption, bj which we Itnow material •nbttancet in certain
model, or in the exercise of certain qnalitiei; and, (2.) Self-GonacionsneM, bj which we
know self in certain atatee.
It. The RetentiTC and Reprodnctive Powere^ ae, ^1.) Memorj, which recalls what has been
before the mind, with a belief that it has been before the mind in time past ; (2.) Imagina-
tion, which puts what has been before the mind in new and non-existing forms. Both of
them poiseM an Imaging, or Pictoral power. When this might fall, we have, (3.) the Sjmbolic
power, which enables as to represent objects bj signs.
AboTC the presentatlye and representatire powers, we bare ;
III. The Gorrelatire fhcalties, discovering sncb relations as that, (1.) of whole and parts ;
(2.) of sameness and difference, in respect of sncb qaallties as space, time, qoantitj, and
active property, and, (3.) of cause and effect.
IV. The Moral Facnltj, determining in regard to certain menul states, that they are right
or wrong.
Associated with the exercise of these powers, we have :
V. The Bmotions, attaching us to certain objects, and withdrawing ns from others.
VI. The Will, or Operative Power, choosing or rejecting among the objects presented to
the mind.
It should be added that there are laws of association, determining the order of sncceseion
of the states produced bj these various powers.
Science is the interpretation, by the mind, of the actualities of existence. The ideas of
the mind are science or truth, onlj when thej are correct expressions of the phenomena and
laws of the universe. The end of science, and the proof of its troth, is the power
which it confers upon man, of predicting future events.
For the discovery of truth and the establishment of science, we roust have a mind endowed
with special faculties, capable of analysing and comparing its own phenomena, and of Infer-
ring their fixed relations or laws ; capable of receiving impressions through the nervous sys-
tem and organs of sense, from exterior bodies, and of decomposing, analysing, classifying
and determining the fixed relations or laws of the exterior universe. If the faculties of the
mind be altered, whilst the surrounding machinery of the material body, and of the external
universe remain unaftered, the discovery of the relations of the facts and phenomena of the
external universe would be impossible. Thus the love of Truth, as Truth, and for no other
reason, is a fundamental principle of the human mind, the knowledge of the existence of
which is derived from consciousness ; it is a primary principle, whose existence must be
referred immediately to the Divine command. This is true of all the faculties of the mind ;
we can give no other reason for their existence and modes of action, than the will of tho
Greater. If the love of Truth was not a fixed disposition of the human mind, it would be
impossible to receive any fact on testimony — it would be impossible to carry forward any in-
vestigation— it would be impossible to construct science. In like manner, if the structure
and functions of the nervous apparatus, which relates the intellecual faculties with the
exterior world be altered, whilst the intellectual faculties and the exterior world renmin un-
altered, the discovery of truth would be impossible.
It is evident, therefore, that imperfections of toe senses, imperfections of the nervous appa-
ratus, and peculiarities of mental endowments are the first sources of error in the prosecution
of knowledge.
The miud has no direct communication with exterior bodies ; its relations with the exterior
world are through the nervous system, endowed with special sensibilities, and developod
upon the exterior Into the organs of sense. The organs of sense are nothing more than por-
tions of the nervous system adapted by conformation, and the addition of peculiar apparatas,
to receive and transmit impressions from exterior bodies. The mind can have no other
knowledge of the exterior world, than that which is derived from the cognisance of the
excited states, modifications or disturbances in the apparatus endowed with special senai-
bility, when acted on by the impressions of external bodies ; and if all the organs of soaae
were absent, the mind would be shut up to itself, and would never acquire any knowledge of
the various forms of nmtter, and of the various affections and motions of matter in the exie*
rlor world.
The phenomena, or associated facts of the exterior world are Innumerable ; matter Is nerer
at rest ; it is constantly undergoing alterations of form, appearance and oonstitutioo— p«r^
petual change is written everywhere ; even the sun with his planets are sweeping m^jeatlc-
ally through space, around a distant, unknown centre ; these changes of states, iorms and
conditions, and these modifications of relations, are the subjects of sensations and percep-
tions, and are represented to the mind as simple ideas. The causes of the incessant aettvlty
of the component members of this world and of the universe, cannot be discovered by the
unaided senses ; because the senses represent only the superficial exterior appearances and
relations of bodies, and cannot penetrate beyond, and are therefore limited in their respective
Introduction to the Study of Diseases qf the Nervous System. 133
cipadtiif to tht rcoeptioo of Bimpl< ideMjSnd can never give aoj information of the immu-
uhle lavs wfaieb govern matter ; the trne nature, therefore/ of exterior objects^ the laws
vhteb rsgvlate the phenomena of matter, and the relatione between the component member •<
of Um nuTeree, are problem! which tMe reasoning powers of man, and not his senses, can
After the obserration of the facts and phenomena of the exterior world, the intellectual
fMiiltice, bj their powers of analysis, synthesis, cansalion and judgment, separate each fact
from dissiflsilar facts, and arrange the simple ideas into species, genera and orders ; thns
scqniriBg a knowledge of new phenomena and associations of facta inaccessible to the exter*
Qsl senses. By decomposing phenomena into their eompon^t facts, by analysis and com-
paziaoD of these facts, the intellectual facnltiea form abstract ideas, which sum up the princi-
ples sod laws of associated facts. The perfection of erery science will, therefore, depend
opoB the dilUgence and care with which its cultiTators study the simple properties and rela-
tions of bodies, and analyse, and decompose, and compare the more complicated phenomena,
lo the language of Bacon, **Man, as the minister and interpreter of nature, does and under-
sUnda as much aa his observations upon the order o^nature permit him, and neither knows
Qor is capable of more."
The neglect of this, the only true method of acquiring a knowledge of the laws governing
ioorgioic and organic bodies, has been the cause of the failures of the ancient systems of
philosophy. Upon the imperfect knowledge of a few ill-observed facts and phenomena, the
Afldents reared immense soperstruetures, whose bases were points and their summits infinity.
The history of the origin and progress of human knowledge, at all times and in all places,
dcmoostrates that in the pursuit of knowledge, and in the direct study of nature, facts alone
do oot constitute science, and reasoning alone does not constitute science. We must have
for the construction of science, the exercise of the senses, furnishing the primary ideas, facts
•od phenomena of the exterior world ; and then the exercise of the reasoning powers deter-
niniog in virtue of their constitution, and relations through the senses to the exterior world,
the fixed relations or laws of these fadts and phenomena.
To the formation of science two things are requisite : Observation of things without,
ud to inward examination, decomposition, analysis and comparison of the results o' observa-
tioo.
It hu been well said **that true knowledge is the interpretation of nature ; and therefore
it reqoires both the interpreting mind and nature for its subject; both the document and the
logeDsity to read it aright. Thus invention, acuteness, and connection of thought are neces-
ssry, on the one band, for the progress of philosophical knowledge ; and on the other hand,
tbe precise, and steady application of these faculties to facts well known and clearly
perceired.
Tbe great end, therefore, of all human knowledge and investigation is to determine the
fixed reUuons or laws of the universe ; so that the precise condition of things at any future
Uoe may be predicted with absolute certainty : and so that the human mind may appreciate
its relations with the universe, and with the Creator of the universe.
ll it etidttU from tkue prmegfie$, thai edueation tihould eommmet unlh the exereUe and diseipUne qf
i^ «uef . Tht nUeUeetual /oaUiieM $hould be taught, eare/uUff to obeerve and note the propertiee and
^t'stiM* emd force* of wurromndmg bodiee^ and to arrange and eiaeeify the phenomena,
Iq the first exercises of the senses and intellectual faculties, we should imitate, in a man-
ser, tbe action of the human mind in the first dawn of science, when it first began to observe
pbeoomena, and accumulate facts ; and the method in which at the present time it originates
sod derelops new sciences. Man commenced the construction ot science, by viewing gen-
ual classes of phenomena ; tbe chronological commencement of science, therefore, is with a
coaplex mass, whilst the logical development is with the individual elements. Thus,
Aitroaooy, which is conversant with the sublimest and most striking phenomena in nature,
btd the earliest origin ; its first cultivators were shepherds, who confined their attention to
aotiog tbe most obvious phenomena of the motions and eclipses of the sun and moon, and
tbe rising and setting of the stars. These, the first builders of Astronomy, slowly accumu-
l^tBd materials for the formation of science, and in due time the reasoning faculties com*
psnd the individnal facts with each other, separated the dissimilar and combined the similar,
ud thus arrived at a knowledge of the fixed relations or laws which sum up and express the
vhole detail of associated facts.
It is efident from the mode in which the mind obtains its ideas and constructs science,
^ba( science is tbe resalt of patient and hard labor. The first knowledge acquired by the
sacieets consistad of isolated facts ; gradually facts were accumulated, complex phenomena
obienred, decomposed, and their component elements arranged and compared, and the errors
^ftbeseeses corrected, and it whs not until after many ages that the great fundamental laws
of Aitronomy and physics were established.
We bava thus endeavored in this physiological outline to sketch tbe general relations of
"^ to the exterior universe, and to give a comprebensire demonstration of tbe extent and
134 Introduction to the Study qf Di$e(ues qf the Nervous System.
•
complexity of hit phenomena ; and we are thnt led to eonclude the subject with tome ^o-
eral obtenrations upon the extmU and impeffeetiant of PcUholoffieal mvutifftmotUf that coanectiag
the preoedtng phjsiological stodies with the tncoeeding pathologieal inyestigatioai.
If man be related to celeitial and terrestrial bodies— if the existence of man be dependent npos
the adjustments of the solar system, the seasonSi the climate, the action of the regetable
kingdom, the soil, and upon the great circulation of matter, kept up bj the forces of the son —
if the derangement of onlj one link in this complicated chain of phenomena would result id
the destruction of the human race — if the phenomena of man in health be thus eomplicated,
how much more complicated must be the phenomena of disease, when the eoostitution of the
complex solids and fluids of man maj be altered in manj wajs, and the relations between tbo
physical, chemical, vital and nervous forces, and intellectual and moral faculties may be Cor-
respondingly deranged ?
In Tiew of the immensity and complexity of physiological and pathological phenomena ; id
▼iew of the fact, that no single man, even dnring a long lifetime, is capable of InTestigating
thoroughly the phenomena presented by disease, the iuTestigator should state clearly his
views of the extent and bearing of phytiological and pathological phenomena, and define the
scope and bounds, and methods of his investigations, and candidly acknowledge their omis-
sions and imperfections.
We will now proceed, in a condensed hnd brief manner, to point out the sources of disease.
1. Astronomical changes are attended by corresponding changes in the phenomena of
man. The changes of the day, and month, and year, and seasons are attended by correspond-
ing changes in the constitution and phenomena of man. Not only would derangement of the
adjustments of the solar system be attended by corresponding derangements in the little world
of man, but his diseases, arising from whatever cause or causes, must be influenced by those
changes. As the sun with his attendant planets are progressing continuously throurh spaoo,
it is not unreasonable to suppose that the phenomena of man might be modified by the proper-
ties and forces of the regions of space through which the solar system travels. 'That a re-
sisting medium does exist in space, to which the transmission of luminous and thermic vibra-
tions may be referred, has been conclusively demonstrated by astronomers in the case of
Encke's comet. What the matter is composing this resisting medium, and whether this mat-
ter is uniform, or varies with the different regions of space, and whether it exerts any influence
upon the phenomena of man, are questions worthy of solution.
Geology teaches that the climate of this earth has been altered during different period* of
past time, and that causes have in past times destroyed whole races of plants and animals.
Whether these causes were astronomical or terrestrial, it is nevertheless true that similar
causes may be the sources of disease.
If the existence of man upon this globe be viewed in the light of the teachings of geology
and astronomy, the conclusion appears to be reasonable that it will be limited to a definite
period. The causes which may produce a final extinction of man, and of animals and of veg-
etables upon this globe, appear to have been and to be active in other worlds, and to require
for their complete manifestation great periods of time. The changes, cosmic and astronomi-
cal which may result in the final destruction of the human race, will probably be so slow and
almost imperceptible in their action, as to be detected only by the careAil comparison of
records covering vast periods of time. Such investigations, have not as yet found a place in
medical science, and it may be possible that centuries may elapse, before the slow action of
agencies which have been operative in the past history of this and other worlds, shall arrest
the serious attention of tbT>se who are specially charged with the investigation of the nature
and canaes of disease.
2. The surrounding medium may be physically and chemically altered, either by an excess
or deficiency of its ordinary Ingredients, or by an excess or deficiency of the forces by which
it is circulated.
Whilst it is true that the amount of force annually received by the earth from the son is a
fixed quantity, it is nevertheless true that, owing to the peculiar constitution of the atmos-
phere, the nice adjustment of iu forces (the ease with which one mode of force may be con-
verted into another, as heat into electricity, and viee o«rfa), its relations to moisture. Its rela-
tion to the distribution of the forces of the sun. and Its relations to the distribution of the
solid and fluid nmsses of the earth ; and that climate is subject to variations which cannot be
predicted, and are not uniform. Corresponding disturbances are produced in the phenomena of
man. The truth of this proposition is conclusively demonstrated by the relations of certain
diseases, as pleurisy and pneumonia, to the weather. And even when diseases are not directly
produced by the disturbances of the structure and forces of the surrounding medium, it is
nevertheless true that the course and phenomena of disease are modified, to a great extent, by
meteorological phenomena. The value of the determination of these relations in the investi-
gation of the origin, progress and treatment of disease, cannot be over estimated.
3. As the compounds composing the body of man have all been formed by the vegetable
kingdom, from the inorganic elements, It follows that any deficiency of the necessary elements
IrUroduetion to the Study qf Diseases qf the Nervous System. 1 35
of U^ toil would b« mtended bj deficiencies io the coattitution and compotiiion of the
food, elaborated bj the regetable king^dom, and bj corresponding disturbances of the consti-
tatioa and phenomena of man. Corresponding changes in the constitution and phenomena
of plants may be induced bj meteorological phenomena. Hence, in the iuTestig^tion of the
origin and phenomena of disease, it is necessarj to determine the chemical and physical con-
stitsttoD of the soil, and its relations to the vegetable kingdom.
4. The saltf of the blood,*which are absolutely necessary to its healthy constitution, are
obtained in part from the water daily introduced into the system. These salts may exist in
deficiency or exceM ; and other abnormal noxious, saline and organic matters may exist in the
watf r. Bach of these oauses may be a source of disease. Hence the necessity in pathologi-
cal laTestigations of a eareful examination of the water. '
5. Any one of the norasal constituents of the body of man, may be deranged, and occupy
different relations to each one of the other constituents. As these constituents are numerous,
the reaulting derangements may he correspondingly numerous. The forms of this class of
disease may be as numerous as the different positions which the elements mny be made to
assume towards each other.
6. Any one of the elements of the body may be in excess or deficiency, and the diseases
may bo as numerous as the elements themselres, and at the same time, totally different from
the diseases arising from an alteration in the relative position of the elements.
7. Foreign morbific agents may be introduced into the fluids and solids, which will excite
abaomal changes in the solids and fluids. The generation of these morbific agents will de-
pend, in great measure, upon the relations of climate and soil, and water and organic matter,
and the forces of the sun. The number of diseases of this class will correspond to the number
of distinct SBorbific agents.
Combinations of these morbific agents may produce still more numerous and complicated
8. As the matter composing the human body is fashioned into definite organs and tissues
destined to accomplish definite results, and combined into apparatus, definitely related to
each other, it is evident that the disturbance of the mutual relations of any one of these
organs and tissues and apparatus must, to a greater or lesser extent, produce corresponding
distarbaaces in the component members of the human organism.
9. The Creator has associated the vital force with a definite constitution of matter.
WhateTer interferes with this constitution, interferes with the action of the vital force. What-
ever interferes with the vital force, necessarily disturbs its relations with the physical, chem-
ical, and nervous forces. If the balance of the forces, and their correlation be disturbed, the
chemical action between the elements may not only be deranged in kind, but also in degree,
aad the generation of the physical forces which work the machinery, and the manifestation
of the nervous, intellectual and moral phenomena, correspondingly altered.
to. The development and structure of the vegetable kingdom — ^the development and struc-
ture and actions of the most simply constructed animals — the appearance of the nervous sys-
tem ia the animal kingdom, and in the foetus of the higher animals, subsequently to the
groapiag of the atoms of formless matter into definite forms and apparatus — the formation of
the digestive and circulatory apparatus, before the formation of nervous cells and nervous
s> stems, demonstrate onequi vocal ly« that development, nutrition, and the direction of the
forces of matter to the fashioning of another part are under the guidance of the vital principle
•demonstrate that the nervous system is itself developed and its perfection maintained under
the gatdance of the vital principle. Hence diseases may arise independently of the nervous
system. Hence we may have chemical and physical changes of the elements of all the organs
and systavs of organs,* incompatible with the existence of the vital force in that altered mat-
ter.
Whilst we admit these propositions, we must at the same time bear in mind the true otRces
of the aerrons system. The nervous system is the last and best work of the forces of matter
directod by the vital force, and is destined to form the medium of communication between
the intellectual faculties and the exterior world ; and is destined to connect together and in-
fluenca the Tarious organs aud apparatus : and Is destined to regulate secretion and excre-
tion, aad the consequent development of force ; and is destined to excite and control the
actions of the dynamic muscular apparatus, not by the possession and emission of a peculiar
force gtaerated de novo^ but rather by a modification of physical force generated by the mu-
tual chemical reaetioas of the blood and nervous system.
That the nervous force is not capable of itelf of carrying on the acts of outrition, secretion
aad excretion, is demonstrated by the fact that plants, and the simply constructed animals,
which ara devoid of a nervous system, are capable of carrying on the offices of generation,
develapsaeat, digestion, assimilation, nutrition, secretion, excretion, and of preserving a defi-
nite forsB amidst uaeeasiag chemical changes. Many of the simply organised animals,
although without a nervous system, still possess sensation and voluntary motion. The
136 Introduction to the Study of Diseases of the Nervous System.
nerTOQS Sjrstem appears oaljr when the parts of the machinery are complicated, and need
special means of communication.
The dcTclopment and perfection of the nervons system correspond exaeUj to the derelop*
mentf perfection and complication of the organs and apparatos. This fact is true of the ani-
mal kingdom in its snccessiTc degrees of dcTelopmenti and also of the snccessive stages of
the deFelopment of the solids and fluids of each indiTidnal highly organised animal. Physical
and chemical actions take place in a similar manner in all animus, simple or complex ; they diflbr
only in intensity. The higher the animal, the more complicated its parts, the more rapid
the chemical changes, and consequent generation of the forces, and the greater the neeea-
sity for some special apparatus which will hring all the complex organs and actions ipto
harmonious relation.
Unless the actions of different organs can be telegraphed (so to speak) to each other, con-
fusion in a complicated organism will necessarily resnlt. Thus, if the amonnt of blood circa-
lating through any organ and the chemical actions are too great, how can they be regolatod
without some medium of commnnication, and some means of regolating the chemical and
physical actions 7
The true relations of the nerrous systtm to disease must be based not only upon the rela-
tions of the sympathetic system to the organs, and to circulation, respiration, secretion, ex-
cretion and nutrition ; and of the cerebro-spinal system to motion and sensation ; and of the
sympathetic system to the cerebro« spinal system ; hat also upon the relations of the intel-
lectual faculties to the nerTOUs system, and throagb the nerrous system to drcalation, respi-
ration, secretion, nutrition and excretion. If the Tiews promulgated by Proehaska and Oall
be true, that each faculty of the intellect is connected with a special portion of the brain, as
the organic, material condition of the associated faculty* then aberration of those facalties
would point to organic or functional alterations of the corresponding portions of the brain,
Just as an aberration or loss of sensation would point to the functional or structaral altera-
tions ef the nerTous apparatus dsToted to the reception and transmission of sensational im-
pressions ; just as an aberration or cessation of respiration woald point to a structural or
fu actional alteration existing either in the nenres or in the apparatus of respiration. Whether
the Tiews of Proehaska and Gall, and of their followers, the phrenologists, be true or false, it
would be, netertbeless true that if the action of the intellect, when manifested by motions,
or sensations, or consciousness, is always attended by chemical and physical changes of the
n^rrons structures, then aberrated intellectual acticm would point to organic or functional
changes in the nerTous system. As in the case of aberrated motion and sensation, and of
secretion and excretion, circulation and respiration, the cause of the aberra'ton may lie en-
tirely without the nerTous system, in chemical and physical changes of the bloo i. induced by
the catalytic action of morbific agents, so also, in the case of aberrated Intellectual action it
may arise from chemical and physical changes in the blood, arresting or altering the homal
chemical changes of the organs of the intellect.
11. In iuTestigations into the causes and eflTects of disease, the pathologist should remember
that the origin of the disease may be connected with derangements in the constituents of the
blood and of all the organs, independent altogether of the nerroos system. Thus, in mala-
rial fsTor, the poison, wbaterer it be, destroys the blood corpascles, destroys the ferment in
the blood, which couTerts the animal starch, elaborated in the liver, into grape sugar, and
produces profound alterations in the structures, blood and secretions of the llrer and spleen.
Now, in the beginning, these effects may take place entirely independent of any alteration in
the nerTOUB system In this case the nerrous system will be secondarily affected, and its
action seriously disturbed, and this disturbance will give rise to a distinct s t of phenomena ;
but it is CTident that the cause and origin of this disease lies back of this disturbance.
The study of the physician does not cease with these phenomena.
12. Whilst in the physical uniTcrse and in the structures of animated beings the phenomena
are connected by determinate, definite relations, in the moral world there is a disturbing
element acting contrary to all harmony. The history of the world presents a mournful pic-
ture of a strife between two great antagonistic priuciples of good and eril. Erery indiTidnal
that is bom into this world forms a fresh battle-field for the conflict of these principles. In
his present state, man resembles the ruins of a majestic temple ; those columns, though
marred and broken, still retain enough of beauty and symmetry to remind us of its former
grandeur ; the inscription upon the wall of the innermost chamber, although coTered with
the damp and decay of ages, still poiots to a hand Divine. The pleasant sentient emotions
excited in the nerrons system by benevolent actions and the strict adherence to tmth, prove
thai the cultivation of the virtuous affections is Ikvorable to health. While, on the other
hand, the irritation, weakness, and morbid excitability of the nervous system prodaeed by
the indulgence of the evil passions, envy, jealousy and revenge — the han?*rd countoaaaee,
the withered, blasted form of vice— prove that the indulgence of the principle of moral evil
injures and wastes the body ; prove that the intellectoal and moral faculties act npoa the
material body by which they are environed ; prove that the material body may be rendered unflt
Introdaetion to the Study qf Diseases qf the Nervous System. 1H7
for the Dormkl eierciie of Ibe moral >ad ialeltBctaal facaltiea ; proTc that Ibe knowledge of Ihe
pbjsician tboiild extend not merel; 10 tbe pbjBicnl, chemiCBl, pbjeiologicml and patbolugical
pbeaomena of the body, bot should embrace the itrueture or tbe iotellectual and moral facul-
tie«, and their relalioni to tbe material body bj which tbej are environed,
II II erident, then, that the complete inTeatigatioo of the origin, cansea, eflectl and treat-
ment ot dUeaje denuads an examination or the relation! of man, during health and diaease.
to Mtronomickl pheaomena ; demandg an examiQation ot the relations of man to tbe dislri-
bntion of tbe (erraitrial ma^ies, to the soil, climate and waters, not only at tbe present time,
but in the paal hiatorj of the relations of man to astronomical and terrestrial phe-
nomena ; demands an eiamination of the structure and relations, and alterations of the solids
aod flaid* of tbe organs and systems of organs, and tissues, and blood, and secretions,
and excretions; demands an einminatioa of tbe pbysical and chemical changes, and the
relations of tbe physical, chemical, vital, and nerTous forces ; demands an exami nation of
tbe relslioDS of the physiological and pathological alterations df the nervous system to aecr?-
lioa, excretion, aroiation, motion, and intelleclaal and moral actions.
INVESTIGATIONS
ON
THE NATURE, CAUSES, RELATIONS,
AND TREATMENT OF
TRAUMATIC TETANUS,
ILLUSTRATED BY
Observcbtioixs on VcLrioTZS ^)isecLSB3 of tJte Newoixa
Syaterrh, andL by Ej^e^rirrtervta on
Ltxring jlnimcbls TfritK
CevtoLvn JE\}i307xa.
INVESTIGATIONS, ON THE NATURE, CAUSES, RELATIONS AND
TREATMENT OF TRAUMATIC TETANUS, ILLUSTRATED BY
OBSERVATIONS ON VARIOUS DISEASES OF THE
NERVOUS SYSTEM, AND BY EXPERIMENTS
ON LIVING ANIMALS WITH CERTAIN
POISONS.
CHAPTER II.
OBSCBTATIONS ON THE HATVBAL BI8T0BY OF TBAUMATIC TKTAKU8. CHAKG£S OF THS PULSE,
BE8PIBATI0N AND TEMPEBATURE. CBABACTEB AMD CHAKGES OF TUE
UBIMABT EXCBETION.
ObtervAtions on the Natural History of Traumatic Tetanus. Cbangts of the pulse, respira-
tion and temperature. Characters and changes of the urinarj excretion, qualitative and
quantitaiiye. Cases illustrating the Natural History of Traumatic Tetanus. The essential
pbeDomena of lever and inflammation, absent in Traumatic Tetanus ; the symptoms exaggerated
manifeitations of nervous and muscular actions, rather than of structural alteration ; an
irritation in a distant nervous branch is propagated to the spinal cord, and the disease after
its eaiablisbment, appears to be dependent upon an undue excitability and increased action
of the entire spinal ganglia, as manifested in the greatly exaggerated reflex actions. Reflexion
of the increased activity of the ganglionic c^lls ol the spinal cord, to the sympathetic nervous
»ysteni.
Denonstration of increased chemical change in the muscular and nervous systems in Trau-
matic Tetanus. Historical notes upon the condition of the animal temperatuie in this disease.
Ohaervaiions of Hippocrates, Aretseus, Paulus ufigineta, Celsns, John Brown, William GuUen,
Lionel Chalmers, Benjamin Rush, John Hunter, James Currie, Benjamin Travers, Robert Bently
Todd and others, upon the Natural History and more especially upon the condition of the
temperature in Traumatic Tetanus.
The sudden and rapid rise of the temperature in certain cases of Traumatic Tetanus near
the fatal issue, referred to several causes, as 1st, the effecta of the violent muscular contrac-
tions and agitations : 2d. Impeded respiration ; 3d. The supervention of inflammation of some
one or other of the internal organs, but more especially of the lungs as in pneumonia; 4th.
The translation or extension of the irritation of the gray matter into true inflammation ; 5th.
The extension of the irritation from those portions of the spinal cord especially connected
with the reflex functions to those ganglionic centres within the brain and spinal cord, which
regulate the production of animal heat; 6th. The extension of the irritation to the sympa-
thetic or vaso-motor system of nerves ; 7th. Chemical and physical alterations of the blood.
Portion of the nervous system involved in Traumatic Tetanus, intellect unaffected. Cases.
Tetanns essentially consists in such a state of exalted functional activity in the nerve cells, as
is attended with the constant generation of a larger supply of motor fpice, than is necessary
for the maintenance of the normal relations between the nerves and muscles. Discussion of
the mode in which the local irritation is conveyed by the nerves to t|ie ganglionic cells of the
spinal axis. Examination of the views of various anatomists and physiologists, as to the
mode of termination and ultimate structure of nerves. Circulation and Respiration in Tran-
t42 Observations on the Natural History of Traumatic Tetanus.
mfttic Tetanus. Intermifcteat action of the heart — obserTations upon spasm of the heart In
this disease. Function of the skin actifitj performed ; bowels constipated. Mntual relations
of cerebro-spinal and sympathetic Sfstems in this disease. Changes of the nrine daring the
fartons stages of Traamitic Tet-inns. Hypothesis as to the nature of the disease.
NATURAL HISTORY OF TRAUMATIC TKTANU8.
In the first case of Traamatic Tetanus reported in this Chapter, the yarious phe-
nomena were closely observed and noted, the urine carefully analyzed, the yariooa
phenomena examined and compared, and general results and conclusions deduced.
The true nature and laws of disease can only be established by the Inductive Method.
Each case properly examined and recorded, throughout its entire course, will afford
data for the establishment of general principles ; because under like circumstances, and
in similar constitutions, each well marked case of disease, will present characteristics as
fixed and as well marked, as the different species of animals and plants, and the laws
by which it is governed, will be found to be as fixed and as characteristic as those
which govern the healthy organism under the action of well known agents. Whilst
holding the belief in the fixed characters and laws of disease, it is at the same time
admitted, that observations should be extended to the farthermost possible limits, because
diseases may present differences, as distinct as the varieties of the human constitution,
and may be influenced in their manifestations, by modes of living and by climate : and
in each case nature performs an experiment, as it were, the subjects of disease being
placed in so many diverse conditions, by which the different morbid manifestations may
be developed or modified ; and in these various modifications and their manifest results,
the student is fi^uently enabled to gain an insight into the working of hidden laws.
No disease presents more uniform, or more strongly marked characters than Traa>
matic Tetanus ; and hence we can, with the more confidence, attempt to settle, general
principles, from isolated cases.
Ooue No. 1 : lUmtrcUvug the Natural Hiitory of Ihiumatic Teianui,
Oillstrap, Confederate soldier ; a^e 37 ; dark complexion ; dark hair and ejes ; height, hr^
feet six inches; weight, 145 lbs; athletic and strong in health; muscles well developed; has
been in the militar/ service of the Confederate States six months ; previous to this time hii
occopatioa was farming.
At the battle of Secession ville, on James' Island, South Carolina, June 16th, 1862, whilst
standing in a small house, and in the act of taking a cartridge from the box, a minnie ball
passed through a plank in the side of the house, three inches in thickness, and entering the
lower part of the anterior fleshy portion of the right fore-arm, passing through the extensor
and flexor mnselee, between the ulna and radius, splintered both bones, without however,
fracturing them acrois.
The wound suppurated freelj and appeared to be doing welt, until Julj 6th, when the sap-
puration sensiblj diminished, and the patient complained of spasmodic twitchings, and pain-
ful sensations iu the muscles of the wounded arm and corresponding side, and along the spine,
especiall/ between the shoulderj, and in the region of the cervical and brachial plexus ; stiff-
ness and uneasiness about the muscles of the jaws, and a painful sense of tightness aboat the
ensiform cartilage ; torpor of the bowels, and " loss of rest at night." The spasmodic eon-
tractions and twitchings of the muscles of the wounded arm, were excited and increased by
the slightest movements, and were especially aggravated by coughing. The act of coughing
was not only attended with great pain, but also with spasmodic contractions of the mnselea of
the thorax and neck.
For several days previous, the bowels had been constipated, and in like manner with this
characteristic symptom, the sense of oppression of breathing, restlessness, and loss of sleap,
preceded the well marked symptoms of tetanus.
The expression of the countenance is that of distress, and even of pain, aad the musclss of
the face are greatly distorted daring the paroxysms.
During the night and following day, (July 9th,) the pain in the arm and between the shoal-
ders, and at the pr«eordinm increased, and in like manner the stiffness of the Jaws; the
tetanic spasms became more violent and frequent ; opisthotonos became more marked, aoa the
disturbance of respiration was profresstvely increase! during the paroxysms.
Administered in thj morning, ten grains of calomel, which was followed with half aflaid-
ObservatioTis on the Natural History of Traumatie Tetanus.
143
ounce of castor oil, in four bonrs. These purgatiTes failed lo move Ibe boweis. At bed-time,
Administered forty drops of tincture of opium, (Laudannm) ; and as tbis doee failed to produce
sleep, thirty drops more were admiDistered two hours afterwards. After the second dose the
patient rested somewhat better ; the spasms appeared to be slightly moderated, and the patient
slept a little between the seTcre spasms.
inly 8tb, 12 o'clock, m. Patient says that he feels a little better; at the present moment
the spasms do not appear to be so violent, Pulse 82, soft and full ; respiration quiet and
reinilAT between the paroxysms, but disturbed and almost arrested during the spasms.
Temperature of hand, 37*>.6 C. (99«.7 F.) : of axilla, 37®.9 C. (100°.3 F.)
ExammatUm of Urine — High colored and scanty : amount excreted during sixteen hour?,
(from July 7th, 8 o'clock, p. M., to July 8th, 12 m.,) 4823 graius (Troy) ; if fiom this data, the
Amount of urine be calculated for twenty-four hours, it would be equal lo 7234.32 grains.
Specific gravity, 1021.55. Reaction, strongly acid ; Color deep orange inclining to red. Urine
clear when first passed. After standing about 72 hours, a deposit fell, consisting chiefly of
the phosphates; a dense yellowish white layer, also rose and completely coated the surface
of the urine, to the depth of an eighth of an inch ; this was composed of the phosphates of
lime, magnesia and ammonia, amorphous granules, stellate and prysmatic crystals and vege-
table cells. I ba?e seen a similar thick scum, rise on the urine of typhoid fever, after stand-
ing for some time ; but never upon the urine of malarial fever.
The composition of the urine is given in the following table : —
Ko. 1. — Analytu of Urine poMted during 16 howt^ from Jvfy *lthy B A, M. to July Sih^ 12 if.
Amounts expressed in Troy Grains.
Amount of Urine... • ,
Water
SoUdi
Urea
Uric Acid ^
Free Acid..
Phosphoric Acid
Sulphuric Acid ^
Chlorine ,
Equivalent Chloride of Sodium ^
Fixed \ Entire Saline Constituents....
i<a)ine > Pbospates of Lime and Magnesia...
Constitu'ts j Sulphates, Chlorides and Phosphates
of Alkalies
VHbc puMd da*
riBf 16 ta'n. Jaly
Tth, 8 A. M. to Jnly
mhltu.
AaMOBtudoam*
potition of UiiBC
MlenlatodftHrMh't
ATcnge aaioBat
•Bd oonporitloa of
Urtne puMd «Mk
hoar.
OaAIHS.
OBAUIS.
OKAIXS.
.. 4823.00
7234.32
301.43
.. 4544.20
6816.24
418.08
284,01
278.74
17.42
145.60
218.40
5.52
13.68
16.32
11.28
31.68
51.84
9.10
3.73
0.23
9.26
0.57
10.89
0.68
7.01
0.47
21.13
1.32
34.67
2.16
67.49
101.04
4.21
8.76
12.90
0.54
!S '
58.73
88.08
3.67
Upon consultation with Burgeon L. D. Ford, it was deietmined, to administer internally,
sulphate of quinia, and a mixture of equal parts bj measure of chloroform, sulphuric ether
and tincture of opium.
K. Qninise Sulph : Grains XX ; divide into four powders, and administer one powder at
13 H., 2 F. M., 4 p. M., and 6 p. H.
R. Chloroform!.
.£theris Sulph :
Tinct. Opii : of each equal parts: mix: administer 10 drops every hour in sweetened
water.
Nine o'clock, p. m. Pulse 88: bowels still unmoved : has taken twenty grains of quinine, and
does not complain of any unpleasant effects in the head from this. The chloroform mixture
has been administered continuously each hour, and the patient thinks that it has had the
effect of somewhat diminishing the pain, and the severity of the spasms. I administered forty
drops of Laudanum, and ordered this dose to be repeated in two hours ; and the chloroform
miztare to be continued, ten drops every hour.
July 9th, 12 H. Continues much the same; pulse 74; skin in a profuse prespiration. Sur-
face feeli cool. Tongue coated with white fur. The chlorofoim mixture appears to have
slightly diminished the intensity of the spasma; they are however, very severe and frequent,
and the suffering of the patient is very great.
Temperature of hand, 37.*»55 C, (99.<»6 F.) ; of axilla, 37.*»85 C. (100.<»2 F). Continue chloro-
form mixtnre : — Diet, chicken and beef soup, corn gruel and milk punch. The nourishment
and the medicine are taken with great difficulty, and it is only when there is an intermission
of the paroxysms, that the patient is able to suck them carefully through a quill.
144 Observations on the Natural History of Traumatic Tf tonus.
Examination of the Urine — Dark brownish red color; Sp. G. 1023; reaction ftroagly acid ;
the microscopical ezamiaation yielded similar results to those previoasly recorded: In like
manner, the thick scum formed upon the urine after standing.
No 2. — Anah/nt of Urine patted during 24 hourt.from July 8M, 12 if. to July 9lh^ 12 M. Amount*
. expretted in Troy Graint,
Urine pm*tmi dn- ATerafr Amount
ring 24 houra, Jalv utd eoai|KMilthib <■/
Mh.llM. io Julj9tB Urine fm*mtA nch
12 H. hoar.
aiAIXS. OIAIXS.
Amount of Urine 10444.83 435.20
Wrtler : 9852.65 410.53
Solids 592.18 24.67
I'rea 381.35 15.88
Trie Acid 4.09 0.17
Free Acid ^ 27.61 1.15
Phosphoric Acid 39.96 l.^iO
Sulphuric Acid 21.24 0.88
('hlorine 45.22 1.88
Kquivalent Chloride of Sodium 73.84 3 07
Fixed ] Entire Saline Constituents 148.94 6.2o
Saline v Phosphates of Lime and Magnesia *. 13.29 0.55
Constituents j Sulphates, Chlorides and Phosphates of Alkalies 135.65 5.65
Nine o'clock p. m. No improrement of symptoms. Continue Chloroform Mixture, twelve
drops every hour ; administer at once ten grains of Blue Mass (Pill Hydrargyri), and follow
in four hours with one fiuidounceof Castor Oil ; and in the morning administer fivt grains of
Quinine at 5 ▲. m., 8 ▲. m. and 11 ▲. m.
July 10th, 12 M. Tetanic spasms have increased in frequency and violence ; bowt'ls obsti-
nately constipated ; the Blue Mass and Castor Oil hare had no effect. Fifteen grains of Quinine
have been taken this morning without any apparent effect. Pulse 80; Temperature of Hand
37°.6 C. (99® 7 F.) of Axilla 38° C. (100«.4 F.)
Ecamination of Urine. — Brownish red color. Sp. 6r. 1025.25. Strong acid reaction.
No. 3. — Analytit of Urine patted during 24 hourt^from July 9M, \2 M. to July 10/A, 12 if.
.\monnt of Urine
Water
Solids
Urea *.
Uric Acid
Free Acid
Phosphoric Acid ,
Phosphates of Lime and Magnesia.
Urine pMaed do-
rlBf 24 hoan, Julr
9th. 12 M. to JulV
lOUi. 12 M.
■ad 0<><u|«*'lU'>{ ..r
Urine iiiywMl «*• m
• hour.
OKAINS.
OKAIXS.
11,625.76
901.07
10,962.17
873.4«
663.59
27.64
466.56
19.44
11.45
0.47
3:j.88
1.38
4:>.76
1.90
16.00
0.66
Nine o'clock p. m. No improvement. Administered an enema of: molasses, one fluidoance.
Common Salt one ounce, and water one pint ; this in like manner with the purgatives failed
to produce any action on the bowels. After the trial with the enema administered thirty
drops of Laodanum, and ordered this dose to be repeated in two hours. Continue the Chloro-
form Mixture ; and in the morning administer, five grains of Quinine, at 5 ▲. m., 7 ▲. m., and
11 A. ac.
July Ilth, 12 M. Continues to grow worse; bowels still without any movement; has taken
fifteen grains of Quinine this morning. Pulse 84 ; Respiration 15 ; Temperature of Hand 37^
6 C. (99« 7 F.,) of Axilla 38» C. (100° 4 F.)
Continue Chloroform Mixture.
Ernmination of Urine. — Light red color; after standing 48 hours, notwithstanding the heat
of the weather the reaction was still strongly acid; no deposit fell during this time ; after
standing a still longer time, however, a deposit of the phosphates was thrown down, and the
thick scum rose upon the surfkce.
The urine emitted a distinct smell of Chloroform. Sp. Ur 1024.75.
Observations on the Natural History of Traumatic Tetanus.
145
No. A.-^Analfftii of Urine pasted during 24 how9f July lOtA, 12 if. to July llM, 12 M,
Amoant of Urine ^.
Creft.
Cric Acid
Free Acid ',
Pbotpboric Acid
Snlpbaric Acid
Chlorine
Eqniralent of Chloride of Sodium,
Phosphate of Lime and Magnesia....
Urine pMaed du-
ring M hoort, July
lOCb, IX M. to July
nth, ISM.
ORAINi.
6,457.50
302.62
6.40
2K60
16J)4
15.66
10.59
17.37
10.39
Average Amoant
and .Compoeltlon of
Urine p«se«d during
Bh luHir.
OEAIKl.
269.06
12.60
0.22
0.90
0.70
0.64
0.42
0.72
0.42
Nine o*cIock p. m. The tetanic spas ms have greatly increased in violence and frequency
since 2 p. m. Patient emits a shrill, piercing crj, during the- spasms, and the head and neck
are drawn back and downwards towards the heels, whilst the lower extremities are drawn in
like manner backwards and upwards towards the head, with great violence. The patient
cannot lie down even in the intermissions, and is compelled to sit up upon the edge of the
bed, his lower extremities being forcibly .bent backwards under the bed. Two strong soldiers ,
acting as nurses, are required to support the patient during the intermissions, and to hold
him firmly do ring the spasms ; for, without their assistance, the patient would be thrown
violently against the wall, by the powerful contractions of the muscles of the neck and back,
dragging the bead backwards towards the heels. At one time, when the spasms came on
violently, the patient was projected with force over the bed, and his head struck the wall
with a heavy and painful blow.
The jaws are very rigid; it is impossible, even during the most complete remissions, to
protrude the tongue; and it is only by the greatest care, and by a careful selection of the
most complete remissions, that he is able to take the Chloroform Mixture and a little nour-
ishment.
The spasms are excited by pounds, by currents of air, or by a sudden touch. The mus-
cles of the face are contorted, and the angles of the mouth drawn up; the nostrils are ex-
panded ; the eyes fixed and drawn inwards, the forehead is deeply wrinkled, and the whole
countenance is expressive of great anxiety, distress and suffering ; complains of great pain,
and '^ drawing'* in the muscles between the shoulders, in the neck and in the region of the
diaphragm.
The wound in the arm looks dry and is of a bluish and purplish red color, and has ceased
to discharge pus ; — the discbarge now consists of a small quantity of serous fluid.
Tincture of Iodine was poured into the wound; the fore-arm was also painted with it.
The application of Tincture of Iodine directly to the wound appeared to increase the spasms.
Immediately after, the patient bad several terrible spasms, during which be emitted sharp and
piercing cries.
The puiie vrae intermittent during these violent ^aeme^ but became regular again after a short time^
t/ter they had passed off. The intermission in the action of the heart, did not take place until the estab^
itthmmt of the spasm, and continued for some time after the intermission of the spasm j the disturbance
rn the action of the heart was therefore evidently caused by the spasm.
Has passed no urine since 12 m., and says he is unable to do so.
I administered thirty drops of Laudanum, together with thirty drops of the mixture of Chlo-
roform, Ether and Laudanum, and directed this dose to be repeated in two hours, together
with the hourly administration of fifteen drops of the Chloroform Mixture, and in the morn-
ing five grains of Quinine at 5 ▲. m, 7 a. m., and 9 ▲. m.
July 1 2th, 12 M. Spasms not so violent as yesterday ; appears to have been benefitted by the
increase in the Chloroform mixture. Pulse, respiration and temperature continue much the
same. Pulse 84 per minute ; intermittent during the spasms. Has taken fifteen grains of
Qniolne this morning. Thus far I have observed no beneficial effects whatever from the
Qaioine; on several occasions it has appeared to aggravate the spasms; whilst, on the other
hand, improvement always appeared to follow the free use of the Chloroform Mixture. Ad-
ministered thirty drops of Laudanum and thirty drops of Chloroform Mixture, and repeated
this dose half an hour after, and ordered the continuance of fifteen drops of the mixture each
boar.
Exammaiion of Urine. — Deep red color. Sp. Or. 1024 5. Strong acid reaction. During
twenty-four hours, from July 11th, 12 m., to July 12th, 12 m., has passed only 4026 grains of
Qrine.
19
146
Observations on the Natural History qf Traumatic Tetanus.
The patient affirms, and his statement is confirmed hj the nurse, that this is the entire
amount passed during this period. During the serere spasms, it was impossible to Toid the
urine, and the diffieultj is still great. After standing, a thick scum rose upon the surface.
No. 5. — Analytii of Urine patsed during 24 hours, July lUA, 12 JT. to July 12M, 12 if.
Amount of Urine... .>
Urea.
Uric Acid
Free Acid
Phosphoric Acid
Sulphuric Acid
Phosphates of Lime and Magnesia.
Urln« pamed da*
riogM luran, Jolj
Ifth, II H. to Jnl/
ISUi. IS M.
OBAIirt.
4,026.28
177.50
3.26
16.37
12.87
9.67
5.03
Arcnif* A
c
of
VrliM puMd
•ainrs.
167.77
7.39
0.13
0.64
0.53
0.37
0.20
Nine o'clock p. m. There appears to be a slight improvement of the symptoms.
Pulse 88. Has passed no urine this day. Bowels obstinately coustipated. Painted the
wounded arm with Tincture of Iodine, and poured the Tincture into the wound ; this caused
some pain, and an increase of the spasms ; administered forty drops of Laudanum, with thirty
drops of the Chloroform Mixture, and ordered this dose to be repeated in two hours, and also
the continuance of the Mixture, fifteen drops each hour.
July 13th, 11 A. M. Appears somewhat more quiet. The second dose of Laudanum and
Chloroform Mixture, administered last night, induced some rest, and the patient slept two
hours. The Tetanic spasms appear to hare lessened a little in severity, and the wound is
commencing to suppurate. Administered thirty drops of Laudanum and thirty drops of
Chloroform Mixture, and ordered the Chloroform Mixture continued in the usual dose, also
fire grains of Quinine at 12 m., 2 p. m., and 4 p. m.
Nine o'clock p. m. Has passed more urine than usual this day.
The symptoms hare changed for the worse — the paroxysms are more riolent, and the suf-
fering more acute— the patient cries out in each spasm. Position, sitting upon the edge of
the bed, held by two strong soldiers, as preriously described ; the action of the muscles also,
in drawing the head towards the heels, is similar, and fully as powerful. Pulse 90 in the
sitting posture.
During the spatmt, and for $ome time after , the puUe beats irregularly. One powerful impuUe, foU
lowed by two feeble impuUee, and then a complete eeuation of action ; no impulte whatever.
When the spasms are delayed, the heart gradually returns, between the paroxysms, to its
normal regular action and the pulse resumes its regular heat.
I carefully examined the relations of the perturbations in the heart's action to the Tetanic
spasms, and found that ihej eueeeeded^ but never preceded the spasms; thus indicating that,
either an influence was transmitted from the medulla oblongata, through the Pneumogastric
nerres to the ganglia and nerres of the heart, causing spasms in the muscular fibres similar to
those excited in the muscles under the control of the Tolition, by the peculiar state and force
of the spinal axis and motor nerres ; or else the sudden contraction of the muscles and the
suspension of respiration, not only suddenly forced much blood upon the heart, but also
forced blood improperly oxygenated, and abounding with Carbonic Acid, upon the heart,
and thus deranged its actions by distending the carities with venous blood.
The first supposition appears to be the most reasonable, because the phenomena were too
regular, and the irregularity of the heart's action lasted too long after the disappearance of
the spasms, and gradually disappeared after the entire cessation of the spasm ; and farther,
because muscular exertion, and the presence of renous blood accelerates, rather than retards.
the action of the heart. A fact stated by physiologists, that on stimulating the cf rrical
trunk of the Pneumogastric nerves, with an electro-magnetic current, the action of the heart
is generally arrested, while, when the experiment is successfully repeated on the tronk or
branches of the sympathetic, its pulsation is always accelerated, would strongly support this
view.
Twenty-fire drops of Laudanum, with an equal number of the Chloroform Mixture, were
administered, and as they appeared not to afford any special relief, the dose was repeated at
the end of half an hour. The continuance of the Chloroform Mixture, as usual, together
with fire grains of Quinine at 5 a. h., 7 a. m., and 9 a. m., were ordered.
July 14th, 11 a.m. The patient did not rest during the night — it was impossible for him
to recline, even for a few moments, althouifh a most comfortable chair was fixed, which
afforded the opportunity of resting in the sitting posture. The chair could not be used, oo
Observations on the Natural History qf Traumatic Tetanus. 147
ACCOQDt of the great contraction of the muscles of the back, neck and legs. The patient was
compelled to sit upon the edge of the bed all night, as in the preceding nights, supported bj
two strong soldiers. Pulse 98, in sitting posture. Respirati9n natural between the parozysmSr
Surface of the skin, as usual, bathed in perspiration. Temperature of Hand 38^ C. (100^. 4 F).
It waa difficnlt to determine the temperature of the axilla, on account of the Tiolence of the
spasms ; it appeared, howerer, to preserre the same relations to that of the hand prerionslj
noted, being a little less than one degree Fahrenheit abore the latter.
During the intermissions, when the spasms are delayed for some time, the pulse was regu-
lar; daring the commencement of the spasms, the pulse became fuller and more rapid for the
first few moments, and then it became irregular — one full impulse, then two lesser impulses,
and then a cessation of one beat. Has taken fifteen grains of Quinine this morning.
R. HagnesisB Sulphatis one ounce; Aquas Distillatse, six fluidonnces; make a solution,
and administer at once.
R. Chloroformi, one fluidonnce ; Pulv : Camphors one ounce ; Tincture Opii, one fluid-
ounce ; Olei Olifse, four fluidonnces ; dissolve the Camphor in the Chloroform, and then
mix with the Sweet Oil and Laudanum; Use this as a liniment to the muscles of the
neck and back.
Continue the application of Tincture of Iodine to the wound, and also rub the entire arm
with Iodine Ointment.
After applying the Tincture of Iodine to the wound, introduce a small quantity of the
Iodine Ointment into the wound. I hoped by these measures to excite suppuration in the
wonnd, and also to produce counter-irritation orer the region of the nerres connected with
the injnred textures.
EramuKUum of Urine. — More abundant, and not so highly colored, being a deep reddish
orange. Strong acid reaction. Specific gravity, 1022.
After standing, the nrine presented the same characteristics as those preriously noted.
No. 6. — AruUytit of Urine paated during 48 kaura, July \2th. 12 M. to July 14M, 12 if.
Urine pamed da> Avanige Amooiit ATeng* Amoont
riog 48 hmin, Joly and CompMitkm of and Cempoaltloii of
ISth, II M. to Jnty Urine puMdMoli 14 Urine pueed each
14Ui, II H. hoon. hoar.
OBAINS. OaAIMS. O&AIMf.
Amoantof Urine 24,139.64 12,069.82 502.90
Water 22,651.58 11,325.79 471.66
Solids 1,488.06 744.03 30.00.
Urea 1,042.20 621.10 21.71
Uric Acid 13.46 6.73 0.28
Free Acid * 98.43 49.21 2.06
Phophoric Acid 78.02 39.01 1.62
Sulphuric Acid 67.47 33.73 1.40
Chlorine 77.66 38.83 1.61
Kquivalent Chloride of Sodium 127.41 63.70 2.66
Fixed ) Entire Saline Constituents 188.96 94.48 3.93
Saline [ Phosphates of Lime and Magnesia 33.06 16..V3 0 68
Constituents [Sulphates. Phosphates and Chlo-
) rides of Alkalies. 156.90 _ 77.95 3.24
Nine o'clock p. m. Through mistake, the nurse failed to administer the Chloroform Mixture,
and the patient has suffered greatly during the day. The Epsom Salts (Sulphate of Magnesia)
failed to exert any effect upon the bowels.
The Chloroform liniment afforded some slight relief to the pain between the shoulders ; at
present, however, the spasms are not so severe as they were this morning. I hare again care-
faily examined the phenomenon of the action of the' heart during the spasms. The effects of
these lighter spasms, are not so marked as those of the severer spasms— they do not when
light, canse the intermittent action of the heart, although they produce a certain amount of
distnrbance in its action.
Administer at once, forty drops of Laudanum and twenty drops each of Chloroform and
Solphnric Bther, with one ounce of Sulphate of Magnesia, dissolved in six ounces of water.
Continue chloroform mixture and liniment.
July 16th, 12 m. More comfortable; spasms not so violent: they appear to be diminishing
both in frequency and force. Pulse, 84, regular. Respirations in the remissions regular.
Temperature of the extremities and trunk quite uniform, and about the same as last recorded.
Says that be obtained some rest at 12 m. last night.
Administered 30 drops of Laudanum, and the same number of Cblorform Mixture, and
ordered the mixture continued as before.
148 Observations on the Natural History of Traumatic Tetanus.
Examination of Urine. — Deep red color; Sp. Gr. 1026. The orlne upon Btaoding teTer^I
dajB, presented similAr phenomena to thoee previonslj recorded.
No. 7. — Analym of Urine paUed during 24 how$, July 14<A, 12 if. to July 15M, 12 M,
Amount and Con. ArentM bmovm
MltoMta •/ Urin* of CotMataMU of
daring 14 Urine paaaed each
OKAIHf. OBAIHl.
Amount of Urine 8,074.62 336.44
Water 7,585.46 316.06
Solids 489.16 20.38
Urea ^ «... 386.00 16.08
Uric Acid ^ 8.81 0.36
Free Acid 40.40 1.68
Phosphoric Acid « 37.86 1 .59
Sulphuric Acid....M............M........M 38,34 1.59
Chlorine . .. 16.53 0.68
EquiTalent Chloride of Sodium........ „».... 27.13 1.12
Fixed Saline ConstituenU (Entire) . 88.14 3.66
Phosphates of Lime and Magnesia... 14.93 0.62
Phosphates, Sulphates and Chlorides of Alkalies...................^ 73.21 3.05
Julj 16tb, 10 o'clock. A. M. Patient appears to he much better; spasms much less seTere ;
jaws are much more relaxed^ and the patient is able to talk with more ease. Pulse 86 ; Res-
piration 18 ; Temperature of Hand 37<».8 C. (lOOM F.) of axilla 38^ C. (100<>.4 F).
Continue the Chloroform Mixture and paint the arm with the Tincture of Iodine.
Examination of Urine. — Light red color; Sp. Gr. 1025.10. In twelve hours a deposit of
Triple Phosphate fell ; this is the first deposit thrown down in so short a period ; heretofore,
a heavj scum formed upon the surface of the urine, previous to the formation of a deposit,
and in fact, itself afterwards became a large portion of the deposit, in consequence of por-
tions sinking down after remaining on the surface for several dajs.
No 8. — Analytis of Urine passed during 24 hours^ July 15M, 12 if. lo Jufy 16M, 12 M.
Ajnonnlnnd Coo- Avaraf* A—n t
•titatloa of Urine nnd Ciinipeidrten sf
MaMddnrincMh't. UriM pumttg mmth
July If
inly ISlli, It M. ta
JntylSlh. ItM.
•BAIKi.
Amount of Urine 9,840.96 410.04
Urea 546.26 22.76
Uric Acid 7.48 0.31
Free Acid 23.62 0.98
Phosphoric Acid 16.37 0.68
Sulphuric Acid u 77.67 3.23
Fixed \ Entire Saline Constituents 57.60 2.40
Saline V Phosphates of Lime and Magnesia '. 29.18 1.21
Constituents j Sulphates, Phosphates and Chlorides of Alkalies 28.41 1.18
Nine o'clock, p. m. Pulse 100 in sitting posture, and intermittent after the severe spasms.
Twenty-five drops of Laudanam, and an equal quantity of the Chloroform Mixture, with oae
ounce of French Brandjr, diluted, were administered with good eflfect ; and this combioation
repeated in half an hour, resulted in the " best night's rest^" since the onset of the disease.
Ordered an Enema of Salt and Molasses at once, to be repeated if necessary in the momiag.
July 17th, 10 ▲. H. Continues to improve, rested much better during the night than at any
previous time. The spasms continue to diminish in frequency and force. Pulse in sitting
posture 82, full, soft and good. Tongue coated with light white fur. Temperature of Hand
37«.95 C. (100«.3 F.) Temperature of Axilla 38* C. (100<».4 F).
Continue Chloroform Mixture.
Examination of Urine. — Only 4,039 grains of urine hare been collected during the last
twenty-four hours. The patient afllrms that this is the whole amount passed ; he is a moat
reliable man, and I have every reason to believe that this is the amount, as both he and bis
nurses have taken the greatest interest In the examination of the symptoms, and especially of
the changes in the urine, and have manifested every anxiety to aid me in all my inquiries.
Four Injections of salt and molasses were administered daring the night, which failed entirelv
Observations on the Natural History of Traumatie Tetanus.
149
to produce anj effect apon the boweU ; daring the action of these the patient maj possibly
hare lost some urine, he insists, however, that none was lost at any time.
Color of Urine mnch lighter; deep orange.
Reaction of Urine not so acid.
Specific Orarity, 1025.3.
The following is the Composition of the Urine passed daring tw^nty-foar hours.
Xo. 9. — Anafytia of Urine pasted during 24 houre^ July 16M, \2 M. to July 1*1 th^ 12 if.
Amoant of Urine ^
Urea
Uric Acid
Free Acid
Phosphoric Acid
Sulphuric Acid
Chlorine
EquiYilent Chloride of Sodium
Phosphates of Lime and Magnesia ^,
Amoant and Com-
poaltion of Urina
puMd daring M
noon.
OBAIIfS.
4,029.42
183.36
6.29
8.10
5.67
22.57
5.25
8.63
8.64
Arernge Amoant
nnd Constitation of
Urine pMsed each
hoar.
0RAIH8.
167.64
7.64
0.26
0.33 *
0.23
2.98
0.21
0.36
0.36
Xine o'clock p. m. Suffering somewhat more severely this evening. Ordered Brandy two
floidounces, Laudanum one fluiddrachm, Chloroform thirty minims, sweetened water, six
floidoooces ; mix, and divide into two parts ; one to be taken immediately, and the other at
the end of one hour. Continue the Chloroform Mixture, as before.
Poise 90 in the sitting posture.
July 18th, 11 o'clock ▲. m. Much better ; says that he feels 'Mike a new man ;" rested well
during the night ; the expression of his countenance has greatly improved.
Pulse 86 ; Respiration 14 ; temperature as in previous observations. Twenty drops of
Laudanum, with a similar.number of Chloroform, were administered ; and this dose was repeated
at the end of one hour. Continue Chloroform Mixture.
Brammation of Urine, — Amount of Urine passed during twenty-four hours, July 17th, 12 M.
to July 18th, 12 M., 7722 grains. Sp. Gr. 1021.55. The color of the urine is less marked;
th*t which was passed yesterday, being of a light red color, whilst the color of the urine of
this day is light orange and almost normal.
No. XQ.^Analytm of Urine paued during 24 houre, July 17M, 12 if. to July 18M, 12 M,
Anoant of Urine %.
Urea.
Uric Acid
Free Acid
Phosphoric Acid
Sulphuric Acid
Chlorine
Equivalent of Chloride of Sodium
Fixed 1 Entire Saline Constituents
Saline > Phosphates of Lime and Magnesia
Conslitoents j Phosphates, Sulpb'tes and Chlorides of Alkalies
▲meant and Gem-
pealtlon of Urine
Daaaad daring S4
noan.
OBAIira.
7,722.54
314.97
7.56
18.89
12.64
45.39
23.17
38.02
36.28
17.69
18.59
Average Amoant
and Gonetltatloa of
Urine pniaed eaoh
hoar.
OlAim.
321.77
13.12
0.31
0.78
0.52
1.89
0.96
1.58
0.77
0.73
1.51
Nine o'clock p. m. Is now asleep ; appears to be improving. Pulse 80. When the patient
awsJies. administer twenty-five minims each of Chloroform and Tincture of Opium, with three
Buidonnees of Brandy.
July 19th, 11 A.. M. Continues to improve, has had only three spasms this morning.
Poise 73. The patient had a light spasm, whilst I was coanting his pAlse ; this did not
however affect the pulse and the action of the heart, as in the previous severe spasms.
Bxammation of Urine. — Deep orange color; Sp. Or. 1016.5. Urine more copious, the
anoant passed daring the last twenty-tour hours, being 10,876.55 Orains.
150 Obserations on the Natural History of Traumatic Tetanus.
No. II. — AnalyM of Urine fMU$ed during 24 howt, July 18M, 12 M, to July 19M 12. M.
Amount of Urine
Urea
Uric Acid
Free Acid
Phosphoric Acid
Sulphuric Acid ,
Chlorine
Equivalent Chloride of Sodium
Phosphates of Lime and Magnesia.
AnooBt and Com*
porttloa «r UrtM
puMd daring M
boon.
ATtngc AsMMiikt
■ad Cempo«Mda «»r
UriiM pamed each
bow.
amAiiis.
OBADIS.
10,876.55
388.47
453.18
16.18
8.56
0.35
30.44
1.26
20.59
0.85
30.32
1.26
37.82
1.57
62.05
2.58
21.40
0.80
Nine o'clock p. m. Pulse 76 ; sleeping quietly ; the examination of the pulse excited two
slight spasms, which did not affect the rjthm of the pulse.
Julj 20th. Much better ; sitting up. Pulse 88.
Continue Chloroform Mixture.
R. Olei Ricini, one fluidounce.
Julj 21st, 1 o'clock p. M. Continues to improve; the oil acted once during the oigfat;
another fluidounce of Castor Oil was administered this morning, and was followed by an Enema,
composed of one fluidounce of Molasses, half an ounce of common Salt, twenty drops of oil
of Turpentine, and one pint of water.
These measures produced a large evacuation from the bowels, which as in the previons
action, contained hard balls of foecal matter.
Pulse 80; Respiration 16; Temperature of Hand 38^.5 C. (101^.3 F.) Temperature of
Axilla 38®.6 C. (101^6 F.)
At the present time, the patient does not appear quite so comfortable ; had several spasraa
during the determination of the temperature. Tongue slightly coated with yellow fur. Ad-
ministered thirty minims of the Chloroform Mixture, together with one fluidounce of Brandy,
properly diluted with water, and ordered the Chloroform Mixture to be continued each hour.
The patient has continued steadily to improve, taking regularly the Chloroform Mixture,
and Brandy, and occasionally Castor Oil, when indicated ; which latter purgative, assisted by
Enemas of Molasses, Salt and Water, have happily produced on this day, (July 21st), the
first free evacuations from the bowels, since the sixth of July.
Examination of Urine. — Light orange color. Sp. Or. 1010.
No. 12. — Analytii of Urine paued daring 48 kourt^ July 19M, 12 Jf. to Jtdy 2Uf, 12 Jf.
ABKNUt sad Com- Arctaf* C«a- Arcnif* C<<*b
podtloa or Urlao peoMoaorUriaa poahlaaorrnae
' duHag 46 oaekMkoari
in.
OIAIIIS. OBAUrt. oaAtsig.
Amount of Urine 21,018.40 10,509.20 437.88
I'rea 489.03 244.61 10.18
Free Acid 50.95 25.47 1.06
Phosphoric Acid 41.57 20.78 0.86
Sulphuric Acid ^ 27.81 13.90 0.57
Chlorine - 84.85 42.42 1,76
Equivalent Chloride of Sodium • 139.20 69.60 2.90
Fixed ) Entire Saline Constituents 117.52 58.76 ' 2.44
Saline V Phosphates of Lime and Magnesia ^^^ 9.36 4.68 0.19
Constitu'ts j Phosp'es.Sulp'es and Chlorides of Alkalies 108.16 54.08 2.30
Nine o'clock p. m. Much betur. Wound discharging pus, which presents a thick, healthy
appearance.
July 22d, 9 p. m. Pulse 80 ; has had a few light spasms, but, upon the whole, baa been
quite comfortable. The muscles of the Jaw have gradually relaxed aa the other symptoms
improved, and he can now open his mouth with considerable ease. Had one action on the
bowels after the administration of the Bnema. Administered thirty drops of Laadaaaa and
Chloroform, with one fluidounce of Brandy ; and ordered an Bnema of Salt and Molaaees in
the morning.
Observations on the Natural History of Traumatic Tetanus. 151
Jaij 23d, 12 M. Maeh better; has had do general spasms, onlj slight twitchings of the
arm : rested well during the night PnTse 80. Repeat Enema of Salt and Molasses, and
continae chloroform mixture.
Examination of Urine,— Dd^tk Red Color, Sp. Gr., 1015. ^
Xo. 13. — Analytit of Urine passed during 48 Aour«, July 2Ut, 12 M. to July 23(/, 12 if.
AmoiiBt and AT«ra«« Am't Arcnge Am't
' Oonttitatfoii of and Constlt'tion aodConttltation
UrlaejDMMdda* of Uriae eack S4 of Urine pancd
I riAff 4n boon. honn. enoh hoar.
aaAnii. oeaiks. oraiits.
Amoont of Urine 31,160.50 15,580.25 649.17
Urea 617.21 303.60 12:65
Uric Acid 30.70 15.35 0.64
Phosphoric Acid 42.51 21.25 0.88
Sulpharic Acid 31.54 15.77 0.65
Chlorine 137.40 68.70 2.86
EqaiTalent Chloride of Sodium 225.41 112.75 4.69
Fixed 1 Entire Saline Constituents 232.92 116.46 4.85
Saline I Phosphates of Lime and Magnesia 34.02 17.01 0.70
ConatitaHs I Pho8ph'e8,Sulph'es and Chlorides of Alkalies 198.90 99.45 4.14
The increase in the constituents of the nrine, was no doubt due in great measure, to the
increased amounts of food and fluids consumed. During the active stages ot the diseasef
bat little solid or fluid nourishment could be taken, hence all the constituents of the urine
were diminishedi and this excretion in the present case, was produced under a state approach-
ing starTation.
The pbjsical conditions induced hj the peculiar nervous and muscular derangements^ inde-
pendeat of anjr lesions of the internal organs, exerted powerful effects upon the character of
the chemical changes in the blood and tissues, and corresponding effects upon the amounts
and characters of the constituents of the urine.
To understand the sigrniBcation of the changes of the urine in this case, they must be com-
pared with the changes of this excretion under different states of rest and exercise, under
rarious kinds of food, and especially during starvation.
Nine o'clock p. m. Patient says that he does not feel as well as he did this morning ; pulse
90, fall and strong ; surface feels a little warmer than usual.
The enema this morning induced an evacuation of hard balls.
Ordered ten grains of Dover's Powder, (Pnlv : Ipecac, et Opii), to be administered at
once, aod repeated in two hours, if rest is not induced.
Continae Brandy and Chloroform Mixture, and repeat the Molasses and Salt Enema in the
morning.
July 24th. Says that he feels better, rested well during the night, having taken twenty
grains of Dover's Powder.
The Enema has been retained, and has not yet acted ; says that he feels an inclination to
•▼acaate the bowels.
Poise 76 ; Temperature of Hand, 37^.6 C. (99<».8 F.) ; of axilla, 38<*.4 C. (101<*.2 F).
This morning, for the first time daring his illness, the patient has complained of ** feeling
kmn^fry."
Examined the wound carefully with a probe, and extracted from the orifice, upon the
internal surface at which the ball entered, a flat piece of lead, about one-fourth of an inch in
diameter, the edge of which had come in contact with the radius, and was curled over, hav
ing evidently Impinged against the bone ; for small fragments of bone were impacted in the
lead. This particle of lead was most probably detached from the ball during its passage
tbroagh the thick plank ; the remainder of the ball, as before stated, passed entirely through
the fore-arm, between the radius and ulna. This fragment of the ball was surrounded by a
thick fibrous capsule. The edges and sides of the wound, upon both surfaces, the internal
aod external (points of entrance and exit of the ball), were much thickened and hardened,
and the bones along the track of the ball have evidently been injured. Owing to the severe
spasms, which attempts at even slight examinations, induced, a thorough examination of the
woood was not made until this time. The examination with the probe was not made when
the patient first entered the hospital, for he had been wounded several days, and the wound
appeared to be doing as well as usual in the most favorable cases. I made incisions upon
both surfaces, through the thickened tissues, and introduced a tent, smeared with Basilcoii
ointment, for near one inch in the track of the wound; painted the surrounding parts with
Tincture of Iodine, and ordered the fore-arm to be rubbed with the following liniment: R.
Cbloroformi. one fluidounce; Pulv: Campborie, four ounces; Tinctures Opii, four fluiil>
152 Observations on the Natural History qf Traumatic Tetanus.
ounces ,' Olei Olive, three flQldonoces ; disiolTe tl^ Camphor in the Chloroform and mix well
with the other ingredients.
Has taken no Chloroform since 3 ▲. h. this morning. Ordered^ that the Chloroform Mixture
be stopped.
Examination of Urine, — Deep Yellow Color, Sp. Gr. 1019. Heavy deposit of Urates and
Phosphates opon standing a few hours. Reaction, after standing twenty-four hours, strongly
allcaline.
This is a decided change from the previous reactions, which were always acid, and con-
tinued so for several days. Similar changes are characteristic of the urine in the paroxysms
of malarial fever.
No. 14. — AnalyttM of Urine pasted during 24 hourt^ July 23d|y 12 if. to July 24M, 12 Jf.
AmoaatandGon- Arerac* •■ooat
■tUutlOB of UriDe and CoBpoaitlea of
DMMd during M Urine pM«id cack
hoara. iMmr.
OBAna. eaAivt.
Amount of Urine 15,724.18 656.16
Urea 326.32 13.55
Uric Acid 20.83 0.85
Phosphoric Acid 17.79 0.74
Sulphuric Acid 23.97 0.99
Chlorine 107.79 4.49
Fixed ] Entire Saline Constituents 326.00 13.58
Saline VPhospatesof Lime and Magnesia ^ 22.20 0.1^2
Constitu'ts j Phosphates, Sulphates and Chlorides of Alkalies. 303.80 12.65
July 25th, 12 m. Last evening, at 8 p. m., the patient says that he had ** a very bad turn,"
'* felt as if I was all drawn up, stiff, and unable to breathe ; " and the muscles of the arm,
back and body generally were spasomed.
The retorn of the spasms appeared to be due to the discontinuance of the Chloroform Mix-
ture. The Chloroform Mixture was re-commenced immediately after the spasm ; forty drops
of this, with forty drops of Laudanum, produced some relief, and he fell asleep about mid-
night. This day he is quite comfortable. Pulse 76. The wound does not look so well ;
suppuration is somewhat diminished; urine light colored, with heavy deposit.
Continue the Chloroform .Mixture, fifteen drops every hour, and administer an Enema of
Salt, Molasses and Turpentine at once. The patient has been taking Brandy frequently, at
short intervals during the attack, averaging about eight ounces each day. His diet also has
consisted largely of .Milk Punch.
Nine o'clock r. ac. The Chloroform .Mixture has produced good results. Ordered twelve
grains of Calomel to be takeu at once, and to be followed with one fluidounce of Castor Oil
in the morning. Continue the Brandy and Chloroform Mixture.
Jply 26th, 12 M. The Calomel and Castor Oil produced the desired effect, and are still act-
ing; patient says that he feels much better. The daily introduction of a tent smeared with
Basilicon Ointment into the wound, has produced good results, causing the suppuration
and the evacuation of a deep-seated abscess between the wound and the elbow joint. This
morning this deep-seated abscess discharged suddenly, through the wound, several fluid-
ounces of pus, to the great relief of the patient. After this, the swollen parts of the fore-
arm, below the elbow, were sensibly reduced in sise. Pulse 80.
Eizamination of Urine, — Orange colored ; undergoes change rapidly, and gives off a putrid
odor, and in a few hours loses the acid reaction, and lets fall a heavy deposit of Phosphates
and Urates, Sp. Or. 1016.
With the improvement of the general symptoms, there have been eoneorrent and marked
changes in the urinary secretion, the color has diminished, and it has become more abundant,
33,666 grains having been excreted during the past forty-eight hours, and the acidity is much
less, and it more rapidly undergoes the alkaline fermentation.
Observations on the Natural History of Traumatic Tetanus.
153
No. IS. — Analytia of Urine patted during 43 hourt^ July 24M, 12 if. to July 21«f, 12 M.
Amoant and Com- ATermg« An't ATcrage Am't
ponlUon of Urln« sad OompotltloB uidOompoaltloii
puMd during 48 ofUrlii* during of Urloo poued
nooM. M boon OMh hoar.
OBAIMS. ORAIirt. OBAIKf.
Amount of Urine 33,665.12 16,832.56 701.35
Ure* 745.75 372.87 15.53
Uric Acid 16.63 8.26 0.34
PhoBphorie Acid 27.97 13.98 0.58
Solphnric Acid 26.41 13.20 0.55
Chlorine • 128.07 64.03 2.66
EqniTalent Chloride of Sodium 210.10 64.03 2.66
Fixed \ Entire Saline Constituents 508.40 254.20 10.59
Saline > Phosphates of Lime and Magnesia 46.40 23.20 0.96
CoPBtltn'ts J Phosp^es, Snlp*es and Chlorides of Alkalies 462.00 231.00 9.62
Nine o*clock p. m. Has been taking onljr ten drops of the Chloroform Mixture, each hour
during the daj, and has intermitted several times, so that not more than sixtj drops have
been administered.
The pains, and contractions, and spasms of the arms and legs and back hare commenced
again ; the diminution of the Chloroform has been attended with a return of the spasms. The
symptoms, however, have been verjr mild, and for the first time since his attack he has been
able to stand upon his feet, and to walk across the ward, supported on either side by assist-
ants. Pnlse 76. The purgative last administered has acted nine times.
Thirty drops each of Laudanum and Chloroform, with one flnidounce of Brandy, were
administered, and the Chloroform Mixture ordered regularly, ten drops each hour.
July 27tb, 10 o'clock a. m. Rested well after midnight ; all the symptoms appear to have
improved ; pulse 76 ; urine light colored.
Continne Chloroform Mixture, ten drops each hour.
July 28th, 12 o'clock M. Continues to improve ; the swelling in the arm has almost entirely
subsided ; says that he feels quite well, with the exception of stiffness in the muscles, and
some pain between the shoulders, and '' is hungry all the time." Pulse 84 ; bowels readily
moved by purgatives ; were moved freely yesterday, and " feel as if they would be moved
soon again."
Ezamination of Urine. — Light yellow normal color. Specific gravity, 1014.5. Heavy light
yellow deposit after standing twelve hours. This deposit forms a crust along the sides and
at the bottom of the glass vessels in which the urine is received, as in the urine excreted
daring the intermission of malarial fever.
No. 16. — Analysit nf Urine paued during 48 Aourt, July 26M, 12 if. to July 28M, 12 if.
Amount of Urine
Urea
Uric Acid
Phosphoric Acid
Sulphuric Acid...
Chlorine
Equivalent Chloride of Sodium
Fixed
Saline
CoBftitnents
Entire Saline Constituents
Phosphates of Lime and Magnesia..
Chlorides, Phosphates and Sul-
phates of Alkalies
AmoQBinnd Con*
poattlon of Urine
puMM dorlng 46
noon.
OBAIKS.
39.940.86
864.50
23.62
P7.53
23.75
189 13
310.16
371.62
39.12
Avengo Amount ATormgo Amount
nnd CompodtloB of nnd Compooltion of
UrlnnpuMdoMhSA Urine puMd eeck
hoar*. honr.
332.50
eaAiHt.
19,920.43
432.25
11.81
28.76
11.87
94.56
155.08
185 81
19.56
166.25
e&AOis.
830.01
18.01
0.49
1.19
0.49
3.94
6.46
7.74
0.81
6.92
P. M. Continues to feel "Quite comfortable." Complains only of a slight cough, and
paia in the muscles of the back — most probably the result of the severe tension of the mus-
cles during the previous spasms.
July 29Ui. Continues to improve, and walks, unaided, about the ward.
July 30th. Continues to gain strength ; wound looks well, and is rapidly healing. Amount
of urine excreted from July 28th, 12 m., to July 30th, 12 m, (forty-eight hours), Grains,
51fS06.70. Specific gravity, 1016 ; normal yellow color.
154 Observations on the Natural History of Traumatie Tetanus.
p. M. Has taken no Chloroform this day ; Brandy in small quantities has been adminis-
tered every three or four hours. Has experienced no ill effects from the cessation of the
Chloroform. Temperature of Axilla, 40^.2 G. (104^.4 F).
I was unable to assign any cause for this increase of temperature, as the patient manifested
no special increase of pulse or respiration, and complained of no febrile symptoms.
July 31st. Walks about; says that he feels perfectly well; tongue clean; urine normal iu
appearance ; has taken no Chloroform during the last two days ; takes nothing but n tea-
spoonful of brandy erery three or four hours.
August 1st, 12 M. Patient appears to be entirely restored. The improvement of the arm
has been very rapid ; the symptoms of irritation, inflammation and swelling have almost en-
tirely disappeared, and the wound is nearly closed. Takes no medicine, except a little
Brandy occasionally. Bowels moved regularly each day ; pulse 84 ; respiration 20.
The Intermittent action of the pulse has disappeared entirely, with the disappearance of the
spasms. Urine normal in color.
Specific Gravity of urine, 1013.
Reaction of urine, acid, when first passed, but it rapidly changes to the alkaline reaction
after standing a few hours. During the height of the disease, on the other hand, the urine
often retained its acid reaction for several days.
No. 17. — Analytit of Urine patted during 24 hours, July 31«<, \2 M.io August Ul 12 if. (24 hours,)
Amount of Urine
Water
Solids
Urea
Uric Acid
Phosphoric Acid
Sulphuric Acid *.
Chlorine
Equivalent Chloride of Sodium
Fixed \ Entire Saline Constituents
Saline !• Phosphates of Lime and Magnesia
Constitu'ts j Phosphates, Sulphates and Chlorides of Alkalies
_ - — — _
—
▲aoant and C<mb«
pMltioB or Urine
panad daring 14
Avaraffe Aaaaat
and CoaBpoaltloa «r
tjritia puaad aaek
boar.
OEAXMS.
QMAUn.
28.060.10
1,169.07
27,190.53
1,132.84
869.57
36.23
543.48
22.64
11.46
0.47
15.98
0.66
20.62
0.85
120.30
5.01
197.47
8.22
296.52
12.34
18.64
0.77
278.08
11.58
This patient continued to gain strength ; the wound healed up ; and he was sent home on
a furlough, ten days after the preceding observation.
This patient was treated in the General Hospital, Augusta, Ga.
The following obserratioDs and conclusions have resulted mainly from the study of
the preceding case ; and as this example should be accepted as a type of Traumatic
Tetanus, as occurring in Military and Civil practice, these observations and conclusions
may be regarded as general in their nature and application.
The enentiai phenomena of Injlammatton and Fever were ah$ent ; the symptoms
were exaggerated manifestatioM of jiervous and muscular actions, rather than remits of
structural alterations ; an irritation in a distant nervous branchy was propagated to the
spinal cord, and the disecue after its establislitnent^ appeared to be dependent upon an
undue excitability, and increcued action in the entire spitial ganglia as manifest^ in the
greatly exaggerated reflex actionx ; the disturbance or increased activity of the gtm-
glionic cells of the spinal cord, was reflected to the sympathetic nervous systev%, inducing
deranged action of the heart, obstinate constipation of the bowelsy and increased activity
of the skin.
TKMPKRATURB IN TRAUMATIC TETANUS.
Elevation of Temperature, dependent upon, and accompanied with increased chemical
action, is characteristic alike of Inflammation and Fever.
In the case of Traumatic Tetanus, now under consideration, there was iDcratfed
Observations on the*Natural History of, Traumatie Tetanus, 155
chemical change ia the nervous and muscular structures, without corresponding eleva-
doD of temperature. The temperature remained stationary or varied within small
limits from those of health, and the normal relations, between the temperature of the
trunk and extremities were preserved, and none of the perturbations of temperature
ebaracteristic of the various forms of fever and inflammation were at any time observed
iD this case ; whilst at the same time, there were great nervous excitation and muscular
action, and these actions were attended with marked increase of chemical action, as
nuiDifested in the constitution of the Urinary excretion. The slight elevations and per-
tarbotions of temperature may be accounted for, by the increased actions of the muscles.
I hare produced (as will be elsewhere shown,) similar slight elevations and perturbations
of temperature in aninials, by exciting tetanic spasms of the muscles, by the administra?
doD of strychnia, and by passing strong interrupted electrical currents through the spinal
axil. In these experiments as well as in the present case, the elevation of temperature
duriog the muscular agitation, was slight, and not at all like the great elevations and
changes, and in some cases depressions of temperaturo characteristic of Fevers and
lofljimmations.
The philosophical explanation of the remarkable phenomenon, of the existence of
active and increased chemical change in the muscles and nervous structures, without a
corresponding elevation of temperature, is that, the result of these increased chemical
actions, was the generation of the mechanical force of the muscular structures. The
force generated by the increased chemical change in the central ganglionic motor cells of
the spinal cord, excited the muscles to violent contractions, and was thus expended in
accomplishing mechanical motion, and was not therefore, manifested as heat. Without
thifl application of the forces, generated by the nervous and muscular apparatus^ heat or
some other mode of force would have been manifested. The correlation is thus estab-
lished in the living body, between chemical chatage, and nervous muscular or electrical
action.
In the elevation of temperature in Fever and inflammation, there is in like manner
iooreased chemical change, but it takes place chiefly in the blood, and results in the
development of hecU, rather than in the generation of nervous and muscular force.
And even when there are increased chemical changes in the nervous and muscular sys-
tems 10 Fever and inflammation, the resulting nervous and muscular forces are irregular
in their applicatiuu and manifestations,^ because the chemical chan'ges take place, as it
were, at random in all parts of the structures — in the blood, in the capillaries, in the
ganglionic cells, in the commissures and nerve fibres, and in and around the muscular
fibres ; and as a necessary consequence, the resulting forces, heat, electricity, and nervous
and muscular force, however great, cannot be correctly directed and applied. And hence,
the irr^ular and depressed character of the forces in fever and inflammation. According
t3 the view now presented, the muscular and nervous systems, are nothing more, than
apparatus, for the application of the forces developed by chemical change to the aooom-
plisbment of such results, as sensation, locomotion, ciroulation, excitation and con-
trol of secretion, by the control of the supply of blood ciroulating through the organs,
and by the transmission of impulses of physical force.
It is important to determine whether the absence of an elevated temperature be cha-
racteristic of Traumatic Tetanus ; for whilst the intrinsic value of carefully and honestly
recorded observations, is almost universally admitted, at the same time the importance
of deductions and general conclusions, must rest upon the universality of their applica-
tioD to the expression or explanation of physiological and pathological phenomena.
As far as my experience in civil and military practice extends, in those cases of uncom-
plicated Traumatic Tetanus, which recovered, as a general rule the temperature, as in
the case just recorded (No. 1,) was elevated but slightly above the normal standard, and
did not manifest the marked elevations and perturbations characteristic of the Pyrexiae
and Phl^masiae. This proposition will be still further illustrated, by the following
156 Obserations on the Natural History qf Traumatic Tetanus.
Coie No. 2 : TSraumatic Tetamu ; Treated with Bromide of Potassium and Cannabit
Indica ; Recovered,
G. E. I. — Negro coacbmfto ; age twenty -ooe years ; strong and well bailt. May Ttb, 1873,
received an injury, (penetrating wound) of sole of left foot ; wound healed, apparently, in
about one week.
May 24tb, lower extremities got wet whilst driring in the rain ; May 24, symptoms of Tetanus
appeared, riz : Trismus, difficulty in swallowing, and contraction of abdominal muscles.
Entered Charity Hospital May 27th. Jaws quite firmly locked ; speaks and swallows with
difficulty ; respiration impeded ; surface bathed with profuse perspiration ; the expression of
the face denotes great contraction of the muscles of the jaws (risus sardouicns). Abdominal
muscles contracted. Bowels obstinately constipated ; urine scant ; tongue coated. One-
third of a grain of Sulphate of Morphia was injected hypodermitally, and reputed at inter-
vals, bnt without apparent benefit. The muscular contractions of the muscles of the abdo-
men and back increased, with frequent spasmtt, and decided opisthotonos. Was thrown into
violent spasms whenever the attempt was made to lie oa the left side. The attending
physician placed the patient, on 3 1st of May, upon full doses of Bromide of Potassium and
Tincture Cannabis Indica: From half a drachm to one drachm of the Bromide of Potassium,
combined with from one to two fluiddrachms of the Tincture of Cannabis Indica were adminis-
tered every two, three, four and six hours, according to the severity of the symptoms.
Up to June 3d, the trismus, spasms and opisthotonos were well marked, and the patient
unable to sleep ; but the beneficial effects of the treatment appeared to be manifest daring
the night of the 3d, when the patient slept. On the 4th of June, the effects of the Bromide
of Potassium and Tincture of Cannabis Indica were still more decided ; the patient swallow-
ing with comparative ease, the spasms diminishing in intensity. On 5th June, had good
action from the bowels. Continues to improve ; spasms less in severity, and occur at longer
iniervals ; and the patient is able to sleep continuously ft'om one to two hours at a time. Con-
tinued to improve up to June 13th, when there was a slight increase in the severity of the
spasms ; and the intellect wandered, apparently from the long continuance of the Bromide of
Potassium, and Tincture Cannabis Indica. 28th of June, was able to dreas himself and
walk about the ward.
The following is the record of the Temperature, Pulse and Respiration :
June 5th, Temperature of the Axilla in the evening, 101^.4 F; Pulse, 100 ; Respiration, 48.
June 6, Temperature, a. m., 99^.8 F.; Pulse, 88 ; Respiration, 30. p. k., Temperature,
101^ F.; Pulse, 96; Respiration, 44.
June 7, A. M., Temperature, 99^.5 F.; Pulse, 92; Respiration, 34. p. k., Temperature,
100^ F.; Pulse, 84 ; Respiration, 38.
June 8, A. M., Temperature 99^ F.; Pulse, 84 ; Respiration, 30. p. m.. Temperature, 100®
F.; Pulse, 84; Respiration, 34.
June 9, A. M.. Temperature, 99 ®; Pulse, 84 ; Respiration, 32.
June 10. Temperature, 99*^.5 ; Pulse, 82 ; Respiration, 34.
June 11, Temperature, 99® ; Pulse, 86 ; Respiration, 32.
June 12, Temperature, 100® ; Pnlte, 84 ; Respiration, 30.
June 13, Temperature, 100®.5; Pulse, 86 ; Respiration. .34.
June 14, Temperature, 100®. 2 ; Pulse, 82 ; Respiration, 32.
June 15, Temperature, 101®; Pulse, 80; Respiration 32.
Juae 16, Temperature, 100®.4; Pul«e, 82; Respiration, 30.
June 17, Temperature, 100®.4; Pulse, 82 ; Respiration, 26.
June 18, Temperature, 100® ; Pulse, 80 ; Respiration, 22.
June 19, Temperature, 100®.4; Pulse, 84; Respiration, 28.
June 20, Temperature, 99®.4; Pulse, 82; Respiration, 22.
June 21, Temperature, 99®.4 ; Pulse, 80 ; Respiration, 26.
June 22, Temperature, 98®. 8 F.; Pulse 80 ; Respiration, 26.
The nrinery excretion was comparatively abundant, varying f^om thirty-two to sixty flnid-
ounces during the twenty-four hours. The specific gravity varied from 1025 to 1030. The
reaction was uniformly acid. The temperature and clinical notes in this case were taken at
my request, by Dr. C. F. Knoblauch, of New Orleans, at that time Resident Student, Charity
Hospital.
In the preoedin^^ case, notwithstaDding the existenoe of well marked synipConiB of
Traumatic Tetanus, the highest point which the temperature reached was ooly
10P.4 F.
Ome No, 3 ; Traumatic Tetanus ; Treated with Sulphate of Morphia and /Vvyri-
tives ; Recovery.
J. D., age twenty years ; cative of New Orleans ; laborer. Admitted to the Charity Ho*.
Observations on the Natural History of Traumatic Tetanus.
157
piul, June 4tb» 1873, with incised wouad of left foot, caased by jumping from a steamship
OD a nail.
Tbe iroo oail passed through the shoe. A piece of leather was taken out of the wound,
and tbe patient discharged on the 5th. Re-admitted to Charity Hospital June 19th. Patient
sajSf that after tearing the hospital, he slept in a low, damp room, on bare wooden floor ;
Jane 1 iib, experienced pain in the small of the back, radiating to back of neck, jaws and
side: Jane I8th, stiffness of jaws, slight spasms, difficulty in swallowing, restlessness and
sleeplessness ; 19th, Trismus ; tongue coated ; bowels obstinately constipated ; skin bathed
io profuse perspiration ; slight spasms excited by movements of any kind. The spasms
commence with a quiTering of one or the other leg. Urine scant and high colored ; intellect
dear.
Tbe patient was placed upon Sulphate of Morphia, from one-sixth to one half grain every
two, fear or six hours, according to the symptoms, Tbe effort was made at the same time to
keep tbe bowels open, by the use of purgative enemas and the internal administration of
CrutOD Oil. June 20th, Opisthotonos well marked, patient perspiring profusely ; the spasms
aod optstbotonofl continued with varying degrees of intensity, until the 5th of July, when
ther^ was marked improvement. The following is the record of the Pulse, Temperature
aod Respiration.
mnPIBA- TSMVBmVlTKSl
(
»ATx. 1 nruB.
TXOV.
AXILLA.
AMOUNT
or
BPBOIPIO
^■^ ^B^ ^k^ A ^Pte ^^ ^«
*#«
OBAVITT
REMARKS.
1873 * •
8
6
8
6
UJtIlfS VK
OP
accwa
A.M.,r.M.
i
1 80
▲JH.
P.M.
A. ■.
P.M.
PLmsouiron
umwx.
Ju« :fl>
luo r
Opiathotonos: Profuaa Perapiration: Triamus.
Profkiae Perapiration ; Bed dothea drenched.
21. 72 • M
22
22
101.5
1013
16
1024
2S| 90 < 92
18
24
102
993
18
1025
BowelH moved ; Proftue Perapiration.
23; 84 , 84
22
22
100
1003
16
1024
STmptonu mvtch the aame— Conatlpation.
Huaclea of Back greatly Ck>ntTacted ; body arched.
24 96 ' 86
24
28
100
101
16
1025
15 86 i 86
28
24
101
100
16
1025
Beatleaa and Anxlona ; aevere apaama of lega ; 'Jona'd
'i6 80 : 84
28
30
101
101
16
1025
Delirlooa doring night, with involuntary twitchi'ga
27 82 90
32
24
101
101
16
1025
Intellect clear; Opiathotonoa leaa; appears better.
i8 80 ; 86
22
24
100<5
101
16
1025
Slight improvement.
29 84 86
26
26
100.6
101
20
1025
Slept well daring the night.
30
84 84
26
24
99
100
10
1025
Contlnnea qniet comparatively ; Spaama leia.
JiJy 1
84 94
24
28
100
1003
30
1015
Mnaclea more relaxed ; Reaction of Urine Alkaline.
2
88 ' 86
24
26
100
100
28
1025
Urine haa been add up to thia date.
3
86 88
28
24
100
100
•^
1015
Opiathotonoa disappearing.
Muaclea of body and neck relaxing gradually.
4
88 88
28
26
100.5
101
48
1015
5
80 86
30
26
100.5
101
136
1025
Reapiration not so proAiae ; Urine abundant.
«
88 88
24
26
100
100
136
1025
Improving ; hasmorrliage from noae.
88 88
30
28
100
100
112
1025
Mnaclea relaxed ; improving ; Urine nbnndant.
fi| 88 86
32
30
100
101
48
1015
Gonvaleaoent, aufferi only from mnacnlar paina and
9; 88 86
28
28
100
101
72
1015
Ckmvaleacent. [atiflTnen in back.
10- 84 66
30
28
100
100
104
1020
Convaleaoent ; Spaama Opiathotonoa have diaappe^d.
ir 86 86
28
28
101 >100
120
1015
M U «« U
12 86 86
26
26
100 99
128
1015
U il «t U
13, 86 88
26
28
100
093
128
1015
Sat np in chair for four houra.
14
8h 86
28
26
100
993
75
1010
Continnee to gain strength.
15
86 86
26
26
99^
100
120
1015
Patient up 4nd walking around the ward.
16
88 86
28
28
100
100
110
1015
Patient up and walking around the ward.
17
86 86
84
26
100
100
88
1010
18
88 88
28
28
100
100
80
1010
19 88 84
28
24
100
99.5
86
1015
20' 84 84
26
24
99
99
64
1020
21 84 86
86
26
99
993
48
1085
22, 86
86
26
22
99.5
100
80
1015
23 84
84
84
24
100
100
72
1020
d4 84
80
22
80
100
100
64
1015
25 SO
80
20
80
100
99
04
1015
26
80
T8
20
20
993
993
64
1020
27
76
76
20
20
99
99
64
1020
•
28
76
74
20
20
993
993
64
1015
2»
74
74
20
20
993 99
44
1025
On ihe 31st of July, this patient was discharged from the hospital at his own request.
Tbe clinical notes of this case were taken for me, at my request, by Dr. William Martin,
of Xew Orleans, at that time Resident Student of Charity Hospiul.
Io Case No. 3, the highest poiDt of teraperatuFe reached, was 102° F., and this con-
tinued only for a short time. As Id the preoediDg cases, the temperature was but
slightly elevated above that of health, and the oscillations were confined within small
limits.
It is important to determine whether the absence of an elevated temperature be
cbaraeteristic of Tetanus, as observed by others.
158 Observations on the Natural History cf Traumatic Tetanus.
* ♦
That Hippocrates'*' had carefully observed the pheDomena of Traumatic Tetanns, is
evident, from the prognostic, or apnorism, that *' Spcum supervening upon a wound^ is-
mortcUy^ and '^ Such persons as are seized with Tet-anus die within four days^ or if
they pass these they recover ^
In those cases of Tctanos which Hippocrates recorded in his Treatise on Epidemical
Diseases, he not only makes no allusion to any elevation of temperature, but advocates
that form of treatment which is applicable to depression of animal temperature, as in
the following quotations from his works :
* Case No. 4. — ** Scamandras, in Larissa had a mortification in bit hip, and an abseeu of long
standing at the bone. A large incision being made, even to the bone, and nstion used after-
wards, a conTnlsion began the twelfth daj after the incision, and held him strong, reaching
from the leg to the ribs, and aflTected also the other side. The leg was sometimes contracted,
sometimes extended, and he had the nse of his other limbs, but his jaws were set. The
eighth day after the first conTnlsion, he died in another. The cure was carried on bj apply-
ing iPdfTii bottlea and fomentationt of taret to the yrhole body, not omitting a glyster ; bj which
the feces that had been long detained came away In a small quantity. He also drank a
hiltoui purge, and even a second ; f^om which, indeed, there was a discharge, but to no advan-
tage. After a little sleep, he took another »trong purge of the like kind, and in the eTening
died about sunset ; but in all probability might have held out a long time, had not the physic
been too strong for him."
Casb No. 5. — '^ Another received an insignificant wound to speak of (for it was not deep),
a little below his neck, behind, from a sharp dart ; which being taken out not long after, be
was drawn and distorted backwards, as in the opislhotonoi. His Jaws were also fastened ; and
if anything moist was put into his mouth, and he attempted to swallow it, it retured again
through the nose. In other respects he grew worse immediately. The second day he died.**
Casb No. 6. — *'The Master of a great ship had the fore-finger, and the lower hone of bis
riffht hand broke to pieces. An inflammation came on, a mortification and a fever. Th<^
fifth day he was purged moderately; the heat and pain abat.d, and part of the finger fell off*.
After the seventh, a little gleet came away ; and after this be said he could not pronounce hia
words plain. A prediction was made that that kind of convulsion which draws one back-
ward, would happen ; to which contributed the jaws being set and drawn down to the neck.
The third day the above mentioned convulsion seized him all over, and he sweated. The
sixth day after the prediction he died."
Cask No. 7. — Telephanes, son of Harpalu's freed woman, received a wound or bruise in his
great toe. An inflammation came on, with a vast deal of pain. Upon its abating, he went
into the field, and as he was going, a pain took him in his loins, for which he used bathing.
At night his jaws were set. and the convulsion that draws one backwards, seised him. What
he spit was frothy, and came from him through his teeth with diiBcuUy. The third dav be
died."
Casb No. S. — "Zeno, the son of Damon, had an nicer about the bone of the leg, or ankle,
by the tendon that was now grown clean. Upon the application of a corroding medicine, he
fell into convulsions of the opisthotick kind and he died." Hippocrates Upon .4i>, Wattr
and Situation. Epidemieat DiteaatM^ and upon Prognostics, Trans, by Francis Clifton, M. D.,
London, 1734, pp. 156, 167, 199, 200.
In the following directions for the treatment of Tetanus, it is Evident that Hippo-
* CEconomia Hippocratis, Alphabeti Serie Distincta. * * Anutio Foesio Mediomatrico
Medico Authore; Francofurdi, apud Andreie Wecheli h e redes : 1588.
The Works of Hippocrates, in Latin and Qreek, edited by Anutio Foesio, and published at
Frankfort, by Andrs Wecheli herdes ; 1595.
Hippocratis Coi Ascelpiade gentis sac re Coryhaei Viginti duo commentarti Zabniis illos-
trati ; Grs^cos Contextus ex doctis. W. Codicibns emendatns, etc. Theod Taingeri Baa
Studio et Conatn, Basilesfr Episcopioram Opera Atq. 1579.
Hippocratis Coi Aphorismi Graeci et Latind Johannis Henrnii. Rapheleogii. 1607.
Magni Hippocratis Coi Opera Omnia Graece and Latine edita. etad omnes alias Editionet
accommodata. Joan Antonidie Vander Linden, Doct. et Professoris - Medic Inae PrarticiP
Primi in jVcademia Lugduno, Batava, 2 vols. Lugduni Batavorum, Apud Danielem Abra-
hamnm etAdrianum & Qaashbeeck. 1665.
Hippocrates Upon Air, Water and Situation ; Upon Epidemical Diseases, etc. Trans, by
Francis Cliflon, M. D., London. 1734,
The Genuine Works of Hippocrates ; Trans, by Francis Adams, LL. D., 2 Volt., London.
1H49.
Observations on the Natural History of Traumatic Tetanus. 159
crates considered Fever as an unasual symptom in the disease, and as in no manner
connected with its production.
<' When the loios are in a tetanic state, and the spirits in the reins are obstructed bjr mel-
ancholic homoors. Tenesection will afford relief, but when, on the other hand, the anterior
tendons are stronglj contracted, and if there be sweats about the neck and face, extorted by
the riolent pain of the parched and dried tendons of the sacral extremity (these are very
thick, sustaining the spine, and giving rise to very great ligaments, which terminate in the
feet), in such a case, unless fever and sleep come on, followed by concocted urine and criti-
cal sweat, give to drink a strong Cretan wine, and boiled barley meal for food ; annoint and
rub with ointment containing wax ; bathe the legs and feet in hot water, and then cover
them up ; and so in like manner the arms, as far as the hands, and the spine, from the neck
to the sacrum, are to be wrapped in a skin smeared with wax ; this must extend to the parts
beyoDd, and intervals are to be left for applying fomentations, by means of leather bottles
filled with hot water; then, wrapping him up in a linen cloth, lay him down in bed. Do not
open the bowels, unless by means of a suppository, when they have been long of being
moved. If there be any remission of the disease, so far, well, but otherwise pound of the
root of bryonia in fragrant wine, and that of the carrot, and give to the patient, fasting early
in the morning before using the affusion, and immediately afterwards let him eat boiled bar-
ley meal in a tepid atate, and as much as he can take, and in addition, let him drink, if he
will, wine well diluted. If the disease yield to these means, so much the better, but if other-
wise, you must prognosticate accordingly." Tfu Genuine Works of ffippocratet. Trans, by
Francia Adams, LL. D., Surgeon. Vol. 1, p. 326.
AretAUB the Cappadocian, in his accvrate and el^nt description of Tetanus, makes
no mention whatever of fever amongst the symptoms ; and treats the disease whether
arising from wounds, abortion or excessive cold, as a disease of the nerves, and recom-
mends castor and assafcetida as anti-spasmodics.
Paulas .^Igineta, not only makes no mention of increased heat and fever, amongst
the symptoms, but quotes Pelops, to the effect that the most potent remedy fvr aU the
rnrieiies of Tetanus^ is a fever supervening when there was none at the commencement.
Hippocrates, Plato, Gklen, Horatianus and Avicenna agree in stating that a fever
coming on tends to remove the tetanic affection ; Ceelius Aurelianus however, seems to
question the truth of this ancient aphorism.
However imperfect and uncertain, the knowledge of the older medical writers may
have been as to the functions of the nervous system, it is evident from the opposition
of many to the employment of cold affusions, and the almost universal advocacy, of the
use of emollient applications, tepid and warm water and oil baths, soporifics, and such
anti-spttsmodics as Castor and Assafoetida, by Octavius Horatianus, Avicenna, Mesue,
Serapion, Haly, Abbas, Rhases, and other Arabian and Greek physicians, in the treat-
ment of Tetanus, that they regarded the disease as essentially different from fevers and
inflammations.
Thus A. Cornelius Celsus, treated Tetanus as a spasm of the nerves by local applica-
ttooa, by warm emollient baths, and by careful attention to the maintenance of a warm
carefully regulated temperature.
John Brown, in his '' Elements of Medicine," affirmed that
** Tetanus is an asthenia, and, therefore, always affects persons in a state of debility,
whether direct or indirect; and like every other asthenia, depends upon debility."
The treatment recommended by Brown, corresponded with this theory, thus :
*' We must, therefore, immediately have recourse to the most powerful and the most diffu-
sible stimoli possible, and continue their use without regard to quantity, not even to that of
opium itself, till the whole tumult of the disease is allayed." Elements of Medicine, DCLII.,
DCLIV., DCLV.
William Cullen, held that Tetanus is seldom attended with fever, and the blood drawn
in thiB disease never exhibits any inflammatory crust.
Dr. Lionel Chalmers,* refers the more frequent occurrence of tetanic complaints in
* ▲• AooovBt of the WMther and diicsMi of Soath Gftiolina, by Lionel ChAlmeri, M. D^ London, 1786 ; |ip. 23-31-
160 Observations on the Natural History qf Traumatie Tetanus. '
Autumn, to the lax and irritable or depressed state of the system, induoed by the effects
of climate.
Benjamin Rush* held that Tetanus
<* Is seated in the mascles, and, while they are preternatarally excited, the blood yeateU
are ia a state of reduced excitement. This is evident from the feebleness and slowness of
the poise. It sometimes beats according to Dr. Lining, but forty strokes in a minnte. By
stimulating the wound, we not only restore the natural excitement of the blood vessels, bat
we produce an inflammatory diathesis in them, which abstracts morbid excitement from
the muscular system, and, bj equalising it, cures the disease.'*
John Hunter, r^arded Tetanus as non-inflammatory in its nature, and as arising
from an irritable habit, but not such as is capable of producing inflammation.
In his observations on the treatment of Tetanus, John Hunter, lays down the princi-
ple that :
" The first appearance of cure, is a recovery of strength, as weakness is a pre-disposing
cause ; and the first indication should be to strengthen the system." Works of John Hunter,
edited by James F. Palmer, London 1837, vol. 1, pp. 583-^89.
Aooording to James Lind, Tetanus occurs most frequently in hot countries ; and
there appears to be no fault in the blood in such oases, nor an universal disorder in the
solids, preying on the vital organs, or debilitating the principle of life, this being merely
a local muscular spasm. An Essay on Diseases Incidenkdto Europeans in Hot Climates,
London 1768, pp. 257-259.
Dr. James Currie, who more than sixty years ago, advocated strenuously, and fre-
<(uently employed the thcnnometer in the Diagnosis and treatment of disea&t'S,
in that portion of his Medical Reports, which relates to the effects of water, warm and
cold, as a remedy in Fevers and other diseases, remarks upon the nature and treatment
of Tetanus :
<* It is deeply to be lamented that this disease should ever have been considered as of an
ioflammatorj nature, and that there are eren now, physicians who treat it bj ▼enesecUon.
It is in raj mind decisive against this supposition, that though the general system is so power-
fullj affected, the animal heai is not increased which, it uniformly is, so far as my obserTa*
tions ezteo 1 in all cases where there is an infiammatory affection of the system, whether
originating or terminating in local phlegmonic inflammation. The same consideration ia
decisive with me as to the supposed infiammatory nature of hydrophobia, a notion which
respectable physicians have lately revived. Of this most singular and affecting disease, I
have seen five cases, in none of which was there any increase of animal heat. All thes«
terminated fatally. Hydrophobia has some resemblance to tetanus, but is however in mj
judgment obviously and essentially different." Mtdical R^porU^ Phiiai.^p. 133.
The ca^es of Traumatic Tetanus reported by Benjamin Traversf in his Inquiry con-
cerning Constitutional Irritation^ were unattended by fever, and the blood presented no
marks of inflammation, and both his pathology and treatment are based upon the view
that It is es»esUiaUy a disease o/ /unction, and destroys by exhaust if m, if not by sadden
translation of the spasm to the heart.
The late Dr. Robert Bendy Todd, in his valuable article on the Nervous System, coo-
tainod in the 3d volume of the Cydopmdia of Anatomy and Physiology^ and in hia
more recent Clinical Irxtures on Diseases of the Nervosa System, held the view that
Tetanus consists not in an inflammatory condition of the cord and its membranes, nor
in congestion of them, but simply in a state of prolonged physical excitement ; the
natural polar force of the central ganglia, being greatly exalted, and kept so by the
constant irritation propagated to them by the nerves of the injured part.
Mr. O. Burne. states that amongst about two hundred cases of Tetanus, which he
had witnessed, not one was accompanied by fever.
Dr. John D. Jackson, of Danville, Kentucky, has given the details of an interestins;
• MMlcal InqalriM and OtwenrAtiont. Vol. 1, po ift6-2»7.
t A FAither Inquiry Concvrnlng OoiMtltotloQal IrritntloD, bj BemnmlBtfmwnL LoadoD, lS3ft, pp, tSfK Sas.
Observations on the Natural History of Traumatic Tetanus. 161
caw of Traumatic Tetanus, (Richmond and Louisville Medical Journal, November,
1^71, pp. 4vS4-493,) which occurred in a negro boy, aged 14, from a wound of the foot by
a piece of glass ; and in which the daily record of the temperature showed with the
exr(?pti()n of three days, the absence of anything like afebrile condition^ and that the
h-.^at of the patient "was rather snb-noruvd than the reverse." The highest point
nMohed in this case was 100^. F. on the 6th day, and the temperature of the axilla
from the 2.")th of August t^ the 8th of September oscillated, with the single exception
mentioned from 97 to 9i)°. F.
Dr. Jackson also states that in two other cases in which he had noted the tempera-
ture, it did not reach above 101°. F.
The number of recorded observations upon the temperature in Tetanus is very
limited, and we have searched in vain for accurate thermometric determinations in the
writin^rs of many distinguished Army and Navy Surgeons, as Pringle, Blane, Trotter,
H *nocn, Abernethy, Guthrie, Larrey, Baudons and Macleod.
The weight of medical testimony is therefore to the eflfect, that the symptoms of
F- r-r aid luji inifnafi'ja^ are almjst universally absent in Tetanus.
That in some cases of Traumatic Tetanus, the temperature is elevated considerably
ah ive the norm d standard, is evident from the following observations :
Cask 9, — Tranmitic Tetanus ; rapid rise oj Temperature a sJiort period before death,
M, B., laborer; native of Xew OrleAOS, ajje 21. Patient received Xovember 24th, 1873, gun-
shot wound through right foot ; the ball making a hole of about half an inch in diameter on
tho dorsum, and about two inched in sole of foot, metatarsal bone of big loe shattered. Edges
i>f wound ra^^r>d. Kntered Charity Hospital, November 2 4, a short time after the reception
of the wound. The spliuters of bone were removed as far as possible, and the wound dressed
with carbolic wash.
About nine days after the reception of the wound, viz : on December 3d, the patient com-
fii.iiiicd of pain in the foot, and stiffness of the jaws. The wound has never discharged
l.i i'{:ible pus, but has exuded an offensive sunious discharge. R. Tinct. Cannabis Indicas three
•! . llr.4;hn:; l*ovv4si:e IJromidi hilf oun^e ; Syrupi sim.iUcis four tluidounces ; tablespoon-
1 1! every 'i iiours. Decem'jer 4th. symptoms of Tetanus well m irked; trisu.is; rigid abdo-
ro.-.i : opisrhoionos; occasional spasms, p. m., Tem;>erature, 9J°. Respiration, 25.
I>e«em^)er Tith. Symptoms more intense, bowels obstinately constipated. Temperature of
Atilia in the morning, 0:i^. 5; Respiration 24. Urine scant, only two fluidounces during the
L'l nours. In the eveuin;^ the temperature of the axilla had risen to 108'. F. The patient died
af i o'clock A. M., the next morning, December <ith.
Tiie Clinical notes in this case, were taken at mv request, by Dr. C. Fred. Knoblauch, of New
U.-iHAfi-t, and at that time R.'sident Student of Charity Hospital.
In the pree'lin^ Ciise, it in worthy of note, that the case terminated fatally shortly
af'-r th" temp3r.ituro rcachjJ lOS^. F. It is probable that the temperature of the
iiiu_rnal organs, was between 110 and 111°. F.
r'v-^E 10. — Tt-'tntniftr Tcfanus ; rapid rinp of T'inp!iratare, sud'len fatal termination.
Ii''porf*id bj/ Dr. Y. R. L^Monnier^ of New Orlean$.
X. a^p 2ft years, brick-layer; entered Hospital Pitie, Salle Si. Louis, Paris, June 22nd,
I- . »; dii d, July luth. 18 ;:♦. This mm enterL-d the HjspitaL, for a dislocation of the thumb
• .*' the ri^ht haul, with a perfoiMiion of tbe bo.'ie thro'i^h the skin. The dislocation had
»i .Mj rel'K'el, ati 1 the wouo'l was healin;^ kinlly, when on the evening of the 7th of July,
•. \\y of injury,) th' first symj>:oms of tetania showj«i the nselves by an inability to com-
iM itMv open the mouth. VViien wo saw the p.itient for the first time in the morning of July
' 'I, a*« lilt H ho'irs after the appearance of lii3 tir-«t sym >toms of Tetanus, opium and mor-
P line, f«y the miuth and sub 'utaneously, had b"en freely administered. It was resolved to
•j'»' w.»orara by subctitan -ou-* injections. At 9 v. m.. the axillary temperature 103°. 8 ; at 10
' * \. M. when the tirst injection of woorara was male, the pulse was 121 large, and com-
'. ^-^^ible; Rectal temperature 1oJ)°. h F.; Respiration 40, short and intermittent. The spasms
r • irred every two or three minutes, bv.'tween which the patient was a'lle to rise and flex the
« '. r'*mUiei, and also to clrink and urinate. The temperature was very high during the last
.: • hoan. The patient died on the 10th of July; at the hour of death the pulse was 1<>8
a'ld thready; respiration 44, and diaphragmatic, face cyanosed ; general muscular con-
tractions less m irked at inferior extremities; pupils dilated; skin intensely hotto the
162 Observations on the Natural History of Traumatic Tetanus.
toach, and apparently from 108®. to 110®. F. Having obuined no yedatire elTeeta from
the subcataaeous injections of woorara, marphine in the same manner was again used on the
last daj, Jaly 1 0th.
The following tables show the nambsr of sabcutaneon? injectioiifl of Woorara, and the
state of the Pulse Respiration and Temperature on July 9th :
10:45 A. K., two Sub. C. Injections Woomara } grain, each in fifteen minims of water.
11:47 A. M., two Sub. C. Injections Woomara | grain, each in fifteen minims of water.
No marked effects, spasmi continuing.
9. A. M., Poise, ; Temperature Axillary, 103®. 8; Respiration, — .
10:50 A. M., Pulse, 124; Temperature Rectal, 106®. 8; Respiration, 40 per minate.
11:20 A.M., Pulse, 120; Temperature
12:15 p. M., Pulse, 118; Temperature Rectal, 105®. 8 ; Respiration, 44 per minate.
12:30 p. M., PuUe, 116; Temperature Rectal, 105®. 4; Respiration, 42 per minate.
1:20 p. M., Pulse, 112; Temperature Rectal, 105®. 4 ; Respiration, 40 per minote.
1:45 p. K., Pulse, 114.
The temperature continued to rise, and the pulse to increase in frequency, and at the mo-
ment of death, on the 10th of July, it was edtimated that the temperature ranged between
108® and 110° in the rectum ; the pulse was 168, and thready ; respiration 44, and diaphramatic.
Dr. Le Monnier desired to determine the changes of temperature after death, but throagb a
mistake, the body was removed immediately from the ward.
Post-mortem^ twenty-four hours after death. Dr. Le Monnier was not present at the pott
mortem examination, but the following is the result as given to him by M. Le Prof. Broca,
attending surgeon. The brachial portion of the spinal cord was altered and softened down into a
eream-Uke substance ^ for a distance etteniinj from the fourth to the sixth ctroieal nsroeSj right side.
The anterior or motor roots of the nerve in this portion of the cord were also altered and
softened, whilst the posterior roots appeared to be normal. The softening was most marked
at the roots of the fifth pair.
The Tetanus was caused by an irritation of a collateral branch of the median nerve of the
thumb, excited, apparently, by friction ai^aiast a rough, bony surface on the external side of
the inferior extremity of the thumb. This extremity had been dennded by the accident. The
head of the metacarpal bone, at its palmier surface, was partly fractnred.
The case just recorded, is important in that an elevated temperature and rapid, fatal
result in Traumitic Tetanus, wore attended with rapid circulation and raspiratioQ, and
with inflammatory softening of the cervical portion of the spinal oord.
Dr. Le Monnier informs me that he observed a similar condition of the spinal cord
in one of his dogd, which died from the effects of Traumitic Tetanus, caused bj a
penetrating wound of one of the fore-legs. Although the temperature in the animal
was not accurately noted by the thcrmomoter, it nevertheless appeared by the sense of
touch to be considerably elevated above the normal standard.
Cask No. 11. — M Prevost, of Gvjneva, had a patient, a boy twelve years of age,
afflicted with Tetanus, which was accompanied by an extraordinary development of
heat. A thermometer placed in the axilla, was raised to 110^.75 F. If the original
temperature be reckoned at 98^.2, there was an elevation of 12^.5 Fahr.
Cask No. 12. — In a case of Traumatic Tetanus described by Dr. Bright, the tem-
perature in the axilla on the third day was 105^. F.
Casks 13 and 14. — Dr. Jamt^s Copland* observes, that the "amount of animal
heat necessarily varies in different cases — ^probably from 100° to 106®. F. I observed
it 105.5 in the axilla on the second day of a case, which terminated fatally oo tlie
fourth day, and 106° in another, which died on the third day." After a careful exam-
ination or the entire article on Tetanus, by Dr. Copeland, we have failed in finding any
accompanying observations which would enable us to determine whether or not there
was any fever or inflammation preceding or accompanying the Tetanus, which would
account for this increase of animal heat. According to Dr. Copland,
*' The pulse in Tetanus has been variously described by different authors. This has been
owing chiefly to the different states of the heart's action in the several sutes or stages of the
disease, and the varying grades of frequency in th * acute and sub-acute cases, as well m,n in
the idiopathic and symptomatic forms of the malady. Dr. Morrison, Uenneo, Macgregor and
others, have remarked that the pulse is seldom much effected ; but the greater naniber ef
writers have stated the pulse to be very much accelerated, and most remarkably to in acnta
• PicOoMiy of PmcUaU Medicine. Hew Torfc ; lftS9. Vol. ill, p. llOi.
(X>$ervati(mi on the Natural History qf Traumatie Tetanus. 163
eaaet. This is the resalt of mj owo obserTation in the Dumerons cases which I bare had an
opportunity of obserying in France and Germany, in 1815 and 1816, and subseqnently in
warm climates. In an acute case which I attended in 1820, the palse was 120 in the minute,
in the first day of the developed attack. The patient died on the third day. The pulse is
generally much less frequent during the intervals than in the paroxyEms, but the degree of
frequency varies in diiTerent cases, as well as in the course of the diEcase. The treatment
adopted has often a considerable influence in quickening the pulse, and towards a fatal issue
ibis is especially the case. The changes taking place in the spinal cord, medulla, etc., and
their membranes, according to their nature and amount, also influence the pulse. As the
powers of life sink, or are depressed by sedative agents, as by tobacco injections, etc., the
palse becomes remarkably quick, and often feeble. Both the pulse and respiration are greatly
accelerated by the spasms, and hence are varied in character and in quickness, with their
severity and frequency of accession. During their continuance, especially towards the close
of the malady, the pulse is often so frequent, weak and irregular as not to admit of being
accurately counted, while the respiration is labored, or gasping." p. 1104.
Thomas Blizard Curling, in bis valuable Treatise on Tetanvs, says that:
" It is true that in some instances, even of the traumatic form of the disease, fever has been
present, and the blood has been found cupped and buffed ; but in nearly all such cases the
symptoms of Tetanus are independent of those of inflammation. The latter sometimes co-
exiatiDg with the former, but arising from distinct, and often accidental causes, as in case 10,
in which the wound was so severe as to occasion inflammation at the seat of the injury ; or,
as in case 89, where pleuritis supervened after the accession of the spasm. It will, however,
be shown hereafter, that tetanic symptoms may result from inflammatory action in the
medalla spinalis, which rarely occurs in the traumatic, but is occasionally the cause of the
idiopathic disease.
Inflammation and fever, therefore, when present, must not be viewed as the necessary
effects of the spasmodic disease." Treatiieon Tetanus; Phila., 1837; p. 19.
Cases 15 anb 16. — Ir a case of Traumatic Tetanus, wbicb occurred in the prac-
tice of Mr. T. Holmes, of London, (reported in the article on Traumatic Fever, by
Mr. John Croft; System of Surgery, 2d. Ed., Vol. 1, pp. 297, 299), the disease
appeared whilst the patient was suffering with traumatic fever, consequent upon a spike
wound of hand. The temperature declined from 101°4 F., on the third day, to 98°6,
on the fifth day ,when it gradually rose to 102°.4, on the sixth day, when Tetanus super-
vened and proved fatal, on the evening of the seventh day after the reception of the
injorj, when the temperature had reached 104°.8 F.
Id this case, the temperature had commenced to rise before the appearance of Tetanus,
and it is impossible to determine, from the meagre report of the case, whether the
progressive rise after the appearance of tetanic spasms, was due to the supervention of
this disease. It would be more reasonable to refer the rise of temperature to the same
causes as those which had induced the traumatic fever, for in another case, (which
occurred in the practice of Mr. Holmes, and which is quoted in the same work), of
trauroattc fever, caused by a gunshot wound of the hand, the temperature stood at
102^.4 F., upon the evening of the second day, and then rose to 103^.6 F., on the morn-
ing of the third day, when trismus appeared. The temperature fell, upon the evening
of thu day to 10(1°.4 F., and rose again to I02°.6 F., on the morning of the fourth
day, descending in the evening to 101^.5 F., and continuing to descend and falling to
lOO^'S F., on the morning of the fifth day, and rising again to 102°. 8, on the morn-
ing of the sixth day, and with slight oscillations, descending to the normal temperature
98^.2, on the morning of the 14th day, when the trismus us well as the traumatic
fever disappeared. If the oscillations of the temperature in these two cases of wounds,
in which Tetanus supervened upon Traumatic or Hectic Fever, be compared with the
tbermoroetric record in the same work, only negative inferences can be drawn as to the
effects of Tetanus in increasing or diminishing the febrile excitement. More extended
and critical observations are needed, before the relations of the traumatic spasm to the
rise or fall of pre-exisiing Hectic Fever, can be accurately determined. Thus, it is
very evident that the rise of the fever in the first ease, might have been due to other
causes, as the extension of the irritation to other organs, and to an increased absorption
and diffusion of the inflammatory products. Precisely similar oscillations of tempera-
164 Observations on the Natural History of Traumatie Tetanus.
tare have been recorded in cases of Traumatic Fever, in which no tetanic symptoms
supervened.
Wunderlich, first drew attention to a peculiar symptom, which has been since con-
firmed by several observers, (Billroth, Leyden, Ebniier, Ferber, Erb, Quintko, and
Monti V, namely, that in the last stajros of fatal nenrosos,and more particularly in tetanus,
although met with in very many othor disorders of the nerve-centres, (of the brain, )
the temperature begins to rise, and rises in the briefest space of time to extniordinary
heights; to heights indeed, which are only exceptionally reached in diseases which ar<»
of distinctly febrile origin, sometimes to 4:5'^ V. (1()I)°.4 Fahr.) nr even to above 4P ('.
(111°.2 Fahr.) and in one ease of Tetanus to 44°.75 C. (112''.rK) Fuhr. ), wliich in
usually si!cceede<l by a still farther post-mortem rise of temperature, amountinjr to a
few tenths of a degree. Fifty-seven minutes af)er death, the temperature in tho c;im»
of Tetanus observe<l by Wunderlich, amounted to 4r)°.:n5 V. (li:r.(;7r> F.ihr».
l^hmann, noted 4 t°.4 ('. (111°. 9 F. ), in a case of tetanus just before death. Her
Hofrath (^ifttrberfjn\, Professor (»f Vetinary Surgery in Dopart, inft»rmed l*n»frs>or
Wunderlich, in a letter, that he had observed temperatures of above 42° C. (ItiT^.t)
Fahr.,) in fatal cases of Tetanus in Horses.
Such elevations of temperature have been but rarely observed in disease : Currie
found a temperature of 44°. 45 C. (112° F. ) in a cnse of Scarlet Fever; Simon observed
44°. 5 C. (112°.l F.) in a wise of Variola lIj\»morrhagiea, although, indeed the t«*mpe-
rature was taken after death; Quincke 44°. 3 C (111°. 74 Fahr.,) in a case of Acute
Kheumatism ; Brodie in a case of destruction of the lower cervical portion of the sj>iu:il
marrow, 43°.9 C. (111°.02 F.) W^underlich has seen several similar cases to that «»f
Brodie, where the temperature reached 44° C. (111°.2 F. ); and Dr. Woodman, tb«»
English translator of the work of Wunderlich, has recorded some fatal cases of ScarK'l
Fever, in which the temperature amounted to 115° F. ( UJ°.l C.) In two cases of
Pneumonia, which recovered^ under my treatment in the Charity Hospital, during tlu'
Winter of 1873, the temperature in the axilla reached I0i)°, and was probably about
112° F. in the inticrnal organs. These cases were of interest as illustrating the fart.
that this degree of temperature is not necessarily fatal. I have observed a temjH*ratuie
of 108°. 5 F., and over in the axilla in a case of Yellow Fever, which terminated fatally
shortly after this high degree of heat was reached. The delirium and restles>nes^ **\*
this patient, preventt'd the thermometer being well held in the axilla ; the actual tem-
perature was therefore somewhat above 108°, and probably reached from 110° to 1 !.'>*,
in the cavities of the heart. Dr. William Arnold has recorded a temperature of llO^
F., in several fatal cases of Yellow Fever. In a case of Small- Fox attended with violent
delirium, and with expansion of one ])Upil and contraction of the other and which
terminated fatally, and which occurred in my private practice during the month of
April, 1H74, the temjterature just before death as indicated by placing the bulb \A' thi*
thenuometer between the scrotum and the thigh, was 110^.5 F. The teniptratun' of
the internal organs in this case pn bably reached lllJ"' F.. and over.
Wunderlich* conceives, that the \ery high ten.peraturcs ohKTVed by hiuiM'lf and
others, with the e<jually extraordinary high ti ni] eiaturcs, \\hi<h are oIlmtvi d in li>.^ue
changes of the braiu and upfer jart of the ^pinal core!, ajpiar to }»how, that tlure aro
moderating centres or apparatus in the brain, the paraly?»ir* (»t which is succei d< d b\ .i
morbidly increased action of the firoccssis which prcduce wannth. This olHr\aii('ii i-»
of practical importance, b(<-auhe it indicates that any c<'il^i(leIaMe elevation of tenipi fu-
ture in patients sufiering from ncures<s, when no ] articular reason can be a^^il:u(d \*'T
the fever, which is developed, affords the worst possible progno>is.
It n.ust be observed, however, that these ol'bervaii(»iis of Wunderlieli and uth*rs,
relate onlv to the last stage of fatal tetanus.
In the case reported by Wunderlich in which the temjeraturo reached 44°. 9. a .•^ln-rt
time before death, the disease was of six days duration, a!»d during the fir>t five daxw
• On the Temperature in DiseftRc? ; a mnnual of Medical Thiniioniclr}-, bj Dr. C. A Wurd* r*
Ucb. TruuF. New ^'ytl. Sfoc, London 1871. pp. 204-42.').
Observations on the Natural History of Traumatic Tetanus. 166
the temperature was not above 37°. 6 C. Thus in this case in which the temperature
had remained at the normal standard during the first five days, in the last hours of life
increased 7°.3 C, and fifty-five minutes after death, the temperature was still more
I'U'vated, rcachinpr 45°. 5 C; and in one hour and a half after this observation,. the tem-
}M.Tature descended to the point at which it stood at the moment of death, viz: 44°.9
('. It has been shown by the experiments of Bernard and others, that in warm-blooded
animals, a temperature ran^ring between 45° and 46° C, destroys the contractility of
the muscle^; thus mechanically as it were causing death, by the arrest of circulation and
n^piration. And Kiihne has shown that the rigidity of the muscles is due in such
(■:iM> to the coagulation of a speeial constituent. In a case of Tetanus observed at the
Il4<>|iital Pitit', by M. M. IVte.r,* the temperature remained normal (37°. 3 C.) during
\\w tirst five days, although the pulse was 12(); on the morning of the sixth day difli-
culry of respiration and asphyxia, commenced and the temperature was elevated 3°
|o .:^ . in tight hcmrs, and the pulse was only lOd; during the next ten hours the
t« »i|^trature rose to near 1° C. (41° C); in eleven hours and five minutes, at the
nioiuent of death when the patient was fully asphyxiated, the temperature was 42° C.
The sudden and rapid rise of temperature in Traumatic Tetanus, near the fatal termi-
nation may ha referred to the following causes :
1st. To the effects of the violent muscular contractions and agitations.
2d. To impeded respiration, causing, a less rapid cooling of the blood in the lungs
h\ the inspired air and by the loss of caloric in the expired air ; and also causing the
r»t«ntion of carbonic acid, which deranges the normal chemical changes of the consti-
tuents of the blood, and excites abnormal actions in the muscular and nervous systems.
3d. The supervention of inflammation of some one or other of the internal organs,
but more especially of the Lungs, as in Pneumonia,
4th. The translation or extension of the irritation of the gray matter, and especially
that portion in connection with the motor nerves, into true inflammation, attended with
^'•^teuing of the nervous structures.
5th. The extension of the irritation from those portions of the spinal cord especially
<>Hjriected with the reflex functions, to those ganglionic centres within the brain and
^jimil cord which regulate the production of animal heat.
Gth. The extension of the irritation, to the sympathetic or vaso-motor system of
fi»nvs, either through the branches connected with the diseased structures, or through
a n'fl»'x action from the cerebro- spinal axis.
7th. The chemical and physical alteration of the blood, either by the perverted
aitions uf the muscular and nervous systems, or by the generation within the living
s.-tt-m of some poison which acts as a ferment, or by such impeded elimination of the
♦ l.-ratuts of chemical change, as leads to an alteration of the normal cycles of chemical
C'Oibinations and decompositions of the blood.
It mi^ht at tirst be supposed that the 7th and last hypothesis, was sustained by the
fa t that in certain cases of great elevation of temperature at. the moment of death, the
i*^fn|K-rature of the body had slowly risen, a degree or the fraction of a degree, during a
"'lort period ; but this sli<:ht pust-mortcm rise, may be explained by the sudden arrest
<t ihf re^pi^^tory process, and also to a great extent of the transpiration from the surface,
tlius favoring an accumulation of heat within the body.
The rise of temperature, is most probably due to the causes stated under the third,
fourth, fifth and sixth hypotheses.
There arc facts to sustain the fourth hypothesis, and in a subsequent portion of this
iQvr>tigation, we will show by the results of pcst-morttm examinations, that the spinal
'•rd. and even portic ns of the l»ia!n undergo structural alteraticn in many fatal cases of
T» ranu.s ; and we must rtjiaid (he rise of ttmperature, as not characteristic of Tetanus
a* a disease^ (that is, for example, as certain oscillations of temperature, chraraterize
Malarial Fever, Yellow Fever and Small-Pox. and distinguish them fiom each other
* Cw«U^ H.elj^Qtnad^ire, 26 Janvier 18 T2, p. 54.
166 Observations on the Natural History of Traumatic Tetanus.
and ftom all other diseases,) but as iDdicatiog stractaral alterations in certain portions
of the Cerebro-Spinal Nerroas System or in the Lungs.
Such observations therefore, do not invalidate the proposition, which we have endeavored
to maintain by an impartial examination of the testimony of the best writers, as well as
by our own direct observations, that Traumatic Tetanvs is not rteceManly accompanied
by ftver^ that it is not related to the Feftrife Diseases ; and at the same time it dfffers in
some, important sympto^is Jitm frve ivjiammatioft. The rapid rise of temperature
observed in certain cases of Traumatic Tetanus, is evidently a phenomenon engraAed
upon or added to the uncomplicated disease.
The weight of testimony, ancient and modern, sustains the view, that in unc< mpli-
cated Traumatic Tetanus, /ever, (rapid pulse, rapid respiration, nervous and muscular
prostration, and great elevation of temperature), is, as a general rule, absent; and when
present, the increase of temperature cannot be referred to the special condition of the
nervous system characterizing this disease.
The establishment of the proposition, that Traumatic Tetanus belongs neither to the
Pyrexiae, on (lie one hand, nor to the Phlegmasia^, on the other, whilst under certain
circumstances, both fever and inflammation may be engrafted upon it, has an important
bearing upon the treatment of the disease.
PORTION OF TBI NEBVOUS SYSTEM INVOLVED IN TRAUMATIC TETANUS.
In the first case of Traumatic Tetanus, which we have regarded as typical of the
uncomplicated disease, the Intellect remained clear and unaffected during the entire
progress of the disease.
All observers, ancient, as well as modem, agree, that in Traumatic Tetanus, the
intellect is unaffected, and that delirium, stupor or failure of the intellectual faculties,
appear only in the general exhaustion and failure of the powers which in some cases
precedes death. As is well known, a large proportion of fatal cases terminate suddenly
during the violent spasms, from the sudden arrest of the respiration, whilst the intellect
is unimpaired.
The peculiar expression of the countenance in Tetanus, characterized by the wrinkled
forehead, contracted eye-brows, partially open eyes, dilated nrstrils, partially open mouth,
with the angles of the mouth drawn backwards and a little upward.«<, expohing the teeth,
is manifestly dependent upon the involuntaiy contractions of the muscles of the face,
and the expression of uneasiness und apprehension is not dependent upon mental dis-
turbance.
Even in the remarkable case recorded by Professor E. Gcddings in the Charleston
Medical Journal, July, 1852, although the tetanic spasms appeared to be caused by
the fracture and depresHion of the cranium, and was relieved by trephining, and eleva-
tion of the bone, the di^eose was unattended by cerebral disturbance.
Dr. Geddings acknowledges his indebtedness to Dr. H. R. Frost for the following
notes of this case :
Case 17. — Tra umat ic Teta n us.
On ibe iTth Aagupt. 1P51, Mr. M-^ rece'iTed a eevere blow on the nppfr part of the right
side of the forehead, with the end of «d iron beUjipg pin, mhirh was ihrown st him, end
foremost. The scalp was divided to a limited extent, and, as was ^ubtequently difcovered, (he
craniun fractured and driren down upon the dura^niater.
As no nnplensant symptom?, except those of an evane>cent character, were manifested, the
case was submitted to simple treatment, and the wound continued to heal kindlj for seTerml
days, although it was found on introducing a probe, that the bone beneath was denuded.
On the I3th day after the injory, a feeling of uneasiness was experienced about the jaws,
with a stiffness and inability to open the month. The B)mptom8 of Traumatic Tetanua thus
declared, extended by slow steps to the muFcles, tongue, neck, shoulders and back ; to the
diaphragm and abdominal muscles; and those of the hips and thighs. On the I7ih day tba
Jaws wera so firmly closed, that he could not vasticatc, and tha loognc felt so large and atUT
Obiervations on the Natural History tf Traumatic Tetanui. 167
that he coald scarcely protrade it from the moath. Sitting at the table he was seized with
pain in the shoulder of one side, which seemed to stretch across to the other; pain at the
scorbiculns cordis next succeeded, which extended to the muscles of the small of the baclE
and legs. The muscles of the face, particularly about the eye-brows, were also much
affected.
AH the abore symptoms gradually increased in intensity, until the 12th of September,
thirteen days from their inception. The mental faculties even at this late period, were not in
the slightest degree disturbed, but the nnfortunate patient was under the full influence of
general opisthotonos. He complained of extreme we.ikness of the knees. The mouth was
half contracted ; the jaws rigid, a sense of spasmodic contraction extended to the throat,
attended with a feeling of choking. There was also pain in the back, increased by the fre-
quent tonic spasms ; rigidity of the abdominal muscles; frequent spasmodic contractions of
the muscles of the face, impressing upon this countenance that peculiar expression of distress
so common in Tetanus. The skin was covered with a profuse perspiration, but there was
neither pain in the wound nor head.
The opiate treatment which had been previously instituted, with light diet, was still con-
tinued, but without manifesting the slightest control over the symptoms. The diet consisted
of arrow-root, thin broth, etc.
Daring the afternoon the spasmodic contractions grew more violent and alarming. While
reclining on a bench, he was seized with such violence as to be thrown upon the floor, from
which he was unible to rise. The family greatly alarmed at this, sent for the attending
physician, and on entering the room, the patient was found to be affected with violent spas-
modic action of the whole body, manifested particularly by twitches of the face, rigidity of
the muscles of the back, abdomen and the system generally, with tonic contractions of the
muscles of the lower jaw ; pain at the scorbiculns cordis ; a profuse and general perspira-
tion— the pulse being about one hundred, and irregular.
At this juncture, Prof Frost, feeling that merely medical treatment could be no longer
relied on, requested the aid of Professor Qeddings in consultation. Professor Geddings
found the patient very much in the condition described above. The tetanic spasms, which
were general, and somewhat violent, were of frequent occurrence, being called into action by
the slightest effort to move or speak. The mind was clear, however, and unusually calm ;
the pulse was hurried, feeble and irregular; the respiration embarrassed by the frequent
recurrence of the spasms ; and the whole surface cold, and covered with a profuse, clammy
sweat. A wound of limited extent occupied the scalp, upon the upper part of the right side
of the forehead, on probing which, Prof. Qeddings found the bone beneath denuded, and im-
plicated in a moderately stellated fracture, and depressed considerably below the natural
level of the centre of the fracture, so that the sharp spicula encroached upon the dura mater,
and compressed the corresponding portion of the brain.
After conferring upon the nature of the case, it was determined to perforate the cranium,
and elevate the depressed bone. This, Professor Geddings proceeded to do immediately, in
the following manner: An incision, with two branches, so as to form a small obtuse-angled
flap, was made through the scalp down to the bone ; the flap was turned up ; the pericra-
niuna was detached to the requisite extent, and the edge of the undepressed portion of the
bone cautiously perforated with a small trephine. This done, an elevator was passed
through the aperture, and all the depressed portions of the bone were in succession elevated
to their proper level, while the smaller detached fragments and spiculae were removed. The
flap was then adjusted, and secured by adhesive slips, and cold water dressings directed to be
applied continuously.
Before the dressing was completed, the patient expressed himself greatly relieved. His
countemtnce became more composed ; the spasms were relaxed; the twitchings were much
mitigated ; the respiration became freer ; the pulse, which was before frequent, small and
irregular, now became more expanded ; and instead of the cold and clammy surface, a gen-
eral warmth diffused itself over the whole body. He was put to bed, an anodyne prescribed,
and all visitors were excluded. Directed to be confined to water, tea, arrow-root, etc.
September 13th. In the morning Professor Frost visited the patient and found his aspect
DQcb improved. There was no longer any excitement, or general spasms ; had rested quietly
daring the first part of the night and slept towards morning ; pulse, 88 ; breathing, easy ;
jaws still contracted; but the spasms of the other portions of the body, much abated in vio-
lence ; no pain of the head or in the wound ; had taken nourishment and expressed himself
much better.
Afternoon. No increase of spasmodic symptoms ; general feeling improved ; slight fever ;
palse, 100.
Utb. The tetanic spasms still gradually subsiding. The night was spent for the most
part, io a state of sleepless disquietude, but some sleep was obtained towards morning. The
paUe, 80 ; slight heat of skin ; with trifling soreness and pain in the wound. The spasms
•ccaaiooally recar in the muscles of the back, in those about the eyes and face, and his jawa
ids Observations on the Natural History of Traumatic Tetanus.
CED be only partially separated. lie moves bimself freely in bed ; assists tbe nurse in
adjusting bis position, and feels so macb better, that lie craves for animal food ; but his diet
is still restricted.
Afternoon. Condition of the patient nearly the same ; pulse, 80 ; spftsniodic twitchings still
take place down tbe back with rigidity of the jaw ; wound partially united and healthy.
I5tb. Improvement progres>ive ; spent a comfortable night ; puUe HO, nnd regular ; slight
twitches still experienced in the back. Afteruoon ; no uufavorahle changes, wound healing.
From this time, tbe patient continued to improve without interruption, aud by tbe r.'ib day
after tbe operation, the tetauic symptoms bad entirely subsided.
In the preceding case, the tetinic spastns, were diniiiiisheil in intensity, but not
immediately and completely removed by the operation, and in tact the .symptoms <lid
not subside until the 19th day after the operation. Tbe tetanic apasni.«< were c;iusr<l,
either by the direct pressure of the fractured botie upon the brain, or by the transmi.^-
sion of the irritation to the medulla obloiipita and spinal cord, throiiL'h the nervc.<<
connected with the injured parts. If the fir-st suppo.^^ition be correct, the irritation was
transmitted from the surface of the brain, through its .structures, to tbe medulla oblon-
gata and spinal cord, whilst at the sjime time, those portions of the brain which are
supposed to be connected with the int^^iUcctual faculties ap[»cared to remain unaffected.
Baron Larrey hiiS recorded a cjlsc, in wliich tetanus supervening upon a lance wound
in the right side of the forehead, Wiis relieved by an operation, whilst the cerebral
symptoms increased in severity, and the patu>nt was destroyed by tlie inflamfnation of the
brain. The following is the history of this interesting case, as detailed by Baron
Larrey.
C<tf(C 18. — Trautnatic TifmniH.
In a charge of Cavalry, Mr. Markeski was wountled by a lance on the riL'ht side of the
forehead, the point of which glanced obliiiuely upwards and inwards, making a «leep
fissure in the os-frontis. One of the branche.s of the frontal nerve was divided by the cutting
edge of the lance. Nine days passed without the appearance of any unpleasant syinplom, an 1
tbe wound was treated as usual ; but on the night of the ninth day, tetanus came on, with
convulsive motions of the lids of the eye, on the injured side and tntal lo-*s of :<ighi in this
organ. He bad slight delirium, acute local piin, locking of the jiw->, and etnprt^alhotonos
was evidently about to take place. I tirst applied eniollient-, on the woundrd purt, and pre-
scribed opiates and diaphoretic drinks ; they procure«l no relief, and the ilisease advanced
with such an alarming aspect, tliat I doubt not he must h ive dn'ti in tw«nty-four hotirs.
I probed the wound and -^oon a-scerlaiufd its direction. The i»roi>e |tioliictd ^rreal pain, and
I was induced to lay open the wouad from oxw". end to the other, with a hisiouiy and grooved
director; with a single cut 1 divided the frontal muscle, nerves and vessels.
He wa-* instantly relieved, and in les-« Ih in twenty-four hour*! all the l»'t mic symptom? h.id
disappeared. I now thought he might recover, hut on tin- twenly-litih day. spnj[itoms tif
inflammation of the brain atid itsi menini^es with the ch iracieri^tics of etf'i^ion appeared. I
had been prepared to expect these consecjuences from the delirium lu-lnre noticed, which U
n^urr a symptom of Tetanus. But at thil time I hid ili^i-nvrreil only a *\\\y\\ furrow in the
external table of the os-frontis, made by the point of the lance. I now apjilied a lar;:e ve<ii-
catory over tbe scalp, and prescrihed coi»lin.^ drinks and anii-sp.x-iinniliis. The di-^e.ise <U\\
advanced, the fever increased, delirium foil iweil, ajid he dii'd (ui tip* 2Tt!i day.
On inspecting the cranium, wp fouu"! the internal lal»le of the frinitiil hone tlftached at tl.e
end of the fissure, and a con<»itlerible etl'usion of hlno ly jMirnbnt matter under the ri.: -t
anterior lobe of the brain, which was here aUo m a state of suppura'-on. When the ti-t
symptoms of compression appeared, after those of tetanus had {?uh.-id«'d, I proposed the app'.-
cation of the trephine on this fissure, bui wa-* induced tt) omit it tVoin the «ieci-.ij)n of several
of my colleagues, who were of opinion that no effusion would loll«»w s > -mill a fi-^^ure. I
regret that I did not pursue my first intention; o ••■ /i<«> y;r.7.-»y»^ y»/. //'•.«/« «/w/'.<.'<. .Meiuoirs of
Military Surgery, Vol. II, p. 3«»t»,
It would appear in the pree.»dinij cv**e, rej'orled by B iron Larn^y, that the irritation
causini; Tetanus was transmitted to the medulla iddoimata and spinal cord, throUL'b tbe
injured nerves rather than through th'» cerebrum ; for a clear divi.'*ion by llie knite of
the injured nerves relieved the tetanic spasms, l)ut had no effect whatever upon thej^ub-
sequent inflamtnatioD of the brain.
Observations on the Natural History of Traumatie Tetanus. 169
It has been up to a comparatively recent period generally admitted, that the hemi-
spheres, or cerebral ganglia, are entirely destitute of both sensibility and excitability,
throughout their whole extent ; for the experiments of various physiologists have shown
that both the white and gray substance may be wounded, lacerated, crushed, or gal-
vaoued in the living animal, without exciting any convulsive movement or any apparent
sensation ; on the other hand it appears to have been equally well established, that the
cerebral hemispheres are the seat of the reasoning powers, or of the intellectual faculties ;
for when these ganglia are destroyed, the intellectual faculties are the only ones which
tie lost ; in lesions of the cerebral substance, the earliest and most constant phenomenon
\s the impairment or loss of the mental powers ; and the development of the mental
Acuities in man and animals, is in proportion to that of the cerebral hemispheres. The
iovesligatioDS of physiologists, and more especially of Longet, have established that the
application of Caustic Liquids, of galvanic currents and mechanical irritation to the
olfactory ganglia, the corpora striata, optic thalami, tubercula qoadrigemina, and to the
white and gray substance of the cerebrum and cerebellum, are without any manifest
excitatioD and do not cause the slightest convulsive movements in the muscles below, or
any painful sensation.
The anterior surface of the medulla oblongata, the tuber annulare, and the lower part
of the crura cerebri ; that is the lower and central parts of the brain, containing continua-
tions of the anterior columns of the cord, are the only portions of the brain in which irrita-
tion is followed by convulsive movements ; and in like manner, the upper part of the
crura cerebri, the processus e cerebello ad testes, the restiform bodies, and the posterior
surface of the medulla oblongata ; that is those portions of the base of the brain, which
contain prolongations of the posterior columns of the cord, are the only sensitive
parts of the brain. The ganglionic centres of the brain which receive and originate the
Dervoua impressions, are therefore regarded as being destitute of both excitability and
i^n^ibility ; only those portions being capable of excitation by mechanical irritation,
which conduct sensations and nervous impulses.
If therefore, these results of carefully conducted physiological experiments and
extended pathological investigations, be accepted as established, then the conclusion
appears to be unavoidable, that the cerebrum is not involved in Traumatic Tetanus.
The results of the experiments of Schiff, Hitzig, Fritsche and Ferrier, with the
application of electrical currents to different portions of the brain, as well as the results
uf the experiments of MM. Fournie and Beaunis, in France, and Nothnagel, in Ger-
Qiany, upon the effects of destroying Small Parts of the Brain, have been fully unfolded
Id the preceding chapter, (Chap. Ist, Medical Memoirs ;) and the objections to certain
results of the experiments impartially considered.
If the results of these experiments, and especially those of Hitzig and Fritsche, and
Ferrier, be confirmed by more extended and careful investigations, in which the elec-
trical currents are absolutely hcalixed so as to act alone upon the parts svhjected to
rzperimentcU investigations ; and if it be clearly established that certain definite regions
of the cerebral centres preside over the voluntary and combined movements of the
mosdea of the face, eyes and anterior and posterior extremities ; it is clearly manifest
that the proposition that in Traumatic Tetanus the cerebrum is unaffected, cannot be
folly sastained.
That the cerebellum is probably involved to a certain extent in severe cases of
Traumatic Tetanus, may be inferred from the results of the experiments of Flourens,
confirmed by Hertwig, Budge. Longet and others, demonstrating that it regulates and
cuordinatee all the voluntary movements of the frame ; and from its extensive connec-
tions with the oerebroH3pinal axis. In the experiments of Flourens, during the removal
of the superficial layers of the cerebellum, there appeared only a slight feebleness and
vant of harmony in the movements, without any expression of pain ; on reaching the
middle layers an almost universal agitation was manifested, without any sign of convul-
sion, the animal performed rapid and ill-regulated movements, without losing the power
of seeing or hearing ; afler the removal of the deepest layers, the animal lost completely
170 Observations on the Natural History of Traumatic Tetanus.
the power of staDding, walking or leaping, or flying, and when placed apon its back was
unable to rise. The animal however did not remain quiet and motionless, as those de-
prived of the cerebral hemispheres do ; but whilst retaining volition and sensation, evinced
an incessant restlessness, and an inability to accomplish any regular or definite movemenL
Whilst the power of exciting movements remained, the power of coordinating these
movements into regular and combined actions was lost.
The remarkable revolutions performed by animals, when only one hemisphere of the
cerebellum is injured or cut away, have been referred by some physiologists to the one-
sided action of the muscles of the body, being no longer counterbalanced by thoee of
the other side ; whilst others have referred the cause, not to unbalanced voluntary
movements, but to abnormal tonic contractions excited by the injury, the spine, especially
its anterior portion being twisted, and the animal evidently trying to check the move-
ments.
Whilst the cerebellum is connected only slightly with the hemispheres of the brain,
by the processus cerebelli ad testes, or more immediately wiih that part, which may be
regarded as the centre of sensation, viz : with the optic thalami ; on the other hand, it
is brought into direct and extensive communication with each segment of the great
nervous centre upon which all the movements and sensations of the body depend — ^it id
connected with the medulla oblongata and spinal cord, through the restiform bodies ;
with the meso-cephale by the fibres of the pons, and thus with the anterior pyramids
and corpora striata ; and through the processus e cerebello ad testes with the optic
thalami.
Baron Larrey has recorded an interesting case of wound of the cerebellum followed
by Tetanus, which is as follows :
Que 19, — TraumcUic Tetanus.
A light horseman, of very amoroQS disposition, receired a sword-cut, which divided tfae
skin and all the convex portion of the occipital bone, throaph to the dura mater. The right
lobe of the cerebellum was seen through the opening of the dura mater, and the sligbtett
pressure upon this organ caused giddiness, fainting and conTulsive moTements. The patient
loses sight and hea/ing of the right side, experiences acute pain in the course of the dorsal
spine, and tingling in the testes, which in fifteen days were reduced to the sise of a bean. The
patient died of tetanus with loss of the functions of sight, hearing and generation. On dissec-
tion there was great loss of substance at the occiput, the medulla oblongata and upper part
of the spinal cord were of dull white, of firmer consistence, and reduced in size one-fourth.
The nerves rising from those parts, were likewise wasted.
The Btififness and uneasiness about the muscles of the throat and neck accompanied
with difficulty in opening the jaws, masticating and swallowing, and in rotating the
head ; the sunken watery immovable eyes, the suffused face, contracted brows, wrinkled
'forehead, expanded nostrils, with the distorted mouth, and sardonic grio ; the forcible
contraction of the pharynx and Gesophagus. the fixed and elevated larynx, the hareh
altered voice, the pain at the pneoordium, the /forcing forwards of the shoMers^ the
contracted chest, confined diaphragm, the rigid parietes of the abdomen, approaching the
vertebral column, and forcibly pressing the viscera of the cavity, and the forced convat-
sive reHpiration ; together with the violent tonic spasms of all the various muscles, and
the contortions of the trunk and extremities in various directions, as one or all the
opposing sets of extensor or flexor muscles were most powerfully oontnoted ; were all so
many manifestations of the exalted functional action of the cells of the gray matter of
the cerebellum, medulla oblongata and spinal marrow.
In connection with this association of the tonic spasms, it is worthy of note, that in
many oases of Tetanus, the first symptoms which attract the attention of the physician,
after the reception of the injury, is a complaint on the part of the patient, of stiflfbeas
and uneasiness about the joints of the jaws, the throat or neck, no matter what may be
the location of the injury, whether in the head, or in the superior or inferior extremitiey.
In such cases it would appear that the state of functional exaltation, first manifested
Observations on the Natural History of Traumatic Tetanus. 171
itself in the region of the origin of the Trifacial (fifth pair) and of the Facial (seventh
pftir) of nerves ; that is in the region of the junction of the peduncles of the cerebellum,
with the medulla oblongata, and of the restiform and olivary bodies, and of the gray
sabetanoe of the fourth ventricle, where the tension of the nervous force of the
oerebellum and medulla oblongata appears to be greatest, as indicated by the convulsive
moscolar movements, spasm of the glottis, difficulty of deglutition, and irregular
breathing following irritation of these portions of the medulla oblongata, and by the
dependenoe of respiration upon this portion of the spinal axis, which as the concourse
of all the nerves of sense, is also the medium for the transmission of sensitive impres-
sioDs to all the regions of the head, trunk and extremities. And in such cases, it is
probable that by the establishment of the state of super-functional activity in the cere-
bellam and medulla oblongata, the excitement propagates itself chiefly in a descending
and peripheral direction, thus establishing a similar state of excitement in the gray
matter of the spinal axis. The muscles connected with the spinal axis are thus excited
to sucoesBive spasmodic contractions by sudden discharges of the nervous force gene-
nted in the cerebellum and medulla oblongata, after the manner of successive electrical
dischaiges, through the different diastaltic arcs of the spinal system In this manner
when the irritation commences in the medulla oblongata, we may explain the gradual
iDTasion of the different ganglionic centres of the spinal axis, and the gradual generaliza-
tioo of the convulsive manifestations.
It would be an error however, to refer the manifestations of tetanic spasms, alone to
this mode of origin in the superior portions of the spinal axis. In the first case, the
irritation appeared to commence first in the nerves of the arm, and to affect first, those
portions of the spinal cord, from which the brachial plexus is given off, and from this
segment, the irritation appeared to be reflected to the medulla oblongata and cerebellum .
Daring the American civil war, cases which might be appropriately termed partial
')r localiied tetanus, have been recorded, in which the irritation transmitted from the
local injury, did not extend beyond the segments of the spinal cord, which received the
oenres of die injured parts; and the spasms were limited to those muscles which received
their nerves from the irritated segment of the spinal cord. In such cases, where the
excitation of the nervous centres, was limited to a portion of the spinal cord, and did
Qot involve seriously the medulla oblongata and cerebellum, the comparatively harmless
d^ease yielded readily to treatment, As a general rule the favorable issue, was due to
the limited extent of the irritation, rather than to the nature of the remedies, and this
fact will account for the comparatively large number of cases of Tetanus reported cured
upon the Field and Hospital Reports.
If this explanation of the mode of origin of a certain proportion of cases of Tetanus
be correct, we are forcibly impressed with the necessity of an early and energetic use of
Rich means as will tend most surely to arrest the propagation of the disease to the
varions segments of the spinal axis ; for in proportion to the extension of the nervous
excitement to the gray cells of the spinal axis, medulla oblongata and cerebellum, will
be the certainty of a fatal termination.
We will in the next place, endeavor to extend this view of the phenomena of Teta-
nus, by the aid of the more recent discoveries of physiological science.
The riew of the older anatomists, that the spinal cord was nothing more than a bun-
<lle of nerves, proceeding to, or from, the brain, and emerging at various parts of the
vertebral canal, to be distributed to the destined regions, has been disproved by the
rmltB of anatomical explorations, as well as by the teachings of experimental physiology ;
^ physiologists now regard the spinal axis, as devoted to the manifestations of excito-
iB^'tor phenomena, and as coordinating the movements of the trunk and extremities,
^ilst it is true, that when the spinal cord is severed from the encephalon, it takes no
^hare m the mental perception of sensations, and in voluntary actions ; and that when
initcd to the encephalon, its integrity is necessary to the perfection of the sensori-
volnntaiy actions ; it is on the other hand well established, that it is itself a ganglionic
^t'Qtre, capable of generating nervous force for the excitation of movements independently
172 Observations on the Natural History of Traumatic Tetanus.
of volition or Bensation, in parte supplied by spinal nerves, and that these actions of the
spinal cord may be excited, either by peripheral stimulation, of the extremities of its
nerves, independent of mental change, or by the direct irritation of its substance.
The gray matter of the spinal cord, is now regarded as a collection of ganglionic
cells, capable of generating nervous force, and thus exciting independent action. Thus
when an irritation is applied to the skin, a nervous impulse passes upwards along the
sensitive fibres of the posterior roote, to the gray matter of the cord, and is from the
ganglionic cells, reflected back along the motor fibr^ of the anterior root, until it finally
reaches the muscles and produces contraction. The function of the spinal cord, as an
independent nervous centre, is simply to convert an impression received from the skin,
or organs, into a motor impulse, which is sent out again to the muscles ; and this
'^ rejUx tMctiofiy' of the cord, is not necessarily accompanied by volition, conscious sensa-
tion or judgment.
According to the teachings of modem physiologists, the cord is divisible into a
number of ganglia, each forming a centre of innervation, to ite proper s^:ment of the
body, and connected by longitudinal commissures, to the other ganglionic masses of the
oerebro-spinal system : and the nerves which issue from the cord, by motor and sensific
roots, unite and form compound or mixed nerves, whose filaments pass from their origins
to their destinations isolated from each other, the sensific ramifications passing to the
surface of the part which is moved by the muscles receiving their motor fibres from the
same compound nerve, so that while the former supply sensation to the part, the latter
convey the stimulus to excite the act of motion. The motor (anterior), and the sensific
(posterior) roots of the compound or mixed spinal nerves, have certain relations with
the gray corpuscular elemente of the spinal cord, which are accumulated throughout
the central portion of the cord ; the former arising from the cord itself, taking their
origin out of the ganglionic cells of the anterior horn, each cluster of which forms a
ganglionic plexus, connected with the cerebellum and cerebrum, by the anterior medal>
lary fibres or commissures through which the influence of the brain is conveyed to the
ganglionic plexuses of the central nerves : the latter subdivide into two sets of radicles
or rootlets, one set of which at the posterior part of the cord ascends immediately in
the white substance and appears to proceed directly upwards into the brain, thus oon-
stituting the channel of sensation, whilst the other portion of the posterior or sensitive
nerve roote or radicles, penetrates the white substance of the cord transversely towards
the posterior horn of gray matter.
This latter portion of the sensific nerves has been traced towards groups of ganglionic
cells, in the centre of the gray matter, supposed to constitute the apparatus of re/lex
action^ directing their stimulus, through the group of ganglionic cells, with which they
appear to be connected, into the ganglionic cells of the anterior horn, from whose plexus
of cells, the filamente of the motor roote arise. The posterior nerve roote include two
descriptions of ner^'e fibres, the one for sensation proper, the other for reflex action.
The difierent groups of ganglionic cells are united throughout the cord, by longitudinal
fibres, and through the commissures, coordination of motion is effected. The mote of
the motor nerves, thus receive the excitement or stimulus to action, irom the ganglionic
cells in which they originate ; and these ganglionic cells receive their stimuliifl either
anteriorly from above, from the gray matter of the cerebellum and cerebrum under the
guidance of the intellect ; or posteriorly through the reflex filamente of the sensific
nerves, or from the peripheral parte of the body, through the sensitive nerves. The
ganglionic cells of the motor nerves, are therefore susceptible to psychical as well as
physical stimulus. Keflex action therefore takes place, by a definite channel, ite operation
being regulated by the communicating fibres which unite the different plexuses of nerve
eel Is and secure coordination and combination of movemente.
By this arrangement, sensitive or motor impulses, may be propagated from group to
gn)up of jganglionic cells, and a stimulus conveyed from any portion of the body to the
ganglionic cells of any portion of the cord, may either be transmitted to the brain, and
excite sensation, or be reflected upon the motor nerves and stimulate the muscles to
Observations on the Natural History of Traumatic Tetanus. 173
contract, or both results may take place at the same time, as the result of one and the
same stimulus.
In a state of health, the controlling influence of the will, prevents many of the sen-
sitive impressions from developing corresponding movements ; but in the intense excite-
ment, and in the super-charged state of the nerve cells of the gray matter of the cord,
in Tetanus and in poisoning by strychnine, not only are all the parts of the surface
capable of exciting nervous action, the slightest touch causing movements, not merely
in the limb touched, but throughout the entire body ; but the nervous apparatus, appears
to discharge itself at intervals, independent of external stimuli, and entirely without
oontrul of the will.
According to this view, Tetanus essentially consists, not in an inflammation of the
nerve oeUs and structures, nor of the membranes of the spinal axis, but in such a state
of exalted fonctional activity in the nerve cells, as is attended with the constant gene-
ration of a larger supply of motor force, than is necessaiy for the maintenance of the
normal healthy relations between the nerves and muscles. We will show in a subse-
quent portion of this inquiry, that this state of increased functional activity both in
Traumatic Tetanus, and in that form of Tetanus induced artificially by the action of
Stiychntne, is accompanied by a congestion and increased supply of blood in the gray
matter of the cord. This congestion of the cord accompanied by all the characteristic
Kymptoms and manifestations of Tetanus, may continue throughout the disease without
the establishment of true inflammatoiy action : on the other hand, in some cases during
the progress of the disease, this state of congestion leads to the transmigration of the
colored blood corpuscles and proliferation of the connective tissue and structural alter-
ations of the nervous elements of the cord. We regard the latter condition as super-
added to or engrailed upon the state of capillary congestion and exalted functional
activity of the spinal cord, and not as essential to the manifestation of Tetanic pheno-
mena.
The tetanic manifestations in this view express the state of exalted superfunctional
activity of the cerebellum, medulla oblongata, and spinal cord ; and it follows as a neces-
sary ooosequence from that law of the animal economy, that for the exertion of force,
we must have the chemical change of a corresponding amount of matter, (and as the
amount of the force-generating elements of the gray matter of the nervous system
chiefly afiected in Tetanus is limited,) that the progressive exhaustion of the patient by
the eDormous expenditure of excito-motor, and muscular force, must be one of the most
important causes of death in the disease. We cannot over-estimate the value of this
indication in the treatment of Tetanus.
We will briefly examine in the next place, the mode in which the local irritation of u
wound, may be reflected from the periphery upon the central ganglia of the spinal
axia.
Our knowledge of the mode in which the nervous irritation oric;inates in the injured
parts, would be much advanced by correct and minute anatomical descriptions of the
mode in which the nerves terminate in the organs, muscles and integuments, to which
they are distributed, and in which they are supposed to terminate. JThe philosophical
explanation of nervous action, must rest to a certain extent, upon the views of anatomists
as to the ultimate arrangement and distribution of the nerve fibres. Our knowledge of the
minute anatomy ot many organs, is at present, by no means as perfect as we have every
reason to believe that it will be in the future, by the aid of improved instruments and
methods of microscopical research. Up to a comparatively recent period, the methods of
preparation as well as the character of the optical instruments employed, were unsuited to
the accurate determination of the mode of distribution of the nerve fibres, in such struc-
tures as the papillas and tactile bodies of the skin, in the Pacinian bodies, in the retina and
cochlea, and in the mucous membrane of the nose and mouth. Thus Geber in his efforts to
determine the ultimate distribution of the cutaneous nerves, overcame the opacity of the
cutaneous tissue of man and quadrupeds, by boiling portions of skin, and then steeping
them in oil of turpentine, until they were rendered transparent ; and Kratise in similar
174 Observations on the Natural History of Traumatic Tetanus.
investigations, treated the skin with nitric acid ; and many of those violent modes of boil-
ing, and coagulating, and metamorphosing, and coloring with strong chemical-re-agents
are still used in microscopical investigations of pathological as well as normal structures.
In all future anatomical discussions of difficult questions, the method of preparation, as
well as the power and character of the instruments employed, should be so fully and
emphatically stated, that the observation may be repeated and the drawings subjected to
that critical scrutiny which the importance of the subject demands. We look with great
expectations to the application of the art of photography to the correct representation
of the minute anatomy of structures. Whilst it is true, that no mere photograph can
ever convey the knowledge acquired by patient, and intelligent microscopical investiga-
tion of delicate structures, viewed in thousands of varying attitudes and lights ; at the
same time, the photograph when perfect, will tend to correct those regular diagrams so
beautifully executed by some anatomical artists, and will also tend to expose the errors
of those who are able to make the anatomical structures which they delineate, corres-
pond exactly to pre-existing theories.
It would be foreign to the present inquiry, to present the results of an extended and
critical examination into the views of various distinguished observers, as Valentin,
Kolliker, Kiihne, Krause, Waldeyer, Englemann, Letzerich, MM. Conheim, Yulpian,
Rouget, Langerhaus and others as to the mode of distribution and termination of nerves
in voluntary muscles.
It is now generally admitted by competent observers that the ultimate nerve tubules
consist of four distinct parts, viz : the sheath of Schwann, or tubular membrane ; the
medullary matter or white substance of Schwann ; the axis cylinder ; the elements of
the axis cylinder which may be one or many fibrils.
Numerous conjectures have been formed as to the ultimate structure of the axis
cylinder, which fills the tube formed by the white medullary tissue around it ; by some
histologists, it has been described as composed of minute longitudinal fibres, while others
regard it as made up of luminse placed one upon another. According to Schultze, the
ultimate anatomical neural element is the primitive fibril, of which a number, great or
small is needed to make an axis cylinder, so that the primitive fibril is the essentia!
nerve element around which, or around groups of which, may be the medullary sheath
and the sheath of Schwann.
Frommann, and more recently Grandey (Jour, de TAnat. et Phys., 1869, p. 269,') by
exposing the nerves to a peculiar treatment with nitrate of silver, reached the conclu-
sion that the axis cylinder is composed of disks superimposed and isolated by a substance
differing from them in composition. Dr. S. Wier Mitcnell, of PhiUdelphia, (Injuries
of Nerves and their Consequences, p. 17,) has verified these observations on the iwiatic
nerve of the rabbit, with preparations made by Dr. Keen, and obtained the same result ;
and he concludes that it is difficult, considering the regularity of the structure thus
brought out, to reach any other conclusion than that the axis is probably less simple in
construction than has been believed. According to the same observer, if we admit with
Schultze (Disc. Acad., Bonn. August, 1868,) and Strieker, that this substance also pos-
sesses longitudina^strisB, the likeness to the anatomical disposition of the muscle would
be remarkable — a likeness for which there may also be some physiological foundation.
A recent observer. Professor H. D. Schmidt, M. D., of New Orleans, ( Microfloopical
Journal, 1874, pp. 200-221) in his observations ^^On the Constitution of the Dark
or Double-bordered Nerve Fibre,'' states that according to the results of his inves-
tigations :
^^The axis cylinder consists of minute granules about ^^^^ MM. in diameter, which are arrangtd
in rtfjular rote* and united by a homoycneou* interfibrillous sabstance, and th ns form a bundle of
f/rtmuiar fibrih. Each axis cylinder is, therefore, accordinf; to its thickness, composed of a
number of these granular fibrils which united into a bundle, are enclosed within a ditUnci
ihlirntf memhranotu iheath. The difference between the view of Maz Sehultze and my own, con-
<(i8t8 therefore only in the nature of the fibrils and the interfibrillous substance, and alio in
the absence and presence of a sheath. * *
Observations on the Natural History of Traumatic Tetanus. 175
The granaiar fibrillous structure of the axis cylinder is rery distinctly recognized on those
of the finer nerve fibres of the spinal marrow or the brain, consisting of two or even only
one fibril, and on which no sheath is any more to be seen. The contours of these, namely,
do not appear as straight lines, but as a row of small convexities, each of which is produced
by a projecting granule. * * On the finest ramifications of some processes of the ganglionic
bodies of the cortical substance of the brain, or in the termination of fine nerve fibres in its
nervous network, the granular nature is unmistakable.
The fibrils of the axis cylinder extend through the processes of a ganglionic body over its
surface. A considerable number of them connect the processes with each other, i. e. a part
of the fibrils of one process arising at the ganglionic body, pass over its surface and take part
in the formation of other processes. The course of the rest I must leave untouched for the
present. * "i^ In examining, therefore, the surface of a gani^lionic body illuminated obliquely
with an amplification of 700 diameters, it will appear to be composed of minute groups of
granules. This is especially the case in specimens prepared with a solution of chromic acid ;
in fresh ganglionic bodies, however, these groups of granules appear almost as so many
minute polygonal bodies with a dark point in the centre. As such I had also regarded them
until a year ago, when by a careful re-examination of the subject, I found that the ganglionic
bodies, as well as the processes proceeding from them, were composed of the same granular
fibrils as the smaller axis cylinders. * *
For a further evidence of the granular-fibrillous bodies and their processes, I may be per-
mitted to point to the observations of F^^mmann and Orandryy made on nerve fibres and gan-
glionic bodies, previously treated with a weak solution of nitrate of silver ; the axis cylinders
and processes here showed, as is known, for a certain time a distinct transverse striation,
until, after a continued action of the light, the specimens assumed a brownish-black color.
It is very obvious in this instance, that the fine transverse striae, represented the intermediate
sabstAnce, connecting the granules, and in which the metallic deposit first took place, and that
accordingly this substance must possess in a higher degree the property of decomposing the
metallic salt, than the granules, and must also have a different chemical composition. After
a continued exposure to light, this property also manifests itself in the granules and causes
the coloring of the whole specimen.
In comparing the granular-fibrlllous structure of the axis cylinders and processes, as above
described, with that of the striated muscular fibres, we can hardly overlook the analogy exist-
ing between the two, particularly during the earlier stages of embryonic life. In a tolerably
fresh human embryo about 17 mm. in length, I found these muscular fibres still in their first
stage of development, and those furtherest advanced, only represented by narrow bundles,
consisting of very distinct granular fibrils. The intermediate substance, connecting the
granales is here, like the axis cylinders, only sparsely represented, in consequence of which
the latter almost touch each other. Not until the intermediate substance becomes more
developed in volume, do the characteristic transverse striae of these muscular fibres appear,
while the granules become more separated from each other. In the embryo of three months,
tbe striation is already quite distinctly seen ; at the same time, the granules appear in the form
of minute quadrangles. If we take further into consideration that the electro-motor behavior
of tbe striated muscular fibres in a state of activity, are similar to those observed in the
oervea, it might be presumed that perhaps, between the terminations of the motor-nerve fibres
and these muscular fibres, a more intimate relationship exists than is now supposed. And
further, if we consider those so-called aareotu elementt of Bowmann as the elementary bodies or
AgenU through which the contraction of the muscular fibre is effected, we might, judging from
the above mentioned analogy of structure, also look upon those granules, composing the
fibriU of the axis cylinders, as the true nervmu elements^ i. e. those anatomical elements through
which the propagation or transmission of the nervous force takes place.
It appears to be generally admitted that the tubule may be finally traced into the
cells of the ganglia composing the spinal medulla and the brain, and that before joining
these cells it loses its sheath and ^hite co?ering, becoming thus reduced to the single
element of the axis cylinder, which has hence been regarded as the essential portion of
the ultimate tubule, the exterior portions serving merely for protection or for insulation.
A similar loss of the external medulla and sheath, and a like thinning of the axi.^
cylinder, is usually observable in the peripheral extremities of nerve tubules ; but great
diversity of opinion exists as to the manner in which they terminate in muscle and
HCDsitive surfaces. The sensitive nerves may be traced for the most part to a plexifonn
fieries of loops which underlie the skin and other sentient surfaces, and which accordin*:
to Beale, and some others, constitute the true periphcrdl termination of many senbitive
nerves, which, returning again to their central cell connections, form, as it were, a
oeural circuit.
176 Observations on the Natural History of Traumatic Tetanus.
If we accept as true, the recent observations of Professor Lionel S. Beale, of Lon-
don, (An AnaUmiiccd Controversy; the Distribution of Nerves to Voluntary ^ etc.
Archives of Medicine^ 1865,) upon the distribution of nerves to voluntary muscle, we
will be able to form a conception of the mode of origin of Traumatic Tetanus, which
will correspond with the well-established laws previously examined with reference to the
structural relations and modes of action of the various elements of the cerebro-spinal
system.
Dr. Beale claims that he has demonstrated that the nerve fibres passing to a muscle,
divide at length into a vast number of exceedingly fine, pale granular fibres, which
ramify upon the external surface of the sarcolernma, connected with which fibres at cer-
tain intervals, are oval nuclei, and that these fine fibres, afler an extensive and in many
cases very circuitous course, arc continuous with other fibres to form dark bordered
fibres, which at length pass toward the nervous centre, either in the same bundle as the
dark bordered fibres passing toward the muscle, or in other bundles. It therefore
follows, that of the dark-bordered nerve fibres distributed to a muscle, some pass from
the nervous centre towards the muscle, some from the muscle towards the nervous
centre, and that the nerve fibres do not end in the muscle at all. The results of these
researches considered in connection with those arrived at from the investigation of various
kinds of nerve centres, justify the inference that the fiindamental arrangement of a
nervous apparatus, is a complete and continuous circuit. These observations of Dr. Beale,
the importance of which cannot be over-estimated, as they involve the typical arrange-
ment of various nervous instruments, show, therefore, that so far from there being
distinct ends to nerves, that in all cases, complete circuits exist ; and that in these cir-
cuits are included centrrd nerve cells, and peripheral nerve cv/&, generally termed nuclei,
which are connected by intervening fibres. The course of any given fibre may be
extremely complicated, and there may be many minor circuits connected with the
greater one, but in all cases there is a circuit — a nerve never ends.
These views differ materially from those of Klihne, who holds that the nerves terrai-
nute in ends beneath ths sarcolemma, and are in fact, continuous with rows of nuclei
which lie among the contractile tissue; and from those of Kolliker, who agrees with
Kithne, as to the termination of nerves by ends, and with Beale, as to the fine nerve
fibres being upon or external to the sarcolemma, instead of penetrating through this
membrane, and coming in contact with the contractile tissue. MM. Krause, Waldeyer,
Engelmann, Letzerich, MM. Conheim and Vulpian, all admit the existence of a terminal
plate, and its entire independence of any nervous network. According to M. Rouget,
the terminal division of the axis cylinder of the motor nerve fibre, constitutes by
anastimosis and fusion, a terminal expansion of finely granular substance identical with
that of the terminal filaments of the corpuscles of Pacini, of the ultimate lamina or
electrical plates of fishes, etc., and in immediate contact with the contractile substance
of the primitive bundle \ this nervous expansion is traversed in every direction by
minute canals, establishing a connection between the numerous nuclei of the plate, and
communicating probably on the one hand, with the space intermediate between the
sarcolemma and the contractile fibrillae, and on the other hand, with the intersticas
between the matrix of the nervous tube and the medullary layer.
The importance of the results of the investigations of Dr. Beale, are seen in a clear
light, when we attempt to apply them to the explanation of certain nervous diseases.
Thus if we attempt to apply these anatomical facts to the explanation of Traumatic
Tetanns, we observe :
Ist. The nerves in their ultimate branches and ramifications, form a net-work of
;rrcut complexity and extent.
2d. Within this extended network, and connected by both afferent and efferent
nerves, with the central ganglia, are potential elements, true nerve- force generating
ft'll.M.
8d. A local injury or irritation is capable of producing a state of super-functional
activity in the nerve cells of the jK^riphery of the seiwitive and motor nerves. As tht^*
Observations on the Natural History of Traumatic Tetanus, 177
cells exist in immense numbers even in comparatively small portions of structure, arjd
as they are within the same closed circuit with the nerve cells of the gray matter of
the cerebro-spinal axis, a state of superfunctional activity or irritsition might be readily
transmitted from the periphery to the central ganglia. Thus a local nervous exaltation
nf Der\'ous functum in the peripheral nuclei, may be capable of propagating itself, first
to the nervous cells included in its own peculiar circuit, and from these latter, through
the channels of intercommunication, to the various segments of the spinal axis. The
irritation thus excited may also be communicated to the special system of nerves which
accompany the neural-blood-vessels : for Sappey has shown that contrary t'j the common
opinion, the vascularity of the nerve sheaths is greater than that of ligaments, tendons,
or aponeuroses, and approaches in this respect the spinal or cerebral pia mater. The
arteries are exceedingly numerous, and lie chiefly between the walls of the fibrous par-
titions in the spaces formed by their juxtaposition ; and the veins, like the arteries,
form an intricate plexus. Sappey has described as nervi nervorum^ the minute neural
fibres which follow the path of the vessels and are distributed to the sheath of the ner\^es.
The fact that the neural arteries and nerAcs, are not met with in the sheath of the
idtlniatc nerve fibrc^ would indicate that the subsequent congestion of the nervous trunks
in traumatic tetanus, was due to an extension of the irritation from the peripheral net-
work of the ultimate nerve fibres. Without doubt the nervi nervorum, or nerves of the
blood-vessels of the nerves, form a portion of the general system of vaso-motor nerves,
and through this channel as well as directly through the irritated nerves of the injured
part, the excitement may in tetanus be conveyed to the vaso-motor nerves of the spinal
axia, and lead to increased supply of blood to the central ganglionic cells, and increased
excito-motor action.
It is but right, that we should add, that in the preceding observations, and in our
application of the results of the microscopical investigations of Dr. Beale, to the ex-
] Sanation of the mode of origin of Tetanus, we do not at all claim for Dr. Beale, the
discovery of the formation of extensive networks in the peripheral fibres of the nerves,
and the reunion of the ultimate fibres composing the networks, into nerves which
ntum U) the central ganglionic masses.
Tlius, Valentin, Burdach and other observers, represent the nervous fibres dis-
tributed to the skin of the frog, as dividing into numerous small fibres, and forming a
clue^ti anastimosing net-work, which does not end in the tissue, but after coursing for a
longer or shorter way, returns, sooner or later, to the larger branches of the nerves.
Scliwann observed that the nerves in the web or fin of the tadpole's tail, and in the
mo>M*ntery of the amphibia, divide into numerous fine fibres destitute of the white sub-
stance, without any dark outline, and jn'esenting little enlargements, from whence deli-
tat4* fibres spread out in various directions, and connect themselves in the form of a
di-rw-ate and extensive net-work. The sulisequent observations of Quain, confirmed by
t!i<k-ie of Schwann, also showed that the smallest nerve fibres presented here and
then* along their course elongated corjiuscles, like cell nuclei. The researches of Ru-
dolph Wagner ujMm tiie distribution of the electrical organs of fish, in like manner
• ^tablish the doctrine, that the jKTipheral nerve fibres divide and sub-divide, and
n-unite. and are distributed in a picxiform manner, like the ramifications of the capil-
laries. Her Bilharz has shown that the small nerve which suppliers the electrical organ
of the electrical Silurus, ( MalapteriL«;, keeps continually dividing, until it finally resolves
it.-^idf into an enormously great number of raniifi(!ations, Avhich spread themsi'lves out
ujMm the electrical organ, tlius allowing of the sudden difTusiiui of the nervous influence
ov«'r the whole extent of the eb*etrical plates. The investigations of Mei.ssner and Bill-
r a\\ have shown that the sub-iuucous layer of the intestines is, Jis Willis had l<»ng
iH'fore de<-lar(Hl it to be, a nervous tunic. The jifl'erent nerves of the intestine, after
having divided, finally break up into extensive net -works, presenting, at certain points,
n««<JnU^. having tlie appearance oC ganglia, from which tht; nerve fibres spread out into
inti-rlacements, like tht; net- work of capillaries. This arrangement not only enables us
to understand the nature of fKjristatic action, but it also otters a ground-work for the
178 Observations on the Natural History of Traumatic Tetanus.
explanation of tetanic spasms, and convulsive affections, arising from irritating sub-
stances in the alimentary canal, similar to that afforded by the distribution of nerve
fibres to voluntary muscles.
We are enabled by such facts to uiidcrst^md how a local irritation may excite super-
functional activity in the adjacent nervous centres, and there, in virtue of their com-
munications with other nen'c centres*, may extend the influence over larger tracts of the
intestines, and the excitation may also extend to the central sympathetic ganglia, and
from thence be reflected upon the spinal axis.
Such physiological and pathological applications tm we have made of these anatomical
facts, which tend to the establishment of the peripheral division and expansion of the
nerves into extensive net-works, or of their direct connection with special apparatus, as
the retina of the eye, and the tactile bodies, do not appear to have suggested themselves
to the observers to whose labors we have referred. We have thus endeavored to refer
the phenomena of Tetanus to anatomical and physiological relations and laws.
CONDITION OF THE CIRCULATION AND RESPIRATION IN TRAUMATIC TETANUS.
In the First Case, the respiration Wiis disturbed during the paroxysms, but between
the paroxysms it was performed as usual ; thus affording a striking contrast to the res-
piration of (ever and inflammation in the acute stages.
In the first case, the pulse, and the action of the heart were disturbed during the
spasms, but gradually resumed their natural tactions during the intermissions.
When the heart was uninfluenced by the nervous and muscular disturbances, it mani-
fested the actions of health, rather than those of inflammation or fever. After a careful
examination of the relations of the perturbations in the heart's action, to the tetanic
spasms, it was established that they succeeded but never preceded the spasms, thus
indicating that either an influence was transmitted from the medulla oblongata, through
the pneumogastric nerves to the ganglia and ner\'es of the heart, causing spasms in its
muscular fibres, similar to those excited in the muscles under the control of volition, by
the peculiar state and force of the motor nerves, or else the sudden contractions of the
muscles, and the sus|)ensioM of Respiration, not only suddenly forced much blood upon
the heart, but also forced blood iniproi)erly oxygenated upon the heart, and thus
deranged its actions, by distending its cavities with venous blood. The first supposi-
tion appears to be the most reasonable, because the phenomenon was too regular, and the
irn^lar action of the heart lasted ailer the cessation of the spasms, and gradually dis-
appeared, to be again suddenly renewed upon the supervention of a new spasm.
This intermittent action of the heart, during the tetanic spasms, appeared to be worthy
of more than a ca;sual observation and bare record.
The intermittent action of the heart appeared to be immediately associated with the
violent disturbances of the cercbro-spinal nervous system, and resembled the disturbance
produced in the action of this organ, by the transuuKsion of electrical currents through
certain portions of the cerebro-spinal and sympathetic systems.
The heart as is well-known is supplied with nerves from the sympathetic and par
vagura ; the sympathetic branches come from the superior middle and inferior cervical
ganglia, and frequently also from the first dorsal ganglion ; the branches from the
par-vagum, come directly from the trunk of the nerve, and indirectly from the recorrent
and inferior laryngeal : and these nerves, after forming different anastimoses, and
plexuses with each other of the same side, converge at the upper and back part of the
arch of the aorta, where they form a free anastimosis with those of the opposite side,
and then pass on to the heart. The motor and sen.«<itive filaments received by the
sympathetic from the oculo-motorius ner>'e, inferior and superior maxillary, opthalmic
and lingual branches of the fiAh pair, facial nerve, and from the spinal nerves, establish
a relationship between the heart and corebro-.*«pinal system. The Pneumogastric (par-
vagum) nerve, by its origin from the lateral [)ortion of the medulla oblongata, in the
groove between the olivary and restiform bodies, and by the branches which it receives
Observations on the Natural History of Traumatie Tetanus. • 179
from the spinal accessory, facial, sub-liDgual, and anterior branches of the first and
second cervicals, in like manner establishes a relationship between the heart, and the
cerebro-spinal system, and more especially, as in the case also of the sympathetic, with
the medulla oblongata. AVe are thus enabled to understand that it is possible to trans-
mit a nervous impulse from the cerebro-spinal system, and more especially from the
medulla oblongata to the heart.
The following experiments establish a close similarity between the perturbations of
the heart's action, during the violent spasms of Tetanus, and the action of powerful
electrical discharges upon the medulla oblongat^i and Pncumogastric nerves.
£. H. and £. Weber, discovered the singular fact, that when the par-vagum or the
medulla oblongata is excited by a powerful electro-magnetic current, in a living animal,
the movements of the heart are suddenly stopped. According to G. Valentin,* when
shocks of the electro-magnetic machine, are made to act upon the trunk of the vagus
nerve, in a newly killed and still highly seasitive animal, the pulsation of the heart is
instantly brought to a stand still. If the electrical action be not continued too long,
the state of diastole, will last during the whole time of the experiment ; but if it be
continued, the heart af\er some time recommences beating. The roots of the vagus or
accessory nerve lead to what are essentially the same results when stimulated in a like
manner. On the other hand, when the experiment is successfully repeated, on the trunk
and branches of the sympathetic, the pulsations of the heart are always accelerated.
The same antagonism is oflen repeated by the roots of the vagus, and those of the
sympathetic, or the corresponding spinal nerves. Hence, there is some peculiar differ-
ence, which the intervening ganglia can neither originally produce, nor subsequently
remove ; at least, not as regards the powerful stimulus of repeated electrical shocks.
The arrest of the heart's action by repeated irritation of the roots of the vagus, is a true
diastole, having no resemblance whatever to a tonic systolic spasm ; and indeed the
teoaioD of the arterial blood is considerably diminished, although it finally remains at a
coimiderable height. On laying bare the nervous centre of a living frog, and applying
electrical irritation to the whole medulla oblongata, the heart is always arrested in the
diastole. The rudimentary cerebellum, and corpora quadrigemina, sometimes give rise
to the same result ; while the optic lobes only do so under circumstances of special
central excitement. The corpora callosum, and the deeper lateral portions of the
cerebral hemispheres, as well as the crura-cerebri and corpora quadrigemina, frequently
evince a most unquestionable action on the heart of the recently killed animal. When
the heart of a newly killed frog has ceased to beat, it is just as capable of being excited
(o new contractions, from the spinal cord as from the sympathetic. In the application
of a rapid succession of electrical shocks, the same contrast 'm repeated between the
medulla oblongata, and the upper part of the spinal cord, as between the vagus, and
Hympathetic ; the former arresting, and the latter ({uickening the action of the heart.
When a defined poition of the vagus has been stimulated for some time continuously,
the heart again begins to pulsate ; when a portion of the ner\'e above this point is now
Htimulated, no effect is produced ; when, on the other hand, the stimulus is applied to a
portion further down, nearer the heart, a cessation of its movements is again produced.
The circumstance that the heart, after the stimulus ha^ been applied to the pneumo-
gastric for some time, again commences to beat, is attributed, by Weber, to the part of
the nerve becoming exhausted, or losing its restraining influence, when the heart being
thus freed again, begins to pulsate. Budge, however, attributes the cessation of the
movements of the heart, produced by the application of galvanic stimulus to the pneu-
mogastric, not to any restraining power exercised by that nen'c, but rather to a tempo-
rary exhaustion produced by the strength of the stimulus. In support of this view,
he states that, although the movements of the iris chiefly depend upon the oculo-motor
nerve, yet Weber found, when the wires of the magneto-electric rotation apparatus
were applied to this nerve within the cranium, that the pupil became dilated, remaining
♦ Twt book of Physiology, J 1754, 1787, 1800, 2003, 2005.
180 Observations on the Natural History of Traumatic Tetanus.
so for a considerable time after the stimulus had been withdrawn, and then a<raio
slowly contracting. The effects thus produced upon the iris are, according to him.
analogous to those produced upon the heart by the application of the galvanic stimulu.^
to the pneumogastric. Moreover, the nerves which are sent to the heart of the fn»g,
do not present the arrangement which Weber has described. No other filaments than
those which pass from the vagus, arc distributed to the heart of this animal, at K*ast.
no others have been demonstrated. The vagus nen'o becomes united with the sympa-
thetic in the ganglion, which is situated about one line from the n ot»s of the pneunm-
gastric ; and from this ganglion which contains fibres of the vagus and sympathetic,
springs, amongst other branches, a slender filament, which is destintil for the hitiin.
This runs downwards on the inner aspect of the lungs, and passes along the veins Ut t\u-
auricle and ventricle, the former receiving the greater number of the nerve fibres. Tb»-
branch in question contains fibres derived from the pneumogastric.
Again, such a restraining power must hold an opposit^^ relation to the moving jx>wit
in the normal condition ; the moving power would, therefore, express itself only in
part, according as the other is in a latent state, or In a state of activity, and conse-
quently section of the vagus nerve ought, did it exert the restraining power in quei^tion.
to be followed by an acceleration in the movements of the organ, which is not the ca>e.
Budge, therefore, seems to regard the fibres which arc sent to the heart in the frog, by
the pneumogastric, as possessed of motor and sensory properties. Schiff also found
that when the heart's action has been made to cease, by application of the wires to thv»
groove between the auricles and ventricles, this effect cannot be counteracted by apply-
ing them to the bulbus arteriosus. The phenomenon of the cessation of the heart •=
action, produced by the application of the gjdvanic stimulus to the pneumogastric. lb-
explains, by supposing that its fibres are in a state of activity during the systole of th-
corresponding part of the heart, but (juickly became exhausted, thus allowing the dias-
tole to take place: thereafter, their activity being again renewed, a .'<<^cohd systole
results. When, therefore, strong gidvanic stimuli are applied to the nerve, the stat«* »«t*
exhaustion continues longer, and in the same proportion the dia.stole, or cessation of tin-
heart's action, is also hmger.*
On the other hand. Dr. Brown-Secjuardf has observed that section of the pneum«»-
gastric ner\'es, is followed by paralysis and dilatation of the blowl- vessels of the heart,
and that the excitation of these nerves, (by galvanism or otherwise), produces contra«-
tion of the blood-vessels. He explains by this contraction the stoppage of the heart >
action, when the medulla oblongiita, or the pneumogastric nerves are galvanixtnl, a> in
Weber's experiments. The heart, according to Dr. Brown-Sequard's theory, owiir^ ii-
contractions to an excitation produced by some <'lenient (»f the blood exist injij in th*-
small arteries and veins, Xow, if we suppose that galvainzaticm of the juir-vauunj
produces a ccmiplete constriction of the caj)illaries of the heart, it is oa.sy to undei^:a«» I
why the heart is stopjied ; it is because the excitation cannot take place, on a<*eouiit «»;*
the expulsion of the blood from the capillaries. Tf it be objected to this view, tb f
the effect of galvanisation is immediate, and that the arteries and veins posse.^siu^ niilv
fibro-muscular cells cannot contract suddcnlv, it mav be answered that it is a faet, th •♦
although there are only organic or non-striated muscular fibres in their vessels, they »1«»
contract immediately when the pneumogastric nerves are galvanized: an»l Bmwp-
Secjuard has discovered that the cai)illaries of the face and car are constriete<l when tin
sympathetic nerve is galvanized in the cervical region. It is known that the iiorvo «^'
the heart are distributed much more to its blood-vessels than to its muscular ti»ui-
By this supposition, the stopj)ing of tlie heart's movements is plaeeil among the wrll
known flicts, that an excitation of a motor nerve produces a contraction of the imiMlr-
* Wagner's Handworterbuch der Physiologic, band iii ; AsUierbuug, ii, p. 45; band ii.. p.
415; Cyclopajdia of Anatomy and Physiology, Vol. v, pp. 4»10, 401.
f Experimental Researches Applied to Physiology and Pathology, pp. TT-tO; Principlo.- of
Uu.map Physiology, by William R. Carpenter, M. V., etc, Phila., IS^O; pp. ZAX t»-l4.
Observations on the Natural History cf Traumatic Tetanus. 181
to which it is distributed ; and, therefore, we are not obliged to admit that an excita-
tion of a nerve is able to produce directly either a contraction or cessation of existing
cttntractions.
According to this view, then, when the medulla oblongata is excited by the electrical
current, the stopping of the heart is not produced by a loss of irritability of this organ ;
and the practical inference follows, that in cases of syncope occurring in Tetanus, and
in other diseased states, from the influence of the nervous force, or of an emotion upon
the medulla oblongata, it might be possible to excite the beatings of the heart, either by
compression of the chest, or by an application of galvanism.
If* the view of Dr. Brown-Sequard be correct, we ought te find that the heart will
i^-ai. if, during the stoppsige produced by galvanization of the medulla oblongata, we
^u^^titute for the missing excitation, (in consequence of the expulsion of blood from the
iirtereies and veins), another stimulus. This has been done, and it is found that a me-
chanical or galvanic excitation re-establishes the Movements of the heart. Another
fart has been discovered by Dr. Brown-Sequard, which he considers very important.
When a galvanic current is applied to the heart, or to the pueumogastric nerves in the
nt'i^hborhood of this organ, it is known that its pulsations are not stopped by it, and
that S4>metimes, on the contrary, they appear to be quicker and stronger. Now, if the
thernT of Dr. Brown-Sequard be right, how is this to be explained ? In this case, the
ves^ls of the heart are contracted, as when the medulla oblongata is galvanized ; but
the muscular fibres are directly excited by the current which produces the same effects
a< the missing excitant expelled from the vessels. The truth of this explanation appears
t.» be proved by the fact discovered by Dr. Brown-Sequard, that if the galvanic cuirent
i- interrupted, the heart ceases at once to beat, and resumes its action if the current is
applied again. Another very important fact is, that if an energetic galvanic excitation
i-* applied to the medulla oblongata of a fn)g, for ten, fifteen or' twenty minutes, (some-
times five minutes are sufficient), the heart, which had stopped, at once resumes its
actiiin.
This fact, discovered by the brothers Weber, and unexplained by them, is thus ex-
[»lained by Dr. Brown-Sequard.
The vessels of the heart, as well as the vessels of any other part of the body, cannot
rt niain contracted a very long while, their contnictility diminishing gradually during
thfir contraction. Dr. Brown Sdquard has seen the same thing when he applied gal-
vanism to the cervical sympathetic nerve ; the vessels of the ear remained. contracted
five or .six minutes, or a little more, and then gradually became dilated, although the ex-
• itatifin of the nerve was continued.
Whilst therefore it is tnie that the ordinary movements of the heart arc but little
•l«>p^;ndent upon nervous influence of any kind, as may be shown by the cDntinuance of
it-* action after destruction of the entire cerebro-spinal nervous system and even after
it> complete separation from the chief centres of the sympathetic system, and removal
(.ntirely out of the body ; on the other hand, the results of the experiments with the
application of the magneto-electric current to the medulla oblongata^ superior portion of
the spinal cord, pueumogastric and sympathetic, the depressing efl'ects of sudden emo-
tions, of shock, of crashing suddenly the spinal marrow, or of a limb, the fatal effects
• f «udden and violent blows upon thq epigastrium, and the effects of the tetanic spasms
in arresting or accelerating its motions, all establish the fact, that the action of this
f r.rdn may be influencad by disturbances and abnormal actions in the cerebrospinal and
sympathetic systems.
In traumatic tetanus, its actions may not only be arrested in some casts, but in many
• thenj they are vastly accelerated, without any corresponding elevations of temperature,
a> in the rapid action of this organ in fever. And it is a question worthy of invesli-
Tdtion, how far the fatal termination in Traumatic Tetanus, may be due to disturbances
io the action of the heart, induced by influences transmitted from the medulla oblongata
and spinal cord through the pneumogastric and sympathetic.
Dr. C. H. Parry, in his work on Tetanus and Hydrophobia, attached great importance
182 Observations on the Natural History of Traumatic Tetanus.
to the state of the heart, which he imagines becomen exhausted, and first loses its vital
powers. {Cases of Tetamts and Kabies Contagiosa, p. 81 ).
Mr. Benjamin Tnivers held that the uUimate tendency of the disease, is to travel mU^
the legion of organic life, and affect the heart and other viscera with its spasm. Mr.
Travers considered Tetanus as essentially a disease of function, which destroyed by
exhaustion, if not by sudden translation of the spasm to the heart. (Further inquiry
concerning Constitutional Irritation , and the Pathology of the Nervous System, pp.
882, 388).
Dr. Currie renuirks, that the patient when the case tenninates fatally, probably dit^
at last from spasmodic affection extending to the heart. ( Medical Reports, vol. i. p.
118). Dr. Currie in common with other obseners, refers the fatal issue in a certain
proportion of cases, also to arrest of respiration.
Case ^^ : Traumatic let anus,
Mr. Howship published a case (Med. end Phys. Jour, xxii, p. 185. London ISlM.i. >
where the patient in describing his suffering, is reported to have said, that he " felt that
his heart was at times ready to break with the distress of its pain." The heart when
examined eleven hours after death, the body beting still warm, was found so much
reduced in size, as not to occupy a fourth part of the cavity of the pericardium, and
appeared to be very much and unnaturally shortenc d freni the basis to the apex. Tpon pre? -
sing the muscular ventricles, they jiave the resistance <»f a very firm and even horuy
substance, rather than of mere fleshy cavities. The auricles as we»ll as the ventriclt>.
were greatly contracted, and felt unnaturally tiim. The sidt»s of the left ventricle w*t»'
found in the closest contact, k) much so, that when a section of the heart was made, the
exact situation of the cavity was not immediately to be perceived. About half an ouu<^*
of blood still remained in the right ventricle. The auricle on the right side, containe<l
about an ounce of bKK)d, that on the lefl, a much less j)roportion. The heart wa>
removed from the body, and lipon Wing examined a' few hours afterwards, it was found
to have become comj)leteIy relaxed, was much larger and softer, as well as very flacvid.
having entirely lost that very peculiar and remarkable state of tone which it posse^M»<i
at the time of its being first ins|)ected. Mr. Howship deveribt^s no other morlud
ap])earance, and concludes, " that it was on every side clear, that the muscular structurt*
of the hoart had in this ca-^^e become at length subject to the .same affe*ction which, durinir
the earlier stage»s of the diseust», was confined priiicij>ally to those |>arts of the \hh\\
subser\ient to voluntarv motion."
Whilst we have no anatomie'al data, by whi<h to determine the relative fre<|uency of
such a ctmdition of the heart, as that deserib*^! by Mr. H(»wship. it is however establisheii
that it is by no means unifonnly present in death from tetanus, and may also be pn*9*ent
when death is caused by other dis<»aM's. Thus Dr. John KeiJ, after describing tin-
morbid appearances in a case? of Tetanus, observt's, that
•
"The diflTerence of the p.iiijrlionic system from the spinal vviis well amrked, by the influeo^r
nf the disease not extending in a .<>imi)ar mnnner to the musrular orj^ans of both B^'tftem*.
This is marked by the muscular part of the heart unci intestines being paler than nattir4!
trhile the rou?cular orjrans belonjin;: to the spinal system arc remarkably florid and red.' "^
fhe Xitture and Tmitrntnt of 7*'t'inus nnd J/t/'fiopfn fno, ttr. Dublin, is IT.
Dr. James Copland sfate^ that in two acutv* traiiinatie ca.'ies, which he examinol
afU»r death,
**Tlie heart did not ]»rescnt any appearance different from that observed in cases of suddrn
or rapid death from other causes, lloth the-^e case?* terminated in a«phyxi;i.*' Ihrfumar*! *j
•i*rtfctical ^filiane. New York IS.*) 7, vot. lii, p. llo:).
Dr. Curling says :
" That ia other diseasei, ibc uenrt wheu examined within u few hours after death, may often
Observations on the Natural History of Traumatic Tetanus. 183
sttm exceedingly rigid and closely contracted, in consequence of irritability remaining in the
nascnlar fibre after life is extinct." Treatise on Tetanus, Philad., p. 14.
It has also beeu supposed that the unstrij>c(l muscular tis.sue of the arteries may be
afftvted with spasm in tetanus. Thus in a case of amputation on account of Tetanus
>apenreniDg upon a lacerated wound, performed by Mr. Listen, the vessels contracted so
(-(>iuplet«]y that there was no haemorrhage, and ligatures on the mouths of the divided
vessit»Is became unnecessary (Ed., Med. and Surg. Jour, xxi. p. 292). AVhilst the con-
tractile power of the arteries Wjis evinced to a remarkable extent, this appears to be an
bolated case in the history of Tetanus, and Mr. Curliug affirms that he has witnessed
it in almost an equal de<^ree, in an amputation performed upon a patient free from
Tetanus.
That the direct and decided influence transmitted to the heart during the spasms,
in some cases of Tetanus, is of a powerful nature, and resembles the effects of a current
of electricity passing through the medulla oblongata and roots of the pneumogastric
Derrcs, is rendered still farther manifest by the effects of great muscular exertions and
.<pa.sms in increasing the frequency of the pulsations of this organ, even when it has
been isolated from the spinal cord.
The normal effect of the violent spasms in Tetanus is to increase the action of the
heart, both in frecjucncy and force ; it is therefore difficult to determine how far the
increased action of the heart in a certain proportion of cases, may be due to the trans-
minion of an impulse through the sympathetic nervous system, which, as has been
^howo. acts in a manner the reverse of that of the electrical and nervous impulses
traojODitted through the pneumogastric.
Dr. Parry has attempted to establish grounds for forming a probable conclusion as to
the final result of death or recovery, in this disease, by attending to the state of the
|»iilj<e. Thus, he says :
"If in an adult the pulse, by the fourth or fifth day, does not reach one hundred, or perhaps
one handred and ten beats in a minute, 1 believe the patient almost always recovers. If on
'le other hand, the pulse on the fourth day is oue hundred and twenty or more in a minute,
fcir instances will, I apprehend, be found in which he will not die."
It is well established however, that the danger in Tetanus, is neither proportional to
the inten^fity of the spasms, nor to the rapidity of the action of the heart, but is depen-
dent rather upon the particular class of mu.scle8 affected. Thus, if the muscles of the
thnait and chest, the muscles of respiration, be early and decidedly invt)lved, the great
•kiiger is asphyxia, from the sudden arrest of respiration as well :ts fr(mi the injurious
ainl depresning effects of the impeded respiration.
Ih*. Parry's rule cannot with our present knowledge be adoj^ted as a guide for accurate
(^i;nKiHis, not only because the action of the heart, may Ini greatly influenced by the
r>'Diedie!* employed, but also because the rule is not sustained by the testimony of other
writers, as Sir James Macgi'cgor, Dr. Morri.son, Dr. Henneii, >Ir. (Mrlingand others.
Ill many fatal cases, the pulse hits varied but little from the normal standard of health,
whilst in other cases in which the pulse exceeded one hundred and ten beats, the patients
r. i-ovt-ptjiL In all the cases witnessed by Mr. Curling, the action of the heairt, as well
:-^ the rvfipirat<»ry movements were in some degree accelerated ; and during the paroxysms
Tberv was jjenerally a further increiLse, of about ten or twelve jiulsations in the minute,
whilst t4»wanlt« the close of the disease, the pulse Ixjcame fecible, irregular and sometimes
nit«-miittent. The circidation in tetanus do(js not therefdre present the marked and
tiiiiiorm acceleration and slight oscillations, characteristic oi' certain di.seases, as Yellow
F-vtT. Malarial Fever and Small-Pox.
M.\<TlON OF THE SKIN A4'TIVELV PERFORMED; TONiJlE HIT SLKIIITLY FIRRED:
R«»WELS OBSTINATELY CONSTIPATED, DIHINC} THE ACTIVE STAGES OF TRAl MATIC
rtTANTS-
A> a general rule, in Traumatic Tetanus, the function of the skin is actively performed,
jad the patients are frequently bathed in perspiration.
184 Observation^ on the Natural History of Traumatic Tetanus.
It does not appear to be necessary to refer the profuse perspiration of some iu^n^^ of
Tetanus, to deranged nervous action, either immediately, or as the sole caiL"^\ TLi-
incretused activity in function of the skin, appeared to be the result in great moib-uri' <•:'
the increased muscular actions. Without doubt also, the pressure of the muscles ujnu
the internal organs and vessels, and upon their own veins and capillaries must im{Kirt ti.
the fluids a j)eripheric impulse. As far as our knowledge extends, the cutaneous hm r*
tion in Tptanus, is not '* aifical,' and its amount and character, furnishet* no gnmrwl^
for a favorable or unfavorable })rognosis. In those «isej5 which recover, we ha\«.' um
reason to suppose that any poison is either wholly or in part, eliminated by the skin ii-
this disease.
In the FIRST CASE, the tongue was but slightly furred, and at no stage of the di-i-ii-
did it present the dry furred appearance so common in many fevers and inflammation^.
The bowels were obstinately constipated. This constipation preceeded the vitil»M •
spasms, and was not therefore the result of muscular pressure. This state of tlie Imjwi!-
was most probably connected with disturbance in the nervous system. Closure of tli
anus by the spasmodic action of the sj>liincter ani, would not account for the coiistija
tion, because \i preceded the stage of rigid contraction of the muscles ; neither will tl:.-
violent pressure of the muscles upon the alimentary canal, in conjunction with the '^r«:.'
transpinition from the skin, account for this symptom, for a similar reason, that tlu-
were subsequent to the establishment of C(»nstipation.
Without doubt, the pressure of the abdominal muscles, the profuse persjiiratimi. a'cl
the effects of the opiates administered, all tended to render the IkjwcIs tor|>id ; but tli-
fact which we wish to establish, Ls that this state preceded these conditions, and coull
not therefore be more than aggravated by them. Whether the constipation was duf t<.
spasm, or persistent contraction of the unstriped muscular fibres of the bowels, iliu-
preventing all peristaltic motions, or to derangement in the secretory and excn't4.n
apparatus of the mucus membrane of the alimentary canal, or to both causiv combiti' il.
cannot in the present state of our knowledge be accurately decided ; it is however w»H
known, that in other diseases (»f the brain and S2)inal cord, besides Tetanus, the Ih'PTi '>
are torpid.
Whether we incline to the opinion of Bicliat and draw a broad line of demantiti«»';
betwe(?n the eerebro-spiiuil nervous system, as presiding over the functions of auiin;/.
life, and the sympathetic, tus presiding over the involuntary movements, and ovit \b
processes of secretion and excreti(m, the functions of vegetation and reprotluction. an 1
regjird the sympathetic ganglia as entirely independent of the cerebro-spinal ; or t4» th
view of the older physiologists, which luus been revived and ably advocatc»il in n^- -w
times, that they are not independent systems of nerves, but that the .sympathetii i^
dejKMident upon the cerebro-spinal for its properties and forces, and must thert^for.' b.
rejranled as one of its sv.'-tems of nerves: we ai*e in either case ju.'^tified l>v such i\.*!'
established facts, iis the distur})ane<' and jKTversion of nutrition by mechanical injnri-
and pathological alterations of nerves, the mutual actions of the digestive, urinary a!.-:
generative organs, the variations under nervous excitation of the circulation and MH-n'tion<
in the various abdominal organs, the production of convulsions by the prc.»<tiu*e of unT
gested matti'i-s in the alimentary canal, nausea attending pregnancy, temporary' aniaum-iv
double vision and even hemiplegia following derangement of digesti<in, diarrh<H'a ::nl
inflammatioii of various internal organs following exposure to cold and wet, disturb:iii««-
in the action of the heart and in the digestive functions by moral and mental eniotioijv
dilatation of the pupil under the impix'ssion of terror, sudden injection of IiIo<mI intniii.
capillaries of the face ns an effect of* mental emotion, and otber similar facts, in h(»l«iii..:
that reflex nervous actions may take place, through the sympathetic system fViKn «n:
organ to another, or from the organs through this system to the cerebro-spinal, ai. 1
through this portion of the nervous system to the voluntary muscles and smsirivr
surfaces ; and also that they may take ])lac(5 from the exterior sensitive surfjuw*?, thrmij'i
the cerebro-spinal system to the synipathetic, and through it again by reflexion, ext i:»
the involuntary muscles and various abdominal organs.
Observations on the Natural History of Traumatic Tetanus. 185
These well established phjaiological and pathological facts, and these mutual relatioDs
and interchange of impressions, between the sympathetic and oerebro-spinal systems,
may as is well known, be readily explained by the anatomical connections of the two
systems. The sympathetic receives fibres /rom the cerebro-spinal system, through its
oommnnication with all the spinal, and nearly all the cranial nerves, and in turn appears
not only to send its own fibres into the spinal axis but even its peculiar ganglionic cells are
now said to exist in the gray matter of the spinal cord. According to M. Jacubowitsch,
•tmctures which are analogous to the ordinary ganglionic cells of the sympatheUc, occur
ID the middle of the spinal marrow, and in several parts which are regiurded as belonging
to the brain. This observer has distinguished three kinds or forms of cells, in the
<^y matter of the cord, which he affirms lie generally in separate groups, and which
he distinguishes as motor, sensitive and sympathetic. It follows from the observations
of Jacubowitsch, that the whole cerebro-spinal nervous system (the spinal marrow, the
elongated marrow, the quadrigeminal bodies, the brain, and the cerebellum,) and the
entire ganglionic system, consist in a general way of four kinds of nervous elements ;
the eelloles of motion, the cellules of sensibility, the ganglionic cellules, and the cylin-
ders of the axis of all these cells. According to this view the ganglionic nervous
system does not constitute a separate system but belongs essentially to the cerebro-
spinal system. The different cells are the roots of the nerves of the same nature as
themselves. All the nerves issuing from the brain, the cerebellum, the spinal marrow,
and medulla oblongata, are, according to their origin, of a mixed nature, and they con-
tain filaments originating in different cellules, in greater or less proportion, so that there
are found in them nervous filaments of motion and sensation. The nerves of the great
sympathetic have their roots in the ganglion cells. Large multipolar cells are adcumu-
lated in those parts of the cord, which are subservient to motor actions, as the anterior
and lateral parts of the anterior horns, they are met with in the cerebellum, corpora
quadrigemina, and in the anterior cornua and gray matter of the medulla' spinalis, but
not in the oblongata ; they have been traced into efferent nerves of the anterior root,
and give origin to motor nerves, and are therefore designated as motor cells. The
small many rayed fusiform cells, found in the direction of the posterior horns and in
the medulla spinalis, oblongata, cerebellum and corpora quadrigemina, and in all parts of
the cerebral hemisphere, are connected with the fibres which run into the posterior root,
and are therefore thought to be subservient to the functions of sensation. Those cells
which Jacubowitsch has called sympathetic, are larger than the sensitive cells, have
fewer branches, and are distinguished by a greater roundness of shape. The bipolar or
sympathetic cells are of an oval form, and have two axis cylinders. They are found in
the medulla spinalis and oblongata, in the cerebellum and corpora quadrigemina, but
not in the cerebrum. In the medulla spinalis, they are principally found around the
central canal. They are very abundant in the medulla oblongata, constituting its
greatest portion. Whilst the special position and connections of the sympathetic cells,
have not as yet been so clearly defined, still the view appears to be reasonable, which
considers them as the origin of the sympathetic roots which run from the spinal
marrow to the main trunk of the sympathetic.
Aeoording to Professor Jacubowitsch, the axis cylinders proceeding from the multi-
polar cells form the nerves of motion ; and it is for this reason that they are called cells
of motion ; the axis cylinders of the fun/omi cells, form the nerves of sensation, and
these cells are termed the cells of sensation ; the axis cylinders of the bipolar cells,
are in relation with the great sympathetic, and the cells are termed ganglionaiy
celts.
The same and different species of cells communicate with each other as follows:
(a.) The cells of motion communicate from one side to the other of the anterior
oommiflsure, or rather this commissure is formed by the intercoming in eveir direction
of the axis cylinders which proceed from those cells. Those of the same side also com-
municate by the axis cylinders which proceed directly from one to the other.
(&.) The cells ot Mentation communicate from one side to the other, by the posterior
u
!%& Observations on the Natural History of Traumatic Tebmus.
comiuissttre, or rather they constitute that cnmmiasaro ; but they r«Qiaiii parallel to ettch
other and do not intercross. Those of the same side commanicate directly.
(c.) The aziS'Cylinders of the ganglionic cells pass by either the anterior or pos-
terior commissure ; and thus communicate from one side to the other, like both the
other species. Communications also take place between those of the same side.
((/.) Communications moreover take place between the different Tartetiea of eelk ;
but Jacubowitsch has only met with them in the cerebellum and in the corporm oiudri-
gemina, in which the three varieties of cells occur. The differepi species of ools are
not equally abundant in all the regions of the medulla spinalis. Thus in the eenrical
and lumbar regions, the cells of motion predominate, while in the dorsal region thoee of
sensation are not numerous. The medulla oblongata, according to the views of Jacubo-
witsch, is purely and simply a prolongation of the medulhi spinalis ; a proiongatioii
entirely formed of cells of sensation, containing in their centre, a nucleus of gangUooiG
eells.
The cerebellum, according to this observer, is formed of four elements, vis : Fint, of
the elements constituting the white substance, and which are prolongations, by meaoe
of the peduncles of the pyramidal bodies which furnish the elements of the eells of
motion, of the restiform l>odies, which furnish the elemente of senBation, and of tho
ganglionary element, which enters with each of the other two. Second. Besides tboM
three elements, the periphery, or coritical substance of the cerebellam, is formed of
characteristic pyriform cells peculiar to this organ. From these pyrifbrm cells pro-
longations are sent to the surface of tho organ, forming a layer, termed by Jacubo-
witsch, Conche en baguettes.
The corpora qwidrigeminay formed by the prolongations of the peduncles of the
cerebellum, by the restiibrm bodies and by the horse-shoe-shaped commissure, contain
the three varieties of cells, which they derive from their various origins. But this is
the last point where these three varieties are found together. Above this, is the
hemispheres, as already stated, the eells of sensation, of which the corpus callosam
forms the commissure, are alone met with.
With the exception of the optic, tho olfactory, the auditory, the vagus, glosso-pharyn-
geal, and the hypoglossal nerves, which only consist of cells of sensation and gaogliooiq
obIIs, all the nerves are formed of the three varieties of cells, with this difference among
them, that the nerves of motion contain especially the cells of motion, and so on.
It results fVom these facts :
1st. The three entirely distinct functions of the nervoys system, motility, sensi-
bility and organic action, are not only exercised by the different orders of nerves, but
morever, these orders of nerves take their origin in difierent oentral anatomical ele-
ments.
2d. The medulla sptjuila, whence arise the general nerves, contains equally and
naturally the three orders of elements, but the brain, the oi^n of the intellect, contain:i
but the elements of sensibility, (which abound according to the intelligence of tho
animal), and the nerve of the special senses are also made up of the same element, with
which is united in small proportion, only the ganglionary element.
3d. In affections of the nervous system, in which the most minute ordinary exam-
ination can detect no material lesion, such lesion may, nevertheless be coosidenble«
since one or more of these orders of elements may become greatly altered in their
fbrm, or even ucdergo destruction. (Moniteur dcs Hdpitaux, Sept 8, 1857. Am.
Jour. Med. Sci., N. S., 1858 ; Vol. 35, p. 237.
The preceding results of the investigations of M. Jacubowitsch, if fully confirmed bj
competent observers, will not only expUdn the mode in which irritation of stractnies,
aa tJie mncua membrane of the intestinal canal, supplied entirely with sympathetic
fibres, may be propagated to the spinal axis, and give rise to tetanus, but they also cast
light upon the singular phenomenon, noticed two thousand years ago, and which ap«
pean to be chamotoristio of the disease in the traumatic form, in all cliniataB and
via : That the iateUoQt is unaffqcted in Traumatic TetanuA^
ChBervattons on the tfaiuYal ttistory of Traumatic tetanus. 18t
By the light of theso physiological and anatomical investigations, we are led to infer,
that in Traomatic Tetanus, the motor and ganglionic cells are chie€y, if not entirely
ioTolved ; and the former to a greater extent than the latter.
The intimate relations of the two great systems of nerves, is still farther shown by
the fact that the pneumogastric nerve, which aids in forming three of the sympathetic
plexuses, the pharyngeal, cardiac, and solar, gradually predominates over and supplies
the pboe of the sympathetic in the lower animals, and this gradual substitution of the
former for the latter goes on in the descending series, until in the Cephalopodous
moHoaks the sympathetic almost entirely disappears, and the pneumogastric occupies its
plaoe and performs its office.
The intimate mingling of the elements of the two systems would seem to indicate
thai the difference in the functions of individual nerves cannot be referred so much to
dtflerencQB of structure, as to the peculiarities of tlie structures with which they are con-
nected ; that is, the f\inctions of the ganglionic central organs, and the nature, struc-
ture and functions of the organ in which the nerves terminate, as well as the arrange-
neot of the periphery or distal apparatus of the nerves afibrd the ground for the deter-
minataon of Uieir special functions.
As, therefore, the peculiar ganglionic cells of the sympathetic exist in the spinal
marrow, and as it receives both motor and sensitive fibres from the spinal axis, it can*
not th^efoce be considered as an isolated self-acting system in a highly organised
aniaal ; bat, whilst admitting this proposition, it would be erroneous to affirm that it
derives its powers entirely from the cerebro-spinal system, and is dependent upon it for
a eonatant renewal of its force.
By these anatomical and physiological principles we are enabled to understand, not only
the node in which a nervous influence may be transmitted from the cerebro-spinai system
to the sympathetic, and through it to the unstriped muscular fibre of the alimentary
canal, thus cansing obstinate constipation, by the arrest of peristaltic action, but also
the mode in which tetanic spasms may be induced by the irritation of undigested mat-
ters, and by the presence of worms in the alimentary canal. When tetanic spasms are
indaoed by irritating matters in the alimentary canal, the irritation extends from the
mneoa somce of the alimentary canal, to the surrounding net-work of nerves in the
sab-mucns layer, and from thence it is reflected to the sympathetic ganglia, and finally
to the spinal ganglionic cells.
The irritation is repeated as it were, in the spinal cord, and from this centre impulses
are aent oat to the motor nerves and muscles.
TlMse ehanges without doubt take place slowly in many cases, and hence it is not
neoeMaiy to assume, as some have done, that the obstinate constipation of Traumatic
TeCaaoa stands in the relation of a cause to the spasms.
We are also led to this practical conclusion : That whilst, in the treatment of Trau-
BMlie Tetanus, we should hope to derive some benefit from the free evacuation of the
bowda, at the same time, when the disease is dependent upon an injury of the nerves,
the eonatipation is dependent upon the excited state of the spinal ganglia, and does not
■taod ia the relation of a cause in the production of the dbease, and will be soonest
overoone by thoee remedies which have a direct efiect in controlling the exalted action
of the gjaagtionic cells of the spinal axis.
We will close this portion of the inquiry with a single observation, — in those dis-
eaaea, as J^phoid Fevety where there is great loss of excitability and power in the cerebro-
apinal and sympathetic nervous systems, we find a reverse condition to that which exists
in Tetanos ; instead of an exaltation of the reflex actions of the cord attended with
obalinale oonstipation, there is general insensibility to impressions, mental dullness,
dqwesDon of nervous' and muscular power, and loss of tone in the unstriped muscular
fibres, and tympanites, and profuse diarrhoea.
188 Observations on the Natural History of Traumatic Tetanus.
CHAN0B8 OF THK URINE DURING THE VARIOUS STAGES OF TRAUMATIC TETANUS.
The changes in the amount and character of the urine were important, in fumishing
data for the establishment of the relations *of the disease to fever and inflammatioD.
The following observations refer to the First Case of Traumatic Tetanus.
(a). The amount of water excreted during the active stages, was greatly diminished from
the normal standard ; thus the following amounts were excreted during the twenty-four
hours preceding the date : July 8th, grains, 6816 ; 9th, grs. 9852 ; 10th, grs. 10,962 ;
11th, grs. 6185; 12th, grs. 3796; average amount fur Jnly 13th and 14th, grmiDS,
11,325 ; 15th, grs., 7585 ; 17th, grs., 3792.
As soon as the remedies employed had made a decided impression on the nervous
system, as manifested by marked diminution of the force and frequency of the spasnas,
and oonsequent increased ability to take solid and fluid food, the watery element of the
urine increased greatly ; thus, the following amounts of water were excreted during
convalflscduoe : Average amount of water excreted each day, July 22d and 23d, graios,
15,035 ; 24th, grs., 15,028 ; average amount July 25th and 26th, grs., 16,204 ; aver-
age amount July 27th and 28th, grs., 19,245 ; July Slst, ghi., 27,190.
This concentration of the urine during the active stages of the tetanic spasms, ap-
peared to have been duo chiefly to two causes : 1st, to the inability of the patient to
drink fluid in any very large quantity. 2d, to the loss of fluid from the skin, the cause
of which we have before attempted to explain. When the jaws were relaxed, the
usual amount of fluids were drank, the spasms ceased to cause the loss of fluids fiom
the surface, and then the usual amount of water was separated from the blood by the
kidneys.
. We have thus dwelt upon the concentration of the urine in Tetanus, because this phe-
nomenon is one that is common to fevers and acute inflammations. Thus, I have almost
invariably witnessed, and have frequently recorded a diminution of the watery elemeat
of the urinci in Intermittent, Remittent, Pernicious, Yellow and Typhoid Fevers, in
Small Pox, Pyaemia and Hospital Gangrene, in Pneumonia and PleuriUs.
It is evident. that the cause of the diminution of the watery element of the urine in
Traumatic Tetanus is dependent upon well defined causes, which will not aooount for a
similar diminution in fevers and inflammation.
'b). Urea, The urea was increased daring tlie active itaget of the dUeam.
\n determining the truth of this proposition, it should be borne in mind, that during
the severe spasms, the patient was able to take only fluid nourishment, and that in much
smaller quantities than in health : in fact the patient was in a state of partial stanraCaoo.
The following amounts of urea, were excreted during the active stages, in 24 iMmrs :
July 8th, grains 218; July 9th, grains 381; 10th, grains 466; 11th, grains 302;
12th, grains 177 ; average amount, 13th and 14th, grains 521 ; 15th, grains 386 ; 16th,
grains 546.
The averagft amount of urea, excreted daily, from July 8th to July 16th, indnaiTe,
(9 davs,) waa grains 413.39 ; whilst the average amount of urea excreted daily during
oonvaleseenoe from July 17th to July 3l8t, (13 days), was only grains 342,46, notwith-
standing that during this time more food was taken than during the active stages of
the disease. In this latter period, it is important to note, that just after the nnmslion
of the severe spasms the urea sank to a low flgure, and continued thus for sevend days,
and then gradually rose to the standard of health, being on the 31st of July, 543
grains.
The estimates by various observers, as to the average amount of urea excreted dariog
twenty-four hours, by adult men, vary within wide limits ; but the variations nay,
however, be leoonciled by referring them to the differences of methods of analysis, and
to the different circumstances and conditions of rest, exercise and food.
Beoquerel^ estimated the amount of urea excreted by heaJthy adults at from 225
• Becqnertl'i and Rodier*i Pathological Chemiatry.
i
0h$ervation8 on the Natural History of Traumatic Tetanus* ISO
to 270 gnuDS in tweDty^four hoars. Golding Bird"*" places the average amount excreted
by healdij mea duriog tweoty-four hours, at 270 grains. The following are the results
deduoad by M. Lecanu from a series of 120 analyses :
Maximum Mean Minimum
QraioB. GimiQB. OiuIdb.
Adult UcD 510.3G 433.13 357.5
Adolt Women 437.15 295.15 153.2
Old Men (84 to 86 yean) 295.15 125,22 61.0
Children of Kight Yeart 254.20 207.99 161.7
Children of Foor Yean i 81.83 69.55 75.2
I
r
Acoording to Lehman Q,f a healthy man excretes duriog twenty-four hours, from 340
to 600 grains of urea. This physiologist obtained the following results from experi-
neots upon himself:
. Urea Secreted (A TtcentV'four Hourf.
Mixed Diet. , Grains, 501.76
ADioial Diet ^ .. 821.37
Vegetable Diet 347.10
NoD-ltl(rogeD008 Diet 337.90
Id the first set of experiments Prof. Lehmann adopted an ordinary mixed diet, and
took no more solid or liquid aliment than was needed to appease hunger and thirst, and
afaiteiiied from fermented drinks. Every two hours he took exercise in the open air,
bat mmded immodorate exertion of every kind ; the result given upon the first line reprc-
seate the average amount of urea passed, under these circumstances, for fifteen days.
Id the second set of experiments, Professor Lehmann lived for twelve days on an ex-
dusiTely animal diet, which, during the last six, consisted solely of eggs ; he took
thirty-two eggs daily ; which eontained 2929 grains of dried albumen, and 2431 grains
of fiitty matter, or about 3532 grains of carbon, and 465.5 grains of nitrogen. From the
table it is seen that the urea increased from 501.76 grains to 821.37 grains, and con-
taiaed more than five-sixths of the whole amount of nitrogen ingested. In the third
set, the experimenter lived upon a vegetable diet, and during this period the average
dailT apnottnt of urea fell to 347.10 grains. In the fourth set, the diet consisted en-
tiray of pore farinaceous and oleagenous snbstances, so that the azotized matter of the
DfiiM (orea) moat have been solely the result of the disintegration of the tissues ; and
it is aeao to have undergone a rapid and marked diminution, for this diet was used only
two days ; the health of Professor Lehmann was so seriously afiected, that he was
Baahb to eoDtinne this diet longer.
Dr. JohD C. Draper found the average quantity of urea excreted during twenty-four
hoon to be 408 grains. Bischoff ^ places the average for adult men at 540 grains.
The aversge daily amount of urea excreted by adult males, between twenty and
fetiy years of age, has been given at the following figures by the different observers :
PMea,' 371.5 grains ; Benke/ 378.2 ; Soberer,' 416.8-460.4 ; Moos,"^ 444.6 ; Bocker,
444.9; BehDeller/ 458.2; Neubauor,' 511.2; Kaupp, 535.1 ; J. Yogel,' 540.0 ; V.
Deposits ; Joarnal De Pbarmacie, 1R39, t. zxr, p. 681.
I Pbysiological Cbeniitrj, (Gavendiili Soc. Ed.) Vol. ii, pp. 450-452.
1 HanistolTals Mais der Stoffwechieli, 1853.
2 Conpotltion of Urine.
S Dia Weikanf dei Nord<— See Dades, 1855, p. 30.
4 Warsbarf Yerbandlongen, Band ii!, p. 184.
5 Heala's Zeits, filr rat.* Med., Band vii, p. 291.
6 Talentia's Baport on Pbjf. CansUtU Jabreab, fur 1855, p. 108.
7 Arcbiv. dcs Vereias tat Wiis. Heiik, Band ili, p. C3.
• Meabaner's Anleitnng, 2d Ed 1855.
190 Observations on the Natural History tf TrautMtio Tetanus.
Fraoque/ 541 .3 ; Beigel, 551.0; Mosler/* 558.9; Rammel," 563.6-605.2; Keraer/*
588.2; Raake,^ 656.0; Hammond/' 670.6; Gentle, 512.4; Warneeke," 520;
HaiightoD,*' 575.8 grains. Dr. Edmcnd A. Parkes," in his work on " ne Com-
position of (he Urine in Health and Dueasej and under the Action oj Remedietf*
gives 08 the mean result of numerous analyses of the urine of adult males, between
twenty and forty years of age, (the mean in the analyses being generally drawn from
more than six, and often ten to twenty days), at 512.4 grains during twenty-foor
hours. Dr. Thudichum in his work on the Fatf^olopy of the Urine, affirms that numeroufl
experiments have shown that a healthy man, who lives well, dischai^es from 30 to 40
grammes (463 to 617 grains) of urea in twenty-four hours. The discrepancies in theie
results arc referable chiefly to differences of chemical processes, and in the diet mud
modes of living of the subjects of the experiments. Thus, the procera employed by
BecQuerel (the separation of the urea as a nitrate, yields lower result^ than the toIu-
metric method of Liebeg), which was employed by most of the observers, whose r^ults
have just been presented, and which method was also employed by myself in the analy-
ses of the urine recorded under the head of the Ftr$i Ocue qf^JT^umafie l^etanM, to
addition to this, the subjects of Becquerel's experiments were Frenchmen, who, ftom
their size and diet, appear to yield a less amount of urea than Englishmen, and proba-'
bly also than Germans. Professor Lehman n, according to his statement of the amount
of food consumed during his investigations, evidently excreted more area than usual 4
and the average founded upon his experiments would be somewhat higher than the
avera^ with Americans. If wo adopt the standard of Dr. Thndichom, whichia fkll
high for Americans, and too high for Conlederate soldiers daring the Amerioan civil war,
1861-1865, when they were compelled to dispense with all the luxariea and aapar-
fluitics of diet, it is evident that notwithstanding the state of almost abaolnto starrailoa
to which this patient was subjected during the active stages of Tetanus, the area, so fiv
from being diminished, maintained very nearly the standard of healthy men actively
employod and supplied with full diet
If we compare the amounts of urine, excreted during the same paroxynna, with the
amounts excreted by Prof. Lshmann, in a vegetable diet (347 grains) and on a non-
nitrogenous diet, (232 grains,) it is evident that it was grcaitly increased.
In the experiments of Dr. William Hammond, we have still more valaable data Ibr
determining definitely the increase or decrease of the urea. At the time that theee
experiments on the nutritive value and physiological effects of albumen, staroh and gam
were performed. Dr. Hammond was 28 ( yean of age, 6 feet 2 inches in kdg^t ; 381
inches around the most prominent parts of the chest ; weight ranging from 215 to 230
pounds; temperament sanguine-nervous; habits temperate, using neither aleohoiie
liquors nor tobacco. As to his exercise, Dr. Hammond states : '^ I rose from bed at
61 A. M., and retired at 101 p> m. : eight hours of the twenty-foor wera aooordingly
passed in inactivity, the remaining sixteen was apportioned in the following manner :
eight were occupied in conducting the necessary analyses, and in other work in tke
laboratoiy ; four were given to chemical and philosophical studies ; and four were taken
up with the duties of his profession, physical exercises, recreation, etc. The eseraw
was quite limited, consisting of walking about one thousand yards per day.'**
9 Soberer*! Report on Pk^s. Clictn., Ciin8tAtt,H Jalire sbf 1855, p. 206.
10 Arcbir des Verciiis, Band iii, p. 431.
1 1 Warzburg, Verhandiiingen, Band v.
Ti Arcbir des Vereiiis, Bund iit, p. 027.
13 Composition of the Urine, by Pnrkes; London, 18(i0, p. H.
14 American Journal Medical Sciences, April, 1K59.
15 Dublin Medical Press, .luly, 1859.
16 Dublin Journal, Aug., 1859.
17 Tomposition of Urine, pp. 7, 8.
* Experimental Researcbes relative to ibe value and Pbysiologtcal Bffects of Albon^o,
Starch and Qum, when singly and exoluBi?elyus«d as food, etc. By William A. HaatoMnd,
M. D., etc. Traas. Am. Med. Ass. 1857.
Observations on the Natural History of Traumatie Tetanus. 191
. Upon a diet exclusively of starch, amount of urea excreted 1st day, grains 421 ; 2d
day, 369; 3d day, 225; 4th day, 204 ; 5th day, 160 ; 6th day, 175 ; 7th day, 157 ;
8th day, 185 ; 9th day, 132 : 10th day, 121 grains. Daily mean for the ten days 215
grains.
Upon a diet exclusively of gum, amount of urea excreted Ist day, grains 330 ; 2d
301 ; 3d 282 ; 4th 275 ; giving a daily mean of 279 grains.
The effects of this insufficient diet upon the excretion of urine, in this observer, is
placed in a clear light, when compared with the results of the examination of hb urine
in health, under ox^dinary diet, and under a diet exclusively of albumen. Upon a full,
g<eiierou8 diet, the average daily amount of urea, excreted by Dr. Hammond, was 694
gnuns ; and upon a diet exclusively of albumen 715 grains. Dr. Hammond upon a
unevigus occasion determined the amount of urea excreted during exercise and rest ;
dunqg moderate exercise 682 grains of urea wqre excreted during 24 hours ; increased
cucereiae 664 grains; and during no exercise or rest, 487 grains.
If now we consider that Dr. Hammond weighed from 70 to 85 pounds more than
this patient, and farther, that during the active stages of the disease the patient suffer-
ing with Tetanus (Case No. 1) did not consume as much food as Dr. Hammond did,
when upon the starch diet : and still &rther, that during his experiments. Dr. Ham-
mond waa actively exerting his muscular and nervous energies, whilst the Tetanic patient
waa at rest, as fiir as his voluntary motions were concerned ; we must come to the con-
donon, that the amount of urea was increased, and in fact was more than double that
which would have been excreted, if the patient had been in a similar state of starvation,
withoot the tetanic spasms, and in the enjoyment of his usual health.
This increased amount of urea was clearly referable to the incessant muscular and
nervous exertions, during the tetanic spasms — for as soon as they were relaxed, the
urea diminished in amount, notwithstanding that large amounts of food were consumed.
The rapid diminution of the urea below the standard of health, after the disappear-
ance of the spasms, appeared to be due, chiefly to the cessation of the muscular and
nerroos actions ; or rather to that chemical change of matter by which the muscular
and nervous forces are generated. AHer the cessation of the spasms, the patient re-
mained perfectly auiescent, unable even for a length of time to stand alone ; during this
period of rest, altnough food was liberally supplied, it was most probably employed in
the economy, to replace those portions of the muscular and nervous tissues, which had
been consumed in the development of the increased foroes ; and as the forces during
this period were feeble, so also the changes necessary to the generation of the forces,
were correspondingly feeble, and the amount of matter altered correspondingly small.
It should be carefully noted, however, that the urea was not increased during the
active stages of the violent Tetanic spasms, to that extent which is common in Fevers,
and aciite Inflammations.
In the active stages of Typhoid Fever and Pneumonia, I have found that it is by no
means uncommon for the urea to be doubled and even trebled in amount, and to average
from 772 to 1235 grains during the twenty-four hours ; and that, too, whilst the pa-
tients were taking, as in this case of Tetanus, little or no food. In yellow fever, when
the kidneys perform their normal functions, and when there is no abdominal alteration
of these organs, and diminution of their excretion, the urea is in like manner greatly
ioGTBaaed ; and in those cases in which the lesions of the kidney arc so great as to lead
Co the suppression of the urinary excretion, the urea is in like manner formed in large
aaoont, and accumulates in the blood, and induces symptoms of uremic poisoning.
Whilst, then, in the case of Traumatic Tetanus, (No. 1), th.c urea was increased
above the standard of starvation, it was not increased to that extent which is common
in feven and inflammations.
This hei sustains fully the conclusion previously announced, that uncomplicated
Tetanos should be classed neither with the Pyrexias nor with the Phlegmasia^.
(c.) Une Add: The urio acid was diminished during the active stages, and waa
increased during oouYalesceQQC«
192 Observations on the Natural History of Traumatie Tetanus.
This constitQtent of the urine, therefore, preseated the reverse change to that of the
urea. This result corresponds to that obtained by some physiologists daring aetiTO ex-
ercise of the muscles, and during rest. Thus, Dr. Hammond found, that whilst daring
acfive exercise, only 8.7 grains of uric acid were excreted during twenty-lbor hoara,
during moderate exercise, 13.7 grains, and during perfect rest, 24.8 grains were ezereled
during a similar length of time. Lehmann and other observers have obtained similar
results. The change from partial starvation to full diet, during convalesoenoe, withbat
doubt, as has been conclusively showu by the experiments of Lehmann, Hammond and
others, caused an increase in the amount of urio acid : it appears, however, that the
state of rest, after the paroxysms, had as much to do with the increase of thift aric add,
as the increase of food. If the relations supposed to exist between urio acid and area
in their origin in the animal economy, be assumed as established, it might have been
inferred that the reverse condition should have been manifested, that is, that the dis>
turbance of respiration during the paroxysms, should have caused the increase of the
uric acid ; it should be remarked, however, that the disturbances of respiration daring
the tetanic spasms were not such as to cut off or materially lessen the supply of oxygen,
for the disturbances were temporary and partial, and even during the most poweriol
spasms, sufficient oxygen was received into the lungs.
{d). Free Acid, If we receive as true the statements of Yogel, that the ftec acid,
during health, may range fix)m 30 to 61 grains during the twenty-four hours, it ia
evident that in this case, if due allowance be made for the effects of th^ hot weather,
and for the fact that the determination of the free acid was frequently neoeanrily
delayed for hours afler the urine had been voided, it is evident that no special change
in the amount of this constitutent can be discovered. And even if sach change hwl
been noticed, it would be difficult to determine its true significance, for it is even 'a mat-
ter of doubt with some physiologists, whether the free acid be due to the reaction of
phosphoric acid in the form of acid phosphates, or to the presence of' some organic
acid, or to both phosphoric acid and an undetermined organic acid.
The latter supposition is certainly correct in some diseases, as mahmal fever, in aome
stages of which phosphoric acid almost entirely disappears ; whilst the orine still pre-
serves a strong acid reaction.
The rapid disappearance of the free acid in the urine of convalescence, a few hoare
afler it was voidc^l, was by no means an index of an absolute diminution in its quantity,
but was rather the result of the rapid changes of the urine, induced by the hot weather,
and of those changes in this excretion which were dependent upon a fbll diet. The
increased susceptibility to change in the urine in convalescence, may also arise ^m the
more unstable constitution of the urinary excretion during that state of the system,
which is characterized by a return of appetite, an arrest of the waste of tissae, and the
formation of new, living or organized matter.
(e). Phosphoric Acid, The phosphoric acid was increased during the active stagea
of the disease, and gradually diminished in amount afler the cessation of the spasms.
The increase of phosphoric acid was coincident with the spasms ; the decrease was
coincident with the cessation of the spasms.
Afler the relaxation of the jaws, and the return of the appetite, the ainoant of phos-
phoric acid excreted by the kidneys greatly increased. Thus, during the active stara of the
disease, the following amounts of phosphoric acid were daily excreted : July Bth, gra.,
16.32 ; July 9th, grs., 39.96 ; 10th, grs.. 45.76 ; 11th. grs., 16.94 ; 12th, gw., 12.87 ;
average amount for July 13th and 14th, grs., 39.01 ; 15th, grs., 37 ; 16th, 16.3 gra.;
thus giving jin average during the nine days, when' the spasms were in greatest intensity,
of grains 28.03.
During convalescence, on the other hand^ the following amonnta of phosporic aoid
were daily excreted: July 17th. grs., 5.67 ; 18th, grs., 12.64; 19th, gn., 20.59;
average July 20th and 21st, grs., 20.78 ; average July 22d and 23d, gm,, 21.26 Joly
24th, grs., 17.79; average July 25th and 26th, grs., 13.98 ; average July 27th and
28th, grs. 28.76 ; July 3l8t, grs., 15.98 ; average for these 13 days, gt9., 18.63.
Observations on the Natural History of Traumalie Tetanus. 193
In seUling definitely, whether the phosphoric acid was increased or diminished during
the different stages of the disease, it is necessary to establish the amount of phosphoric
acid which is excreted under similar circumstances of rest and starvation. By these
data we wiU be able, not merely to determine whether the phosphoric acid was actually
iDcreased or diminished, but will also be enabled to discover the effects of partial starva-
tion upon the excretion of phosphoric acid, and thus eliminate the true effects of the
disease.
Dr. Breed, from thirty examinations of urine of four healthy persons, determined
the average daily amount of phosphoric acid to be, grains, 57.44 ; Neubauer, in the
fint individual, grains, 47.86 ; in the second individual, grains, 24.70 ; average for
twenty-four hours, grains 36.28 ; Mosler, first series, 37.05 ; second series in the same
individual, grains, 57.12; average grains, 45; Dunblkenburg, grains, 32.94 ; Kaupp,
35.46; Bencke, 39.21 ; Ranke, 41.53; Aubert, grains, 43.23.
The mean of twenty-five sets of observations collected by Dr. Parkes, was 48.8
ffnina a day.
Dr. William Hammond determined the amount of Phosphoric Acid excreted by
himself under different circumstances of increased and diminished intellectual labor,
and under the use of tea and coffee. During these experiments Dr. Hammond lived
generouslv, for he says : '^ during the twenty -four hours, I consumed sixteen ounces of
fresh beef, (boiled and roasted), twelve ounces of bread, one ounce of butter, eight
ounoes of potatoes, and two drachms of common salt. In the same period I drsmk
thirty-two ounces of water. No other food, solid or fluid, was taken into the system."
Under ordimuy exercise and intellectual work the average daily amount of phosphoric
acid excreted during ten consecutive days was, grains, 43.66 ; during a simitar period,
under increased mental exertion, grains, 66.15 ; under diminished mental activity,
grams, 25.10 ; when tea was used, grains, 38.07 ; coffee, 43.94.
If we compare the amount of phosphoric acid excreted by healthy, active, well-fed
men, as above indicated, with the results obtained in the first case of Traumatic Teta-
nus, we might, if the peculiar circumstances of the case were left out of view, conclude
that the phosphoric acid was actually diminished in Traumatic Tetanus. Correct con-
clusions, however, can only be drawn from a comparison instituted upon results obtained
with individuals similarly situated.
Absdnenoe from food, or from food containing phosporus and its compounds, dimin-
ishes the amount of phosphoric acid in the urine, but does not, as in the case of chlo-
ride *of sodium, cause its entire disappearance, for, whilst a larse portion of this acid
excreted by the kidneys, is derived from the portions of food wnich accomplish their
(»ffices without entering into the actual composition of the various structures, still the
portion, which varies according to definite laws, is derived from the changes of those
Ktmctures, which normally contain phosphorus and its combinations, as the nervous
and muscular structures. Thus, Mosler found, during abstinence from food, that the
phosphates of the urine sunk to half the ordinary quantity ; whilst, on the other hand,
under larger amounts of albuminous substances consumed as food, the amount of this
constituent of the urine was doubled.
The experiments of Dr. Hammond, from which we have before drawn facts for
camparison, are still more striking than those just referred to, and enable us to set-
tle definitely the question of the increased production and excretion of phosphoric acid
in Traamatic Tetanus.
Dr. Hammond confined his diet to the well-washed albumen of the serum of bullock's
blood, and his drink to distilled water, for ten days ; during this period, his strength
progressively declined, the pulse incr^sed in frequency, and upon the ninth da^ a
fterions diarrhoea, with thin, dark brown discharges commenced, and was attended with
1(«8 of appetite and disturbed rest ; and upon the 10th day the diarrhoea continued with
iDcreased violence, the debility was so great that the experimenter was compelled to lie
down, and the intellectual faculties were somewhat confused. The following amounts
of phosphoric acid were e^icreted daily: First day, grs., 36.17 ; second, 34.17 ; third,
194 Observations on the Natural History of Traumatic Tetanus.
48.21; fourth, 22.29 ; fifth, 17.25; sixth, 18.45; aeventh, 13.17; eighth, 11.08;
ninth, 10.52 ; tenth, grs., 9.15 ; average amount of phoephoric acid excreted daily
during the ten days' subsLstance on albumen, grains, 22.04.
During a similar investigation upon the nutritive value of starch. Dr. Hammond suf-
fered in a like manner, with headache, derangement of the bowels, loss of appetite and
great debility. Amount of phosphoric acid excreted daily, upon starch diet : First day,
grains, 27.18 ; second, 25.07 ; third, 26.61 ; fourth, 18.29 ; fifth, 10.55 ; sixth, 5.64 :
seyenUi, 5.70 ; eighth, 5.86 ; ninth, 5.50 ; tenth, 5.31 ; average for the ten days, grs.,
13.66.
In the experiments upon the nutritive value of gum, pure gum Arabic was the
article used, and nothing farther than distilled water, or rain water, was taken. The
injurious effects arising from this article of diet were far more rapid and obvious than
those previously recorded ; hunger, pains in the bowels, face, and great debility induced
Dr. Hammond to discontinue the experiments upon the fourth day. Amount of phof«-
phoric acid excreted during the experiments upon gum : First day, grains, 24.14 ;
second, 13.35 ; third, 7.09 ; fourth^ 4.55 ; average amount of phosphoric acid for four
days, mins, 12.28.
If It be borne in mind that Dr. Hammond weighed over '225 pounds, and at Icai«t
one-third more than the patient (case Ist) suffering with Traumatic Tetanus, and that
he was ftunished with far larger supplies of nourishment than that consumed by the
patient, and that he certainly, in the experiments upon albumen received larger supplies
of phosphorus and phosphoric acid in his food, it must be admitted that during the
active stages of Tetanus, the phosphoric acid in the urine is greatly increased above the
amount normally excreted by strong, healthy men, similarly situated as to diet and
rest.
This increase of phosphoric acid in the urine during the active stages of Traumatic
Tetanus, must be referred to the increased nervoi» and muscular actions.
(/*). Sulphuric Acid, The sulphuric acid, in like manner with the phosphoric
acid, but in a less degree, was increased during the active stages of the disease.
The following amounts 'of sulphuric acid were excreted daily during the active stages :
July 8th, grains, 11.28; July 9th, 21.24 ; 11th, 15.56; 12th, 9.57 ; 13th and 14th.
daily avenge, 33.73 ; 15th, 38.84; 16th, 77.67. A portion of this sulphuric acid,
especially in the highest figures, was, without doubt, derived from the sulphate of
magnesia, adminstered as a purgative ; the sulphate of c|uinia, daily administered, may,
in like manner, have, to a small extent, increased the amount of sulphuric acid. If we
exclude the figures, which were evidently affected, to a certain extent, by the sulphuric
add of the sulphate of magnesia, and if we accept the results of the observations of
Clare, Gruner, Neubauer. Parkcs and others, and place the daily amount of sulphuric
acid excreted by healthy men, at between twenty and thirty-eignt grains, with a mean
of thirty-one grains, it is evident that the truth of the statement, with reference to the
increase of this acid during the active stages of this case of Tetanus, will not be evident
without farther consideration of the amounts of this constituent of the urine excreied
during circumstances similar to thone in which this patient was placed.
The experiments of Lelunann, Vo^el, Clare and othere have shown that the charac-
ter and amount of the food infiuenccs the amount of sulphuric acid discharged by the
kidneys ; animal food increasing, and vegetable food diminishing the amount of «ul*
phuric acid.
The experiments of Dr. Hammond funiish reliable data for the determination of the
question now under consideration.
Upon the albumen diet, the following amounts of sulphuric acid were excreted daily :
First day, grains, 28.65 ; second, 23.05 ; third, 29.18 ; fourth, 21.18; fifth, 15.12 ;
sixth, 12.18 ; seventh, 10.73 ; eighth, 11.24 ; ninth, 8.96 ; tenth, 8.36 ; avenge for
ten days, on albumen diet, grains 16.92.
Upon starch diet, first day, grains. 30.45; second, 19.68; third, 12.07, fourth,
10.56 ; fifth, 6.70 ; sixth, 4.12 ; seventh, 3.81 ; eighth, 3.09 ; ninth, 2.60 ; tenth^
2.26 ; ayenge for ten days on starch diet, grains, 11.12.
Observations on the Natural History of Traumatic Tetanus, 195
The comparison of these results demonstrates conclusively that the sulphuric acid
toa$ increoied during the active stages of Tetanus.
Recent investigations have not confirmed in all respects , the observations of Ber-
lelius and others, with reference to the presence of sulphuric acid and sulphates
in any considerable amounts in the juices of fiesh ; and they point to the kid*
neys and blood as the positions where these chemical changes are completed, in the
final conversion of the sulphur of the albuminous compounds, into sulphuric acid.
The absence of sulphates from the juices of muscle, may also be due to the constant
passage of these salts from the muscular fibre into the blood; and the continuous and
efficient elimination of the elements or compounds, by the kidneys. Whatever view we
adopt with reference to the formation of sulphuric acid in the animal economy, it is
evident that its increase, during the active stages of any disease, indicates an increased
change of those nitrogenous tissues which contain sulphur. It is reasonable to suppose
that the increased amount of the sulphuric acid eliminated during the active stages of
this case of Tetanus, was due to the more rapid chemical changes during the severe
Hpasms.
(y). Chlorine — Chloride of Sodium, The chlorine was diminished during the active
stages, but gradually increased, and finally attained the usual standard during oonva-
lesoence.
Thus, the following amounts of chlorine were excreted during the active stages:
July 8th, grains, 31.68; 9th, 45.22; 11th, 10.59; 13th and 14th, average each
day, 38.83 ; 15th, 16.53. A portion of the chlorine, and perhaps a greater part of it,
may have been derived from the chloroform administered internally. This statement,
however, would admit of extensive discussion, and perhaps the ultimate facts as to the
amount and character of the transformation of chloroform in the living body are
wanting.
During convalescence, the following amounts of chlorine were excreted : July 17th,
^Trains, 5.25 ; 18th, 23.17 ; 19th, 37.82 ; average daily amount during July 20th and
21«t, 42.42; average 22d and 23d, 68.70 ; 24th, 107.79; average July 25th and 26th,
t;4.03 ; average 27Ui and 28th, 94.56 ; August 1st, 120.30.
It is important that we should determine whether the decrease of the chlorine during
the active stages of the disease be the result of diseased action or of physical circuiB*
Mtances, as the character and quality of the food, aside altogether from the effects of
disease. We must, in settling this question, determine the effects of circumstances
^milar to those in which this patient was placed, upon the excretion of chlorine in the
urine of healthy men.
H^rar, from a series of accurate observations upon eight young gentlemen, students
at the University of Geissen, found the average daily amount of chlorine discharged in
the urine to be 161.96 grains.
According to Parkes, the daily amount of chloiiue discharged by healthy men,
ranges from 51.87 to 58.05 grs. J. Yogel gives 92.06 grs. as the daily average ; and
Boekheim, 105.6; Mosler, 108.23; Bischoff. 134.32; Neubauer, 136.87 ; Wilde,
145.60; Hammond, 154.80; Kaupp, 155.94: Kerner, 156.71; Bencke, 162.12;
< tenth, 173.23 ; mean of the results obtained by these obser^'er8, grains, 126.76. If
the whole of this chlorine were united to sodium, it would make nearly 210 grains of
rhioride of sodium ; an amount which Dr. Parkes considers as too large ; and this dis-
tinguished observer believes that it is safe, with Vogcl, to put the amount of chlorine
at 7 grammes, which would give nearly 11} grammes, or 177 grains of chloride of
ividinm in twenty-four hours.
If these results be accepted as correct, then there was a most decided diminution of
chlorine, during the active stages of Tetanus.
The naked statement of this fact, would at first excite interest, because Rethenbacker,
Vogel, Beale, Thudichum, and others, have shown that in Pneumonia, and in fact in
acnte febrile diseases, generally, the amount of chlorine discharged in the urine, rapidly
decreases, and even disappears entirely for a short time, and then as the diseased action
196 Observations on the Natural History of Traumatic Tetanus.
abfttes, the amount iocrenBes during oouTalesocnoe. .Viewed in this oonnection, Uiifl
fact would seem to oppose the view, previously recorded, and to indicate that there was
some true inflammation, or febrile excitement in this case of Tetanus.
To settle this question, we must determine, whether the diminution of chlorine may
not have been entirely due to the state of partial starvation in which the patient was
placed by the disease, and the consequent absence or diminution of chlorides in the
food. It is now well established that the chlorine dischaiged by the urine, is almoat
entirely derived from the chlorides (chiefly Chloride of Sodium,) of the food, and
consequently difiers in amonnt in different individuals, and varies in the same individ-
ual in aocoraance to the amount and character of the food consumed : it results from
this, that during starvation, even in health, the chlorine will rapidly diminish, and may
almost entirely dbappear. Thus, Dr. Hammond, upon a diet of Albumen, excreted
the following amounts of chlorine during twenty-four hours : First day, grains, 30.54 ;
seoond, 21.54 ; third, 10.45; fourth, 5.37 ; flfth, 5.01; sixth, 4.22; seventh, 3.61;
eighth, 3.25 ; ninth, 2.39 ; tenth, 2.12 ; average during ten days subsistence on Albu-
men, gndns 8.86 : upon an exclusive diet of starch, with pure water for drink, as in
the prisvious experiment: First day, 85.26 grains of chlorine; second, 31.04; third,
14.27; fourth, 8.41; fifth, 8.03; sixth, 6.22; seventh, 4.74; eighth, 4.30; ninth,
3.01 ; tenth, 1.89 ; average grains, 16.71 : upon an exclusive diet of gum, first day,
grains, 46.28; second, 21.15; third, 6.33; fourth, 3.20; average grains, 19.21 of
chlorine.
The results of these investigations, enable us to affirm, that the decrease of chlorine
in the urine, during the active stages of the Jirst case of Traumatic Tetanus, was due
to the limited amount of food, and consequently, the limited amount of chlorides con-
sumed by the patient, and not to any inflammatory condition, similar to Pneumonia,
and the acute stages of certain febrile diseases, as Typhoid Fever and SmaD-Pox.
From this extended examination and comparison of the phenomena manifested
during the progress of the first case of Traumatic Tetanus, for the continuous invest-
igation of which we enjoyed unusual advantages, and to which a large amount of time
was devoted, we draw the following general conclusions :
1st. The essential phenomena of inflammation were absent. The phenomena were
exaggerated manisfestations of nervous and muscular actions. An irritation in a dis-
tant nervous branch was propagated to the spinal cord, and the disease, after its estab-
lishment, appeared to be dependent upon an exalted exdtability of the entire spinal
ganglia, as manifested in the greatly exaggerated reflex actions.
2d. The increased actions in the nervous and muscular systems, were attended by
corresponding changes in the materials composing these structures, thus indicating that
the two were intimately connected and were even dependent upon each other in the
relation of cause and effect. In these phenomena of the human organism, as wdl as
in the physical and chemical phenomena of the exterior world, we find no excepdon to
the law, that for the production of definite physical, and the to^dUtd vital actiom and
results, a certain amount of matter must be chemically altered : that is, be deprived of,
or emit, a certain amount of force, inseparably connected with certain forms and com-
binations of matter.
3d. The phenomena during the active stages of Tetanus, point to a change in the
electric conditions and relations of the nerves and muscles.
We will not now discuss the question, as to whether the peculiar spasms of Tetanoa
were caused by a pn-exiiting change in the conditions and reladona of the musdes, or
whether they were directly tracei3>le to the transmission of the irritation ftom the
wound ; but will confine our attention to the examination of those fiu^ whidi throw
light upon the physical phenomena of the nerves and muscles, during thetr vi
-^-"^' in Tetanus. •
We have discussed at length, in the Phvsiological introduction, the rektions of th^
muscuhr and nervous forces : and shown that :
Observations on the Natural History of Traumatic Tetanus. 197
a. There is a close analogy between the structure and mode of action of the elec-
trie orgiDS of certain fish, and the nerves and muscles of living animals.
6. Animal life is not possible without constant chemical and physical changes in
the moleciiles of the body ; and since such disturbances are always accompanied with
the libentaon of electricity, we infer that electrical currents exist in all living stmctures,
and that the intensity of these electrical actions, varies with the amount and character
of the physical actions of the tissues.
c Electrical currents circulate in all tissues in which active nutrition is carried on,
and the electro-motive force, is strongest and at the same time is capable of the greatest
and mo«t sadden variations in intensity and direction in the nerves and masdes.
d. There exists, both in the muscles and in the nerves of all animals, a natural
eleotricity, which is manifested under the form of closed circuits, circulating along the
nmaclea, or nerves of the animal, and of which we can collect, but a very small derived
portion, by the assistance of. our instrumento ; and the preservation of thi^free electricity,
w snbordinate to the state of life of the animal, and disappears with the cessation of
the normal chemical and physical changes characteristic of life.
e. An electro-physiological law of great interest, in the study of the phenomena of
Tetanus, has been established by DuBois Reymond, for the motor nerves, and may be
ezpraned thus : the motor nerves are not excited by the absolute amount or density of
the eorrent, but merely by the variations which occur in the density of the current,
from one instant to the other, and the more considerable the variations in the density
of the eorrent, the greater the physiological effects. It resalts from this, that unstable
eonditions of the closed, muscular and nervo^us currents dependent upon derangement
of the chemical and physical properties and actions of the molecules of the muscles and
nerves, would be necessarily attended by deranged muscular and nervous actions : vari-
ations in the density of the currents circulating in the motor nerves, may be attended
with either exaltation or depression of muscular action.
/. Contractility is inherent in the muscles : and is not the result of a force commu-
nicated to the muscles by the nerves. The muscles do not derive their state of tone,
or power of contractility from the oerebro-spinal and sympathetic nervous systems, but
posMSS within themselves, all the conditions necessary for the generation of their
proper force.
^. The muscular force results from the chemical changes involved in the healthy
notrition of the muscles ; the chief influence of the nervous system, therefore, upon
the mnscolar system, is by the disturbances of the electrical condition, and by an influ-
eooe upon the nutrition of the muscle, through the variations of the amount of blood
eirenlatAng through the muscular structures.
A. If in the state of health, the molecules of the nerves and muscles are retained
in a parUcnlar arrangement, by the vital force, and if under the action of the will, or
other canaes determining muscular contraction, or relaxation, this arrangement is modi-
fied, BO as to become similar to the condition of a conductor transmitting an electric
current, it is probable that when derangement of the molecules is caused by almost
every cause, however slight, capable of dirturbing the electric equilibrium, and even
b^ond all control of the will, and even so powerful in its effects, as to rend asunder
the mnscolar structures, there is either a want of proper action of the vital force, in pre-
serving the mutual and definite rclaticTns of the molecular forces, or an undue activity in
the nolecnlar changes in the nerves and muscles. We have previously demonstrated,
that daring the active stages of Traumatic Tetanus, there is an increased chemical
diange of the nerves and muscles ; we must conclude therefore, that the disease is due
not only to a disturbance in the electrical conditions and relations of the nerves and
mnsdea, bat chiefly to a great augmentation of the intensity of the electrical actions in
both nerves and muscles. This view is farther sustained by the fact, that the contract
tiona of the maadea in tetanus are far more violent and prolonged than those of health,
ezflited by any cause whatever, internal or external, by the will, or by mechanical
li — so violent in fact, that the muscles are frequently ruptured, and that toO)
198 Observations on the Natural History qf Traimatic Tetanus.
against do other pointB of aotioD, than the bony levere, and in no other action, than in
that of simple involuntaiy contractions ; and by the equally striking ftct, that a oon-
tinnons corrent of electricity may, when passed m a certain direction, relieve the spasms
of Tetanus.
f. If it be tme, that the nervous force is electricity, or a modification of electricity,
and if all the chemical actions in the body, develop this force, together with heat, it
follows as a necessary consequence, that nerves may be capable of influencing secretion,
in virtue of the power which their active force has of exciting chemical change. Thus
an impulse originating in the central masses of nervous matter, or reflected from the
circumference, may be propagated by changes of the molecules of the nerves, and
reproduce ite original effects, by transmission to distant organs. We would thus have
an example of chemical change in the periphery of the nerves, and in the various
organs, whether muscular or secretory, to which they are distributed, analogous to that
which takes plaoe, at the terminals of the galvanic battery.
In Tetanus, where there is an exaltation of the acts of the ganglionic cells of the
gray matter of the spinal axis, constant impulses are sent out to the voluntaiy muscles,
and to the sympathetic, in virtue of the nervous connections, between the two systems ;
and thus the ganglionic cells of the sympathetic become in turn excited, and the oigami
to which this system is distributed, such as the kidney, liver, and alimentary canal and
heart, are in turn affected.
CHAPTER III.
OBtfEKVATTOKS ON THE PATHOLOGICAL ANATOMY OV TRAUMATIC TETANUS. COMPARMON OF
THE PATHOLOGICAL CHANGES IN THIS DISEASE WITH THOSE OF INSANITY. EPILEPSY AND
FARALYSI& GENERAL CONCLUSIONS AS TO THE NATURE OF TETANUS AND ITS RELATIONS
TO CLIMATE AND CHANGES OF TEBIPERATURE.
Ob^erraiioos on the Pntbological ADatomy of Traumatic TetaDus. Comparison of the
pHtbologieal cbangcs in this diseage, with those of Insanity, Epilepsj, and Paraljsii . Gen-
rral conclusions as to the nature of Tetanus, and its relations to Climate and changes of
Trmperatnre. Cases illustrating the Pathological Anatomy of Tetanus. Blood-vessels of
j;nijr matter of spinal cord congested and dilated. Discussion of the cause of the congestion
find dilatation. Analysis of the investigations of various anatomists and physiologists, upon
the effecta of congestion of the blood-vessels of the spinal axis: more especially of S. Weir
)1ilrhcll and Benjamin Ward Richardson. Analysis of the labors of various pathologists-
wiib reference to the lesions of Traumatic Tetanus, as Morgagni, Rokitansky, Larrey, Dupny
iren, Pellitier, Ilennen, Craigie, Curling, Copland, Parry, Travers, Sandwitb, William Aitken,
Lockbart Clarke, Dickinson and others. Comparison of the lesions, characteristic of Trau-
mntic Tetanus, with those of Insanity, Paraplegia, Hemaplegia and Epilepsy. Cases. Rela-
tions of Traumatic Tetanns to soil and climate. Statistics of various C*ities, as London,
Philadelphia, New York, Boston, Calcutta, Savannah, Charleston, Augusta, Nashville and
New Orleans. Relative prevalence and fatality of Tetanus, in White and Black racfis.
PATHOLOOICAL ANATOMY OF TRAUMATIC TETANUS.
In the preocdiDg chapter, I eodeavored carefally to iovestigate the phenomena pre-
sented by a typical case of Traumatic Tetanos, and to interpret the characteristic mani-
festatioDfl, by the light of Physiological and Pathological observations, experiments and
researches.
We desire in the next place, to determine, whether hny pathological alleratiom arc
reeogDixaUe after death from Traumatic Tetanus, wbich can be assodated with the
abnormal manifestations during the progress of the disease.
In this inquiiy we will endeavor to pursue the inductive method, first presenting
our own observations, and then comparing them with the facts reoorded by other patholo-
gisU,
Ccue 21 : Traumatic Tetanu$ ; Life of the patient pmerved temporarily by Marshall
Baltt Ready Method; po8t»mortem examination. Structured Alteration qf Qn'd,
J. A. Roak, Company K., 1st Alabama Cavalry, Hagan's Regiment ; private; age, twenty-r
one ; black hair; fair complexion ; nervous temperament ; admitted in the Third Georgia Hos-
pital, A agosta, Oa,, February 11, 1865. Was wounded February 2d, in a skirmish, near
Alendisle, S. C, by a ball from a Spencer rifle. The ball passed through the abdominal mus-
cles pf the right side, one inch above the crest of the ileum, entering anteriorly. Distance
from one orifice of the wound to the other, about four inches. From all appearance the ball
pasied entirely within the muscular structures of the wall of the abdomen, and did not pene-
trate the cavity. Patient's health good, before the reception and at the time of this wound.
After being wounded, be was sent to the Division Hospital, in which he remained nine days,
moving along with the hospital in ambulance to Augusta, Georgia. During this time the
wound was dressed once a day, aa4 kept moiit with a wet rag. Patient felt well during
200 Pathologiccd Anatomy qf Traumatic Tetanus.
that time, but when entering the hospital, complained of cramps ( to use the patient's own
expression ) in the wounded side and back.
On the 12th of Febrnary, Opisthotonos gradually commenced. From 10 a. m., one tea-
spoonfnl of Laudanum (Tincture of Opium) was adminiittered every one and a half hoars,
until 6 o'clock p. m., (the whole quantity or Laudanum given np to this time wai about one
wineglaisfbl, which produced no perceptible effect.) No medicine given daring the night —
patient slept very little. One natural evacuation of bowels this day.
February 13th. Trismus commenced this day, Chloroform was given by inhalation, which
allayed the nervous irritation for about one hour. This was continued during the day, with
the addition of one tea-spoonfnl of Chloroform, and another of Landannm, adminittered
internally every three hours, until three doses were taken, when the trismus increased to inch
an extent at to prevent deglutition. The Chloroform appeared to diminish the volume of the
pulse. Respiration during the day, tolorably easy. The tongue, at far at could be teen,
natural. Condition of skin natural, sometimes moist. Bowels constipated. Urine' nataral
in color and quantity.
February 1 4th. Trismus and opisthotonos increased. Respiration more labored. Infection
of Turpentine and Castor Oil given with no effect. One tea-spoonfnl of Chloroform, Laada-
num and Ether, mixed in equal quantities, were given by the mouth, every three hours, with
no perceptible effect.
February 15th. Tetanic symptoms increased. Respiration more labored — no evacoation
of the bowels. Ao enema composed of one tea-spoonful each of Tincture of Camphor and
Tincture of Opium ( Laudanum ) was given every three hours. No benefit appeared to be
derived from this mode of medication and it was discontinued.
Patient continually kept under the influence of Chloroform, to relieve his sufferings-— no
sleep obtained without Chloroform.
February 16th. Symptoms increased in severity — deglutition more diflBcult — Chloroform
continued by inhalation.
An attempt was made to administer egg-nogg, by the mouth, but failed — patient could not
swallow, and immediately after the efforts, was seized by a violent tetanic spasm, la the
spasm, the muscles of respiration became involved, which soon arrested the thoracic respi-
ration, so that the latter function was only performed by the diaphragm and abdominal muscles.
At length, however, these muscles also became involved, and respiration ceased entirety.
The patient's face turned blue and livid, the black blood overcame the cerebro-spinal system,
the eyes were fixed — all signs of life disappeared, and death from the asphyxia appeared
already to have taken place.
Artificial respiration after the method of Marshall Hall, was established and kept ap for m
few minutes, when the patient gradually revived. The spasms of the respiratory mascles also
gradually relaxed, and after sometime, the patient commenced to breathe again natarally.
At this time two ounces of whisky with one tea-spoonfnl of Chloroform, were administered
by enema. This was kept up with the addition of half a pint of beef-tea, every two bonrs nntil
the evening; with the exception of the Chloroform, the supply in the hospital having giveo
out.
Evening — patient more quiet — pulse 100 ; respiration more easy — conversed and swal-
lowed half a glass of water. Patient remained in this comfortable conditloD, aflbeted
with an occasional slight spasm. About 3 o'clock, a. m., he asked for water — a little was
given him, which brought on another slight spasm, during which he expired about ten min-
ntes after taking the water. This spasm was similar in its nature to the one already described
and it is highly probable that if the method of artificial respiration, had been practiced, the
life of the patient might again have been prolonged.
In viewio^ the Tetanic spasms of this patient, wo were forcibly reminded of the
graphio descnption of Aretadas"^ the Gappadocian.
Sixteen Centuries have not impaired tne accuracy or force of this pioture.
Auup9y fix houn after (ffoxA.— Spare but muscular man ; rigor-mortis very strongly narked— »
hands contorted and fingers clenched; and feet twisted as in srychnine poisoning.
The brain and spinal marrow carefully removed. The nerves leading from the spinal aar-,
row, to the wound, were also carefully dissected and examined in situ. The entire ttass of
flesh surrounding the wound, was then examined, and together with the spinal cord and iia
nerves and muscular attachments were removed.
OondUicn qf the awimtf.— The wound was a superficial flesh wound. The ball was a small
one, apparently not larger than a pistol ball, and had passed directly through the stractnres
without lacerating them.
When the tetanus first manifested itself, the discharge from the voaad is said to have
•Th« Extant Worfct of Aretitut, pp. 247—249.
Palhologieal Anatomy of Traumatie Tetanmn 261
grttLtif dtutnUhtd, and almoBt eniirelj diaappeared. Several deyi before death, however,
•od op to the close of life, the wound secreted small quantities of pus. When the entire .
tract was laid open, it was found to be granulating throughout its entire extent. The gran-
ulatioos were carefuUj examined with a magnifying glass. Thej were small and rather pale
The wound was dryer than usual, that is there was less discharge than in healthy wounds.
t Oder the microscope, the pus presented an unhealthy appearance. The corpuscles wer« •
small, few ID number and inpeffectly formed, and amorphous granules abounded.
The wounded surface was surrounded or underlaid by a thick fibrous wall, the result i f
ioAammatory action.
la the track of the ball, numerous sharp filaments of wool, were found sticking into thi;».
granulations, and passing in some cases, entirely through the fibrous wall, to the muscular;
structures beneath.
AcroM tupplying the dUetuid paria. — These were dissected, and traced into the parts immediate
)y surrounding the wound. These nerves presented no distinct evidence of congestion or
inftammation.
Spinal Marrow. — The nerve leading from the diseased and wounded part, was the liui dorsal.
This sent off a branch to the lumbar plexus; for two inches above its junction with the spinal
cord, the blood-vessels of the cord were engorged with blood, and the vessels presented a.
marked enlargement.
The congestion extended from thence, to the termination of the spinal cord, and the corda
equinse was also much congested. The thigh upon the affected ( right side ), had been quite
stiff at the hip. The congestion was greatest upon the posterior surface of the cord..
Sections of the cord were made at the various parts, from the junction of the medulla
oblongata, with the pons variolf, to the termination of the spinal cord, and the gray matiev
presented a pinkish, deep colored congested appearance.
Both the gray and white substances, were examined carefully under the microscope, the
nerve fibres presented the usual appearance; the cells of the gray matter appeared indistinct.
The blood-vessels of the gray matter were filled with red corpuscles.
This case presented the following points of interest :
itft. The restoration of the patient, after apparent death, by artificial respiration, was
a matter of importance.
The life of the patient was prolonged at least eighteen hours by this method.
A large portion of the cases of tetanus, terminate fatally from spasm of the respiratory
maselci. If artificial respiration had been practiced the second time, it is probable that the
patient would again have been restored. The narcotic effects of the Oarbonic Acid of the
blood, tend to overcome the spasms, and hence the possibility of instituting artificial
respiration.
This subject is worthy of mo^t careful consideration, and of practical application in Uiis
terrible disease.
3d. The granulations and the pus of the wounded surface were imperfectly formed ; and it
is Dol aoreasonable to suppose that the irritation of the injured nerves may have arisen in a
measura from these unhealthy products of inflammation. The particles of wool penetrating
the Usauei, may also have been exciting causes of the peculiar nervous disturbances. It is
ireportaot that the most careful examination should be instituted of the wounded parts and
prodncts of the consequent inflammatory action.
3d. The gray matter of the spinal cord, was decidedly congested with blood ; and the
coogeeiion was so great, as to render this portion of the cord of a decidedly reddish pink color.
Tetaaic spasms were attended with great waste of the nervous and muscular elements, and
espacially of the former, as I have shown by careful analysis of the urinary excretion in this
diseasa.
The gray cells of the spinal cord, and medulla oblongata, during the stages of actionr,
excitement and change, need an increased and sufficient supply of blood.
4lh. The tetanic spasms in this case, were attended with palpable lesions of the spinal
cord ; and the most prominent condition of this state was hyperemia.
Case ift&; Traumatic Tetanus; death; cerebro-npinal $yntein examined after death I
itructural lesions discovered.
Julia Jackson, colored, aged nineteen, stout, athletic negro woman. Has never borne chil-
dren.
On the 5th of March, 1869, a clothes-line pole fell upon her left shoulder, and a splinter
passed downwards and forwards, under the skin, over the deltoid muscle. On the 15th of
March, after the wound had apparently entirely healed ( the injury was very slight, And the
splinter was removed immediately after the reception of the blow ), the jaws became stiff,
and tetanic symptoms inaqUestcd themselves.
S02 Pathologieal Anatomy of Traumatic Tetanus.
KnUred the Charity Hospital, New Orleans, March 19th, two weeks after the reception of
the ii^vrji external wound healed. Locked jaw and tetanic spasms, bodj drawn towards the
left arm and side ; that which had been injured. Patient complained of pain in left arm,
•boulder and side.
The attending physician administered Opinm and Bromide of Potassium, beef-tea and
brandy. One grain and a half of Opinm and ten grains of the Bromide of Potassium every
three hours, The opium appeared to quiet the spasms, and the patient enjoyed some reat.
On the 21st of March, this plan of treatment was changed, and one-twelfth of a grain of
Strychnine, administered every four hours. The patient took only two pills, and died soon
after the administration of the second pill, on the 22d of March. The contraction of the
muscles of the left side and arm, continued up to the moment of death ; and the patient
appeared to die from spasm of the respiratory muscles and asphyiia. The preceding facts
were furnished by the attending physician.
Auioptjf MX Aourt after death. — The brain and entire spinal cord were removed from this atout
young negro woman, whose form possessed the fulness and roundness of great muscular
power and of the most robust health.
The pia-mater of the brain and spinal cord, were srreatly congested with blood ; the con-
gestion wai greatest at the base of the brain around the medulla oblongata. The gray and
white matter of the cerebrum presented the usual consistence, but the cerebellum appeared
to be somewhat altered, being softer than usual. The gray matter of the spinal cord was
aniTertalJy congested, whilst the white matter was softened. The white matter protruded
from the smallest puncture of pia-mater and arachnoid membrane of the cord.
The most marked alterations were discovered in the floor of the fourth ventricle. The
blood-veasels of the fourth ventricle were not only greatly congested, but a small quantity
of blood waa effused about the middle and upper third of the fourth ventricle, beneath the
arachnoid membrane, and into the meshes of the pia-mater.
The internal viscera were healthy, and upon carefHil examination presented nothing abnormal,
with the exception of the dark colored blood resulting f^oro the sudden arrest of the process
of respiration.
The long on the leftside, was congested with dark blood and presented a marked difference
in thii respect from the right lung ; which presented some congestion only in its most
dependent portions. This condition of the left lung appeared to be due in a measure to the
eontractlon of the muscles upon this side, and the consequent interference with respiration ;
but It is also probable that the impairment of the function of the pneumogastric nerve on
thii ilde, may have been one of the causes.
The aeat of the wound was examined with great care. Two cicatrices were observed, the
one of entrance, near the upper border of the deltoid, and the other near the axillary fold.
An Incision between these two points, revealed thickening of the texture, but the Injury
had healed entirely.
GontlnnlBg the incision downwards, an abscess, with indurated walls, filled with about two
drachms of thick fmtid 'bloody pus, or rather grumoos fluid, apparently resulting from the
liquefaction or disintegration of the textures was revealed, occupying the upper turface of
the bleeps muscle. Within the abscess, two pieces of cloth were found, about half an Inch in
diameter, and apparently detached from her calico dress and undergarment, by the splinter,
and driven into the flesh. These particles of cloth were the only apparent cause of the
abscess, as no splinter or other foreign body was discovered upon careful and minute
dissection.
This case presents the following points of interest :
let. The strychnine accomplished no good, and appeared rather to aggravate the symptoms.
Sd. The disease appeared to have been caused by the presence of the particles of clothing.
If the existence of the abscess causing the tetanic spasms had been diagnosed during lif^, it
might have been possible to relieve the patient by laying it open, and exciting heallbj
suppuration.
3d. The muscles were most affected upon the side to which the injured arm was attached.
The nervea coming off from the muscles around the abscess, were more congested than those
supplying healthy structures ; and it appeared that the irritation was reflected most strongly
upion those muscles supplied with motor and sensitive nerves from the same lateral half of
the spinal cord.
4th. The pus, or rather fmtid fluid contained in the abscess differed widely f^om the pro-
duet of healthy inflammation, and the absorption of this matter, may have been one of the
exciting causes ef the tetanic spasms.
6th. The medulla oblongata, and spinal oord, exhibited palpable lesions, in the congestioa
of the blood-vessels, and the softening of the white matter.
In both the preceding ctmen, the Uood-vittbelj of the gray matter of the spinai eord
W6te dUlted. And congestod with blood. Tltat the oongeetion w«8 not d^ndent upon
Pathological Anatomy of Traumatic Tetanus, *W
ekaoges indnoed daring the last hoars of life, or subBoquently to death, were dearlj
•hown by the &ct that the patients died suddenly before the powers were exhausted,
md also by comparative examinations of the cord a]%er death firom other diseases.
Two questions immediately present themselves for discussion :
1st What was the cause of the dilatation and congestipn of the blood-vessels of the
spinal cord and medulla oblongata ?
• 2d. Did the diktation of the blood-vessels of the spinal cord and medulla oblongata
bear any relations to the tetanic spasms ?
In the first chapter we have dwelt upon the experiments of Bernard and Brown*
S^uard, showing that when the branches of the sympathetic nerve leading to any part
of an animal's body are divided, the arteries of the parts become AiUer, and the tem-
perature is raised by the increased quantity of blood which runs through ; and that
when, on the other hand, the same branches are excited by an electric influenoe, the
arteries contract, and the blood is driven out, and the temperature descends.
It was thus shown that the great sympathetic plays the part of a constrictor to the
small arteries, and slackens the capillary circulation ; when, therefore, this nerve is eat,
the small arteries become paralyzed and proportionally relaxed, whilst, on ihe other
band, exciting the action of the sympathetic by galvanism, causes such a constriotion of
the small arteries that their area is greatly diminished or obliterated. The results of
such experiments are manifestly dependent upon the anatomical structure of the arteries,
the walls of which may be conisidered as practically consisting of yellow, elastic tissue, and
unstriped muscular fibres, the functions of which are in a manner antagonistic to each
other, for, whilst the contraction of the unstriped muscular fibres of organic life tend to
alter the calibre of the arteries, the elasticity of the yellow elastic tissue, tends to restore
the area to a constant form ; when, therefore the nervous influenoe supplied to the art^
rial walls is cut off, the vessels dilate, because the yellow tissue still exerts its elasticity,
while the muscular coat is paralyzed. By these means, the distribution of the blood,
which la sent out in an intermittent manner by the heajrt, is regulated by the action of
the arteries. It is also well established by the existence of the circulation in the lower
animals devoid of a central organ of circulation, and in the heartless foetus, which lived
several days after birth, and in animals after the heart has been cut off from the vessels
by a ligature, that the arteries have a propulsive force in themselves, independent of
their elasticity, and of the action of the heart, which has been compared to the peri-
staltic action of the intestines.
The researches of Messrs. Legros and Onimus, (Recherches, Experimentales sur la
Oirculation, etc., Journal de 1' Anatomic et de la Physiologic, 1868, 1869, 1870^,
have rendered it probable that there is a peristaltic movement of the microscopic
arteries in man as well as in the lower animals.
The attention of these observers was first aroused by the fact, that in the normal
ormdition the contraction of unstriped muscular fibre is rarely spasmodic or in mass,
bat oontinuously alternate, wavy and vermicular, and they argued that the blood in the
aoridea was most probably passed on by a movement similar to that which propels the
oontenta of the digestive canal. The experiments of Messrs. Legros and Onimus, on
living animals, where the cardiac action has been annulled by tying the large vessels,
have shown that their circulation is continued for a certain short period even in mam*
malia, and for a much longer time in cold-blooded animals ; and in animals when the
sympathetic has been divided on one side, and the action of the heart paralysed by
poiflons, suoh as dilorofomi or alcohol, the temperature is found highest on the side
where the sympathetic has remained untouched; thus showing that the small arteries
poaaeas a power over the circulation of the blood independent of that of the heart, and
that the action of the sympathetic w to enable the small arteries to propel the blood,
by the alternate contractions and peristaltic movements of the unstriped muscular fibres.
These experiments not only sustain, but enlarge and magnify the results obtained by
Claade Bernard. It is thus rendered probable that the movements of the miorosoopic
arteriea are consecutive upon reflex action ; that is, the impulse communicated to the
t04 Patholoffiedl Anatomy qf Trawnatie Tetanus.
oolnmn of blood bj the hearty progreBsivel j dilates the arterioles, the seDsitiTe Sbrai of
the sjrmiMthetie distributed to their walls transmit the impression to the ganglia, and
the motor fibres acting on the contractile coat of the vessel, just as the di^stive eanal
progressively presses onwards the digestive fluids and materiab. Aooording to this
view, there is no neoessaty antagonism between the rjrthmical action of the heart and
the peristaltic motion of the microscopic arteries. By this theoiy, also, we are enabled
in a matiner to comprehend the mode in which alterations in the quantity and chemical
constitution of the blood, by blood-letting, and by the introduction into the vital fluid
of remedial agents, as well as morbid products and poisons, may act upon the nerves of
the Uood-vesMls, and by reflex action cause a diminution or augmentation of the eurrent
of blood supplied to each organ or tissue, and thus lead to disturbance of the normal
secretion, and nutrition, and excretion. It is evident, therefore, that as the blood-ves-
sels which supply each separate organ arc regulated by a distinct department of the
nervous system, external forces acting upon the nervous system may transmit their
eflects specially to these organs, and induce deranged secretion, nutrition and excretioD,
a«d such derangem ents may in turn, act upon the nervous system. If the eontroUtng
nerve force of the unstriped muscular fibres of the minute arteries be weakened or sus-
pended, an alteration or suspension of the normal circulation must ensue ; thus, when
paitial dilatation of the vessels has occurred from a slight degree of arrest of the peri-
staltie action of the unstriped muscular fibres, the powerful action (vU a terpo) of the
heart drives the blood more fully and freely than is -natural into the small arteries and
capillaries, and active hypersDmia is established, which mav be temporary or perma-
nent, aooording to the action of the disturbing force upon that portion of the nervous
system distributed to the blood-vessels.
Thus, we may have, on the one hand, every degree of hvpermmia, from the sadden
and temporaiy injection of the capillaries with arterial blood, in blushing, and the
throbbing of mental emotion, to the excessive secretion of irritation and incipient in-
flammation, and congestion, and stasis, leading to complete arrest of circulation, trana-
migration of colored and ooloriess corpuscles, and even rupture of the capillaries ; and,
on the other hand, such a d^>;ree of spasm of the unstriped muscular flbte of .the minute
arteries, as induces the diminution of temperature, and bloodlessnees of the surftoe in
the cold stage of fevers, and especially of Intermittent and Congestive Feven. As is
well known, in the cold stage of malarial fever« the surface is cold and pale, while the
blood is accumulated in the internal organs and large vessels ; and the action of a mor-
bid poison is still farther shown in the rise of the temperature of the blood in the
central organs and vessels.
During the cold stage of various diseases, and especially of malarial fevers, the arrest
of the peristaltic action, and the spasm of the minute arteries act antagonistically to the
heart ; when, however, owing to the intermittent action of the organic s^rstem of nerves
and muscles, the spasm passes off, there is a corresponding and consecutive dilatation of
the small arteries, which admits an increased amount of blood, and thus the cold stage
if snooeeded by the hot stage, which is attended by increased respiration, oironlstioa,
chemical change and secretion. In malignant malarial fever, we may have iatsl pam*
lyiis of the vcMels of the brain, leading to coma, or of the liver, leading to destmotiTe
Janndiee and alterations of the colored blood corpuscles in the capillanes of the liver
and in the spleen, or of the kidney, leading to hsomaturia, and complete arrest of the
urinary excretion. In a similar manner the suddenly fatal effects of sim-slroAM, have
been referred mainly to paralysis of the blood-vessels of the brain and spinal oord,
induoed by the efleots of increased heat and the altered blood loaded with oarbonie aeid
gas. In some cases of Mun-Hroke, the temperature of the bodv attains an eztnordinary
degree in a short period of time, ranging ftom 110 to 115^ F. Such a degree of heni
must necessarily prove fatal, from paralysis of the muscular flbres of the heart and
arteries, ss well ss from the necessary alterations of the blood and derangements of the
eersbio-spinal and lympathetio nervous systems.
We are thus led by the resoarohes of Legros and Onimns, to consider in a asors
Pathological Anatomy qf Traumatic Tetanus. 20^
fiTonble Iigfaty the views of Stahl, HoffmaD and Cullen, who perceived the impoiianoe
of the Bervoua sjBtem as a factor in disease.
We are therefore compelled in view of these ^ots, to regard the dilatation and con-
geitioD of the small arteries of the spinal cord and medulla oblongata in Tetanus, as of
great inportanoe, and as indicating not only an increased functional aetivity (secretion)
in the oentnl ganglionic cells, but also, panlysis or arrest of the action of that portion
of the sympathetic nervous system, which presides over the circulation of the medulla
oUofOgata and spinal cord.
Theieoond question, viz: Did the dilatation and congestion of the Uood-vessels of
the spinal cord and medulla oblongata, bear any relation to the tetanic spasms ? now
praseots itself for discussion.
The experiments of Dr. S« Weir Mitchell of Philadelphia, upon the effects of cold
to the cervical spine, are of interest in the light which they throw upon the effects of
eoageetion upon the production of spasms and exalted reflex actions. I have repeated
the nost important of these experiments, and obtained results similar to those announced
by Dr. Mitchell, in his article in the American Journal of Medical Sciences, 1866.
Daring the Spring and Summer of 1863, Dr. Morehouse, and Dr. Mitchell, engaged
in 1 prolonged research on the eerebro-spinal fluid, and the influence of pressure in
prodttring convulsions. When the small end of a tube, twelve inches long, and two
■uIlimetKs wide, (open at both ends, and drawn to a point at one extremity, and
ezpaaded fonnel-like at the other), was introduced into a minute opening through the
nenbnine which fills the oocipito-altoid space, previously exposed by an incision in the
middle line of living rabbits, and pressure was made upon the medulla oblongata and
spinal cord, by means of water poured into the upper end of the tube, held upright, it
wu possible, in this manner, to pour through the tube into the spinal canal, at least
katfojL ounce of jiaid.
At a ocftain point, usually when there was a pressure of ten inches in the tube, con-
TsLiioDs ensued and checked the experiment. Experiments were instituted to deter*
mioe the effects of water at different temperatures, and it was found that greater
pretture, and more continued pressure was borne, with water at 100^ F. than at 120°
or 60® ; and when water at 32° F. was employed, spasms followed almost instantly
opoB the introduction of the first few drops of fluid.
The convulsions which ensued, when water at 32° F. was introduced into the spinal
cord, were very remarkable ; the animal rolled, turned, leaped, shivered, and in fad,
exhibited every variety of convulsive action, in remarkable perfection. This effect
seemed to be due to the direct influence of cold on the medulla oblongata, since like
effects were produced when a morsel of ice was laid gently upon that organ, or when it
*tf exposed and ice water was dropped upon it. This very striking experiment led
Dr. Mitchell at a subsequent time, to test the possibility of suppressing the functions
of the central ganglia by the use of cold ; and after numerous unsatiafaotoxy experi*
BieatB with ioe and ice in salt-bags, applied to the spines and brains of rabbits, Omnea*
pigs, and kittens, in 1863 and 1864, he finally made use of the valuable method of
<aoai&g local ansoethesia by cold, invented by Dr. B. W. Richardson, of London, and
<jhtaiaed the following important results :
The method of research was much the same in each case : Richardson's atomiser was
womaiy when sether was used, in general, however, Rhigoline was employed with the
ud of a cross jet of air ; in some instances, the atomised fluid was thrown upon the
skia, io othen, upon the bony case of the nerve centres, and more rarely on the nerve
sabetanoe previously laid bare, or merely guarded by a thin patch of Caoutchouc ; the
aoiaials employed, were pigeons^ chickens, rabbits, cats and pigs.
When a jet of rhigoline was thrown upon the back of a pigeon's head, the bird
Bhi?ered towards the close of freezing ; when released, walked away, shook itself, cleaned
its feathers and bill ; after an interval of one minute of apparent quietude and health,
^^ to move suddenly backwards, as if by its own will, and before each motion of
^•kind, squatted close to the floor, and as he began to move, threw the tail up and
206 Pathologieal Anatomy of Traumatie Tetanus.
the faeiul down, And to one side in a spaamodic manner. In the intervals between the
backward motions, the bird sought a comer, and sank into a stupid condition, or ebe
walked about as usual until either a backward motion overtook it, or the bird fell anew
into stupor. The bird was easily aroused from the stupor, and then aj^peared to be in
full possession of all its faculties. The backward movements, at length beoeme vkibie
only as sudden checks which overtook the pigeon now and then while wiJking forwardt.
The delay, before any noteworthy phenomena were seen, the sudden onset of a
strange form of convulsive movements, the state of partial stupor following, and the
healthy appearance of the animal, in the interval, reminded Dr. MitefaeHof the symptoms
of certain epileptic cases, and induced him to repeat the observations.
When the jet of rhigolinc, was thrown lower down, so as to more exactly inflnenoe
the cerebellum, the results were similar, with the addition of rapid somersaults baek-
wards.
With the exception of the temporary cessation of spasms^ these ezperimente devel-
oped no new facts, in addition to those previously established by mechanically injuring
the cerebellum, but the following experiments opened a new fidd.
*' .1 pigeon, whose cerebellum bad been previously frozen many times, was chilled on boib
sides of the neck during one minute, by a double jet of rbigoline, at the level of both cerrical
vertebra, just above the junction of the neck to the body. When released, he became at
once the sport of violent general convulsions. They were very complete, and offered no
other striking character for a few moments ; then there were occasional backward soMer-
sanlts, or an effort in this direction. At the second minute, the backward motion began to
be seen, as the general spasms and the somersaults ceased. The stupors also appeared, and
alternated with the running backward, until within an hour, the animal gradually recovered
its usual health."
Afler witnessing the remarkable result of the production of general convulsions and
backward spasms from injury to the spine, below the medulla oblongata, Dr. Mitohel]
repeated the experiment again and again upon a number of pigeons, with procieely the
same result^), sometimes obtaining backward somersaults, and at others, only retrogrMle
movements, alternating with periods of stupor and intervals of apparently Aill control of
all the normal movements : he also endeavored to determine by a series of ezperimentu,
commencing at the cerebellum, the limits of the ri^on, which being chilled, will give
rise to these abnormal motions.
It appears from these experiments, that in pigeons, the application of cold to the
cervical spine occasions, after a brief period, peculiar backward movements, resembKii|[;
those which have been previously produced by mechanical injury of the cerebellum ;
these abnormal actions are, in extreme cases, backward somersaults, followed by spells
of backward walking, and accompanied with spasmodic movements of the head ; in
milder cases only the backward walking occurs, (both of these forms of consthuned
movement are met with when the cerebellum has been chilled ) ; on the other hand«
when the cold is applied to the spinal cord, at or about the fourteenth vertebra, counting
from above downwards, the backward spasms and stupors are not produced, and only
weakness, violent tetanic Hpasms of legs and tail, and tetanic rigidity in the legs, ooning
on some time afler the freezing, and reaching a maximum in ten minntes, are (Amerred.
The real seat of the backward impulses in birds would seem to be at any point, from
the lowest cervical vertebra up to the cerebrum, whose power to originate them is ml
least doubtful. Two facts, or two sots of facts, led Dr. Mitehell to think it possible,
that it was in every case the cerebellum or the medulla oblongata which was the oifpin
finally responsible for the production of the spasms of retrograde motion. The first of
these facts is the well known and valuable discovery by Brown-Sequard, that in Gninen-
pipi, mechanical injury of certain regions of the spinal cord, from the seventh doranl
to the third lumbar vertebra, subjected the animal to fits of an epileptiform nature, which
might be induced by various means, or might arise spontaneously. Moreover, these
Kpasuis began about the faiT, ho that the spinal wound, ( partial section ), nuat hare
produced an over-excitable innidition of the nerve-centres above the point of injury. In
Pathologiedl Anatomy of Traumatic Tetcmus. 207
Dr. Mitchellfl experiments, likewise^ the spasms began with a flexing of the neck, so
that it is altogether possible that in these animals also, the spinal irritation may act by
caosiQg an undue excitability of organs within the skull. The second set of &ct8 which
msde Dr. Mitehdl hesitate in assigning to the point of the spine injured by the cold
the entire Tesponsibility of producing the retrograde spasms, were the baokwud somer-
eattlts and violent movements, sometimes continuing for days ailer certain deep injuries
of the cerebellum, as observed by Magendie and other physiologists. The spasms
caused bj cold applied to the spine, were also of this retrograde nature^ and we are
therefore iiimished, by this comparison, with an additional motive for suspecting that
they might really be due to a reflex affection of the cerebellum.
After making a large number of experiments to determine the relation between the
backward spasms, originating in mechanical injury of the cerebellum, and those due to
ehiiling of the spine, xh, Mitchell could not attribute the spasms fromcold'to the spine
tlone, but felt strongly inclined to regard this organ as merely the point of departure
of a morbid excitation, which is finally translated, so to speak, by the cerebellum into a
language of its own, and thus occasions a peculiar form of compulsory movement. This
view is still farther strengthened by the state of stupor to which the animal becomes
liable when cold is applied to the spine ; &r it is plain that this is a state of system in
which the oerebrum is affected, and for a time loses its functional activity. If, there-
fore, chilling the spine determines a marked cerebral disturbance, there is no reason
why we might not assume, with logical propriety that the cerebellum may be ultimately
Tmdble for the backwurd spasms.
. Mitchell terminated his important inquiry by experiments designed to determine
the natyre of the injury done to the spine or brain, by cold applied through the skin
or dirediy. It was seen throughout his experiments, which reached ninety in number,
that in almost every case an appreciable interval — and often a long one — existed be-.
tween the dose of the freezing and the access of the spasm. This period varied from a
few seeonds to twelve minutes. If there was any primary effect it was merely feeble*
neas or disorder of movement. It was suspected at once that what is seen on the skin
after freesing repeats itself in the nerve substance. First, there is chilling and con-
traction of the blood-vessels, and then actual freezing, which is rarely very deep ;
indeed, it is most difficult to freeze the pigeon's entire breadth of spine ; when this does
occur in the upper cervical r^on, death by apnoea follows at once.
The freezing being over, the part thaws, and long-continued, intense congestion
ensues, as any one may observe who will try the effect of the rhigoline or ether douche
im his own skin.
To detennine whether the congestion actually took place in the uerve-substance. Dr.
Mitchell laid bare the cerebellum of a large pigeon, and carefully noted the color of its
tisBoe, and the number and position of the chief vessels of the meninges. The jet of
rhigdine was then used directly upon the part. The visible vessels were instantly
ftotmif with their contents. As the part thawed, it became intensely congested, tho
brain darkening distinctly, and the vessels of its transparent coverings increasing in
aiie and number, so that those which could before be seen were lai^^r, and new opeH
prmooflly unseen, came into view. This experiment was repeated several times, with
no esMDtially different result. After the careftil removal of the membranes, the bare
cerdbeDam protected with thin caoutchouc was dulled. As it thawed, an intense oon-
j^estion speared, with numerous points of much deeper color. This condition increased
during several minutes, but caused no notable disturbance of function. Similar
apneafmnces were noted in the spine. Dr. Mitchell concluded, that the singular con-
vnwiona and stupors which he had described, were due to the palsy of the vessels which
have been chilled by the cold, and which may or may not have undci^one previous ex-
treme contraction ; the congestion from cold, whether in the nerve tissue or the skin,
is most intenM at a certain time after the part has been thawed, and it is then in the
centres that tthe. e^^citatiou becomes such as to determine a convulsive attack.
203 Mhologieal Anatomy qf Traumatic Tetanus.
Aooordtng to this view, the cottgentioH must be regarded as tY^etsential partnl ft/the
ntrte tkamgeB^ which finally result in the spasm or stupor.
We should not lose sight, however, of the possibility of the nerve substance being
itself dlredly altered by the intense cold, to which it is subjected ; for the nerve oolls
may be most seriously affected during the physical changes of condition, which grnit
alterations of temperature occasion.
In order still fkrther to elucidate the relations of the congestion to the abnominl
phenomena, Dr. Mitchell instituted numerous experiments, and finally succeeded in
causing by irritants, spinal congestion and backward spasms ; that is to say, the same
train of symptoms which succeeded the use of cold. The Tincture of Capsicum gave
the most striking results.
It thus appears fVom these experiments, that the backward movement and convulsive
affections aaa stupor may be excited by agents, which like Tincture of Capsicum, irri>
tate, congest, and perhaps by virtue of the alcohol, chemically alter the spinal tissue ;
it is also worthy of note, that as in spasms from cold, in like manner In those caused
by an irritant, attacks appear only after an interval has elapsed, and are therefore no4
due to primanr alterative mfiuenoes, chemical or physical.
Xhe fbllowmg conclusions may be drawn from the preceding faetH :
Ist In Traumatic Tetanus the blood-vessels of the cerebellum, medulla oblongata
and spinal cord are dilated and congested.
2d. It is possible by cold and irritants applied directly to the cerebellum, medulla
oblongata and superior portion of the spinal cord, to produce dilatation and congestion
of the blood-vessds ; and the congestion thus produced, is attended with exalted and
aberrated action of the gray cdls, increased reflex action of the spinal axis, and spaamn
of the voluntary muscles, resembling the abnormal nervous actions characteristic of
Traumatic Tetanus.
3d. When the dilatation and congestion of the blood-vessels of the cerebellum and
spinal axis, characteristic of Traumatic Tetanus, are examined by the light of carefbl
physiological experiments, they appear to be dependent upon some arrest or alteration
of the nervouB infiuenoe supplied to the unstriped muscular fibre of the minute arteries
leadinff to dilatation of their diameters, and enfeeblement if not complete arrest of the
normal peristaltic actions. The gray cells of the cerebellum, medulla oblongata and
qpinal cord are thus supplied in Traumatic Tetanus, with an increased and abnormal
amount of blood, even when there is no increase in the force or frequency of the heart'a
action.
4th. The sympathetic nervous system which regulates the circulation of the blood
in the minute arteries, appears to be involved in Traumatic Tetanus as well as the oens
bro-«pinal system.
5th. Wnilst it is difficult to determine the exact relationship of the disturiiaooes in
the two systems of nerves, viz : whether the imitation is reflected from the wounded
sur&oe first to the sanglionio cells of the cerebro-spinal system, and secondarily totheaa
of the sympathetic m &e spinal axis, as well as in the ganglia of organic life, in viitoe
of the intimate rdationship of the two systems, and in virtue of the dependence of the IciKr
upon the greater for a oontinuous supply of nerve force ? or whether the influence afcela
primarilv the ganglionic cells of the entire sympathetic system ?— at the same tine we mnj
dednoe mmi such facts important therapeutic principles, which will be discuaed ommw
fUly hereafter, in a separate section of this inquiry. It would appear that aftw ihm
establidiment of the state of increased functional activity in the ganglionic oella of tbe
spinal axis, ihere is at least an enfeeblement of the sympathetic system, and espeoiaUy
that portion which presides over the circulation of the eentral ganglionic maases ; and
the question arises, whether this impairment of its normal functions be due to a divenioo
of we nervous force oidinarily received by the sympathetic from the cerebro spinal
system ? The question also, as to whether the condition of the nervous sysifln pre-
ceding the reception of a wound, may have some influence in the production of the
disease, although of great interest, cannot as yet be determined with aoouracy ; thie
Pathologieal Anatomy qf Traumatic Tetoinus. - 209
fketB bearing upon this queBtton wilK in like manner, receive specii^I iuveetigAtton in a
ditttnot division of the inquiry.
In connection with the preceding facts and conclusions, it is important that we should
examine the results of the labors of pathdogists, with fpferenoe to the structural altera-
tions discovered after death from the disease under consideration.
We have looked in vain through the writings of the older physicians, as Hippocrates,
Galen, Aretieus, Celsus, Paulus, ^gineta, AetiuR, Rhascs and others, for any facts
illustrating the pathology of Tetanus.
Mr. Curling remarks with truth, that,
'* N'otwiibstAoding the labor and atteo lion which have been assiduously directed to patho-
logical iDrestigation^ of late years, both in this country and on the continent, such researches
have, as yet, effected little in elucidating the nature of Tetanus.
"Those writers who have recorded morbid appearances, in the inferences drawn from them,
have, for the roost part, taken but a partial and confined vitw, too otten attributing the
disease in general, to morbid action in such structure or organ, as in the particular case or
cases, the subjects of their examination happened to be in some degree deranged.
*' In many instances, conclusions have been formed, when the inquiries have been much too
linited ; for, not only is it essential to examine minutely th^ brain and spinal cord, bat the
JDvestigation cannot be considered complete, until the sympathetic system, and ths whole
alimentary canal hare been accurately inspected, and the perves traced from the seat of
injury to their apparent origin. The execution of this necessitates much time, and oo slight
degree of labor, and when the task is accomplished, the rssults can only be rightly estimated
by one conversant with pathological pursuits." Treatise on Tetanus, p. 29.
The first record of a trust-worthy post-mortem examination in this disease, with
which we arc aoqnaint^Nl, is found in the writings of John Baptist Morgagni, and is
as follows:
(*aHe J'i : Traumatic Tetanus.
*' A yoang man, of two and twenty years of age, having the wheel of a cart pass over
almost the lower part of the left heel, seemed to have receied no other disadvantage from it
bat this, that the common integuments were torn away. While the cure of an injury which
appeared slight, went on very well, behold I after some d%ys, the neck and the back became
rigid ; so that, as if he had been seised with a kind of Tetianas, he could move his limbf, in-
deed, bat conld not move either his neck or bis back. To this was added, that, at iatervalf,
he was shaken by the most violent tremors of the whole body. And all these symptoins.
going on in this manner for twenty days or more, his senses being always perfect, he having
thrown op a round worm, by vomiting, and the stertor being much increased, he died*
The foot being examined about the evening of that very day on which he died, the heel wai)
fonnd to be almost healed.
The abdomen, which was turgid, being opened, a small quantity of water was Sfen to be
eitrmvasated therein ; all the intestines and the stomach itself being sound, but distended
with air to a venr great degree. Within the colon, near to the appendicnla vermiformis, was
a round worm, dead. i
The thorax also had a small quantity of water effused in its lef\ cavity ; the lungs of that
lide were bard posteriorly, and of a subsUnce like that of the liver. There were polypous
coocrettoDs in the large vessels, and in the ventricles of th^ heart ; in the right of which .
cavities, there was blood also, together with airy bubbles.
t'pon opening the cranium, in the right lateral sinus of the dura-mater was coagulated
blood ; In the other was seen a fluid blood, notwithout some pretty large bubbles. There wera
many bobbles, also, under the pia-mater, especially about the left anterior lobe of the cranium.
I'oder the same membrane was water besides ; the taste of which water seemed to one
who was willing to taste it, nothing at all, ur at least nothing more than a Might saltiness.^
In the ventricles of the braiu was a pretty large qiiantiiy of water. And no small quantity
vas discharged from the tube of the vertebrae, especially when 1 ordered the loins and the
OS sacrum to be raised up. The cerebellani was lax, the cerebrum firm ; and the sangnrifer-
oqs vessels, that crept through the ventricles of the cerebellum, and the plexus choroides, were
not at all of a white color." The Seats and Causes of Fheeates. London, 1769 ; Vol. iii, pp.
The author of ** Kecherches et Ohservatiuutf Fathologiaues sur le Spinitis, ou Inflam-
uataon de la Moelle ^pioi^re, faites a L'HoteUDieu de Jlarseille," published in 1820,
210 Ptithologieal Anatomy qf Traitmatk TeUmi.
under the aiupioes of the ProfeBBore of the Faculty of Medieine of Mon^iellier, ad-
vanoed the view that both Tetanus and Epilepsy were due to, or dependent upon, an
in/lammation of the tpinal marrow. The proposition with reference to the fint dis-
ease was sustained by two cases, furnished by M. le Doetenr Ducros ; the first of which
was evidently idiopathic, and the second Traumatic Tetanus.
The following outlines contain the main points of interest in these two cases :
Ccue 2 4 : Idiopathic Tetanu*,
Joseph Toj, age 19, of strong constitution, waiter in coffee house ; 29th September, 1818,
after severe' exertions, which caused profuse perspiration, exposed himself to cold air. The
sadden exposure to the cold air, and the consequent check of perspiration, was followed bj
Tlolent chills, and pain, and spasmodic contractions of the muscles of the jaw, back, abdomen
and ehest. The pain was sererest about the ensiform cartilage. The next daj the joung
man attempted to resume his occupation, but the difficulty of deglutition and speech, together
with the spasmodic contractions of the muscles, compelled him to keep his bed, on the 3d of
October. On the 4th of October, he was transported to the Hotel Dien. On the 4th of Octo-
ber, the patient presented the following symptoms : Jaws firmly locked, head immoTable and
inclined backwards ; permanent rigidity of the muscles of the posterior portion of the neck,
baok and abdomen ; obstinate insomnia ; pain in region of xiphoid cartilage ; anorexia ;
toagve somewhat furred ; bowels constipated ; respiration irregular and spasmodic ; pulse
hard aad fk'eqaent ; perspiration not abundant.
These aymptoms increased in intensity, and were attended by sudden clonic spasms of the
muscles of the trunk, followed by violent pain in the back and neck ; also, by violent spasms,
which were proToked by the slightest movement or noise.
. Veaeseetion was fully practiced, bnt without any apparent good eifect. The perspiration
becaase abundant on the 7th day, and urine scant. On the 9th of October ( 10th day of dis«
ease) the spasms were so severe that the patient rests only on the heels and back of the head.
October 10th, eyes fixed and projecting ; spasms, constipation and interrupted respiration ;
subsultus tendinum ; skin hot. During the night of October 10th, emesis and catharsis were
induced by antimonial ptisan. Skin hot ; urinary excretion suppressed.
October lltb, (12th day), miliary eruption over the whole surface of the body; eyes im-
movable ; spasmodic contraction of the angles of the lips ; respiration difficult and impeded.
During the night the patient experienced a violent convulsion, and died a few moments after.
Auiopty; AumtU Apptamnte: Abdomen tense ; skin shows the impressions of the pimples
which covered the whole surface ; extreme rigidity of the muscles of the neck, chest and
back ; eeltutar tissue beneath the skin reddened and congested with sangnineous infiltrations ;
these ebaages greatest over muscles of neck aad back.
Verttbral (hnal: Engorgement, congestion, and sanguineous infiltration of the cellular tia«
sue enveloping the neurilemma of the spinal marrow ; veins of membranes of spinal cord
congested. Traces of inflammation are most marked about the superior portion of tlio
spinal marrow, in the region of the first cervical vertebrae, and the inferior portion of tbo
lombar. Serous membrane of the cord more inflamed than the aeuriTemma, which preseota
a purplish color; serous effusion, and fahe membrnneM in the intervals of the nervous trunks
composing the can da equina.
Chut and Abdomen: Traces of phlogosii upon superior surface of diaphragm and upon sur«
fkeo of heart.
Out 26 : Tniujuatic TWaiiirs, J'tAhwing after the extirpation of a smattj (Jmcttusm
Tumor,
Pierro Fournier, age 56 years, admitted into the Hotel Dieu, of Marseilles, with acaoceroat
ttlctr occupying the right commissure of the inferior lip, which had made rapid progress, aad
Invaded the neighboring parts. Arsenical paste was applied without success ; the diseased
parts were then incised, and the lips of the wound united by the twisted suture. The wound
appeared to be healing, but the patient removed the dressing ; the needles were drawn oat,
and the edges of the wound pulUd asunder. As soon as the considerable inflammation whieb
followed the operation, had subsided, the lips of the wound were again united by the inter-
ropUd suture. On the 2d day after the last operation, violent pains were felt in the cerri-
eai region, aad were accompanied by violent and convulsive contractions of the masteter and
temporal muscles, and the fever, which had been abated during the first day, augmented,
and was attended by paroxysms ; the muscles of the abdomen became hard and contraetad.
Tho muscular spasms became general, and the life of the patient was coatiaaally threataaad
by suffbcation. Venesections, opium, camphor and musk were tried, bnjt wUhont aay appra
MhcloglQal Anatomy of Traumatic Tetanus, 211
«tAt>1e cflbct. So Ihe 8Up«rficial muscles were affected one by one, the contfACtion being
most marked in the flaxors.
The stitches of the suture were torn apart by the Tiolence of the spasms, and on the 3d
daj the needles bad been completely torn oat of the lips of the wound. The contraction of
the muscles and the retraction of the lips of the wound, gave the patient a horrid expression.
The free and continued use of opium, musk and camphor, ameliorated somewhat the symp-
toms, and appeared to prevent the destruction of the patient by suffocation, which forseTeral
days was imminent. The muscles which had been affected the first day, became less con-
tracted, the patient could open the mouth and execute a few movements with the head ; the
constipation ceased, and the abdominal parietes became less rigid. Nevertheless, the dorsal
raascles and thoracic muscles remained rigid, and the difficulty of respiration eohtinned
extreme. The patient, enfeebled by the continued and abundant loss of saliva, by the dlfB«
calty of swallowing, and by the continued spasms, and enfeebled and embarrassed respiration,
and by the intense pain, died on the 23d day after the invasion of the Tetanus.
AuUip9jf Thru if oun After Death: The examination of the cranial, thoracic and abdominal
cavities revealed nothing abnormal.
When the spinal canal was opened, a whitish, serous effusion was found between the mar-
row and its envelopes. The surface of the spinal marrow and of the arachnoid membrane
was covered by a soft substance of the same color with serum (coagulable lymph), This
elFosed matter was denser towards the lumbar region, and was mixed wiih false membrane.
This matter was denser, and of a lardacions character in the lumbar region, and contained a
^raater proportion of false membrane, which united in one mass the larger nervous trunks
^vea off from the lumbar portion of the spine.
The aathor of the Researches on Spinitis, concludes that the Idiopathic Tetanus, so
common in warm climates, was similar in its patholgj with Tetanus arising from
wounds and injuries, hoth being dependent upon ^^ inflanvntation of the tpinal marroto"
'^ The profound alteration in the actions of the muscles, which characterises Tetanus,
csmnot be explained without admitting that the centre, whence the nerves spring which
go to the muscles of animal life, is itself affected." * * " The fatality of Tetanus
can only be explained by the importance of the organ (spinal marrow) which is its
seat" — Recherches, etc., pp. 41-60.
The testimony of Carl Rokitansky, with reference to the condition of the cerebro-
spinal nervous system, after death from Traumatic Tetanus, as contained in his Man-
iiial of Pathological Anatomy, is not so clear as in many other diseases, the pathological
leaioos of which have been so fully illustrated by his extraordinary labors. Thus,
under the head of Diseases of Texture of the Spinal Cord, Rokitansky remarks :
" Congestion of the spinal cord is a spmptom in the course and sequel of sundry acute an-
chronic diseases. Such, most probably, is its real import, .in those who have died of Teta-
nus, convulsions and hydrophobia. It is almost constantly met with in those cases, com-
bined wttb an eqnal degree of congestion of the brain."
When descril^ing the diseases of the texture of the nerves, this pathologist calls
special attention to the following condition of the nerves in cases of Traumatic Teta-
nus, which he affirms to be the only real fact which has be3n made out m such cases
after death :
*' Froriep has ascertained, that, besides the inflammation which is seen in the nerve at the
apot which has been injured, a rosj red is produced at irregular intervals in its course, by
fbe injection of its neurilemma, but it is unaccompanied by any distinguishable products.
The reddening is most confined to the surface of the nerve, though it sometimes dips a little
way between the fasciculi. If a plantar nerve, for instance, has been injured, it is repeated
three, foor, five or more times in the course of the tibial and sciatic nerves, up to the sacral
plexns; but neither where these nerves enter the medulla, nor in the cord itself, is any simi-
lar appearance to be found."
Rokitansky is evidently in error, when he attributes the discovery of certain changes
io tJie injured nerve in Traumatic Tetanus, to Froriep, whose observations upon seven
cases of Tetanus, which had been preceded by injuries of nerves, were published in
1837. Various surgeons and pathologists, both previous and subsequent to Froriep,
have recorded similar observations.
212 Pathological Anatomy pf Traumatk Te^anm.
Baron Lairey baaed an important portion of his treatment upon the view that irrita-
tion is first set up in the wound, and in the injured nerves. Thus, he says ;
** The first object is to remove causes of irritation, and to re-establish the suppressed excre-
tions. This is ta'be effected bj suitable incisions in the wound made before Inflammation
takes place, for,-shouId this be much adranced, incisions are useless, and even dangerous ;
when |iecessa>j, they should include as much as possible of the wounded nervous cordt and
membvaaff ; but incisions at the articulations are injurious, and appear generally to increase
tba lymptoms ; I hare seen examples of this. Caustic applications to the wound may be made
with advantage on the first appenrance of the wound ; provided the same rule be observed as
in case of incisions."
The unexpected and complete succetis that followed the amputation of a wounded
limb of an officer attacked by Chronic Tetanus, induced Baron Larrey to propose the
query, whether, in this disease*, which arisos from a wound in some part of the ex-
tremities,
<* Is it not better to amputate the wounded^ limb as soon as the symptoms of Tetanus
appear, than to rely on the uncertain resources of nature and art to affect a cure ? * * Ampu-
tation of the limb being made on the first appearance of the symptoms, all commttnioation
with the origin of the evil is cut off. This operation unloads the vessels, renovea the
twitchiags of the nerves, and convulsive motions of the muscles. The first effects are fol-
lowed by a general collapse, whi'ch promotes the excretions and repose, and re-establishes
the equilibrium of the body." « « ^
After recounting several cases in which Traumatic Tetanus was either cured or
greatly relieved by incbion of the nerves and siiiputatitiu of the injnrcd limbs, Baron
Larrey affirms,
*' That amputation performed at a proper time, is the most certain nivnns of arresting teta-
nus, when it is produced by a wound in the extremities.**
In one case in which tctantis had supervened and proved fatal after the amputation
of the arm, Baron Larrey found that the median nerve was included in the Ug*t«re
with the humeral artery, and was tumefied below the ligature, so as to reaemUe a
mushroom, it was also much swollen above the ligature, and of a red color. On
inapecttng the body of another soldier, who had died of this disease, and whoee leg
haa been amputated nineteen days before, Baron Larrey found the nerves enlarged at
their extremities, and adhering to the surrounding parts. He affirms, that he had
often removed the symptoms of incipient tetanus, by adopting such means as are suited
to remove ita causes, vix : by cutting the ligature of an arteiy in which a nerve is
included, and to which the patient refers all his pain, and where the nervous irritatkm
takes its rise. This division of the ligature arrestad the disease in its forming sta|pe
and expedited the cure of the wounds, there being no danger of hiemorrhage if tlie
vital powers be not debilitated ; — a few hours of direct compression bringing the walk
of an artery into contact, being sufficient to induce adhersive inflamnuition.
Baron Larrev also records several cases illustrating the cure of Traumatic Tetaana.
by the application of the actual cautery to the wounded surface, and to the extremitiea
of the injured nerves.
Baron Dupuytren discovered in the arm of a boy who had died of Tetanus a few
days after, being struck by a coachman, a portion of a whip enveloped in the reiy sab-
stance of the cubital nerve.
John Hennen, in his Military Surgery, mentions that in one case he found ihe radial
nerve connected with the injury, thickened, and a spiculum of bone sticking in it,
(p. 251, 3d Ed).
M. C. Pelletier, Chief Surgeon at the Hospital at Mans, is 1826, communioated to
the Royal Academy at Paris, a Memoir in which he attempted to show that in all osaea.
Tetanus originates in inflammation, extending ftt>m the neurilemma of the nerves of
the part injured, to the membranes or substance of the medulla spinalis.
Pathological Anatomy of Traumatic Tetanus. 213
Cases 26 and 27 : Traumatic Tetanus.
Id ft case where Tetanus occurred afler a compound fracture of the humerus, M.
Pelletier found the neurilemma of the cubital and median nerves red and inflamed,
as jdso the envelopes of the brain and spinal cord ; and it was remarkable, that the
appeftrftnoes of inflammatory action were confined to Ihe left side of these membranes,
being the side corresponding with the arm that was fractured. In another case, in
which the disease appeared on the seventh day, afler an incision made into a carbuncle
on the inner part of the lefl leg, on dissection, foi-ty hours after death, the membranes
of the spinal cord were found to be unusually vascular, and the cord itself, from the
fourth cervical to the fourth or fifth dorsal vertebra, red and very soft. The branch
of the sciatic nerve distributed to the sit-c» of the carbuncle, was encircled by a vascu-
lar network.
Cane .AS' : Tnnnwtfiv Ttitnmis,
M. Pelletier also communicated to the Academy of Medicine, the particulars of a
third case of fatal Tetanus, supcrvenint; upon amputation of the leg. A lad fifteen
yemrs of age, and of a feeble constitution, had his lefl leg removed in conse(|uenoe of a
malignant affection of the heel. He Went on very well for three days, and the wound
partiftlly healed by the first intention, when he experienced considerable tenderness in
the stump, with convulsive twitchings of the muscles. On the sixth day, the patient
was attacked with trismus, the respiratory muscles shortly became affected, and not-
withstftuding he was largely bled, the disease proved fatsU on the eighth day, after the
mmpntatioii. On dissection, a small depot of purulent matter was discovered in the
Ktninp at the head of the fibula, the parts around being inflamed. The sciatic nerve
at this place was found softened in structure, and of a violet blue, bping much
iigected with blood, and the appearance was continued for eight or ten inches to
the hip, being also obser>'able in some of the branches of the nerve. For some days
prerioofi to the accession of tetanic symptoms, the patient had complained of pain in
the track of the nerve when it was pressed upon. The pia-mater of the medulla
fipinftlis, at the part corresponding with the origin of those nerves supplying the muscles
affected with spasm, was highly injected) reddish effusion was found under the mem-
branes, and the spinal marrow itself, in the middle of the dorsal region, was in a state of
nunoilisaement. Stance, October 12th, 1826 : R6vue M^dicale, 1827, tom iv, p. 183,
Joamal de Progres, 1828. Archives <fC'neraIes de M^'decine, tom ii. Second Series,
Treatiae on Tetanus by Curling, p. 41.
Case 2U : Traumatic Tetanus.
In the caie of a feiDfiic, !'.> years of h^c, who died of Tetanus, cousequeut upon a wound
io one of Iter fingers from a splinter of wood, which inflamed, and was followed by the form-
Atioa of an abscess, it is stated that ou inspection of the body by Dr. Hesselbach, in some
placet the nerre of the arm was remarkably congested, and between the dura-mater and
arachnoid was contained a pretty Ur^e quantity of bloody serum, the vessels being much
injected with extravasation of blood throughout the whole course of the spine. (Glasgow
Hedical Journal, vol. iii, p. 191).
Casf *J0 : Tra u m atic Tata n us»
In the 'id volume of the Glasgow Medical Journal, a case of Tetanus is reported of a boy
that was scorched ou both legs. After death the nerves were accurately examined. The
cataaeous nerves of both legs, particularly the communtcans tibialis, the communicating
braachea of the peroneal nerve with the tibialis communis were inflamed at the seat of
Injury; tracing them upwards, above this point, they were perfectly healthy, except that
portion of the peroneal which turns over the head of the fibula, there again it was distinctly
vascnlar, thus leaving' an intermediate portion perfectly free from the appearances of inflam-
mation. The vascnlarity seemed to be confined to the sheath of each nerve ; the deep seated
braachef appeared to be quite natnrai.
214 Pathologieal Anatomy qf Traumattc Tetanus,
Caae 31 : Traumatic Tetanm,
In another case reported in the same joarnal, the patient had the ring and middle fingers
of the right hand much lacerated and injured by machineryi and the last phalanx of the mid-
dle finger being adherent to the second only by a small slip of skin, it was remored accord -
toglj. It was discoyered on dissection, after death, that the nerres on each side of the
remaining phalanx of the ring finger were Tery vascnlar. On tracing upwards the ulnar
nerre from this point to the elbow, it was of its natural color ; bat here again it became
▼erj Tascular for about the extent of two inches. In the axilla, it again presented a similar
appearance to that at the elbow, the portion of it intervening betwixt these two points being
healthj.
Tracing the median nerve in the same waj an the ulnar, it was found pretty natural from
its digital branch which supplied the radial side of the ring finger (and which as stated
above, was much inflamed,) to about the middle of the arm, where it again presented aa
inflamed appearance for the extent of one inch and a half. The portion of it iDterventng
betwixt this point and that confined to the axilla, where it again became vascular, was natural.
This vascularity throughout was not confined to the sheaths of the nerves, but occupied
their substance ; the radial and superficial nerves of the arm, along with its veins and arteries
were perfectly natural. — Glasgow Medical Journal.
Cities S.2^ '/'/, J^, 3o : Traumatic Tetanus,
Mr. Curling, in a ca^e of Traumatic Tetanus, on examining the wound, (after death), at
the back part of the thigh, which was inflicted by a spike that had penetrated deeply into
the semi-tendiqous muscle, driving a piece of wadding before it, f^und the sciatic nerve which
passed close to the bottom of the wound, highly injected with blood.
In another fatal case, Mr. Curling traced the internal plantar nerve to the wound which was
occasioned by a compound dislocation of the great toe, where it appeard thickened and it^
neurilemma unusually vascular, In the dissection of a patient of Mr. fiwbanks, who bad
died of Tetanus, after a wound of the leg by a pitchfork, the prong was found to h^^t p«oe-
trated to the peroneal nerve, which was bruised, and implicated in the inflammation set up
in the part. (Treatise on Traumatic Tetanus, p. 39, Medical Oasette, vol. ii, p. 34C.
In a case of Traumatic Tetanus following laceration of the hand, which was amputated by
Mr. Liston, as soon as the tetanic symptoms made their appearance, the branch of the median
nerve going to supply the thumb, was found torn two-thirds across, and its extremiiy
inflamed and thickened for nearly an inch.
Dr. Murray, as quoted by Mr. Curling, has related a case where the wound giving ri«e to
the disease, was a severe laceration of the integuments of the leg, with fracture df the tibiA
and fibula. When examined after death, the sheath of the popliteal nerve was highly injected
with blood, and from the ham downwards, the nerve was remarkably red in all it* ramifica-
tions in the directions of the fracture, some of them being enlarged. Treatise on Traumatic
Tetanus, pp. 39-40.
Cases fiO and 37 : Traumatic Tetanus,
In two cases mentioned by Dr. David Craigie, in his EUmetUt of Oeneral and Patkoto^u^l
Anatomy, in which the injuries were similar, viz : fracture of the middle phalanges ot the
finger, the symptoms of tetanus came on about three weeks after the infliction of the injury,
and proceeded in the course of a few days to a fatal termination.
In both cases the nerve coat connected with the injured part, was reddened, vascular and
injected, and manifestly thickened, while the nervous matter of the nerve was reddened,
swelled and softened.
In the first of these cases which took place in the person of a young man who bad bean
brought from Musselburgh to the Edinburgh Royal Infirmary, Dr. Craigie examined the whole
spinal cord with care. He found it quite sound, except in the cervical portion where the
envelopes were reddened, and had evidently been the seat of inflammatory injection. Beneath
these envelopes, the spinal cord, in the cervical portion was reddened and softened for the
Bpaceuf between one inch and a half and two inches. So far as he could determine, thi9
was the point which gives origin to, or is connected with those branches of the cervical
nerves, which proceed to, and chiefly form the brachial plexus. In this case, therefore, i>t.
('raigie inferred that the injury done the finger, and the subsequent inflammation, especially
nf the digital nerve, and its nerve coat had been reflected, as it were, to the spinal origma of
these nerves, and thus Induced inflammation and Irritation of the spinal marrow then soften-
ing ; and that theite were the efficient causes of the tetanic symptoms and their fatal termi-
nation.
In the second esse in which the patient died under the care of Dr. Paterson, of L«itht the
PUthologiccU Anatomy of Ttaumatie Tetanus. 215
contttied cods of Ibe nerve were red and softened, and its tunic in like manner red, injected
and thickened ; and in the same manner, on inspecting the spinal marrow, a portion- of that
organ in the cervical region, no less than two inches in length, very distinctlj reddened and
fofteoed, indeed quite creamy, while the rest of the cord was firm and of normal consistence.
The spot thfls affected with softening, corresponded very accurately with the origins or spinal
coQBectionB of the cervical nerres, which contribute to form the brachial plexus.
' Dr. Cnigie* affirms that he had repeatedly seen the nerve or nerves of parts injured
and oontusoi in Tetanic cases presenting redness, vascularity, thickening of the neuri-
lemma and softening of the nerve, but he had not had opportunities of examining the
Kpinal cord in any other case.
Id view of the preceding cases (36 and 37), Dr. Craigie expressed his belief, that
iu Traumatic Tetanus, the irritation is propagated irom the injured parts in the reflex
direction, to the spinal connection of the nerves ; that there it is followed by another
irritation, and by inflammation of the spinal marrow ; and that the last is the cause of
the tetanic symptoms. This further seems most probable, when we consider that sonic
lime always elapses between the date of the infliction of the injury, and that of the
tetanic symptoms ; that id to say, the establishment of the inflammatory irritation of
the spinal marrow.
Various abnormal appearances and lesions in some part of the brain, spinal cord, or
the investing membranes have been recognized and recorded by various pathol(^ist8, as
Brousaais, Leirrey, Magendie, Recamier, Professor Frank Brera, Dr. Reid, Dr. Kenedy,
Dr. Craigie, Mr. Clarke, Dr. Aitken, and others ; and inflammation in the^ textures
has beea viewed by several writers as the cause of tetanus.
Baron Larrey states, that in the numeroiu inspections of the bodies of the soldiers
who died of Tetanus in the hospital of Louvain, aft^er the battle of Waterloo, which
were made with the greatest care, *^ he constantly discovered evident traces of inflam-
mation on the spinal cord, with serous effusion more or less of a reddish color within
the sheath." CUnique Chintr^cale, tom i, p. 88. " Unequivocal marks of inflam-
mation,'* in the medulla spinalis and investing membrane, have been observed by Mr.
Castley, an Army Veterinary Surgeon, (London Medical and Physical Journal, Vol. iv,
p. 197).
According to Dr. James Copland,
** The apioal cord, medulla oblongata, brain, and their membranes, have frequently pre-
sented changes, more or less decidedlj morbid in tetanus and trismus. I believe that these
changes are rarelj altogether absent, especially as respects the spinal cord, medulla oblongata,
the pons varolii and their membranes, when the inspection is made within twenty-four hours
after death, and when these parts are carefully examined, * * The changes more com-
monly observed, are vascular injection of the pia-mater, sometimes with exudations of lymph
on ita fnt larface ; hardeningor softening of one or more of the columns of the cord, or of
the nedolla oblongata, softening being more frequently observed when the inspection has
been long delayed ; opacity of the arahnoid, or deposits of small plates of bone or of car-
tilage Id the free arachnoid, the surface of those plates, being rough on the sides next
to the pia-mater ; generally increased vascularity sometimes with recent adhesions, and
coagttUooa of the veins and venous sinuses of the spine. These changes may extend
more or leM generally along the cord and medulla oblongata, often also to the pons
varolii, aad even to parts in the vicinity of the latter, and surrounding the fourth
ventricle. They were thus observed with several ossifBc plates in the arachnoid, in an
aeuto caM of tctanaii which was under my care in 1820, and of these appearances I
made a colored drawing, which is still in my possession. In addition to these, the sub-
ttaaco of the cord and medulla Is somewhat reddened or injected, and exhibits numerous
red points when divided. In some cases, the membranes are more decidedly inflamed
and thickened, generally the spfnal fluid is abundant and somewhat altered or turbid. In
rarer instances, a pnriform exudation is found between the membranes, and the softening of
a portion of the cord presents a pnriform infiltration, with capillary injection. In still rarer
cases, the serous exudation is of a rose color, or even more deeply tinged, or even blood is
extravasated and extended along a considerable part of the cord. Die Prac. Med., Am. Ed.,
Vol. IU, p, 1107."
Gf««ial and Pattialoglcal Aaatouy, Sec. Bd. pp. 385-3^7.
216 Pathological Anatomy of Traianatie Tetanus.
lu a paper published by Dr. Copland, in the Jjondon Medical Repository for May,
1822, Dr. Copland suggested that the ganglia and sympathetic nerves were the seat or
pathological cause of tetanus, and especiaJly of the idiopathic form of the malady.
He contended that the ganglia, or the organic system, is the souroe of irritability in
contractile tissues: and that when this ' property is inordinately excited, without th^
control of the will, that changes should be looked for in this system.
Some years subsequently, Mr. Swan directed attention to the sympathetic system in
Tetanus, and stated that the ganglia were pretematurally injected in this disease ; and
appearances said to support this statement, were observed by Andral, Aronsaohu, and
Dupuy ; while Meyer, Vetter, Bright, and others, have adduced instances of tetanus)
consequent upon ossific deposits irritating branches of ganglionic nerves.
In two cases, Mr. Curling found the cervical ganglia of the sympathetic unusually
vascular, whereas in a third instance, they were natural: M. Dupuy states, that he has
frequently discovered disorganization of these ganglia, and of other nervous trunks in
horses that have died of Tetanus. In Plouoquet s Litenitura Medica Digesta, a case
is referred to by Meyer, in which Tetanus is supposed to have been induced by an omi-
fioation of the pleura, irritating the splanchnic nerve. In the same work, there is
likewise an allusion to a case from Vetter, in which irritation of the par-vagum, from
the sharp point of an ossified gland, in the vicinity of the trachea, was supposed to
have given rise to the disease. Mr. Swan has also shown that the ganglia of the sym-
pathetic nerves are rendered unusually vascular in animals poisoned with gamboge,
arsenic, strychnine and mercury, and he has met with these appearances in cases where
great constitutional irritation has followed severe injuries. VV^ith reference to sueh
observations. Dr. James Copland remarks, that it should not be overiooked, that the
ganglia are oflen very vascular, even in health ; that they are not always, or even gen-
erally, usually or excessively vascular, and much less manifestly inflamed in Tetanus ;
and even granting them to be excessively injected or inflamed, it cannot be shown that
their inflammation could be more* productive of tetanus, than a state of irritation or of
vascular erythism, this latter condition being manifestly more compatible with excessive
discharge of function than a state of inflammation.
In some of the cases reported as Tetanus, it is evident that the disease has been ooa>
founded with cerebro-spinal menengitis. Thus in a case which occurred at Udina,
and which was at the time brought forward to show that tetanus ^' is inflammation of
the spinal cord," and as confirming Mr. Bell's idea, that movement depends on the
anterior, and sensation on the posterior roots of the spinal nerves, the disease arose in
a woman, without any external injury, and as the coiisetiueuce of over-exertion and
cold. On examination after death, the brain was found in a healthy state ; the verte-
bral canal was filled with a bloody serum ; the anterior portion of the spinal .oord was
of a yellowish dirty white color, and covered with small round and oval bodies, des-
cribed as hydatids, from the size of a millet seed to that of a pea, which were probably
coagulable lymph. The substance of the spinal cord exhibited reddish spots ; the pos-
terior part was healthy ; the posterior ruots of the spinal nerves had a very dificreDt
appearance from the anterior roots ; the latter were evidently softened, and presented a
yellow color ; the former were perfectly healthy. Annali Tniv. di Milano, Londoii
Lancet, Vol. i, 1828-9, p. 135.
In two cases of Traumatic Tetanus reported by Dr. Parry, in the Glasgow Medical
Journal, February, 1831, morbid appearance.^, irregular congestions, and •' inflammation
at the seat of itijury/' were observed in th« nerves connected with the injured pwta.
In one case, a considerable quantity of partly fluid and partly coagulated blood, existed
between the theca and the vertebrae, and both lob(*s of the cerebellum presented a
congested and ecchymosed appearance.
Cit9e .y<y : Trati matte lifauut.
lu a casQ of Traumatic Tetanus, terminating fatally in Westminster Uospiial, tea di^a
aftar the manifestation of Tetanic symptom', which sppesred ten days after tba fool of tlua
Pathological Anatomy qf Traumatic Tetanus, 217
lad had been pierced by a nail, the following alterations were observed iu tbc brain and
spinal cord :
** Immediately after dcatb, tbc body was placed prone, to prevent tbe gravitation of tbe
blood towards tbe spine. Twenty hours after the demise of the patient, he was laid on a
dis«ectiD|B^ table, and bis spine was opened. There was slight sanguineous extravasation
between tbe bony sides of the vertebral canal and the theca vertebralis. On opening the
tbcea, a serous effusion was discovered, so copious in the sacral parts of the spine, as to
produce compression. There was also a considerable quantity of serum in the cervical por«
tion of the theca ; the spinous arteries and their filaments wer^ injected.
In tbc cranium, the brain and its meninges w^re more than naturally distended with blood,
and in each lateral ventricle, half an ounce of a pink-colored serum was found ; the velum
intcrpositum and choroid plexus were also universally turgid. There was no evidence of
disease in any of the other viscera." London Lancet Vol 1, 1831-1832, p. 715.
Caie ti9. — Traumatic TetanvR.
Another case, occurring iu Westminster Hospital, yielded somewhat similar results. The
disease was caused by a contusion and laceration of the index finger of the left hand. The
patient, a lad, was treated by Mr. Guthrie :
The day after deuth, the body was opened in the presence of Mr. Guthrie and several medi-
cal men. As soou as tbc breath was out, the body had been placed prone, with a view of
preventing the gravitation of tbe blood or other fluids towards the spinal cord. In the
brain, the pia-mater was found injected, and a cosiderable deposition of lymph was discov-
ered bctm-een tbe pia-roater and tunica arachnoidea. All the sinuses and veins of the brain
were gorged with blood. There was no flnid in the ventricles, but the plexuses of the velum
interpositum were excessively distended. In the theca vertebralis a large quantity of dark,
extravasated blood was found. The pia-mater of the medulla oblongata and of the spinal
cord was much injected, and this heightened color of the membrane was traceable for a con-
siderable distance in the neurilemma of each spinal nerve. London Lancet, Vol. I. 1833-
1^34, p. 389.
Case JjO : Traumatic Tefanutt.
Dr. William Wallace describes the nerve leading to an injury in the right leg inducing
TrAomatic Tetanus, as inflamed and thickened in the immediate neighborhood of the injury ;
a quantity of a serous bloody fluid existed in the cavity of the arachnoid. The vessels of the
tuembrancB of tbe cerebrum, cerebellum, medulla spinalis and oblongata were very turgid.
Great eflTusion between the pia-roater and arachnoid — particularly on the superior surface
uf ibe hemispheres. An effusion of blood on tbe outside of the sheath of the spinal marrow,
nearly opposite to the middle of the chest. The plexus choroides livid from congestion ;
some reddish serum in the ventricle ; the substance of the brain very Arm and over-vascular.
Loadoo Lancet, 1835-1836, Vol. 1, p. 847.
Case 41 : Traumatic Tetanuit.
A ** highly inflamed state" of the covering of the anterior crural nerve, and of its super-
ficial and deep-seated branches, was observed by Mr. Richard Dritohistlc, in a case of Trau-
matic Tetanus, following a gun-shot wound of leg. London Lancet, 1836-37, Vol. I, p. 298^
Cane 4 J : Traumatic I'etanus,
A I tbe autopsy of a patient who died in the Hotel Dicu, of Paris, with Tetanus superven-
ing on frnciure of the leg. numerous ecchynioffs were found in the fibrous sheath of the
spinal cord; and rxtcinal to that mrmbrniie n collection of blnck and liquid blood occupied
toe lower part of the vcrtebriil canal to the height of five or hx inches. The spinal cord
itself was softened througout its lower two-ihirds, nnd closely ndhercnt to its pia-mater ;
aoU tbe ramollissrment continued, though iu a less dcgrfc, to (he oc('i]»ital foramen, termin-
atiog just below the corpora pyramiilalin.
Wiibiu tbe cranium, the pin-roatcr wneulFcivid to le grciitl}- injected, and there wiis
extensive softening of the left anterior snd middle lubes of the brain. In the sciatic nerve
of Ibe right side, (the side of the fracture), ec(li\ muses and inflnmnmiion were perceptible,
Imt there was neither in tbe nerve of the opposite side. Arehiv. dc la Med., April, 18lo.
London Lancet, 1842-33, Vol. ii, p. 508, July 8th, 184.'!.
Cane 4'^: Traumatic TvtanuH.
lo an iotoresting case of Tetanus, given by Pr. Ueid, la lUe *' Transact ious of the Associa-
;8B
218 Pathological Anatomy of Traumatic Tetanus.
lion of Pbrsicians in Ireland/' Vol. i, p. 113, great ▼ascuUritj, and an effusion of blood
were found round the spinal marrow.
Case 44 : Traumatte Tetanus,
In another case detailed by Mr. Brayne, of Banbury, in the *' London Medical Repository. '
Vol. iiT, p. 1, two or three inches of the inferior dorsal portion of the spinal marrow, were
iuffttsed by a continuous blush of inflammation, and three small, hard, white lamin« were
seen between the arachnoid and pia- mater.
Cbse 4^: Traumatic Tetanus,
The post-mortem examination of the body of a man aged 70, who died from Traumatic
Tetanus, occurring one month subsequent to the reception of an extensire lacerated wound of
the integumenU of the fore-arm, performed in Guy's Hospital, by Dr. Hodgkin, revealed
softening of the gray matter throughout the greater part of the cerrical portion of the spinal
medulla. The softening was more particularly observed in the right lateral medulla. Lon-
don Lancet, November 241h, 1827, p. 325.
In 62 deaths occurring in Guy's Honpital, frcm Tetanus, during a period of thirty-
two years, from 1825 to 1857, 18 were not examined, and of the remaining 44, in
only 34 were inspections recorded. The brain was examined in 20 cases ; in 11 it was
healthy and firm, with nothing morbid in color or consistence ; in 9 it was congested,
darker than natural, dark and flabby, pinkish, with ulcerations on under surface of
anterior lobes, and decomposed. The spinal cord was examined in 19 cases; in a few
it was redder than natural, congested and softened, but in the greater number nothing
aboormal was recorded. The condition of the nerves at the seat of the wound was
noted in 14 cases ; in five they were inflamed. The heart was violently contracted in
only one case ; and in this, the patient died on the second day, from suffocation, aAcr
laryngotomy had been performed for his relief. In 28 cases, in which the condition of
the lungs is given, in 7 they were congested, in 3 pneumonic, and in 4 apoplectic. The
larynx, in one case, in which the patient died in a paroxysm, was found closed by the
epiglotidean folds being caught in the rima. Nothing of special importanoe was notinl
in the condition of the other organs of the body. Out of 7 cases, there was unusual
post-mortem rigidity in 6, and in one case this was observed, five hours after death,
and in another fifty. ((luy's Hospital Reports, 3d Scries, Vol. iii ; Am. Jour. Med.
Sci., Oct., 1868 ; Brit, and Foreign Med. Chir. Rev., April, 1858.)
Mr. Benjamin Trovers, whilst holding that ''the evidence before the public to
establish that Tetanus has its origin in iiiflummation of ner\'ous structure, has failed ; *'
and that " even the common Htati*uicnt of incroasiHl vascularity and effusion beneath
the investing membranes, arc as common in other acute diseases as in this, and they
are by no means univerHul in TetauuH," iicverthelctis, records several cases occurring in
his own practice, which illustrate the fact that the disease is characterixed by oertain
lesions of the spinal axis. Thus, in a fatal case (46) of Tetanus occurring IVc.,
1820, in a porter, aiter fracture and amputation of the middle finger,
*'0n examination, half an ounce of reddish scniro issued from the «pinal canal, and the
medulla ipinalis irns pulpy."
In another case (47), caused by compound fracture of the right leg, (Oct., 1822 \
" The vcBself," of the brain, *' were turgid, and a considerable cITugion of serum was foun«l
between the opaque aruchooid, and the pia-matcr ; the membranes of the cord preacatc«l
Qoiversal vafcularity."
In the Case (48), of a lad, March, 1828, ^^somo effusion under the arachnoid, and
general increased vascularity of the cerebral and spitial membranes.*'
t<iw 4'^ ' Traumatte TrtauMS,
In a case of violent tetanic spnsms, which supervened two days after a blow on the cervical
iplnsi and which praTcd fm^vl in twent,v*,four hours, tb.e cervical portion of tht spinal cord
Pathological Anatomy of Traumatic Tetanus, 219
Will lofteacd Co the extent of an inch, whilst tlie membranes of the apinal cord were inflamed
nnd thickened.
In his " Further Inquiry on Constitutional Irritation," Mr, Travers rewrds only a
single post-mortem in this disease, in- which no special lesions of the oerebro-spinal
system were observed. He says that after the occurrence of a certain case of Tetanus
in Gay's Hospital, in which he observed, after death, that the arachnoid coat of the
bniio was raised in pouches by an unusual quantity of serous fluid, and that the ven-
tricles were fuller than natural,
"It became the custom to inspect the spine in every case of death from Tetanus; and in
five out of eijirht, some morbid disposition was discovered in the substance of the arachnoid
tunic covering the medulla. With one exception, they presented the appearance of distinct
osMooi patches, chiefly on the lower part of the cord, or cauda equina, so brittle as to
crackle on pressure, and of the thinness of silver paper. In the exception referred to, the
deposit bad a cartilaginous appearance." Further Inquiry, pp. 299, 314, 318, 320, 321.
John Hennen made few, if any, post-mortem examinations of the brain and spinal
cord in Traumatic Tetanus, as is evident from the following observations upon the
pathology of this disease, contained in his Military Surgery, (Third Ed., London, 1829,
pp. 252, 253.
" The host of authorities referred to by Plouquet, and indeed all other authorities upon
Tetanus, lose much 6f their interest if unaccompanied by dissections. Some recent occur-
rences, and particularly a case detailed by my friend, Mr. Webster, Surgeon of the 61st Regi-
ment, in the Medico-Ghirurgical Journal, for October, 181*7, have determined roe to .lose no
opporianily of minutely examining the spinal cord and the theca vertebralis, in all future
cases of acate Tetanus, or of a disease in many points very analogous to it, — hydrophobia;
a delermioatioo in which I am strengthened by the opinion of the author of the excellent
paper in the Medico-Chirurgical Transactions above referred to. I have already had many
comma nlcAlioos on the subject, and while some of my informants assert that they have found
the vessels of the spinal marrow in a state of congestion, others, of equal accuracy, assure me
that they could detect no change whatever upon them. Prom some of my correspondents,
1 have obtained information, by which I am perfectly satisfied that some of the changes
described as morbid, were natural to the parts, and that others were the consequence of a
rode use of the saw and chisel. The point, therefore, may be considered as requiring much
more accurate observations, and more accurate dissections than have hitherto been made ;
although of the frequent existence of congestions in the vessels of the spine, and of conse-
quent effusion intD the canal in tetanic cases, there can be no rational doubt."
Traoes of inflammation and congestion about the brain and spinal marrow were
Ujiierved in a case of Traumatic Tetanus, resulting from injury of the fingers of a
young man aged twenty-seven, recorded in (Juy's Hospital Reports, April, 1844.
W. W. Valk, M. D., has recorded the appearance presented by the spinal cord in two
cases of Tetanus, as follows :
Cate 50 : Traumatic Tetanus.
Mary Henson, a't. 14 ; died on the fifth day from the accession of tetanic symptoms; her
body was examined nine hours after death. With some difficulty the vertebral canal was
laid open from the cervix to the sacrum. To judge from appearances^ active inllammation had
fiisieil upon its investing membrane, the vessels of the pia-mater being very conspicuous,
numfrous ami greatly distended. Nothing remarkable in the aspect of the tunic arachnoidea,
or the medulla. On tearing up the skull cap, much blood escaped from the laceration of the
tessels of the dura-mater; the brain being exposed, presented no unusual appearance,
Dothing indicative of congestion, or extravasation.
Qise 51: Traumatic Tetanus.
Rebecca Peterson, et. 47 ; di d on the third day of the disease ; examined twelve hours
after death.
spinal cord healthy, vessels of pia-mater much congested^ serous effusion between it and the
tunica arachnoidea ; no other part examined. Am. Jour. Med. Sci., Vol. ix, 1831, p. 540.
We find the following interesting experiments upon the artificial production of Teta-
220 Pathological Anatomy qf Traumatic Tetanus.
iius in dogs, by the introduction of irritating bodice into the nerves, recorded in some
observations on Tetanus, by Dr. W. A. McDowell, published in the New Orleans Medi-
cal Journal, Vol. ii, March, 1846, p. 578.
NoTember 22d, 1840. — Introduced roinutc tack points into the mascular spinal mrrc of
dog Oumbo, at tbe point where the nerve passes over the lower end of the radius; and on
the same day, into the ulnar nerve of the dog Watch, at the point at which the nerrt pasMS
over the upper head of the os ulna; passing the taulcs completely into the nerves, burying
both extremities within the thcca. The wounds healed kindly, the licking of the dogs pre-
venting the ability to determine whether with or without suppuration.
They fed well, and continued healthy for six weeks.
On tbe morning of the 5th of January, 1841, Gumbo was found convulsed, with bis jaws
firmly clenched. Nothing was done in the case until three o'clock p. m., when tbe whole mus-
cular system had become, rigid, respiration difficult, the abdomen retracted, and a bloody-
looking sanies flowed from the bowels. In this condition, with the assisunce of Dr. Finley,
he was trephined, without e\incing sensibility to the operation. On compressing the brain
with the ball of the thumb, complete relaxation of alt the muscles was effected in the coarse
of a few seconds. In about nn hour and a half the spasms recurred, when they were again
relaxed by the compression, the animal recovering some degree of sensibility during each
relaxation ; on the next recurrence of the spasm, at nearly six o'clock, an incision was made
at the wrist, and the portion of nerve containing the tack, was removed, when the spasms
relaxed, and returned no more. This circumstance may, by the by, be attributable to ex-
haustion. The animal died half after seven o'clock.
The second dog. Watch, became affected three days after Gumbo's decease, with irregular
spasms; these increased as the day advanced, and in the morning he appeared unusually
uneasy and restless ; the following morning he was missing, and has never since been
heard of.
Such expcriuients strongly support the view that Tetanus has its origin in local irri-
tation of the nerves. Mr. Poland has shoXrn that lacerated wounds are muoh more
frequently attacked with Tetanus than incised wounds ; thus, at Guy's Hospital, the
disease occurre<l only in one case out of 1364, where the wound was made by a sharp
kiiifOf but it ensued in one out of 55, where the nerves were injured, as in accidents.
Cases have been recorded in which the spasms were almost entirely limited to the
side injured. Three ea.HeH recorded by Lanp:enbeck« sustain the view that Tetanus, in
its origin, may be dependent on local irritation ; in the first, the removal, by an inci-
sion of a fragment of a needle, was attended by an immediate subsidence of the symp-
toms, and the recovery of the patient ; (Syd. Soc. Year Book, 18G3, p. 220) ; the
removal of a ligature, which had been tied en magne^ after castration, at once stopped
all the symptoms in the second case ; and in the third case, the reduction of a fracture
which was atu^nded with great displacement, had the desired eflfect. Hasse states that
very fr(H|uently the IcKlgnient of splinters of bone, or the like, among the tissuesY ha.H
decidiHily influenced the development of Tetanus ; and Mr. Krichson says, that be has
never failed to find the nerve running from the wound more or less inflamed, and ofWn
f(»r a considerable distance, whenever it has been looked for. Dr. Packard, of Phila-
delphia, fuiind fatty degeneration of the ulnar nerve, in a case of Tetanus, in which
the fore-arm was amputated two and one-half inches below the elbow. The Tetanu.^
ha<l been preceded by extensive sloughing of the tissues :
*' By the sloughing, was laid bare a portion of the ulnar nerve, which was excised bj Dr.
Pancoast, with a faint ho])C of arresting the symptoms. A portion of tbe excised bit of nerve
seemed to the naked eye to be healthy, the rest was abnormally vascular. The former, and^r
the microscope, was proved to be actually in a normal state ; the latter was througbont io a
condition of well marlced f«itty degeneration." North Am. Med. and Chir. Review, Jan., 18:i!»,
p. loY.
The preciHltiig }X)st-uiorti'm examinations which we have recorded, as well as the
ol»ser\'ations of Kn»riep and others, supplied undtmbted proofs of the origin of Trau-
matic Tetanus in nervous irritation, and we have merely introduced these facts as cur-
n>b<irative evidence.
Pathological Anatomy of Traumatic Tetanus, 221
Dr. Humphrey Sandwith has recorded the following interesting ohservationa on the
pathology of Tetanus :
"DaTing Utelj witnessed the post-mortem examinations of the spinal cord in Traumatic
Tetanus, in all of which there were traces of hyperaemia in the nervous mass or its mem-
braoes, aud in which, though topicnl depletion of the spinal column was employed, the chief
reliance had been placed on morphia and cathartics. I resolved on the adoption of a more
decidedly aotiphloRistic course at the first opportunity. All the three cases alluded to, had
occurred at the Hull General Infirmary, an 1 in one of them, Mr. Wailis, (who intends to pub*
lisb an account of them, with colored sketches of the medulla spinalis and its investments),
contrasted the spinal marrow of the tetanic patient, with that of one who had died the same
day, of a disease not involving in any way the nervous centres.
** In Ibis and in the other tetanic cases, there was increased vascularity of the cellular mem-
brane, surrounding the thoca-vertebralis, together with increase of fluid, within the theca,
and the tunics, as well as the substance of the medulla, were extremely vascular. But when
trantverie sections or slices of the spinal marrows of the tetanic and noo-tetanic patients
were both submitted to a microscope of immense magnifying powers, the greatest difference
in the two structures became apparent. In that of the tetanic patient, the vascularity was in
ezcetf as welt externally as internally, in the gray, as well as in the medullary matter. The
medulla of the non-tetanic patient was not only without signs of marked vascularity,
bat had a more granular appearance ; whereas, that of the tetanic, on the contrary,
had a mure areolar or reticular aspect, and looked softer and more spongy. Thus we had
presented to us not only palpable hypera^mia, (which, as many pathologists believe, may
exist in various structures during life, and yet leave no positive trace behind,*) but also a
real modification of structure, characteristic of inflammation, the change having occurred in
tbe very system of nutrition of the nervous tissue.
•* I am aware that a few observers, on the ground even of a reference to the results of ana-
lysis by the scalpel, have objected to the doctrine of hyperaemia, of any part of the nervous
iiystem in Traumatic Tetanus. Thus Dr. Gerhard of Philadelphia, states that he has ex-
Afnined the bruin and spinal marrow in ten or twelve cases, and that he could not detect any
lesion which seemed to have the slightest influence upon the production of the symptoms.f
Sir Benjamin Brodie, and others, have made a similar observation. Two replies may be
made by neutralizing tins allegation, both of which appear to me of great weight. In the
firs^ place, to adopt the language of Dr. Cowan, (spoken generally, and not in reference to
ihii particular subject), the narrow limits of unaided sense are again marvellously enlarged
I y microscopical discovery, our past acquisitions regarded as elementary and incomplete, and
the whole subject is again to undergo renewed and unexpected revisions. ;( In short, the
rcfiAed examinations of the nervous structure commenced by Khrenberg, with the aid of the
microscope, promises to throw a stronger light on its pathology, even than it does on its
physiology. In the n"Xt place, post-mortem examinations of tetanic patients have been mostly
much too limited, the brain and spinal marrow having been usually alone examined, and
other portions of the nervous system having been comparatively seldom explored. Before
the doctrine of hyperemia of some part of the nervous system in Traumatic Tetanus, can be
considered as disproved, we must have the whole of the nervous system examined, and
examined microscopically. This negative mode of reasoning, is strengthened by much positive
proof educed by the scalpel, that different parts of the nervous system are found after death,
in a hyperscmiu condition. ' In the greater number of observed cases,' says Dr. Dunglison,
* hyperemia of the medulla or its membranes, has been found on dissection.' Even Mr.
(darling admits that 'serous effusion, with increased vascularity, is generally observed in the
membranes investing the medulla spinalis, and also a turgid state of the blood-vessels about
tbe origin of the nerves. Treatise on Tetanus, p. 47. Dr. Saunders also states, as the result
of his anatomical inquiries in tetanus, that if any muscle, voluntary or involuntary, has been
affected with spasm, it is found on examination, that the nerves which su])ply that muscle
are covered with turgid vessels at their visible origins, or where they appear to set off from
the brain, medulla oblongata, or spinal marrow ; but that the nerve serving the muscles,
which have not labored under spasm or convulsion arc free from turgid vessels. Ed. Med.
and Surg. Jour., vol. xvi, p. 474.
" Tbe observations of Mr. Swan, that the ganglia of the grand sympathetic nerves, are the
parts of the nervous system, to which irritation arising in the intestinal canal, tends, and
from which it proceeds to the rest of the nervous system, constitutes another link in the
chain of evidence confirmatory of the hypencmic theory of Tetanus. Irritation set up in
thoee ganglia, obviously disturbs the capillary circulation in them, and hence, probably the
•INni(lkK»n*« Pnictic«» of MMlicin«>, vnLi, p. 74.
il>«agll«>n> Pneticf of MMllciiie, vol. ii, p. XtO.
tTiUMartiimn of tlj<* Pruvincfal McmIIcaI ami Hiirir. AfMnriatioii, N. H., vol. i, p. 4.
222 Pathological Anatomy of Traumatie Tetanus.
Bvai,e oi (;rr»i. irriiaiioD, many very vascular paicnea were ODservea on ii. ana
with a green and jellow slime and mucus.' Along with these appearances in t
tineSf he records that ^ in all the ganglia of the grand sympathetic nerve,
decided marks of irritation.' The vessels usually pale and colorless were inji
spasms. In the case which illustrates Mr. Swan's remark, — one of acute idiopathic teunn^.
— ^ the villous coat of the small intestines throughout, had the marks of having been in a
state of great irritation, many very vascular patches were observed on it. and it was loaded
the small iotei-
there existed
(ually pale and colorless were itgected with red
blood, and the same was observed in some of the intermediate portions of the nerve. The left
semilunar ganglion exhibited a few vessels, but the right was injected in a betutifnlly minatc
manner, quite as much so when seen through a magnifying glass, as the conjunctiva in a
state of high inflammation. This fact harmonizes with an interesting exhibition of the
highly congested state of the ganglia of the sympathetic in cholera patients, as shown to me
by the late Dr. Mackintosh of Edinburgh, in his extensive museum of tnorbid anatomy. Tbe
phenomena in both cases, threw the strong light of analogy on tl^e assumed hyperaemic con-
dition of the nervous centres, or of the sympathetic system, or of the nerves immediately
connected with the seat of injuO" in tetanus ; the spasmodic contractions both in tetanus and
cholera, apparently owning a similar cause." Lancet, 1846, vol. i, January 10th, p. 40.
Dr. William Aitken, in the section of the second volume of his work on the
^^ Science and Practice of Medicine,^ ^ which relates to the discoveries r^arding the
structure and iunctions of the spinal cord and nerves, records the following important
observations on the pathology of Tetanus .
Four cases of tetanus which he accurately examined, all exhibited one character in
common, which pointed out the spinal cord as the seat of lesion in the formidable mal-
ady. The lesion discovered by Dr. Aitken, was not manifest to the naked eye, but wa^
determined to exist with certainty by an examination of the Specific (Iravity of the
cord substance. For this purpose, the cord was separated from its nerves, and dividod
into parts of a uniform size, and the Specific Gravity of each determined :
" Each of the four cases showed that the general specific gravity of the cord throughout,
is increased in cases of tetanus, the average specific gravity of the healthy cord, being 1.03i>.
They showed also, that a change is suddenly indicated about the region of the cord in imme-
diate communication with the wounded part, and that in one case of idiopathic tetanus, the
change was uniform throughout. In the first case I examined where the wound was on the
occiput, the uppermost three inches of the cord were of the highest specific gravitj*, and 'be
difference became suddenly and not gradually, manifest at the fourth inch. In the third rn^e,
a very marked difference was apparent when the cervical region was compared with the rtst
of the cord; and the difference was suddenly marked, where the roots of the cervicHl ftml
first dorsal nerves left the cord to form the brachial plexus. The wound in this insstunct* %Ta<
on the fingers.
"Mr. Lockhart Clarke has since examined the cord in tetanus cases microscopicallv. And
has found peculiar lesions of a most minute kind, scattered throughout its suhstauc-«*. Med.
Clin. Reports, August, 1805.
" In the last case the difference was suddenly manifested in the lowermost part of tho rord,
corresponding to the region where the nerves were in communication with the lower lirohf,
which were the seat of the injury." Glasgow Medical Journal, No. iv, January, is:>4.
Science and Practice of Medicine, Am. Ed. from 4th London Ed., vol. ii, p. 479.
According to the more recent labors of Ilokitansky and Demme (Sehmidt*8 Jalir-
bucher, vol. cxii), tetanus has a constant anatomical lesion, consisting in a prolifenUion
of the connective tissue of the whole medullary substance, of the medulla oblon^ta.
of the inferior peduncles of the cerebellum, of the crura cerebri, and of the spinal
<!onl, producing a viscous mass abounding in nuclei, and never progressing to the form-
ation of fibres. It is fre<(uently mentioned, that great congestion of the brain and
spinal cord was observed, a condition on which the lesions of the connective ti.s8ue jui^t
de.Mml)ed, are believed to depend. (Southern Medical and Surgical JournaL editetl b\
JoHeph Jones, M. T)., July, 18(>(>, p. 11(5).
In a case of Traumatic Tetanus, occurring in a German Butcher, aged 45, which
provtnl fatal on the 4th day, reported by Dr. Kssbine Mason, acting House Surg*H»ii «»f
Bellevue Hospital, (Am. Med. Times, Sept. 1, 18G0, pp. 150-1): there wajj cunsidei-
able effusion over the membranes of the spinal cord, which were very much congest4Hl.
The cord was also exceedingly soAened. The dura mat^r of the brain was natural .
PathologiccU Anatomy of Traumatic Tetanus. 223
supeificial v&sels very much injected and of arterial hue. Brain suhHtancc very much
Hoftened, as well as the medulla oblongata. There was nu effusion in the ventricles,
the other orpiDS were not examined.
Mr. Loekhart Clarke, in his communication On the Pathology of Tetanm, in vol.
xlviii, 1865, of the Medico Chir. Trans. : observes that in six cases the spinal cord
exhibited lesions of structure of different kinds and frequently of surprising extent..
According to this observer, the pathological alteration seems to consist of disintegration
xnd softening of a portion of the gray substance of the cord, which appeared in certain
parts to be in a state of solution. The fluid thus formed, however, is at first, more or
\m granular, holding in suspension the fragments and particles of the disintegrated
\]!»ne, but in many places it is perfectly pellucid. Mr. Clarke asks, whether the struc-
tural lesions, and disintegration of tissue are the effects of the functional excitement of
the cord, manifested in the tetanic spasms? or are they the cause of the spasms? He
negatives the former question, and as to the latter, he states that they are not the direct
or Mile cause, since in those cases of paralysis, in which similar lesions exist, they do
not give rise to tetanic spasms or convulsions. He believes that the lesions
depend on the conjoint operation of injury of the peripheral nerves; with hyperaemia
and a morbid state of the blood-vessels of the cord, and the resulting exudations and
degenerations. Mr. Clarke finds the lesions of structure, consisting in exudations and
diiiint^;ration8 of tissue, precisely similar in character, to those discovered in the cord,
in many ordinary cases of paralysis ; and on comparing together the lesions and symp-
toms of both kinds of diseases, he arrives at the following conclusions : 1st. That the
leftioDS are either not present, or are present only in a slight degree, in those cases of
tetanus which recover. 2d. That they are not the effects of the great functional activ-
ity of the cord manifested in the violent spasms, but are the effects of a morbid state of
the blood-vessels. 3d. That they are not alone the causes of the tetanic spasms. 4th.
That the tetanic spasms depend upon two separate causes : first,, on a morbidly excit-
able condition of the gray substance of the cord, induced by the hyperaemia and mor-
bid state of its blood-vessels, with the exudations and disintegrations resulting therefrom.
This stale of the cord may be either an extension of a similar state along the injured
nerves from the periphery, or may result from reflex action on its blood-vessels, excited
hy those nerves, secondly, that the spasms depend on the persistent irritation of the
peripheral nerves, by which the exalted excitability of the cord is aroused ; and thus
the cause which at first induced in the cord its morbid susceptibility to refiex action, is
the same which is subsequently the source of that irritation, by which the reflex action
i» excited. (A System of Surgery, edited by T. Holmes, 2a Ed., vol. i. Studies on
FoDctional Nervous Diseases by C. Handfield Jones, 2d Ed., p. 237).
Dr. Dickinson, in vol. li, of the Medico-Chirurgical Transactions, p. 265, et seq., has
giren a Teir accurate description of the spinal cord, in a case of Traumatic Tetanus, in
a man, aged 25 years, who died in eighteen and a half hours. The following are the
alterations desenbed by this writer. The cord presented three remarkable enlarge-
ments, one in the cervical, and two in the lumbar region. The morbid changes were
1st; a general intense injection of the cord, with dilatation of the blood-vessels in the gray
matter, more than in the white, and in the left posterior horn, more than in the rest of
the gray matter. The blood-vessels of certain portions of the cord, were replete to
distenston with the natural contents, and in some situations, blood corpuscles had
escaped irom their proper channels, and diflfused themselves among the nervous ele-
ments.
2d. A structureless, transparent material had been poured out in the immediate
vicinity of the vessels, not only into such vacant spaces as exist in the fissures of the
cord, but forcibly intruded into many parts of the solid structure, tearing up the tissue
and displacing the neighboring parts. Besides these changes, which affected both the
white and gray matter, the white columns presented circumscribed alterations, which,
ia conjunction with the effusion described, caased the swellings which were so con-
spicuous on the surface of the cord.
224 PathologiccU Anatomy of Traumatic Tetanus,
' Both Mr. Clarke and Mr. Dickinsun recognize fully the existence and importance of
peripheral irritation, and do not attribute more to the organic lesions they have dis-
covered, in the way of causation, than that they promote and intensify the morbid action.
Mr. C. Handfield Jones very justly remarks, that it is possible that the existcooe uf
such lesions in the cord, atler recovery, may account * for the persistence of ccrtaiii
symptoms in a modified form, as a degree of painful rigidity of the muscles, very liable
to be aggravated by slight causes, or the peculiar alteration of the features noticed in a
case recorded by Dr. Currie, when it is said that the patient's eyes appear hollow, his
face sharp and pale, his cheeks and lips being skinny, and his masseter muscles hard
and shrivelled ; — such alterations ai*e very suggestive of persistent spasm of the vajH>
motor and musculo-motor nerves, which must depend on some abiding lesion.
Dr. Clifford Allbutt has recently reported several cases of Traumatic Tetanus tu the
Pathological Society of London. Comparing the appearances of the cord in the scvcnl
cases, it was seen that they were similar, only differing in degree as regards sofleniDg ;
i^ two out of the four cases, meningeal hemorrhages were observed, the vessels of the
cord were greatly distended, thickened, varicose and plugged ; and in one case there was
universal thrombosis, with spaces around the vessels filled with matter, resulting from
the granular disintegration of the clots. In two of the cases, there was considerable
blood-staining of the cord, by oozing from, if not actual rupture of the vessels, and ia
two cases haemorrhage into the cord in different places. Both in the pia-mater and iu
the central gray matter similar vascular changes were observed. The central canal uf
the cord was stuffed with epithelial matter in over-abundance. There was nuclear pm-
liferation in the connective tissue, probably in excess of health. The cells in the ante-
rior horns were singularly wasted in a very symmetrical manner ; — no doubt due ia
part to exudation about the vessels, but also to changes in the cells themselves. The
cells were the subject of yellow disint^ration, b^inning iu the centre of the cells, and
invading them from centre to periphery. Many were seen to have run together, form-
ing an irregular, and more or less fatty mass, these masses giving rise to the appear-
ance of smsJl yellow masses in the anterior horns. At any rate, the latter were de-
stroyed more or less by exudation into them, and peculiar degenerate changes in the
cells. Dr. AIlbi|tt considered the haemorrhage and thrombosis as ante-mortem, and not
post-mortem conditions. — London Lancet, February 25th, 1871, p^ 270.
The improved physical and chemical methods of modern pathological research, will,
without doubt, in the progress of careful investigation, render still more accurate our
knowledge of the lesions of Traumatic Tetanus ; but the facts recorded in this chapter
are amply sufficient to show that this disease is characterized by distinct and recog-
nizable lesions of the spinal axis.
COMPARISON OF THE LE8I0N.S OF THE CERED110-8PINAL SYSTE31 I.N TRAUMATIC
TETANU8, WITH THOSE OBSERVED IN VARIOUS DISEASES OF THE NERVOIS
SYSTEM, AS EPILEPSY, SYPHILITIC NEUROSES, INSANITY AND PARALYSIS.
It is important that we should in the next place compare the lesions discovered in
the cerebro-spinal system in Traumatic Tetanus, with those observed in other diseast^
of the nervous system. Whilst we have observed a large number of diseases dependent
upon iiinctional and structural alterations of the nervous system, we shall, in illustrat-
ing this coiQparison, confine ourselves to those cases which we have had the time and
opportunity to study during life and to examine afler death. In this country it is
rarely within the power of the physician to make carefiil post-mortems in fatal cases
occurring in private practice, and many of thu most important cases of nervous diseases,
which we have treated and studied with care and interest for long periods of time, as
well as such sudden and fatal cases as occur in Traumatic Tetanus ancl ocrcbro-spinal
meningitis, have unavoidably been lost, without that final minute post-mortem examin-
ation, which would have given precision and value to the careful observatiotus during
life.
Relations of Tetanus to Various Nervous Diseases. 225
I shall, therefore, in selecting cases for record and comparison, confine myself to those
in which I was enabled to complete the investigation after death, in virtue of the pres-
eace of Uie patients within the walls of an hospital.
Gue 52: Lou of Mental Power (partial insanity)^ ending in Gonia, Delirium and
Death, and attended with Structural Alteratums of Brain,
Cbftrles U., ngcd 38 jeftrs ; a Dative of Dabliu, Ireland ; has been ia the United States
Army for ge%'tfral years, served during the recent war, and worked his way up from the ranks
to the position of Ist Lieutenant; was mastered out of service at Greenville, in March, 1868,
ftt nrbich time he moved to New Orleans, and entered the family of Mrs. A. Patient assisted
Mrs. A. in various ways, doing work about the house as directed. After a time, about six
raoatbs before bis final illness, it was noticed that the patient exhibited less intelligence than
formerly. The iutellectual powers appeared to Tail gradually, and the patient became " unre-
liiiblc, " and when sent on an errand, would go to some other place than the one specified.
Tbree weeks berore his entrance into the Charity Hospital became delirous and insensible,
with short lucid intervals, when he -appeared to recognize Mrs. A. and her family. Bowels
constipated, and daring three weeks, is said to have had only one action from the bowels. The
sitending physician applied a blister over the head, and administered purgatives, but with-
out Any apparent benefit.
Entered Charity Hospiul March 8th, 1869, ward 29, bed 430. Medium height; blue eyes;
light hair, red beard ; reduced in flesh ; lies in a state of delirium and apparent insensibility,
csBoot be aroused ; twitching of tendons and picking of bed-clothes. Bowels obstinately
constipated ; passes his urine in the bed, which has a powerful ammoniacal odor.
Fargatives were freely administered, and a blister was applied to his head ; those measures,
however, produced no perceptible benefit, and the patient died on the fourth day after bis
Admission.
Autoptjf eight hours after Death, — The Brain and Spinal Marrow were carefully removed. The
pia-mater and arachnoid were thickened, with fibrinous deposits thrown out, especially along
the track of the blood-vessels.
The two hemispheres of the brain were firmly adherent, and could only be separated by
dissection with the scalpel.
Blood-vessels of pia-mater greatly congested with blood. Gray matter of brain congested ;
white matter somewhat softened. Fibrinous effusion around base of brain.
Pia-mater and arachnoid of spinal cord, greatly congested with blood and the blood-vessels
of the spinal cord were not only distended to their full capacity with blood, but they also
presented a tortuous and varicose appearance. Gray matter of cord somewhat congested ;
white matter soltened. The spinal cord was removed and examined throughout its entire
length.
The blood-vessels of the brain presented not only an enlarged appearance, but thickened
walls.
Microscopical examination showed that the fibrinous effusion was being organized, and that
tbe cbaogea in the membranes of the brain were of slow development, and dated back in
their origin, weeks and even months.
Tbe two hemispheres of the cerebrum, were so completely adherent, that the longitudinal
fiiinre coald be displayed only by the use of the scalpel and considerable force.
The sympathetic nervous system was dissected out, and examined microscopically, no evi*
dence of disease was discovered in it.
The lumff§ and heart were normal. The abdominal viscera presented nothing unusual, with
the exception of a light bronze color of the liver, and some enlargement of the spleen.
These changes of the spleen and liver however, were of long standi iig and had no connec-
tion whatever with the fatal attack. The liver and spUen, when cut and exposed to the
action of the atmosphere, assumed a bright arterial hue.
Kidneys congested, but otherwise healthy.
In this case we have an instance of the connection of deranged mental action with
^tmctarml alteration of the hrain and its membranes.
Co§e 53 : Temporary hiManity^ . occurring occasionally during a period of years^
fiMowed finally by Lou of Mental Fo^oer, ParalynU and Death, Structured
Alterations discovered in the Brain and Spinal Cord.
John L. B., native of Mississippi, aged 50 years, admitted to ward No. 28, bed 416, Charity
Hospital, October 20th, 1868; was in comfortable circumstances previous to the recent civil
war, aod has a wife and family.
226 Relations of Tetanus to Various Nervous Diseases,
TweUe years ago attempted to take the life of his partner, without apy known cansa, and
since that time has bad occasional fits of temporary iosanity, although he has continued in
business.
Three years after the attack on his partner with fire-arms, he killed his horse, cutting ite
throat in the road, whist harnessed in his bus^fryt without ( as in the first instance ), any known
reason for the outburst of passion. The patient is said to have continued in a wild delirioae
state for several days after these violent manifestations. Daring the war lost his property, and
at its ulose roamed about the country in a demented but harmless state.
At t^ time of his entrance into the hospital, walked with great difflculty, — spoke slowly
and with effort, mind obtuse, and pttient gives no rational history of his past life, each time
giving a new story. In attempting to walk about the wards, fell several times ; motions fee-
ble and unsteady ; apparant want of co-ordination of the muscular motion ; cannot turn with-
out help in bed, requires assistance in dressing. Sensation apparently impaired. General
appearance that of a large, stout man. with full limbs, but in a low cachetic state, with pale,
sallow complexion. Passes bis urine and faeces in bed at night.
The powers continued gradually to fail, and with this progressive loss of muscular and
nervous power, the circulation in the extremities appeared to grow more sluggish. January
1st, 1869, the patient has several large bed-sores upon the hips, caused by pressure, and the
action of the Involuntary discbarges of urine. The bed-sores were dressed with a eerate
composed of one drachm of crystallized Carbolic acid mixed with one ounce of Simple cerate.
The internal treatment consisted or one-twentieth of a grain of Strychnine, and fifteen drops
of the tincture of the Sesqui-Cliloride of iron, three times a day, together with the most
nutritious diet afforded by the hospital ; under (bis treatment, with attention to the state of
the bowels, and to the personal cleanliness of the patient, with occasional blisters to tha back
of the neck, the general health improved in a marked manner ; there was a temporary ineraase
of muscular power, the patient became more cheerful and rested better at night; and at the
same time, effects of the iron were manifested in an improvement in the complexion. The
bed-sores also healed rapidly and fully. Thi^ improvement, however, was only temporary,
and in the early part of February, the difficulty of walking became so great, and the tendaacy
to fall, even when sitting in the chair, so constant, that the patient was compelled to lie tha
most of the time in bed. Remains as usual in a vacant, listless state.
The powers have progressively failed up to the present time, February, 19th, when the
patient lies in a state of mental vacuity, with mouth open, and eyes staring, unable to answer
the simplest question intelligently ; with almost complete loss of musenlar power in tha lower
extremities, and with large bed-sores forming upon the exposed parts of the trunk, notwith-
standing every effort to prevent their appearance, by friction and stimulating appUoatioaa.
The students had daily opportunities of witnessing the gradual and progreesive failara of
the intellect, and muscular and nervous forces in this patient; the progressive loss of power,
was also clearly shown in the fact that in December, the patient was able, with snpporta oa
either side, to walk down from the third story of the hospital to the floor of the amphitheatre
on the first floor. In January it was necessary to bring the patient down in a chair; and
at the present time he lies prostrate unable to sit up.
It is worthy of note that up to the present time, there has been no fever, no incraaae of
respiration orcircniation, or of animal temperature, and the nutritive functions have been per*
formed with regularity.
From the history of this case, we are justified In the conclusion that the disease of the
brain has been of long standing ; that the ituanity was dependent upon some sfmeMrwl mUer"
9iion of the ^rain; and that the atieration^ degeneration or softening of the brain has gradnally
extended to, and affected the spinal system.
This care presents a progressive failure of the intellectual, nervous and mnscalar forces,
without any sudden paralysis or contraction of the muscles, and the only sudden end violent
nervous agitation with which the patient was aflSicted since his entrance into the boapiul
was a slight convulsion about noon on the 12tb of February, after making unusual eflbrta at
sitting up and attempting to walk. So far as coold be learned, this was the only attack of
this kind that he had ever had, and we are led to exclude epilepsy as the canse of the pro*
gressive failure of the intellectual and nervous powers.
The patient continued progresglvely to fail ; lay in an unconscious condition, oecaaioaally
groaning and crying aloud, especially at night, when ho disturbed the entire wmrd. One
fourth of a grain of Morphine, was tried at bed-time, without any special benefit. Tha patient
does not reply when addressed, and appears to be wholly unconscious of any thing paeeiag
around hia, and is oblivious of bii distressing condition. Urine and Aaeat panted in bed ;
bed-sqre forming upon back over sacrum ; circulation sluggish ; surface of the skin In depea*
dent portions of the body, of a purplish red, mottled appearance. Patient unable to tur»
in bed, or to move his lower extremities. When the feet and legs are pinched, tha patieat
contorts the lace, and evidently suffiers pain.
The patient continued to sink ; gradually lost the power of swallowing, and could take na
RelatUms of Tetanus to Various Nervous Diseases. 2&*l
noarisbment ; breAtb became very offensive, and the teetb loaded with sordes ; four days
before deatb, the right thigh was coutracted and drawn op towards the trunk. Patient
Appeared to suffer pain when the attempt was made to straighten the limb.
Died March 3d, at 8 o'clock, p. m.
A. careful autop»y was made the next morning, at 8 a. m., with the following result:
Exterior, fall and not wasted ; heart normal ; lungs pale, but perfectly healthy , with no
depoffits ; alimeniary canal and all the abdominal organs, liver, spleen, and kidneys normal
in appearance.
Ifead, — Well-formed and large cranium, with Rymmctrical arch. Nothing peculiar, however,
was noted with reference to the cranium.
Dwa^mateTy firmly adherent to the bony structure; pia-mater, greatly congested and thick-
ened ; the arachnoid was in like manner thickened, and presented much more of an opalescent
Appearance than usual.
Bram, large, well formed, and unusually firm. The blood-vessels of the nutritive membrane
of the brain, were everywhere larger, more numerous and more congested than in healthy
brains. This condition was in no manner connected with mere stasis of blood, because it was
fts great lYi the most elevated portions of the brain, as in the most dependent. When cut, sec-
tions of the brain revealed a state of remarkable congestion. The congestion was greatest
in the yray matter of the convolutions and of the optic thalami, giving to those collections of
gsnglionic m.itter a pink high-colored appearance.
The blood-vessels of the brain tn all parta, were larger and more numerous and more con-
gested, than in healthy brains. The blood-vessels were not only more congested, but they
were permanently enlarged.
The large size of the small blood-vessels and even of the capillaries, as well as the state of
eoagestioo, imparted to the gray matter a deep pinkish tint.
Undtr the mkraaeoptj the ganglionic eelU of the gray matter ^ and ganglia of the brain appeared to
be diminished in number, whilst the eapiUaries were increased in size^ with thickened walls. Exudation
eorpusclet were observed amongst the brain structures^ and especially along the tracks of the blood''
tsshIs,
The pia-mater of the spinal cord was, congested in a similar manner. The spinal cord was
covered all around by a net-work of large anastomosing (varicose) blood-vessels, engorged
with blood. The blood-vessels appeared to be fourfold more numerous than io health. Upon
section, the blood-vessels of the spinal cord, in all parts, were found to be similar to those Of
the cerebrum and cerebellum. They were greatly enlarged and congested with blood.
The vessels were largest, most numerous and most congested in the gray matter (ganglionic
central columns), of the interior of the cord. So marked was the enlargement of the blood-
vessels of the cord, and so great was the congestion of blood in them, that the gray matter
of the cord, everywhere presented a bright-red color, wholly different from the gray color of
health. The cord was firm in texture. Under the microscope, the ganglionic cells appeared
to \>t more numerous in the gray matter of the spinal cord, than the gray matter of the brain ;
and the capillaries were enlarged and their walls greatly thickened. Exudation corpuseUs^ were
also seem in the neighborhood and around the capillaries ; and both in the spinal cordy and in the bram^
some fragments of the coloring matter of the blood were discovered in the textures.
It is a question whether the insanity was caused by this congestion and enlarged capillary
circalatiott. The temporary nature ofthefits^ as well as their violence ^ would indicate that the primary
lemon exieted in the circulatory apparatus of the brain and spinal cord.
In this case, we have as in the preceding one, . an instance oF the connect ton of
thronged mental action with structural alterations of the brain.
It is of great importance to the science of medicine, that every case of insanity,
t«hoald not only he subjected to the most rigid investigation during life, but also that
the mo6t careful examination of the nerve structures, should be made after death.
The brain is liable to disease, as well as any other organ in the body, and as it is the
orpia of the intellectual faculties, it makes a vast and important difference in our
pathological views and therapeutical principles, whether we r^ard insanity as connected
with and dependent upon structural alterations, or as a disorder of the intellectual
faculties and moral power.
Whilst vnrious causes may be active in the production of that terrible state, in which
man is degraded to the level of the brute, by loss of those powers which enable him to
direct and control the forces of matter, and even immaterial agents ; it is certainly of
jTeat importance to medical science to determine with utmost accuracy the structural
lesions of the brain and spinal cord, in all the various forms of insanity.
A wide and important field of research is opened to the medical superintendents,
228 Relations of Tetanus to Various Nervous Diseases,
directors and attending physicians of the various Insane Asylama in this oountij.
Each case of insanity should be subjected to rigid scrutiny ; accurate measurement
should be made of the cranium, and all peculiarities of confonnation and of phjriog*
nomy should be noted and compared with the peculiar phases of the insanity ; and thu«
careful examination should be completed by a thorough examination of the brain after
death. If a small portion of the funds of each State Asylum were devoted to the care-
ful investigation and delineation of the peculiar conformation of the cranium and ooan-
tenance (by photography), and to the publication of the annual results of the patholog-
ical labors conducted by competent men, important resiilts would be achieved for the
science of medicine.
The researches of Pathologists are gradually undermining the theory or bdief, m
long held, that Insanity is an affection of the mental and moral nature, or immaterial
principle, independent altogether of structural alteration of the material instrumeDt^
by which the mind manifests itself The question as to the relations of pathologiical
alterationB of the brain, to aberrated moral and intellectual manifestations, cannot be
determined by any process of reasoning, but must be settled by careful pathological
researches.
The belief that in Insanity, the encephalic nervous textures are primarily implicate<l,
Sdns ground, and is now ably supported by such men as Van I)er Kolk, Winslow,
oshnan, Bucknill, Tuke and Laycock. Van Der Kolk says, that more than thirty years'
experience has led him to a totally opposite opinion to those who deny that in the insane,
the phenomena found b the dead body, throw any light on the nature and course i f
the disease:
** And I do not remember to have performed daring the last twentj-five years, the dissec-
tion of an ioiane pergon, which did not aflbrd a sati^actorj ezplaaation of the phenomenA
observed during life." Minute Structure and Functions of the Spinal Cord and MedalU
Oblongata, etc. New Syd. See. Pub., vol. iv, p. 231.
The researches of Drs. Saukey, Bucknill, Skae and Boyd, have established the ex-
istence of marked variations in the specific gravity of the brain and its component
parts in insanity. Bayle, Delaze, Calmcil, Pachappe, Linas and others, have shown
that the general paralysis of the Insane, is the effect of an inflammation of the enoepha-
Ion, or of its membranes.
Bayle opened one hundred coi^pses of paralytic insane, and Calmeil forty-seven ; thef^e
observers found the meninges of the convexity of the cerebral lobes opaque, injectinl,
hardened, infiltrated with serosity, and offering frequently granulations or faise mem-
branes.
M. Linas opened one hundred and fourteen bodies of paralytic insane : in twelve
cases the pia-mater was cxccsnively injected ; the cerebral substance was quite full of
blood, the gray matter being from an intense red, to a dark violet color. In twenty-
eight cases, besides the preceding alterations, there were adhesions between the t^^n-
volutions and the meninges. In seventy-four cases the meninges were infiltrated,
op^ue, and as tough an a fibn)us membrane ; the cortical substance of the brain,
sometimes violet, sometimes yellowish, according to the degree of the paralysis, always
softened, less thick than in normal brains ; the white substance injected, and sometimes
infiltrated ; the convolutions meagre, and the whole mass of the brain more or lev^
atrophied. In thirteen cases besides the preceding alterations, there was one or many
small circumscribed places where the encephalitis had been more violent than ebewhcn\
In eight cases, there were also effusioKu^ of blood.
From these facts, it appears that woralysis of the iiifiane dependa U|>ob « cbfoaic in-
flammation of the brain and its menuiffes. Whether the disease begins ia tike laeiabram'
as Bayle has said, or in the brain ilg^elr, as M. Calmeil maintains, is a questioft of ooin>
paratiyely little importance. The .^reat point isi, that, the brain is always inflitfnedL M.
Calmeil has ascertained with thc^ microscope^ that in doubtful cases, wheoe the hnin
did not seem tQ b^ nuich »keix4 to the na^ed ey^ thi^TQ. wer^ nnvertheteos, all (b<^
Relations of Tetanus to Various Nervous Diseases. 229
microflcopic appearances of ioflammation. M. Linas has recorded cases to prove that
an acute cephalitis may cause the paralysis of the insane. As regards the first symp-
toms of this affection, M. Linas declares, that sometimes, intellectual disorders first
appear, and in other cases, muscular paralysis and insanity appear at the same time.
Ccfge 54': Insanity caused by Syphilis : Structural Alteration 0/ Brain.
The case was that of a white female, who had had syphilis, and the mental derangement
came oa, after the sapervention of constitutional symptoms, and appeared to be directly
referable to the structural changes induced in the brain by the syphilitic poison.
It was obserred during the life of the patient, that she was insensible to bad odors. Thus ,
as she was suffering from diarrhoea, the excrementitious matters were frequently daubed upon
her nose and face, by her own hands, and the patient appeared even in the lucid moments, to
be wholly oblivious to their presence and offcnsiTe odor.
After death, it was found that the structures of the brain, were extensircly softened and
altered in the neighborhood of the origin of the olfactory nerves.
The alterations of the hrain and the symptoms of insanity, in this case, were referred
to the action of the syphilitic poison.
It has been established by the researches of various observers, that the brain may
be affected indirectly by syphilis, as in caries, necrosis, exostosis of the cranial bones,
g:ummy tumor of the skull, or deposits in the dura-mater, which membrane has been
compared to an internal periosteum.
These lesions may excite inflammation of the dura-mater, which may extend to the
arachnoid, pia-mater and surface of the hemispheres.
It has in like manner been shown that the brain may be directly affected by syphilis ;
the nervous substance being the seat of syphilitic, gummy deposit, followed by soflen-
in;r, and cases have been recorded, in which white and red softening of the cerebral
substance have been caused by syphilis.
In the neuralgic affections, paralysis, epilepsy, and dementia, following the appear-
ance of the constitutional effects of syphilis, good results, and even effectual cures may
be obtained by the judicious use of the Bi-chloride and Bin-iodide of Mercury, and the
Iodide of Potassium.
The syphilitic poison induces profound alterations in the constitution of the blood,
and marked derangement in the nutrition of the tissues and organs, and especially of
the nervous structures, and the syphilitic origin of many ner>'ou8 diseases is at present
admitted by those practitioners who hold that syphilis ought always to be considered as
a possible cause in cases of obscure nervous disease, where its existence is not manifestly
imposmble. I fully endone the opinion of I)r. Thomas Buzzard, that if the physician
waita to act in an anti-syphilitic sense, until he obtains a clear and unmistakable history
of past syphilis, he will lose many lives, and leave uncured a great deal of perfectly
cnrmble nervous disease.
Daring the past twenty years I have treated a number of cases of insanity, epilepsy,
parmlysis, sciatica, and various forms of neuralgia in hospital and private practice, which
Dad been induced by the action of the syphilitic poison, and which were relieved in
most instances by the free and continuous employment of mercurials, iodides of mer-
cury, iron and potassium, and the various preparations of iron and arsenic ; it would be
foreign, however, to the present inquiry to detail these cases, or to enter upon any dis-
cnaaion of the relations of syphilis to various diseases, and especially to those of the
nervous system. Like malaria, the syphilitic poison induces such changes in the blood
and tissues as modify the character and progress of all supervening diseases ; and the
apace afforded by an entire volume would be scarcely sufficient to discuss these relr>-
tions. I will therefore dismiss this subject, with the observation, that I have derived
the greatest benefit from the Bi-chloride or Bin-iodide of Mercury, in combination with
the Iodide of Potassium, given in the proportion of one-sixteenth of a grain of either
the Bi-chloride or Bin-iodide of Mercury, to from three grains to two ncruples of the
Iodide of Potassiumj three times a day. The following is a convenient formula ; B,
230 Relations of Tetanus to Various Nervous Diseases.
Hydrargyri Bin-iodidi, four graiim ; Potassae lodidi, one ounce ; Aquas distillaitjo
eight fluidouncea ; mix ; sig.; t^'a^poonful in wineglaasfull of water three timea a day*
when it is desirable to use the iodide of iron in combination with the iodide of
potassium, the following formula has been found convenient : R. Potassn iodidi, one
ounce ; Tinct. iodinii, two fluiddrachms ; Syrupi Ferri lodidi, one fluidounce ; ayrupi
Zinziberis, seren fluidounces ; mix ; sig., teaspoonful in wineglassfull of water three
times a day. Id the severest cases of nervous derangement I have used the Iodide of
potassium freely in doses varying from one scruple to two drachms, three times a day.
In anaemic cases, and especially in those patients who had been subjected to the
combined action of malaria and the syphilitic poison, the following remedies have been
used alternately with the iodides of mercury and potassium : B. Strychnias sulph.,
two grains ; QuinisD sulph., two drachms ; Ferri et Qumise citratis, four drachms ; Acidi
Citrici, three drachma ; Aquie distillatse, eight fluid ounces ; make a solution ; stg.,
teaspoonfull in win^lassfull of water, three times a day. Also, as a substitute for the
preoBding : R. Strychniie sulph., three grains ; Acidi Arseniosi, two grains ; Quinin
sulph., three drachms ; Ferri redac, two drachms ; Extract Rhci, two drachms ; mix ;
divide into one hundred pills ; sig., one pill, three times a day. Each of the preced-
ing prescriptions constitute what may be called a course, extending about throe weeks.
In many cases it is necessary to repeat these remedies at regular intervals during periods
varying from two months to eighteen months, and even longer. Failure in the treatment
of such cases frequently arises from the irregular and timid use of mercurials and the
Iodide of Potassium.
Que 55 : Dementia, Paxalytis and Death ; Clots m Corpora Striata and Optic
Thalami,
In ibis case the patient, a negro woman, was brought into the hospital in a dull, listless,
speechless state, with loss of muscular power, and want of coordination of the muscular
movements, and it was said by her companions that she had been the victim of sorcerj or
witchcraft. The disease was said to have been suddenly induced in a slate of health, by an
aged negress, who practiced witchcraft.
After death, it- was found that blood-vessels had been ruptured, and blood extrarasatad
into the gray matter and nervous structures of the optic thalami and corpora striata. The pa-
tient was a large, stont old woman, apparently near seventy years of age, and the ruptured
blood-vessels were found to be degenerated, having undergone fatly degeneration. It is pos-
sible that the rupture of the blood-vessels may have been the result of some unusual meatal
or physical effort.
As the practice of sorcery and witchcrafl amongst the negroes in certain sccttous of
the South,, is thought to have been revived and extended since the war, we reprodaoo
one of the fullest and most accurate accounts of tlie superstitiotis practices of the
negroes.
The foHpwing very curious account of the extraordinary Huperstition of the African
race, was transmitted by the agent of Jamaica to the Lords of the Committee of Privy
Council, and by them subjoined to their report on the slave trade, and it is said to have
been the result of the diligent researches and accurate pen of Mr. Long.
The term Ohcah, Obiah, or Obia, (for it is variously written), we conceive to be the anQert-
ive, and Obe, or Obi, the noun substantive ; and that by the word Obia>-men or woisan-^«re
meant, those who practice Obi. The origin of the term we should consider of no inport-
ance in our answer to the questions proposed, if, in search of it, we were not led to dls^ai-
sitions that are highly gratifying to curiosity. From the learned Mr. Bryant^s* commentary
upon the word Oph, we obtain a very probable etymology of the term. A serpent, in the
Egyptian language, was called Ob or Aub — Obion is still the Egyptian name for a ■erpevt.
Moses, in the name of God, forbids the Israelites ever to enquire of the demon, Ob, which is
translated in our Bible, charmer, or wizard, divinator, and sorcilegus. Thewoasaoat Eador
is called Oub or Ob, translated Pythonissa ; and Outmio* (he cites from liorut AppoUo)^ va<
the name of the Basilisk or Royal Serpent, emblem of the sun, and an ancient oracular deitf
• ll7tbol(«y, vol, 1, pp. 4^, 47:1 and 47rt.
Relations of Tetanus to Various Nervous Diseases. 231
of Africa. This derivatiooi which applies to one particular sect, the remnant probably of a
rerj telebrated religious order in remote ages, is now become in Jamaica the general term to
denote those Africans, who, in that Island, practice witchcraft or sorcerj, comprehending
also the clast of what are called MyaUmen, or those who, by means of a narcotic potion,
made with the Jnice of an herb (said to be the branched ealalue or species of tolanum) which
occasions a trance or profound sleep of a certain duration, endeavor to conrince the deluded
spectators of their power to re-animate dead bodies.
As far as we are able to decide from our own experience and information, when we lived in
the island, and from the current testimony of all the negroes we have ever conversed with on
the subject, the professors of Obi are, and always were, natives of Africa, and none other ;
and they have brought the science with them from thence to Jamaica, where it is so univer-
sally practiced, that we believe that there are few of the large estates possessing native Afri-
cans, which have not one or more of them. The oldest and most crafty are those who
Qsaally attract the greatest devotion and confidence ; those whose hoary heads, and somewhat
peculiarly harsh and forbidding aspect, together with some skill in plants of the medicinal and
poisonous species have qualified them for successful imposition upon the weak and credulous.
Tha negroes in general, whether Africans or Creoles, revere, consult and fear them ; to these
oracles they resort, and with the most implicit faith, upon all occasions, whether for the cure
of disorders, the obtaining revenge for injuries or insults, the conciliating of favors, the dis-
eoTery and punishment of the thief or the adulterer, and the prediction of future events.
The trade which these impostors carry on is extremely lucrative ; they manufacture and sell
their Obies adopted to different cases, and at different prices. A veil of mystery is studiously
thrown over their incantations, to which the midnight hours are alloted, and every precau-
tion is taken to conceal them from the knowledge and discovery of the white people. The
deluded negroes, who thoroughly believe in their supernatural power, become the willing
acconplices in this concealment, and the stoutest among them tremble at the very sight of
the ragged bundle, the bottle of the egg-shells, which are stuck In the thatch, or hung over
the door of a hut, or upon the branch of a plantain tree, to deter marauders. In cases of
poison, the natural effects of it are by the ignorant negroes, ascribed entirely to the potent
workings of Obi, The wiser negroes hesitate to reveal their suspicions, through a dread of
incurring the terrible vengeance which is fulminated by the Obtah-men against any who
should betray them ; it is very difficult therefore, for the white proprietor, to distinguish the
CMeoA^ro/easor from any other negro upon his plantation ; and so infatuated are the blacks in
genarali that but few instances occur of their having assumed courage enough to impeach
these sniscreants. With minds so firmly prepossessed, they no sooner find Obi 9ti for them near
the door of their houses, or in the path which leads to it, than they give themselves up for lost.
When a negro is robbed of a fowl or a hog, he applies directly to the Obeah man or woman,
it It then made known among his fellow blacks, that Obi it set for the thief ; and as soon as
the latter hears the dreadful news, his terrified imagination begins to work, no resource is
left but in the superior skill of some more eminent Obeah-m^n of the neighborhood, who may
counteract the magical operations of the other ; but if no- one can be found of higher rank
and ability, or after gaining such an ally, he should still fancy himself affected, he presently
falls into a decline, under the incessant horror of impending calamities. The slightest pain-
ful eeuiation in the head, the bowels, or any other part, any casual loss or hurt, confirms his
apprehensions, and he believes himself the devoted victim of an invisible and irresistible
agency. Sleep, appetite and cheerfulness forsake him, his strength decays, his disturbed
inmgination is haunted without respite, his features wear the settled gloom of despondency ;
dirt, or any other unwholesome substance become his only food, he contracts a morbid habit
of body, and gradually sinks into the grave. A negro, who is taken 111, inquires of the
O^eak'WUH the cause of his sickness, whether it will prove mortal or not, and within what
tine he shall die or recover? The oracle generally ascribes the distemper to the malice of
some particular person ; but if no hopes are given of recovery, immediate despair takes place,
which no medicine can remove, and death Is the certain consequence. Those anomalous
symptomSi which originate from causes deeply rooted in the mind, such as the terrors of 06i\
or from poisons, whose operation is slow and intricate, will baffle the skill of the ablest
physician.
** Considering the multitude of occasions which may provoke the negroes to exercise the
powen !of 06i against each other, and the astonishing influence of this superstition upon
their minds, we cannot but attribute a very considerable portion of the annual mortality
asnottgthe negroes of Jamaica to this fascinating mischief
•* The Obi Is usually composed of a farrago of material, most of which are enumerated in
tbe Jamaica law,* vis: blood, feathers, parrots' beaks, dogs' teeth, alligators' teeth, broken
bottlea, grave dirt, rum and egg-shells."
nso.
232 Relations of Tetanus to Various Nervous Diseases.
Pere Labalf* in bis history of Martioico, has mentioned some iustAncoa of this prdcttce
which are verjr remarkable.
'• It may seem very extraordinary, that a practice alleged to be so frequent in Jamaica,
should not have received an earlier cheick from the legislature. The truth is, that the skill
of some negroes, in the art of poisoning, has been noticed here since the chemists became
much acquainted with. them. Sloan and Barham, who practiced physic in JamaicA in the
last century, have mentioned particular instances of it. The secret and insidious manner
in which this crime is generally perpetrated, makes the legal proof of it extremely difficult.
Suspicions therefore have been frequent, but detections rare ; these miiderers have aonuUme*
been brought to justice, but it is reasonable to believe that a far greater number have
escaped with impunity. In regard to the other and more common tricks of Obi, such as
hanging up feathers, bottles, egg-shells, etc., etc., in order to intimidate negroes of a thiev-
ish disposition from plundering huts, hog-styes or provision grounds, these were laughed at
by the white inhabitants as harmless stratagems, contrived by the more sagacious for deter-
ring the more simple and superstitious blacks, and serving for much the same purpose, as
the scare-cows which are in general used among our English farmers and gardeners. But in
the year 1760, when a very formidable insurrection of the Koromantyn or Gold Coast negroes
broke out in the parish of St. Mary, and spread through almost every other district of the
Island, an old Koromantyn negro, the chief instigator and oracle of the insurgents in that
parish, who had administered the fetish or solemn oath to the conspirators, and furnished
them with a magical preparation which was to render them invulnerable, was fortunately
apprehended, convicted and hung up, with all his feathers and trumperies about him ; and
his execution struck the insurgents with a general panic, from which they never afterwards
recovered. The examinations which were taken at that period, first opened the eyes of the
public to the very dangerous tendency of the Obeah practices, and gave birth to the law
which was then enacted for their suppression and punishment. But neither the tenor
of this law, the strict investigation which has ever since been made after the professors of
Obi, nor the many examples of those who from time to time have been hanged or transported,
have hitherto produced the desired effect. We conclude, therefore, that either this sect,
like others in the world, has flourished under persecution ; or that fresh supplies are annually
introduced from the African Seminaries. "
Bryan Edwards, in his " History, Civil and Commercial, of the British Colonies io
the West Indies," (1806, vol. ii, p. 303), quotefl the following narrative from a planter
in Jamaica, whom he characterizes as a gentleman of the strictest veracity :
<^ Upon returning to Jamaica, in the y«^ar 1775, he found that a great many of his negrora
had died during his absence; and that of such as remained alive, at least one-half werv de-
bilitated, bloated and in a very deplorable condition. The mortality continued after his
arrival, and two or three were frequently buried in one day ; others were taken ill, and begna
to decline under the same symptoms. Kvery means were tried by medicines, and the must
careful nursing, to preserve the lives of the feeblest; but in spite of all his endeavori, this
depopulation went on for above a twelve months longer, with more or less intermissiou, and
without his being able to ascertain the real cause, though the Obtah practict yrd^a %XTMn\g\y
suspected, as well by himself as by the doctor, and other white persons upon the plantuiion,
as it was known to be very common in that part of the island, and particularly among the
negroes of the Pawpaw or Popo country. Still he was unable to verify his suspicions, because
the patients constantly denied their having anything to do with persons of that order, or an/
knowledge of them. At length a negress, who had been ill for some time, came one day and
informed him, that feeling that it was impossible for her to live much longer, she thought
herself bound in duty, before she died, to impart a \ttj great secret, and acquaint biro with
the true cause of her disorder, in hopes that the disclosure might prove the means of stop-
ping that mischief, which had already swept away such a number of her fellow-slaves. She
proceeded to say, that her step-mother, (a woman of the Popo country, above eighty years
old, but still hale and active) had put Obi upon her, as she had also done upon those who
had recently died ; and that the old woman had practiced Obi for as many years as she coald
remember.
"The other negroes of the plantation no sooner heard of this impeachment, than they ran
in a body to their master, and confirmed the truth of it, adding that she had carried on this
business ever since her arrival from Africa, and was the terror of the whole neighborhood.
Upon this he repaired directly, with six white servants, to the old woman's house, and fore*
ing open the door, observed the whole inside of the roof, (which was of thatch), and every
crevice of the walls, stuck with the implements of her trade, consisting of rags, feathers,
bones of cats, and a thousand other articles. Examining further, a large earthen pot or jar,
•ToDic 11, p. AO, 447, 490, 'i««J.'
Relations of Tetanus to Various Nervous Diseases. 233
close covered, was found concealed under her bed. It contained a prodigious quantity of
round balls of earth or clay of various dimensions, large and small, whitened on the outside
and variously compounded, some with hair, or rags, or feathers of all sorts, and strongly
bound with twine ; others blended with the upper section of the skulls of cats, or stuck
round with cats* leelh and claws, or with human or dogs' teeth, and some glass beads of differ-
ent colors ; tliere were also a great many egg-shells filled with a viscous or gummy substance,
the qualities of which he neglected to examine, and many little bags stuffed with a variety
of articles, the particulars of which cannot at this distance of time be recollected. The house
was instantly pulled down, and with the whole of its contents committed to the flames,
fimidst the general acclamations of all his other negroes.
In regard to the old woman, he declined bringing her to trial, under the law of the island,
which would have punished her with death ; but, from a principle of humanity, delivered her
into the hands of a party of Spaniards, who, (as she was thought not incapable of doing;
some trifling kind of work), were very glad , to accept and carry her with them to Cuba.
From the moment of her departure his negroes seemed all to be animated with new spirits,
and the malady spread no farther among them. The total of his losses in the course of about
fifteen years preceding the discovery, and imputable solely to the Obeah practice, he esti-
mates at least one hundred negroes."
Some of these remarkable results may be referred to the force of the imagination,
and the power of fear over the animal economy ; because it is well established, that tho
nenrons system is not only the centre and channel of sensitive and motor impulses,
conducting the motor influence of the will to the muscles, receiving and transmitting
to the cerebral ganglia sensitive impressions from the exterior world, and balancing and
c"K>rdioattng the motions of the body, but is also intimately related to the acts of cir-
culation and respiration, and the nutrition and secretion of the organs.
Numerous examples might be given of the influence of fear over the bodily health :
Thus, Sehenckius relates the instance of a noble Spaniard, Don Diego 089rio, who, being
in love with a young lady of the Court, had pi^vailed with her for a private confer-
ence within the gardens of the King ; but, by the barking of a little dog, their privacy
was betrayed, the young gentleman seized by the King's guard and imprisoned. It
wa« a capital ofl^ence to be found in that place, and Osorio was condemned to die. He
was so terrified at hearing this sentence, that one and the same night saw the same
penoti young and old, being turned gray, as in those stricken in years. Moved at the
Hight, the goaler related the accident to King Ferdinand as a prodigy, who thereupon
pardoned him, saying he had been sufficiently punished for his fault.
A similar circumstance is related of a nobleman of the Roman Court,' in the time of
the Kmperor Caesar, who was also detected in an intrigue, cast into prison, and sen-
tenced to be decapitated on the morrow.
Dr. Manhall Hall has recorded the case of a gentleman, who was suddenly affected
with epileptic seizures, the effect of fear — the fear of the cholera. After each epileptic
i«oizare, the hemtphlegic paralysis of the right side took place ; but this yielded com-
pletely, except that the patient could not direct his mind from the idea that the feeling
of the affected side was somewhat different from that of the other. At length, a fourth
attack proved fatal ; and on a post-mortem examination, the arachnoid was found
.nlightly opafjue, the tentricles containing serum, whilst in the left corpus striatum there
waa the remnant of a small clot of blood in a cyst slightly discolored. The arachnoid
wa« raised in one part by serum, resembling a vesicle, and a small vesicle was attached
to the plexus choroides.
On the oUier hand, the effects of strong mental and moral emotions, as the heroic
enthuaiasm of the excited warrior and the devoted martyr, may completely deaden the
nervous system to fear and pain, so that the dreadful wound and the burning flames
are alike disregarded. In the dancing mania of the middle ages, described by Hecker,
the patienta, at the height of their excitement, seemed to have had their external
Hciwca Hterallj sealed, ^^ While dancing," says Ilccker, " they neither saw nor heard,
being insensible to external impressions through the senses.*'
Under tho influence of fear and ftight, paralysed muscles and limbs that were useless^
have suddenly been thrown into action, haemorrhages have been iustimtaueously checked,
30
234 Relations of Tetanus to Various Nervous Diseases.
Mud fits of th^ gout) ague, and other disorders of a periodic character have been
cured.
Anger accelerates the progress of the blood, hurrying on the circulation with rach
fearful impetuosity, as to threaten the brain, and the organs contained in the chest ;
grief depresses the action of the heart, and causes serous accumulations in the lai);e
vesseb and lungs, and gradually undermines the health of the body by weakening the
energy of the nervous system, and causing the functions to be carried on in a alow and
unequal manner ; even excessive joy has been known to occasion as strange and fatal
results as anger and grief
Fienus mentions an instance of a malefactor who was carried out, as he conceived,
to execution ; and in order thereto his cap was pulled over his eyes, and a cold, wet
doth being struck hastily about his neck, he fell down dead, under the conceit of h'w
decapitation. A similar case is recorded by Charron ; — a man bavins his eyes cov-
ered to be put to death, as he imagined — ^being condemned — and uncovering them again
to receive his pardon, was found really dead on the scaffold.
It is said, and the statement has been often repeated, that a person was directed to
be bled to death \ his eyes were blinded, and he was made to believe, bv water trick-
line down his arms, that the sentence was being carried into effect. The mimicry is
said to have produced death as effectually as would the real operation ; the powers of
life were destroyed by the power of imagination.
Sophocles, at an advanced age, and in full possession of his intellectual powers, com-
posed a tragedy, whiqh was crowned with such success, that he died through joy ;
Chilon, of Lacedemon, died from joy whilst embracing his son, who had borne away
the prise at the Olympic Games ; Juventius Thalma, to whom a triumph was decreed
for subjugating Corsica, fell down dead at the foot of the altar, at which he was offer-
ing up his thanksgiving ; and Fouquet, upon receiving the intelligence of Louis XIV.
having restored him to liberty, fell down dead.
These and many other cases of sudden death, from powerful emotions and unexpected
joys and sorrows, are doubtle»<8 to be attributed to the effects produced by the nervous
system upon the sanguiferous system. Dissection has shown that in a large proportioo
of such cases, the heart and large blood-vessels are either structurally altered or en-
gorged with blood ; in some cases, death is clearly referable to effusions upon the brain^
and especially at the ba^^; of this organ in the neighborhood of the origin of the respira-
toiy nerves.
I have, by numerous experiments upon living animals, demoQstrated to the Medical
Students of the University, the sudden fatal effects of the arrest of the cireulation and
respiration, by destruction of the respiratory ganglia, and bv the action of such
poisons as Hydrocyanic Acid, which act directly upon the medulla oblongata.
The sudden withdrawal of the influence of the medulla oblongata, during fright or
excessive joy, may be also assigned as one cause of sudden death.
Numerous examples of the production of convulsions, hysteria, epilepsy, madness and
idiocy have been recorded by various writers, as being produced directly and absolutely
by fear and terror ; but it will be sufficient for the illustration of this subject, to record
some instaoocs illustrating the effects over disease of the imaginati6n.
Mr. Coleridge related the following anecdote to Dr. Paris:
As soon as the powers of Nitrous Oxide were discovered. Dr. Beddoes at once eon*
dnded that it must necessarily be a specific for paralysis ; a patient was selected for the
trial, and the management of it was entrusted to Sir Humphry Davy. Previous to
the administration of the gas^ he inserted a small pocket thermometer under the tongue
of the patient, as he was accus^>c4ttcd to do upou such occasioos, to ascertain the degree
of animal temperature, with a view to future comparison. The paralvtic man, whoUv
ignorant of the nature of the p^iKcss to which ho Yaa^to submit^ m veply impresBeti.
mm the representation of IV &^ue8, with lljue <MiMuiity of its success, n«i aMner fdt
the thennometer under his k>nga& than he concludlKL the taluman was in* full efoa-
tion, and, in a burst of eotU^Hinsm, declared thfi^t he alr^y ex^rienood the effeeta oC
Relations of Tetanus to Various Nervous Diseases, 235
its benign influence throughout his whole body ; the opportunity was too tempting to
be lost ; Davy cast an intelligent glance at Coleridge, and desired his patient to renew
his visit on the following day, when the same ceremony was performed, and repeated
eveiy succeeding day for a fortnight, the patient gradually improving during that
period, when he was dismissed as cured, no other application having been used.
At the time that Nitrous Oxide excited almost universal attention, several persons
were exceedingly anxious to breathe the gas ; and Professor Woodhouse administered
to them, ten gallons of atmospheric air, in doses of from four to six quarts. Impressed
with the idea, that they were inhaling the Nitrous Oxide, quickness of the pulse, dit-
siness, vertigo, tinnitus aurium, difficulty of breathing, anxiety about the breast, a sen-
sation similar to that of swinging, faintness, weakness of the knees and nausea, which
lasted from six to eight hours, were produced ; symptoms entirely caused by the breath-
ing of common air, under the influence of an excited imagination.
At the commencement of the present century, a man by the name of Perkins, intro-
duced oertain pieces of metal, called tractors, which he contended would cure certain
diseases by merely drawing them over the affected parts. The extraordinary effects
which were said to have been produced by their operation, were referred to galvanic,
electric or magnetic influences.
Dr. Havgarth resolved upon putting the metallic tractors to the test of experiment,
and selecting five patients from the general Hospital at Bath, he submitted them to the
operation of a pair of false tractors, composed not of metal but of wood, yet so painted
as to resemble the metallic ones in color. The patients thus selected had been ill several
months with various diseases of a chronic character, as gout and rheumatism. Upon
the affected parts being stroked in the slightest manner by these pieces of wood, the
patients all declared themselves relieved ; three of them were particularly benefitted,
and one immediatelv improved so much in his walking that he had great pleasure in
exhibiting proofs of the benefit he had received. One said he felt a tingling sensation
for two hours. Similar experiments with wood, slate-pencil, tobacco-pipes, etc., were
made at the Bristol Infirmary with the same results ; and the fame attending these
cases was so spread abroad, that more patients crowded for relief than time could be
afforded to bestow upon them. Men that were unable to lifl their arms and legs, were
speedily restored to their use, after the application of the supposed metallic tractors.
Such examples explain the miraculous cures ascribed to empirical and inert remedies.
It has been well said, " it is the confidence of the quack, and the hope of the patient
which work the cure. Disease is well known to depress the powers of the understanding as
well as the digestion. A sick person is, in particular extremely credulous about the
object of his hopes and fears. Whatever promises him health, may easily obtain his
confidence, and he soon becomes the dupe of quacks and ignorant pretenders.'*
Dr. Reid has said that he who in the study or the treatment of the human machinery
overlooks the intellectual part of it, cannot but entertain very incorrect notions of its
nature, and fall into gross and sometimes fatal blunders in the means which he adopts
for iui regulation or repair. Intellect is not omnipotent ; but its actual power over the
or]ganiied matter, to which it is attached, is much greater than is usually imagined.
The anatomy of the mind, therefore should be learned, as well as that of the body ; the
study of its constitution in general and its peculiarities, or what may be technically
called idiosyncrasies, in any individual case, ought to be regarded as one of the most
eMential branches of a medical education.
Plato says : *^ The office of the physician extends equally to the purification of the
mind and body ; to n^lect the one, is to expose the other to evident peril. It is not
only the body, that by its sound constitution strengthens the soul, but the well regu-
lateid soul by its authoritative power maintains the body in perfect health."
Hippocrates admitted that, that physician performed most cures, in whom the patients
plaoea the greatest reliance.
236 Relations of Tetanus to Various Nervous Diseases.
Cau 66 : Epilepsy ; Death; Atrophy ami Induration of the Cereh^Uum,
The patient, a young man, died soddenljr in an epileptic lit; or ratlier the patient became
eomatoie after the cuuTalsionB and lay in an insensible state for eighteen hours before death.
The cerebrum was normal in its structure and appearance; the cerebellum on the other
hand, was atrophied, and the gray and while mutter hardened.
The gray matter of the cerebellum was greatly diminished in amount, and the hardening
was of the most marked character. A large amouut of serous fluid, was effused between the
dura-mater and the arachnoid membranes of the brain and spinal cord. The liver, spleen and
alimentary canal, appeared to be healthy ; but both kidneys were atrophied, being not more
than one-half the natural size, with numerous cysts, (containing light yellow fluid), scattered
OTer the surface, and throughout the secreting structures; the aurface of the kidneys pre-
sented a granular appearance. Both kidneys presented a pale color, more nearly resembling
that of fatty degeneration than the normal color. The kidneys huve been preserved in the
Pathological Department of the Museum, University of Louisiana.
The results of the autopsy in this case arc intcre8tin<;, for in the great proportion of
the brains of epileptic patients that have been examined, the structure of that organ
has been said to have been in all respects healthy ; and this terrible disease has been
regarded as merely functional, the particular seat of lesion not being determined.
It must be admitted, however, that in some cases the brain and its membranes have
been found in every state of disease to which these parts are liable ; the former bein^
indurated, or soflened, the seat of various structural diseases, as abscess, cancer or
tubercle, the latter being inflamed, thickened or ossified ; and Wensel has stated that
the epileptic state has been invariably found associated with a morbid state of the pitui- •
tary body, in the cdla tunica.
The occurrence of the epileptiform convulsion in this case, in connecti<m with the
marked pathological alterations and degenerations of the kidneys, appear to support
the theory of this disease proposed by Dr. Todd. He referred the particular features
of epileptic seizures to the general accumulation of a morbid material in the blood,
from the cessation or impairment of the depurative functions of the kidneys, until it
reaches such an amount as to operate upon the brain, as it were, in an explosive manner,
exciting a highly polarized state of the brain, or of certain parta of it, so that the
nervous power is discharged upon certain other parts of the cerebro-spinal centre, in
such a way as to give rise to the phenomenon of fit. A connection has clearly been
established 'between defective renal action, the presence of urea in the blood and epilep-
tic convulsions ; and in the present case, the most rational explanation appears to be to
refer the fatal convulsions, to the arrest of the eliminative action of the kidneys.
This case illustrates in a striking manner, the importance of a critical examination
of the amount, character and chemical constitution of the urine, in each case of epilepsy.
Such investigations should not be limited to the paroxysms, but should extend abo to
the free intervals.
With reference to the treatment of epilepsy, it is important that the physician should
make minute inquiry into the condition of all the organs and functions and habits of
the patients ; and establish the treatment upon correct diagnosis and general principles.
Almost every potent agent in the materia medica has been recommended for the cure
of epilepsy, and cures have been recorded sustaining the recommendation ; but it will
be found upon a careful study of the disease, that a certain per cent of cases, get w^
gradually and spontaneously without the use of drugs ; in females the affection is some-
times connected with derangement of the menstrual function, and when that is regu-
lated, the disease may disappear, without farther treatment ; in nudes mastoibation and
excessive veuery may be causes of epilepsy which are to a certain extent controllable.
Some cases are clearly referable to gastric and intestinal irritations and derangements,
which may be removed or greatly benefitted by treatment ; whibt a certain proportaon
of cases are dependent upon structural alterations of the kidneys, and upon both stnic>
tural and functional derangements of the cerebro-spinal nervous system, and often
march steadily on to insanity, idiocy or sudden death, uninfluenced by the most potent
Relations of Tetanus to Various Nervous Diseases, 237
drags. When epilepsy is clearly the result of the action of the syphilitic poison, the
disease may be cured by mercurials and iodide of potassium.
Minute attention to the menstrual function, to the moral and mental habits of the
patients, to the state of the digestion and bowels with rigid rules for diet, exercise and
sleep, are all important.
Amongst drugs, Bromide of Potassium holds at present a high place with some prac-
titioners ; and certainly does good in some cases, but like all remedies in this affection,
its action ia uncertain, and many cases are wholly uninfluenced by it. In the case of a
stout young man, twenty-six years of age, aiHicted with epilepsy, and treated in this
hospital before the Medical Class, Bromide of Potassium in large and repeated doses
were tried, without avail ; as much as three drachms (180 grains) having been admin-
istered just before a paroxysm, without any perceptible effect. I have employed the
Bromide of Potassium, with marked benefit in some cases, whilst in others, no benefi-
cial effects could be perceived. I have employed Bromide of Potassium in my wards,
with apparent good effects in the treatment of delirium tremens. Milk punch and^
nutritious diet were also of great benefit in such cases, for the patients as a general rule
had neglected their aliment. A mixture of tincture of Assafcetida, fluid extract of
Valerian, and Acetate of Ammonia, had also given sati.sfactory results in the treatment
of delirium tremens.
Arsenic, Nitrate of Silver, Atropia and Iron, deservedly hold the first place in the
treatment of epilepy, especially when combined with proper exercise of mind and
body, change of chmate, sea-voyage and foreign travel.
In this connection it is important to note that the same kind of changes, characteristic
of the cord in Tetanus, viz : distension and dilatation of vessels, exudation of albumin-
ous fluid and extravasation of blood, have been detected in the medulla oblongata in
Epilepsy, by Schroeder Van I)er Kolk. He directs the attention of the physician, to
the condition of the medulla oblongata, in cases of epilepsy ; and afiinns that he has
frequently succeeded, where the disease has not been of long duration in procuring a
recovery through derivative ap[)Iications to the nape of the neck ; while the pathologi-
cal changes resulting from protracted epilepsy are not iinfro(juently manifoi^ted by
induration of the medvVa ohUmgata.
Professor Schroeder Van Der Kolk conchided his Rs.say on the Spinal Cord, published
by the Koyal Academy of Sciences at Amsterdam, in 1854, with the following general
c<mclasious :
*' The medulla oblongata is tlie principal centre, whence the more general reflex move-
meats and convulsions, derive their origin. I have for years been accustomed to seek iu it
ibe starting point of epileptic attacks, and consider that to it the pliysician should direct his
9pccial attention. Even though tbo primary irritation may be remote, for example, in the
iotestinef, a morbidly elevated sensibility and irritation in the medulla oblongata, always
form the foundation of such attack;), and render the organ in qucstiou more capable of, as it
were, discharging itself in involuntary reflex movements.
" An accurate examination of the minutestructureof the medulla oblonsrata, and especially
of the pathological changes produced in it by epilepsy of lon<T standin;;, which I have often
observed under the form of hardening, yet in reference to which no microscopical investiga-
tiont bare been made, may still throw much light upon the subject. I have not yet had
opportonity to put in execution these investigations, to wiiich I was anxious to direct the
attention of physicians.
** In this way alone, will It be possible to escape from the unhappy, rude and empirical
Ireatnent, which is ttill so commonly prevalent in reference to epilepsy, and of which I have
witnessed so many sad examples. A rational system of treatment of this disease can be
based only opon a better acquaintance with the functions of the medulla oblongata, whence
we mast endeavor more accurately to trace the naUire and essence of the disease."
Impelled by the wish to conti:ibuU; his share in the solution of this difllicult (|ue.stion
for the advantage of so many unhappy beings, Van Dor Kolk applied himself diligently
to the investigation of epilepsy, bringing to his aid, in addition to his great skill as an
anatomist, and valuable ex[>erience as a pathologist, the microscope ; and after having
238 Relations of Tetanus to Various Nervous Diseases.
examined the medulla oblongata in not less than fourteen epileptic patiente, he brou,;;ht
to bear upon the facts thus established, a thorough knowledge of the important experi-
ments of Brown-S^|uard and other distinguished physiologists, upon the cerebro-spinal
and sympathetic nervous system.
This observer, in entering on a more accurate investigation of the proximate cause of
convulsive movements, directed his attention first to the ganglionic cells, as the parts of
the nervous system whence all action proceeds, and which is conveyed through the
nerve filaments as conductors to the muscles. These ganglionic cells, which are almost
always collected in groups, and are mutually connected, he compared to galvanic or
electric batteries, which must be charged to a certain extent before the electricity accu-
mulated in the Leyden jar has acquired sufficient tension to discharge the flash. The
discharge in this case is effected, not by a constant stream of fire, but by a sudden
spark. Or, perhaps, a comparison with, the phenomena in electric fish is still better,
when, likewise, a violent discharge takes place, which reouires some tune, especially
when there is any exhaustion, before it can be repeated. There is, however, in these
ganglionic cells something peculiar, which is not yet fully explained. Thus they are
connected on the one side with nerve filaments, which, as conductors of the orders of
the will, are derived from the brain. Through these the ganglionic cells can be imme-
diately brought into action, and the muscle contracts almost at the same moment in
which the orders of the will are issued. These ganglionic cells are also connected on
the other side with nerve filaments, accompanying the sensitive nerves, which Van Der
Kolk has described as reflex nerves. Usually the action does not take place so quickly
on stimulating through the reflex filaments, and at least when the ganglionic cells
are discharged som^ time is necessary before the reflex action manifests itseli anew. If,
however, the action has once begun, the muscular contractions follow rapidly, as in
sneezing, swallowing, coughing, etc. The more irritated the condition of the cell now
is, the more quickly does the reflex action take place, and the slighter will be the
stimulus to the reflex ner\'e8 re(|uired to produce a reflex action. If the cell is ex-
hausted, some time is necessary, as it were, to charge it again, just like an electric jar,
which, if it is discharged by a spark, must be charged afresh before it can again exhibit
the same electrical phenomena. Van Der Kolk does not attempt to ofl^er any satisfac-
tory hypothesis in explanation of the fact that the orders of our will act otherwise on
these ganglionic cells, so that we can maintain a muscle for a long time in a stato of
strong or weak tension, while, in reflex action, the power of the cell b exhausted in a
moment, and the action ceases for a shorter or longer period. It is enough, he says,
that experience proves its truth, and we must therefore receive it as an unexplaincni fact,
and infer that the action of the reflex nerves on the ganglionic cells difl^ers from that
of the orders of our will. He suggests, however, that the cause may exist in the pecu-
liar nature and action of the reflex cells ; since, if our will acts directly on thene roflex
cells, as in swallowing, the action rapidly interrupted, is performed by way of di8char;}?e.
It has, however, been clearly ascertained, that for the restoration of this activity a cer-
tain quantity of arterial blood is required, on the efl^ect of which on' the ganglionic cells
their capability of action depends. It is indeed true that we see convulsive move-
ments ensue also after loss of blood in hsomorrhages ; but here Van Der Kolk con-
ceives that so many causes co-operate to produce a change in the cell, that we arc not in a
state to follow with sufficient accuracy the whole course of active causes and effete in
their several relations, and to watch nature everywhere in her hidden agencies. Quite
in accordance with this view is the great number of blood-vessels which are present in
the gray substance of the spinal cord and brain, in comparison with the so-called white
or medullary matter, which consists of conducting filaments. Nowhere did Van Der
Kolk find the quantity of capillary vrssels so great, and presenting such a densj, inter-
woven tissue as in the corpus ciliare of the corpora olivaria ; this body, in fact, affords
one of the most beautiful capillary net-works to be met with in the system, the vesecels
existing here in much greater number than in the gray comua of the spinal cord it^ilf.
Thus also it has been observed that the other groups of the ganglionic cells occurring
Relations of Tetanm to Various Nervous Diseases. 239
in the medalla obloDgata, as those of the hjpoglossus, vagus, etc., with the accessory or
ittxilliaij ganglia, are uncommonly rich in blood-vessels.
From these facts the inference was deduced, that more arterial blood flows in the
gBnglionic groups of the medulla oblongata, and thus also a more active metamorphosis
of tiflsue takes place there, than in the gray horns of the spinal cord. Whilst admit-
ting the great vascularity of the arbor-vitie of the cerebellum, and of the thalami and
corpora striata, he does not include these parts in his explanation of the phenomena of
Epilepsy, because he was at that time unacquainted with their use ) and whilst it must
be admitted that many points relating to the functions of these important portions of
the Denrotts system are not yet settled, still sufficient is known from the results of
direct physiological experiments upon varioud portions of the brain, to show that these
jx^rtions are involved, if not primarily, at least secondarily in Epilepsy.
It is evident that the vascularity of the ganglionic groups, and the quantity of arte-
rial bk)od supplied to them, are directly related to the intensity of their action. The
capacity for reflex movements is thus promoted by a strong arterial afflux of blood,
which increases the vital actions of the ganglionic cells ; as, however, the ganglionic
^ops in the medulla oblongata receive the most vessels, the reflex movements should
alflOf by preference take place here ; and this again agrees with the function, for exam-
ple, of the corpora olivaria, whereby such diffierent reflex movements as we observe iu
DootheriNut of the nervous system, are produced, or with the constant reflex move-
ments, which are incessantlv developed from the vagus on the lateral columns of the
medalla, for regular breathmg. Van Der Kolk hence infers that, other things being
er|aal, where there is general excitement of the vascular, an increased activity of the
Denroos system, involuntary reflex phenomena should, perhaps, after the application of
a slight stimulus, first arise in the part in which vascularity is greatest, and where the
Dataral capacity for reflex phenomena is strongest, namely, in the medulla oblongata.
And he r^ards this extremely probable conjecture as having been converted into cei^
taiDty, by the important experiments of Brown-S^quard.
Thus, Brown-S^quard found, that if he injured the spinal cord in mammalia, especi-
ally by catting through one-half of the cord, or the posterior columns and posterior
hums of the gray substance (wherein, as Van Der Kolk has shown, that very fine lon-
intudioal fibres exist, which appeared to serve to unite in an harmonious movement the
reflex impressions on severally distinctly situated ganglionic groups), and if the animal
surrived this dangerous operation, after the lapse of three weeks, convulsive movements
were excited, quite agreemg in every respect with epileptic attacks, at the same time
the very remarkable phenomena was observed, that if the left side of the spinal cord
was cut through at any spot between the seventh or eighth dorsal and the third lumbar
vertebra, it almost invariably followed that stimuli applied to the letl side of the face,
occasioned convulsive movements, while, if applied to the right side, they by no means
bad this eflfect.
This capacity for reflex movement did not manifest itself until after the third week
from the receipt of the injurv. The convulsions extended over the whole body, with
the exception of the part paralyzed by the transverse section, and were, consequent! v.
Dot unilateral. After some time these convulsions again ceased, and were subsequently
repeated. The convulsions sometimes arose spontaneously, without any external stimu-
ladon ; but among all parts of the body, there is only one where slight irritation was
efficient to excite them, namely the side of the face, or as was subsequently more par-
ticularly shown by Brown-S^quard, of the cheek. The space in question was bounded
iWe by a line drawn from the eye to the ear ; anteriorly, by one drawn from the eye
t^raigfat down to the under jaw ; and inferiorly, by one passing from hence to the ear,
and the lateral parts of the neck, sometimes even to the shoulders ; it consequently
(tirresponded to tne region supplied by the second and third branches of the trigeminus.
If only one side of the spinal cord was cut through, only one cheek was capable of
exciting these convulsive or epileptic movements, and the other cheek might be irri-
tated with impunity, and pinched without any result, !3ut if both posterior columns
240 Relations of Tetanus to Various Nervous Diseases.
were cut through, tho symptoms were occasioned by irritating either one or the other
cheek. These experiments led to important conclusions.
Id the first place, this capacity for convulsive movements did not take place until
the third week after the infliction of the injury, and then originated in the medulKi
oblongata, which is far removed from the injured part. Van Der Kolk hence inferrcJ,
that the irritated condition developed by the injury of the inferior dorsal or lumbar {coi-
tion of the spinal cord, extended slowly upwards to the whole cord, and particularly to tht-
medulla oblongata. Indeed, he affirms that these convulsions could be excited by irri-
tation only from the medulla oblongata, through the nervous trigeminus, and probably
through the accessory. This is still further confirmed by the course of the convulsion'*
themselves. Thus the first convulsive movements which arose, were confined to spasniA
of the face and of the eyes ; some days after this first attack, the muscles of the larynx,
neck and chest were affected with convulsions, and finally, the muscles of the trunk
and extremities participated in the movements. One of the first phenomena of a com-
plete attack, consisted in a spasm of the glottis, or of the muscles of respiration.
Brown-S^qiiard has thus, by his experiments, produced an exact picture or . mani-
festation of a violent atti\ck of Epilepsy, with all its symptoms, in the order in which
they occur in an epileptic patient.
It is important to observe in the foregoing experiments, that after an injury of the
dorsal or lumbar portion of the spinal cord (there is no doubt that injuries of higher
parts of the spinal cord would produce the same phenomena, but these affect the life of
the animals so much that they die before this change in the medulla oblongata \vas
occurred), the exalted reflex phenomena do not exhibit themselves in irritation of that
part of the cord which is situated next the wound, and which we should expect to bt*
first and most violently affected by the application of the stimulus. But the phenom-
ena exhibit themselves first in the medulla oblongata, where the part commences to par-
ticipate in the general morbid excitation of the spinal cord, occasioned by the injury.
And even then, irritation of the inferior portion of the cord is not competent to excite
these convulsions, but according to Brown-Sequard, only irritants, directly applied to
the medulla oblongata are capable of producing such effects. Even irritants applied to
the paralyzed foot, which on unilateral section of the spinal cord, changes into a condi-
tion of hypenxjsthesia or increased sensibility, do not produce these convulsions.
Van l)er Kolk points out the agreement of these investigations by Brown-S^Hjuaid.
with the results previously deiluced by Pfliiger, from a great number of ob9crvation.<.
his conclusion b^ing that, on irritation of a sensitive nerve of the brain, (^tn'^niinus\
the progreas of reflex movements is downwards, or towards the medulla oblongata, wbii<',
on irritation of a spinal nerve the progress of reflexion is inverted, from below upwards,
that is, likewise towaixls the medulla Oblongata. Hence, if the reflexion occurs in the
motor nerves lying even very distant from the irritated sensitive nerve, the reflectorally
excited motors are always such as arise from the medulla oblongata; and it is therefore
not until the irritation has reached the medulla oblongata, that the reflex movements
can pass to the other side and extend over the whole body. But if the irritation of the
medulla is not too great, it may, when it has reached the medulla oblongata, extend
over the body, but not on the same side. Cousequently, a higher degree of irritation
is necessary for thj transferrence of tho spasms to the opposite side, than for their
extension on the affected side ; therefore, tetanus is a result of a greater irritation than
that by which intermittent spasms are excited. From all this, it is clearly seen, bolh
that the medulla oblongata is distinguished by a greater sensibility to irritation, and
also, that this is the situation where bilateral convulsions originate ; but thus we must
regard the medulla oblongata as the prox im.it j starting point in oonvulsions, such a^
t'lose which occur in Epilepsy and other nervou'. affections ; and that in the minority
of cases, the most violent action takes placo on the side whence the irtitation of the
spinal cord or from the brain has proceeded.
While the medulla oblongata is particularly rich in blood-vessels, because an abun*
dant current of arterial blood is required during its increased activity ] on the other
Relations of Tetanus to Various Nervous Diseases. 241
hiDd, in reflex movements, its activity in commonly rapidly exhausted, and the ooti-
Tulsive motions set at rest ; — to begin again subsequently, or to be coDtinually repeated.
The experiments of Brown-S^uard have shown, that after the infliction of a wound
io the inferior part of the spinal cord, a certain morbid condition has been slowly de-
veloped ; that is, inflammation has arrived, as a necessary result at the seat of itijury,
and a state of exalted sensibility has gradually been communicated to the entire cold,
snd finally to the medulla oblongata ; and although the exciting cause, the irritating
voond inflicted on the spinal cord, and the more excitable state of the medulla oblongata
so produced, are constant, the phenomena are nevertheless intermittent.
From a great number of clinical facts, it has been shown, that to produce epilepsy,
DO disorganization is necessary, no great change in the tissue, but only inereased excit-
ability, and commonly augmented determination of blood and chemical change is
required. But it is not necessary in order to excite this exalted capacity for reflex
action in the medulla oblongata, that this stimulus should always be applied through a
Bpioal nerve, the sympathetic and the vagus effect the same ; thus, in children, convul-
tioDs arise from the irritation of teething, as well as from worms, acidity, exalted
intestinal sensibility, and inflammation of the intestines, when the dilated pupil, suffi-
ciently indicates the exalted activity of the sympathetic, under whose oonliol the dilator
of the pupil is placed. Thus a stimulus applied to the sympathetic or vagus, from the
gtomach and intestines, acts us much in increasing the sensibility and activity of the
medulla oblongata, as inflammation in a spinal nerve.
But these causes are not so limited ; thus through the abundant supply of blood,
must the vital metamorphosis of tissue, and with it, the organic activity in the medulla
oblongata, as in all parts of the body be kept up ; but if the blood itself be diseased,
if it has deviated from its healthy composition, it no longer supplies the normal stimu-
lus; it no longer furnishes the nutritive matters in the state in which they are required
for the maintainance of the vital functions. Thus, all kinds of convulsions and nervous
attacks, even epilepsy, arise from chlorosis, in which irop or hcematin appears to be
deficient, and the lymphatic blood globules predominate. By the administration of
ferruginous preparations, and by «^ood feeding, all the nervous phenomena cease, and
eren the epilepsy may be dissipated. The same thing is seen in the administratioii of
strychnia, when the blood is poisoned by the absorption of this powerful agent ; but
although strychnia, which is taken up into the blood, circulates in it, and therefore
comes in contact and interchange with the medulla, the phenomena are not persistent,
bat manifest themselves in intermittent spasms. Hence, it follows, that in these violent
spasms and exalted capacity for action, which, with strychnia, is not confined to the
medulla oblongata, the ganglionic cells are more or less rapidly exhaustisd ; that is, a
change takes place in the cells, which must be counteracted by fresh nourishment, and
bj the influence of a copious stream of arterial blood. It is, therefore, not until the
exhausted irritability is restored by some rest, that the capacity for reflex action, or the
mdiation of power, once more attains the heighth, at which only a slight stimulus, or
CTen no external stimulus is required to excite convulsions.
The same thing is true of epilepsy. It is a well known fact, which has been fre-
<(aently observed, that if an epileptic patient has been attacked by a severe fit, be
remains proportionally much longer free ; but if he has had only a slight attack, this is
repeated after a shorter time, often on the following day, in a more violent form, and
Qow again the patient continues longer exempt. Even the exalted irritability of the
Dervons system, and especially in the medulla oblongata, and in the brain, which arc
reciprocally so closely connected, manifests itself in the epileptic patient before the
attack, veiy oflen by greater restlessness and increased tendency to passions, and some-
times in an unpleasant sensation, from which the sufferers are again delivered for a
time, by the -more or less rapid occurrence of the fit.
It seems to be scarcely doubtful that the excited action of the ganglionic cells^ in the
medulla oblongata must extend its influence to the vaao-motor nerves of the brain, and
this altered, or more or less disturbed st*U<J of the circulation is, in the opinion of Yau
242 Relations of Tetanus to Various Nervous Diseases.
Der Kolk, the cause of the loss of consciousness daring an attack of epilepsy ; while it
is ioconeot to suppose that this loss of consciousness always precedes the attack. He
freely admits, with Kussmaul, that in an epileptic attack the whole brain participates
more or less in the change ; but the cpmmencement of the fit, or of the discharge, must
be referred to the medulla oblongata. In like manner, this pathologist explains the
loss of consciousness as the result of the action so produced on the walls of the vessels
of the brain, while consciousness may in some slight attacks even be maintained, or else
may be lost without convulsions being produced.
We have thus presented in foil the theory of Epilepsy, so ably developed and sup-
ported by Van Der Kolk.
From a careful investigation of the Pathological Anatomy of Epilepsy, Van Der
Kolk arrived at the following conclusions :
That the first cause of Epilepsy consists in en exalted sensibility, and excitability of
the meduUa obl<»igata, rendering the latter liable to discharge itself on the application of
several irritants which excite it in involuntary reflex movements. This irritation may
either be external, (irritation of the trigeminus), an irritated condition of the brain, or,
as is still more ftequent, it may proceed from irritants which excite it, in involuntary
reflex movements, as from irritants in the intestines. In children, worms in the intes-
tines, aoidity, a torpid state of the bowels, etc., are among the most common causes, in
adults there may be irritation of the intestines, particularly of the mucus membrane,
constipation of the colon, connected therewith, but above all, onanism, which acts so
veiy much on the medulla oblongata, and must be regarded as a very frequent causo
of Epilepsy. Amenorrhaea, chlorosis, plethora of the uterus, hysteria, etc., are alt*o
to be enumerated.
In the commeneenient there is still only exalted sensibility. If this can be removed
or moderated, the Epilepsy gives way of itself, especially if the sensibility is not renewed
by remote causes.
But if the disease has already lasted long, organic vascular dilatation takes place in the
medulla, the consequence being that too much blood is supplied, and the ganglionic group?i
are too strongly irritated, and too quickly overcharged. Every attack then becomes a
renewed cause of a subsequent attack, and the vascular dilatation is afVesh promoted by
eveiy fit. In the commencement of Epilepsy, therefore, it would seem that no apparent
organic change exists. Rapidly, however, probably in consequence of the repeat^ con*
gestion, the presence of a more albuminous fluid between the ner>'e filaments is mani-
fested, which may first cause more or less hardening, and may 8ubse<|ueDtly give rise to
fatty degeneration and softening. In addition, dilatation of the arterial capiUaries, and
thickening of their walls ensue.
These Uood-vessels in the medulla oblongata run chiefly in the region of the hypo-
giossus and vagus, as well as in the septum, and in the corpora olivaria. The posterior
half of the medulla oblongata in epileptic subjects, app>etfrs on a transverse section, red-
der and more hypenemic than in the normal state, whether the sufferers died during
an attack or not
EpUeptics may be divided into two classes : Those who bite their tongues during the
fit, and those in whom this never, or extremely rarely occurs. In the former, the capil-
lary vessels are usually wider in the course of the hypon:lo8.siis and corpora olivaria ; in
the latter, in the oonrse of the vagwt. In the»e last, the disease is, on account of the
greater tension in the organs of respiration, more dangerous, and the patients die during:
a fit, most frequently in consequence of arrest of respiration, which appears to occtir
less frequently in patients of the first class.
This mcreased vascular dilatation, with thickening of the walls, whereby the afflux
of arterial blood b augmented* and the ganscHonic cells are more rapidly charged, and
the altered exudation of intercellular fluid, appear to constitute the proximate cauiies of
the incurability of many long-standing cases of Epilepsy. Liistly, increased exodatioa
of albumeu woaes froQ\ tb^ oqw constantly distended v<^^s. whose walls at tl|e 8^ni<;
Relations of Tetanus to Various Nervous Diseases. 243
time become thickened, producing increased hardnofls of the medulU, aabseqaently
passiog into fatty d^eneration and softening, and rendering the patient incuraUe.
With these changes, vascular dilatation of the brainj and particolarly in the cortical
substance, goes hand in hand. The small ganglionic cells, which are here present in
gQch ftbandancoi become compressed by the dilated yeasels, and perhaps also in oonso-
quenoe of the more albuminous nature of the intercellular fluid. Dullness and loss of
memoiy are the results ; or if afler a fit, an unusual current of arterial blood is sup-
plied, we have, following immediately upon the paroxysm, over-irritation, rage and
acute mania, which is present in so many epileptics. This dullness of the mental
powers, which may represent apparent, until it finally passes into true demenUa, differs
very mnch Mm dementia after acute, or chronic mania— a point which is not suffici-
ently kept in view. Dementia after epilepsy is for a long time the result of vascular
dilatation, and if we succeed in conquering the Epilepsy, the silliness, the blunting of
the mental powers, and the shortness of memory give way, and the patient gradually
r^ios his former powers of mind, although not always in a perfect degree, which
depends on the amount of the affiection. The dilatation of the vessek, kept up by
no fresh attacks and convulsions, begins by degrees to disappear, the vessels contract,
regain their tone, the albuminous exudation becomes absorbed, and the patient
recovers.
In cases, however, of dementia after acute mania, the state o¥ things is quite differ-
ent Here the affection begins with irritation of the cortical substance, especially, of
the anterior lobes, under the os frontis ; this passes under the form of chronic menin-
gitis, which manifests itself, only by increased excitability of the patient into inflamma-
tion.
The sufferers from mania have no great prospects ; tiiey have become rich, play with
millions, are generally kings and emperors, prophets or embassadors from heaven.
There then ensues a formation of cells and granijdar cells, and the cortical substance
becomes firmly adherent to the pia-mater. The blood-vessels become atheromatous ;
with meningitis, effusion of much serum ensues ; the vessels exude a more watery fluid,
ind the cortical substance begins to atrophy. It becomes paler and thinner, and true
dementia, which is absolutely incurable, follows the previous excitement.
Thus, although the phenomena may be the same, as in both cases, there is compres-
sion of the cortical substance, the latter, aft«r mania and the co-existing inflammation,
passes lapidly into degeneration, and the disease becomes incurable; whUe in Epilepsy,
the vascular dilatation, which is only occasionally promoted by an attack, may last for
a long time without producing active degeneration. Patients have completely recovered
from a high degree of silliness and dullness in consequence of Epilepsy. In patients
epileptic in a very slight degree, where absence of mind took place, almost alone, with-
out convulsions, where, therefore, the brain was more directly affected than the medulla
oblongata, stupidity, diminution of memory, incapability of continued thought, or of
comprehending anything, arose much more rapidly than in those cases where spasms
were constantly repeated without loss of consciousness. Accordingly, the longer the
sleep lasts after each attack, and with it, the severe congestion of the cerebral vessels
continues, so much the more injuriously does epilepsy act on the mental powers, so
mnch the more does dullness ensue. — (Professor Schroeder Van Der Kolk, on the
)Iinnte Structure and Functions of the Spinal Cord and Medulla Oblongata, and on
the Proximate Cause and Rational Treatment of Epilepsy; Trans, by W. D. Moore,
New Sydenham Soc., London ; 1859 ; pp. 80, 207, 208, 205-218, 221-226, 230-250,
251, 252, 283, 284, 285).
The main points of agreement or disagreement, between the views and theories of
Van Der Kolk and Brown-S^quard, may be gathered by the comparison of the obser-
vations of the former, just recorded, with the following brief analysis of |he labors and
views of the latter, as contained in his Researches on Epiteptyf published in tiie Boston
Medical Journal, November 1856 to November 1857.
244 Relations of Tetanus to Various Nervous Diseases.
Dr. Brown-S^uard deduces the following conclusions from his experiment, upon
the artificial production of Epilepsy.
Ist. That an injury of the spinal cord, may give rine to an epileptiform affection.
2d. That there is a relation between certain parta of the spinal cord, and certain
branches of a portion of the nerves of the face and neck. 3d. That epileptiform con-
Yulsions may be the constant effect of slight irritations of certain nerves. 4th. That
eren when an epileptiform affection has its primary cause in the nervous centres, some
cutaneous ramifications of nerves not directly connected with the seat of injury in these
centres have a power of producing convulKions, when other nerves even directly connected
with them, have not. Iith. That the raniificHtionH of certain nerves may have the
power of producing coiivulsions, while the trunks of the nerves have not this power.
In regard to the division of Kpilepny, into centric and nen'phcrai, Brown-S^uard
endeavors to show that even in CM<i^ where the disea-sc appears, most certainly, to be of
peripheral origin, it may sometimes he, in reality, of centric origin. To determine
the fact daring the life-time of the patient, is often impoKsibie.
Dr. Brown-S6quard, adduCv^s a nnnihcr of obsorvation.s from different writers on ner-
vous diseases, which would seem to show that, in the human subject, tho peculiar distur-
bances of the cercbro-spinal axis, which constitutes epilepsy, may be generated by
alterations of different parts of this nervous axis, and by many nerves ; and arrives at
the conclusion that the seat of Epilepsy is very various. Usually the first spasmodic
contractions occur, in the muscles of the larynx, of the neck, of the eyes, of the chest,
of the face, and in the blood-vessels of the. bniin propiM*. showing that the disease is
ordinarily seated in the enccphalon, or upper portions of the spinal cord, or in both.
But that its seat, may also be in other portions of the spinal cord, would seem to be
proved by the occurrence of the first spasmcniic contractions in one of the limbs, either
the inferior or superior. After the firat Kpasms, all the muscles of the body may be
attacked with convulsions ; so that if Iohs of the actions of tlij brain proper, be iJone
regarded, there is ground for thinking that the seat of the disease, is both in those parts
of the eerebro-spinal axis, where reside the faculties of perception and volition, and in
those endowed with the reflex faculties ; but according to Dr. Brown-Sequard, this view
is correct only in appearance. Thus he attempts to show, that the loss of perception and
volition, does not prove, that epilepsy has it» seat in the brain proper, but that it is
highly probable, that a contraction of the blood-vessels of >the brain proper, due to an
irritation of their nerves in the spinal cord and medulla oblongata, causes the loss of the
cerebral faculties ; and as regards the increase of the reflex faculty, a partial and local
increase, is sufficient for the production of fits.
Dr. Brown-S^oard believes that Epilepsy is always the result of an excitation of the
oerebro-spinal axis. This excitation he supposes, may, in some cases, arise from
chemical and physical changes occurring in the elements of the nervous centres in oon-
seouenoe of bad nutrition, and other causes.
In regard to the production of Epilepsy by a poison in the blood, Dr. Brown-S^nard
admits that such may be the case, when the functions of the kidneys, liver, skin or other
depurative organs are suspended, and, in coose<[uence, certain deleterious matters are
allowed to accumulate in the blood, and also in cases where poisonous substances are
admitted from without, as lead, strychnine, Cyanhydric acid. Nearly all of these latter
poisons act only as causes of convulsions by increasing the reflex faculty of the cerebro-
spinal centre — they give to the nervous centres, the faculty of causing oonvulsioQS
when they ate irritated , hut they do not irritate. He knows of no pcisofa which causes
convulsions, by a direct irritation of any part of the nervous system, excepting carbonic
acid, when it is allowed to accumulate fVom any cause in the blood. Whde it seems to
destroy the reflex power of the cerebrospinal centre, the decarbonised blood at the
same time, irritates violently this centre, and therefore causes directly powerful coo-
Tulsiooa.
While he admits that in epilepsy, there is very generally, perhaps always an increased
reflex excitability, with or without an increased reflex force, he recognises also, that
Relations of Tetaiius to Various Nervous Diseases. 245
there is, in a gteat many oases of epilepsy, a special kind of excitation acting on the
nervouB centres.
According to Brown-S^uard, there are therefore three distinct elements for the pro-
ductioD of a fit : Ist, Increase of the force of the reflex property ; 2d, Increase of the
excitability of this property ; and 3d, An excitation of a special nature, or of a veiy
violent one. Of these three elements, the last two arc the most frec{uent, and perhaps,
the first of these two is essential.
Dr. Brown-S^uard, thus explains the paleness of the face, the spasm of the larynx,
and the loss of consciousness, which either one, or all of them, usually present them-
selves, in the commencement of the epileptic paroxysm.
When the excitation takes place in the spinal cord, and the basis of the encephalon,
which gives rise to the fit, the nerve fibres, which go to the head, are irritated and pro-
dace a contraction of blood-vessels. Of course this contraction expels the blood, and
in consequence the face becomes pale. Very often, another effect, depending on the
nerve fibres of the cervical sympathetic is produced — ^the dilatation of the pupil. But
the reverse, sometimes takes place — a contraction of the pupil occurring instead of a
-dilatation. This last phenomenon is easily explained, by admitting that the excitation
in the nervous centres take^ place near the origin of the third and fiflh pair of nerves,
and not of that of the cervical svmpathetic, as is the case when the pupil dilates. The
pakoesB of the face, and the dilatation of the pupil when it exists soon disappears,
chiefly in consequence of the obstacle to the venous circulation in the head, and of the
stale of asphyxia. The cause of the obstacle to the rctuni of the blood from the head, is
not only the contraction of the muscles of the neck, as Dr. Marshall Hall seems to think,
but also the state of the chest. Among one of the first symptoms of the fit, and as a
cause of the cry, there is a spasm of the laryngeal muscles, and a contraction of the
expiratory muscles. This contracted state of the chest acts on the heart, so as to
diminish the force of its beatings, as is the case in the experiment of compressing the
chest, made by K. Weber and others, and it acts on the veins iu preventing the circula-
tion in them. Although compressed, and unable to beat freely, the heart quickly
reooven an apparently great strength ; the blood losing its oxygen and becoming black
acts as a powerful irritant upon the central organ of circulation, so that palpitations,
sometimes very violent occur. Nevertheless the pulse often remains weak, because the
quantitj of blood sent to the arteries by the heart is smaller than usual, partly on
account of the venous circulation.
Dr. Brown-S^uard, thinks that at nearly the same time, when the origin of the
branches of the sympathetic nerve going to the blood-vessels of the face receive an irri-
tation in the begmning of a fit of epilepsy, the origin of the branches of the same and
other nerves going to the blood-vessels, of the brain proper, also receive an irritation.
A contraction then occurs in these blood-vessels, and particularly in the small arteries.
This contraction expelling the blood, the brain proper loses at once its functions, just as
it does in a complete syncope. Now as it has been well proved by the researches of
Kellie, Abercrombie, John Reid, Henle, and Folitz, that the quantity of liquid, in the
cnnio-spinal cavity, cannot change suddenly, it results that if there is less blood in the
brain proper, there must be more in the basis of the encephalon, and in the spinal cord.
In consequence of the impediment to respiration, the blood sent to the encephalon, as
wdl as to other parts of the body, contains but little oxygen, and is charged with car-
booie add, so Uiat the large quantities of blood accumulated in the basis of the
encephalon — the medulla oblongata, the pons varolii, the tubercula quadrigemina, etc.,
and in the spinal cord, is endowed in a high degree with the power, which Brown-
S^vard has shown that such blood possesses ; i. e. to excite convulsions. It may be as
Heme, has supposed, that the basis of the encephalon, is also excited to cause convul-
moDS, in eonseanenoe of the pressure exerted upon it, by the accumulation of blood.
The spinal cord also in all its length, is then excited to produce convulsions by the
Mood, which dfcnlatos in it
Brown-S^oard illustrates, by means of the following table, the mode of production
246
Relations of Tetanus to Various Nervous Diseases.
and the iDterchangement and sequence of the moat interesting phenomena of a complete
fit of Epilepsy.
CAUSES :
1. Excitation of certain parts of the
Excito-motory side of the Nervous System.
2. Contraction of the blood-vessels of
the face.
3. Contraction of the blood-vessels of
the Brain proper.
4. Extension of the Excitation of the
ezcito-motorj side of the nervous system.
5. Tonic Contraction of the laryngeal
and of the expiratory muscles.
6. Farther extension of the excitation
of the excito-motory side of the nervous
system.
7. Loss of consciousness and tonic con-
tractions of the trunk and limbs.
8. Laryngismus, trachelismus, and the
dxed state of expiration of the chest.
9. Insufficient oxygenation of the blood,
and many causes of rapid consumption of
the little oxygen absorbed, and distribution
of venous blood in the nervous centres.
10. Asphyxia, and perhaps a mechani-
cal excitation of the base of the encephalon.
syPKCTS :
1. Contraction of the blood-vessels of
the brain, proper, and of the face, and tonic
spasm of same muscles of the eyes and
face.
2. Paleness of face.
3. Loss of consciousness, and accumu-
lation of blood in the base of the encepha-
lon and in the spinal cord.
4. Tonic contractions of the laryngeaJ,
the cervical and the expiratory muscles —
laryngismus^and trachelismus.
5. Cry.
6. Tonic contractions extending to most
of the muscles of the trunk and limbs.
7. Fall.
8. Insufficient oxygenation of the blood,
and general obstacle to the entrance of
venous blood in the chest, and special ob-
stacle to the return of the blood f^om the
head and spinal canal.
9. Asphyxia.
10. Clonic convulsions everywhere ; con-
traction of the bowels, of the bladder ; of
the uterus ; erection ; ejaculation ; increase
of many secretions, efforts at inspiration.
11. Cessation of the fit : coma or fati^f ne ;
headache; sleep.
11. Exhaustion of nervous power gene-
rally, and of reflex excitability particularly,
except for respiration. Return of regular
inspirations and expirations.
We have thus endeavored to present with accuracy and minuteoeas, the moat important
results of the labors of Schroeder Van D^r Kolk and of Browo-Sequard.
Whilst Marshall Hall treated of epilepsy, as an affection of the medulla obloiigaui,
he failed to point out the distinctive pathological changes characteriatic of epilepsy, and
the Tarioos diseases of the nervous system, which he classed with it, as apoplexy,
paralysis and mania : Van Der Kolk, on the other hand fint investigated and disclosed
the organic changes undergone by the nervous system in epilepsy and mania, and thus
Slaoed the pathology of convulsive diseases, upon a firm and scientific basis. Sucli
ibors reflect light upon all the various affections of the cerebro-spinal nervotts aystem,
and they especially furnish material of the greatest value for comparison, and oapeciAlly
for the elucidation of Traumatic Tetanus.
The recent investigations of M. Oonzalez Echeverria, have sustained the aocuncy of
the pathological observations of Van Der Kolk, and he has been led to embrace a theory
of the disease, which docs not differ materially from that of Van Der Kolk, via :
** That epilepsy is a disease constituted by chronic paroxysms, excited upon a direct or
reflex action of the medulla oblongata, in a condition of exalted irritability, co-incidant viib
sudden depression of the cerebral circulation and with loss of conscionsness, with or vtUioot
muscular spasm. The medulla oblongata is the original seat of epilepsy and the disease
primarily involves the vaso-motor nerves."
Dr. Echeverria, bases his views of the pathology of epilepsy, upon twenty -six amlopsacs
of epileptics.
Relations of Tetanus to Various Nervous Diseases. 247
The observatioDS of this pathologist upon the lesions of the sympathetic are important.
Granular degeneration, irregularity, and pigment infiltration of the cells, in addition to
more or less hyperplasia of connective elements, prevailed in the sympathetic, reflecting,
as it were, the influence of the disturbance, giving rise to the modifications in the other
nervous centres. Dr. Echeverria, is inclined to consider such change, as a primary and
not as a consecutive derangement, for it is not the less the fact that it has appeared in
every instance, and more constantly than the cerebral alterations. The propagation from
the fourth to the third ventricle, corpora striata, and cortical substance, frequently
noticed, seemed to follow up the tract of sympathetic fibres in the brain, which may be
perhaps, the first to be disturbed in this organ. The sympathetic was examined in
fiAecn cases of epilepsy, and in each case, a more or less impaired state of the cervical
ganglia was detected ; and not unfrequently, there was a conspicuous similarity between
(be injured ganglionic cells and those of the medulla, or in the middle and between the
comna of the spinal gray matter. Whilst admitting with Jacubowitsch, that sympa-
thetic cells are located in these regions, yet Dr. Echeverria did not derive from his
pathological observations, sufficient evidence to ground the opinion, that the sympathetic
suffered more damage than any other cells, or that those in the spinal cord, so hurt, were
mainly sympathetic cells. Neither did he arrive at distinct results every time; on
investigating the net-work or nervous plexus around the cerebral arteries, participating
in advanced cases of the degeneration in the arterial parietes, and displaying prolifera-
tion of nuclei, in their attenuate primitive fibres. This observer attributes the absence
of cadaveric rigidity and earlier putrefaction of the paralvzed muscles, in cases of epi-
lepsy, attended with paralysis, to the lesion of the sympathetic. The fact is principally
exhibited by the muscles of the paralyzed limb, which are affected with permanent
contraction. Similar observations have been made by Charcot and Bouchard.
Changes were discovered in the ganglionary roots and peripheral extremities of the
dorsal nerves, in a case in which a herpetic eruption of zoster encircled the base of the
breast.
The ganglia presented their cells reduced to a mass of pigment deposited in the granu-
lar contents, with an exuberance of connective tissue and nuclei, which did not exist so
much in the other regions. As to the nerves connected with the eruptive patches,
they bad undergone a fatty degeneration of the primitive fibres, with the same rank
prowth of connective elements. The blood-vessels in the vicinity of these spots exhib-
ited a marked amyloid degeneration. Similar changes were observed in the ganglia
and peripheral nerves of four other cases attended with eruptions and modifications of
the akin commonly observed with epileptics. These phenomena are in accordance with
(hme pointed out bv Recklinghausen and Baerensprung, in the case of aii infant with
unilateral zona on the breast ; more recently, Charcot and Cotard had likewise reported
a caae of alteration (neurits), of the right cervical plexus, and corresponding spinal
gao^sonic roots, attended with zona on the same side of the neck.
Dr. Echeverria refers these and other disturbances to the sympathetic, and expresses
his firm belief that the circulatory system is especially concerned in the pathology of
Epilepsy. Thus, he says :
<* There appears from the onset of the epileptic disease, a disturbed action, aad whether due
to the slowness, or complete stoppage in the supply of blood, or to a primary trouble in the
nenroas elements, it sooo brings a structural modification of the blood-vessels. And it is
not less positire that the metamorphosis commences with paralysis and dilatation, and closes
with a retrograde or fatty degeoeratioo of the blood-resseis. I assert that so far as I have
had opportunities to judge, the dilatation is mainly the result of paralysis, and not of partial
coDtractton in the calibre of the blood-vessels, on account of the lengthening associated with
it, wbtcb conld proceed only from a lack of tonicity in the vascular walls. Even when a
tbrombas or migratory clot obliterates an artery, causing stagnation of blood, the aneuris-
mal dilatation acknowledges as cause, in great part, the weakening of the vascular walls.
However, in this latter circumstance, there are two more important elements to take into
accoant; the increased tension of blood, in consequence of the obliteration of the vessel, and
the reflux of venous blood from want of vit-a-tergo in the artery, as imagined by Virchow.
To the impedimeat la the local Qirculation must be referred the circnmscr^b^d abnormalities
24S Relations of Tetanus to Various Nervous Diseases.
in the itnicture of the nervous cent rc9, and the thickening or growth of graDuUlionB nnd
adrentitioQS patches in the cerebio-spinal membranes. These adTentitions deposit! do not
belong, as generally supposed, exclusively to old age. I hare not seldom encountered them
in indiTidnals dying in the prime of life from epilepsy or other cerebro-spinal affections/' —
(On Epilepsy, Anatomic, pAthological and Clinical Notes, etc., Now York; 1870, pp. Ill-
178).
It would be foreign to my purpose to enter into any critical examination of the vari-
otu views which have been propounded, with reference to the nature and causes of epi-
lepsy ; the preceding analyses of the labors of those obeenrers who have most fully
investigated the natural history of this disease by microscopical, anatomical, physio-
logical and pathological inquiries, fully sustain the proposition, that in epilepsy distinct
and reoogniiable lesions have been detected in the cerebro-spinal and sympathetic
nervous systems. The following cases wiU, in like manner, establish the existence of
structural lesions of the nervous system in variouB forms of paralysis :
Que 57 : Lo$$ of Muscular and Xervous Power — ParafysU — Death ; Structural
Lesions of NcrvouM System.
The history of this case resembled, in some respects, that of the succeeding ; the subject
being, in like manner, a negro man, (aged 50 years), who had been working during the last
two years upon a rice plantation, his duties compelling him to stand iu water abore bis
knees. Prerioos to this occupation, had been a healthy, stont man.
During the spring months, he began to suffer from *^ rheumatism in the left knee,'* which
extended to left elbow, and right knee and elbow, and the use of the extremities was grad-
ually lost. The paralysis appears to hare begun in the lower extremities, and the lower ex-
tremities were snid to hare been cedematous before being paralyzed.
In the month of August the power of locomotion was lost, and the patient became bed-
ridden.
The oedema of the lower extremities disappeared during rest ; the rheumatic pains, how-
ever, have continued to harrass the patient up to the present time, and the muscles of the
extremities have gradually emaciated, until they are now much reduced in size. Has had no
trouble in defecstion or urination.
At the present time, skin warm and moist ; temperature of axilla 99^.5, and patient lies on
his back ; subsultus teodinum, and pains in the shoulders, the former only occasionally, the
latter persistent ; paralysis of upper extremities, flexors of left arm partially contracted,
paralysis of extensors of left arm more complete than in right ; extensors of lower extremi-
ties unaffected ; flexors paralyzed ; tongue slightly furred ; appetite good ; bowels regular ;
respiration regular, about twenty per minute ; pulse seventy-two, small.
The treatment has consisted ot Iron and Strychnine, and the patient has gradually im-
proved since bis entrance into the hospital, and the power over the voluntary muscles
appears to be slowly returning. As in the succeeding case, this patient had been exposed to
the action of malaria, and to cold and wet, in a low, unhealthy region; and in like manner
the gradual loss of power in the extremities, was preceded and accompanied by rheumatic
pains, which were more decided, and attended with more marked local inflammation ; in like
manner there is asthenia, with no loss of sensation or intelligence. It appear* to be reason-
able to refer the nervous derangement to the same causes in both cases.
The paralysis progressively increased, until the patient became utterly powerless, and was
conflned to bed.
The flexors of the fore-arm were firmly contracted ; and the muscles of the foroHtrms and
legs wasted considerably. Strychnine and Iron appeared to accomplish no good in this ease, .
and death occurred March 31st, ldt>9. Tp to the time of death, there was no alteration of
sensation, notwithstanding the paralysis of motion.
Autopsy ^ Jive hours after death, — The brsin snd spinal cord were carefully removad. The
gray matter of the brain and spinal cord was of a deep reddish gray color. Blood-vessels of
arachnoid and pia-matcr congested with blood. The arachnoid of the medulla oblongata
and superior portion of the spinal cord wns discolored, presenting the appearance as If it had
been washed over with a weak solution of the Nitrate of Silver. Spinal cord somewhat atro-
phied, with the white matter firmer than usual, and the leray matter softened.
The brain and spinal cord of a patient that had died with phthisis pnlmoaalis were removed
and compared with the one under consideration, and it was observed that it was far lighter
in color; and it was especially observed that the gray matter of both the brain and spinal
oord were far lighter. Spleen somewhat enlarged and softetted. Liver of slats and brodM
color, with a patch of incipient fatty degeneration^
Relations qf Tetanus to Various Nervous Diseases. 249
Mteroteopieal Examinaiion of Nervout Structures. — The colored portions of the ipinal eord
were dae to a deposit of coloring matters in the form of grannies or crystalline masses in and
AroQod the mesbes of the blood-vessels of the dura-mater. The coloring matter appeared to
bare been dertred from tbe colored blood corpuscles.
The %TAy matter of the cerebellum, medulla oblongata and spinal cord was entirely changed
Id its appearance, as in the case of insanity and tetanus. It presented a deep reddish, gray-
ish and pink color, from the great enlargement and increase of tbe capillaries. The gangli-
ooic cells had disappeared to a great extent, and their place was occupied by enlarged capil-
laries. Masses of hsmatin were also discovered amongst the nervous strnctures. Many of
the nerve cells were filled with granular matter.
Comparative examinations were made with a healthy brain and medulla and spinal eord,
•od it was thus clearly shown that the nerve cells in the diseased brain and spinal cord were
diminished and altered in the most marked manner, and appeared to be not one-fonrih as
Donerousas in healthy nerve-structures.
1¥e have here, as in tbe preceding cases, grounds for referring the aberrated nervous pbe*
Qomena and paralysiit during life, to palpable structural alterations of the ganglionic cells
aod capillaries.
In the following case, which occurred in uiy hospital practioe, EfephantioMii of the
lower extremities was accompanied with parafysis apitans and atrophy of the spinal
cfird : Stephano Boralick, age 52, native of Austria ; entered Charity Hospital Oct.
19th, 1871, and died November 7th, 1872 ; remained in the Hospital twelve months
and DtneteeD days. When the patient entered Ward 13, on the 19th of October, 1871,
both 1^, from the knees downwards, and the feet were much enlarged, and the surface
uf the extremities presented a nodulated and livid appearance. The enlargement of
the extremities was due to the hypertrophy of the integuments, and I regarded the
disease as similar to the Elephantiasis of the Egyptians. There was also loss of power
in the spinal system of nerves. The hands and legs trembled incessantly when the
patient made any motion. Stephano walked with difficulty, with a tremulous, unoer-
uio gait Alteratives (Iodine, Iodide of Potassium, Iodide of Iron, Arsenious Acid,
Red Iodide of Mercury), and nervine Tonics (Strychnia, Quinia, etc.), and generous
diet, produced temporary improvement, with slight increase in strength and flesh. The
improvement, however, was only temporary, and endured for about six months. Then
the patient began to decline gradually in strength, and- at the end of eight months fh)m
his entrance into the Hospital, was permanently confined to his bed, from a total ina-
bility to stand upon his feet, or to coordinate the movements of the lower extremities.
With the gradual loss of nervous power, and especially during the period in which the
patient was confined to bed, the legs gi'adually decreased in sixe, and at the time of
desth the int^uments presented a shrivelled appearance. The intellect appeared to be un-
affected throughout the disease. After death, I exposed the spinal cord, anjd found it to be
hardened and atrophied. The gray cells of the cord were diminished in» number; and
the whita commissural matter was much harder than normal.
f'/*' .jS : PanifygU; progressive failure of muscular a}id nervous power; Death;
Sfimciural Lesion in Spinal Cord,
Vegro man ; aged 45 years ; native of Louisiaua ; has lived and worked all his \\Sp on a
iofsr plantation, where he was often necessitated to work in water, and was subjected to the
actioo of malaria.
Admitted to the Charity Hospital, January 8ih, 1869; patjent states that he has saflered
daring his life with frequent attacks of malarial fever, of the intermittent form; last Jnly,
vbilst working every day in deep water, often without eating food until night, began tojuffer
viih pains in different parts of his body, but more especially in the lower extremities; '.these
paios grew worse from day to day, and about Christmas he found that he had lost the power
or using his legs, not being able to walk without great difficulty.
I^oring tbe summer and fall months, the patient had suffered much with cephalalgia and
mtermittent fever. Has never had syphilis. At the time of his admission suQsred from con-
stipation of the bowels; but the bowels were regulated under the use of Strychnia, Iron and
Aloe*.
Magneto-electric shocks, seemed rather to Inor^asQ, than to benefit the loss of nerroua
»*4
250; Relations of Tetanus to Various Nervous Diseases.
power, and this agent wai consequently abandoned. The patient had been kept upon small
doses of Strychnia and Iron, with benefit. At the present time, the patient has but little nse
of the lower extremitieSi cannot raise himself from a sittinf^ to a standing posture, except by
climbing, as it were, up the bedpost, raising nearly the whole weight by the muscles of the
arms and shoulders; after getting to an erect position, cannot take a step, without holding
to a support ; by the aid of two walking canes be can walk slowly across the floor, by mov-
ing bis feet about two inches at a time, dragging his toes along the floor. Paralysis of the
flexors of his legs in his eflorts to walk, the feet appear to be raised by lifting the entire leg,
by means of the muscles attached to the hips ; subsultns tendinum in left leg. General sen-
sation and reflex action, unimpaired ; no failure of special senses; intellect as bright as usual
in his race ; digestion normal ; thoracic and abdominal Tiscera in healthy condition.
In this ease, the prolonged action of malaria, repeated attacks of intermittent fever, together
with the depressing effects of working in water, knee deep, were attended with rheumatic
pains, gradual loss of power in lower extremities, constipation, general asthenia, snbsultus
tendinutt in his legs, and inability to rise from the sitting posture. It is possible that the
affection of the spinal cord, may have been due to rheumatic inflammation of its membranes,
as well as to the slow and prolonged action of malaria and other depressing agencies.
This patient died on the 6th of May, 1869. Tbe powers gradually failed, and he died
apparently from exhaustion of the circulatory and respiratory systems.
The brain and spinal cord, were taken dut and carefully examined. Nothing special was
noticed in the cerebrum and cerebellum, but tbe pia-mater and arachnoid membrane of the
spinal cord, in several portions, presented a light brownish discolored appearance, as if dis-
colored by a weak solution of the Nitrate of Silver.
This discoloration was found to be due to the deposition of minute crystalline dark masses
of hssmatin in tbe cellular tissue. *
The blood-vessels of the pia-mater of the spinul curU, appeared lo be larger and more
numerous than normal.
When a section of the cord was made, tbe great and characteristic alteration was observed
in the ganglionic matter. The gray matter, presented a pinkish appearance; under the
microscope the gray cells were found not only to be greatly diminished, but many of them
were entirely altered, being filled with colored granule r masses, and some also contaiued oil
globules. Masses of hssmatin, were also seen in the intermediate spaces. The blood-vessels
( capillaries), were greatly increased in size, with thickened walls, to which colorless exuda-
tions and spindle-shaped corpuscles were attached. Tbe change in the capillaries was marked.
■
Gasb 59 :>— Kegro man, aged 03, a cooper by trade, who bad been quartered in a low, damp
locality, with poor diet, consisting chiefly of salt pork and bread ; habits intemperate. Has
suffered for some months with pain in back, located chiefly in lumbar regions. About one
month ago was attacked with intermittent fever of tertian type ; suffered with three parox-
ysms, and up to the present time has been subjected to *' light fevers at night." Suffered
with constipation of the bowels for two weeks from the first chill. Says that pains in the
arms and knees came on about the time of tbe first chill, and these have gradually inoreaaed
in intensity. During the last four weeks the patient has gradually lost powir iu the upper
extremities.
February 6tb. The patient complains of ecnfations of cold in arms, and keeps them
wrapped np in flannel; pains in lower extremiiies and back, in. lumbar region; some snb-
sultus tendinum in arms ; paralysis of both arms and of extensors of fore-arms; want of full
control of lower extremities ; when walking, inclines his body forwards, and walks with an
unate«dy, swinging gait; complains of stiff'oegs in tbe bacit, and of inability of standing
erect; unable to arise from the sitting posture; unable to retain his water and fieces ; invol-
untary micturition and defecation occurring, if he does not obey the calls of nature at once :
arcus senilis present ; some enlargement of tbe parotid gland on tbe right side ; no loss ot
•ansation ; tongoa moist ; back of tongue coated with yellow fur, tip and edges clean and red ;
appetite good, bowels regular ; slight cough, with bronchial expectoration; sounds of heart
feeble, and not well defined ; pulse soft, weak, irrcguliir and intermittent, eighty-four to the
minute.
The patient was put on Cod-Liver Oil, Strychnine and Iron, with nutritious diet, and the
arms rubbed with Volatile Liniment combined with minute portions of Strychnine.
Patient continued to improve slowly, with an increase of power in the arms, and was able
to get the left hand to his mouth in eating until the 15th of February, when he had a chill
followed by fever. On the night of the 15th, the patient took ten grains of Blue Mass, which
was followed by flfteen grains of Sulphate of Quinia, on tbe ICth. The bowels were moved
fluently, and the discharge passed involuntarily ; and tbe patient appeared much exhaust-
ed; and In sleeping the left cheek appeared flabby, and there was a pufling of tba loft buc-
cinator during respiration.
Stimvlaiiti and natrUlQVI diet appeared tQ ^xcrt no beneficial effects, and the patieat gradu^
Relations of Tetanus to Various Nervous Diseases. 251
allj laok and died on the 18tb. Cooscioosness and ioteUigenee wer« retained to lasttbe
moment.
AtUopty thru hours after death, — The post-mortem was performed three hours after death,
and the braiD, and spinal cord and viscera, exhibited to the Medical Class. Structures
ansmic ; heart pale and apparently undergoing fatty degeneration. The degeneration ap*
peared to be greatest in the muscular structures of the auricles. Under the microscope, the
fat globules were more abundant in many portions of the heart than in health, but the mus-
cular fibres were generally healthy in appearance, and presented well marked tUim; the oil
globules were most abundant between the muscular fasciculi.
Nothing abnormal was discovered in the valves of the heart and pulmonic artery and aorta,
the feeble, irregular action of the heart, with its abnormal sounds during life, were clearly
referable to the anffimic condition of the blood, and to incipient fatty degeneration.
All the cavities of the heart contained clots firmly attached to the mnseular colamos and
valvular cords. The right auricle was especially distended with an enormons clot, which,
when removed, presented a complete cast of its interior. These clots were composed of two por-
tions, a well defined, fibrous, light-colored, dense, elastic portion, and coagulated blood. From
their compound and laminated structure, they bad evidently been partly formed during the
last hours of existence. The spleen was enlarged to twice the size and slightly softened.
The liver and alimentary canal appeared healthy ; so also the kidneys.
The aCfected muscles were exhibited, and presented a red, healthy appearance, quite diCfer-
ent from that of muscles undergoing fatty degeneration, or progressive atrophy. After care-
ful microscopical examination, it was impossible to discover any marks' of disease In the
muscles, even in those which had been most completely paralyzed.
The entire brain and spinal cord were exposed. To the naked eye no structural altera-
tions conld be perceived upon the exterior. There were no marks of inflammation of 'the
membranes, and no deposit, or tumor, or abscess, which would account for the paralysis of
the arms, and of the extensors of the fore-arms, and inability to rise from the sitting posture,
and loss of power in the lower extremities, and want of control over the bladder and sphincter
of the anus and rectum during life.
Great difficulty is experienced in such examinations, as the modes of hardening the nervous
stmctores, and the act of making sections of the brain and spinal cord, may, If not carefully
performed, lead to deceptive appearances and erroneous conclusions. In many cases, patnolo-
gists have failed to detect well marked lesions of the cerebro-spinal system, in the paralysis of
lead-poisoning, of mercurial cachexia, and in the tetanus produced by wounds and strychnia.
The cerebral function in this caac was unimpaired, and sensation and reflex action were
intact ; it appeared reasonable to refer the loss of power, chiefly to some lesion of the
motor ganglia of the spinal cord. As the upper extremities were more affected than
the lower, whilst the impulses of the will were unimpaired, and sensitive impressions
were communicated with the usual intensity, it seemed most reasonable to refer the
lesion to some alteration or loss of power in the ganglionic cells of the anterior horns of
the spinal cord, which may be considered as the origin of the anterior roots of the motor
nerves.
Microscopical investigation was directed to the determination of the condition of the
(ranglionic cells of the anterior horns of the spinal cord ; it appeared that they were
dimmbhed in number. The gray matter of the spinal cord also presented a redder
color than in health, and the capillaries supplying the ganglionic cells were laiger, and
their walls thicker than in healthy nervous structures.
OCIIEBAl CONCLUSIONS AS TO THE NATURE AND PATHOLOGICAL LESIONS 07 TRAV*
MATIC TETANUS AND OTHER DISEASES OF THE NERVOUS SYSTEM.
From the preceding investigations and researches into the pathological alterations
characteristic of Traumatic Tetanus, and other diseases of the nervous system, the fol-
lowing conclusions may be drawn :
Ist. The nerves leading from the wound in cases of Traumatic Tetanus, exhibit, in
moat cases, evidences of congestion, irritation, and in some cases, even inflammation and
alteration of texture. Besides the inflammation which is seen in the nerve at the spot
which has been injured, a rosy reddening is produced at irregular intervals in its course
by the injection of its neurilemma.
2d. In Traumatic Tetanus, the blood-vessels of the cerebellum, medulla oblongata
252 General Qmelutiens on Pf^thology of Nervous
mad Bpaul eoid, and especially of the gray matter of the medulla obloogala and spinal
eoid, are dilated and eongoted.
It is poanble, by cold and irritants applied directly to the cerebrum, medoUa oblon>
gata and soperior portions of the spinal cord, to pn)dace dilatation and congestion of
tke Uood-Teseels, and the congestion thus produced, id attended with exalted and aber-
nted ifction of the eerebdlum and spinal axL<. and spasms of the volnntary mnscles,
itsemblMythe abnormal nervous action chamctenstic of Traumatic Tetanus. We an?
tlioelbre oompelied. in view of those facts, to re^rd the dilatation and congestion of
the small arteries of the cerebellum, medulla oblongata and spinal Cf>rd in Tetanus, a;^
of great importance, and as indicating, not only an incroastni functional actirity in
the eentnl ganglionic cells, bat also paralysbt or attvui iif thi* acti«m of that portion <»f
the sympathetic ner^'ous system which pit^idcts over i\u* circulation of the cerebellum,
mediuk oblongata and Kpinal cord.
3d. When the dilatation and con^i'stion of the bl«iud-Ti'»-.'l> of the ct*Tvbellam and
OHBal axis, eharacteristic of Traumatic Tetanus, aire cxamine<l in the light of careful
pnjsiolqgical experiments, they appear to h^ dependent upi>n }«ome anvKt or alteration of
the iniuenoe supplied to theunstripc<l ma^-ular fibn's ofth*.' minute arteries, leading to
dilatation of their diametral, and cnftvblemcnt. if ni»t complete a^\'^t f>f the normal
peristaltic actions. The gray cells of the i-erelH*lluui. mi'^lulla oblongata and spinal oonl
are thus svpplied in Traumatic Tctana^. with an incrvam^d amount of blood, even when
there is no inereaae in the fbroe and fre«|uency of the heart's action. The Kympathetic
nenroos system, which rcgulat^^s the circulation of the bl«Mwi in the minute arteries.
appears to be involved in Trmnmatic Tetanu.^.
4th. It is difficult to determine the exact n*lationship of the di^tturbances in the
two systems of nerves, vis: Whether the irritation L< ivflectid from the wounded sur-
&ee, int to the ganglionic cells of the cerebro-spinal svittem. and secondarily to those
of the sympathetic in the spinal axi». as well as in the ganglia of organic life, in virtue
of the intimate relationship of the two systems, and in virtue of the dependence of the
leaser npon the greater, in highly organized animaL^. for a continuous supply or renewal
of nerroiis fbroe ? or whether the influence aflfects primarily the gan^ionic cells of the
■ympathetic system ? It would appear that af^er the establishment of the state of in-
creased functional activity in the ganglionic ct^lb: of the spinal axis, there is at least an
enfeeblenent of the sympathetic system, and especially of that portion which presides
over the cirmlation of the central gan^Hionic masM^ ; and the question arises, whether
this impaiment of its normal functions be due to a divention of the nerve force ordi-
narily received from the oerebro-spinal system ?
If the vaao-Botor nerves be connected with the motor and sensitive ganglionic cells,
aa wcfl aa with sympathetic ganglionic cells in the spinal cord ; and if the arteries art*
normally kqit in a due state of contraction, and the capillaries duly retentive of their
contents, by the influence propagated continuously from the sympathetic ganglionic
cells, then it is evident that if the motor and sensitive cells be over-excited, the
nervooa inflnenoe may be withdrawn from the sympathetic cells, and through them
from the va^o-mitor syst?m. and entri^rj: ^m nit. eflfu^i »n s'l 1 alteration of nervous struc-
ture resole
When, therefore, the condition of superfunctii»nal activity L* e&^tablished in the motor
and aemdtiTe cells of the spinal axis, by the transmission of the irritation along the
nerrca connected with the injured parts, this very exaltation of nervous action tends
to propagate and perpetuate itself by withdawing the nervous influence from the
veasels npon whidi the ganglionic cells depend for the proper supply of nutritive mate-
riala. We are thus enabled to understand why a certain length of time elapoes between
the reception of the iiyuiy, and the manifi^s^tation of the tetanic spasms.
By theae inqniriea, and by this chain of reasoning, we are led to the conclusion that
the irritation is transmitted along the injured nerve U> the motor and sensitive gangli-
onic cells of the spinal cord, and extends gradually from the point of entrance of the
irritated nerve, until the medulla obhingata and ganglionic masses at the base of the
General Conclusions on Pathology of Nervous Diseases. 263
brain are involved, and the gradual exaltation of the nervous force in the motpr and
sensitive cells is attended with a corre^nding diminution in the sympathetic cells, the
blood-vessels become dilated and engorged, and with this change we have the full mani-
festation of the phenomena of Traumatic Tetanus ; the disease, therefore, advances
slowly at first, and when once established, tends, as it were, to propagate itself
5th. The continuance of the state of consostion leads to structural alterations of
the spinal cord, characterized by increased specific gravity, commencing most generally
in the r^on of the cord in immediate communication with the wounded part ; exuda-
tion of organisable material from the congested blood-vessels ; proliferation of the con-
nective tissue of the medullary substance of the medulla oblongata, of the inferior
peduncles of the cerebellum, of the crua cerebri and of the spinal cord, producing a vis-
cous mass abounding in nuclei and nerves pro^cressing to the formation of fibres ; exu-
dation of structureless, transparent material in the immediate vicinity of the vessels,
forcibly intruding itself into the tissue, and displacing the neighboring parts ; escape of
blood corpuscles from the blood-vessels replets to distention with their natural con-
tents.
The pathological lesions of the spinal cord in Tetanus, are frequently of surprising
extent, consisting of disintegration and sofleniug of a portion of the gray substance,
which appears in certain parts to be in a state of solution.
6th. The structural alterations of the cord in Traumatic Tetanus are not primary,
but secondary ; they are the resuiiB pf, rather than the cause of, the congestion of the
blood-vessels, and cannot therefore be looked upon as the cause of the aberrated, nervous
actions. This is clearly shown by the pathological investigations of Insanity and Para-
lysis: for in these diseases, we have similar lesions, without tetanic spasms. And in
epilepsy, in which similar lesions to those of Traumatic Tetanus are found in the
medaUa oblongata, the spasms are separated by long intervals, and a careful analysis of
the phenomena of this disease, showed that whilst they were aggravated and perhaps,
rendered incurable by the pathological changes of certain portions of the spinal axis, at
the same time, these changes followed rather than preced(id the establishment of the
diseased action. The lesion of the spinal cord in Tetanus, consisting of exudations and
disint^Trations, are similar in character to those observed in Insanity, Paralysis and
Kptlepsy ; and clearly depend, as in these diseases, upon a morbid state of the blood-
vessels of the cord. Whilst therefore these lesions may intensify the symptoms, and
render the disease incurable, they are by no means necessary to the manifestation of the
flpasms ; and it is highly probable that in these cases of Tetanus which recover, they
are either not present, or are present only in a slight degree.
7th. The following appears to be the order of the lesions of the nervous system, as
deduced from the preceding investigation :
Isi. Peripheral irritation of the injured nerves
2d. Extension of the peripheral irritation to the ganglionic cells of the segment of
the spinal oord, connected with the injured nerve.
lid. Extension of the irritation to other segments of the spinal cord, and especially
to the medulla oblongata.
4th. Exalted action of the ganglionic cells of the spinal axis, arising either from an
extension of a similar state along the injured nerves from the periphery, or from reflex
action on its blood-vessels, excited by the injured nerves.
5cli. Congestion of blood-vessels, hypers^mia, and morbid state of blood-vessels of
spinal axis, and especially of gray matter of medulla oblongata and superior portion of
Kpinal cord.
6th. Exalted reflex actions, morbid excitable conditions of gray substance of cord
and oerebellom, and tetanic spasms, trismus, emprosthotonos, etc.
7lh. Exudations and transmigrations of colorless corpuscles from the distended
vessels, and stmctural alterations of nerve cells and fibres.
8Ui. The character and extent of the pathological lesions discovered in the spinal
axifl afler death from Traumatic Tetanus, will depend in large measure upon the duration
254 Relations qf Traumatie Tetanus to Climate.
of the disease. Thus, if the patient dies, in the earlier stages, from sudden spasm of
the respiratory muscles, or of the epiglottis, little else will be discovered besides dilata-
tion and congestion of the blood-vessels of the injured nerve, and of the mednlla
oblongata and spinal cord, and especially of the gray matter of the spinal axis.
The diverse views held by writers upon the pathology of Traumatic Tetanus (a large
number including all those who have made careful sections and microsooptcal examina-
tions of the cord, holding to the existence of distinct recognizable lesions ; others who
have only supeificially examined the brain and spinal axis, giving forth confused, con-
tradictory, and unreliable assertions as to the purely. functional nature of the disease,)
are clearly referable to the stage of the disease, at which death took place, and to the
mode in which the post-mortem examinations were conducted.
9th. Pathological alterations have been detected in the sympathetic nervous system,
in some cases of Traumatic Tetanus ; but farther and more careful observations are needed
to determine the character and uniformity of these changes ; for the number of cases in
which the organic system of nerves has been examined, is comparatively small.
10th. Certain external conditions, <u sudden changes of temperature, extreme* of
heat and cold, and variations in the moisture of the atmosphere, appear evidently to
induce such changes in the wound, and in the nervous system, and in the entire organism,
as/avor the devdopment and progress of the disease.
RE8KARCHES PROSKCUTXD WITH THE DK8ION OV DETERMINING THE RELATIONS Ol*
CERTAIN EXTERNAL CONDITIONS, AS CLIMATE, SCDDEN CHANGES OF TEMPERA-
TURE, EXTREMES OF HEAT AND COLD, AND VARIATIONS OF MOISTKRE TO THE
DEVELOPMENT OF TRAUMATIC TETANUS.
Whilst Tetanus is met with in every part of the globe, it is to a certain extent,
influenced in its origin and progress by climatic causes ; thus it is said to occur often er
in sultry than in temperate climates, and prevails more at the hot seasons, or during
sudden changes from hot to cold, especially in a mobt state of the atmosphere, so com-
mon in the tropics ; sudden vicissitudes of temperature, therefore, have always been
looked upon, as most powerful exciting causes of the disease. Baron Larrey has
recorded numerous observations, illustrating the effects of cold and damp, and sudden
changes of temperature, in the production of Tetanus afler gun-shot wound. Aroon;r
the wounded in the battle of the Pyramids, five were attacked with tetanus occasioniHl
no doubt, by the humidity and coldness of the night. Ader the combat of El- Arich,
the wounded were put into tents, on a damp soil, exposed to continual rains. Eight
were seised with tetanus, which presented itself under all its symptoms, and terminated
in death, on the fifth and seventh days from its commencement.
Those who were wounded in the battle of Aboukir, 1798, were carried to the hospi-
tals of Alexandria, as soon as they had received the first dressing ; ten of them bein<;
exposed to the air and coolness of the nights, were seized with tetanus. Its rapid progress
and the situation of the wounds, in the head, trunk, or superior part of the thigh ren-
dered all assistance of no avail.
Baron Larrey observes that :
" In cases in which cold contributes to the deTeIopui«nt of tetanus, the irritation tnns*
Bitted from the woond to the nervoua sjsXitm, ii augmented bj the snppreiflion of caUiBcoot
perspiration, which extends its effects to the organs and priucipallj to the parts already
diseased ; but the irritation is principally concentrated in the nerves of the neck and throat.
at the commencement of the disease, or its termination. Their direct connection with the
medulla oblongata, and spinal marrow, their numerous interlacings, and frequent anastomoses
render them liable in the slightest impressions, to violent irritabilitj which causes the con-
traction of the muscles of these regions, in such manner, as quickly to interrupt deglutiiioo
And respiration."
Baron Larrey remarked, both in Egypt and in Germany, that Tetanus was not often
caused by wounds, unless the temperature of the atmosphere pass suddenly from one
Relations of Traumatic Tetanus to Climate. 255
•xtreinc to another. The wounded who were exposed more especially in the spring, to
the oold moist air of the nights, when the northwest winds prevailed were more
obnoxious to tetanus ; on the contrary, the disease seldom appeared when the tempera-
ture of the air was nearly uniform. Hence he concluded that this change of temperature
is a predisposing cause of tetanus, and that surgeons should guard against it in their
treatment of the wounded.
Dr. B. Huck, physician to the English Army, in the last century, states that of
thirteen wounded men, whom he had seen afflicted with locked-jawj nine received their
Wounds at the attack of the French lines at Ticonderoga, in the year 1758, and remained
exposed to the cold air, the night after the action, in open boats upon lake George.
M. Francois, of Auxern, observes that on board the Amazon Frigate, before Charles-
town, during the American War, after some stormy and ve^ wet weather, which had
BQOoeeded a continuance of dry, most of those wounded by fire-arms were attacked by
Tetanus on the 14th day.
Dazille, Campet, Rush, Chalmers, Curlingand others, have given illustrations of the
predisposing influence of climate and atmospheric changes in exciting this disease.
Bryan Edwards, in his History of the British Colonies in the West Indies, mentions
a »pecie9 of tetanuM or locked jaWy which causes great mortality among the negroes in
the West Indies, ^'affecting infants between the fifth and fourteenth days after their
birth, and of which it is supposed that one-fourth of all the negro children pertsh,''
Vol. ii I). 352.
Sir Gilbert Blane, in his Observations on the Diseases of Seamen, thus attempts to
explain why Tetanus
" Ii more frequent in hot than In cold climates. External beat, even when It exceeds that
of the liTiog body, bat no effect In raising its temperature. So that we are to seek for the
effects of It in some of those affections peculiar to animal life. And as the outward tempera-
ture of the Air does not affect the (i^eneral mass of the body, all the effects produced by It
most depend on impressions made on the surface of the body and lungs ; and the skin which
may be considered as a large expanded tissue of nerrous fibres endowed with universal sym-
pathy and great sensibility, affects every organ and every function of the body, according to
the atate of the air, In contact with it, whether cold or hot, moist or dry, pure or vitiated.
The tama may be said of the trachea and bronchia. This sympathetic sensibility of the skin
is chiefly affected by the state of the perspiring pores on the surface ; for it is only when
these axe open, that the impression of the air on the skin produces catarrhs, rheumatisms,
and iDternal inflammations in cold climates; and the external temperature in hot climates,
betag such as to keep the pores almost always open, this seems to be a principal reason of
that aaiversal irritabilily prevailing there, and of the general sympathy that prevails between
every part, particularly as connected with the organs of perspiration. This readiness of one
part to be affected by another, in hot climates, is well illustrated by the sudden translation of
certain diseases. I have seen for instance, a catarrh cease, and be converted as it were into
a diarrbcea, and this as quiokly disappearing a pain in the foot would rise like an attack of
rottt. All this would happen in the space of a few hours. (Observations on the Diseases of
."^eamen, 3d Rd. 1799, pp. S64~566).
The same circumstances appear to induce the disease in animals.
Hurtrel d*Arboval relates, that twenty-four horses were castrated on the same day, at
Bee, in the deoartment of Tfiure. They were afterwards led four times in the day,
through a pona of water supplied from a very cold spring. Sixteen of them died,
between the tenth aud fifteenth day after the operation. At Bcnnes, a horse after
castration was oze^ised, until he was covered with perspiration, and then suddenly
plunged into the river. This was repeated three times, and the animal died tetanic.
( Dictionnaire de MMecine, et de Chirurgie Yi^ti^rinaire, tom. iv, p. 263).
After the battle of Bautzen, the exposure to a very cold night, produced over a
bandred cases, and after the battle of Dresden, when the wounded were placed in like
circumstances, they lost a very large number from tetanus.
Baudens, gives a very interesting instance from his African experience, showing the
ioflaence of cold and moisture, in producing this disease : forty slightly wounded men
were placed, in tho month of Pocember, and during the prevaleD<^ of |k northc^at wind,
256 Relations of Traumatic Tetanus to Climate.
iD a gallery on the ground floor, whioh was open to the north ; fifteen different cases
of tetanus appeared in a short ttino —among this number, twelve died. The remainder
were remoyed to a more sheltered place, and these were no more attacked.
Opposite extremes of temperature, appear to cause similar effects ; thus in the Indieft.
heat is looked upon as a predisposing cause. While in the arctic r^ons, extreme cold
excites under certain circumstances idiopathic tetanus. According to Sir Gilbert Blanc,
out of 810 wounded, men, who came under his observation in the West Indies, in 1782,
thirty were seized with tetanus, and seventeen died.
Dr. Kane, during his explorations in the Arctic r^ons, records the interesting fact,
that intense cold produced '^ an anomalous spasmodic affection allied to Tetanus/* which
affected most of his party, and destroyed two men, and killed all his dogs.
In hi j '^ Report upon the Cases of Tetanus in the Jamjetsee Jejeebhoy Hospital.
Bombay, from January, 1845, to December, 1851/' Mr. J. Peet, Assistant Surgeon tii
the Hospital, states that during these seven years, 195 cases of Tetanus were admitted
into the hospital, exclusive of some 78 or 80 persons who were attacked subsequently
to their admission, making the whole number treated during this period, about 2G0.
This appears to be the largest number of cases of Tetanus treated in any single hos-
pital in the world. Mr. Peet concludes that the idiopathic form of Tetanus i;4
much more frequent in Bombay than in other parts of the world, and that, contraty to
the experience of the disease in other places, it is more severe and fatal than the trau*
matie species ; and that it is often traceable to direct exposures at those seasons, during
which there are the greatest alterations of temperature. — Trans. Med. and Phys. Soe*
of Bombay, No. 1, N. S., Bombay, 1853.
Mr. Waring, in his ^^ Xotes on the Diseaaeas of India," has recorded valuable ob-
servations upon the relative frequency of the occurrence of Tetanus, of which the ft>l-
lowing is an analysis :
Frequent as this disease (Tetanus) is represented to be in Demerara, Trinidad, St.
Domingo, and in some other localities in the West Indies, no comparison can be insti-
tuted between its frequency in these places and in some of the towns of India, Bombay
especially, as will he neen by a perusal of the following statement, showing the deaths
from Tetanus in the town of Bombay, for a period of throe years, 1851, 1852 and
1853:
X TOTAL >>BATU8 "
9P DKATHt.
TETANUS.
1851 14,724 332 One death from tetanus to 44 from all causes.
18521 13,763 341 •• »* 40 '» •'
1853| 14,164 239 •• '* 30
( 42,651 012 ,One death from tetanus to 46 from all causes.
Large as thi^ number is. both absolutely and comparatively, it is still bdow the
mark, as under the heading of total deaths are included still births, whilst under that
of Tetanus is excluded that peripheral form of the disease, which is both frequeDt and
fatal in Bombay. There is no means of comparing the proportion of tetanic desthy
in Calcutta and Madras with thoK> oi' Bombay, but ii' an opinion i9ay be formed from
hospital returns, it appears that the disease is not of so frequent occurrence in C«lciitU
as in Bombay. Thus, in the Calcutta (tenend Hospital, (Dr. Jackson ; India Annals
of Medical Science, No. 1, 1853. p. 5S>, during five years, (1W7-51), only 56 wen?
admissions with Tetanus, whilst at the Jamjotxe.^ Jejeebhoy Hospital, (Mr. Poel« Bt>m*
bay Med. Trans., No. 1, N. S.. 1853, p. 1 \ in Bombay, during a period of seven ymr»»
(1845-51). the admissions under this heading, amounted to 195.
Comparted with nion» temperate climates, the ratio of deaths from Tetmius appemi:
still more striking ; tbun wc find the following proportion to QWi\
Relations of Traumatic Tetanus to Climate.
257
P L A C B.
T^ondon....
Ireland ...<
New York
Bombaj...
PBRIOD.
TOTAL
DBATHB.
DBATHB
FBOK
TBTANDB.
1850-3-4
1831>1861
1819-1834
1851-1853
224,515
1,187,374
83,783
42,651
73
238
112
912
pbopor'm
1111.3075
lio.4987
lin. 748
1 in. 46
The proportion existing in Bombay, taken in this light, cannot but be regarded as
very Ibrmidable.
Influence of Sea$on». — In seeking to ascertain the canse of so prevalent a disease,
one of the first questions which presents itself, is, what were the atmospheric and
meteorological conditions of the locality during the^peripd of its prevalence ? Fortu-
nately, good data exist, from which a judgment may be formed as to the relations of
Tetanus to the seasons in Bombay. The following table presents the monthly deaths
from this disease in Bombay, during a period of three years, 1851-1853.
MOM TDB.
February ..
March
April
M^J
Jone
July
AugQit
September
October...
NoTember.
December^
Jannary ...
ToUl .
1
- • •
1851|1852'
1853
14
Total.
28
32
74
26
35
24
85
26
36
21
83
28
22
25
75
21
34
21
76
27
21
21
69
29
24
17
70
31
28
18
77
30
24
25
79
29
35
22
86
29
29
14
82
18
21
341
17
239
50
332
912
Total Dftaibs in Qaartera,
and per cent.
}
1
}
}
242, or 26,5 per cent.
230, or 24.1 per c^nt.
226, or 24.9 per cent.
224, or 24.8 per cent.*
This table shows that in Bombay, seasons per te, exercise no influence on the mor-
tality in Tetanus, each quarter presenting very nearly the same proportions of death.
A slight increase is observable in the month preceding the rains, (May), but nothing
saiRciently marked to allow us to place any stress upon it. For some other cause,
therefore, must we look ; it cannot well be lowness of site, as both Madras and Cal-
cutta arc, equally with Bombay, very slightly elevated above sea-level. So, likewise, it
cannot be poverty, wretchedness or want of drainage, otherwise Calcutta and Madras
would produce quite as many cases as Bombay. From the preceding investigation,
Mr. Waring concludes that its cause yet remains to be discovered. — Half- Yearly Ab-
stract of the Medical Sciences, edited by W. H. Ranking and C. B. Radcliff, July,
1856, pp. 55-^6.
From an important ^^ Report of Seventy-two Cases of Tetanus, occurring in 6uy*8
Hospital/' from 1825 to 1857, by Alfred roland, we extract the following statistics,
illnstrmting the relations of Tetanus to climatic causes :
In 32 fall years, there occurred 72 cases of Tetanus in Guy's Hospital, in 113,020 total
admissions, making an average of 0.063 per cent; and there were 62 deaths from Tetanus,
in 1 1,052 total deaths, or 0.56 per cent. Of these, all but three had a co-existinfi; or
previous lesion of the surface ; tncy were called Traumatic, and hence might be rariked
and included under the surgical class of cascs« Thus, there will be 96 cases of Teta-
DOS, with lesion of surface, to 64,3(58 cases admUtod i^ith external lesion and surgical
»
268 Relations of Traumatic Tetanus to Climate.
disease, being 0.107 per cent.; and 61 deaths from Tetanus, to 4,218 cases of deaths
from external and surgical disease, being 1.444 per cent.
In the Bombay Hospital, from 1848 to 1853, 0.8 per cent, of the total admissions
were of Tetanus, and 3.9 per cent of the total deaths. Dr. Leith, Registrar of Deaths
at Bombay, returns 1,716 deaths from Tetanus during the same six years, and states
the per oentage to be 2.5 on total deaths from all causes. In London, in six years, in
345,132 total deaths, 110 of Tetanus, or 0.031 per cent. In England, in the same
space of time, the total deaths are 2,431,602, and 759 arc of Tetanus, being 0.031 per
cent.
A reviewer, in the October number of the American Journal of the Medical Sciences,
1858, presents, for the purpose of comparison, the following additional figures :
In 1853, the number of deaths from Tetanus in New York City, was 49, of which
35 were males and 14 females ; the total deaths during the same yearbeing, 28,568, wc
hare one death from Tetanus in 583, or 0.17 per cent. In 1857, in Philadelphia, there
were 13 deaths, in a total of 10.895, or one death in 836, which gives 0.12 per cent.
From the tables of Dr. Emmerson ( published in the American Journal of Medical
Sciences, in the years 1827, 1831 and 1848 \ wo have, that from the 1st of January,
1807, to the 1st of January, 1827, in a total of 53,004 deaths, in Philadelphia, 125
were from Tetanus, giving 0.236 per cent. ; from Ist of January, 1827, to tne 1st of
JtontiT, 1830, there were 29 cases, in 16,579 deaths, giving 0.175 per cent ; from 183U
to 1840, there were 51 cases, in 49,686, giving 0.103 per cent. From these data, the
dimae would appear to be coming less common in this city. In Massachusetts, in five
¥Bars, the total number of deaths from all causes, was 104,873 ; of these, 55 were from
etanus, or, 1 in 1,907, which gives 0.05 per cent. These data are sufficient to show
that Tetanus is much more common in this country, even in the more northern por-
tioni than in England. In Charleston, S. C, in 1856, in 1,428 toUl deaths, 57 were
from Trismus Naacentium, and 6 from Tetanus, giving for Tetanus a percentage of 0.42,
and for both diseases 4.42. In the Southern States, Tetanus seems to be much more
frequent among the blacks than the whites ; in Charleston, for example, fiom April,
1857, to April, 1858, there were 8 deaths from Trismus, and 2 from Tetanus, among
the whites, and 37 from Trismus, and 8 from Tetanus among the blacks, while in the
total deaths, there were about one-third more of the latter than of the former. ( Am.
Jour. Med. Sci. Vol. xxxvl N. 8. 1858, p. 476.)
I have oarefUly examined and consolidated the mortuary statistics of several South-
em Cities, and the following tables embody the results of my investigations, with refer-
ence to the r^tive mortality from Tetanus, and the relationi* of this disease to Climate.
Relations of Traumatic Tetanus to Climate.
259
Deaths from Tetannt each month, and total yearly deatht from all cauies, in Savannah^ Georgia^
amongtt the white itihalntanU, during a period of fifty yeare^ 1804-1853, ineluiive.
■PUPULA-
YEAB. i TION,
WHITES.
Jan.
1
Feb.
Mar.
Apr.
May
Ju'e
July
Aug
Sept
Oct.
Nor.
Dec.
De*ih
from all
Ganses.
1804
2799
207
238
159
230
219
183
163
212
226
214
300
233
272
461
211
610
817
385
291
268
136
126
235
321
146
209
159
147
21fi
1805
* *
1806
1807
1808
3010
1809
1810
1811 .1
1
1812
1
1813 ,
1
1
1814 1
1
1815
I
• • • • ■
1816
1
.
1817
1
1
1818
p......
1819
1
1820
••••« •••••«
2
1821
1822.,
1
*"•"*••••••••»••»•••
1
1824 1
1H26
1
1
1
1H27
1828
1
1829 '
!
1830 1
1
lft31
1
•
1
1H32
■
•••■..
202
1834 r
197
228
249
358
1
••••••*•••■■•
IHA^ I , i '
i
1
1
1
. . • A . .
' 1 1 1
_
1*<'SH '
'
331
' ■ 1
1
1
1
3B7
Irt40
5888
1
380
305
272
256
247
IH41 1
****** 1
1
1
1
......
1
1842 ■
;:'::i i::::::
......
j
1843
'
... ..1...,,. 1
1
|M44
2
1
[
1
••••••
1 :
1*<45
1
....1
1
1
1
229
Ih4C
1
1
1
1
1
1
■ •••••
1
1
1
240
IK47..,^ '
1
1
3
210
298
l'*4'<
7250
, ^ 1
1
1
,
3
1
»
••••••
IH49
1
1
1 1
1
2
357
384
IM.%0 8395
1
I
...... i...^..
iHf,!
1
•••••• ••••••
414
lHr»2 1
% %. «• •
642
lM5:i !
,17' -"V"
4
1
3
1
4
7
1
5
******
470
1
4
«
3
3
Total, 50 y'rs,
|Mii4.)8.'»3
1
u
4 4
14,332
lo SaTiDoah, Georgia, daring a period of 50 yeara, 1804-1853 ; out of 14,332
«l«4tlM occurring amongst the whites, from all causes, 58 are recorded as caused by
TeCaons, under the several heads of Tetanus, Locked-Jaw and Triamuv Naacentium.
Thw would give amongst the whites, one death from TeUnus, in 229.8 deaths from all
2fm Relatims of Traumatic Tetanus to Climate.
cansea. Thaw aUtuticH do not, however, repiesent the entire number of detthi (Vom
TeUnns, and MpecUllj from Trismiu Nucentiam, for a large number of deaths occarriax
in infiuic; a short penod att«r birth, are recorded aimpl; under the head of Spamu and
OMmlnont, a§ wiA be seen from the fullowing table :
Dtatktfnm Spatati and Giteultioni amongtt Ihr a 'lil't in S-ieann th, Ot'irgia, itaritij a period of
t 7, and ODC II.
toe II, and one 3 w'ka.
Uji old.
la,Ti ; one two week*.
old ; one 5 montlii.
)1d ; one 16 diji.
>ne i week).
old ; two 8 weeki.
Be 4 moathi.
I lUODtht.
Kjt old ; one 6 weelci.
daji old; one 1 w'ka.
■ old; fiTe4toe w'ki.
(.old; III S to 10 no*,
days and under ; eii
[6 week*.
Six hundred and fift;-aii deathi were rcoordcd as due to cooTulaiooi and S]
Relations iff TrmaiMiie JeiajMs to Climate.
261
SaTanoah, amoDgst the whil«a dnriDg a period of fitly yeais, (1804-18Q3,) oat of a
total of 14,332 deaths from all caawa ; qt one death from spasms and convulBions in 20.8
daatlu from all caosM. Nearly one-half of theae deaths recorded as due to spasms and
eooToluoDS, vii : 314, ocoarred during the months of Aogast, September, October aod
November, in which period it is well known that malarious difieaees and especially inter-
mittent, remittent and oongesUre or peroiciouB ffyers, prevail with the ^eatest intensity
in this cjtj, which is surrounded with marshes and low lands lying along the Dluggish
and mnddy river. Whilst therefore a certain proportjon of these deaths may have been
caused shortly after birth by Trismus Nasoeotium, the greatest proportioa must be
referred to the action of the malarial poison.
It would have been of great interest to have presented the statistics of the black
population of Savannah, but after a carehl examination of the records, I found them
to be 10 imperfect, that no reliable data conld be gathered for an accoiste judgment and
comparison. It appeared to be generally admitted, however, that the negro children
were much more liable to Infontile Tetanus ; and also that injuries were more frequently
followed by Tetanus amongst the negroes.
The mortuary records of Charleston, South Carolina, furnish valuable data for the
determinslJon of the relative prevalence of Tetanus and Trismus Nascentium, in the
white and black races, as will be seen from the following tables, which I have consoli-
dated from the yearly mortuary reports.
naOJufrmn Trmntatic Tetanm in Cttarltilon, South Carolina, amonfftt Wiilt, Btaek and Outorcd
In^aiitanU, during a period o/faurtecn yean.
Selaiions (^ Traumatie Tetanus to Climate.
From the preceding tables, the following conclusions may be drawn ;
let. Dunng a period of 14 jeara, in Charleston, South Carolina, amongst the
whites, the lai^est nnmber of deaths from Tnumatic Tetanus, occurred during the
month!) of June, September and October, the total for these three moatha being tti out
of 39 for the eotire period: amongst the blacks and colored the largest number of
deaths occurred daring the months of March. April, July, October, November and
December, 61 deaths occurring during these six months out of 93 deaths during the
entire period. It is evident, therefore, that we can trace no special relationship between
the climate and the occurrence of Traumatic Tetanus from those mortuary statistics
furnished by Charleston, South Carolina.
2d. The total number of deaths from Traumatic Tetanus, occurring amon;^:*-. both
races during this period was 132, out of a grand total of 17,1 50 deaths from all c-tiu^-s :
or one death from Traumatic Tetanus in 129 deaths from all causes.
'ii. The deaths from Ti^aumatic Tetanus were relatively much more froiucut atiioiigst
the blacks and colored.
Thus, amongst the whiles during a period of H years, 3U deaths from Triiinii.-itic
TeUnus occurred, out of a total of tJOHO deaths from all atutwa, or one diMtli from
Traumatic Tetanus in 207.1 deaths; amongst the blacks and colored, during tlie Mtuo
period 97 deaths from Traumatic Tetanus, in 9021) deaths from all causes, or otic deuth
from Tetanus in 97 deaths from all causes. This fact indicates that the bl:ick ood
colored race, is more liable to Traumatic Tetanus than the white ncc.
4. Duriug a period of 14 years, the deaths from Trismus Nasccntium, auinngst
the whites, numbered 120, and amongst the blacks and colored 520; to,tAl deaths
amongst blacks and whites U40, out of a total of 17,150 deatlu from all causes ; or
one death from Trismus Nasccntium in 2G.1 deaths from all cau.ncs.
5. If the deaths from Trismus NB.scenlium be added to those of Telanu.*, wc
have a total of 772 deaths, or otic dcjth from these various forms of Tetanus in 22-t!
deaths from all causes.
)!. The tarj^t numljcr of deaths from Trismus Nasccntium occurred amotigt^t the
whites in the months of July, August.Septcmber, October and November, 7ti deaths
out of 120, occurring during tlicse months ; amongst the blacks and oolorcil, tht-
largest number of deaths occurred during the months of January, July, Auguxl, Sep-
tember, October and November. '.i'Ai deatlis occurring in these months out uf a total uf
520 deaths.
7. Trismus Nasccntium, in like manner with Traumatic Tetanus, caused a much
greater number of deaths amongi^t the uolored and black race than amongst (he whittw :
thus, amongst the whiles, out of a total of 808l> deaths from all causes, 1211 were
Relations of Traumatic Tetanus to Climate. 263
caused by TmniuB Nascentium, or one death in 67.3 ; amongst the blocks and colored
this disease caused 520 deaths, or one death in 17-!^ deaths from all causes. It U
evident, therefore, that Trismus Nascentium is much more frequent and fatal amongst
the hiacic and colored race.
8. CouTulsioDS aud spasms, »o called, caused during the period of 14 years, 245
deaths amongst the whiles, aud 403 deaths amongst ihc blacks and colored, giving a
total of 647 deaths ; or one death trvm coDVulsioos and spasms emoagst the whites in
32.5 deaths, and one death amongst the blacks and colored in 22 4 deaths, and one
death in both whites and blacks and colored in 26.5 deaths from all causes. The
largest nnmber of deaths from convulsions and spasms, occurred both amongst the white
and black races during the months of May, June, July, and August ; and the inercaBcd
mortality from these convulsive diseases, may therefore be referred lo the increase of
temperature and the more potent action of malaria.
The following results of my examination and conEoUdation of the mortuary statistics
of New Orleans, Louisiana, will illustrate the relative mortality caused by Tetanus,
Trismus NaBccotium and Convulsions, in ihi? city, situated on a low, alluvial, damp mala-
rious plaio, on the banks of the Mississippi, in the sub-tropical zone of North America.
During a period of 21 years, including the years, 1847, 1848, 1849, 1852,1853.
1856,1857.1858, 1859, 18G0. 18C3, 1864, 1865, 1866,1867, 1868, 186D, 1870,
1871, 1872, 1873, the total deaths from all causes in New Orleans, amounted to
165,435; of thb grand total during the periods just specified. Tetanus caused 1727
deaths, or 1 death in 95.7 from all causes; Trismns Nascentium, caused 3627 deaths,
or 1 death in 45.6, deaths from all causes-. Tetanus and Trismus Nascentium, together,
tensed 5354 deaths, or 1 death in 30.9 deaths from all causes ; convulsions, caused
tiltftl deaths, or 1 death in 25.9 deaths from all causes ; Tetanus, Trismus Nascentium
and Convulsions, caused during the period specified 11, 715 deaths, or 1 death from
ihcM convulsive diseases, in 14.1 deaths from all causes.
The relative prevalence of Tetanus, Trismus Naaoentium and Convulsions, amongst
the white and colored race, maybe gathered from the following tabic embracing the
years 1849 and 1850.
pradu /ram Trtanui
Dt»llafn>m OmeuUioni tach monCi, amanfil WMri and Blackt in Xcw Orlian;
1849, 1850.
IMO „..
3
g
IE
S
i;
±
s
Z
,
.
™
;■:
■k
8
2
;
-
2 S! «
TbW _
Sf
U
m
b
\M
la
k
[»
MB
Aj\
[tU
A
uJ
A
'A
m wo 111--
264
Relations of Traumatie Tetanus to Gimate.
Death* earned by Tetania^ Trismus Nasceniivm and Gmvulsions each month^ ami
Total Deaths from all cavses in New Orleans^ during a period of 10 years,
embracing the following years : 1S49, '50, '52, '53, '67, '69, '70,
'71, '72, '73.
Year.
D
""S
K
>
K
«-i
«^
>»
OQ
o
%
c?
<0
9
"O
9
e
s
B
<o
A
o
A
or
•5
o
«<
•9
•
^
•
C?
tr
•
•
•
•
•
•
•
•
•
•
:
•
•
•
•
•
•
V
•
•
•
•
H
DIATD8 CAC8BD BT TBTANU8 IV HBW ORLEANS.
1849
1850
1852
1853
1867
1869
1870
1871
1872
1873
Totals
3
7
7
3
2
7
5
5
6
4
4
5
4
5
3
6
12
5
4
4
49 52
2
4
4
6
7
2
7
9
6
2
4
4
2
2
8
2
1
4
6
10
6
13
16
5
10
8
5
13
2
4
4
9
4
5
10
8
6
6
8
11
45
50
72
77
3
3
10
3
15
11
17
10
4
15
3
7 1
3
6
19
21
n
13
! 10
14
; 9
9 1
i 10
13
6
6
7
6
1
3
4
9
3
4
5
4
12
5
23
18
9
9
3
2
10
11
4
5
18
12
8
8
3
7
0
4
3
5
6
17
8
5
3
6
90 ' 77 99 i 90 ! 86 . 66
49
71
6C
49
128
134
119
79
7.1
74
M2
DBATB8 CAUSED BT TRISMUS NA8CBNTIUM IX XBW ORLEANS.
1849
1850 ,
1852 <
1853 ,
1867
1869
1870
1871
1872
1873
Totols
21.
10
9
6
12
10
1
5
13
17
9
8
13
8
20
13
10
9
12
6
10
7
10
9
6
8
8
5
14
29
13
19
22
10
25
12
6
4
6
7
2
9
20
16
16
6
8
8
11
21
24
10
23
13
9
18
23
17
22
13
9
21
15
16
26 ! 10
16
14
18
16
27
172
'120
113
133
104
122
174
21
16
22
13
20
21
22
34
23
21
17
25
24
21
25 I 23
37 . 18
18
20
231 I2IO
. 12
13
31
15
42
31
I
216
15
23
16
15
I 28 I 16
i 15 1 11
I 13 I 19
! 15 25
I
24 '
15 I,
35 1
16 I,
28 |-
14 ll
20 .
19 >|
22 I 21
31 I 23
183 1215 I 1!«4&
172
16:i
177
144
246
\'Mi
18C
234
2;ti
3:>o
DEATHS CAUSED BY C0XTUL8I0XS AND SFASMS IN NEW ORLEANS.
I
1849.
1850.
1852.
1853.
1867.
1869.
1870.
1871.
1872.
1873.
, 36
I 20
I 20
22
13
16
28
21
23
23
18
16
27
16
16
13
19
16
21
18
36
14
17
I 22
. 18
' 24
16
> 18
8
IG
40
30
34
38
28
52
17
19
22 I 25
26 I 31
49 55
42
13
25
23
16
14 ' 35
15 30
53
26
34
28
26
39
27.
I"
•I-
24
16
38
44 '
33 !
20 ,
26
12
45 .
34
68
51
107
43
15
13
39
29
39
31 30
47 43
44 • 38
39 36
56 57
25 30
33 16
9 t 13
31 16
14 34
38 ' 23
33 39
30 I 36
35 ' 20
30 t 21
31 36
12 I 8
15 15
33 30 I 16 . 10
31o
35o
44:1
4k5
34 1
3«»T
34H
224
34H
3S3
Total? 222 180 189 '280 280 1334 '282 ' 390 307 298 243 211 3224
Relations of Traurnatie Tetanus to Climate,
266
TOTAL MONTHLY AND TBARLY DEATHS IK MBW ORLBANfl.
1849
U82
582
486
581
397
360
494
477
447
642
5648
601
425
477
463
362
323
456
381
630
556
4674
1395
840
462
456
401
435
634
525
430
603
3153
1068
481
502
532
350
590
580
471
418
600
55ft^
997
601
627
671
316
631
651
444
713
930
TfiRl
870
479
1163
656
561
560
712
585
672
562
435
584
769
2216
551
588
529
522
483
773
T4rin
485
916
883
6201
1039
451
521
592
569
498
666
653
725
1627
2498
461
904
485
425
624
911
620
957
674
1942
520
738
478
532
713
622
899
890
712
959
473
596
624
430
500
6605
630
756
752
844
720
609
570
475
473
504
6335
9862
1850
7836
1852
9693
1853
15633
1867
10096
1869
6001
1870
7391
1871
6059
1872
6122
1873
7505
Totals
12155
9068 8085
86198
From the preceding tables, consolidated from the mortuary records of New Orleans,
the following conclasions may be drawn :
Ist. During the years 1849 and 1850, 96 deaths were caused by Tetanus amongst
the whites in a total of 14,306 deaths from all causes in this class, or one death in 149
deaths from all causes amongst the whites ; 34 deaths from Tetanus occurred amongst
the black and colored, in a total of 3376 deaths in this class, or one death in 99.4
deaths from all causes amongst the blacks and colored.
It is evident, therefore, that in New Orleans, as in Charleston, South Carolina, tetanus
is more fatal amongst the black and colored race than amongst the whites. During the
same period Trismus Nascentium caused 227 deaths amongst the whites, or one death
in 63 deaths from all causes in this class : amongst the blacks and colored, 108 deaths,
(or one death in 31.2 deaths from all causes in this class) were caused by Trismus
NaaoenUum. It is therefore in like manner evident, that this form of Tetanus is rela-
tively more fatal amongst the blacks and colored, than amongst the whites.
2d. During a period of 14 years, including the years 1849, 1850, 1852, 1853, 1867,
1869, 1870, 1871, 1872 and 1873, out of a total of 86,198 deaths from all causes in
New Orleans, 842 deaths were caused by Tetanus, or one death in 102 deaths from all
caoses in the white, black and colored races: 1945 deaths were caused by Trismus
Xasoentiam, or one death in 44.3 deaths from all causes; convulsions caused 3224
deaths, or one death from convulsions in 26.7 deaths from all causes.
.'id. The largest number of deaths from Tetanus occurred in the months of June,
July, August, September, October and November, reaching the maximum, viz : 99 in
September; total for these six months 519; whilst in the remaining six months, vis:
December, January, February, March, April and May, the mortality from Tetanus
amounted to only 323. These facts indicate, that in New Orleans, Tetanus is influenced
to a certain extent by the increase of atmospheric heat, and by the increased action of
malaria, for it is most fatal in the hottest months, in which the heaviest mortality is
caiwed by malarious diseases.
4th. The largest number of deaths from Trismus Nascentium occurred in the months
of July, August, September, October, November and December, reaching the maximum
231, in August; total for these six months 1329 ; total for remaining six months, vis:
January, February, March, April, May and June, 616. In like manner it appears,
that in New Orleans, Trismus Nascentium is influenced to a certain extent by the
increase of atmospheric heat and by the increased action of malaria.
5th. The largest number of deaths from Convulsions occurred in the months of
Jane, July, August, September and October, reaching the maximum 390, in August;
total for these five months, 1611 ; total for remaining seven months, viz: November,
December, January, February, March, April and May, 1613. The vast proportion of
these deaths from Convulsions, occurred amongst infants and teething children.
For purposes of comparison, I have endeavored to collect the statbtics of cities
iitaaled within the interior of the Southern States, in more elevated localities than those
26<t
Relations of Traumatic Tetanus to Climate.
of Savaonih, CbarleatoD and New Orleans. At a great expenditure of time and labor,
I have consolidated from the martuary record of the Tarions cemeteries of Naahville,
Tennewee, and Augusta, Georgia, the folloviDg atatisticB. In these labore, I was ablj
aaiiated by my friend and former Assistant, Dr. John Wabton Morton, Jr., (foriBerly
Colonel and Chief of Artillery in the Cavalry Division of Lieutenant Oenenl Fonot,
G. 8. A.)> whilst I held the position of Health OSeer of Nashville, Tennessee, 1807,
Thtttl DtaAt, and Dralk, eauKdbg Ttlanyt, TVi.- : Total DfatU it the C.l.v o/ frathrUU, from M
t AoKfltlhtn aad CunvHltivnt, amongtl Ihe "
Whitn, Btarkt and O/lortd in Aagiutn, Gn., '
duriitf a period of iD start, I»1T-I8'i6.
\tohdattd by Jotplk Juna, M. D.
Iltallh Offietr. from all tkt rrfordi of the M-
riout CtmrttTiu, Mil to 1867, nU animat
dtatk, ratt, and per cent, of drallu to lim;
fi^li
IM?
IS::::=
tE
.™:::::::;
jl::::::
111 ii'i'J
'".''^~.'., wi l-e"!!!."
! If ^ If?
I II •
I "
.■Mm I \»;,
Z !
II
Ei!;i-T'S,
Id AugnMa, Geor)(U, ap u> the ynr 1845, the record gf Jiseuca cansiog death u
Relations of Traumatic Tetanus to Gimate.
267
Teij imperfect, and no separate reoord of the diaeoAes oausiDg deaths amongst the blacks
and colored, appears until 1842. If therefore we exclude the mortuary statbtios from
1817 to 1845, and regard only those relating to the succeeding 22 years, vis: 1845 to
1866, indusive, we have a total of 6645 deaths amongst the whites ; 15 of which were
doe to Teianu*, or one death in 443 deaths from all causes ; during the same period,
*' Chnvuftioiuty Spamm and FitSj* (including Trismus Nascentium, only one death
doriog this period being entered as such, upon the mortuary records) caused 356 deaths,
or one death in 18.3 deaths from all causes- Amongst the blacks and colored during
the same period, out of a grand total of 4240 deaths, Tetanus caused 19 deaths, or one
death in 228.4 deaths from all causes ; " ConvuhtonSy Sp<ums and Fits" (including
Trisnias Nasoentium, only one death being referred to this disease,) caused 240 deaths,
or 006 death in 17.6 deaths from all causes amongst the blacks and colored: TUanuM
caosed 34 deaths in a grand total of 10,885 deaths from all causes amongst whites, bliM^ks
and colored, or one death in 320 deaths from all causes. It is evident from these
statistics:
Finf, That Tetanus caused relatively a much larger number of deaths amongst the
blacks and colored than amongst the whites, in Augusta, Georgia.
Second. That Tetanus is much less frequent and fatal, both amongst the whites and
colored raoeB, in Augusta, Georgia, than in Charleston, South Carolina, Savannah,
Geofgia. and New Orleans, Louisiana.
With reference to the mortuary statistics of Nashville, Tennessee, I found upon
careful investigation, that records had been kept by three different congregations
or aocietieB, separate from those of the large grave-yard (City Cemetery), vis: ny the
CathoJies, and the two Hebrew Synagogues, who failed in many instances to reoord the
discMes causing death. It was therefore impossible to obtain complete statistics show*
ing the total number of deaths from Tetanus, Trismus Nasoentium and Convulsions.
The following general results were obtained by the examination of a series of years,
( 10 years, 1838-1848 ) : Tetanus caused one death in 180 deaths from all causes occur-
ring in the white, black and colored races ; Tetanus was relatively twice as fiital or
caused relatively to the total number of deaths, twice as great a mortality amongst the
blacks and oolored. Tetanus caused relatively a greater mortality in Nashville, than in
Atu^usta, Gra., but much less than in Charleston, S. C. and New Orleans, Louisiana.
From the preceding statistics the following table has been constructed :
PL ACS.
LondoD, EogUnd
IreUnd
N'ew York, U. S. America
Boabaj, lodia
Goj't Hospital, Loodoo
Philadelphia, U. S. America
Philadelphia, '^
PhiladelphU, "
VaMacbatetts ~
^Taanab, 'Georgia, WhiUa
CbarleatOD, South Carolina, Whites
t-harleaton, " Blacks
Charlestoo , '' Whites and BVks
)(ew Orleans, La., Whites and Blacks
.Vev Orleans, La., Whites,,
New Orleans, La., Blacks „..
Aagvata, Oa., Whiles, „,.«
'logaita, Ga., Blacks and Cb/orf</.....,. ..,.„,,,.
Aagvata, Ga., Whites^ Blacks and Colored
5aAbTi]le, Tenn., W hites, Blacks and Oolored...
Period.
l850-3-i
1831-1851
1819-1834
1851-1853
1825-185?
1807-1827
1827-1830
,1830-1840:
5 years.
,1804-18531
jl84(>-1865l
1846-1865!
,1846-186r)j
1847-1873'
,1849-18501
1849-18501
; 1 845-18661
1845-1866!
1845h-)866
1838-1848
Total
Deaths.
224,515
1,187,374
83,783
42,651
11,052
53,004
16,579
49,686
104,873
14,332
8,880
9,020
17,150!
105,435
14,306'
3,336,
6,645
4,240
10,884
Deaths from
Tetanus.
73
238
112
912
62
125
29
51
55
58
39
93
132
1727
96
34
15
19
34
Proportion.
1 in
lio
lio
1 in
I la
1 in
lin
lio
lin
lin
1 in
1 in
I in
1 in
II in
;1 in
:iin
I in
1 in
1 in
3075
4987
748
46.
194
424
573
974
1907
339.8
207.1
97.
130
95.7
149
99.4
443
228
330
180
268 RekUions of Traumatic Tetanus to Gimate.
The preoediog statistics, justify the conclusion that Tetanus is most common and
fatal in low, moist, hot, malarious situations.
The fact that Tetanus is now much less common in Military and Naval Service,
appears to be attributable, mainly to improvements in the hygienic and sanitary regula-
tions of armies, ships and hospitals, and in the treatment of the wounded.
Dr. Lind'*' who was physician to the English fleet, about the middle of the last
century, has recorded the remarkable fact, that after amputation, five cases out of six,
generallv proved fatal from an attack of Lock-Jaw, whereas at the present day, in mili-
taiy and naval practice the disease is comparatively rare.
There are fieicts to show, that foul air tends powerfully to promote the occurrence of
this disease. Thus in the Dublin Lying-in-Hospital, by means of improved ventilation,
ete., the mortality from tetanus in the infants, was reduced to nearly one-tenth of what
it bad been. Tetanus seems at times to assume an almost epidemic charaoter. Dr.
Benjamin Ward Richardson says, that he knew one surgeon, whose operations, it once
followed for some weeks, as though ho carried the cause of it with him. In some
hospitals it appean to have been much more prevalent than at othen ; at St. Marks, it
is mentioned that amongst 1763 operations performed upon hmmorrhoids, with the
Hgatnre, there were 5 cases of Tetanus, four of which occurred in the spring of 1858,
a year in which the disease was more frequent than usual ; in other hospitals, from
1858 to 1865, more than 800 operations have been performed, but no case of Tetanus
has resulted.*
11. Many of the changes observed in the Abdominal and Thoracic Viscera^ in
Traumatic lletanus, are manifestly due to the mode of death, and the oompresioo of
the oigans during the violent spasms. The congestions of the pharynx and glottis,
appear to be caused by spasms of those parts, consequent upon the exalted reflex aotions
of the medulla oblongata and upper portions of the spinal oord.
In some oases, however, morbid appearances have been observed in difierent portiona
of the digestive oanal, which cannot oe viewed either m the results of the malaay, or of
the mode of death, but must be considered either as sources of irritation, or as ooq«
cnrring aids to irritation.
A cSronic ease of idiopathic tetanus, recorded in the Philosophical Trensaetbns for the
year 1764, was apparently caused by worms in the intestinal canal ; Sauvages relates a
fatal ease of Tetanus, in which the intestines were perforated bv worms ; Murainna,
has recorded an instance of trismus in which the disease was cured by the expulsion of
a single worm, ten ells in length ; Dr. Thompson of Jamaica, mentions several caaes of
Chronic Tetanus in n^o children, arising from the irritation of worms, and they were
so ofien met with in the stomach and intestines by M. Laurent, a physician of ooo«
siderable experience, at Strasbourg, that he was induced to attribute the disease in all
cases, to their presence ; worms are noticed as causes of tetanus, by Morgagni, Stohl«
Foumier, Percy and othere, whilst Baron Larrey, frequently found after death, from
this disease, lumbrici in the small intestines, without any trace of inflammatioo ;
increased vascularity and inflammatory state of the mucus membranes of the alimentaiy
canal, were found by Mr. Swann, in all the cases of Tetanus, in which he found unusual
appearances of the sympathetic system ; Dr. MoArthur discovered inflammation of the
stomach and intestines, in four fatal cases of tetanus ; and Andnd has recorded a cate,
ID which on dissection, he found unequivocal marks of gastritis : such factn show the
importance of making accurate examinations of the alimentary canal in this disease ;
and whilst endeavoring to estimate the influence of such a cause as worms, it should be
borne in mind, that they are fVequently present in the bodies of those who have died of
various diseases, and that they are frequently present in the intestines, without indnciog
any disturbance of health.
It should also be considered in this connection that the most various kinds of ulcen
scarcely ever give rise to tetanus; syphilitic sores, primary and secondary, tuberci|kifU5
•An Vwmj on tli« Most Klfectuftl Mmos of Prnw^niog th^ Heath of the SMiueo of the Royal Kavj, 17^7.
•Hedlcal TlniM and GiMttc. t^^t«mbor 2^1, 1 h««'>.
Relations of Traumatic Tetanus to Climate. 269
cavitien, pulmonary gangrene, the intestinal lesions of Typhoid fever, and dysentery,
nrely if ever develop this disease ; and in glanders and farcy, snake-bite, malignant
ptutole, sibbiens, leprosy, small-pox and syphilis, the phenomena appear to be dependent
Father upon profound changes of the blood and upon depression of the circulation, than
upon nenrous excitement.
Sueh facts stand in opposition to that theory, which would regard Tetanus as resulting
from the absorption oT morbid secretions, or matters, fVom wounded and diseased sur-
iaoee. At the same time it must be admitted that changes in the constitution of the
blood, may induce such a state of the nutrition of the ganglionic cells of the sympathetic
aod oerebro-spinal nervous system, as may predispose to the tetanic condition.
lesions of tho muscles, fractures of the bones, and even dislocation of the vertebra,
which have been recorded by various observers, as Baron Larrey, Baron Dupuytreu,
Deeportea, Fournier, Pescay, Mr. Curling and others, are clearly referable to tho violent
and sodden spasmodic contractions of the muscles, during the powerful spasms charac-
teristic of severe eases of this disease.
The engoii^ement of the thoracic and abdominal viscera, observed after death, in
certain cases of Tetanus, appear to be referable not so much to deranged circulation in
these organs, but to the powerful contraction of tho muscles, by which the blood is
forced upon the internal organs, and also to the state of asphyxia, in which the disease
80 frequently terminates.
We cannot apply this explanation, to the engorgement of the capillaries of the oerebro-
rpioal system, because this congestion of the gray matter, is much more marked than
that of the white substance and investing membranes of the spinal axis, and especially
because the congestion of the nervous centres is attended in Tetanus, with those well
marked alterations, upon which we have already dwelt at length.
It is also worthy of note, that the poMt-martem rigidity of the muscles is greater in
Tetanus than in any other disease, with the exception perhaps of poisoning by strychnia ;
whilst at the same time, the disposition in the blood to coagulate, is often delayed, and
^metimefl even altogether lost. This contracted state of the muscles after death from
Tetanus, would therefore appear to be due to irritability remaining in the muscular fibre,
alter all the other phenomena of life have ceased, rather than to the action of a cause
i»imilar to that which is active in the coagulation of the blood.
Some authors, have held, that Tetanus like Hydrophobia is due to blood poisoning.
This view has been sustained by the fact, that a condition so nearly resembling Tetanus
aito be with diflSculty distinguished from it, may be caused by the direct introduction of
strychnia into the blood. It is true that both in Traumatic Tetanus, and in the Tetanic
Spasma induced artificially, the disease is chiefly located in the spinal cord, which is an
oigan, both for the generation of nerve force, and the conduction of impressions to and
from the brain. In tetanus and in the action of strychnia, there is increased action in
the ganglionic cells of the spinal cord, as manifested in the great exaltation of reflex
excitability. It is well known that in some cases of disease, in which the amount of
blood in the oord is increased, very small quantities of strychnia produce the characte-
ristic phenomena of stiflhess in certain muscles, and of augmented reflex excitability.
These &ct8, as well aa the results of the experiments and post-mortem examinations of
Schioeder Van Ber Kolk and of myself, which will be examined more fully hereafter,
warrant the conclusion that in cases of strychnia poisoning, as well as in Tetanus, the
amount of blood in the cord and the excitability of the organ are both increased.
According to Bernard,'*' Strychnia produces convulsions bv exaggerating the sensibility
of certain parts, it also causes reflex movements ; the point of departure being in the
i^ensitive system, for when the posterior roots of the nerves are cut, the animal dies
without convulsions. An experiment performed by Professor Hammondyf of New
York, and Pr. 8. "Wier Mitchell, of Philadelphia, appears to show that tho action of
I nr let Xffeti dci subttaneeB toxl<iTie« M^dicumenteaves, Parw, l^*)?, p. :)8C^
t Aml Joor. Med. Sdence, JqIj, 1869^
2 70 Relations of Traumatic Tetanus to Climate.
Strychnia ia to destroy the ner\*oufl excitability from the centre to the periphery, and
that its influence must therefore be first excited on the spinal cord. Under the skin of
a large frog, whose left sciatic nenre was previously divided, a few drops of a strong
solution of strychnia were introduced. Tetanic spasms ensued in two minutes. Aflor
forty-five minutes the nerves were irritated by galvanism ; that of the left side which
had been cut responded energetically, while no motions could he produced through the
uncut nerve. The former remained excitable for two hours later.
The nMisms excited by strychnia, therefore, as well as those of Tetanus, are probably
due to similar caufies, viz : the congestion of the cord and increased nutrition and func-
tional activity of the ganglionic cells ; and in both cases the congestion may he induced
primarily by derangement of the vaso-motor nerves. It is evident, therefore, that the
similaiity of symptoms in the two conditions do not justify the adoption of the theory,
that Tetanus is caused by a poison in the blood.
The increased prevalence of Tetanus in low, hot, moist, malarious regions, may be
accounted for upon the same principle as th^ increased prevalence of Nenndgia under
the same conditions, viz : derangement of the blood, ana of the vaso-motor system of
nerves, and periodic congestions of the central ganglionic masses of the sympathetic
and spinal systems.
CHAPTER IV.
KXPEUXKNTAL INVESTIGATIONS ON TUB ACTION OF PHYSICAL AGENTS, AND OF CERTAIN
P0180N8, UPON LITINO ANIMALS. INSTITUTED WITH THE DESION OF THROWING LIGHT
ON THB MODE OF ACTION OF FEVER POISONS, AND ON THE PHENOMENA OF CONVULSIVE
DISEASES.
ft
ExperimenUl iorestigatioDi ou the actioQ of physical agents, and of certain poisons upon
liring animals, instituted with the design of throwing light upon the nature and mode of
action of unknown fever poisons, and oa the phenomena of convulsire diseases.
Experiments illnstrating the action of physical agents, abstraction of blood, electricity,
mecbanieal injuries of Tarioas portions of the cerebro-spinal system, introduction of air into
ibe blood-Tcssels. Experiments illustrating the action of poisons, as Hydrocyanic Acid on
living regetables. Experiments illustrating the action of various poisons, as Prussic Acid,
Cyanide of Potassium, Strychnia, etc., upon living animals. General conclusions, drawn
from 185 experiments with poisons. Practical applications of the results to the Therapeutics
of TetAQUs.
EXPERIMENTAL ILLUSTRATIONS OF CONVULSIVE DISEASES.
The manifest inflaeooe of climate, and especially of the vicissitudes of heat and cold,
in moiflt, warm regions, in rendering the human system more liable to both Traumatic
and Idiopathic Tetanus, lead various writers to throw out suggestions as to the probable
dependence of the disease, in a certain number of cases at least, upon some pre-existing
state of the nervous and muscular systems, and which disturbed states were the result
of derangements in the blood and excretions, and in the actions of the excretory organs,
resultlDg from the deleterious effects of the unhealthy climate. The close relations of Teta-
nus to Hydrophobia, a disease manifestly depending upon the introduction of a specific ani-
mal poison into the Uood, also led to the belief that the former might, in like manner, result,
in some cases, ftom the generation of an animal poison, either within the blood itself, or
within the wounds, or from the irritant action of retained and altered secretions and
ezcreCiona. This view was still farther strengthened by the discovery of certain poisons,
as Hydrocyanic Acid and Strychnia, which, when injected into the blood-vessels, even
in smdl quantities, are capable of exciting the most violent and fatal forms of tetanic
spasms.
The greater tendency of penetrating and closed wounds to cause Tetanus, has been
KUggeaUve of the action of some subtle animal poison, which, like that of the mad dog
and serpent's fang, is the more deadly the less the blood flows.
It has been asked, whether the link between chilled wounds and spasmodic par-
ozysmA, may not be an animal poison, generated in the wound during the process of
healing ? and being animal poison, therefore poisonous in extremely minute doses, and
(capable of being latent in the system for long periods, and of being specially fatal to the
nervous system ?
Dr. B. W. Richardson (Trans. Epidem., Soc. of London, vol. 1, p. 28), on the theory
of Zymosis, refers to the question of Tetanus as belonging to the Zymotici. Thus, he
nays:
'* la ibif disease, the poison, in mj opinion, is first dereloped in the wound, as a result of
decoBpasiiloo. Thence carried into the circulation, the new substance, without anj neces-
sary iocreaie of its own parts, excites a Zymosis, ending in the production of an alkaloid or
alkaline bodv, which has all the power of exciting STrnptoms of spasm, as much as Strych-
■iM iuelf.'* '
272 Experimental Illustrations of Convulsive Diseases.
Whilst this theory does not account for the occurrence of Tetanus in some cases and
not in others, and does not define the connection of the acknowledged causes, cold,
damp, vicissitudes of temperature and wound; and it is not at all neceBsary
to the rational explanation of the mode of origin of the disease ; at the same
time, the phenomena of Tetanus in the human being should be- illustrated by well
conducted experiments upon animals, and should be especially compared with tetanic
spasms, artificially produced by such poisons as Strychnia and Hydrocyanic Acid.
In the summer of 1854, 1 commenced a series of investigations, with the design of
determining : First, the effects of poisons on animal temperatore, secretion and excre-
tion, and on the nervous and muscular forces ; second, the effects of poisons upon the
blood and organs ; third, the effects of poisons upon the physical and chemical changes
after death ; fourth, the relations of the changes produced by poisons, with pathological
states, and especially with the pathological conditions product by fevers and inflam^
mations.
As numerous facts indicate that fevers are duo to special poisons, whilst at the same
time, these poisons have not been isolated, and, therefore, many of their aotioos are
involved in obscurity, I supposed that light might be thrown upon the character and
effects of fever poisons, by carefully investigating and comparing the effects of poisoa^
whose chemical constitution and relations are* known. The field of experiment here
opened is of boundless extent, and each experiment may be discussed in various rela-
tions ; in the present inquiry, however, I desire to present those experiments which
bear most directly upon the phenomena and pathological alterations of Tetanus and ita
associated diseases of the nervous system.
It is important that we should first investigate the changes of temperature, cireula-
tion, respiration, nervous and muscular actions of the organs and tissues, indnoed by
what may be called physical or mechanical agenta, in contra-distinoiion to the action of
poisons. It is evident that we can form no distinct ideas of the effects of poisona,
without the establishment of certain definite standards of healthy actions, to which
they may be referred. If the effects of mechanical agents upon the respiration, circula-
tion and temperature be determined, we have the true ground of departure for experi-
ments upon the action of poisons. By limiting the experiments with mechanical
agents to certain parts of the nervous system, or to certain organs; by oqipbining and
varying these experiments, important physiological fiicts and principles may be eslab-
Ibhed, which form data for the comparison of the experiments upon poisons.
The appearance of the organs and tissues of healthy animals after death frooi iiie^
chanical means, should also first engage the attention ; for it is evident that it wonld
be impossible to ascertain with accuracy the true charactenstics of any pathdlogicnl
alteration, or determine the effects of any poison upon the animal structures, witiioui
knowing wherein they differed from the appearances of health.
PRELIMINARY EXPERIMENTS ILLUSTRATING THE ACTION OP PHYSICAL AGENTS.
Experiment 1 : I^ffectn of Abstraction of Blood vpon Animal Trmperainrrf and Hjtfph
the Color and Appearance of the different Vimxray and etpedaJR^ upon tke
Amount of Bhftd containeil in the Blood- Venels of the Brain and Spinal C**rfi,
Medium-sUnd, active, well-condiiioned dog, (crois betireen bull and cur). Temperature of
Burrounding atmoBpbere, \U° C (<i6°.2 F). Temperature of rectum of dog: (The bulb anU
glass stem of a delicate tbermometer having been introduced into the rectum and retained in
this position antil the temperature assumed a stationary point), 40*^.3 C, (104^.6 P).
An attempt was made to sc\er the left carotid artery. As soon as the integamenU were
severed, the dog Htruggled violently for several minutes ; during these struggles the tempera-
tu re of the rectum rose 0°. 22 C. The attempt to sever the carotid artery was abandoned,
until the thermometer ceased to rise, as we wished to observe the effects of mechanical efforts
upon the animal temperature. The thermometer did not rise above the point just meotioae^,
and remained stationary at AO'^.bb C (105° P).
The left carotid artery was then severed ; the blood gushed out in a full stream, and ia ait
minntes after the severance of the artery^ all signs of life were extinct. Daring the lost of
Experimental Illustrations of Convulsive Diseases. 273
blood the thermometer remained stationary at the point last indicated. Tweuty-seren flaid-
ouDcct of blood flowed out and coagulated in a few moments after its abstraction. The dog
was then carefully suspended in the air, so as to maintain the same position thai it had in
the experiment, viz : standing posture ; and the thermometer was allowed to remain in the
rectum.
Fourteen minutes after death, temperature of the rectum still the same ; the temperature
of the surface, however, indicates a slight fall. In an animal like the subject of the present
experiment, viz : fat, and covered with thick, sleek hair, the fall of the temperature in the
rectum is necessarily slow. The following are the actual observations upon the temperature
of the rectum after death : Temperature of rectum at moment of death, 40^.55 (105^ F) ;
fourteen minutes after death, 40^.55 C ; twenty-six minutes, 40^.50 C; fbrty-nine minutes,
40<'.25 ; fifty-five minutes, after death, 40® C (104^' F) ; eighty-six minutes, 39^.25 ; ninety-
nine minutes, 38°.85 C; one hundred and forty-six minutes, 37^.75 G; three hundred and
twenty-six minutes, 33° C. (91^.4 F) ; four hundred and thirty-six minutes, 31^.1 C; thirteen
hundred and eighty minutes after death, 23° C. (73^.4 F). During the first four hundred
and thirty minutes after death, the temperature of the dog fell 19°.45 G. (35°.0 F). During
the twenty-six minutes immediately following death, the loss of temperature was 0^055 G., or
o**.O046 C. per minute, during the succeeding twenty-three minutes, 0°.25 G., or 0°.0104 per
minute; during the next six minutes 0°.25 G., or 0°.4l5 per minute ; next thirty-one minutes,
o«.i5 C., or 0°.024 per minute ; next thirteen minutes, 0°.39 C, 0°.030 per minute; next forty-
seven minutes, 1°.107 G., 0°.023 per minute ; next one hundred and eighty minutes, 4°.75 G.,
0^.026 per minute ; next nine hundred and fifty minutes, 8°. I G., 0°.0085 per minute.
The next morning, twenty-three hours after death, the thermometer in the rectum stood at
23^ C., whilst the atmosphere of the room indicated very nearly the same degree, viz : 22.°6G .
The last determination, therefore, is involved in some doubt, as no observation upon the tem-
perature was made during the night. The slow rate of cooling was, without doubt, due to
the heavy coating of hair on this dog.
Autopty twenty hours after death. — The blood-vessels of the arachnoid, dura-mater and pia-
mater contained but little blood, and the brain presented a pale anaemic appearance. The
spinal cord was exposed throughout its entire length, and presented a similar bloodless ap-
pearance ; the stomach, although containing matters in a state of partial digestion, presented
a pale, bloodless appearance, both upon the exterior and interior. Garcful colored drawing^
were made of the brain and spinal cord, and viscera, for future use and comparison.
Kxpcrhufnt 2 : Effects of Ah»tract\on of Blood.
Thin, medium-sized dog; Temperature of surrounding atmosphere, 19°.5 C. (67°.l F).
Temperature of rectum, 40°. 15 G. (104°. 28 F). The thermometer was placed in the rectum
«o At to occupy the same relative position as in the preceding experiment, and the dog was
held by the aid of several assistants in the standing posture. An incision was made in the
tbigh of the bind leg, just above the knee joint, when the sciatic nerve was cut ; the animal
exhibited signs of pain, and struggled violently for several moments ; during these struggles
there was a slight rise in the thermometer of 0°.05 G. The femoral artery was then severed ;
the bleeding was slow ; the blood coagulated rapidly, and twenty minutes after the large
artery was severed, a fibrinous coagulum had completely filled up, the artery, and arrested
the bleeding; when this ping was pulled out, the blood again flowed freely ; similar clots
formed in the smaller arteries. Twenty-five minutes after the commencement of the bleeding,
the animal appeared to be very faint. Gould not stand up. Respiration labored and pant-
ing ; drew long sighs, und emitted several feeble cries ; and finally died, thirty-five minutes
after the commencement of the bleeding.
Huring the bleeding, the thermometer remained stationary, and, at the momant of death, it
indicated a temperature of 40°. 2 G. (104°.4 F). Twenty-two fluidounces of blood were lost
before death. The thermometer in the rectum indionted an almost immediate fall in thetem-
l>eratnre after death. The following are the actunl observations on the temperature. Tem-
l»eratare of rectum at moment of death, 40°.2 (I04°.4 F.) ; 25 minuUa after death, 38° G.,
( 100*^.4 P) ; 38 minutes after death, 37°.7.'S (\, (99°.9 F.) ; 8.5 minutes after death, 36° G.,
CMt^.% F.) ; 265 minutes after death, :n°.33C., (8H0.4 K.) ; 383 minutes after death, 29®.25 C.,
(«4°.6 F).
The rate of cooling wos as follows: During the first twenty-five minutes after death, the
thermometer fell 2°.2 C., or 0° 088 G. each minute; during the following 13 minutes, 0°.25
4*., or o°.0I9 G. per minute; during the following 47 minutes, l°.75 G., or 0°037 per minute;
ilaring the following 180 minutes, 4°.87 G., or 0°027 V. per minute; during the following 108
minntes, 2°.08 G., or 0°.0I9 G. per minute. During the first 373 minutes after death the
temperature of the rectum fell from 40°.2, to 99°/i&; loss 10°.95 G., (19°.8 F).
The next morning, twenty hours after death, the thermometer in the rectum indieated a
temperature of 22° C., whiUt the tomperature of the atmos|ihcre was 22^.6 C- The temper «»
274 Experimental Illustrations of Convulsive Diseases.
ature of the surroandiDg atmoiphere had risen during the morning, from the kindling of a 6re
in the Adjoining room.
Autop^ twtnty hows after death. — Blood- vessels of brain and spinal cord and their mem-
branes contained but little blood, and presented the same pale appearance as in the preced-
ing experiment. The lungs presented a yellow and light reddish, mottled color ; they were
Terj light, and the blood-vessels contained but little blood. Liver light-colored and blood-
less. The external surface of the stomach was pale ; it contained partially digested food ;
the mucus membrane was corrugated, and of a light yellow, and light reddish, pinkish an«i
brownish color. The intestines, both upon the external and internal surface, presented a
light yellow and whitish appearance. In this case also, careful colored drawings were pre-
served of the spinal cord and viscera.
Experiment 3 : lUu$trating the Effects of Electricity upon Living AnlmaU,
Small female pointer. Temperature of surrounding atmosphere, 26^ C, 78^.8 F. Klectric
shocks from a large Leyden Jar, of the capacity of one gallon, were passed through the head
and through tbe medulla oblongata, through also from one external meatus auditorius to the
other, from eye to eye, from the nose to the commencement of the spinal cord, and through,
from side to side, of the neck in the region of the medulla oblongata.
The first strokes appeared to produce great paiu, tbe dog cried out, and then became in-
sensible, and the shocks from the Leyden Jar then produced no effect, except a very slight
convalsive movement, and spasms of the muscles of the back and neck, causing the bending
back of tbe neck.
Shocks from tbe Leyden Jar, charged continuously by a largo plate glats electrical machine,
were thus passed rapidly through those regions for 50 minutes, and during this time, the
thermometer, which stood in the rectum, before and at the time of the commencement of
tha experiment, at 41^.2 C, 106''.2 F., did not rise, but, on the contrary, slowly descended,
and at the end of this time, stood at 40''.6 C, 105".l F., showing a loss of 0<>.6 C.
Forty minntes after the cessation of tbe electrical shocks, (ninety minutes after the first
shock), the dog recovered from his stupor, raised its head and looked around ; at this time tbe
temperature of the rectum was 40^.4 C.; showing that it had continued to descend after tbe
cessation of the shocks, and during the last 40 minutes, had lost 0°.2 C.
Two and a half hours after this observation the dog was completely restored to conscious*
ness, and was capable of walking about. Temperature of rectum at this time, 40<'.4 C; the
temperature after the return of consciousness, remained stationary up to this time, and grad*
nally ascended, and three hours after this observation, stood at 40^.45 G.
At this time, 5} hours after the first experiment, shocks were again passed through tbe
bead and neck in various directions, as before ; the shocks appeared to exert less ell^ct, an4
the dog appeared to suffer less, and insensibility was not reproduced as fully as in the firsi
experiment.
The temperature of the rectum, as in the first oxporimcnt, descended during the passage of
the shocks through the brain and medulla oblongata, and in llfteen minutes stood at 40^.4 C,
showing a loss, in this time, of 0^05 C.
Tbe dog was now released from the operating table; It appeared to be very feeble, coul4
scarcely walk, muscles trembled, and it hung its head down. The animal subscfiuently recov**
ered its usual strength.
Experiment i: Jllmtrating tlte Effect* of Elect r icily y {Interrupted Magncttf- Elect rtv
Current) upon Anin\al Teni^terature.
Passed a strong interrupted magneto-electric current, generated by the revolution of the
armed keeper around the poles of a large magnet, through from one hand to the other.
In the left hand I grasped the bulb of a delicate thermometer, and in the right axilla tbo
bolb of another thermometer was placed, and so arranged as to express the temperature of
tbe surroiinding parts. Previous to the passage of the interrupted current, the temperature
was earefnlly determined : Temperature of atmosphere, 25^.6 C, 78^2 F.; of left hand. 37^.S
C, 99®.5 P.; of right axilla, 38».8 C, I0P.9 F.
After the passage for seven minutes, of as strong a current as I could well bear, there was
a "ftty alight rise in the thermometer in the axilla* but none whatever in the thermometer io
tbe hand.
Daring the passage of the electrical excitement, the moisture of the skin was increased; the
respiration remained unaltered, whilst the pulse was slightly increased in force and slightly
diminished in frcqaency. After the cessation of the electrical excitement, the pulse slightly
increased in frequency.
After twenty minutes, the current was again passed, exciting, as in the preceding experi*
ment, violent twitchings of the muvcles of the arms and chest ; no effect was produced npoR
Experimental Illustrations of Convulsive Diseases. 275
the temperature of either hand or axilla, — tbejr remained stationary ; and no effect was pro-
duced upon the respiration.
Experiment 5 : Illustrating the Effects of Strong Magneto- Electric Currents %ipon a
Living Animal.
Fine, young, male cur dog, fat and in good condition. Temperature of atmosphere, 27° C,
80«.6 F. Temperature of rectum of dog, 41° C, 105°.8 F.
Temperature of surface of large muscles of bat;k, (the skin being cut, and the bulb of a
thermometer introduced), 38° C, I00°.4 F.
Temperature of surface of large muscles of fore-leg, (the bulb of the thermometer in like
manner being introduced through the skin), 38° C, 100°.4 F Each thermometer was placed
in the bands of a careful assistant, and retained continuously in the same position. Incisions
were next made through the skin in the neck at points opposite the position of the medulla
oblongata, and the terminal wires of a powerful electro-magnetic battery thrust through these
incisions into the muscles.
The passage of the interrupted magneto-electric current produced Tiolent couTulsions and
spasms of the muscles. During these convulsions there was a gradual rise In the tempera-
tare of the rectum, and at the end of eighteen minutes the thermometer in this position
stood at 41°.8 C, 107°.3 F., showing a rise during this time, of 0°.8 C ,* the temperature of
the surface of the muscles of the loins and fore-leg also rose slowly, and at the expiration of
this time, the temperature of the muscles of the loins was 38°.33 C., 101° F., showing an in-
cremse of 0°.33 C; and the temperature of the surface of the large muscles of the fore-leg,
38*^.5 C, 101°. 3 F., showing an increase of 0°.5 C.
The temperature of the rectum continued slowly to rise, and at the end of four minutes,
stood at 42° C, 107°.6 F. The thermometers were now withdrawn on account of the Tiolence
of the spasms and struggles of the dog.
The electrical currents excited, in addition to the violent convulsive motions in all parts of
the body, a profuse secretion of saliva — several ounces flowed from the mouth of the dog ;
the straggles were also attended by evacuation of the faeces and urine.
The thermometers were again replaced as soon as the violent struggles subsided, which
took place in a few moments after the discontinuance of the electrical excitement.
After the elapse of twelve minutis, the interrupted magneto-electric current was again
applied with greater energy. At the moment of the application, temperature of rectum 42°. 1
C, 107°.8 F.; of muscles of loins, 38°.5 C, 101°.3 F.; of muscles of fore-leg, 38°.75 C,
101°.8 F.
Violent muscular contractions were again excited, and at the end of five minutes the ther-
mometer in the rectum stood at 42°.2 G., 108° F., showing a rise of 0°.l C, whilst the tem-
perature of the muscles of the loins was 39° C, 102°.2 F., showing an increase of 0°.5 C.
The shocks were then passed through from the roof of the mouth to above the position of
the medulla oblongata ; from the roof of the mouth to the sacrum ; these shocks produced
powerful tetanic spasms of all the muscles, and death followed in a few seconds.
Temperature of the rectum at the moment of death, 42°. 4 C, 108°.3 F., showing an increase
(loring these violent convulsions, of 0°.2 C. Temperature of the surface of the loins, 39° C,
102°.2 V.f showing no increase.
The temperature commenced to fall immediately after death, and at the end of five minutes
the temperature of the rectum stood at 42°.2 C., and that of the muscles of the back, at
3«°.5 C.
The following are the changes of temperature noted after death : Temperature of rectum
moment of death, 42°. 4 C; of muscles of loins, 39° ; 5 minutes after death, rectum, 42°. 2 C,
lotnSf 38°.5 C; 30 minutes, rectum, 41°.27 C, muscles of thigh, 37° C; 45 minutes, rectum,
41° C, loins, 36°.25 C, thigh, 36°.25 C; 75 minutes, rectum. 40° C, loins, 36° C, thigh,
35°.6 C; 225 minutes after death, temperature of rectum, 35°.4 C, of loins, 33°.75 C, of
thigh, 31°.8 C.
During the first 5 minutes after death, the rectum lost 0°.2 C, or 0°.04 C. per minute ; next
25 minutes, 0°.I3, or 0°.005 per minute; next 15 minutes, 0°.27, or 0°.019 per minute ; next
30 minutes, 1° C, or 0°.033 per minute; next 150 minutes, 4°.6 C., or 0°.03 per minute.
Id 225 minutes, the rectum lost 7° C, 12°.6 F., and in the same period, the muscles of the
loins lost 5°.25 C, and of the thigh, 7°.2 C.
At the time of the last observation, three hours and forty minutes after death, the tempera-
tore of the atmosphere was 28°. 5 0. Cadavaric rigidity well marked at that time.
Pott'nu>rtem Bzaminationy 4 hours after death: Strong electro-magnetic currents passed in
every direction, from the nervous centres to the extremities, and through the individual mus^
cte«, produced no perceptible contractions.
The veins of the skin and muscles were filled with dark, purplish, almost black blood,
which coagulated slowly and imperfectly ; the clot was large and soft, and the separation ojf
J
276 Experimental Illustrations of Convulsive Diseases.
the seram was not bo perfect as it usual in the case of the blood of healthy dogs. Under the
microscope no alterations were obserred in the structure of the colored blood-corpnscles.
Head: The blood-vessels of the dura-mater were filled with black blood. Blood-Fetsels of
pia-mater filled with dark, almost black venous blood.
The spinal cord and its membrane s were exposed throughout their entire length ; blood-
vessels of the fibrous sheath of the spinul cord, and of the nutritive membrane, filled with
dark blood, and in many places it appeared tlmt some blood had been eflTused upon the sur-
face of the cord in the cervical portion of the position .it which the nerves are given off which
supply the fore-legs.
The dark color of the blood in the brain, spin.*!! cord, and in all parts of the body, appears
to have been due to the effects of the electrical excitement in arresting respiration during its
passage through that portion of the medulla oblongata which presides over the respiratory
function, and by the powerful tftanic spasms of the muscles of respiration, resembling in all
respects those produced by ^^trychnin.
Large blood-vessels of stomach, filled with dark purplish blood, and although filled with
matters in process of digestion, the mucous membrane was pale. Small intestines presented
a normal appearance ; the exterior surface, as well as the internal mucous surface was pale.
Liver, blood-vessels filled with dark blood; gall bladder filled with bile; supra-renal capsules
not congested with blood, normnl in npitcarnnce ; bl.idder firmly contracted and void of
urine.
Lungs greatly congested with bluud, presenting n dark purplish appearance; Thymus aud
Thyroid glands unusually large, and greatly congested with blood.
After careful microscopical examination of the cerebro-spinal and sympathetic nervous
structures, and especially of the ganglionic cells, with various powers, 1 discovered no altera-
tions which could be referred to the action of the interrupted electrical currents.
Exit€rime9U 6*; Effects of Mvdutnical li»j»tr*/ of (ervbro' Spinal \trvoH9 Sjftteni ;
Injury of Mediifln OUoii(/ttfa,
Fine, large, full-fleshed cur dog. Temperature of atmosphere (ii° F. Temperature of Rec-
tum 102** F. A sharp steel rod was placed upon the surface of the neck, above the position
of the medulla oblongata, and was struck a heavy blow with an iron hammer. The steel
instrument did not strike the fourth ventricle of the brain, as was desired, but wounded the
left side of the spinal cord, near or about the junction with the spinal cord of the medulla
oblongata, and passed through beyond the spinal column, wounding the soft parts beneath ;
(it is probable that the sympathetic nerve was also wounded, this point however, Was not
definitely settled,) the animal remained quiet, without active movement during the infliction
of the injury, and the only evidence of pain, was a shivering and slight convulsive movement
of all the muscles.
The thermometer in the rectum commenced to rise immediately after the infliction of the
Injury, in a few moments stood at 105*^.50 and then as rapidly sank to 102^.75 F.
Fifteen minutes after the first injury, whilst the dog was supported in the standing posture and
quiet, with the exception of slight twitcbings of the muscles, the steel rod was withdrawn,
and again driven by the hammer more towards the cerebellum, or rather towards its union
with the medulla oblongata. E.\amination after death, showed that It took very much the
course of the first incisiou, and enlarging the wound of the left side of the spinal cord, Jasi
at its junction with the medulla oblongata, it fractured the anterior portion of the atlas, and
penetrated a short distance into the soft parts beneath.
For a few moments, the struggles of the dog were powerful ; the animal however, in a short
time, sank Into a comatose condition, or rather into a powerless state. When the ball of the
eye was touched with the finger, the muscles of the eyelid contracted, and the papil althoofh
somewhat dilated, responded to the stimulus of light. During the violent struggles the ther-
mometer could not be retained in the rectum ; it was returned however as soon as thej had
subsided, and indicated a temperature of 103.2 F., showing a rise succeeding the second i^jary
of 0^.45 F. The action of the heart at the time, 25 minutes after the first injury by the steel
shaft, was full and regular — G4 per minute ; respiration, 13 per minute. Fifteen minutes aAer
this observation, and 40 minutes after the first introduction of the steel shaft, temperature of the
rectum 103** F.; action of heart, 60 per minute ; respiration, 13 per minute. Twenty mlnates
after this observation, and GO minutes after the first injury, the action of the heart was strongs
spasmodic, irregular, 58 beats per minute. By the beats we mean the impnlses of the apex
against the walls of the thorax.
The beatings of the carotid arteries could be plainly seen across the large room in which
the experiment was being conducted, thus indicating the violence of the action of the heart,
and the same spasmodic beatings were manifested in all the large arteries of the trnnk and
limbs.
Experimental Illustrations of Convulsive Diseases. 277
Respiration 13, spasmodic, and accompanied with twitchings of the muscles of the face and
lips, and with spasmodic contractions of the mnscles of the throat.
Temperature of Rectum, 102^.9 F.
A strong, interrupted magneto-electric current, was next passed from the roof of the
mooth to the anus. . Violent couTolsions were excited in all the muscles of the trunk and
extremities; during these couTolsions the thermometer in the rectum rose from 102*^.9 F.
to 104».75 F.
These strong electrical currents exhausted the irritability of the muscles rapidly, and in the
coorse of a few minutes they ceased almost entirely to respond to the galvanic and magneto-
electrical currents — the respiratory muscles ceased to act, and in a few minutes afterwards,
the heart ceased to beat. The respiration and the action of the heart ceased one hour and
fifteen minutes after the first introduction of the steel shaft.
Forty-five minutes after death, the thermometer in the rectum still indicated the same tem-
perature, 104.75. Twenty-five minutes after this observatioo, and sixty-five minutes after
death, the temperature of the rectum was 104.% F. showing a fall during the last 20 minutes
of 0*».75 F.
The following observations were recorded upon the changes of temperature after death.
Temperature of rectum at moment of death, 104°.75; 45 minutes after death, 104.75; 65
rainates after death, 104 ; loss in 20 minutes 0.75, or 0^037 F.; 80 minutes after death, 103?.5
F., less in 15 minutes 0.50, or 0.033 per minute; 200 minutes after death 99^, loss in 120
miuQtes 4^5 F. or 0°.037 F. per minute.
I^Mi^morlem Examination: three and a half hours after death, blood-vessels of dura-matter
filled with dark, almost black blood, and presented an appearance similar to that of the dog
previously killed by the interrupted current. The blood-vessels of the pia-mater, were in like
manner filled with dark blood. The appearance of the brain after the removal of the dura-
roatter was carefully sketched and preserved for future comparison. At the base of the brain
in the posterior border of the left lobe of the cerebellum, there was a small clot, half an inch
io length, one fourth of an inch in breadth, and one eighth of an inch in thickness. The
blood-vessels at the base of the brain were more congested with blood than those of the supe-
rior portions, and blood was effused between tho arachnoid and surface of the base of the
brain, and of the superior portions of the spinal cord. The amount of blood effused, how-
ever, was small, and no coagulation had taken place. The blood-vessels were most probably
ruptored when the atlns was punctured by the steel instrument. Tue stomach was filled with
partially digested matters, and the mucous membrane presented an injected, purplish and red-
difb colour. Mucous membrane of Small Intestines, pale.
Exjyeriment 7 : DlvUion of Medulla Oblongata, Arttji4:ial Respiration.
I«arge, tbio, lean pointer dog. Temperature of atmosphere, 58<^ F. Temperature of rectum
of dog, 40 33, C, 104.6 F. A knife blade was qnickly passed through and across the feurtli
vrotricle, severing in two completely the medulla oblongata, and also at the same time, the
vertebral arteries.
The respiration ceased immediately, a profuse hspmorrhage took place from the vertebral
arteriee, and in a few moments all signs of life were extinct. Several minutes after the heart
bad ceased to beat, and the animal was apparently dead, the thorax was opened, the heart
although motionless, contracted when touched with the point of a scalpel, and as soon as
artificial respiration was established, its cavities contracted and expanded as in the living
animal.
Electro-magnetic currents produced contractions in the voluntary muscles whfch appeared
Io eqom] in force and vigor those of life. The heart continued to beat with regularity and
vigor for more than half an hour, during which time the artificial respiration was maintained.
Temperature of the rectum 30 minutes after the severance of the medulla oblongata, :{9°.9
r. (103.8 F.)
I«oss of temperature during 30 minutes of artificial respiration 0^.43 C; loss of temperature
^acb mioDte, 0.0143. The abdomen was opened at the same time, that we might observe the
motions of the intestines ; and the stomach and liver, and in fact all the viscera were freely
^s posed to the atmosphere. This exposure of the internal organs, together with the profuse
b»aBorrbage greatly increased the rate of cooling in this lean dog.
Temperature of rectnm 120 minutes, after severance of medulla oblongata, .1.'i.45 C, 95^. H
F : loss of temperature during each minute, 0.0493 C.
If we compare the results of this experiment with those of the preceding observations, we
Will fiod that the loss of temperature has been three times as great after the cessation of arti-
ficial respiration and the action of the heart. This increased ioss was due to the cooling of
the l»od/ by the air freely introduced during artificial respiration, and also to the free
exposure of the viscera.
Temperature of the rectum 240 minutes afti>r the severance of the medulla oblongata, 30^.55
278 Experimental Illustrations qf Convulsive Diseases.
C, loss of temperature daring the last 120 minutes, 4®.U C; loss of tciiipcraiurc euch niimiic
0.0408 C. The loss of temperature each minute during artificial respiration was ooljr u.uUU
per minute ; it is evident therefore that the artificial respiration, in that it promoted the action
of the heart, the circulation of the blood and distribution of oxygen, caused a certaih increaie
of heat, which notwithstanding that it was counterbalanced hj the cool air thrown in large
volumes iuto the lungs, and also by the loss of the blood and the exposure of the wtrm
internal organs, was nevertheless an actual increase as evidenced by the increased rate of
cooling after the discontinuance of the artificial respiration.
Experiments <y, t'>, 10, II, I J, I J, IJf^ Repetition of Experiment 7 : Division of
Medulla ObhngcUa, Artificial Respiration,
General results similar to tbosc detailed in ExperimeDt 7.
Experiment 15; Introduction o/ Air into the Venous System; Death,
9
The external jugular vein of a large male bull dog was exposed, and a small inoiiion ma^
through the coats of the vein, and the small end of a silver blow*pipe introduced. Air was
then blown forcibly into the vein, the dog gave a few spasmodic straggles and a loud cry, and
died almost immediately. Air was found after death, mingled with blood in both cavities of
the heart, and in many of the veins, and even in those of the brain.
Death took place as suddenly as in section of- the medulla oblongata, and more rapidly than
in poisoning by Prussic acid.
Experiments 16, 17, 18, 19, ^iO; Repetitions of Experiment 15 ; Introduction of air
into Venous System ; Death ; Results similar to those recorded under 15.
If smaU quantities of uir are gently introduced into the venous system, the animal
although much enfeebled and agitated may live for several hours. When however, air
is forcibly blown into the venous system, death takes place immediately, and as rapidlv
OS in cases of poisoning with the most potent and rapid agents as Hydrocyanic mcii anil
Cyanide of Potassium.
After careful investigation, I have been led to the conclusion, that the forcible intn^
duction of air produces death, by arresting the circulation of the blood in the capillarity
of the lungs and of the brain, medulla oblongata and spinal cord, and of the hesul; aii<i
we are inclined to view the suddenness of the fatid issue, when the air is driven in with
great force, chiefly to the mechanical arrest of the circulation of the medulla oblongata.
When considerable force was used in driving in the air, the organs presented a higbiv
oongeHted appearance, similar to that characteristic of poisoning by Hydrocyanic aci«i .
but in the former case, the congestion was clearly referable to the eflTects of mechanii-al
pressure, suddenly exerted upon the blood within its vessels, and the combination with
this pressure of mechanical arrest of the capillary circulation.
The following conclusions may be drawn from the preceding experiments, illuHtratin::
the action of physical agents.
1st. Violent muscular exertion and tetanic spasms, excited by injuries of the nervna«
system, are attended with an increase of temperature, both in the central organs and in
the mu.scleH.
2d. The vi«>lent tetanic spasms excited by the interrupted electro-magnetic curroni.
arc attended with an elevation of animal temperature.
3d. When an animal has been killed by the interrupted electrical currents of hi:jh
tension, and which have caused violent spasms during their application to the Viwus
animal, the ceiebn)-spinal nervous system (brain, medulla oblongata and spinal cord. > i«
congested with blcNKi, and this congestion extends not merely to the investing memhran-*
but is wellmarktHi in the nervous structures, and especially in the ganglionic tnwl* «•*'
the brain, medulla and .spinal etird.
4th. The temperature progressively falls after deatli from injuries of the iifr>««u*
system, from hsenuirrhage, from electricity and from the injection of air into the veD<»u«
system, and the rate of cooling of an animal after death from these causes, appears to
be dependent upon several circumstances, as the temperature of the surrounding medium
Experimental Illustrations of Convulsive Diseases. 279
the siic and condition of the animal^ whether lean or fat, and the character of its
covering, whether wool or hair and whether thick or thin.
These facts are of interest in their connection with those cases of Tetanus, Acute
Rheumatisni and Yellow Fever, in which observers have recorded a rise in the tempera-
ture after death.
We will proceed in the next place, to present certain observations from our experimental
investigations, upon the action of poisons, instituted with the design of throwing light
qpon the nature and mode of action of unknown fever poisons, and upon the phenomena
of inflammation, which may throw light upon the nature and treatment of spasmodic
diseases.
EXPERIMENTS UPON THE ACTION OF PRUSSIC ACID (HYDROCYANIC ACID) AND
CYANIDE OP POTASSIUM UPON PLANTS.
The plant selected for these experiments was rice, ( Oriza Satira). If grains of rice
bo placed in water, they will, if the water be of the proper temperature germinate, and
the plants will grow several inches in length in the water, without the addition of any
fxtraneous matter. During the period of the germination and growth of the rice, we
have a favorable opportunity of testing the effects of various poisons, simply by adding
them to the water.
Experiment 21 ; Action of Hydrocyanic Acid on Rice.
Ten drops of officinal Hydrocyanic Acid were added to half a fliiidouncc of spring water, in
which the rice seeds had been placed, in an open glass vessel.
The Hydrocyanic Acid retarded germination for several days, but did not arrest the final
deTeloproent of the yoong plants. The degree of retardation was determined by conducting
simoltaoeously experiments with rice and pure water.
Experiment 22 ; Action of Hydrocj/auic Add upon Rice in Closed Vesseh.
m
When the rice seeds and dilute solution of Prussic Acid were put in a partially covered
glass vessel, with sufficient atmospheric air for germination, they did not germinate.
Wl;en the grains were removed from this solution, with very few exceptions they were in-
capable of germination, although originally perfect.
The experiments were performed in the month of June, in an upper, well ventilated
room, where the temperature and light were most favorable for a rapid and vigorous
gennination and growth, and were repeated upon more than one hundred grains of
rice.
If we compare the two experiments, and consider the surrounding circumstances, it
V evident that the different results were due to the fact that when the rioe was sub-
jected to the action of dilute Prussic Acid in open vessels, the poison, from its volatile
nature, was evaporated in great measure, before it produced any deleterious effects upon
the rioe ; in the confined space, on the other hand, whilst the seeds had all the essen-
tial oonditiona of germination, viz : heat, moisture, and a sufficient, if not abundant
napply of oxygen, in the oonfined air, still the absorption of the Prussic Acid continued
animpeded, and arrested the process of germination in its earliest stages, for the seeds,
in almott every instance, presented upon the exterior an unaltered appearance.
Experiment 23 : Action of Hydrocyanic Acid upon Germinated and Growing Rice,
Wbes dilate Hydrocyanic Acid was added to the water in which the young shoots of rice
were growing, it arrested the growth and caused death in periods of time corresponding with
the amount of acid added.
This experiment was repeated upon more than ono hundred stalks of growing rice,
with similar reauHs*
• Action of Cyanide of Potassium upon Pfanttu
In tbe experiments with this salt, as well as in those of Hydrocyanic Acid, rice was
the plant selected, and the surrounding conditions of temperature were the same,
280 Experimental Illustrations of Convulsive Diseases.
KxjHirimcnt ^4 • Action nf CifiuMt it/ Potasuam upon ilic Germination of Ricr.
Both ia closed and unclosed vessels, solntioDS of Cyanide of PoUmi am arrested completelr
the process of germination. Tlie word arretted is here used, because it is difficult io sucii
experiments to affirm that not a single change took place in the organic elements before the
complete arrest of the process ; it is certain, howerer, that if any of the numerous changes uf
germination took place, they did not proceed far. When the seeds thus acted upon by Cya-
nide of Potassium were transferred to pure water, in no instance did generation take place ;
they simply underwent slow decay.
This experiment was repeated, with the same result, upon more than one hundred rice
seeds.
Corresponding experiments were carried on at the same time with pure water.
Experiment Jo : Action of Q/anide of Potassium upon Growing liicc
Solutions of Cyanide of Potassium in every instance arrested the growth and caustMl the
death of the growing rice; and the rapidity of its action corresponded with the amount of
the poison added.
These experiments were in like manner repeated upon more than one hundred stalks of
growing rice.
The following eoncliLsions luay be drawn from the preceding experimeut« :
I. Plants, ius well as animals, may be destroyed by certain mineral and vegetable
substances denominated poisons.
II. As the vc^table kingdom is without nerves, muscles, or any special circulatory
apparatus similar to the automatic apparatus of animals, it is evident that these poisonsi
must act upon the individual living cells composing the vegetables subjected to their
action.
III. As the living, component cells of the vegetable kingdom are capable of elabor-
ating dbtinct products from the surrounding nutritive materials, and as this power Im
destroyed by poisons, we must conclude that the functions of secretion, growth and
nutrition may oc influenced directly by poisons, without the intervention of the ncrvoua •
system.
IV . As, therefore, poisons may act directly upon the individual living cells of v^-
etables, arresting the process of germination in the seed, and of the acts of secretioo,
nutrition and growth in the fully formed cells ; it is reasonable to infer that poisoDs
may act upon the individual living cells of animals. Thus poisons may act direcUj
upon the muscular fibre, or upon the ganglionic cells of the sympathetic aod eerebi\K
spinal system, or upon the secreting and excreting cells of the liver and kidney, or upon
colored and colorless corpuscles of the blood.
We will examine experimentally, in the next place, the action of Hydrocyanic Acid,
Cyanide of Potassium and other poisons on cold-blooded animals.
ACTION OF HYDROCYANIC ACID ON COLD-BLOODED ANIMALS.
Experiment JO : Action of Prvssic Acid upon Siren Lacertina, — Linnaeus.
I placed a large male Siren Laeertina, one and a half feet in length, and recent! j captured
from a rice field in Liberty county, Georgia, in a glass jar, and after pouring orer its hcmd,
gills and back, three fluiddrachms of the oflicinal solution of Prussic Acid, [C £. PJ., added
twelre fiuidouuces of pure water. The experiment was performed in the early part of June,
when the weather was warm, the thermometer indicating during the day, an average teoipcr*
ature of 80° F. ; at this temperature, the motions of the Siren Lacertina, are actire and
powerful. During the space of one hour, no special effects appeared to be produced by the
Prussic Acid, except that the reptile remained more quiet than usual, and when Irritated*
was more quick and violent in its motions. I added fresh portions of the solution of Prutsic
Acid, at successive intervals of fifteen minutes, and at least, two fluidounces of the officinal
solution of the acid, were poured over the head and ^ills, and into the mouth and over the
back of the reptile. Two hours after the first application of the poison, ike Siren coi^
menced of its own accord to struggle violently — would leap up with great violence — the
body was contorted, and the animal writhed as if in pain, and at interraU, the muscular sys-
tem was seized with violent tetanic spa^m?. Simultaneously with the appearance of tliet^
Experimental Illustrations of Convulsive Diseases, 281
spasmodic actions, there occurred profuse secretion of mucous from the slimy skia of the
reptile, causing the water in which it was immersed to resemble thick mucilage. These strug-
gles continued for one hour, and theu the reptile became quiet, and would struggle fteebly duly
when aroused by a foreign body. The head appeared to be especially tensitive. Seniatiem
and the power of motion gradually diminished, and four hours after the appUcaUonVthe^e
were but rery slight movements of the feet and tail when actively stimulated, and aroused
by mechanical means ; and at the end of six hours, all signs of life were extinct. ■ •
Pott'tnortem Examnation : Six hours after the first administration of the poison, and just
after the cessation of the appearances of life, when the abdominal cavity was opened,'no
contractions whatever, were excited in the muscles, by the stimulus of the knife, 'aild
mechanical stimuli failed to excite contractions in any of the muscles. The heart had ceased
to bent, and could not be aroused to action, either by any mechanical stimuli, or by powerful
interrupted electro-magnetic currents. Slight contractions were produced in the voluntary
mnscles, by the electrical excitement. Blood was effused into the abdominal cavity, and
appeared to have been poured out from some of the highly congested blood-vessels of the
intestinal canal. When the abdominal cavity was first opened,' the blood was fluid, but
coagulated in a few moments after exposure to the atmosphere. The color of the blood
changed to the arterial hue, after exposure to the air. Blood from the heart coagulated
readily and firmly When the blood drawn from the heart was examined under the micro-
fcope, the majority of the colored blood corpuscles presented the usual appearance, some of
them, however, were swollen, others presented irregular outlines, and in some the nuclei
appeared to be composed of grannies. The blood-ve$«sels of the stomach and intestines were
loaded with blood.
Experanent .il : Action 0/ Iljj/Jioct/a/u'c Acid on Coluber Quudrivittatus* — Holbrook,
In the month of June., with the temperature of the atmosphere, about 85® F. a large active
chicken snake, six feet in length, was secured, and the heart exposed without any other
injury, than cutting through the integuments. Action of' the heart 68 per minute. By the
term action of the heart, used in this connection, we always mean the number of the impulses
of the ventricle or ventricles, [ventricle in reptiles and cold-blooded animals generally, and
rtntricltt in warm-blooded animals] ; and therefore, the term action of the hearty as now used,
signifies only the number of impnl.^cs, and does not give the collective expansions and con-
tractions of all the cavities.
Sereral drops of a solution of I'nissic Acid were introduced within the peri-cardium, so
as to come in direct contact with tho exterior surface of the muscular structures of the
heart.
The effects were uianifestcif almost instantaneously in diminishing the force and num-
ber of the beats of the heart. Two minutes after the application of the Prussic Acid,
the action of the heart is 44 per minute, and becoming more and more irregular; there
is evident derangement in the relations of the expansions and contractions of the dUSerent
I'avitiet, the 'venous blood is accumulating in the large veins and in the right auricle, and
spasmodic contractions of the voluntary muscles of all parts of the body, but more especially
of the muscles of respiration are commencing.
It is important to observe, that the decided efftct» vpon the action of the heart occurred tmm«-
dtaieijf, whiUt the effecU upon the voluntary mutcles were not manifetted until a sufficient length of time
had elap9edfor the ahiorption and conveyance of the poison by the blood to these structures and the
tfanglionie centres from which these nerves were derived.
Four minutes after the application of the poison to the surface of the heart, its aotion it
2(> ptr minute, and very irregular, the dilatations are much longer than the contraotions-^the
ventricle appears to cease all action, and then to become suddenly and . spasmodically
dilated. At the end of fifty minutes, the ventricle of the heart had ceased to beat, and
could not be aroused by either mechanical siitnuli and injuries, or the strong, interrupted
magneto- electric currents; the auricles, when priciccd, and when excited by the' eleotrioal
•hocks, contracted very slightly, presenting; the appearance, more nearly rMsmbltng a. -slight
tremor, than a well marked contraction. The voluntary muscles qn the other band respoq^d
readily to both inechanical and electrical stimuli. . '
Exprrinient 28 : Action of Ilffdrocyanic Acid on /ary< Coluber GuttcUa^. — Linn.
Tbit experiment was performed in the month of June, and upon the same day with tho
preceding one.
The snake was secured, and the heart exposed. Action of the heart 70 per minute^ , An
incision was made into the pericardium, and a few drops of a strong solution of Prussic i\cid
applied to the exterior surface of the heart. The effects of the poison upon the heart wer^
evident in a few seconds, i^nd in three minutes the aot^ott of the heart was reduced to 28f iM»r
282 Experimental Illustrations of Convulsive Diseases.
raioDte, and ipasmodic contractions of the muscles were excited. At the end of this time a
strong solution of chlorine in water was applied to the exterior surface of the heart, producing
a much stronger and fuller action in the auricles and ventricles. The excitement of the
chlorine, however, was only temporary, for in 12 minutes after the application of the Hydro-
cyanic Acid, and 9 minutes after the application of the chlorinated water the pulsations of the
heart were 20 per minute. The heart continued to beat slowly, with diminishing frequency
and power for one hour, and at the end of this time, it eould be arouted to aetion^ ntHher by
meekameal meant nor by ttrong interrupted electrical eurrentt. The voluntary muscUt on the other
handf responded to the electrical excitement.
It is worthy of note, that the chlorinated water excited the heart and increased its action,
even whilst the organ was under the influence of Prussic Acid.
Experiment 29 : Action of ffydrocyanic Acid on Eni^s Serrata. — Daudiii.
This Chelonian had been kept for 12 months, abundantly supplied with water, but had been
deprived of food. When the sternum was removed, all the structures were infiUrnted with
serous fluid, and the blood was very watery. This experiment was performed upon a warm
day in June, and notwithstanding the heat, the reptile from its lon^r fast was sluggish, and all
its motions were exceedingly feeble. I have elsewhere presented the results of a series of
experiments upon the effects of thirst and starvation upon reptiles, and we will not therefore
dwell upon the physical and chemical changes of the solids and fluids in this Chelonian. The
heart was flabby in its structures, sl3W and feeble in its actions, and the structures offered but
slight proofs of excitement, when pricked with the point of the knife. The application of
Prosslc Acid to the heart was attended by much slower and less decided effects, than in the
case of healthy well fed reptiles ; the ultimate effects, however, were the same, the actions of
the heart were rendered spasmodic and their synchronism destroyed, and the freqnency gra-
doally diminished until all action ceased. Spasms of the muscles were excited before death.
The heart in this case unlike the previous cases continued to beat, after the voluntary
muscles bad lost all irritability under the action of mechnnical stimulants.
From these experiments we may, with reason conclude, that Hydrocyanic Acid exerts
a specific influence upon the structures of the hearty independent altogether of its effects
upon the cerebro-spinal nervous system. It might be objected, however, that in each
case, and even where the poison was applied directly to the surface of the heart, it was
absorbed and acted upon the heart only through the cerebro-spinal nervous system, from
whence, according to some physiologists the heart derives all its powers. However
plain the teachings of these experiments may be to our own mindi it is nevertheless
important that we should, before proceeding further, consider the relations of the nction
of the heart in cold-blooded animals to the cerebro-spinal ncr>'0us system* and th« sym«
pathetic or organic system.
BJCLATIONS OF THE ACTION OF THE HEART IN COLD-HLOODEn ANIMAL!^, TO TU«
CEBEBRO-SFINAL ANP SYMPATHETIC NERVOUS 8VSTBM8,
The relations of the heart to the cerebro-spinal and sympathetic nervous systema, aii«
highly complex, and their complete development would require an extended examination
of the nature of muscular irritability and nervous excitation, and the relations of renpi-
n^ion, capillary circulation and the chemical composition and changes of the blood,
to the heart's action ; and we sliall now present only such well established fitcis and
experinlenta aa will enable us to decide whether Hydrocyanic Acid acts directly or
iDaireoClT npon the heart.
'The met that the heart and the muscular system generally, would in cold-bloodc4
animals, continue to act for a considerable len^h of time after the removal of the brain,
has been known for more than two^thouaand years. Aristotle alluded to the independeoce
of the action of the heart and the motions of tortoises ; and Pliny in his great work on
Natnral History, in the sixty«ninth Chapter of the eleventh book, not only states the
&oi that the heart is formed first among the viscera of the foetus, and is followed by
the formation of the brain and other organs, and last of all, by the eyea, but asserts that
the heart is the last of all the organs to die. Pliny considered the heart as the priDdpal
Best of the beat of the body, the primary source and origin of life, and as contaimng
within itself the primary receptacles for the spirit, and the blood in its vinous csvitie^
Experimental Jllustraticns of Convulsive Diseases. 283
where the mind also, he supposed had its abode ; and affirmed that while all the other
viscera are injared, yitality may still remain in the heart. Rcdi found that tortoises
lived and were even able to walk for six months after he had completely removed their
bmins. Marcot, Wepfer, Stalpart, Brinius, Morga^ni, Haller, Brodie and others, hare
recorded accounts of foetuses without brains. Yesalius more than three centuries ago,
employed artificial respiration, to protract life in animals whose breasts he had opened
with a view to observe the motions of the heart, (De humani corporis^ fabrica, BasUeso,
1555, p. 824;) and thereby demonstrated the d^endenoe of the action of the h^art
apon respiration. Hook, in 1667, presented to the Philosophical Society of London,
''An account of an Experiment of preserving animals alive by. blowing into their lungs
with bellows,'' (Phil. Trans. 1667, No. 28, p. 539,) and confirmed the truth of the
statements of Yesalius. Haller in his great work, Elementa Phyntolope and in his
Pnmm Linett Phisiologie, has given many examples of the action of the heart, after all
connection with the cerebro-spinal nervous system has been severed ; and John Baptist
Morgagni, in the third volume, fifky-second letter, and twenty-seventh Chapter of his
work on '* The Seats and Cannes of Diseases investigated by Anatom^f^* has given
experiments performed by himself, and has brought forward the examples of foetuses
developed and delivered, not only without the cerebrum and cerebellum, but also
wtihout the medulla oblongata and spinalis, which prove the independence of the aotion
of the heart, of the cerebro-spinal nervous system. John Hunter (Proposals for the
recovery of persons apparently drowned, Phil. Trans., Vol. Ixvi, read March, 1776 :
Obserrations on certain parts of the Animal Economy, 1786 ; ) Edward Gbodwyn
(Connection of Life with Respiration, etc.;) William Cruikshank, (Phil. Trans., Vol.
Ixxxv, p. 177,) and Sir Benjamin Brodie (Phil. Trans., 1809, p. 161, 1811, jp. 36,
1812, p. 378,) confirmed the experiments of Yesalius and Hook, upon Artificial Respi-
ration, and rendered still more clear, not only the depeudence of the heart's aotion
upon the supply of arterial blood, but also its independence of the action of the oerebro-
spinal nervous system. Zavier Bichat has in like manner, recorded observatipns and
experiments, which prove the independent action of the heart. The fact that the heart
of oold-blooded animals will 'act for some time after its removal from the body, is now
universally known and acknowledged, and I have witnessed this phenomenon in
numerous experiments, which I have performed, upon Fish, Batrachians, Amphiifmas,
Sirens, Ophidians, Chelonians and Saurians.
Spallanxani from an' extended series of experiments upon the circulation and respira-
tion of cold-blooded animals, under various conditions, and in various stages of develop-
ment, not only confirmed the view of Lavoisier and others, that oxygen is essential to
respiration and circulation, and in fact to all vital actions, but that the rapidity of the
absorption of oxygen, is in proportion to the force and activity of animals: thus warm-
blooded animals, absorb more oxygen and exhale more carbonic acid than cold-blooded
animals. By numerous experiments he demonstrated that in cold-blooded animals, and
in such warm-blooded animals as the bat, muscadine rat, and marmot, in proportion as
the temperature is lowered, the amount of oxygen absorbed, and of carbonic acid thrown
off prop*essively diminishes, and the pulsations of the heart and the respirations beoome
correspondingly feeble and less frequent, and when the absorption of oxygen ceases, the
pulsations of the heart and the respirations, also cease. Spallanzani concludes from his
numerous experiments, that the irritability, in consequence of which the heart contracts
itself during the exclusion of the blood which passes through it, essentially depends
upon the combination of the oxygen with this hollow muscle, and that when there is no
supply of oxygen, the pulsations cease. The oxygen gas absorbed by the pulmonary
blood, obtains access to the heart, and by entering into combination with that visous,
maintains its muscular action in a state of excitement and life. Spallanxani also showed
that the action of the heart, and the development of the red color, in the blood of the
chick, evon whilst enclosed in the egg, is due to the chemical action of oxygen ; and
that whiUit the process of incubation is going forward the most essential use of the shell,
is to convey oxygen to the inert foetus, by which means it becoraieB animated, has ita
284 Experimental Illustrations of Convulsive Diseases.
partfl evolved, and isradually arrives at a state of maturity ; and when on quitting the
shdl, it ceases in this way to receive its usual supply of the priuciple, it immediatdj
reoeivl^ it by the lungs, which the oxygen gas has put into motion. (Hemoirs on
Rcapiration, by Luzarus Spallanzaui, edited from the unpublished manuscript of the
author, by John Senebier, London, 1805.)
The ei|)eriments of Spallanzani, Sylvester, Humboldt and Provincal, on theinfluenoe
of the air eoutained in water on the life of fishes ; the experiments of Smith tind Hum-
boldt, showing the dependence of muscular action upon chemical change ; the expeii-
men^ qf Hunter, Spallan7.ani, Mangili, Prunelle, and De Saissy and Edwards, upon
the hibernation of the bat, hedgehog, marmot and dormouse ; of Goodwin, Buffon, Le
Gtollois, Bichat and Edwards, upon asphyxia ; the expcrinicnta of Crawford, Delaroche
and Edwards, upon the amount of oxygen consumed, and of carbonic acid gas evolved
at different temperatures ; the experiments of Allen and Pepys, of Dulon^, and of Ed-
wards, upon the chemical changes of respiratiou ; the expcrimeut^ of Spallanxani, Vaa*
quelinj Vogel, Brande, Sir E. Home and Edwards, showing the formation of carbonic
acid in the blood and organs, and the extended scries of experiments by Dr. W. F.
Edwards, *^ On the Influence of Physical Agents on Life," all tend to establish the
important law, that all motions 4n the animal economy dopend ultimately upon the
chemical changes of the structures.
From the results of an extended examination of the progressive development of the
organs and tissues of animals, and of a series of experiments upon the chemical change
of the eoostituents of animals, I was led to the following eonclusions with reference to
the action of the heart :
Ist. The forces which work the heart, like those which are active in every muscle,
are developed by the chemical changes uf the couHtitucnts of the heart and blood. '
. 2d. The cerebro-spiual nervous system adds no forc^ or actual motive power to the
heart, although it may influence itA action, through the ganglionic system proper of the
heart, and through that portion of the vaso-motor system of nerves which regulates
the supply of blood to the muscular structures of this organ.
3d. The automatic and rythmical actions of the heart are chiefly dependent upon a
system of ganglia distributed through its muscular textures.
The cessation of the action of the heart afler its separation from the oerebro-sptnal
nervous system and from the organs and general circulatory system, is due to many
causes besides the mere deprivation of any nervous force supplied by the oerebro-«pinal
system, vis : the changes induced in the blood of its capillaries, and in its mojscolar
fibres, the products of which changes are deleterious to the living tissues. In tbe living
animal the blood supplying the heart is constantly purified from these products by
speeial organs, as the liver, and kidneys, and lungs. If the chemical compositioii of the
blood circulating through any organ be greatly changed, derangement and final oettta-
tion of the action of the organ must necessarily ensue. In the living animal, tbe iDteg-
rity of the blood is constantly prescr\'ed by various organs ; the liver forms the birth-
place of its corpuscles, elaborates its cinidc compounds, supplies it with grape sugar and
albumen, and removes various deleterious coloring matters and salts ; the spleen exert*<
certain efiects upon colored and colorless corpuscles; the kidneys continual] j remove
from it such products of chemical change as urea, uric acid, the phosphates, sulphat^f?^.
chlorides and extractive and coloring matters ; and the lungs supply the great dement
of chemical change, oxygen, and at the same time eliminate the poisonous carbonic
acid. If the heart be removed from the body, its actions will contmue as long as the
elements of chemical change are supplied in the proper portions, and until its moacolar
structures and ganglionic celb, and special system of nerves are poisoned by the chemi>
cal compounds resulting from its physical and chemical changes and actions.
However logical and true these conclusions may be, it is nevertheless importaat that
they should be examined by the light of direct experiments upon the action of the
oerebro-spinal nervous system upon the heart. We shall confine our attention chiefly*
to the experiments performed upon cold-blooded animals ; the action of the heart in
Experimental Illustrations of Convulsive Diseases, 285
wann-blooded animals will receive fiirther examination; as the phenomenon is more
complicated in this class, notwithstanding that the principles which we have just
extmined,and the experiments which we are about to recount, apply also to the relations
the nervous and muscular of forces in all animals.
Spallaniani performed numerous experiments upon frogs and salamanders, to deter-
nuDe the relations of the circulation to the s{&nal marrow and brain. He found that
irritation of the brain and spinal marrow was attended with violent convulsions of the
mnsdes ; during these disturbances of the muscular system, the circulation in the capil-
laries could not well be observed, but as soon as they subsided, the circulation was
found to be unimpeded and unchanged. Destruction of the brain and spinal marrow
did not aifect the circulation in any appreciable manner.— ^Experiences sur le Circula-
n'on ; ouvrage par J. Tourdes, Paris ; Exp. cvi-cxviii.
Fontana placed the source and principle of life, and of all animal motion, in irrita-
bQity, and contended that the circulation is independent of the brain and spinal marrow.
Ue sustains this view by the results of experiments upon the nervous circulatory and
respiratory systems, in which he affirms that irritation of the nerves supplying the
heui, destruction of the brain and spinal marrow in cold-blooded animals produced
neither an acceleration nor retardation of the action of the heart. — ^Traite sur
le Venin, de la Vipere; Florence, 1771 ; Tom. I, pp. 81, 1)0, 93, 289; Tom. II,
p. 169.
Dr. Whytt, after decollating a frog, destroyed itjs spinal marrow, by pushing a small
probe down through its spine, which occasioned strong convulsions of all the muscles,
especially those of the inferior extremities. Ten minutes after this, the thorax was
opened, and the heart found beating at the rate of 45 times a minute. Sixteen minutes
alter decollation, it moved 40 times in a minute. After half an hour, it made 36, and
after fifty minutes, only 30 pulsatidns in the minute, which were now also become very
^mall and feeble. This observer, after decollating another frog, destroyed its spinal
marrow with a red hot wire, which produced terrible convulsions in all the muscles, as
in the last experiment. Thirty-five minutes after the decollation and destruction of the
(tpinal marrow, the thorax- was opened and the heart observed, beating 30 times in a
minute. One hour and fifty minutes after decollation, the heart made 20 pulsations in
a minute ; three hours and twenty minutes, when the room was become warmer by the
nbining of the sun. the heart beat 25 times in a minute, and when placed in the sun-
beams, it performed 31 contractions in that time. After this the frog was removed to
an east window,, where it was exposed to a cool breeze, upon which the motion of its
heart became slower, so that in a short time it made only 25 pulsations in a minute.
Exposure anew to the sun-beams quickened its beat to 30 times in a minute. Six hours
and sixteen minutes after decollation and the destruction of the spinal marrow, the
aarides of this firog's heart which were still filled with blood, contracted 12 times in a
minute ; but the ventricle lay without motion, was swelled and very red ; however,
when pricked with a pin it performed two or three pulsations, and then remained at rest
till roused by a new ttimulus. Ten minutes after this observation, the ventricle seemed
to be quite dead, but the auricle continued its motion. Three hours after the ventricle
bad been without motion, the auricle which was very near as much filled with blood, as
vhen the heart was first exposed, beat 11 or 1 2 times in the minute ; its pulsations,
however, were not so r^:ular, as to time as they had been before. Dr. Whytt concluded
from these experiments, that an influx of fluid from the nerves into the muscles, and
espedally into the heart, is not necessary for their contraction. Edinburg Physical
Estay$, vol. ii, pp. 282-285.
M. Le Grallois, concluded from his experiments upon cold and warm blooded animals,
that the heart derives its power from all parts of the spinal cord without exception ] but
his experiments upon frogs did not fully sustain this proposition, for although the sud^
den destmcdon of the brain and spinal cord was followed by a temporary cessation in
the action of the heart, the organ subsecjuently renewed its pulsations.
286 Experimental Illustrations of Convulsive Diseases.
Dr. A. P. Wibon Philip,"^ concluded from hu numerous experimcnte upon cold-
blooded animals, that the power of the heart is independent of the brain and spinal
marrow, for it continues to perform its function after they are destroyed or removed,
and that their removal is not attended by any immediate effect on its motions. It mav
be urged with some degree of justice and force, against the series of experiments insti-
tuted by Dr. A. P Wilson Philip, to show that certain agents as solutions of Opium
and Tobacco, and Spirit of wine, are capable of influencing the action of the heart when
applied to any considerable portion of the brain and spinal marrow, that the effects
upon the heart were due to the absorption of the agents by the blood-vessel system and
their direct action through the blood upon the ganglia and muscular fibres of this oigan.
From his experiments upon warm and cold-blooded animals, Dr. Philip not only arrived
at the conclnsion of Hallcr, that the heart and other muscles possess an excitability
independent of the nervous system, but was carried a step farther, and affirmed that
they are all equally capable of being stimulated through this system ; by which view he
thought that the great objections to Haller s doctrine were removed.
Mr. William Clifl, shortly after Dr. Philip's researches, performed similar experiments
with similar results upon the carp. The heart was exposed, the effects of the destruction
of various portions of the brain and spinal cord observed. Mr. Clift concluded, that :
whether the heart is exposed or not, its action continues, long after the brain and spinal
marrow are destroyed, and still longer when the brain is removed without injaiy to its
substance. The action of the heart is accelerated for a few beats, by exposure of that
organ ; by exposure of the brain ; injury to the brain ; destruction of the spinal marrow
while connected with the brain ; by the connection between the brain and spinal marrow
being cut off; while removing the whole brain, produces no sensible effect upon the
heart's action, and destroying the spinal marrow after its separation from the brain
renders the action of the heart slower for a few beats. Phil. Trans., 1815, pp. 91-96.
M. Flourens, from an extended series of experiments, arrived at the following con-
clusions :
The circulation does not depend immediately upon the Brain and Spinal Marrow ;
but its dependence, although not^immediate, is none the less real. Thus in proportion
as the nervous system is destroyed, the circulation becomes circumscribed and enfeebled ;
first the sub-cutaneous capillary circulation is extinguished, then that of the larirer
vessels, and finally, the circulation is confined to the heart and large trunks. The
energy and duration of the circulation, depends therefore, upon the nervous syntom,
for in proportion as the brain and spinal cord are destroyed, the circulation is enre-^blvd,
and at the end of a certain tim3, after the destruction of the nervous syjtem, the
action of the heart and the circulation is entirely destroyed. In the second place, the
cirouktion depends upon the power and existence of the nervous system, not only in a
general and absolute manner, but in a special and determinate manner. For when any
special region of the nervous system, is alone destroyed, it is always alone in those
partB corresponding to the portion destroyed, that the circulation shows itself enfeebled.
There is then a general influence exerted by the whole nervous system upon the entire
circulation, and also local and partial influences of the different portions of the one,
upon the different regions of the other. Finally, in all cases, the complete destruction
of the nervous system, so enfeebles the entire circulation, that sometimes when the
vascular circulation still survives, the sub-cutaneous capillary circulation » almost imme-
diately stopped. This last point is worthy of attention, for it has led several others to
regard the capillary circulation, cither as independent of the general circulation, or on
the other hand to be more exclusively subjected to the nervous action. The capillary
circulation is neither more particular nor exclusively dependent upon nervous action
than the general circulation ; but it manifests soonest this action, because being placed
ExiierioMMitv nuulc ttilh n vifw to ftM-frUiii the pliocliilc on which the •ction of the h«aft d«p»n4i, and th*
npUUont which suLHat brtwefn that oripui aud th« n«>rvom fly»t«m. Philuaoplilcal TimQMcUoM IttlAy ni. <5-4flk
mw al«o Phil. Timn*.. 1M17, pp. i-i-iM ; lH•i•^ pp. 22. a-, 1H27, pp. 2«7-.«iO; 1H-1», pp. 26!--/:8; 1«1, pp. 4hMW; 1*31.
pp. .W 7:2. Phil. Trmoa.. pp 7:^-^7; iV^U, pp. ir>7 1H8, 1836, pp. 34:i-370. An lBqfilf)r lata tli« Law* of tha Vital
l^UBCtioltf
Experimental Illustrations qf Convulsive Diseases. 287
at the periphery of the vascular circulation, it is roost sensitive to impressions. But,
however related, the nervous and circulatory systems may be, this relation is not instan-
taneous, because the former may be destroyed, and yet the latter continue for a certain
time ; neither is the relation immediate, because a particular connecting link is found in
the Great Sympathetic. Du Systdtoe Nerveux, Paris, 1827. More recently, M. FIou-
rens adopted the opinion that the circulation was more especially dependent upon that
portion of the spinal marrow and medulla oblongata, which is essential to respiration,
and endeavors to sustain his view by experiments, the results of which do not differ
materially from those of Spallanzani, Whytt, Philip, Le Gallois and Cliff.
Dr Marshall Hall repeated the experiments of these observers, with the following
results :
The brain and spinal marrow of a frog were removed with the utmost precaution, to
avoid the effect of shock. The circulation in the web, which had been most vigorous,
was observed to become very gradually slpwer ; it was lost in the capillaries in five
minutes, in the veins in ten, and in the arteries in between fifteen and twenty. The
whole of these changes were slow and progressive. Some intervals elapsed before the
lung was examined, and its circulation had ceased. The heart still beat feebly thirty-
iflx times in a minute. Scarcely any blood was lost. A flat stilet was introduced and
passed through the brain and spinal marrow of another frog at various times, until the
whole was destroyed, yet so slowly, that no shock was produced. The circulation in
the web was at first nearly natural, but in a very short time it ^rew gradually slower
and feebler, until it ceased. The -movement in the blood in the arteries first became
slow, and like that in the veins ; then oscillation as when the heart is removed. The
capillary circulation and that in the veins gradually ceased. There was still a degree of
circulation in the large vessels, and even in one or two of the capillaries in the lungs,
and this organ was moved by each contraction of the heart. The heart itself still beat
vigorottsly and regularly forty-eight times in a minute. These experiments were
repeated by Dr. Hall, upon another frog, and upon two eels, with similar results, and
they led him to believe, that the action of the heart is enfeebled from the moment it
is deprived at onoe of the influence of the brain and spinal marrow ; and that the con-
nexioD of the heart with the nervous system, is precisely of the same nature as that of
ibe voluntary muscles ; .both possess a degree of irritability independent of the large
maftes of the nervous system ; both if separated from these masses, gradually lose
their irritability : the irritability, therefore, is doubtless a faculty or property of the
muicular fibre, yet it may become extinct without any obvious change in that fibre ;
its oootinuance or renewal, depends ultimately upon the masses of the nervous system.
Dr. Hall believed that from the moment of the abstraction of the brain and spinal
iDarrow, the irritability of the heart begins to fail ; the circulation is first enfeebled,
then lo9t ID the most distant parts of the system, then in parts less remote ; the distance
to which it extends may aptly be taken as expressive of the remaining power of the
heart, the principal organ of the circulation.
Dr. Marshall Hall endeavored to determine the effects of destroying the part of the
medtUla oblongata on which respiration depends, and of the entire brain and spinal
manow, by saccesaive portions at distant intervals, and found that the destruction qf
the medulla oblongata did not arrest the circulation, as had been asserted by M.
Fkmreiw, and finally, that the frogs lived much longer, and the circulation continue^
much more active for a greater length of time, when the brain and spinal cord were
remoyed by successive portions. In one instance the circulation continued, but little
altered, for about forty hours afler the entire destruction of the brain and spinal cord.
A repetition of the experiments of applying various substances, as alcohol and infusion
of opiiini and tobacco directly to the brain and spinal marrow, was attended with very
different results from those announced by Dr. Wilson Philip : Dr. Hall found that alco-
hol and infusion of opium affect the circulation equally, whether they be applied to the
brain and apinid marrow, or to the exterior of the body and extremities, and that after
ftogH were rendered ipsepsibte by immersing the extremities iu Uud^num, alcohol ap-
288 Experimental Illustrations of Convulsive Diseases,
plied to the Hurface of the brain and 8ptnal cord, as in Dr. Philip's experiments, pro-
duced no stimulant effect wbat^^vcr upon the circulation. Dr. Marshall Hall sInj
repeated Dr. Wilson Philip^s experiments, illustrating the effects upon the circulation,
of crushing the spinal cord and brain suddenly, and was again led to dissent from bi^
conclusions, by finding that the heart's action is e<|ually arrested by crushing th'
stomach or even the extremities. A frog was made perfectly insensible by the applies*
,tion of laudanum or alcohol. Its respiration ceased^ it did not move on the application
of any irritant. The circulation in the web was carefully observed. When it had
long continued in the same enfeebled state, without change, the thigh was crashed.
The circulation in the minute and capillary vessels ceased at once, and never returned.
The stomach was now crushed in the same manner. The heart ceased to beat for many
seconds. Its beats then returned, but never regained its former force. The effect w±s
precisely such as was observed by Le Gallois on crushing the spinal marrow. Ther.*
was not the slightest indication of pain in either experiment. This experiment was
repeated twice, with similar results. The spinal marrow being removed in an eel. the
circulation became ut length much enfeebled in the pectoral fin. The part one inch
and a half below the heart was crushed. The circulation in the pectoral fin nowceimnl
suddenly and entirely. In an eel, in which the brain had been carefully removed, and
the spinal marrow destroyed., the stomach was violently crushed with a hammer. Tho
heart, which previously beat vigorously, sixty times in a minute, stopped suddenly, and
remained motionless for many seconds. It then contracted again, and slowly and grad-
ually recovered an adion of considerable frequency and vigor. No experiment can
more clearly demonstrate the effects of violence inflicted upon the system generally.
The experiment is the more remarkable, because the connexion and influence of th*
brain and spinal marrow were entirely removed. The physiological deduction which
Dr. MarshaJl Hall drew from these experiments, was that ho much insisted on by Hi|H
pocrates, that every organ or part influences, and is influenced by every other ; that
there is a pre-disposing sympathy ; the whole system may be compared, in this point of
view, with rings entwined together, they naturally support each other, any one may bt'
removed without destroying the form of the rest, but their strength is immediately im-
paired, and if one be violently crushed, the other will scarcely escape from destruction ;
these rings may represent the nervous, vascular, and organic circles in the animal
irame.
Dr. HalP does not attempt to determine the mode in which this sympathy is exertcKl.
neither does he in any part of his experiments refer it to the sympathetic nervous sys-
tem. If his experiments upon crushing the brain, and spinal cord, and the oigans indi-
cate anything of physiological importance, it is intimately associated with the action t)f
the heart, arteries and capillaries. In crushing an organ, no matter how remote fntni
the central organ of circulation, we crush the bloodvessels of the organs dostroytnl ;
now, as these blood-vessels are surrounded with the fibres of the sympathetic or vas^o-
motor nerves, which form a chain of communication with the sympathetic ganglia and
nerves of the heart, it is but resisonable tb suppose that their destruction should exert
an effect upon the general circulation.
Bidder removed with great care the arch\3s of the second oervical vertebra^ no that
little blood was lost during the operation, and then completely destroyed the spinal oord.f
Frogs treated in this way, often lived six w6eks, sometimeis ten weekff, the circttla-
tion, as seen in the web of the foot, remaining at the same time active, and not diflfvr-
ing from that in uninjured fn>gs. The heart beat powerf\illy and quickly ; in a fVeHhly
killed frog, in winter, the heart pukated thirty-five times in the minute ; while in a
frog, the spinal cord of which had been dcHtroyed twenty^ix days previously, the pal-
* A Critical and Experimental Essay on the Circulation of the Blood, Bspeoiallj as tHi.
served in the Minute and Capillary Vessels of tho Datracbla and of Fishes. Phil., I9^i5^ p|i
y2-135.
f Cyclapwdia of Anatomy and physiology, Part x\y'x\, Aug^ IW.'i, pp. 457-^M,
Experimental Illustrations of Convulsive Diseases. 289
ntiona were forty per minute. When the brain and spinal cord were destroyed, the
medulla oblongata being left, frogs were retained in life until the sixth day ; and when
the entire central organs of the nervous system were removed, they lived until the
second day ; the rapidly ensuing death in the latter case being due, acoording to Volk-
mann, to the effects produced upon the respiration. Within a few weeks after the
destruction of the spinal marrow, the muscles of animal life were found to have lost
their irritability in a marked degree, and still later, no contraction could be produced
in them by application of chemical or mechanical stimuli ; the heart, however, in such
cases, still continued to pulsate eleven times in the minute, and retained its property of
responding to exiemal stimuli. The intestinal canal, in like manner, retained its irri-
tability ; application of stimuli giving rise to contractions which were sometimes of a
local nature, at other times extended for a considerable distance on either side of the
part stimulated. Digestion, in like manner, suffers but little from destruction of the
central parts of the ner\'ou8 system ; healthy frogs, and others which had been operated
upon, were, after being stan^ed for a considerable time, fed with worms, and kept in
separate glasses. In the one as well ns in the other, the worms were found after
twenty-four hours to be fully digested, and the stomach and duodenum were filled with
colored mucus ; such was observed to be the case even in animals whose spinal cord
had been destroyed twenty-nix days previouslv. The secretion of urine also continues ;
when, in animals in which the brain or spinal cord had been removed, the bladder was
emptied by external pressure upon the walls of the abdomen, in a short time it again
became filled and distended to an enormous size, unless emptied in the way just men-
tioned. It had been observed by Valentin and Stilling, that after destniotion of the
spinal cord in the frog different derangements in the nutritive process ensued ; there
were frequently observed dropsical swellings, especially of the limbs. On these also
i«ore8 formed, which often penetrated as far as the bones. In reference to these results,
Volkmann states that they are, as shown by Bidder, chiefly accidental. Bidder found
that when the bottom of tne vessels in which the frogs were kept was covered, not with'
water, but with moist grass or moss, no such derangements ensued.
The rapid death which ensued in warm-blooded animals, when operated upon in the
above manner, depends, according to Volkmann, upon the difficulty of sufficiently keep-
ing up respiration by artificial means, as well as upon the loss of blood and diminution
of animal neat. The circumstance, then, that a certain number of the vital phenomena
disappear suddenly and irrecoverably after destruction of the spinal cord and brain,
while others continue for a greater or shorter time, and this very perfectly, can only
depend, according to Volkmann, upon the circumstance that the brain and spinal cord
is a necessary condition for the existence of the former, but not of the latter. If the
latter depend upon certain nervous organs, and if the nerves of the sympathetic or vege-
tative organs do not rcf|uire, as a fundamental condition of their activity, the presence
of the brain and spinal cord, the only possible centres on which they can depend for
this, are the ganglia of the sympathetic.
The sympathetic and its ganglia, therefore, according to Volkmann, constitute an inde-
pendent whole, from which proceed the impulses to, as well as the regulation of, those
actions which continue after .the brain and spinal cord have been destroyed, and
which notwithstanding, require the co-operation of a central organ. That the move-
meota in question, require such an organ, and are not produced by the mere stimulus of
the blood, faeces, air, etc., in the same way as the twitchings of the muscles of a frog's
leg are produced by galvanism, is shown according to Volkmann, by the different
characters exhibited by the two. When stimulus acts immediately on motor nerve fibres
contraction ensues only in that muscle, or part of the muscle, to which these are distri-
buted ; whenjt affects the whole trunk of such a nerve, many museles aro exdted to
contraction ; the contraction so produced, however, is a mere quivering, quite different
from the combined and plan-like movements of the muscles of respiration, etc., or those
reflex movements which are produced artificially. In these there is a cerUiQ unity and
37
290 Experimental Illustrations of Conuulsive Diseases.
«
plaD, in the others not ; the difference depending on the circumstanoe that in the one
a regulating principle associates the muscular movements for the attainment of an
organic act or purpose ; in the others this does not take place. When the regular and
plan-like manner in which the pulsations of a heart removed from the body take
place, is compared with the tumultuous and purposeless quiverings of a diaphragtki
similarly circumstanced, it is hardly possible to suppose that the two kinds of movement
proceed from the same principle. Irritability acted on by the stimulus of the blood or
air, might explain the mere contraction of the heart ; the regular order however, in
which this takes place, implies the existence of a regulating principle ; and a regulating
principle implies the existence of a regulating apparatus. While the regular movements
of the voluntary muscles suddenly cease when the brain and spinal cord are destroyed,
Ihoso of the organic muscles continue ) and hence their regulating apparatus cannot lie
In the brain and spinal cord^ and can only therefore be situated in the ganglia of the
sympathetic.
We have thus endeavored to examine the various experiments of Physiologists illus-
trating the relations of the action of the heart to the cerebro^spinal and sympathetic ner-
vous system, and this research has only still farther strengthened the conclusion that
Qortain poisons, as Hydrocyanic Acid, may act directly upon the muscular and nervous
Btfttctttres of the heart, and thus arrest its movements without any intervention of the
eerebro-spinal nervous system.
We propose, however, still farther to illustrate this proposition by the following :
BXPERIMB1IT8 ILLUSTBATINO THB DIRECT ACTION Or PBU88I0 ACID, CYANIDE OF
F0TAB8IUX AND STRYCHNIA, UPON THB HBART OP COLD-BLOODBD ANIMALS,
WHEN BBMOYBD PROM ALL CONNECTION AND COMMUNICATION WITH THB
CERBBB0-8PINAL NBBV0U8 8T8TEM.
Experiment SO : preUminary on a fine active corn snake ( Coluher GatttUiu — Luiuxus^)
in the month of June ^ iUxistrating the effects of renwmng the heart entirely from the
influence of the cerebrospinal nervous system.
The heart of this snake was exposed, nnd after the excitement induced by the operation bad
subsided, the action of the heart was 76 per minute.
The trachea and (Esophagus were serered just below the head, opposite the cervic&l Tertebm.
nod all the viscera (langs, heart, lirer, spleen, pancreas, intestined and kidneys,) removed, aoti
the cloaca secured just below the junction of the ureters. Previous to, and during the ope-
ration ligatures were applied, so as to retain the blood, both in the blood-vessels of the Kruok
nnd of the viscera. After the removal of the viscera, and whilst the lungs were completeljr
collapsed, the heart bent only 30 times to the minute. The action of the heart commeoccd to
diminish !n frequency during the removal of the viscera, owing to the complete ezpnlsion of
air from the lungs at the moment that t^e wind-pipe was secured. The whole operation
occupied 10 minutes, so that in 10 minutes the heart had lost 4G beats per minute. The lan^t
were then inflated so as to imitate the respiration of the snake ; in a few moments the action
of the heart was increased, both in frequency and force, and soon rose to 76 per minute. The
movements of the heart appeared as usual to the naked eye, and felt as usual when the fiog«:ra
were placed around the organ and gently pressed against it.
The heart continued to beat for two hours, although the lung had beep allowed to collapse.
One hour after the entire removal of the heart and viscera out of the body, from all connection
with the cerebro-spinal nervous system, notwithstanding the collapsed state of the lung, iho
heart was beating regularly 16 times per minute, and presented both a natural appearance
and regular normal actions.
Experiment 31 ; Illuttrating the Action of Hydrocyanic Acid K/>oii th4i Heart remor<rti
entirely from the Cerehro- Spinal Nervous System of a largCy active King Snttk*-
(Ooronella Getula — Linnstus^) Ofeet in lengthy in the month of June,
The heart was exposed, its pulsations pear minute were 60 ; the viscera were then removed,
and at the end of the operation the action of the heart was 52 per minute. The pericardium
was opened, and a solution of Prnssic Acid applied upon the external surface of the hearl.
In two miQUtes, th« actiQQ Qf the heart fell to 28 per minute, notwithstanding, that th«
Experimental IHustrations of Convulsive Diseases. 291
respiration in the lang was kept up, after the removal of the viscera bj artificial means. In
4 minates the action of the heart was 18 per minute; the contractions and expansions of the
auricles and ventricles were spasmodic and irregular ; and the shape of the heart changed,
presenting a flaccid, relaxed appearance. When the heart was pressed between the fingers, it
felt perfectly relaxed, and a most marked difference from its full strong resisting feeling,
before the application of the Prnssic Acid. Six minutes after the application of the poison,
action of the heart 14 per minute, very feeble and weak, both to the sight and to the touch,
and its color both in the auricles and in the ventricles, had deepened to a dark purplish black
sod blue color.
Eight minutes after the application of the Prussic Acid, the ventricles of the heart presented
a. peculiar tetanized appearance, the muscles are drawn together and firmly contracted into
knots, and all action in the muscles have ceased, notwithstanding that artificial respiration
has been maintained throughout the whole time. The auricles although more relaxed havo
ceased to beat, and cannot be aroused, either by mechanical means or by strong interrupted
electrical currents.
On the other hand the heart of the snake, which had been removed with the viscera, one
hour before this, was still beating 16 times per minute, although the lungs had been allowed
to collapse completely for one hour — its structure was dense, well colored and firm, and its
contractions vigorous.
The trunks of both these snakes from which the viscera had been removed, continued to
respond and to execute certain motions, as coiling and striking when irritated for more than
one hoar; and the muscles were capable of being excited to contraction and movement
by mechanical and electrical stimuli, for more than three hours after the removal of th.e
viscer*.
It might have been said that in the previous experiments, the action of the Prussic
Acid was reflex; that is, through the ccrebro-spinal system of nerves, but the two
preceding experiments 30 and 31, demonstrate conclusively that Prussic Acid acts
directly upon the heart, independent altogether of any influence through the ccrebro-
spinal nervous system.
In order to settle this important question dofinitcly, the following experiments were
instituted with Prussic Acid and other poisons :
Experiment 32: Effects of Hydrocyaalc Acid on the ILmrt of the King Snake^
(^Coronella Getula), April Ofh, 180 L
A solution of Prussic Acid was prepared extemporaneously, by dissolving forty grains of
Cyanide of Potassium and forty grains of Tartaric Acid in four fluidounces of water.
The heart of the King Snake (Coronella Getula) was exposed, and its pulsations nambered
f^O per minute ; It was then severed from its vascular attachments, and dropped immediately
in a glass vessel containing the solution of Hydrocyanic Acid. In three-fourths of a minute
its pulsations were 60 per minute ; three minutes after its introduction into the poisonous
solution the auricles ceased to beat, and there was only a spasmodic motion of the ventricle,
which was contracted and contorted in various ways, as if the muscular fibres were tetanized ;
10 three and a half minutes, one-half minute after the last observation, the motions of the
rrntricle were very feeble, and the tissues of the heart began to loose the contracted, tetanized
appearance, and finally became flabby and relaxed. The flabby slate was characteristic alike
of the auricles and ventricle.
Haifa minute after the last observation, and four minntes after the commencement of the
eiperiment, every sign of motion and vitality had disappeared from the heart.
The snake continued to contract and contort itself; and to move about, and strike, when
irritated, after the removal of the heart; and after the expiration of twenty minutes, the
solution of Prusiic Acid was poured down its throat, and into the cavity from which the
hi'art bad been removed. The effect of the poison was to produce contractions, contortions
and increased motions at first, and then in the course of fifteen minutes all motion ceased.
Exjtrrtment 33 : Preliminary Experiment on (fie action of Pure Water on tlie Heart
of the YflloW' Belly Terrapin^ (Emys ^errata).
The sternum of a large, female fniys Serrata, (Vellow-nelly Terrapin), was removed
April Clh, 1801, at 4} o'clock p. m., at Montevideo, (residence of my father, Uev. C. U. Jones,
f>. 0.), in the Southern part of Georgia. The weather was warm and pleasant, and the terra-
pin, which had been recently captured in the swamp, was active and vigorous.
Action of the heart before removal from its attachments, 16 per minute. In the month of
April, on the coast of Georgia,^in the swamps and rice fields, the circulation is rather sluggish
294 Experimental Illustrations of Convulsive Diseases.
Experiment J^l ; Effects of Stjychnia on Emys Serrata.
Sternum of yellow-bellj terrapin (Emys Serrata], removed, heart cut out and thrown
immediatelj into solution of Strychnia, (Strychnia, grs., xz ; Citric Acid, f^rs., zz ; Water,
flnidounces, iv) ; the first and immediate eflfect appeared to increase the rapidity of the action
of the heart, and the force also appeared to be increased, and the actions to be rendered
more spasmodic : in three minutes, the surface of both the auricles and Tentricles, presented
a corrugated appearance ; the auricles acting with as much apparent energy as the Tentricle ;
six minutes afterwards, the auricles contracted spasmodically thirty times per minute, whilst
the ventricle contracted fully only once or twice per minute ; in 13 minutes all signs of action
had ceased, and the ventricles and auricles presented a corrugated appearance.
Experiment 42 : Action of Prussic Acid on Heart of Emys Reticulata^ April, 1861,
Sternum of Emys Reticulata (Chicken Terrapin) removed ; heart ezposed. Action of
heart, 34 per minute. Applied solution of Prussic Acid, (Cyanide of Potassium, graini, xl,
Tartaric Acid, grains, zl, water, fluidounces, iv) ; in two minutes the action of the heart was
reduced to 12 per minute, and became spasmodic, exhibiting violent contortions of the muscu-
lar fibres.
The muscular system of the terrapin also appeared to be affected within two minutes after
the application of the poison as manifested by several spasmodic movements of the limbs.
The auricles are greatly distended with blood, as if the muscular fibres had been paralyzed
by the action of the poison. Five minutes after the application, the action of the heart is
becoming more rapid, and is now 22 per minute; 33 minutes after application of poiaon,
action of heart very spasmodic and irregular, 12 per minute ; 38 minutes, 5 minutes after last
observation, action of heart very feeble and spasmodic ; muscles of body respond readily to
mechanical stimuli ; 53 minutes, action of heart very feeble and spasmodic, 12 per minute,
mucles of limbs strongly spasmed ; 80 minutes, action of heart 14, the ventricle contracts
feebly and spasmodically, whilst the auricles are distended with black blood, and contract
scarcely at all as far as can be seen by the naked eye.
The terrapin still elongates the head and thrusts out the limbs. When the heart is simply
exposed, and allowed to remain undisturbed in its natural position, and the poison is applied
directly to its structures, the action is not so rapid as in the former experiments, when the
heart is cut out entirely and plunged into the solution, because it is supplied with blood,
which is constantly renewed, and the absorbed portions of the poison mingle with the entire
muss of blood, and thus the immediate action on the structures of the heart is modified and
weakened.
Experiment 43; Effects of Prussic Acid on action of Heart of Emys Srrrafa
YelloW'Belly Terrapin, April, 180L
Sternum of large Emys Terrapin (female) removed ; action of heart 36 per minute. The
pericardium was opened, and the Prussic Acid solution dropped upon the muscular surfHce of
the heart; the effects were visible in 20 seconds — the motions became spasmodic, and in 3n
seconds the heart beat very spasmodically, and in one minute it ceased to beat and remained
quiet for one minute, when pricked it renewed its action, and then stopped for half a minute,
and again commenced its action, and 5 minutes after the application its beat was 32 per
minute, and spasmodic, the surface presenting a corrugated appearance. Tea minutes after
the first application a few more drops were poured in ; one minute after this second application,
the action of the heart was 32 per minute. At this point, the general muscular system showed
the effects of the poison, and several spasmodic motions were given; 48 minutes, action of
heart 20 per minute, and spasmodic ; 101 minutes, action of heart 18 per minute, and spasmo*
die. The voluntary muscles are still active, the terrapin stretches out his nerk and endeavour*
to breathe, with a spasmodic motion of the throat. Twelve hours after, action of heart 9 per
minute ; 18 hours after first application of poison, action of heart 9 per minute; muscles of
heart and limbs still continue to contract; 24 hours, (6 hours after last observation) ah
motions in the voluntary muscles have ceased, but the heart still acts It tiroes per minute. All
voluntary and refiez muscular movements have ceased, and cannot be excited by stimuli.
In the preceding experiment (48), we nee that the action of the heart continue*!
lon«ror under the action of IVussic Acid, than the excitability of the voluntary uiui^ch-s.
The n'i«ults of thin exj)erinient seem to indicate, that Prusi<ic Acid act« with nion» \ i«»-
lence ufMin the cerebroHpinal nervoui) HyRtem than upon the sympathetic.
Experimental Illustrations of Convulsive Diseases. 295
Esgperiment 44 : Effects of Prumc Acid on Alligator Cooter, ( Ckelonura Ser-
pentind).
Poured a quantity of the Prassic Acid solution down the throat of a powerful and fierce
Alligator Cooter, which was about 12 inches in diameter across the carapace. Although the
poisonoQS dose was twice repeated in the course of one hour and a half, no appreciable effect
was manifesti and the animal remained active and powerful, and appeared to be well 24 hours
ftfter the experiment. From this experiment we gather, that certain animals are less suscep-
tible than others to the action of Prussic Acid, and also that the effects are more marked
when the poison is applied directly to the strnctures of the heart.
Experiment 4^ 9 Effect of Strychnia on the heart of Musk Cooter {Sternot?uerus
Odoratus.')
Steroum of actiYe Musk Cooter removed ; heart cut out and thrown immediately into a
solution of Strychnia (Strychnia, grains 10; Citric Acid, grains 10; water fluidounces iv);
pulsations of heart after severance from the body, and before immersion in solution of strychnia
22 per minute. During the first minute, after immersion in the solution of strychnia, the
pulsations of the heart increased to 40 per^minute; then subsided during the second minute
to 30; during the third minute the motions became feeble and spasmodic, and at the end of the
third minute ceased altogether.
Experiment 46; Effects of direct application of Solution ^ oj Strychnia to the surface
of the Heart of Emys Serrata,
Sternum of large Emys Serrata removed, and heart exposed ; strong solution of strychnia
(grains 10 in fluidounce of water, with sufficient Citric Acid,) applied to surface of heart in
situ ; in 7 minutes tetanic spasms of voluntary muscles action of heart spasmodic and slight,
16 times per minute. In 40 minutes all action in the heart had ceased, with the exception of
a very slight occasional spasm of the muscular fibres of the ventricle. No motion could be
perceived in the auricles, which were greatly distended with blood. The voluntary muscles
were still occasionally spasmed, but the force of the tetanic spasms had greatly diminished.
Experiment 47 ; Effects of the direct application of a sotution of Strychnia to the
surface of the Heart oj Chicken Terrapin Emys Reticulata,
Exposed the heart of a large female Emys Reticulata, by removal of the sternum ; action
of heart 48 per minute ; applied strong solution of strychnia to heart. The effects of the
strychnia in altering the motions of the heart, were visible almost immediately ; violent spasms
of Che voluntary muscles at a later period, in three minutes. One minute after the application of
the strjchnia, the action of the heart had been diminished near one-third, in two minutes
one-balf, and in three minutes it ceased suddenly and completely, and the organ presented a
wrinkled, contracted appearance, as if its fibres were thrown into tetanic spasms.
Experiment 4^ i Repetition of preceding Experiment ^ {47),
Strychnia solution applied to heart of Emys Serrata; results siniilar, with the exception,
that Ibo heart did not cease to beat quite so rapidly as in the preceding experiment.
Experiment 4i) : Effects of Ligating the Large Blood- Vessels of the Heart, and sever-
ing the organ from the body.
The heart of the common toad was exposed, and a ligature thrown around the large blood-
vessels, and secured so as to enclose the blood. Action of the heart, before the application
of the 'ligature around its blood-vessels, 60 per minute. In less than one minute after the
ipplication of the ligature, the heart ceased to beat; and simultaneously with, or rather just
preceding this change, the color of the blood in the cavities of the heart changed to the
\fmou9 bue, a dark, purplish black. It is easy to distinguTsB the color of the blood in the
c<ftvitiefl of the heart of the toad, on account of the thinness of the walls. The heart ceased to
heat because it was paralyzed by the retention of carbonic acid. When cut out and thrown
into pare, fresh, spring water, after a few moments it commenced its pulsations again. This
renewal of its action appeared to be due, not merely to the stimulant action of the water, but
nUo \Q tb« absorption and removal of the carbonic acid gas by the surrounding water.
296 Experimental Illustrations qf Convulsive Diseases.
Experiments 50^ 51, 52, 53, 54, 55, 56, 57, 58, 59^ 60; Repetitions of the preceding
experiments.
On the direct action of Prussic Acid, Cyanide of Potassium and Strychnia, on
the hearts of yarious cold-blooded animals ; results similar to those previously
recorded.
Experiments 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78,
79 and 80 :
Illustrating the effects of the direct application of the mineral acids (Nitric, Hydro-
chloric and Sulphuric), and of such astringents as Alum, Sulphate of Iron and Sul-
phate of Copper, to the hearts of cold-blooded animals.
The effects of these agents varied with the degree of oonoentration ; when oonoentnted,
they coagulated the blood, acted chemically upon the structures of the heart, and rapidly
arrested its action ; when, however, properly diluted, they, especially in the case of
Hydrochloric Acid and Sulphate of Copper, exerted a much less decided effect than
Hydrocyanic Acid, Cyanide of Potassium and Strychnia, and, in fact, in some instaoioea
appeared to act as stimulants.
It is a matter of interest, in a practical point of view, to determine whether there is
any substance which will exert a direct stimulant effect upon the heart, and thus be
capable of counteracting the effects of such poisons as Prussic Acid and Cyanide of
Potassium upon the central organ of circulation. The element which first suggested
itself to my mind, was Chlorine.
EXPERIMENTS ILLUSTRATING THE EFFECTS OF CHLORINE.
Experiment 81 : Illustrating the Action of Chlorine,
A small, active Congo Snake (Ampbiama Means), 10 inches in length, was chosen as the
iubjeci of this experimeni, which was performed in the month of Jnne, 1863. The weather
was warm and the animal was active. The Amphiuma was immersed in a solatton of Chlo-
rine in pure water. The effects of the Chlorine were immediate and powerfnl, prodacing the
most rapid and continuous motions.
Experiment 82 : Illustrating Effects oj Prussic Acid,
Another Amphiuma, immersed in a solution of Prussic Acid, presented the peculiar effects
of this poison as already described, and was rapidly rendered insensible, and finally destroyed.
£xj)eriment 83 ; Effects of Qfanide of Potassium.
A Siren Lacertina, immersed in a solution of Cyanide of Potassium, still farther illustrated
the difference of action between Prussic Acid and Cyanide of Potassium, on the one hand,
and of Chlorine on the other.
Experiment 84 i Action of Strychnia,
The action of the Chlorine was still farther compared with that of the action of StrychalA
upon a large Siren Lacertina.
The muscular motions excited by the Strychnia, were of a spasmodic and violent character,
and the body of the Siren was frequently quite rigid, and the muscles irregularly contracted ;
whilst the motions on the other hand, excited by the Chlorine, were rapid, easy aad uaat-
tended by any spasm or rigidity of the muscles, and the animal appeared rather to be excited
and exhilerated by the Chlorine.
The preceding experiments, 81 , 82, 83 and 84, were performed in large glaas ▼<
so that all the varied motions and effects induced by these agents, via : Chloriiie^
Hydrocyanic Acid, Cyanide of Potassium and Strychnia, could be careAillj noted aint
compared.
In the experiment with Chlorine (81), in a few moments the surfaoc of the bodj of
the Amphiuma Means became viscid, and was oovered iritb «i whitish, ab«iid«Dt, muocKu
Experimental Illustrations of Convulsive Diseases. 297
aecretioD, preseuting an appearance of partial coagulation. ' The wbitish mucus was
detached from the bodj in long shreds. The Chlorine acted in this case upon the
mucous membrane of the skin in the same manner that I have often seen it act upon
the mucous membrane of the mouth and bronchial tubes of warm-blooded animals,
exciting a flow of mucus. After presenting these lively and vigorous vibrations for one
hour, they gradually decreased in number and vigor ; the forces were gradually
exhausted, ^nd in the course of one more hour all signs of life were extinct. Before
life was extinct, and subsequent to the secretion of mucus, considerable endomose
(absorption) of the chlorinated >?atcr had taken place, and the whole body of the
Amphiuma Means was distended. The heart was exposed several minutes after all
HJgns of movement had ceased, and after it was impossible to excite movements by either
mechanical or electrical stimuli ; the heart was still acting regularly and widi force
nearly equal to that of health. Strong, interrupted electro-magnetic and galvano-
electric currents produced but very slight perceptible contractions of the muscles,
whilst the heart still continued to beat regularly and with considerable force. Half an
hour after the exposure of the heart, it was beating regularly 34 times to the minute,
and continued to beat for more than two hours.
Experiment So : Action of Chlorine on Heart of Chicken Snake. June, 1862,
The serpent was properly confined upon its back, and the heart laid bare ; and after the
excitement induced by the preparation and operation appeared to hare passed, the heart pul-
sated 72 times per minute. The pericardium was punctured, and the surrounding space filled
with a strong solution of Chlorine in water.
The contact of the chlorinated water with the exterior surface of the heart was followed by
an almost immediate increase both in the force and rapidity of the action of the heart ; in two
miDotas it pulsated 75 times per minute.
The heart was kept exposed for four hours ; during this time the chlorinated water was
applied to the exterior surface several times, at intervals of about one hour ; the Chlorine
would invariably increase its force and frequency, and especially the power of its movements.
When the Chlorine was withheld, the excitement of the heart gradually subsided.
At the end of five hours, the serpent was loosed,.and appeared as strong and as lively as
ever. The next day, 24 hours after the application Of the chlorinated water, the chicken
snake appeared to be as welt and as active as ever. The heart was beating regularly 62
timet per minute. The exterior of the heart, with the exception of a blackened appearance,
presented nothing unusual ; there were no marks of inflammation.
Chlorinated water was then injected directly into the cavities of the heart until they were
disieoded with it ; the effects upon the blood were immediate and well marked, changing its
color to a dirty, reddish brown ; and simultaneously with this change of the blood, the heart
ceaaed to beat, and could not be excited to action even by strong magneto-electric and elec-
iro-inagoetic currents.
The reptile, however, continued to move about for some time after the cessation of the
aciion of the heart, and even attempted to strike.
la this experiment, the almost immediate cessation of the action of the heart, when the
C*bloriDe was injected into its cavities, appeared to have been due to the almost total abstrac-
tioQ of blood, (the blood having been driven entirely out of the blood-vessels, and even out
of th« capillaries of the heart, by the action of the Chlorine upon the sympathetic ganglia
aod cardiac and vascular muscular fibres), and to the complete chemical alteration of the
I mall quantity of blood which remained in the capillaries of the heart.
Sivall quantities of Chlorine, on the other hand, if they be too small to produce any marked
cbemicAl changes upon the elements of the blood, which are indispensable to the nutrition
and proper action of the muscles, act as a stimulant to the muscular fibres.
We have before shown that Chlorine will arouse the heart, even when under the direct
aciion of Prussic Acid, increasing both the number and force of its actions.
We are justified in concluding, therefore, from these experiments, that Chlorine
exerts a direct stimulant effect upon the heart, and in virtue of this stimulant effect
is capable of counteracting, to a cc^lai^^ e?;tcnt, the cffc<?t8 of Prussic Acid«
w
298 Experimental lUustratums of CofWuUive Dtseases.
EXPERIMENTS TO DETERMINE WHETHER OTHER SUBSTANCES OR AGENTS BESIDES
CHLORINE, ARE CAPABLE OF EXCITING THE ACTION OF THE HEART AND
CEREBRO-SPINAL NERVOUS SYSTEM.
*
Experiment 86 : Actum of Bxnoxide and Peroxide of Nitrogen on Emy$ Serrata,
This ezperiment was performed in the month of Jannary, 1862, when the weather was
quite cool ; the temperature of the room was 50® F., and the Chelonian was in a semi-torpid
state. The introduction of the gases into the receiver containing the terrapin, was followed
by an excitement of the muscular system, the motions, especially the respirations, were
increased in frequency and power. It required a much longer time during the cool weather
for this gas to produce fatal etTects. At the expiration of sixty hours, although all signs of
life had ceased, the heart still pulsated — the cavities of the heart contained fibrinous concre-
tions entirely free from colored corpuscles, which had been formed during life. The blood
from all parts of the body, presented the peculiar brownish color, characteristic of the
action of these gases. AH the large blood-vessels contained clots, and the vessels, and even
the cavities of the heart contained a colorless gas in great abundance.
7*^01 the heart thtnUd ttill have keptpuUating amidst those marked changes^ and aftfr the cessation
of the action of the Cerebro' Spinal Nervous System^ appears to be conclusive evidence that these gases
are stimulant in their action upon the heart.
Experiment 87 : Repetition of Experimeiit 86 on Musk Cooler {Sternothstrm Oiloratuf)'
The results were the same, and indicated thai these gases acted ns excitants to tbe action
of the heart : and that their destructive effects were clearly and chiefly due to the chemical
changes induced in the blood.
The following comparative experimeDta were instituted to test still farther the fact,
whether the action of Pmssie Acid on the heart is peculiar, or is shared by other sub-
stances.
Experiment 88 : Action of Strychnia on Siren Lacertina,
The Siren Lacertina, on account of its naked skin, as well as on account of its amphibious
habits and marked vitality, is especially adapted to such experiments.
A large, active Siren Lacertina, (eighteen inches in length), was placed in ajar, containing
aboQt one quart of water, and six grains of Strychnine were placed upon its bead, in its
month, and over its baok, and mingled freely with the water.
Tbe day was warm, and the animal endowed with all the activity usually inspired in this
class of reptiles, by the heat of summer.
In twenty minutes, tetanic spasms could be excited by merely touching tbe auimal, and
these spasms gradually increased in frequency and force for more than half an hour, and then
gradually declined in force, and in one hour and a half after the reptile was subjected to the
action of tbe poison, all external signs of life were extinct — the limbs and muscles were
rigid, and did not respond to mechanical stimuli. When the thorax was opened at this
lime, tbe heart was still beating slowly and feebly, twelve times to tbe minute. Tbe inter*
rupted electrical current produced but slight contractions of the muscles.
In this experiment, tbe heart appeared to survive the death of the cerebro-spinal system :
as tbe action of tbe heart was without doubt dependent upon the sympathetic ganglia within
its structures, it is evident that tbe poison exerted its most powerful effects upon tbe cerelyo«
spinal system,
Experiment 89 : Direct Action of Strychnia on Heart of Qtrcnellu Getula (Kinj
Snake),
The heart was exposed, and its action, after the excitement of its exposure bad passetl
away, was seventy-two per minute. A strong solution of the Acetate ot Strychnia was then
injected into the peri-cardium^-in four minutes the action of the heart fell to forty-eight
beats per minute, showing the loss of twenty-four beats per minute in this short period ; and
tbe respiration became spasmodic and violent, and the muscles were thrown into tetanic
spasms. The action of the ventricle was sharp, strong, and well defined, whiUt that of the
auricles was scarcely perceptible.
Some minutes after tbe application of the Acetate of Strychnia to its exterior surface, the
pulsations of the heart were only twenty-six to the minute, showing a loss during the last
thre^ miQVt?9 of twenty-two beati: tt\e^ action of the rentricle, la sharp, spasmodic an4
Experimental Illustrations of Convulsive Diseases, 299
ifoick, eomnaaieating to the fiogers which grasp it, a stroog resiatanoe, and sharp spaBmodic
feeltDg.
The eifects of Strychnine upon the mascalar fibre of the heart appear to be similar to those
upon the iDuscles generally.
In poisoning by Prassic Acid on the other hand, the heart feels flaccid, when pressed beneath
the fingers. The ventricle, especially, partakes of this relaxed flaccid condition.
In poisoning by Prussic Acid, the auricles appear to act longer than the rentricle, whilst
in poisoning by Strychnine the yentricle appears to act longer than the auricles.
Ten minates after the application of the Strychnine, the voluntary muscles of the serpent
are strongly and permanently tetanized,.and in eighteen minutes, the heart ceased its pulsa-
tions entirely, and could not be aroused by interrupted magneto-electric and galvano-electric
currents, which also excited little or no effect upon the voluntary muscles.
These experiments confirm those previously recorded, and show that Strychnia, as
well as Prussic Acid, is capable of arresting the action of the heart.
Experiment 90: Action of Cyanide of Potassium on Cjngo Snake (^Amphiumi Means) ^
June, 1862.
This reptile was immersed in a solution of Cyanide of Potassium, 6 grains to \ pint of
water; no special effects were observed for 3 hours; at the end of this time, the muscular
system was thrown into violent spasms, and the muscles of the throat appeared to be perma-
nently tetanized At the end of six hours, all signs of life were extinct. When the' heart
was exposed, it was found to be perfectly motionless, and could not be aroused, either by
mechanical or electrical stimuli. The voluntary muscles on the other band, responded
vigorously and readily to the interrupted magneto-electric current, thut thawing thai aUhough th€
powers of the heart were dettroyed^ ttiU the voluntary nutseles retained their power of reeponding to
The intestinal canal was congested with bl6od, and the abdominal cavity contained effused
blood, which coagulated, upon exposure to the atmosphere.
Coder the microscope, the blood corpuscles from the blood of the heart presented in many
cases perfect forms, whilst in some cases they presented an elongated spindle-shaped appear-
ance, instead of the usual oval form
These experiments therefore confirm those previously recorded, and clearly establish
the unportaDt physiological and therapeutic principle, that whilst two poisons may
both act upon the cerebro-spinal and sympathetic systems, and upon the muscular fibres
of the heart, they may do so in different modes and in different degrees, and that an
antidote which is applicable to one, may have no value in poisoning by the other.
We endeavored to determine whether Prussic Acid exerted a greater effect over one
portion of the cerebro-spinal nervous system, than over the remaining parts ; and to
define as far as possible the nature of the action, and whether it was direct and imme-
diate upon the ganglionic cells of the cerebro-spinal axis.
The following series of experiments were devised for the solution of these qu'sstions :
BXPBRIMCNTS ILLUSTRATING THB DIRECT ACTION OP HYDROCVANIC ACID ON THl
MEDULLA OBLONGATA.
Ths following ten experiments were performed in the month of April, 1862, at Montevideo,
Liberty, Co., Georgia:
A solution of Prussic acid was freshly prepared, of a strength equal to that of the fresh
Acidam Hydrocyanicum Dilutum, U. 8. P.
For these experiments I selected ten young alligators ( Alligator Mississippiensis ) of tbe
same age, and from the same nest.
SfectM of Pruuie Aeid admimetered by the Mouth. Experiment 9 1 . — Poa red a sol tt tion of Prnssic
acid, in amount about f5ss., down the month and throat of a small young alligator. The
rrpttle was only six inches in length, and had not left the eggshell more than a week or ten
days.
In three and a half minutes the alligator manifested signs of tbe action of the poison, in its
staggering gait and convulsive movements ; in twelve minutes, gaping and struggling vio-
lently, with spasmodic movements of the muscles ; in fifteen minutes, breathe;^ only occasion-
ally ( ooce every two or three minutes ), and then in a spasmodic manner, lies indifferently
opon the back and belly, and cannot walk ; sixteen minutes after tbe first application of the
^isoa, and one minute after tbe last observation, all motions appear to have ceased; when
300 Experimental Illustrations of Convulsive Diseases.
thrown into cold water, boweTer, it Appears to be aroused by the shock, and makes several
attempts to swim and turn on its side ; these motions ceased in a few minutes, and when
turned otw on its back in the water, it remained so, whilst an alligator whose cerebrum had
been exposed, and touched with the same solution of Prussic acid, remained vigorous and
strong. ^
Twentj-tix minutes ( ten minutes after the preceding observation ), lies as if dead, with-
out anj motion, except, every two or three minutes, a spasmodic, feeble, respiratory effort;
mechanical stimuli produced but a slight tremulous motion of the muscles, whilst irritation
of the muscles of the alligator whose cerebrum had been exposed and treated with Hydro-
cyanic acid, induced vigorous respiratory motions; in thirty minutes (four minutes after the
last observation), all external signs of life have Tanished, and the animal appears to be dead.
Thirty minutes after the application of the poison, the thorax was opened and the heart
exposed ; auricfts and ventricles greatly distended with blood, beating slowly and spasmodic-
ally forty times per minute ; fifty-two minutes (twenty-two minutes after the last observation),
action of heart twenty-six per minute ; one hundred and twelve minutes (sixty minntes after
the last observation), action of heart twenty-8ix per minute ; one hundred and eighty minutes
(sixty-eight minutes after the last observation), no signs of life in the muscular syBtem;
mechanical stimuli fail to produce contractions ; heftrt still acts in a slow, spasmodic manner ;
the blood presents a brownish, purplish color; auricles and ventricle still engorged with dark
blood ; action of heart, twenty per minute.
Two hundred and fifty-eight minutes (seventy-eight minntes after the last observatioo),
pulsations of the heart still continue, they are, however, slower and more irregnlar and
spasmodic, the rhythm of its action has been destroyed ; the auricles act continuously about
ten times per minute, the ventricle not so often. The action of the heart continued to grow
slower and slower until it finally ceased. The exact time was not noted.
Ptuuic Acid applied to Brain of AUigator, Experiment 92 : Removtd the superior plate of the
cranium of a small alligator (six inches in length), and exposed the superior suifaee of the
cerebrum without wounding the large veins and arteries. The membranes were earefally
removed from both hemispheres, so as not to injure the great central vessels running between
the hemispheres and the cerebellum.
The surface thus exposed was moistened with the solution of Prussic acid.
Four minntes after the direct application of the poison to the surface of the cerebrum, no
signs of the action of the Hydrocyanic acid; the surface of the brain was wounded, and the
poison again applied. In eleven minutes (seven minutes after the last observation), the
effects are beginning to become manifest, in a decrease of activity and life in the mascolar
motions : the reptile is still able to crawl about, and to make the sounds usually emitted by
young alligators. The blood oozing from the wounded surface of the brain presents a brilliant
crimson color.
In fifteen minntes (four minutes after the last observation,) motions spasmodic, gnsps for
breath, and emits quick, spasmodic sounds, like an imperfect bark ; these spasmodic notions
ceased in a few moments. The reptile crawled off and attempted to bite the finger when placed
before its head, and when thrown into cold water it swam rapidly. The effects of the poison
appear to be due chiefly to its absorption by the blood-vessels of the brain, and its distribn-
tiun to other portions of the nervous system, and not to a direct action upon the nervous
structures constituting the cerebrum.
The poison was again applied to the exposed surface of the cerebrum, and its structures
were again injured so that the poison might come in Immediate contact with the nervous ele-
ments. Twenty-four minutes after the first application, still able to swim, but evidently losing
power: the respiration is slow, spasmodic and irregular. In the last application, the ner-
vous structures weie more extensively injured, and the poison more effectually applied.
The forces gradually declined, and thirty-six minutes after the first application (tweUe
minutes after the last observation,) the alligator has so far lost voluntary motion that, when
thrown into cold water it remains indifferently upon the back or belly, as it may be placed ;
still breathing, but the respiration is very slow and spasmodic.
The heart was next exposed ; the act of cutting through the muscles to expose the heart
caused contractions of the various parts of the thorax and fore-limbs ; action of heart thirty-
eight per minute, more regular and active than the heart of the alligator in the preeedinr
experiment, auricles and ventricle filled with crimson blood ; forty-two minutes, action of
heart thirty-eight.
One hundred and sixty-eight minutes after first application of poison to cerebrnm (one
hundred and twenty -six minutes after last observation), the reptile has greatly recovered, and
is attempting to walk; heart beating with considerable regularity and force.
The remaining coverings of the superior and posterior parts of the cerebrum, especially
those portions of the dura-mater and arachnoid which dip down between the bemispherrs.
and between the cerebrum and cerebellum, were removed. Considerable hemorrhage ensued
from the large blood-vessels; this was wiped carefully away, and the Prussic acid again
Experimental Illustrations of Convulsive Diseases. 301
applied to the surfAce of the brain, reaching the cerebellnm (necessarily from the anatomical
relations of the membranes removed and the large blood-vessels cut), and perhaps also in small
quantities the medulla oblongata and Bpiaal cord.
The poison acted almost immediately, producing tetanic spasms; followed by cessation of
respiration and loss of muscular power.
One hundred and seventy -eight minutes after tUe first application, and ten minutes after
the last, the action of the heart was twenty-four per minute ; two hundred and fifty-eight
minutes (ninety minutes after the la^t observation), muscles still respond slightly to mechan-
ical stimnli ; heart still acts ten times per minute spasmodically. Since the loss of blood
from the blood-vessels of the brain, the heart is not so filled with blood, and continued to
diminish in size and in the frequency of action, until it ceased in about an hour after the last
observation. The precise time of the cessation of its action was nob noted.
PntMtie Add applied to Spinal Marrow. Experiment 93 : Exposed the spinal cord in the tail of
a young alligator for half an inch, commencing jtt)t below the Juncture of the hind legs, and
applied the solution of Prussic acid used in the preceding experiments to the surface of the spinal
cord ; immediate contraction of the muscles and cries of pain followed the application ;
these, however subsided, and the animal became quiet.^ No special effect was produced upon
tbe respiratory acts, except to render them fuller and somewhat labored.
Two minutes after, the poison was again applied and produced similar results — contractions
and cries of pain, and full, laborious respiration. As often as applied to the spinal cord, it
produced these effects — they are, however, evidently becoming less marked. Eight minutes
after the first application, when thrown into cold water, the reptile swims; ten minutes after
(two minutes after last observation), spasmodic attempts at respiration, gapings of the
mouth and throat, and spasmodic attempts to crawl; twenty-five minutes, limbs spasmed,
muscular powers feeble, lies in partial stupor. In thirty minutes after the first application of
the poison, all external signs of life are extinct; when the thorax was opened, however, a
convulsive motion of the respiratory muscles ensued, inflating still farther the lungs. Heart
acting regularly, contracted, and not engorged with blood ; the absence of the usual large
amount of blood in the cavities of the heart in poisoning with Hydrocyanic acid, appears to
be referable to the loss of blood which ensued from the tail, which was considerable. Action
of heart, thirty-two per minute.
One hundred minutes after the first application of the poison, the heart ceased to beat.
PruMtit Aeid applied to Spinal Marrow, Experiment 94 : Exposed the spinal cord of a young
alligator midway between the anterior and posterior extremities, and applied Prussic scid of
the tame strength as in the preceding experiments ; spasmodic contractions and motions of
the muscles and limbs were almost immediately excited. The respiration still continued, not-
withstanding several repetitions of the poison. Eighteen minutes after the application, res-
piration still continues; twenty-two minutes, still breathes slowly, although the muscles
respond but little to mechanical excitement ; at the end of forty-two minutes all external
signs of life were gone. Heart still acting fifty times per minute.
Prueaie Aeid app'.ied to Spinal Marrow. Experiment 95 : Exposed the spinal cord of a young
alligator, midway between the fore-legs and base of the brain, and applied Prussic acid —
tetanic spasms of the voluntary muscles followed, without the arrest of respiration. Fifteen
roinatcs after the application of the poison, still breathes and attempts to swim when thrown
into water; swims with the hind, but not with the fore-legs, and appears to have lost much
of the power of the fore-legs. In fifty-two minutes all external signs of life have become
extinct. Heart exposed, still acting thirty-two times in the minute.
/ViMfiV Aeid applied to Brain and Medulla Oblongata. Experiment 96 : Exposed the cerebrum,
cerebellum, medulla oblongata, and superior portion of the spinal cord of a young alligator
( Alligator Mississippiensis) — considerable blood was lost during the removal of the walls of the
cranium and vertebrae, the animal appeared exhausted, and the nervous muscular actions
appeared to be influenced by the loss of blood and the violence inflicted upon the membranes
of the brain and spinal cord ; the motions of the animal were rendered somewhat irregular
and spasmodic. A solution of Prussic acid of the same strength as that employed in the pre-
ceding experiments, was applied to the nervous structures exposed, without, however, taking
ihe preeiutioo to wipe away the blood, which was continually oozing from the divided vessels.
No immediate effect was produced, and eight minutes afterwards the alligator was still able to
«wifla with precision and vigor when thrown into water. After removing the animal from the
walerj the nervous structures were carefully wiped dry, thus removing all the blood and
water, and the poison was then applied immediately to the exposed surfaces. This last appli-
cation appeared to have a more immediate and decided effect than the previous one, and in
one minute spasms with convulsive cries were excited. Fifteen minutes after the first appli-
cation, and seven minutes after the second application, respiration was irregular, not more
than two or three times per minute, and mechanical stimuli caused but little effect upon the
voluntary muscles— 'When thrown into water, the animal lies indifferently upon the batk or
belly. In a few minutes more, all voluntary muscular motions ceased entirely. When the
302 Experimental lUustratians of Convulstue Diseases^
beari wm exposed it was beating regolarlj. aod did not present the engorged appearance of
the alligator into whose mouth and stomach the poison had been introduced.
In the present case the action of the poison produced a powerful contraction of the res-
piratory muscles, and complete expulsion of the air contained in the lungs.
In one hundred and thirty-five minutes from the first application, the heart had ceased to
beat; artificial respiration and inflation of the collapsed lungs restored the action of the heart.
During the process of artificial respiration there was a partial restoration of the irritabilitj of
the muscles. At the end of two hundred and fifteen minutes all action in the heart had ceased.
The more early extioctton of the powers of the heart, in this experiment than in the first, was
due in great measure to the loss of blood.
Prutaic Arid applied to Medulla Oblongata, Experimeni 91 : Exposed the brain and medulla
oblongata of a young alligator, and after wiping off the blood carefully applied the tolotion
of Prussic acid to these parts — in less than a minute, in fact almost immediatelyi riolent coo-
vulsiTc movements were excited, violent expiration of air from the lungs, and death in a few
moments. The lungs remained permanently collapsed and the respiratory muscles contracted.
The collapsed, contracted appearance of the thorax and abdomen was in striking contrast to
the inflated body of the alligator killed in the first experiment by the internal administration
of the poison.
Thorax opened one hundred and twenty minutes after the application of the poison; heart
had ceased to pulsate. Inflation of the lungs was followed by a renewal of the action of the
heart. The cessation of the action i>f the heart, in the two last experiments, sooner tbaa in
the two first experiments, was due to the collapsed state of the lungs, and the greater lots of
blood in the latter. In the two first experiments the lungs remained inflated, and there bad
not been any loss of blood in the firat reptile experimented on, and in the second none for
some time after the commencement of the experiment.
In the present (97th) experiment, the muscles responded to mechanical stimuli after the
institution of artificial respiration. At the expiration of two hundred and ten minutes,
alt action in the heart had ceased. On account of the loss of blood, the heart presented a
pale appearance, contracted, and with but little blood in its cavities.
Pnutie Acid applied to Medulla Oblongata. Expfrtment dS: Exposed the medulla oblongata
of a small alligator, and applied directly to the nervous structures the solution of Prosaic
acid : convulsions, suspension of respiration, and apparent death followed almost immediately.
The air was driven forcibly out of the lungs, and the respiratory and abdominal moscles
remained contracted so as to present a contracted appearance of the chest and abdomen.
The heart, exposed one hundred and twenty minutes after the application of the poisoo, had
ceased to beat; it contained little or no blood, and was pale and contracted. Inflation of the
lungs restored its action. Two hnndred and ten minutes after the application of the poison,
the action of the heart had ceased.
I'ruitic Arid appUtd to Medulla OUonyala. Experiment 99 : Exposed the medulla oblongata of
a young alligator and applied Prussic Acid — the effect was almost immediate; in one minute
the respiratiun was arrested, and the respiratory muscles permanently contracted. The ejes
winked, and the mouth gaped for some eight minutes, and even long after the tj^% and mouth
ceased to move of themselves, the eyes would wink, and the muscles of the jaw wonid con-
tract when pinched. Thirty minutes after the action of the poison, the heart was exposed —
lungs contracted, the act of cutting excited contractions in the respiratory muscles — heart
acting forty-four times per minute regularly.
It is worthy of note in these experiments, that the lungs were collapsed, and the respiratory
muscles forcibly and pcrm.inenlly contracted only when the poison was applied to the medulla
oblongata.
IVuMie Arid applied to Medulla Oblongata. Experiment 100: Removed all the skin over the
cranium and spinal column of a young alligator, and applied Prussic Acid of the same strength
as that U9ed in the preceding experiment. At the end of seven minutes the reptile still shows
signs of great activity, being able both to swim aud walk; at the end of eighteen minntes
after the application of the poison, although manifesting its effects in loss of power and irrr-
gular movements, still it swam with vigor and precision when thrown into water. The bony
wall was then removed, the medulla oblongata exposed, and the poison applied directly to its
surface ; the effect was evident in a few seconds, and whilst there were no well marked tetaoii
spasms, still the respiration ceased, as well as all voluntary motions^ When mechanical
stimuli were applied, reflex actions of the extremities indicated the existence of nervoos and
muscular irritability.
Heart exposed ninety-five minutes aftera*ards; its action was a mere tremor.
From these experiments we conclude that Prussic Acid acts primarily, directly and chiefly,
on the medulla oblongata and spinal cord; and that its ability to produce sudden death is
dependent upon its action on the medulla oblongata.
Derangements in the relations of the medulla oblongata and spinal cord to the motcnlar
Experimental Illustrations of Convulsive Diseases. 303
fyttem generallj, and especialljr to the respiratory gjgtem, are the first pheoomena manifested
in the action of Prnsiic Acid.
When absorbed from a raw surface, or from the stomach and bowels, these phenomena are
maoifMtvd, as well as upon the direct application of the poisoo to the medulla oblongata, but
mora slowly. In warm-blooded animals death takes place almost immediately after the
admioistration or inhalation of the poison ; still, when taken by the mouth, a sufficient time
always elapses for the absorption of the poison and its distribution to the great nerfous
centres. As soon as the poison in the blood reaches the medulla oblongata and spinal cord,
conTaUive motions are excited, and if the impression be sufficiently intense there is an imme-
diate arrest of the action of the ganglionic cells presiding over the respiratory process, and
immediate death follows.
In the young alligator the cartilaginous walls of the cerebro-spinal nervous system can
readily be removed by the knife, and we are thus enabled to apply the poison to successive
portions of the nervous system, and thus demonstrate the immediate and direct action of the
poison upon that portion of the cerebro-spinal nervous system which presides over respiration
and the reflex actions.
Prussic Acid, as we have satisfactorily demonstrated by numerous experiments, acts also
on the blood, and on the muscular fibres and the sympathetic nervous system ; but, as
bag becQ conclnsively demonstrated by the experiments just recorded, the most marked pheno-
mena, nnd those disturbances of the respiration which induce death, are due to the direct
action of the poison on the medulla oblongata.
BXPEBIMENT8 ILLUSTRATING TUB ACTION OF PRUSSIC ACID ON BIRDS.
Experiment 101. Several drops of officinal Prussic Acid were placed in the mouth of a
large, active pigeon, in the month of January, 1860. The effects of the poison were manifest
ID 10 seconds; trembling of all the muscles; puffing up of the feathers; irregular action of
the heart, and insensibility, and finally death in 75 seconds after the application of the
poison.
Efeds of ikepoiMon upon the Animal Temperature : Temperature of the atmosphere, 13^.3 C,
56® F. Temperature of rectum of pigeon, 40® C, 104® F.
The temperatare remained stationary during the action of the poison, and then commenced
to descend immediately after death, and stood at 32° C, 89°.6 F., one hour and five minutes
after death.
Loss of temperature during 65 minutes after death, 8° C, l4o.4 F.; loss of temperature each
Dinate after death, 0®.123 C, 0®.221 F.
p6at-mortem Examination^ 30 minutes after death, ila^morrlmgc had taken jilace from all
Ibote portions of the mucous membrane of the mouth and throat, with which the poison had
come in contact. The vapor of the Prussic Acid had also acted locally upon the skin, around
the month, and upon the neck and chest; in those regions the skin presented a highly con-
gested appearance, and in spots the* blood appeared to have been locally effused. lUood-vcs-
•els of brain and spinal cord, not specially congested with blood. Muscles presented a darker
color than usual in healthy birds. Blood of heart and blood-vessels generally dark, purplish,
almost black; but changed to the arterial hue upon exposure to the atmosphere, and
coagolated readily. Veins of intestines and liver distended with blood.
Experiments 102, lOS, 104, Wo.
RepeiitioD8 of precedtDg Experiment, (101) on the action of Prussic Acid on birds,
remits rimilar to those just recorded.
Experiment 106: to determine whether any agent acts rapidly as a stimulant to the
Heart and Nervotis System in Birds. Action of Chlorine on Piyeons,
The Chlorine was administered by inhalation. After the first inhalation, the effect of the
Chlorine was immediate and well marked, quickly increasing the action of the heart, both in
force and frequency, exciting violent struggles, and causing a rapid rise in the temperature,
which in 5 minutes rose from 41®.a C, 107®.4 F, to 42°.5 C. 108®.5 F.
The inhalation of the gas occupied only a few seconds, the mouth of the bird, was simply
held OTer the month of the receiver containing the gas. After the removal, the temperature
of the body continued to rise for 5 minutes, then remained stationary, and finally commenced
to descend until it reached the same degree before the experiment. The action of the heart
fell in force and frequency, with the fall of the temperature. The bird was again subjected to
the action of the Chlorine Gas— as soon as it was inhaled, the action of the heart which had
subsided with the fall of the temperature, immediately increased with renewed force and the
temperatttr^ COWiWCAced also to rise, and in 2 mioates rose from 4l®.0 C, 107®.4 F,, to 42®.2
304 Experimental Illustrations of Convulsive Diseases.
Cy 108^ F.; at tbe end of this time which was jost 9 minates from the first action of the gas,
the bird gave a Tiolent straggle and died. Tbe intelligence of the bird did not appear to be
affected, antil near death. As soon as death took place, the thermometer in the rectum, after
remaining stationary commenced to descend, and in 50 minutes after death, stood at 36^ C,
96*^.8 F. Loss of temperature, in 50 minutes after death, 6^.2 C, 11^.3 F.; loss of tempera-
ture each minute 0*^.124 C, 0<'.224 F.
The Chlorine Gas appears to have produced death by its alterations of the blood chiefly,
and secondarily, by its direct action upon the nervous structures.
The lungs were completely altered in appearance, presenting a dirty-brownish color, far
different from the bright scarlet color characteristic of tbe lungs of birds.
The blood in the vessels of the brain, and in all parts of the body presented similar
alterations.
The prcocdiDg Experiment dcniuDstratcs that Chlorine acts as a stimukuit upon the
heart of Birds.
ExperimetUi 107, 108, 109, 110,
Repetitions of the preceding experiment (106,) illustrating the action of Chlorine
upon birds : results similar.
The truth of the preceding conclusions with reference to the action of Pmssic Acid
and of its antagonist or antidote, Chlorine, upon cold-blooded animals, is thus established
for birds.
EXPERIMKNT8 ILLI'STRATING THE ACTION OF BYDROCTANIC ACID AND CYANIDE
OF POTAS8IUM ON WARM-BLOODED ANIMALS — MAMMALIA.
Experiment 111 : Action of Hjfdrocyantc Acid on Dog,
Haifa fluidounce of tbe officinal solution of Pmssic Acid was poured upon the tongue and
lips of an active cur dog.
In thirty seconds, slight eifects upon the respiration were perceived, and in the eoorse of
fire minutes, the respiration became labored, the thorax was dilated to a much greater extent
during inspiration than in health, whilst at the same time the action of the heart was ren-
dered slower* and the tongue and mucous membrane of the mouth assumed a bright red,
highly congested appearance. Half a fluiddracbm of the officinal solution of Prosaic Acid
was again introduced within the mouth and nostrils. In a few seconds, the dog emitted
cries of great uneasiness, the respiration continued to become more labored and slow — tbe
action of the heart diminished in frequency, and became more and more irregular and spas-
modic, giving sharp, quick impulses to the band placed against tbe thorax — the muacles
became spasmodically convulsed — during inspiration, there was a spasmodic contraction of
the muscles of the neck and face.
Fifteen minutes after tbe administration of tbe poison, the heart beat twenty-four times
per minute — the respiration was very slow, labored and spasmodic — pupils dilated — tbe inicU
lectoal actions of tbe brain appeared to be suspended : strong spasmodic contractions of tbe
muscles, as strong as those produced by Strychnine. Tbe saliva continued to flow in lajge
quantities from the mouth. The increased secretion of saliva bad commenced immediately
after the administration of tbe poison, and it is important that we should nota in paaaiag.
that a similar result was produced upon the skin of tbe Siren Lacertina, by tbe locsJ action
of Prussic Acid.
At this stage of the ciperimeut, strong aqua ammonia and chlorine gas were passed alter-
nately under tbe nostrils of the dog : these agents exerted marked effects upon the dog, and
although he was not aroused from the state of coma, and apparent insensibility, still the
respiration and the action of the heart were both increased and life was prolonged.
Twenty-five miniitr? after the first administration of tbe poison, tbe heart was still beating
vrry slowly, and the respiration was still slow and spasmodic.
The rrsptration and the action of the heart ceased, thirty-six minutes after the adaiaistra*
tion of the p<>t<on. The respiration erased before tbe action of the heart.
FfrctM vpfin fA/ Antnrni Ttrnprrahtrt : Temperature of the atmosphere 12®.7 C, 55® F. Te»'.
perature of the rectum of the dog. before the administration of the Prussic Acid, 38^.8 C.
10l«.H.% K.
This dog was rather thin, and was not ^ery vigorous, and its condition may accoant for %
diminution in the bodilv temperature.
Experimental Illustrations of Convulsive Diseases. 305
The temperature of the rectum remained stationarj for tea minates after the admioistration
of the poison, and then slowly descended, and at the moment when the heart and respiration
ceased, it was 37*^.5 C, 90^.5 F: thus, during the last twenty-six minutes of life, the tem-
perature fell P.3 C, 2''. 35 F. After death the temperature of the rectum continued
to descend, and in twenty-eight minutes, stood f^t 36® C, 96^.8 F. ; loss of temperature
during twenty-eight minutes following death, 1^.5 C, 2^.7 F. : loss of temperature each
minute after the action of the poison, up to the moment of death, 0°.05 C, 0.0903® F.; loss
of heat each minute after death, 0.0535® C, 0.0964® F.
1\>9l'mortem Examination : Thirty minutes after death, blood-vessels of the dura-mater,
' aracboid membrane, pia-mater and brain filled with dark, purplish, black blood. Blood-ves-
sels of the membranes of the spinal-cord in like manner, filled with dark blood. Cerebro-spinal
fluid abundant. The blood-vessels of the base of the brain, and of the membranes covering
(his portion of the brain, and the blood-vessels of the membranes and structures of the
anterior portion of the spinal cord were more distended with blood, than the superior, and
less dependent portion of these respective structures. This difference in the distribution of
the blood, was without doubt due to the effects of gravitation.
The structures of the brain and spinal cord appeared to be altered neither in appearance
oor consistency. There was a tendency, in some parts, to the exudation of blood through
the walls of the blood-vessels ; this tendency was not, however, so marked, neither were the
vessels of the brain and its membranes so congested with blood as 4n a case of poisoning by
Cyanide of Potassium, which will be subsequently recorded.
The blood of the brain and spinal cord, although presenting a dark, venous hue when the
structures were first exposed, rapidly, after the removal of the skull-cap and membranes,
absorbed oxygen, and changed to the arterial hue ; this change was first evident in the
mioute ramifications of the vessels. The muscles of the body, on the other hand, did not
appear to be as full of blood as in dogs killed by mechanical means.
Lungs not congested, but normal in appearance. The auricles and the right ventricle of the
heart, the pulmonary arteries and veins, the vena-cava, and all the large venous trunks were
distended with dark blood. The right auricle and ventricle of the head were distended to
their utmost capacity with dark, almost black blood. The aorta and the arteries of all parts,
contained bo blood, and the capillaries of the muscles appeared to be almost entirely devoid
of blood.
Strong, electro-magnetic and magneto-electric currents (Interrupted) failed to excite any
contraction in the fibres of the heart, whilst the muscles of locomotion and volition generally
responded to the electrical excitement.
The veins of the stomach and intestines, even in their minutest ramifications, were dis-
tended with black blood. The mucous membrane of the stomacl\ was, in some portions, con-
gested with blood, and there were several dark purplish spots more strongly congested. The
ftomach contained matters in process of digestion, and this fact may account for a portion at
least of the increase of color.
The mucous membrane of the smnll intestines presented a normal, healthy appearance, and
was not congested. The portal vein was distended to its utmost capacity with black blood.
The liver was congested with blood, and presented a very dark purplish color, from the
engorgement of its portal and hepatic system of veins with dark purple, almast black blood.
When cut, the dark blood streamed from the surfaces. The kidneys presented a dark slate
purplish, almost black color, and when cut, the blood, in like manner streamed from those
organs.
Whilst the veins of the spleen were filled with blood, there was no especial enlargement of
(be organ, neither was any blood effused into the cells of the spleen, as in malarial fever.
When drawn from the vessels after death, the blood coagulated in less than one minute. The
coagnlum was soft, and there was a tendency in the colored blood corpuscles to separate
from tht fibrin, and to fall to the bottom of the vessel, and thus color the serum.
Toder tbe microscope, many of the colored blood-corpuscles presented stellate forms.
Cadaveric rigidity had not taken place two hours after death.
In the preceding experiment (111), the congestion was venous. The accumulation
of the blood in the lar^^e venous trunks appears to be due to several causes, as the loss of
power in the muscular structures of the lieurt, and especially in the right ventricle and
right and Icfl aoriclcH, and the spasmodic tetanic contractions of the muscles.
The appearance of congestion in tho veins of the brain, spinal cord and membranes,
was due to the same causes which produced venous congestion in the liver, stomach
and organs, it being evident that the venous iH)ngoBtion was not confined to any organ,
or any special portion of the nervous system, It would, therefore, be unwise to refer the
death of the fti^imal to the congestion of the cerebrorspinal nervous system, Doath
306 Experimental Illustrations of Convulsive Diseases.
appeared to have been caused by the action of the poison upon the ganglionic cells of
the oerebro-spinal and sympathetic system, and especially upon the potential elements of
the medulla oblongata, and of those ganglia regulating the vaso-motor system of nerres
and the lythmical action of the heart.
Experiment 112 : Action of Frussic Acid on powerful and fierce Bull Dog,
A sirong golutioa of PrusBic Acid was placed upon the eyes, lips and nose of a powerful
buU dog. In A few minutes the dog struggled violently, acted as if in a great rage, attempted
to rush at those around, bis tongue appeared to become rapidly of a brilliant scarlet bue,
and presented a swollen appearance ; then succeeded piercing cries, and violent spasmt, and
finallT death in fire minutes after the first application of the poison.
Post-mortem examination 17 hours after death : Cadareric rigiditj well marked.
The blood-Tessels of the brain and its membranes were not congested with blood. 'Spinnl
cord examined throughout its entire length ; structures and blood-Tessels normal in appear-
ance ; neither the vessels of the cord nor of its membranes presented any unusual congestion.
Careful comparisons were instituted with the colored drawings, previously executed, of the
nervous structures and organs of various animals destroyed by mechanical means and by
various poisons.
A careful and Uborious examination was made with the microscope, of the structures of
the cerebro- spinal and sympathetic nervous systems ; but no alterations were revealed which
could be referred to the special action of the poison.
The lungs were congested ; the right lung was more congested than the left, and presented
a dark, purplish slate color. The right lung also presented some spots of marked congestion,
which appeared of a deep purple color.
The cavities of the heart contained dark coagula of blood. When the uncoagulated blood
was removed from the cavities of the heart it coagulated into a firm clot, and absorbed
oxygen, and changed upon the surface to a bright arterial hue.
The right auricle and ventricle of the heart contained long, slender, white worms, several
inches in length, which resembled in all respests the worms from the cavities of the hearts of
dogs, which I presented in 1855 to Dr. Joseph Leidy, Professor of Anatomy in the University
of Pennsylvania, and described by him in the Journal of the Academy of Natural Sciences.
Several of these worms extended from the heart into the pulmonary artery. These parasites
bad been killed by the Prnssic Acid.
When the abdominal cavity was opened, a most disgusting and overpowering g»s
issued, having an odor of Prussic Acid and Sulphuretted Hydrogen. I have observed simi*
lar gases in the abdominal cavity of dogs poisoned with Cyanide of Potassium, as well as
with Prussic Acid.
The blood vessels of the small and large intestines and stomach were distended with dark
blood, and the whole exterior surface of the stomach and iutestines presented a dark red and
purplt color, as if the coloring matter of the blood had escaped from the vessels and pene-
trated the structures. The peritoneum was colored in a similar manner. Both the perito-
neum and lungs contained deposits of melanotic matter. The mucous membrane of the
stomach and intestines presented a reddish, purplish color. Liver and kidneys greatly cob-
gested with blood. The blood corpuscles did not present any changes of sufficent importance
to be noted.
Experiment 113: Action of Prussic Acid on a (arge^ malt Hound Dug.
This dog, although active and endowed with a ravenous appetite, was lean, and could not
be fattened even by the most generous diet. This dog also emitted an unpleasant smell, cha-
raotaristic of that of dogs, suffering with worms in tlie cavities of the heart. I have found
worms in the hearts of several dog^, who presented similar symptoms, and emitted similar
odors; and in the present case, I was led to predict the presence of worms in the beart befon*
death.
An incision was made into the skin of the hind leg, in the region of the knee, and abuut
two fluiddrachms of a strong solution of Hydrocyanic Acid were injected into the sobcu>
taneons cellular tissue. After the removal of the nozzle of the syringe, a considerable portion
of the solution of Prussic Acid poured out. About one to two drops of the .\nhydrous An<ft
(that IS an amount of the solution corresponding to this quantity) were retained.
The dog was staqc|ing when the poisoa was injected ; in one minute there were evident
signs of its action; \a two minutes there was trembling and twitching of all the musclrf.
spasms, then inability to stand up, i\nd in a few moments more, loud bowling followed by
piteous whining ; during the tremb\i^g twitchings and spasms of the muscles, the themometf r
in tM rectum rose O^O^. (7, Tt^ spasms and he.wUne and vhinUig, were succeeded in '«
Experimental Illustrations of Convulsive Diseases* 307
niaBtes bj profoaDd coma ; 15 miDates after the injection of the poison, the dog still lies in
a profound coma, respiration labored (inspirations Terj full, thorax dilated to its utmost
in a spasmodic manner, expiration violent, forcing out almost all the air; and attended bj a
peculiar spasmodic motion of the diaphragm and abdominal muscles, giving a flattened
appearance to tlie abdomen, and only two per minute; pulsations of heart 120 to 160 per
minute, quick and spasmodic; action of large arteries beating with a quick spasmodic motion,
as if they would leap out of the surrounding flesh. The temperature remains stationary.
One minute after the close of this observation, and l&juinates after the injection of the
poison the heart ceased to beat, the respiration having ceased a short time, about 20 seconds
previous to the cessation of the action of the heart. If we date the death of this dog, at
the moment of the cessation of the action of the heart, then the poison destroyed life in 16
minntes.
EffeeU on ikt Temperature. Temperature of atmosphere 21® C, 69.8° F.; temperature of
rectum 39^.5 C, 103^.1 F. During the spasmodic struggle of the dog, there was a slight
rise in the temperature of the rectum amounting to 0^.05 C. At the moment of death the
thermometer indicated 39^55. C. 103^.2 F. During the last ten minutes of life the ther-
mometer remained stationary. The thermometer in the rectum remained stationary for 15
minntes, after the cessation or the action of the heart, moment of death ; and in 20 minutes,
35 after death, indicated 38^.75 0. 101^.8 F. Temperature of rectum 70 minutes after
death, 35 minutes after last observation, 37° C. 98.6; 130 minutes after death, 34°.9 C,
fU°.8 F.; 140 minutes after death, 34.66'' C, 94°.4 F.; 240 minutes after death, 3I°.8C., 80°.3
F.
Loss of temperature each minute after death during the first 15 minutes, 0°.0 C; during
the following 20 minutes 0°.04 C; loss during the 35 A)llowing minutes, 0°.05 C; during 60
following minutes, 0°.035 C; during the 10 following minutes, 0°.024 C; during the 100 fol-
lowing minutes, 0.0286° C. per minute.
Loss of temperature each minute, during 240 minutes after death, 0°.03229 C.
Poei-moriem Examination: 240 minutes after death, ri^or-mortis well marked. Powerful
interrupted magneto-electric and eIectro-roa(;netic currents produced no effect whatever upon
the muscles.
Dora-mater, adherent to cranium. Brain not congested with blood, and it presented a pale
anxemic appearance. Spinal cord in like manner not congested with blood, but pale and
ansemic. Careful microscopical observations, showed no alteration which could be referred
to the action of the poison, either in the white or gray substances of the cerebellum, medulla
oblongata and spinal cord. Upon the exterior the sympathetic presented the usual appearance
of health, without any alterations which could be referred to the poison. No alterations
which could be referred to the action of the poison could be found by the microscope, either
in the nerve fibres or in the ganglionic cells.
The right turicle and ventricle of the heart contained numerous slender white worms,
many of which were four inches in length.
The cavities of the heart just mentioned, contained also coagulable blood and a fibrinous
concretion, which was entangled with the worms, and the carnec colnmnc and chordsB
teodiaesB, and which from its structure was without doubt, formed before death. Lungs not
coogeaied. The intestines and stomach both upon the exterior and upon the internal mucous
•arfacc, presented a normal non-congested appearance, which was in striking contrast to
the ajfpearance of the intestines of the dog examined after long periods had elapsed after
death.
The veins of the stomach and intestines were distended with dark, almost black blood, and
appeared to be filled almost to bursting with blood. These viscera were set aside, and in the
coarse of 24 hours the blood or rather its coloring matter, passed into the surrounding tissues,
aod discolored them, so that they presented the peculiar congested appearance of the intes-
tines in the previous cases.
This fact is interesting, in showing the effects of time alone upon the appearance of viscera,
and the consequent necessity to estimate correctly post-mortem changes. Blood-vessels of
liver and kidneys filled with dark blood. The blood contained numerous active larvsB of the
worms which had not been affected by the poison. The colored blood corpuscles were not
altered from the normal appearance.
Experiment 114 : Action of Prussic Acid on large ^ male Cat,
Several drops of a strong solution of Prussic Acid were placed upon the tongue of this
aaimal — the effects were manifest in a few moments, and at the expiration of 3 minutes, the
reapirmtion and action of the heart bad ceased. Aftor death, the cardiac rigidity was slow
and imperfect, forming a striking contrast to cats killed at the same time with Strychnia. The
blood coagulated perfectly a few moments after its abstraction, both before and after death ;
the clot was firm, and the separation of clear serum well marked. Under the microscope tome of
308 Experimental Illustrations of Convulsive Diseases.
the colored blood corpatcles preseated altered appearances, assaming stellate forms ; this
change however in the colored corpascles is not characteristic of the action of Prussic Acid,
as I baye seen it in the blood of healthy cats as well as in the blood of animals destroyed by
rariotts poisons.
This experiment was performed in winter, and the blood remained without any signs of
pntrefaction, for several days.
One hour and a half after death, the muscles responded feebly to the action of the inter-
rupted electric current. The blood-yessels of the brain were filled with dark blood. Careful
microscopical examination failed to detect any characteristic alterations in the brain, spinal
marrow or sympathetic system, which could be referred to the action of the poison.
Lungs not congested with blood, except in the dependent portions.
BIood-Tcssels upon the exterior of the stomach and intestines engorged with blood ; mucous
surface not specially discolored. Blood-vessels of liver filled with dark blood.
Experiment 115 : Repetition of preceding Experimeni$ on several Cats, Pntuic Acid
administered by the Mouth and by Sub-aUajieous Injections.
The results corresponded in the main, with those just detailed; no uniform effects wer«
observed after death in the cerebro-spinal or sympathetic systems, which could be referred to
the action of the poison. The blood-vessels of the alimentary canal, were uniformly eoo-
geated with blood. Both the external and internal surfaces of the intestines were examined
immediately after death ; presented a normal color without any discoloration from the color-
ing matter of the blood corpuscles. If the examination was delayed for many hours, then
the intestines and stomach presented a reddened appearance as if the poison had produced an
intense inflammation accompanied by an effusion of the altered coloring matter of the blood
into the surrounding tissues.
These changes were clearly referable to causes acting after death.
In the majority of cases, the blood-vessels of the liver were filled with dark blood, this
condition however was not uniform. Whenever the poison entered the stomach, it produced
a reddish, inflamed appearance of the mucous membrane, and the lips and tongue, with which
the poison came in contact, changed also to a more brilliant red during life.
Experiments 116, 117, 118, 119, 120, 121, 122, 123, 124, ^-^.- RepetUion of prece^U
ing Experiments toith Prussic Acid upon various warm-blooded animals — ( Cats^
Dogs, Rats, Rabbits, Guinea Pigs, etc.) ttith similar results.
The points which we wished especially to establish at this stage of the inquiry, were :
1st. Does Prussic Acid exert any special effect upon the action of the heart in the
Mammalia ?
2d. Is there any other poison which is capable of arresting the action of the heart ?
3d. If Piiissic Acid arrests the action of the heart, is there any agent, or remedy,
capable of counteracting the direct action of Prussic Acid on the heart.
We ha?e before demonstrated that Prussic Acid acts directly on the heart ii^ cold-
blooded animals, independently altogether, of any influence transmitted through the
oerebro-spinal nervoUs system ; and that Chlorine acts as a stimulant to the heart and
tends to counteract the action of the Prussic Acid on the heart, and also that Chlorioe
acts as a stimulant to the cerebro-spinal and sympathetic nervous and muscular systcmit,
and in virtue of this action also tends to counteract the action of Prussic Acid.
The ends of the present inquiry, therefore, are similar to those of the previous experi-
ments upon oold-blooded animals.
In attempting^ to determine whether Hydrocyanic Acid exerts any special and direct
effect upon the action of the heart in warm-blooded animals, it was necessary, aa in the
case of the cold-blooded animals, to determine first, the relations of the heart to the
cerebro-spinal nervous system. It is a matter of importance to determine whether the
sudden destruction of the brain and spinal-marrow in warm-blooded animals, will exert
any effect upon the action of the heart. If Hydrocyanic Acid suddenly arresta the
functions of the brain. and spinal cord, and, if the action of the heart is at the same
time arrested, it is highly important to determine which was affected first? whether
one was affected and not the other ; whether the death of the brain and spinal-manow
was caused by the death of the heart ; or whether the death of the heart waa canaed by
Experimental Illustrations of Convulsive Diseases, 309
the death of the cerebro-spinal system , or by the death of the sympathetic system ; or
by the direct action of the poison on the fibres of the heart ; or by the action of the
poiaon on the blood.
The first point in this inquiry is to establish the relations of the heart to the brain
and spinal-marrow, and to the sympathetic system. In endeavoring to discover these
hidden and complicated relations, it was necessary to examine, and compare, and analyze
the experiments of various physiologists, who have controlled the opinion of the pro-
fession. We shall present merely an outline of the results of this inquiry.
RELATIONS OF THE ACTION OF THK IIEAKT IN WARM-BLOODED ANIMALS TO THE
CEREBRO-SPINAL AND SYMPATHETIC NERVOUS SYSTEM.
We have prepared the way for the consideration of this branch of the inquiry, by the
previous consideration of the relations of the action of the heart in cold-blooded animals
to the oerebro-spinal and sympathetic nervous systems, and the principles then estab-
lished apply with equal force and truth to warm-blooded animals ; as however, the
phenomena of life are more complicated, less general, and more restricted in warm-
blooded animals, the establishment of correct principles by experiments, is apparently
more difficult.
Numerous facts showing the independence of the brain, uf the action of the heart,
and even of the voluntary muscles in warm-blooded animals, have been accumulating
for oeoturies past. The Emperor Commodus is said to have amused himself by cutting
off the hearts of ostriches, running in the circus, with arrows in the form of a crescent.
The loss of the brain did not prevent the birds from running as before, and they only
stopp^ at the end of the course. Lametrie, and other physiologists, obtained similar
results, with decapitating various birds. Franciscus Antonius Cattus affirmed in 1557,
chat be could easily prove by experiment, that if all the other parts of the brain be
wounded, death is not a natural consequence thereof; yet when the posterior ventricle
is wounded, the animal immediately falls down and dies. Coiterus, sixteen years afVer
C*«ttu8, states that afler laying open the brains of various animals, he had wounded them in
various ways, and even removed the entire brain, without destroying the voice, respira-
lion or other signs of life. Peyron, Petit, Beningerus, Borelli, Morgagni, and others
have recorded observations of severe injuries of the brain in man, which were not imme-
diately fatal. Morgagni aUcr exposing the brains of two cats, removed the cerebrum
by suooessive slices. The destruction of the cerebrum did not destroy the motion and
seosation. Destruction of the cerebellum and upper portion of the spinal cord, were
attended however by immediate loss of motion, and of all the functions, except that of
the heart, which continued to beat as before, even af\er the complete removal of the
head, and even pulsated several times afler its complete removal from the body. Mor-
pagoi on Diseases, Vol. iii, p. 149. We have before referred to the experiments of
Vesalius and Hook, on Artificial Respiration.
The opinions of Haller, with reference to the action of the heart, appear to have
been founded on a careful study of both the anatomical structures and physiological
functions and relations of the heart. Afler describing the muscles and mechanical
actions of the heart, Haller affirms that the muscular fibres of the heart, like other
moflcles, are furnished with numerous nerves of their own of various origin ; and then
proceeds to enumerate the various nerves supplying the heart.
Haller, after giving the opinion of eminent anatomists, that these nerves conduced
powerfully to the motion of the heart, based upon the consideration of the common
nature, and supported by the increase of motion in the heart on irritating the eighth
pair of nerves, or brain, or spinal marrow, and from the fatal effects of tying these
nerves, affirms that something else is comprehended in the cause of the action of the
heart besides nervous influence, because the motion of the heart remains undisturbed
in tile living animal afler excessive irritation of the nerves, b&cause the action of the
heart continues afler the most extensive wound.s of the head, and even of the cerebellum
310 Experimental Illustrations of Convulsive Diseases.
and medulla spinalifl, because the action of the heart continues even when it is torn ont
of the body, and can be excited in moribund, and even in apparently dead animab, by
various stimuli, and the fibres of a dissected heart contract when no longer supplied
with either nerve or artery. From these facts, and others, Haller concludes that there
resides in the fibres of the heart a power of acting when excited by the proper stimuli,
and that the irritability of the fibres of the heart was similar to that of all the muflcles,
differing only in degree, and remaining longer in the heart than in any other part of the
body, so that by stimulating it, the motions of the heart may be renewea at a time
when that of no other muscle can. This mobility then is inherent in the heart, and is
neither derived from the brain nor the soul, since it remains in the dead animal, and in
the heart when torn out of the breast, and cannot be accelerated or retarded by volition.
Elements of Physiology, pp. 42—45.
The following important experiment, demonstrating the independence of the action
of the heart of any nervous influence transmitted from the brain and spinal Marrow,
was performed by William Cruikshank, in 1795 :
<* By detaching the scapula of a dog from the spine and partly from tfaaribs, I got at the
azillarj plexus of nerves on both sides, from behind. I separated the aiieries and veiof from
the nerves, and passed a ligature under the nerves close to the spine. I thought I coold dis-
cover the phrenic nerves, and instantly divided two considerable serves going off from each
plexus. The action of the diaphragm seemed to cease, jijid liie abdominal moscles became
fixed, as if they bad been arrested in expiration, the belljr appearing contracted. His rMplra-
tions were now 25 in a minute, the pulse beatioj^ 120. As I was not willing to troat the
experiment to the possibility of having divided •aljr one of the phrenics, which I afterwards
found was really the case, and some diffeeent nerve instead of the other, after carefully
attending to the present symptoms, F divided all the nerves of the axillary plexus on each
side. The ribs were now more elevated in the inspiration than before ; respirations were
increased to 40 in a minute, the pulse still beating 120 in the same time. Finding that rtapira-
tion went on very easily without the diaphragm, in about one-quarter of an hoar after
dividing the axillary plexus on each side, I divided the spinal marrow between the last ver-
tebra of the neck and the first of the back. The whole animal took the alarm, all the flexor
muscles of the body seemed to contract, and instantly to relax again ; he died as soddealy as
if the spinal marrow had been divided in the upper part of the neck. I then opened the chest,
and found that the heart had ceased its jnotioo ; I immediately introduced a large blow-pipe
into the trachea, below the cricord cartilage, and inflating the Inngs, imitated rtapiratioa.
The heart began to move again, and in about three minutes was beating 70 in a minute. I
recollected that there was still a communication between the brain and the thoracic and
abdominal viscera, that the par-vagum and intercostals were entire, and turning to the caro-
tids, divided the nerves. I then went on inflating the lungs as bafore ; the heart, which bad
stopped, began to move again, beat 70 in a minute, and continued to for nearly half an hoor
after the animal had seemingly expired. These appearances were not confined to the neigh-
borhood of the heart ; one of the gentlemen who assisted me, cried out once that he felt the
pulse in the groin. I now ceased to inflate the lungs, and presuming that I could easily
reproduce the heart's action, allowed three minutes to elapse. On returning to inflate the
lungs, 1 found the heart had lost all power of moving, and that irritating the external snrface
with the point of a knife did not produce the smallest vibration. I then irritated the phrenic
nerves with the point of a knife ; the diaphragm contracted strongly as often as the nerves
were irritated. I irritated the stomach and intestines, which also renewed their peristaltic
motions. 1 then irritated the par vagum and the intercostals, about an inch above the lower
cervical ganglion of the intercostal ; the oesophagus contracted strongly through its wholt
length, but the heart continued perfectly motionless." — Phil. Trans., vol. Ixxxv, p. 177.
This experiment by William Cruikshank, oonfirmed those previously made by John
Hunter, (Phil. Trans., vol. Ixvi, read March 2lst, 1776), in which he recovered ani-
mals by inflating the lungs, and on which his method of recovering drowned p«K>plv
principally rests, and it removed the objections which might be raised that the atiimaU
on which Hunter experimented, had the connection with the brain entire, as the par
vagum and interctwtalfl were not divided.
John Hunter was led by his profound and extensive investigaUous in oompaimtivr
anatomy, to the imp<irtant observation, that in certain animals the heart is not iieice»>
sary to the circulation nf the bltxKl. and that it is even absent in many aniniaL
Experimental Illustrations of Convulsive Diseases, 311
which possess organs of generation. Hunter regarded the heart as a truly mechanical
engine :
"For althoagh muscles are the powers iu an animal, yet these powers are themselves often
coDTerted into a machine, of which the heart is a strong instance ; for, from the disposition
of ita maseolar fibres, tendons, ligaments and rmlves, it is adapted to mechanical purposes,
and this coDStmction makes it a complete organ or machine in itself." — Treatise on the Blood
and Inflammation, 1793.
Xavier Bichat, in his work on ^* Life and Death," 1799, held that no direct influ-
ence is exercised hy the brain over the heart, which, on the contrary, is immediately
dependent, with regard to its operations, on the movement communicated to it by the
blood. Bichat attempted to sustain this proposition by the facts, that : 1st, all violent
irritation of the brain produces either partial or general convulsion in the muscles of
animal life, but no such effect upon the muscles of organic life ; 2d, all compression uf
the cerebral mass has ordinarily the effect of paralyzing the voluntary muscles, but so
long as the aifection does not extend to the respiratory muscles, the action of the heart
is in no degree diminished ; 3d, Opium and Wine, when taken in a certain quantity,
diminish the cerebral Energy, and render the brain unfit for the functions of the animal
life, the action of the heart, on the contrary is increased ; 4th, in palpitation and the
different irr^pilar movements of the heart, it is not observable that the principle uf
these derangements exists in the brain ; 5th, the numerous phenomena of apoplexy
and epilepsy, concussion, etc., do all of them certainly tend to show how independent
the heart is of the brain ; 6th, every organ which is subject to the direct influence of
the brain, is, for that very reason, an organ of volition : the heart, on the contrary, is
not subject to the volition. Bichat endeavored to establish the independence of the
actions of the heart from those of the cerebro-spinal system, by the following experi-
ments:
1st. If the brain of an animal be exposed and irritated, either with mechanical or chemi-
cal agents, a variety of alterations will indeed be produced in the organs of the animal life,
bat none in the heart so long as the muscles of the breast continue to perform their fane-
tioos.
2d. Experiments made in the same mauner upon the spiual marrow of the neck, ]iresent
the lamt resnlts.
If the eighth pair of nerves be irritated, the movements uf the iieart will not be accelerated ;
tbcj will not be arrested if these two nerves be divided. In all these experiments, however,
we nast be cartful to make a proper distinction between the emotions and passions of tiie
animaly and what it really suffers from the experiment.
4th. The nature of the great sympathetic nerve is supposed to be known ; now, if the
same experiments be made on the cardiac branches of the nerve, as were made upon the
eighth pair, the same results will follow.
Sir B. C. Brodie, in the series of experiments which he instituted, to ascertain how
far the ioilaenoe of the brain is necessary to the action of the heart, found that when
an aniiDal was pithed, by dividing the spinal marrow in the upper part of the neck,
respiration was immediately destroyed, bat the heart still continued to contract, circu-
lating dark colored blood, and in some instances, from ten to fitWn minutes elapsed
before its action had entirely ceased ; when the head was removed, the divided blood-
veasels being secured by a ligature, the circulation still continued, apparently unaffected
by the entire separation of the brain ; when artificial respiration was instituUHl in the
beheaded animals, the heart continued in some instances U) contract for two hours,
with apparently as much strength and frequency as in a livin^; aninial. Fnmi these
rxperiments, Sir Benjamin Brodie concluded, that '* The influence of the brain is not
necessary to the action of the heart ; and that when the brain is injured or renioviHl,
the action of the heart ceases only because respiration is under its influence, and if,
onder these circumstances, respiration is artificially produced, the circulation will still
wmtinue."— Phil. Trans., 1811, pp. 8t>-48.
Sir Benjamii^ Brodie, froni his experiments upon the action of Alcohol, concluded
912 Experimental Illustrations of Convulsive Diseases.
that the Bjmptoms prodaced by a large quantity of spirits taken into the stomach, arise
entirely from disturbance of the function of the brain ; the complete insensibility to
external impressions ; the dilatation of the pupil of the eye, and the loss of motion,
indicate that the functions of this organ are suspended ; respiration, which is under \U
influence, is ill-performed, and at last altogether ceases ; while the heart, to the action
of which the brain is not directly nccessaiy, continues to contract, circulating dark
colored blood for some time afterwards. His experiments upon the action upon living
animals of the essential oil of Almonds, the juice of the leaves of Aconite, of the UpaK
Antiar,'the oil of Tobacco, Arsenic, Muriate of Barytes, Tartar Emetic and Woonira,
in like manner convinced him that poisons might act directly upon the cerebro-spinal
system, destroying all its fiinct ions, without interfering with the actions of the heart,
whilst, on the other hand, poisons may act upon the heart, causing death from such
action, without specially acting upon the cerebro-spinal nervous system. — Phil. Trans.,
1811, pp. 178-208; Phil. Trans., 1812, pp. 205-227.
We have already considered, in the first chapter of the Medical Memoirs and in the
present chapter, the experiments of LeGallois, and endeavored to show that they not
unly established the fact that the spinal cord is the especial seat of the reflex actions,
but also that the continuance of the action of the heart after decapitation and the des-
truction of the spinal cord, is dependent rather upon the respiration than upon any
nervous influence transmitted from the cerebro-spinal ganglionic centres.
The correctness of this view is sustained by the remarkable experiment, in which Le
Gullois maintained the action of the heart and " life,*^ for upwards of three-quarters of
an hour, in the detached and isolated breast of a rabbit thirty days old. In thia exper-
iment, the belly of the animal was first opened, a ligature passed around the aorta,
immediately below the Coeliac trunk, another was passed around the vona-cava near the
liver : a simple knot was tied in each of these ligatures. This being done, the trachea
and both carotids were laid bare ; each of these arteries were tied conjointly with the
external and internal jugular veins ; the trachea opened for the inflation of the langa ;
the spinal marrow was then divided with a needle, near the occipnt, and artificial rcspi>
ration instituted, without waiting until the asphyxia had extinguished sensation ; after
it had been continued for three or four minutes, the animal being fully alive, the tra-
chea is separated forward from the larynx, then the head is cut off at the first verte-
bras of the neck, with a pair of scissors ; and immediately resuming the ioflatioo,
which is to be continued for three or four minutes, after which the knots are to bo
tightened, which had been previously prepared upon the aorta and the inferior vena-
cava ; the inflation is then to be renewed, and again interrupted, at the end of three or
four minutes, to cut off the hind parts, which is performed by taking away the ioteatinal
tube from the beginning of the duodenum, then by dividing with scissora the soft partA
surrounding the vertebral oolumn, and then the column itself, immediately below tho
ligatures made on the aorta and the vcna-cava. In this manner, there remains only the
breast, the stomach and the liver, which might also be removed if oare be taken to
prevent hsemorrhage. The operation being finished, all that remains is to ooDtinue
inflation of the lungs, as long as the breast has any signs of life. The most apparent
of these signs, are the motions and the sensations preserved in the fore feet> aud tbe
small writhing moti<uis obncrvcd in the thorax, when the skin is severely pinched, aod
when the posterior extremity of the dorsal portion of the medulla spinalis is touched.
In some cases after carrying the experiment thus far, the remainder of the cervical
portion of the medulla spinalis and part of the dorsal were destroyed, and althoiaprli
life existed only in the two poHt<Mior thirds of the breast it could still be prolonge^l.
KxfHTtmenfs on the Principle of lAfv^ etc,
l)r. A. P. Wilson Philip, whoso oxporinient^ upon cold-blooded animals we ka%*t>
already conHidered, also examined the relations of the heart to the cerebro-spinal ocrvou.^
system, and denion.<«t rated the independen(!0 of the action of the heart by such cxperi^
ments w the following
Experimental Illustrations of Convulsive Diseases. 313
■
Dr. Philip deprived a rabbit of seasatiou and roluutary power, by a stroke on the occiput
and sapported the circalation bj artificial respiration. The spinal marrow was then laid bare
from the occiput to the be^inninfr of the dorsal vertebrze, the cbest was opened and the heart
foQod beatiog regularly, and with considerable force. The spinal marrow, as far as it had
beco laid bare, was now wholly removed, but without the least affecting the action of the
heart. After this the artificial respiration being frequently discontinued, the action of the
h?art became languid and increased on renewing it. The skull was then removed, and the
whole of the brain removed, so that no part of the nervous system remained above the dorsal
vertebrte, but without any abatement of the action of the heart, which still continued to be
more or less powerful, according as we discontinued or renewed artificial respiration. This
being for a considerable time discontinued, the ventricles ceased to beat about half an hour
after the removal of the brain. On renewing the respiration, however, the action of the
ventricles was restored. The respiration was again* discontinued and renewed with the same
eflectf. In another rabbit rendered insensible, and the circulation supported by artificial
respiratiooi and the thorax opened and the heart carefully observed, the spinal marrow was
destroyed throughout its whole length by a hot wire. The action of the heart was not at all
affected. These experiments were repeated and varied in some instances, by the destruction
of both the brain and spinal cord — in each case the result was the same; no special effect,
was produced upon the heart; and Dr. Philip satisfied himself that the circulation wad con-
tiooed to the usual way. and with sufficient force in the distant part. Philosophical Trans-
acliooB, 1815, pp. 63-m*; Phil. Tran.**., Ifilfi, pp. 42-t-44(>.
Dr. Philip, in his luMt paper publishetl in the Philsophical Traiitjaetiuus of 183G,
which he states, comprehends the results of the iuvcHtigationH of his life, expresses his
l>uUef, that neither the brain nor Hpinal marrow beHtows any power on the heart or ves-
Mels; bttt that on the other hand, each of these organs is e((ually capable of directly
influencing both, (the vesKels even to their utmost extremities^ and that not only by
exciting their powers, but also by im])airin(; and even wholly destroyin*^ them, according
U> the nature and power nf the agent operating on the bruin or spinal marrow;
although in their usual functions, the heart and vessels like the other muscles of invol-
untary motion obey neither of these organs, but agents peculiar to themselves. Phil.
Tmns., 183tj, pp. 34t>-H4H.
Sir Charles Bell held that the ordinary tiction of the heart hi dependent upon the
*:anglionic system, but that its connexion with the respiratory and sensorial functions
was derived through the eerebro-spinal nerv-es or par-vagum. Thus, after demonstrating
the extensive connections and omees of the respiratory nerves, he thus proceeds to
iliustpite the nuMlc in which the mind influences the body during emotion or passion :
** In tenor, we can readily cunceixc why a man stands with eyes intently fixed on the object
iif^ his fears ; the eyebrows elevated, and the eye balls largely uncovered ; or why, with he'si-
latiog and bewildered steps, his eyes are rapidly and wildly in search of something. In this
we onlf perceive the intent application of his mind to the objects of his apprehensions, and its
direct influence on the outward organs. Rut when we ob^^erve him farther there is a spasm
un bis breaft ; he cannot breathe freely ; the chest remains elevated, and hip respiration is
ibort and rapid : there is a gasping and convulsive motion of his lips ; a tremor on bis hoHow
( heeks; a gulping and catching of his throat; his heart knocks at his ribs, while yet there is.
no force io the circulation, the lips and cheeks being ashy pale.
Il is obvious that there is here a reflected influence in operation. The language and seuti-
incotf of every people have poiuted to the heart as the seat of passion, and every individual
must have felt its truth. For though the heart be not in the proper sense the seat of pasfipn,
it is influenced by the conditions of the mind, and from thence its influence is extended .
ihrongh the respiratory organs, so as to mount to the throat and lips and cheeks, and account
tor evtry movement in passion which is not explained by the direct influence of the mind on
the features.*' Phil. Trans., 1822, pp. :!o7, :;oh.
Prior to Scarpa, many eminent anatomists, as ilallcr. Wisberg, Soemmering and
otheiv, appeared from their descriptions to hold the view, that no nerves arc distributed
to the muscular substance of the heart, and that its contractions were independent of
Dcnrous influence. James Benign us Winslow, in his Anatonucal Kj-planatwn of the
Simdure of the Unman Body, (which appears fVout the author's preface to have been
composed in 1722, but n<>t publisheil until .•<omo ten years afler,) describes the "i'/cxi/t
314 Experimental Illustrations of Convulsive Diseases.
Cardiacugy' as being formed by communicating branches of the Eighth Pair, and the
Intrrcoital or OrecU SymjfcUhetic Nerve. According to this eminent anatomist,
'*Tbe Plexus Cmrdiacos, is formed above the lang, on the fore side of the Broochia, and
prodaces a great namber of filaments; some of which go to the Pericardiam, and the rest go
through it, round the great vessels to be distributed to the heart."
Winslow states that while some of the filaments from the cardiac plexus, run down
over the trunks of the great blood-vessels, and over the auricles and ventricles of the
heart, other and the chief filaments run in the cellular substance behind the aorta, or
between that and the trunk of the pulmonary artery, and af\er being divided into a
great many small nerves, which run before and behind the aorta, are distributed to the
base and auricles of the heart. In Winslow's description of the mode of action
and uses of the heart, he makes no reference to the nerves distributed to its sub-
■tanoe.
William Cheselden, in his Anatomy of the Human Body, gives no descriptiou
of the nenres of the heart ; he appeared however to be aware of their relations to ith
aotiona, from the ingenious attempt to account for the systole and diastole of the heart,
and the reciprocal actions of the auricles and ventricles, which he quotes frcm Mr.
Munro. Anatomy of the Human Body ; iz £d., London, 1768, pp. 197, 199.
B. J. Behrends (a pupil of Soemmering,) who whilst admitting in his Ditaertatw qua
demanttratur Cor Nervh Carrere, 170^ y that nerves accompany the Coronary Arterie**,
distinotly asserted that the muscular structure is entirely destitute of nerves.
Scarpa, clearly delineated and described nerves running on the heart independtrutly
of, and distinct from the Coronary Arteries, and in his elaborate work {Talvitt Xev-
roiogiem, 1794,) has given fine views of the neives of the human heart, in seme of
which, upwards of twenty filaments may be counted on the same transverse line, near
the base of the heart, together with numerous anastomotic angular enlargements, which
Scarpa does not specify as ganglions in his text. In the hearts of the large herbiverou^
Mammalia, however, Scarpa describes and delineates both ganglia and fusiform enlarge-
ments of the nervea, which he called corpora olivaria, and these not only upon the nervcsi
at the base of the heart, but upon those that are spread over the superficies of the
Tentride. Scarpa also describes and figures several nerves independent of, and not accom-
panying the blood-yessek of the heart, and avails himself of the fact to refute tho
conclusions to which Behrends had arrrived.
In Mr. Swan s splendid plates, the nerves are represented as accompanyin;; the
Coronary Arteries, and but few are distributed to the muscular tissue, and M. Chassaigoau
who transUtad in 1838, Mr. Swan's "Demonstration of the Nerves of the Uuma^
Body," denies that any nerves besides those which accompany the Coronary Arteries
have ever been discovered in the heart.
Mr. Robert Lee, in an important paper published in the rhiiuhophual Tramftc(ti»M*
of the Royal Socitty, 1849, pp. 43, 47, has demonstrated by careful directions and draw-
ings, that the nerves and ganglia of the heart are far more numerous than tho^e
described and delineated by Scarpa. The series of dissections performed by Mr. I^,
show that the nerves of the heart which are distributed over its surface and thrt)ughcot
Its walls to the lining membrane and columtte carncw, enlaipe with the natural growth
of the heart, before birth, and during childhood and youth, until the heart has attained
Its full siie in the adult, that the nervous supply of the IcR ventricle is greater than
that of the right; and that when the walls of the auricles and ventricles are affected
^^^ j*yP«rtrophy, the ganglia and nerves of the heart are enlarged, like those of tho
gravid Uterus. In one of the dissections of the heart, on the anterior surface, there
were distinctly visible to the naked eye, ninety ganglia or ganglionic enlargements ot>
the nerves which pass obliquely acnvs the arteries and the muscular fibres of the ven
tncles from their base to the apex. These ganglionic enlargements arc observed on the
nerves, not only where they crosa the arteries, but where they ramify on the muscular
9ubi^twice^ wirtoat the bl99d-ves^]s, Qn the posterior surfece, th.^ principal branchc>.
Experimental Illustrations cf Convulsive Diseases. 315
of the Coronary Arteries plunge into the muscular substance of the heart near the base,
and many nerves with ganglia accompany them throughout the walls to the lining mem-
hraoe and columnar carneie. From thcs udden disappearance of the chief branches of
the Coronary Arteries on the posterior surface, the nervous structure distributed over a
considerable portion of the left ventricle, is completely isolated from the blood-vessels,
and OD these, numerous ganglionic enlargements are likewise observed, but smaller in
sixe than the chains of ganglia formed over the blood-vessels on the anterior surface of
the heart. Mr. Lee, has clearly demonstrated that every artery distributed throughout
the walls of the Uterus and Heart, and every muscular fasciculus of these organs, is
supplied with nerves, upon which ganglia are formed.
It would be foreign to my purpose to examine critically the theories advanced by
various writers as to the cause and nature of the heart's action ; we desired simply to
record such experiments and anatomical facts, as were directly related to the question
en ler consideration.
From the preceding inquiry, and from on extended examination of the views of many
writers, besides those quoted, and from actmil experiments and dissections, the following
coodusions may be drawn :
1st. Both experiment and pathological observations show that the action of the
heart may be influenced through the pneumogastric nerves, through the cerebro-
spinal centres : thus its action is disturbed, or even abruptly suspended, by severe injury
or destruction of the brain or spinal cord ; and its action is excited or depressed by the
emotions and passions, or by various diseases of the brain.
2d. Nevertheless the movements of the heart do not depend upon the oerebro-spinal
nervous system, because it continues its pulsations after the brain and spinal cord have
been removed ; and if the injury either to the cerebro-spinal or sympathetic system be
gradually inflicted, the heart's movements will continue with slight perturbations, even
although the entire brain and spinal cord be removed, if artificial respiration be
performed.
3d. The regulating agents of the heart's movements exist around and within the
heart itself; the numerous sympathetic ganglia connected with the nerves of the heart,
are the sources of the stimulus or force which excites the rythmical contractions of its
fibres. When the rythmical movements of a part depend on a nervous centre, they
oeaae immediately after the connection between these parts and the nervous centre is
broken ; thus the rythmical movements of the muscles of respiration, depend on the
medulla oblongata, and as soon as this is destroyed they cease ; in like manner, if the
action of the heart depended on the medulla oblongata, or on any other portion of
the oerebro-spinal system, it would cease pulsating as soon as it is removed from the
influence of its cerebro-spinal centre ; but Bidder and others have shown that the heart
continues its pulsations, and the circulation continues, if the respiration be maintained,
after complete destruction of the brain and spinal cord.
4th. The cardiac ganglia must be regarded as nervous centres, which originate or
generate the force, which stimulates the muscular fibres of the auricles and ventricles,
to perform their characteristic movements in regular and periodic succession ; and the
synchronous combination of the auricular and ventricular motions on the two sides in
the double heart of warm-blooded animals, is without doubt due to connections between
the several ganglia ; therefore the movements exhibited by the heart after the central
masses of the nervous system have been destroyed, are not mere movements of irritation,
due to the inherent irritability of the muscular fibres, acted on by the stimulus of the
blood, whether arterial or venous, and the thermic and electric currents developed by
the mutual reactions and chemical changes of the muscle and blood. Mere muncfUar
irriiabiliiy, (although its existence is not denied, but strenuously maintained,) excited
by the stimulus of venous or arterial blood, or by the absence or presence of the oxygen
of the blood and atmosphere, will not explain the simultaneous contraction of bo^h
auricles or both ventricles, or the successive contractions and expansions of the auricles
and ventricles ; the rythmical order of these contractions, like the movements of the
316 Experimental Illustrations of Convulsive Diseases.
respiratory muscles, must be regulated by special nervous centres. If the hypothesis
previously unfolded, as to the close relationship, if not absolute identity of electricity
and nervous and muscular force be adopted, the continuous and rythmical action of the
heart may be comprehended ; and we also find in this theoiy an explanation of the effects
of mechanical stimuli and chemical agents and variations in the amount and character
of the blood and nutrition of the organ, in exciting or depressing the heart's action,
and also of the mode in which the cerebro-spinal nervous system may exert an action
on this organ, through the pneumogastric and sympathetic.
5th. The heart therefore, like all muscles, possesses motor nerves, which communicate
to its fibres motor impulses. The motor nerves of the heart are excited by the centres
situated in the heart itself, and which act independently of the oerebro-spinal nervous
system, and of the will, and are excited by variations in the temperature and chemical
composition of the blood. Although receiving its motor impulses from its own ganglia,
the heart is connected with the cerebro-spinal centres by centrifugal and centripetal
fibres, which, on the one hand, under the influence of cerebral excitations, modify both
the rythm and force of its contractions, and on the other, communicate to the brain and
spinal cord a series of sensjUions and impressions corresponding to the character of it«
movements.
6th. Poisons may act directly upon the ganglionic centres of the heart, on which its
movements depend, deranging that concert of nervous impulses upon which the r^n^lar
succession of the contractions of the auricles and ventricles depend, and even destroying
totally the nervous power and muscular irritability of the heart ; poisonous agents may
also influence ' the action of the heart by their efliects on the cerebro-spinal nervous
system ; but the derangements thus produced by reflex action, are comparatively insig-
nificant and unimportant.
This last proposition, which was fully illustrated and demonstrated by the experi-
ments on cold-blooded animals, needs further illustration and demonstration with
warm-blooded animals, and we accordingly devised and performed the following addi-
tional experiments :
RXPERIMENT8 TO DETERMINE WHETHER PRrsSlC ACID, CVANIDE OF POTASSIUM AND
STRYCHNIA, EXERT. ANY DIRECT AND SPECIAL ACTION ON THE HEART, IWDE-
PBNDBNT ALTOOETHER OF THE ACTION OF TIIRSK A<»ENTS ON THE CEREBBO.
SPINAL NERVOUS SYSTEM.
Es.jyeriment 12fj : Prfliminnry^ to (leterminp the rflah'ong of the Heart to the CrrtlfT'^
Spinal Nert'ous Syntcrti^ to the Lmigit, and to the Sympathetic NerrouM t^^Mtrm ;
Effects on the action of the Heart, of dirinion of the Atedidla Oblongata,
A knife blade was passed through the vital point, severing the neduUa oblongata aod also
the vertebral arteries of a large Pointer dog. The respiration ceased iminediatet j ; the hiraor-
rhage was profuse* and in a few mooients all signs of life were extinct. The thorax wa.«
opened' by the removal of the sternum, several minutes after the pulsations of the heart bad
ceased, and the animal was apparently dead. When the heart was pricked with a scalpel it
immediatelj pulsated. Artificial respiration was instituted, and the cavities of ibe heart
contracted and expanded as in living, healthy animals. When the intestinef wera pricked
by the end of the scalpel, the peristaltic motions were excited vlgoroasly. The intarmpied
electro-magnetic current produced powerful contractions of the voluntary masclet ; the
limbs were tossed about in the wildest manner, the mouth was opened and shut, and all the
expressions, of which a dog is capable, were formed in rapid succession, according to the direc-
tion in which the currents were passed, and if the dog had been placed in the standing pos-
ture, it would have been possible to have caused him to bound with the force of health, froa
the table. The heart and intestines also responded to the electricalfcarrents readily and vigor-
ously. The he irt continued to beat with vigor and regularity for more than one hoar, danog
which time, the artificial respiration was carefully performed. This experiment, which has
been performed before by numerous observers, with the same result, demonstrates that the
action of the heart is indispensably connected with respiration, and may be maintained alter
the nervous centre which presides over respiration has been entirely destroyed and aevcred
Experimental Illustrations of Convulsive Diseases* 317
from the respiratory appamtns, if the respiratory acts of the alternate rnflation and expira-
tion of the lungs be niechanicallj performed.
Kxperlmentn 127^ 128^ 129^ ISOy 131^ 1-32 : Bejtpfttwns of preceding cxperinxent
( 126)^ with similtir results,
Kxj>erime}it 133: JUiMtrating action of Pritssic Acid on Warm-Blooded Animal.
AugQSta, Ga., January 30tb, 1861. Fine, large, Pointer dog. Temperature of atmosphere,
•50O V.'j temperature of rectum of dog, 40® C, 104J» F.
Four fluiddrachms of the officinal solution of Prussic Acid were injected into the sub-cuta-
aeoQf tissue of the right thigh. As soon as the nozzle of the syringe was removed, a large
portion of the solution was ejected. In a few moments, the muscles of the neighborhood of
the part injected commenced to twitch; then the dog, in two minutes, manifested great
uoeasiness ; the respiration became (nller, and the action of the heart slower. These phc-
Domena were succeeded by violent struggles and piercing cries, as if the dog was suffering
intense agony. Daring these violent struggles, the temperature of the rectum rose 0^.3 C.
At the end of 12 minutes, the dog was still exerting great strength, struggling violently, and
emitting piercing cries. Half a fluidounce of the officinal solution of Prusic Acid was then
poured into the mouth and nostrils ; the effects were manifested in a few seconds ; the respi-
ration became more labored, and the action of the heart slower; strong tetanic spasms, coma
and finally death, in three minutes. The respiration became spasmodic, and occurred at long
intervals before death. Before death the action of the heart was exceedingly feeble, and
could scarcely be felt through the walls of the thorax., Immediately after the cessation of
the action of the heart, the thorax was opened ; the heart was distended to its utmost capacity
with dark, almost black blood ; not the slightest motion was perceived in either the auricles
or ventricles. When the pericardium was opened, and the auricles and ventricles irritated
with a steel point, there was no huotion whatever excited in the muscular structures. When
graaped in the hands, no motion whatever could be felt. The pectoral, respiratory, and other
muscles of voluntary motion, as well as the diaphragm, responded readily to mechanical
ftimali, and contracted vigorously. The intestines appeared to have lost, in great measure,
tlieir power of peristaltic motion, and responded but feebly to mechanical irritation. Artifi-
cial respiration was immediately instituted ; the opening of ihe thorax, and the performance
of the preceding experiments, consumed less than one minute.
Although the artificial respiration was kept up for more than one hour, not the tUyhteH
motion of the heart vfos produced. The heart was carefully and firmly grasped in the hand, hut
not the slightest contraction or motion of its muscular fibres could be perceived.
A strong, interrupted, galvanic current was passed through the heart after the establish-
ment of artificial respiration, but no contraction could be perceived or felt. The interrupted
electric*! current, on the other hand, produced powerful contractions in all the voluntary
muscles, the diaphragm contracted with great violence, the jaws were brought together with
4ucb force as to bend the steel wires of the muzzle, which were accidentally caught between
the teeth. Every contortion and expression of the muscles of the face were induced, and the
eyes opened, and shut, and winked in response to the electrical excitement. The peristaltic
motion of the intestines, on the other hand, was with great difficulty excited, and then only
very feebly, by the electrical current.
Tcroperatnre of the rectum, 15 minutes after death, 40^.25 C, 104^.4 F.; the temperature
f^U 0^.05 C. during this time, as it stood at 40^.3 C. at the moment of death. The large
f enoua trunks and the blood-vessels of the liver and intextines were distended with dark,
v^noui blood. The liver presented a deep purplish, almost black color. As soon as the heart
failed to respond to artificial respiration, and mechanical and electrical stimuli, supposing
that its extreme distension with blood might, in a measure retard its action, I punctured the
heart, and allowed the blood to escape ; a large quantity of the dark, fluid blood escaped from
the caTities, which coagulated in a few minutes.
The heart, thus relieved, notwithstanding that death had taken place only a minute or two
before, failed to respond to artificial respiration, and mechanical and electrical stimulation.
Temperature of the rectum 30 minutes after death, 39® ('.; 45 minutes after death, 37® C.
The rapid cooling was due to the artificial respiration, loss of blood, and exposure of the
internal organs. The muscles were dark colored and bloodies.^ ; the whole mass of blood
mppeared to have accumulated in the large venous trunk-^and capillaries of the internal organs.
Ueactiott of blood of heart slightly alkaline.
The preceding experiment deinonHtrat4Hl eondiLsively that IVuhhIc Acid acti4 directly
upiiD the heart, arresting ita action, and also to a certain degree upon the sympathetic
318 Experimental Illustrations of Convulsive Diseases.
nervous syBtem. The muscles connected with the cerebro-spinal system were affected
to a much lesH dep-ee than those related more es^Jlecially to the sympathetic system.
Experimenta ISJ^^ i.i.7, i-^v;, 7.77, lS8y ISO : RepetUioru of preceding experiment, with
similar resvitg.
Experiment JjfO : lUustrating the action of Cyanide oj PotaMitim on Warm- Blooded
Animals.
Augusta, Ga., April 1st, 1860. Fine, large cur dog, very fat, fierce and poirerful.
Temperature of rectum, 103°.69 F.
The attempt was first made to pass a strong interrupted current through the mofclu of the
thigh; during the cutting through the skin for positions for the terminals of the electrical
apparatus, the dog struggled violently, and during these struggles there was a slight rise in
the thermometer, which indicated 104® F. In a few minutes, howefer it fell to 103^.79 F.
After the application of the electricity for a few seconds, his struggles were so ▼tojent, and
his strength so great, (the muzzle was torn off and the dog bit the four yooag men who were
assisting me in the experiment), that it was found to be impossible to eon tin oe the applica-
tion of electricity, and a strong solution of Cyanide of Potassium was injected into the eyes
and mouth.
In one minute, the struggles of the dog became violent, (he barked and gnashed bit teeth,
and struggled in the most violent manner to break loose), and the dog died io six mtnates
after tbe solution of Cyanide of Potassium had been introduced into the eyes and mootb.
Before death, the tongue and lips became of a brilliant scarlet color, and the tongue appeared
to be swollen.
About three minutes before death, the dog became convulsed, tbe breathing became spas-
modic ; and at the moment of death, the muscles were violently convulsed, and the body ana
extremities were stretched backwards. . Tbe force of the death spasm was so great tbat the
shaft of the glass thermometer, with its porcelain scale, in tbe rectum of the dog, was broken
into small fragments.
Temperature of the rectum at the time of death, 41® C, 10&®.8 F. Daring the violeot
spasms excited by the Cyanide of Potassium, tbe temperature had risen ]®01 F. Temperature
of rectum 15 minutes after death, 41® C, 105®.8 F.; 88 minutes after death, 40® C, 104® F,;
09 minutes after death, 39®.33 C; 209 minutes after death, 34®.5 C; 234 minates after death,
33®.75 C, 92®7 F.; 234 minutes after death, rigor-mortis well marked.
PoH^mortem Examination^ 20 hours after death : When the skull-cap was removed, tbe
blood-vessels of the membranes and of the substance of the cerebrum and cerebcllam were
distended with dark blood. Blood-vessels of membranes and strnctares of medulla oblongata
and spinal cord greatly congested with blood. As nsoal, the spinal cord was exposed through-
out its entire length. Lungs and liver, stomach and intestines congested with blood.
Exf^riment IJ^I : 1 lliist rating the effects of Cyanide of PotOMsinm on Warm-Blnodr^i
Animal.
Augusta, Georgia, January 23d, 18G1. Thirty grains of Cyanide of Potassium wera dis-
solved in two fluidounces of water, and half a fluiddrachm was injected sab-cotaaeoasly
beneath the skin of tbe left fore-leg of a cur dog. The poison excited violent straggles, loud
and piercing cries ; fullness of respiration, disturbance in the action of the heart — followed
by slowness of respiration, and slow and spasmodic action of the heart. The beat fell in lo
minutes, to 40 beats to the minute. Then followed a long piercing cry; tetanic spasms, long
drawn and loud breathing, coma, and finally death in 20 minutes after the injection of tbe
poison. The animal in this experiment, unlike the one in the preceding experiment, di^
without a struggle.
Temperature of the rectum before the injection of the poison, 39®.4CC., 103® F.; of atmos-
phere, 50® F., during the period of excitement; during the first 10 minates after the injectioa
of the poison, the thermometer rose o®.08 C, and stood at 39®.54 C. Temperature of rvctom
at moment of death, 38®. 7 C, showing a descent of 0®.84 C; during the period in which the
respiration and heart actions decreased in frequency. Temperature of rectum 45 minute*
after death, 37®.05 ; 75 minutes, 36° C.
Pott^mortemy 24 hourt aft ft death. Veins of the brain distended wiih dark blood, which
exhaled the odor of Prussic Acid. Brain normal in color and structure. Blood-vessels of
brain less congested with blood than in the previous case of poisoning with Cyanide of
Potassium.
Spinal cord normal in appearance.
Cavities of heart distended with dark fluid blood. Hepatic, Xeseateric and Inustiaal veins
Experimental Illustrations of Convulsive Diseases. 319
distcaded with dark fluid blood, as was tfae case also with the vena-caTa. Arteries empty.
Liver of a dark parplish, greatly congested appearance. Kidneys of a dark purplish slate
color, and greatly congested with blood. Spleen dark colored and congested.
Langs somewhat congested. Veins of stomach distended with blood ; mucous surface
much corrugated, contained thick ropy mucus, and was of a deep pink and purplish color.
Veins of small intestines much congested with blood ; mucous membrane pale and not con>
(rested, except in the duodenum, near its junction with the stomach. The congestion of the
mucous membrane of the stomach appeared to hare been due to the local action of the poison.
Tader the microscope the colored blood corpuscles, in some cases appeared to bo smaller
than oonnal, and in others, presented a stellate appearance. When abstracted from the body,
the blood coagulated imperfectly.
Experiments 1^2^ H3^ 144} I-i^t I4(>, H^ : Repetition of preceding ExperimeiU^
{140 and I4I)} general results similar.
Experiment I4S : Actian of Acetate of Strychnia on Uirge^ active Dog,
Augusta, Georgia, May 14th, 1860. Fine, large, well conditioned, active dog. Temperature
of atmosphere 24® C, 75^.2 F.; temperature of rectum of dog, 40^2 C, 104^4 F.; temperature
of surface of muscles of small of back, an incision having been made through the skin, and
the thermometer introduced, 37*^.5 C, 99^.6 F.
Immediately after the sub-cutaneous injection of the Acetate of Strychnia solution, into the
cellalar tissue of the anterior portion of the right thigh, the temperature of the rectum com-
menced to descend, and fell ( of a degree C, 0.2^ C. During the fall of the temperature, there
was DO distnrbanee of the muscular or nervous system. In two minutes after the injection
of th« solution of the Acetate of Strychnia, violent convulsive movements of the muscles
wero excited, and the pupils of the eyes were dilated. During these convulsions the thermo-
meter in the rectum sloifly rose, and in three minutes (5 minutes after the injection of the
Acetate of Strychnia,) the thermometer stood at 40^.25 C, 104^.5 P ; showing a rise of 0^.25
C, daring the last three minutes. During this time the temperature of the surface of the
muscles of the thigh, also rose, and stood at 38^.13 C, lOO^'.e F.; showing a rise of O^.GS C.
At this time (5 minutes after the injection of the solution of Acetate of Strychnia,) the pul-
sations of the heart were 52 per minute, whilst the respiration had ceased. The pulsations of
the heart were strong and spasmodic. One minute after this observation the bean ceased to
beat.
If we consider the cessation of the heart's action, as the moment of death, then the Acetate of
StrychoU (about one and a half grains), produced death in 8i.\ minutes. The temperature of
the rectum and of the surface of the muscles of the loins, commenced to descend almost
immediately after the cessation of the action of the heart, and 4 minutes after temperature of
rectum 40^.2 C; of muscles of loins 37° C. In four minutes the temperature of the surface
of the mascles of the loins had fallen I°.12 C; whilst that of the rectum had fallen only 0^.05
r. Thb difference was manifestly due to the relative loss of heat from the exterior and
iaterior of a body by conduction and radiation. Temperature of rectum 10 minutes after
death, AXU^ C.
A strong interroptied electro-magnetic current was then passed in various directions from
the great nerroas centres to the periphery and vice rrrsa; contractions were produced in all
the Tolaiitary mascles; contortions of the muscles of the face, were in like manner produced.
The cottiraetions, thus excited, appeared however to bo much more feeble than those produced
io the maKles of animals killed by mechanical meanc.
Tcmperatore of rectum 32 minutes after death, 39° (*.; of surfMcc of musclen of loins,
3»>«.16C.
Thirty-two minutes after the cessation of the action of the heart, rttfOT'inorLs had not taken
place, aad the dog presented no such contractions and contortions of the muscles, a** have
been said by some writers to be invariably characteristic of the bodies of animals und men,
poieoaed by strychnine.
Rigor-mortis commenced 7 minutes after this observation ; that is 39 minutes after ceisa-
iion of the action of the heart. Forty-two minutes after cessation of action of heart, tempe-
rature of rectum, 39^.2 C; of surface of muscles of loins, 35°.33 (.*.; 72 minutes after cessation
ttt action of heart, temperature of rectum, 37*^ C-.: of muscles of loins, 34^.5 C. At this time
ibe rigor-mortis is well marked, and the limbs are strongly contracted and rigid. .\ strong
ioterrapted magneto-electric current, passed as before in various directions, produced nu
■lOveveQts manifest to the eye; when, however, the ckin was removed, contractions were
visible ia the muscular fibres, under the direct application of the interrupted currents. One
hvadred and ten minutes after death, temperature of rectum 3«J°.2 U.; temperature of surface
of vsusckf vf loiti9t 34°^^0 Cm loss of temperature in rectum dyring I to minutes after death,
32() Experimental Illustrations of Convulsive Diseases.
4^.05 C, losf each minute, 0^.036 ; loss of temperakare in muscles of loins during 110 minutes
after death, 3^.58 C; loss of temperature each minute, 0^.032 C.
AtUoptyf 110 minntes after death.
The blood from the carotid arteries, from the rena cara, and from the carities of the heart,
presented no unusual appearance under the microscope with the exception, that some of the
colored blood corpuscles appeared a little swollen, and others presented a stellate, star-like
appearance.
The blood- vessclji of the membranes and structures of the brain and spinal cord, presented
no marked cong^estion. The nerve cells of the i^ray matter of the brain and spinal cord,
))resented under the microscope the usual healthy appearance. Lungs of a light pinki»h
color and not congested with blood. Heart contracted and normal in appearance. Liver
congested with blood, and of a deep purplish and pinkish color, resembling the color of
venous blood. The stomach was filled with undigested matters — exterior pale ; interior
mucous membrane of a pinkish and light purplish color, so often present during the progress
of digestion. Surface of intestines pale ; blood-vessels filled with dark cherrj red and pur-
plish venous blood Spleen and pancreas, normal in appearance. Bladder greatly contracted.
As in preceding experiment, colored drawings were executed of appearance of brain, spinal
cord and viscera.
Experiment IJ^iU Action of Acetate of Strychnia on Female Dog,
Augusta, Georgia, May 14th, lOUO. Large, well conditioned female dog. Temperature of
atmosphere, 24^ C, 75^.2 F.; temperature of rectum, 40^.33 C, 104^6 F.; temperature of
surface of muscles of thigh, (the skin being cut and the thermometer introduced.) 37^.8 C.
10 1^0 F.
Injected about two grains of Acetate of Strychnia, in solution, into the snb*cutaneoQS tissue
of the thigh of the hind leg. The poison acted in two minutes after its injection. During
these two minutes the temperature remained stationary, then violent convnlsions of all the
muscles ensued ; 6 minutes after the injection of the Acetate of Strychnia, temperature of rec-
tum, 40^.55 C, 105^ P., showing a rise of 0^.22 G. in 4 minutes. Temperatue of surface of
muscles of thigh, 38® C, showing a rise of 0^.2 C, during the convulsions. The heart ceased
to pulsate one minute after this observation, and 7 minutes after the injection of the Acetate of
Strychnia into the sub-cutaneous tissue. There was a atill further rise of O^.Oft C, during
the last moments of life, and after death, the thermometer stood, 10 minutes after the cessa-
tion of the action of the heart, at 40^.6 C, 105^.1 F., in the rectum. At this time there is a
strong peristaltic motion of the intestines. Temperature of surface of muscles, 36^.8 C .
showing a fall in 10 minutes, of 1^.2 C. The temperature of the surface of the musoles com-
menced to sink immediately after the cassation of the respiration and of the puliations of the
heart. 20 minutes after the cessation of the action of respiration and circulation, lenpcra-
ture of rectum, 40^.50 l\; slight fall of 0°.04 C; temperature of surface of muscles of loiaa,
350.4 C, loss of 1*.4 (\
A powerful interrupted clectro-maguctic current was then applied, 28 minutes after death.
in various directions along the nervous centres; rigor-mortis had not as yet cooineoced.
The muscles responded to the action of the electric currents, especially those of the head.
ears and eyes, but to a much less degree than in animals killed by mechanical means, as when
the medulla oblongata was severed. The currents were passed for several minutes through
the entire length of the spinal cord, without any rise in the temperature of the rectum, or of
(he surface of tbc muscles. The effects upon the muscles of the extremities and trunk
appeared to be less than upon the muscles of the face. 43 minutes after the cessation of the
action of the heart, temperature of rectum, 39^.75 C; of surface of muscles, 36^.; 173 miiiates
atter cessation of heart, and \'M) minutes after last observation, temperature of rectum, 46*.*'.
C; of surface of muscles, A'A^.I C: lliG, (23 after last observation), temperature of rectum, ;>•''
(\; muscles, 3:;°. 4 C; temperature of atmosphere, 27^ C; 282 minutes, (186 after lasi obser-
vation), temperature of atmosphere, 26^.5 C: of rectum, 34^.33 C; of muscles, 33^.2 C*.
.1u/o/>fv, 293 minutes after cessation of respiration and the action of the heart.
Uigor-mortis well marked. The blood corpuscles presented similar appearances as in the
preceding case, some were a little swollen, others corrugated and stellated.
The brain and spinal cord presented no marked evidences of congestion. The base of the
brain was more congested with blood than the superior portions. ' The micro8Copic«l exam-
ination of the structures of the brain, spinal cord and sympathetic, did not reveal any recog-
nixable alterations or lesions. I could detect no alterations in the nerve cells or conmia-
sures of the cerebrum, cerebellum, pons varolii, medulla oblongata, or spinal cord and sympa-
thetic, which would distinguish the action of strychnia* from that of Pmsaic Acid. Lung*
greatly congested ; the liver, on the other hand, pale and bloodless. Stomach 61l«d with
digested matters, and presented a much redder appearance upon the exterior and interior
than in the preceding experiment. Intestines, spleen, bladder and pancreas normtl.
Experimental Illustrations of Convulsive Diseases. 321
Bj a comparison of the preceding experimentSi 148 and 149, it is evident that in one case
the lungf were not congested, and in the other greatly congested, resembling liver in appear-
ance, being heavy, and not collapsing; in one case the liver was greatly congested, in the
other not at all ; and in both the brain and spinal cord were free from congestion.
Experiment loO : Action of Acetate of Strychnia on Dog,
Augusta, Ga., March, 180*0. Large dog (cross between Setter and Cor). Temperature of
atmosphere 63^ F.; of rectum 102° F. In this experiment, as in all others, recorded in this
chapter, the carefully graded and accurate thermometer was, allowed to remain in the rectum
for 20 to 30 minutes, and until it ceased to rise for 5 or 10 minutes before the temperature was
recorded.
Four grains of Acetate of Strychnia in solution, dissolved in a small quantity of water
were injected into the sob-cutaneons tissue of the hind leg.
In six minutes, powerful tetanic spasms of the legs were produced, and during these the
thermometer rose one degree P., to 103° F.
Fifteen minutes after the injection of the poison, breathing spasmodic ; spasms of muscles,
short, powerful and frequent. Temperature of rectum 103°.75 F.; one minute after this
observation the breathing ceased entirely, whilst the heart continued to act slowly and spas-
modically. Temperature of rectum 103°. 75 F. The dog died 17 minutes after the injection
of the Acetate of Strychnia. One minute after death the thermometer in the rectum
showed a very slight fall, and stood at 103°. 05 F.; six minutes after«death, temperature of
rectam 103°.'r> F.; 19 minutes, 103°.5 F.; 21 minutes, 103°.5 F.; 28 minutes, 103°.6 F.; 42
minutes, 103°.33 F.; 52 minutes, 103° F.; 142 minutes, 99° F.; 202 minutes, 97° F.; 222
minutes, 95° F.; 248 minutes, 94° F. During the action of the strychnia, this dog was sup-
ported by strong assistants in the standing posture; after death it was hung up, to avoid all
condaction of heat, and to allow the body to cool as in the preceding experiments by radiation ;
In alt cases the animals being suspended horizontally, so as to occupy a standing position.
The orine passed during the last period of life, cobtained no traces of grape sugar.
Autoptf/ fip€ kourt after dralh. Blood presented a cherry red color, and coagulated and
changed to arterial hue when exposed to atmosphere.
The blood was carefully examined before and after the injection of the Acetate of Strychnia,
and after death ; but nothing worthy of note was observed.
Membranes and structures of brain and spinal cord congested with blood to a greater extent
than in the preceding experiment*.
£xj>erim€nt Jol : KjfW'ts of Strychnia on large male Cat.
Solotlon of Acetate of Strychnia, injected sub-cutaneously. Powerful tetanic spasms com-
menced In 30 seconds after the injection, and the cat died in two minutes. Chloroform was
administered by inhalation, a few minutes before death, but produced no permanent effects.
Cadaveric rigidity occurred immediately after death, and the extremities were as ** rigid as
«teel." One and u half minutes after death, the magneto-electric current, passed in every
direction, produced no effects whatever on the muscniar system. Blood drawn after death
coagulated in 10 minutes.
Blood-vessels of brain filled with dark blood.
Kxperimentt 15 J ^ lo*^, loJf^ loo, lotj^ /.J 7, loS^ 15ff, J^)0 : Repetition of preceiUvg
Experiments with Strychnia on Mammalia. Results similar.
Id theso ezperiiiicuts the heart was exposed, and artificial respiratioa instituted,
immediately upon the ceasation ot respiration and of the action of the heart. It was
found to be impossible to excite the heart to action, either by artificial respiration or
mechanical and electrical stimuli after death from Strychnia. In all cases the cavities
of the heart were distended with black hlood, when the thorax was opened and the organ
exposed. This fact I have repeatedly demonstrated to my medical classes, viz : that
Styrchnia acta directly upon the ganglionic centres and muscular structures of the heart,
and so arrests the action of the sympathetic ganglia, that it is impossible to excite the
action of the heart hy any known means. The fact that interrupted electrical currents
excited powerful spasmodic actions in the muscles supplied exclusively by the cerebro-
spinal system, whilst they failed to stimulate the muscular structures of the heart, would
!ieem to show that the nerves connecting the heart directly with the oerehro-spinal system
are related to the ganglionic system proper of the hearty rather than to the mus-
cniar stmcturea of the heart ^ts^lf, la gtryohnia ppiooning thQ cessation of tho
a
322
Experimental Illustrations of Convulsive Diseases.
action of the heart was not due either to the absence of oxygen from the blood, or to
the accumulation of carbonic acid in this fluid ; for in animals killed by division or
injury of the medulla oblongata, the heart may be readily excited to contraction a con-
siderable time nfier the cessation of its action, and when all its cavities are distended
with black, venous blood, deficient in oxygen, and loaded with carbonic acid.
Dr. Charles Bland Raddiflfe, in his " Lectures on Epileptty, Pain^ Paralym^ and cer-
tain other diiordert of the Nervous System. ^^
Affirms that there is reason to believe that one way in which Slrychnia or Brucia, tends
to bring abont spasmodic muicnlar contraction, is bj producing a change in the blood, vhich
is eqniTalent to loss of arterial blood, p. 87.
Dr. Radcliflfe supports this proposition by the following fucts : .
It has been shown by Dr. Harley {Lancet, 7th and 14th June, and J 2th July, 1856,)
that air which has remained for some time in contact with blood, to which Strychnia or
Bmeia has been added, contains more oxygen and less carbonic acid than air, which has
been left in contact with simple blood, for the same length of time. It has been shown
that blood poisoned in this manner respires le£s freely than pure blood. In one of
the experiments by which this demonstration is eflfccted, two tubes, similar in size and
graduated upon the same scale, are filled half full of calf's blood. Then after adding a
minute portion of Strychnia to the blood in one of the tubes, and after freely agitating
the blood in each tube, with supplies of ft'csh air, both tubes are corked up and set aside,
with the corks downwards. During the next twenty-four hours the blood and air thus
corked up, are occasionally well shaken up together. At the end of this time the air
which has been all this while in contact with the blood is analysed by BuDsen's method ;
and it is found as is shown in the following table, that the air which has been in contact
with the |K)isoned blood, contains more oxygen, and lees carbonic acid than the air which
has been m contact with simple blood.
OASES.
I
COVPfKHITION
COMMON AIR.
Conptwltlao otm\r^ C(i«Bpo»lUa« «f kir
•fler b«vtn(b«ra ia mftcr having Wm la
maUct Willi rtaiple coatari with hk*4
t>l<Mid 1^ tvmtj- roataialaf MrT--b-
four koani. ala ffar twatv ■
Oxjgen
Carbonic Acid.
Nitrogen
20.96
.002
ll.:i3
82.71
17.82
2 7:<
7y.45
100,000
100,000
1 00.000
Dr. BadcliflTe, from the results of these experiments, views the change wrought by
Strychnia upon the blood, as equivalent to lobS of blood :
<' For blood which cannot become arterial is as good as lost to all purposes of life. Nay,
this change may be looked npon as equivalent to copious loss of blood ; for in the experimrot
of which the resalti are given in the preceding table, a very minute quantity of the poiton
bat bad the effect of depriving the blood of full two- thirds 6f its natural power of becomioir
arterial. When Bmeia was used in the place of Strychnia, the only difference was one of
degree, the power of preventing the arterialization of the blood being somewhat less energetic
in the case of Brucia, p. 89."
It is impossible to admit this explanation of the poisonous action of Strychnia, when
we conceive how small a dose often produces fatal reHutts, with astonishing rapidity.
Thus Dr. Warner, ast. 89, took by mistake, half a grain of sulphate of Strychnia ;
the symptoms began in less than five minutes, by constriction of the throat, tigbtoeiv <>f
the chest, and rigidity of the muscles, on attempting to move. He finst complained of
want of air, and requested the windows to be open. He died in from fourteen to twenty
minutes, his mind remaining deior until the last. In the case of Mrs. S. Smyth, of
IVnPQeyt tbre^ grains of StiychQJa were taken by mistake for Salacine. This lady wa^
Experimental Illustrations of Convulsive Diseases. 32d
io violent spasms, in from five to ten minutes afterwards, and sbe died in one hour and a
qaarter. A girl, aet. 13, took one grain and a half of Strychnia in solution on an emptj
stomach ; the symptoms b^an by twitchings of the muscles, rather more than an hour
after the poison was taken ; and she died in a yiolent tetanic fit, in two hours after she
had taken the poison. The sixteenth part of a grain of Strychnia, killed a child between
two and a half and three years of age in four hours'.
So powerful are the effects of this drug in certain cases that ordinary medicinal doses
can scarcely be borne. Symptoms of its poisonous action have been frequently
DDexpectedly produced.
It is not necessary to assume any such explanation as that given by Dr. Raddiffe in
the case of ordinary Traumatic Tetanus, which is closely related to Strychnia Tetanus,
in the character and severity of the spasms, and in the rigid condition of the muscles,
Qot only during the actual spasms, and also during the intervals between tham. There
are however, marked differences between the two states ; ordinary tetanus commencing
stiently and progressing gradually as various segments of the spinal axis become
ioTolved, the expression of the countenance at the same time, being peculiar and
characteristic ; Strychnia Tetanus, on the other hand, is announced by violent general
»pQsms, loud screams and moanings, and progresses rapidly to recovery or a fatal result.
In both conditions there is exalted activity of the ganglionic cells of the spinal axis ; in
the former, this condition is gradually induced by the propagation of the excitation to
different portions of the gray matter of the cord, and its prolongations ; in the latter,
(he poison dissolved in the blood is carried to the ganglionic calls, and at once and
directly excites their functional activity. These phenomena are far different from those
iodaoed by abstraction of blood, or by a deprivation of oxygen, or the accumulation of
carbonic acid in the blood. That Strychnia acts directly upon a definite portion of the
ganglionic matter of the cerebro-spinal axis is still further shown by the fact that whilst
it increases the irritability of the spinal cord, it does not materially affect the functions
of the brain ; and its effects will show themselves without essential modification, after
the head has been removed. Thus it has been observed by physiologists that if a
decapitated frog be poisoned with a moderate dose of Strychnine, the body and limbs
will remain quiescent as long as there is no external source of excitement ; but the
limbs are at once thrown into convulsions by the slightest irritation applied to the skin,
1$ for example, the contact of a hair, or of a feather, or even the jarring of the table
uo which the animal is placed. The following fact first noticed by Bernard, has been
adduced to show that the convulsions in oases of pojsoning by Strychnia, are always of
a reflex character and never spontaneous, viz : that if a frog be poisoned after division
of the posterior root&4)f all the spinal nerves, while the anterior roots are left untouched,
death takes place as usual, but is not preceded by any convulsions.
In this instance the convulsions are absent, simply because, owing to the jdi vision of
the poeterior roots, external irritations cannot be communicated to the cord. That
stTTchnine in large and poisonous doses, acts directly upon the ganglionic cells, and not
indirectly by causing congestion of the blood-vessels is shown by the interesting fact
r^beerved in the preceding experiments, and in those performed by Dr. R. B. Todd, that
in rapid poisoning by Strychnia, however great the excitement may have been into which
the cord has been thrown by Strychnine, it exhibits no change of structure which can be
detected by the microscope. The experiments of Professor Schroeder Van Der Kolk,
Xi) which I have referred in the first chapter of these Medical Memoirs, on the contrary,
appear to establish the fact that Strychnia may cause congestions of certain portions of
the spimd cord. Thus he says :
^* There has been a great deal of controversy, as to whether the gray matter of the antero*
Uteral or posterior columnB are at all sensitive or not, and on this subject the most conflicting
''•pinions have been broached, which are stated by Volkmann in a short reriew. Nerven
Phys. 1. c. p. 548.
*' In mj opinion the gray matter in the spinal cord serves solely for motion, the posterior
rather for reflex action and the coordination of movement, while sensation is transmitted
324 Experimental Illustrations of Convulsive Diseases.
DpwArds exclttsiTel/ through the posterior and lateral medullary coluniDa. That inch U the
case, I inferred especiallj from the phenomena produced bj strychnia in a dog: in slighter
attacks the hind feet acted first, and subsequently continued more rigid, the animal standing
upon them with the body inclined obliquely forward. Not only during these conrnlsions, bnt
even when the animal lay more than once upon the ground, with its feet stretched out in
tetanic rigidity, it had not lost consciousness of which my audience were witness with me ;
thus, when a white cloth was accidentally drawn from one side of the apartment to the other,
the dog followed it with his eyes and head, while it appeared from all that occurred, that be
did not experience the least pain. We also know, that after excessiTe doses of strychnia the
patients, without feeling anything, are suddenly seized with abnormal movements and coutuI-
sions. After the death of the dog, I examined the spinal cord and brain chiefly with the Tiew
to discover any congestion which might have existed in the several parts ; in the brain I met
no unusual degree of congestion, but I was particularly struck with a remarkable condition
of the gray matter of the lumbar bulb ; it presented in fact, numerous small effutions of
blood, JSfe alto Eeker, IHtt, land^ pp. 119, et seq.,) while in the medullary portion no abnor-
mality was found. In another dog killed under the influence of strychnia, I found in the
gray matter of the lumbar portion, aneurismal dilatation of the capillary vessels, which were
in consequence on the verge of bursting. Perhaps similar effusions had taken place, hot in
the sections I prepared I had not met with them. In both cases, however, the two homt of
gray matter were most beautifully injected with blood, as was evident after the sections were
dried and placed in Canada balsam' « « «
"Hence, it would appear, that after the administration of strychnia, great congestion and
irritation take place in the gray matter, which in the situation where they are most folly
developed as in the loins, may pass into effusion or dilatation of the blood-vessels, and still
all this occurs without any sensation, without any pain. Were the gray matter in the tpioal
cord sensitive, or did the sensitive nerves penetrate into the gray matter, such congestion and
irritation as excites in a sensitive nerve itself the most intense pain, could not be conceived
to exist without occasioning some sensation. Hence, it follows also, that reflex movements
cause no pain nor sensation in the spinal cord, so that by this observation, the direct ascent
of the sensitive nerves in the spinal cord, — of which I possess the most satisfactory prepara-
tions, is physiologically or pathologically, if we will, confirmed." Minute Strueutre and Funt-
Uon* of the Spinal Cord, pp. 77-70.
The accuracy of the ()b»en'atioua of ProfcHHor Schrocder Van Der Kolk, cannot be
(|Ue8ttoued, cHpocially too as lib obHcrvatious are accompaDied by a drawing of the
section of the spinal cord of one of the dogs poisoned by strychnia, displaying the
dilated and aneurismal capillaries and the circumscribed effusions.
As far as my observations extend, such changes are not uniformly present in the
spinal cord of dogs killed by large doses of strychnia in a short time, and I have been
led to refer the violent tetanic spasms to the direct action of the poison upon the gang-
lionic cells, rather than to congestion of the blood-vessels, which without doubt may
favor and promote convulsive action ; but rarely produce such violent tetanic spasma as
result in death in the course of a few minutes.
Pr. Todd has recorded the observation, that opium has the effect of caaatng a
similar state' of polarity of the cord, which is most conspicuous in cold-blooded animals;
and hence, he concludes, that opium should not be used in large doses, in cases of
Tetanus; and experience has shown the inefficiency and the injurious influence of this
drug when administered in large quantities.
A similar objection may be urged against Hydrocyanic Acid in the treatment «»f
Traumatic Tetanus, for it not only in large doses excites the reflex power of the q>inA]
cgrd and produces violent spasms, especially of the respiratoiy muaclea, but it altera
injuriously the blood and destroys the power of the heart. In such cases of spaamodic
disease, Conium and Belladonna have been found to exercise beneficial effects as seda-
tives.
Dr. R. B. Todd ascertained by sever&l experiments, such as the following, that the
inhalation of Ktber, has considerable effect in controlling the natural polar atAte of the
cord, as well as that which may be produced by Strychnine. A pigeon deprived of ica
cerebral hemispheres, lives in a state of sleep for a considerable time ; it fiiea when
thrown into the air, spreading and flapping its wings ; standing when placed on ita feet.
A bird thus mutilated, was made to inhale Ether ; it oould not stand) and when thrown
Experimental Illustrations of Convulsive Diseases. 325
10 to the air, it fell to the ground like a heavy log, its wings remain ing applied to the
sides of its body, or if the wings w^re drawn out, as it was thrown into the air, they
quickly collapsed. As soon as the effects of the Ether had passed off. it stood and flew as
bofore. Dr. Todd gave Strychnine to a rabbit, a Guinea-pig, and a dog, so as to excite
the tetanoid state. Immediately the spasms showed themselves. Dr. Todd brought it
under the inflaenoe of Kther, the spasms ceased immediately, and the animal became
perfectly relaxed ; but as soon as the effects of the Kther passed off, the spasms came
on again; but were soon subdued by a fresh inhalation of Ether. And thus, Dr. Todd
found that the life of an animal, poisoned by Strychnine, could be greatly prolonged
through successive inhalations of Ether ; for animals of the same kind, poisoned by
equal doses of Strychnine, but not subjected to the influence of Ether perished very
rapidly. (Cyclopaedia of Anatomy and Physiology, vol. iii, p. 721).
Dr. Samuel Jackson, of Philadelphia, informed me that in a series of experiments
which he instituted some twenty years ago, upon digestion. Strychnine was the agent
employed to cause death, and when Chloroform was administered by inhalation, the
effects of the Strychnine on the animals, was not only relieved temporarily, but in
several instances the dogs survived the action of the poison.
I have repeated these experiments of Drs. Todd and Jackson, on the effects of Ether
and Chloroform in poisoning by Strychnia ; and have obtained similar results, and these
must be looked on as the most valuable agents in the treatment of poisoning by
Strychnia, as well as of Traumatic Tetanus.
COMPARATIVK EXPERIMENTS ON THE ACTION OF POISONS, AND THE DIVI.SION
OF THE MEDULLA OBLONGATA, 1860, 1861.
Experiment 161 : Action of Strychnine on Warm- Blooded Animah,
Large, powerfol,^feRiale Bull Dog. 4 grains of Acetate of Strychnia in solution of excess
of Acetic Acid, were injected beneath the skin of the thigh ; symptoms of poisoning were
manifested in three minutes. The animal showed no pain or uneasiness, until a slight spasm
came on, aud succeeded by spasms increasing in violence and duration. These spasms were
separated by intervals of quiet and relaxation. During these intervals, the spasms might at
any time be excited by striking or touching the body with the hand. The spasms became
eiccedingly violent, and when the thorax was struck, it sounded like a wooden cylinder, an«l
the muscles felt as hard as steel : at such times it was impossible to feel the vibrations of the
beact.
The pupils were at one time much dilated and then became contracted. Death took place
io fevea and a half minutes. The respiration ceased before the action pf the heart. After
death, and at the moment of death, the muscles were relaxed, the mouth could be readily
opened, and the limbs could be moved in every direction ; cadaveric rigidity came on, 30
roinotes after death. The moment that the heart had ceased beating, the thorax was opened,
and the heart was found distended with blood. When the heart was pricked with the point
of a scalpel, not the slightest contraction was observed ; handling the heart produced no
rlTect whatever on its fibres. Artificial respiration was immediately instituted on opening
the chest ; this had no effect whatever, on the heart, it remained perfectly still.
loterropted galvano-electric currents were passed through the heart and the nerves sup-
plying It ; but in like manner, no effect was produced upon the heart ; the auricles and ven-
tricle* remained entirely unmoved ; no contractions were observed in the muscular fibres.
Tba electrical currents, on the other hand, excited marked contractions in the diaphragm,
thoracic muscles, and, in fact, in all the voluntary muscles of the body.
The peristaltic motion of the intestines had nearly ceased, and the electrical current pro«
daced but little effect upon the intestines — it excited some movement, but it was feeble and
of short duration. The poison had evidently acted upon the intestines as well as upon the
heart ; either upon the sympathetic system, or npon the unstriped muscular fibres.
It ii evident that the Strychnine acted directly on the gray matter of the spinal cord,
becao^e the tetanic spasms were simultaneous and universal in all the voluntary muscles,
and a tingle touch was sufficient to excite tetanic spasms in all the muscles.
KfteU an tke Umperaiure. — Temperature of rectum previous to the injection of Acetate of
Strychnia, 'AOo.9 C, 103^8 F.; during the yiolent spasms excited by the Strychnine, the tem«
peratore rose tligbtly, and stood at 40^ C, 104^ F. at the moment of death. Temperature of
326 Experimental lUustrations of Convulsive Diseases.
rectum 80 minutes after death, 38^5 C; 3 boars after death, 34°.3 C; 6 hours after death,
290.8 C. Temperature of atmosphere, 5B° F.
The artificial respiration was attended with cooling of the bodjr, which took place more
rapidly than in those animals thus poisoned, in whom no artificial respiration had been per-
formed.
Experiment 162 : Action of Pruisic Acid on Warm-Blooded AnimaU, performed
pari paisti with the preceding.
Three fluiddrachms of ofiicinal solution of fljdrocjanic Acid were tnjected into the tub-
cutaneous tissue of the back of a large, strong dog.
Three minutes elapsed before any symptoms of poisoning were manifested ; then followed
couTulsions, death-cry, or loud, distressed bark, long-drawn, gasping respiration, feeble
action of the heart, occasional spasms of the muscles, and death in 10 minutes.
The thorax was opened immediately ; there was a fibrillary motion or contraction about
the ventricles and auricles, which were distended with black, Tenons blood.
Artificial respiration was instituted; the action of the heart was very slightly Increased,
especially that of the auricles ; the interrupted galvano-electric current was also passed
through the heart; it produced a very slight increase in the feeble "flickering'' motions.
The diaphragm and respiratory muscles contracted under the action of the electrical stimnlas.
Although the heart continued to tremble or contract feebly under the artificial retpiraiioo, still
its action was exceedingly feeble, and in fact, its pulsations could hardly be considered as
anything more than vibratory motions of some of the muscular bundles. The peristaltic
motions of the intestines were very feeble. When the experiment was repeated in other dogs,
no action whatever was observed in the heart or intestines, and could not be excited by
mechanical or electrical stimuli.
Experiment 1G3 : Division of the Medulla Oblongata near the base of the Fourth
Ventricle : Large^ powerfd Bull Dog^
When the blade of the scalpel swept through the medulla oblongata, respiration ceased
immediately ; the intervertebral arteries were cut, and profuse hemorrhage took place.
Thorax opened 8 minutes after death, and several minutes later than in the preceding
experiments. The heart, which was apparently quiescent, commenced to pulsate as soon as
it was touched with the point of the scalpel. Artificial respiration produced a full and strung
pulsation. The electrical excitement produced strong and full contractions of the auricles
and ventricles. The heart continued to beat with regularity and vigor (or near one hour,
during the continuance of the artificial respiration.
When the intestines were touched with the point of a scalp^, the peristaltic motion was
excited vigorously ; the electro-magnetic currents accomplished the same effects.
The in-terrupted electric currents produced powerful effects upon the voluntary muaclee.
The diaphragm and respiratory muscles, and in fact, all the muscles, contracted wiih the
greatest violence ; the limbs were thrown in4o the most violent contractions, also the mas-
cles of the face, and when the current was passed throughout the length of the spine, the most
violent contractions of all the muscles were excited.
The vigoroua action of the hearty and the violent mutadar motions, were in most striking eoniraal viik
(hose of the dog9 poisoned with Strychnine and Prussic Add,
Effects on Temperature. — Temperature of rectum previous to destruction of medulla oblon-
gata, 40^.33 C. Temperature of atmosphere, 58^ F. Temperature of rectum 30 minutes after
cutting medulla oblongata, 39^9 C; two hours afterwards, 35^.45 C; four hours, 30O.55 C.
In the dog killed by Strychnine, the brain was pale, and not at all congested ; in the dog
killed by Prussic Acid, the blood-vessels were fuller, but not congested to a great extent;
whilst the brain of the dog which had been pithed was more congested than in the former
cases. The spinal cord was not specially congested in the three dogs ; and microscopical
examination of the nervous structures revealed no characteristic alteration which coold be
referred to the action of the poisons.
The heart was distended with dark blood, and its muscular structures were flabby aad
relaxed in the dogs killed by Prussic Acid and Strychnine, whilst it was small, contracted
and firm in the dog killed by mechanical means. The liver, in the dogs killed by Prussic Acid
and Strychnine was greatly congested. The blood-vessels of the intestines were also con-
gested and distended with dark blood, whilst they were not congested in the dog destroyed
by pithing.
Experiments JtJj, IfiTt, lOt), 107, ItiS, 169, 170, 171, 172, 173, 174, J75, 176, 177^
178 : RepetUimi of preceding Experiments ( 101, 102, 103), with similar rttultB.
Experimental Illustrations of Convulsive Diseases. 327
Experiments 179, 180, 181, 182, 183, 18 i, 185 : Repetitions of the experiments
on the action of Binoxide, Peroxide of Nitrogen and Chlorine Gas, on Mam-
maUa, tihutra^ng the stimulant effpct of these gases, and especially of tlie lattei;
and establishing the great value of Chlorine as an Antidote to tlie poisonous effects
of Hydrocyanic Acid,
The Bymptoms of poisoning by PnisBic Acid, dcsoribed in the preceding expenniente,
on animalu, are similar to those which have been observed in human beings. Bbcker
oonsidere that there are three stages in the symptoms of poisoning by Prussic Acid,
when the dose of the diluted acid is small, but at the same time sufficient to destroy
life : First, a sense of constriction in the chest — conYulsive breathing, with distortion
of the featores, giddiness, the eyes fixed, projecting and starting, oppression at the
heart ; second, convulsions, with opisthotonos, spasm of the larynx, of the urinary blad-
der, loud cries, involuntary discharge of urine and faeces, loss of consciousness ; third,
general paralysis, pulselessness, coma, relaxation of the muscles, general cessation of respi-
ration and pulsation of the heart, greatly dilated pupils, flow of frothy saliva, and death
in from half an hoar to one hour. In man, the symptoms follow each other with great
rapidity, or the third stage rapidly supervenes upon the first.
Aooording to Taylor, when a large dose has been taken, as from half an ounce to an
ounce Scheele's Add, the B3rmptom8 may commence during the act of swallowing, or
within a few seconds. It is rare that their appearance is delayed beyond one or two
minutes. When the patient has been seen at this period, he has been perfectly insensible
the eyes fixed, prominent and glistening, the pupils dilated and unaffected by light, the
limba flaccid, the jaws fixed, frothing at the mouth, the skin cold, and covered with a
clammy perspiration ; there is convulsive respiration at long intervals, and the patient
appears dead ; in the intermediate time, the pulse is imperceptible ; and involuntary eva-
cuations aae occasionally passed. The respiration is slow, deep, gasping, and sometimes
heaving, sobbing or convulsive When a small dose (i. e. about thirty drops of a weak
acid) has been taken, the individual has first experienced weight and pain in the head,
with confusion of intellect, giddiness, nausea, a quick pulse, loss of muscular power,
■hortoeas of breathing and palpitation ; these symptoms are sometimes slow in appearing.
An increased flow of saliva, as well as vomiting, has been occasionally amongst the symp-
toms when the acid was much diluted, but it is more common to find foaming or frothing
at the mouth, with suffusion, or bloated appearance of the face, prominence of the eyes.
If death results, this may be preceded by tetanic spasms, opisthotonos, and involuntary
evacoations. Vomiting is sometimes the precursor of recovery.
As in the case of animals, so also, with men, the action of Hydrocyanic Acid
resembles, to a certain extent, that of Strychnine ; but it also exerts a decided effect
oo the heart, not only by rendering its contractions irregular, and causing in the arterial
system, variations of pressure, but also by its direct action on the ganglionic cells-
The following conclusions may be drawn from the preceding experiments with Hydro-
cyanic Acid, Cyanide of Potassium and Strychnine on warm-blooded animals.
OBffEEAL CONCLUSIONS AS TO THE NATURE OP THE EFFECTS OF CEKTAIN POISONS,
AS HYDROCYANIC ACID, CYANIDE OF POTASSIUM AND STRYCII.^INE.
I. After the introduction of these poisons into the 3ub-<^utancous tJKsiic, or aflor
their application to the tongue and mucous membrane of the stomach, a certain period
of time elapses before the manifestation of the symptoms of poiHoning ; and during
this period the poison is absorbed, mingles with the blf)od, and is distributed to the vorious
organs and tissues, and is thus brought into contact with the ganglionic cells of thp
cerabro-spinal system.
Yariotia statements have been made as to the rapidity of the effects of Prussic Acid
in producing poisonous symptoms and destroying life, which have not been sustained by
the preying ^xperiQiepts, In the most suddenly fatal cases, the action has beca
328 Experimental Illustrations of Convulsive Diseases.
referred by some physiologists, to nervous action transmitted from the points at which
the poison touched the extremities of the nerves. The incorrectness of this view has
been shown by experiments, similar to the following performed by Blake. The portal
vessels of an animal being tied, seven fluiddrachms of Scheele's Acid were introduced
into the stomach on the *' sentient extremities'^ of the nerves on which the poison is said to
act. Ten minutes elapsed without the slightest effect ; the ligature was removed, and
one minute afterwards, the effects of the poison manifested themselves. It is evident
that those who give this explanation of the sudden effects of Prussic Acid, leave entirely
out of view, the fact that Hydrocyanic Acid is highly volatile, and that if a drop of the
pure acid be approached towards the tongue of a living animal, the add evaporates and
reaches the lungs by inhalation, and is immediately diffused over an immense
absorbent surface, before the drop of acid actually reaches the mucous membrane of the
mouth. It is well known that Prussic Acid is most rapidly fatal in the form of vapor ;
and I have been myself upon more than one occasion most seriously affected by the
vapon of the acid during my experiments. The time of the action of the poison should
be reckoned from the moment that its vapor reaches the capillaries of the lungs, and the
place of action should be considered the extensive absorbent surface of the bronchial
tubes, and air cells ; now it is well established that the poison may reach the heart and
cerebro-spinal and sympathetic systems in an almost inconceivable short space of time
from the lungs. That a sufficient interval elapses between the application of the acid
and the moment when its first effects are produced, to allow of its being brought into
contact with the central ganglionic masses, will be evident from the consideration of the
following facts :
Haller and Sauvagcs were the firet who tried to ascertain by experiment, with what
velocity the blood is carried through the vascular system ; their calculations however,
were erroneous, as they were founded upon the supposition that the movement of the
blood depended exclusively upon the action of the heart. Haller's oondusions reqwoCiog
the velocity of the circulation in frogs and small fish, are more correct, as they were
confirmed by autopsies ; but his observations were confined to oold-bloodeid animals, and
it is scarcely necessary to mention how hasardous it would be to infer from them the
velocity of the blood in warm-blooded animals. The same remark applies to the experi-
ments of Spallanzani and Dollinger. In more recent works on the snbjoot, the com-
parison of the quantity of blood contained in the ventricles of the heart, with the whole
mass of the blood, and with the number of pulsations in a certain time, was oonsidetvd
sufficient to determine the relative velocity of the blood ; a method, the uncertainty of
which clearly appears from the circumstance, that the quantity of blood cannot be made
out with precision, and that the number of pulsations and the capacity of the ventridea
differ very considerably in different individuals. Mr. Bering of Stittgart, found the
capacity of the left ventricle in horses, differing from 3 to 11 ounces, and that of the
right ventricle from 4 to 38 ounces.
M. Hering tried another method which seems to load to more accurate results. He
mixed a solution of the Cyanide of Potassium with the blood ; he then took at oertain
intervals, small quantities of blood from various parts of the body; and fiom the
chemical examination of these different portions of blood, and from Uie comparisoo of
the time which the substance required to arrive from one vessel into another, endeavor^
to ascertain the relative velocity of the blood. The experiments were performed upon
horses, and the following are the conclusions arrived at hy Mr. Bering.
Ist. The time within which the Cyanide of Potassium after having been mixed with
the blood, passes from one of the jugular veins into the opposite, is fh>m twontj to
thirty seconds ; from the jugular vein into the thoracica extecna, twenty-three to thiity
seconds ; into the saphcn magna, twenty seconds ; into the arteria mesenterioa, fifieeQ
to thirty seconds ; into the arteria maxilla externa of the opposite side, f^HB ten ta
twenty-five seconds ; and into the arteria mctatarai, from twenty to forty aeoonda.
i. The Cyanide of Potassium, withiu a very short time after its iptroduotioii inU>
Experimental Illustrations of Convulsive Diseases. 329
the blood is excreted by the serous membranes, but in small quantity. The time varies
from two to eight minutes.
3. In the kidneys the excretion appears to take place with the greatest rapidity ; in
ill experiments, within one minute after the introduction into the blood, the Cyanide of
Pota^um was found in the cortical, sometimes also in the tubular substance, and in a
few instances in the pelvis of the kidneys.
4. Only one minute is required to bring the substance from the jugular vein into the
thoracic duct.
II. Pmssic Aoid produces no absolutely uniform alterations in the ciiculation of the
cerebn)-n)inal system, recognizable after death ; and the cerebral and reflex symptoms
are not due to the engorgement of the blood-vessels. In some cases, the brain was not
it all congested, in others the veins were distended with blood; and the blood after 15
hoais showed a great tendency to transude through the coats of the vessels from its db-
organization, and thus inducing a much greater appearance of congestion and irritation
than actually existed at the moment of death.
The symptoms of cerebral disturbance — delirium, coma, expansion of the pupil, were as
strongly miirked in the cases in which the brain was not specially congested, as in the
cases in which it was most congested. Independent of those facts, it is evident that
the mere state of engorgement of the blood-vessels could not produce death in so short
• time. In some cases the spinal cord was not specially congested ; in others the veins
were distended with blood, and in ethers still, both the veins and arteries were filled
with blood. Violent spasms, opisthotonos and all the phenomena of aberrated spinal
Mtion were as well marked in one condition of the spinal cord, as in the other. We
are compelled from these facts, to conclude, that Hydrocyanic Acid produces no abso-
lutely uniform alterations in the circulation of the spinal cord recognizable after death ;
and that the aberrated muscular actions are not due to the engorgement of the blood-
Teasels of the spinal cord and its membranes. Independently of the fieict stated above,
it is evident that the mere state of engorgement of the Vessels of the spine, could not
produce death in so short a time. Careful microscopical examinations did not reveal
any uniform alterations in the ner>'ous elements.
III. The peculiar phenomena manifested by the cerebro-spinal nervous system, in
poiwning by Hydrocyanic Acid, are due to the action of the poison on the nervous
elementa conveyed to them by the blood ; to the action of the altered blood on the
nervous elements, and sudden arrest of the capillary circulation of the oerebro-spinal
nerves, in consequence of the action of the poison on the sympathetic nervous system,
and moscles and ganglia of the heart ; to the reflex action of the sympathetic system,
and to the complicated actions and reactions of the poison on the individual structures.
IV. In poisoning by Prussic Acid, the disturbances of the sympathetic nervous
tvstem are not less marked than those of the cerebro-spinal nervous system. The slow,
fiiJl respimtion, the slow action of the heart in some cases, and its feeble rapid action in
others, the feeble pulse, the diminution of temperature in the extremities, the rise of
tempeimtare in the trunk during the first stages of the action of the poison — ^the subse-
quent fall in the temperature of the trunk before death in some cases-— the acoumoladon
of the blood in the large veins of all the 9rgans and tissues, in most cases of poisoning
by Hydrocyanic Acid — the engorgement of the veins of the stomach, small mtestines,
s^een. liver and kidneys ; — the suppression of urine in some cases, all point to aberrated
ii4*rvoQs action of the sympathetic system.
The mere congestion of the blood-vessels of the sympathetic nervous system, could
not accoont for any one of these phenomena — in fact, if the sympathetic nervous system
presides more especially over the circulation, the stagnation of the blood in the vessels
of the sympathetic, and in fact in the blood-vessels of the ccrebro-spinal nervous system,
and of all the organs and tissues, is evidently the effect, nither than the cause of the
alienated sympathetic nervous phenomena.
From these facts it appears to be proper, to conclude, thj^t the i^berrated nervous
330 Experimental Illustrations of Convulsive Diseases.
phenomena of the Bjmpathetic Bjsieni, are due to the direct action of the poison, con-
veyed in the hlood on the ganglionic cells of the sympathetic ; to the action of the
altered blood on the same elements, to the congestion of the blood-vessek of the sym-
pathetic, and to the reflex action of the cerebro-spinal system.
If the disturbances in the action of the sympathetic nervous system do not precede,
they are certainly coeval with those of the cerebro-spinal system ; and are in both sys-
tems manifested precisely at the moment, when the blood containing the Prussic Acid,
reaches the nervous elements. The arrest of the action of the heart, and of the peri-
staltic motions of the intestines, must be referred to the direct action of the poison on
the sympathetic ganglia, and to the action of the poison on the unstriped muscolar
fibre.
y. Prussic Acid acts on both the voluntary and involuntary muscles, and decreases
or arrests entirely their property of contractility ; and aiter death from Prussic Acid,
in many cases it is impossible to excite contraction of the muscular fibres of the heart,
by mechanical or electrical stimuli.
m
YI. The blood is altered — its color is changed as if the Prussic Acid hadenteted
into combination with its coloring matter ; in most cases it coagulates imperfectly, and
in some not at all.
YII. Hydrocyanic Acid produces effects on all the organs and tissues, with which
it is brought into contact ; hence, we cannot affirm, that its action is confined exdusivelj
to the nervous svstem ; and more especially would it be impossible to affirm that ita
action is confined either to the cerebro-spinal or sympathetic nervous system ; or that
its primary action is on one or the other.
Prussic Acid induces alterations in the constitution of the blood, and through this
medium affects all the organs and tissues. We have also established that Prussic Acid
and other poisons, act on vegetables which are destitute of nerves, and hence, we may
conclude that it is capable of acting on all the individual cells of the living animal.
VIII. The effects of Cyanide of Potassium on warm-blooded animals, are similar to
those of Prussic Add.
IX. The lerions produced by Strychnine are not uniform.
X. Strychnine acts directly on the ganglionic cells of the spinal axis and sympathetic.
The action of the heart is arrested in Strychnine poisoning as well as under the aotbo
of Prussic Acid.
XI. The blood is much less altered in Strychnine poisoning than in Hj'droeyanic
Acid poisoning ; the latter agent appears to act directly on the colored blood corpusdei^,
forming a chemical compound with the coloring matter, and probably with the iron.
XII. In poisoning by Strychnine, the brain appears to be unaffected, and the action
of the poison appears to be concentrated chiefly on the spinal axis, and in this ngjtect
strychnine tetanus closelv resembles traumatic tetanus ; in both there is an exaltatioQ
of the reflex function of the spinal cord. But strychnine tetanus, differs from ordinarr
teCaous, in that the sympathetic system is involved equally with the spinal axis, and th'o
heart is poisoned and rapidly loses its power of action.
XIII. Prussic Acid Tetanus differs from ordinary Tetanus and Strychnine Tetanu9«
in that the entire cerebro-spinal system, and especially the medulU oblongata, as wcU
as the sympathetic system, and the Heart and Blood are involved.
XIV. A careful comparison of the phenomena of Traumatic Tetanus, with the
symptoms of poisoning by such powerful agents as Strychnine, Prussic Add, and
Cyanide of Potassium and Woorara, leads to the conclusion, that this disease arises
from tb« transmission of thoinri^^tion iq the wounded surfice ai»d pervesto the central
Experimental Illustrations of Convulsive Diseases, 331
gaoglioDic cells of the spiod axis, and that if the irritation be continued for a sufficient
length of time, structural alterations of the spinal axis are established.
XV. Traumatic Tetanus, although influenced in its origin and progress bj exter-
na] circumstances, and the state of the system at the time of the reception of the
injarj, is not caused by the generation within the system of a poison, which acts like
Strychnine, or Prussic Acid, or Woorara.
This conclusion will be still farther illustrated by the following tabular comparison
of the symptoms of Tetanus, Hydrophobia, Woqrara, Strychnine and Prussic Acid
PoiflODing.
Ei^rimetUal lUuttrations of Convulsiue Diseases.
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I
ill
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IP
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ill
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if HiHll
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Experimental Illustrations of Convulsive Diseases,
;ii|lliifiii hi
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334 Experimental Illustrations of Convulsive Diseases.
XVI. In the experiments on the action of Pnissic Acid and Strychnine, no post-
mortem elevations of temperature were observed. This point is of interest, in its
bearing on the action of certain poisons.
The interesting and singular &ct discovered by D3 Haen, of Vienna, about the
year 1760, that the temperature of the body may rise after death, was lost for nearly a
century, until it was revived by Royer, and Dr. Bennett Dowler, the distinguished
Physiologist of New Orleans, Louisiana, and carefully investigated by Wunderlich.
Adolph Valentine has recently endeavored to show, that the occurrence of post-mortem
heat is common to all dead bodies, the difference being only in degree. As far as this
subject has been investigated, it appears that the heat is most quickly and determinately
developed after death, from rapid injuries and lesions of the nervous centres, and
especially of the brain. Thus, in Cerebro-Spinal Meningitis, the tempermtore after
death, has risen from 104^ to 111° F. In Cholera, Huckkenet observed the ther-
mometer to rise from 79° to 92° F. after death ; in Variola, attended with much deli-
rium, Simon observed a rise of temperature form 104° F. at death, to 113° F.
afterwards.
No elevations of temperature on the other hand have been observed after death, in
near three hundred animals which I have destroyed in various ways, bat chiefly by
violent poisons.
CHAPTER V.
TBEATMKMT OF TRAUMATIC TETANUS.
Treatment of Trtainatic Tetanus. HiBtorical Notes on tho Treatment, illastrating tbe
methods adTocated bj Hippocrates, Aretsus, Galen, Celsus, Pelops, Paulus uEgineta, and
mtMj ancient and modern writers. Tabulated cases illustrating tbe results of treatment with
▼arioiit remedies. Discussion of the relative value of tbe different remedies. BJood-letting.
Section of Nerres. Amputation of affected limbs. Local applications. Mercnrj. Anti-
monj. Tobacco. Opium. Indian Hemp, (Cannabis Indica). Woorara. Sulphuric Ether.
Chloroform. Alcohol. Chloral Hydrate. Cold Bath. Warm Bath. Nutritious Diet. Uela-
tive Mortality from Traumatic Tetanus in Civil and Military Hospitals, and in Private Practice.
Relative Mortality in Traumatic Tetanus, under the different modes of treatment and in the
employment of various agents. Discussion of the modes of action of tbe various agents
employed in the treatment of Traumatic Tetanus.
It is important in Traumatic TetanuB, as well as in other diseases, to determine
whether the constitution be able to withstand an attack without the interference or aid
of medical treatment.
The study of the disease, uninfluenced by drugs, would furnish the proper data, for
the determination of the effects of remedial agents on its progress, duration and termin-
mtton. Such, however, is the violence of tbe symptoms, and such the alarming and
almost uniformly fatal nature of the manifestations of this disease, that the physician
has rarely had the resolution necessary to the calm observation of the disease uninflu-
enced by drags. The records of medicine, nevertheless, contain a few observations,
which show that when the respiratory muscles are unaffected, patients have sometimes
Msaed through an attack of even acute tetanus, without medical treatment. ' Thus, Dr.
MonisoD, Mr. Hennen, Mr. Morgan, Sir Astley Cooper, and others, have alluded to
cases of Tetanus, in which, although the patients were led entirely to nature, without
remedies, they recovered.
As Tetanus is of comparatively rare occurrence, the most distinguished physicians
and surgeons rarely witnessing and recording during their entire professional life, more
than a score of cases, I have deemed it of importance to give a condensed and con-
solidated statement, which should connect as far as possible, the outlines of the cases
actoally observed and treated, with the teachings of distinguished authorities, as to the
best methods of treating the disease. This was especially desirable \n the history of a
disease, which renders the human system capable of resisting the action of the most
violent poisons in fatal doses ; for by such an impartial comparison of actual observ^-
vatioDS and theoretical opinions, and empirical practice, we are enabled on the one hand
to emandpato our judgment to a great extent from the influence of mere authority, apd
on the other hand, to establish many important facts as to the laws which govern the
homan system, when subjected to that peculiar excitement uf the ganglionic colls of
the spin^ axis, which has been denominated Traumatic Tetanus.
We have therefore endeavored not only to consolidate and give the outlines uf more
than four hundred cases of Traumatic Tetanus, but also to embody the observations of
many of tho most eminent physicians and surgeons, with the hope, that the results of
oor Ub^n in os^amining many standard ^orks and journals, and tn analyzing and con-
336 Experimental Illustrations of Convulsive Diseases.
densing and oonflolidating a vaBt amount of practical observation and experimental
experience, may prove of lasting value to those who may desire to arrive without m
similar expenditure of time and labor at definite conclusions, as to what the Medical
Profession has really achieved in the treatment of this fatal and horrible malady.
HISTORICAL NOTES ON THE TREATMENT OF TETANUS.
Hippocrates recorded five cases of Tetanus in his work on Epidemical Diseases, each
of which terminated fatally. In the second chapter of these Medical Memoirs, in the
observations on the Natural History of Tetanus, I have given these cases in full as
recorded by Hippocrates. (See Cases 4, 5, 6, 7 and 8): in only one case, viz : that of
Scamandrus, has Hippocrates specified the treatment. In the appendix to his Treatise
on Regimen in Acute Diseases, directions are given for the treatment of Tetanus.
That Hippocrates was well acquainted with the fatal nature of Tetanus, and the
unsatisfactory results, if not absolute futility of treatment in this disease, is evident
from his axiom, that : " a convulsion coming on a wound is mortal." Hippocrates
appears to have employed in the treatment of Tetanus, the warm bath, fomentations,
venesection; glysters, purgativee, nutritious diet and wine.
Arettevs, (he Cappadocian, correctly refers the originW Tetanus to the nerves, and
gives an accurate and finished description of the disease, but records no cases. With
reference to the mortality occasioned by the disease, he remarks that Opisthotonos aad
Emprosthotonos, " are apt to supervene upon the wound of a membrane or of muaokas,
or of punctured nerves, when for the most part, the patients die, for jpeum from a
tcouna ii/ataV*
The following are the directions of AretsDus for the cure of Tetanus :
'* Now, indeed, a soft, comfortable, sDooth, coDniodioui and warm bed !i required ; for the
Derves become unyielding, bard and diitended. * * Let tbe house also be id a tepid con*
dition; but if in tbe summer seaiOD, not to the extent of inducing sweats or fatntness, for
the disease has a tendency to syncope. We must also not hesitate in having recourse to the
other great remedies ; for it is not a time for procrastination. Whether then the tetanus has
come on from refrigeration, without any manifest cause, or whether from a wound, or frona
abortion in a woman, we must open the vein at the elbow, taking special care, with respect
to the binding of the arm, that it be rather loose ; and as to the incision, that it be performed
in a gentle and expeditious manner, as these things provoke spasms; and take away a
moderate quantity at first. Yet, not so as to induce fainting and coldness. And the patient
must not be kept in a state of total abstinence from food, for famine is frigid and arid.
Wherefore, we must administer thicic honeyed water, without dilution and strained ptisan
with honey. For these things do not press on the tonsils so as to occasion pain ; moreover,
they are soft to the gullet, and are easily swallowed, are laxative of the belly, and very mach
calculated to support the strength. But the whole body is to be wrapped in wool, soaked in
oil of musk, or of saffron, in which either rosemary, fleabane, or worm -wood has been boiled.
All tbe articles are to be possessed of heating properties, and hot to the touch. We mvat
rub with a liniment composed of lemnestris euphorbium, natron, and pillitory, and to these
a good deal of castor is to be ad(fed. The tendons also are to be well wrapped in wool, and
the parts about the ears and chin rubbed with liniment; for these parts in particular, suffer
dreadfully, and are affected with tension. Warm fomentations also, are to be used for the
tendons and bladder, these being applied in bags containing toasted millet, or in tbe bladdera
of cattle, half filled with warm oil, so that they may lay broad on the fomented parte. Necea*
sity sometimes compels us to foment the head, a practice not agreeable to the senses, bat
good for the nerves : for by raising vapors, it fills the senses with fume, but relaxes the
nervous parts. It is proper then, to use a mode of fomentation, the safest possible, and
materials not of a very heavy smell ; and the materials should consist of oil devoid of smell,
boiled in a double reesel, and applied in bladders ; or of fine salts in a bag ; for millet and
linseed are pleasant, indeed, to the touch, but gaseous and of aa offensive smell. * « e
After the cataplasms, it is a good thing to apply the cupping instrument to the occiput oa
both sides of the spine, but one muRt be sparing in the use of heat, for the pressure of the
lips of the instruments is thus painful and excites contractions. It is better then to sack
slowly and softly, rather than suddenly in a short time, for thus, the part in which yon wish
to make the incision, will be swelled up without pain. Your rule in regard to the proper
amount of blood, must be the strength.
These are the remedies of Tetanus without wound9^
Treatment of Traumatic Tetanus. 337
Bui if tho spasm be connected witb a wound, it is dangerous, and little is to be boped. Wc
must try to remedy it, bowever, for some persons have been saved, even in such cases. In
addition to tie otber remedies, we must also treat the wounds with the calefacient things
formerly described by me, by fomentations, cataplasms, and such other medicines as excite
gentle heat, and will create much pus; for in Tetanus the sores are dry. Let the application
consist of the manna of frankincense, and hair of poley, and of the resins of turpentine and
pine trees, and of the root of marsh-mallow, and of rue, and of the herb fleabane. These
things are to be mixed up with the cataplasms, melting some of them, sprinkling the
others upon them, and lerigating others beforehand with oil ; but the mallow baying been
pounded, is to be boiled beforehand in honeyed water. We are to sprinkle also some castor
DO tb« ulcer, for no little warmth is thereby communicated to the whole body, because the
rigors proceeding from the sores are of & bad kind. Rub the nostrils with castor, along with
the oil of saffron ; but also give it frequently in the form of a draught, to the amount of three
oboU. But if the stomach reject this, give immediately of the root of silphium an equal dose
to the castor, or of royrrh| the half of the silphium ; all these things are to be drank with honied
water. But if there be a good supply of juice of the Silphium from Cyrenej wrap it to the
amonnt of a tare in boiled honey, and give to swallow. It is best given this way, as it slips,
Doperceived through the palate ; for it is acrid, and occasions disagreeable eructations, being a
substance which has a bad smell. But if it cannot be swallowed thus, it must be given dis-
solved in honeyed water ; for it is the most powerful of all the medicines to be swallowed,
which are naturally warming, diluent, and can relax distensions and soothe the nerves. But if
they can swallow nothing, we must inject it into the anus with the oil of castor ; and thus the
•nos is to be annointed with oil or honey. With this also we are to annoint the fundament,
•long with fat or honey ; and also foment the bladder ; and use it as an ointment, having melted
it with a sufficiency of wax to bring it to the proper consistence. But if it be the time for
eracuating flatulence and fasces, we are to inject two drachms of the purgative hiera along
witb the honeyed water and oil, since along with the expulsion of these it warms the lower
belly ; for hiera is both a compound and beating medicine.'' The Extant Workt of Aretausy
the (hppadoeian. London, 1856, pp. 400 to 404.
The Cyrenise Silphium, employed by Aretaeus, wa^ a superior kind of Assafoetida,
which at odc time p%w copiously in the region of Cyrene. See Paulus i£gineta, t. iii^
p. 337.
Pelops recommends dry, and not moist fomentations, in the treatment of Tetanus ;
and affirms that the most potent cure for emprosthotonos and opisthotonos, is a fever
mipenrening when there was none at the coinmencement. — ^The Seven Books of
Paulus ^Egineta, vol. i, p. 403r
Cselius Aurelianus enumerates nearly the same causes as Aretseus, and describes all
the symptoms of Tetanus with the greatest precision. His treatment also is very
eimilar to that of Aretieus, namely, emollient applications to the neck^ venesection, and
oily clysters. He enjoins the bath of oil, which has fallen into disuse in modem prac-
tice, most probably on account of the expense. He also permits sometimes the use of
cf>aimon baths, but not of cold water. He allows wine in certain cases. He condemns
Hippocrates for giving both wine and emetics, and having recourse to venesection,
without due discrimination. He blames him also for recommending the affusion of cold
water, inasmuch as he himself had pronounced cold to be injurious to the nerves, bones,
etc. Galen, however, remarks, in his commentary upon this aphorism of Hippocrates,
(Sec. V, 21), that cold, in this case, is not the direct cause of the benefit derived from
thin remedy, but that the shock which it imparts to the system proves beneficial by
rousing the vital hea t and energies of the patient. Hippocrates, however, forbade tho
cold affusion in Traumatic Tetanus.
Paulus iGgineta affirmed that Tetanus is to be cured, like convulsions, by depletion.
In reference to the ^^Cure of the Varieties of Tetanus," Paulus ^^gineta says:
la treating tetanic spasms, we must begin with phlebotomy, and wrapping the parts in
wool which has been dipped in oil, 'namely, theSicyonian and Castor, witb old oil; or a broad
bladder containing hot oil may be applied to the tendons. Cupping with scarificators is to
be applied, for dry cupping is hurtful. The neck, both sides of the spine, the muscular parts
of the breast, tha hypochondria, and the region of the bladder, or kidneys, should be cupped.
We mast not be sparing of the detraction of blood, nor yet take away too much at a time,
bat at interrals. The sweats sl^ould be absorbed by WQ(U 4ipp«<l in oil^ lest tl^e patient hap*
peo to oatcb cold.
13
338 Treatment of Traumatic Tetanus.
If the atlack of tetanus continue long, tbe patient must be put into a hip-bath of oil twice
a daj, but not allowed to remain long^ in it, for of all applications, the bath of oil. is the most
debilitatiug. Let him drink tepid hydroniel, boiled to the one-half; and the robust may take
a drachm of Opopanax ; or if not so much, three oboli, or at least one obolus, if we are afraid
of its proving injurious to the storoncb. We must also give gum Ammoniac; or Cjrenaic juico
to the size of a tare, made up with well-boiled honey, may be swallowed. Two spoonfuls of
the root of laserwort may be given in three cyathi of honied water, or in its decoction ; or
one drachm of myrrh in honied water, m the decoction of hyssop. But the least dangerous
and most effective remedy, is Castor, to the extent of two or three spoonfuls in divided doses.
And it will do no harm if you give it after a meol ; but the drink and the other things should
be taken slowly and by degrees, for if swallowed with difficulty, the drink regurgitates at the
nose, the violent agitations of which bring on convulsions. The anus should be smeared with
oil of rue, along with opopanax, and the same things are to be given in a clyster.
The affusion of cold water being as Hippocrates says, exceedingly hazardous, and for that
reason I suppose, rejected by succeeding authorities, we too are disposed to condemn. A
Linimtni of bard (Valerian), one scxtarius : of wax, oz ii : of malabathrum of amomum, of
storax, and of mastich, of each oz i : of castor, of ndarce, of euphorbium, of pepper, of each
oz i : of spikenard, of opobalsam, of each oz i.
A Potion for Opisthotonot — Of the root of panacea, of white pepper, of costus, of myrrh, of
poppy juice, equal parts, give to the size of the vetch called aracus, at bed-time. It is also a
remedy for orthopnoea. Let the diet be attenuant, of ensy diffusion, and by all means not
excitant. The Seven Books of ^Egimta^ Vol. I, pages 404-403.
Octaviufl HoratianuB, recomuieuds bleeding, emollient applications, purgative clysten*,
the tepid bath, antispasiDodics, and sudorifics. The use of the last mentioned class of
remedies, does not appear to have been sufficiently understood by the ancients ; at all
events, they were less partial to them in this case than the modems.
The Arabians, enjoin nearly the same treatment as the Greeks. Avicenna and Meusc
join the preceding authorities in recommending strongly the use of castor and assafue-
tida as antispasmodics. Avicenna, in common with many other ancient phybicians,
praises the bath of oil ; Serapion speaks of a bath prepared with emollient herbs.
Haly Abbas describes minutely the two varieties of tetanus, as occasioned by repletion
and inanition. For the former he approves of purging with hot drastic purgatives, i>f
nibbing the part aflfected with hot oils, and of using the warm bath, with frictions after
it ; he also approves of castor : for the other variety, he praises the affusions of plain
water in which lettuces, barley, etc., have been bt)ilcd. lie recommends the internal
use of milk and other demulcents, and the bath of oil and rubbing the body with oil of
violets. The treatment recommended by Alsaharavius is similar. Rhases, mentions
with disapprobation, Hippocrates' proposal of the cold affusion, but recommends bleed-
ing when there are symptoms of repletion, emollient applications to the neck, the bath
of oil, the application of leeches to tbe part affected, purging with alties, etc., the ad-
ministration of antispasmodics, such as castor, assafcetida and the like. I\tulu$ Ji^inda ,
Vol, If page 407.
A, Vomelivi CcfivSj says:
"That the varieties of Tetanus are cured by the same method; so far physicians agree.
But Asclepiades believed that blood should be let; some again affirmed that ought by all
means to be avoided ; for this reason, that tbe body then stood most in need of heal ; anti
that this resides in tbe blood of the veins. This indeed is filse. For it is not the nature of
tbe blood to be peculiarly hot; but amongst tbe several things which compose the hun&AQ
body, it most grows either hot or cold. Whether or not, it be proper to make this discharge
may be understood from the general directions, which were given about bleeding. Bnt ii i±
evidently proper to give castor, and with it pepper or User. Then a moist and hot foment ««
tion is needful, Therefore, most physicians, pour warm water frequently upon the neck
That relieves for the present, but renders the nerves more liable to cold, which is to be parii*
cularly avoided.
It is more proper then, first to nnoint the neck over with liquid cerate: next toapplr
ox bladders or bottles filled with bo^ oil, or a hot cataplasm made of meal, or pepper, braised
with a fig. But it is most suitably to foment with hot salt When any of these has b^^rn
done, it is fit to hrjpg tbe patient to the fire, or if it be summer time to the sun ; and to rnv>
his neck and shoulders, and spine with old oil, which is fittest for that purpose : if that c«o-
Upt be had with Syrian Oil ; \f that cannot be got, with the oldest fat. As friction is «erTtcfi-
Treatment of Traumatic Tetanus, 339
able to all the yertebrace, so it is particularly to those of the neck. Wherefore, day and night
bat at proper intervalsi this remedy must be used. When it is intermitted some healing
mal&gma must be applied. And cold is of all things to be avoided. And upon that account
there ought to be a constant fire in the chamber where the patient is nursed, and especially
Id the morning before day-light, when the cold is most intense. Neither will it be improper
to keep the head close clipped, and to moisten it with hot ointment of Iris, or the Cyprine, and
to keep it cuvered wich a cap ; sometimes to dip the whole body in warm oil, or in a warm decoc-
tion of fenugreek, with the addition of a third part of oil. A clyster also often relaxes the
superior parts. But if notwithstanding the pain has grown more severe, cucurbitals are to
be applied to the neck, and an incision made in the skin. Eschars are to be made either by
iroDS or mastards. When the pain is abated, and the neck has begun to move, we may know
thst the disease yields to the remedies. But all food that requires chewing must be avoided.
Grnels must be used, also sorbite eggs, or broth made of chickens, or some other tender
flesh. If this has succeeded, and the neck shall appear to be entirely well, we must begin
with pulse or intrita, well moistened. But the patient may sooner venture to chew bread
than taste wine ; for the use of thip is very dangerous, and therefore to be deferred for a longer
time.
A. Cornelias Celsus, Medicine, in eight books. Translated with notes, by James Greive, M.
D., Third fid.; London, 1838, pp. 166, 168.
As far as my information extends, Dr. William CuUea was 0113 of the first to advo-
vote the section of the affected nerve in Tetanus, thus he says :
" When the disease is known to arise from the lesion of a nerve in any part of the body,
the first, and I judge the most important step to be taken towards the cure, is by every
possible means to cutoff that part from all communication with the sensorium, either by cut-
ting through the nerves in their course, or perhaps by destroying to a certain length their
affected parts or extremity."
Wi^ reference to the value of Opium, Dr. Cullen expresses his belief in decided
terms, thus :
'^When the cure of the disease is to be attempted by medicine, experience has taught us
that opium baa often proved an effectual remedy ; but that to render it such it must be given
in much larger quantities than has been employed in any other case ; and in these large quan-
tities it may in this disease be given more safely than the body has been known to bear in any
other condition." ^
Dr. Callen not only advocates the use of Opium in large doses in tetanic affections,
bat he alao advises that it be given persistently at intervals according to the severity of
the symptoms, and to be continued for some time after their subsidence ; and he attributes
the failures with this remedy, chiefly to the timid and temporary manner in which it
hid been employed by practitioners. Dr. Cullen, also recommends purgatives, and the
frequent exhibition of glysters when the power of deglutition fails. He suggests that
Musk and Camphor might be employed with be&efit ih this disease, and in much larger
quantities than they commonly have been in other cases. With reference to the warm
bathing which had been commonly employed in the treatment of Tetanus with advantage
Dr. Cullen says, that so far as he knew, it had not alone proved a cure, and in some
cases either from the movement of the body or the fear of the bath, with which some
patients were seized, the spasms had been aggravated, and even death occasioned. On
the other hand, he was disposed by the testimony of many judicious practitioners, to
regard the cold bath as of great service in this disease, arising from cold, but of less
value in tetanus arising from wounds. With reference to Bleeding and Blistering, Dr.
Cullen observes:
" Bleeding has been formerly employed in this disease ; but of late it has been found preju-
dicial, excepting in a few cases, where in plethoric habits a fever has supervened. * *
Bliateriog also has been formerly employed in this disease; but several practitioners assert
that blisters are constantly hurtful, and they are now generally omitted." Firal Unet of the
Practice of Physic.
John Brown affirmed that the whole disease did not
Consist in spasm, and that the affected muscles are not the whole seat, but that there is
extreme debility in every part, but greater in the muscles than in any other equal part. His
S40 Treatment of Traumatic Tetanus.
treatment is based upon the view that Tetanus depends upon debility, thus be says : after
Tetanus has taken place, as the teeth are closed by the lock jaw, there is neither access to the
weaker and less powerful stimuli of food and drink, which are often sufficient for the care of
diseases of less debility, nor any sense in using them ; we must therefore immediately bare
recourse to the most powerful and the most diffusible stimuli possible, and continue their use
without regard to quantity, uot even to that of Opium itself, till the whole tumult of tbe
disease is allayed. — Elements of Medicine,
Neither Cullen nor Brown report any cases of Tetanus, in support of their views.
Benjunin Rush, of Philadelphia, affirms that Tetanus mav sometimes be arrested
after the appearance of the first symptoms, by an emetic, a large dose of laadanam,
the warm bath, and Peruvian Bark. He also states, that in '^ %nany hundred iMtafux*,^'
the most salutary effects had arisen during the first appearance of the symptoms, by
opening and diladng the wound, and by the application of such irritant substances, as
Spanish flies. Corrosive Sublimate and oil of Turpentine. Dr. Rush recommended
Opium in large and freauent doses, and wine in quarts and gallons daily. Dr. Rush
says that the cold bath nad been revived by Dr. Wright, of Jamaica, and had in many
instances performed cures of this disease ; he admits however, that this remedy had not
proved beneficial in the hands of some, and quotes the testimony of Dr. Oirdlestone, to
the effect that in the £ast Indies, the cold bath had uniformly destroyed life in every
case in which it was used. Dr. Rush has seen the happiest effects from the adminis-
tration of six or eight drops of the oil of Amber, every two hours in this disease.
According to John Hunter, in the treatment of Tetanus :
** All the anti-spasmodics hare been given, but without apparent success ; Opium has kepi
its ground longest, but with little reason, as it only quiets ; but from some patients bayioK
got well under its use, its name has been raised ; I have tried it both in large and small
doses, though always unsuccessfully. I think medicines have no power witbonl they pro-
duce some visible effect : Opium never removes the cause, though it will prevent the effects ;
it cures spasms and removes pain, but it does not remove the cause. It often does good, by
not allowing tbe symptoms to do harm to the constitution. The first appearance of a core,
is a recovery of strength, as weakness is a pre-disposing cause ; and the first indicatioo
should be to strengthen the system. I should recommend everything to produce external
cold, as cola applications, consisting of snow with salt, to the part, and that the patient
should be put into an ice house, or sent to a cold climate, as soon as possible. I know^of no
internal medicine. * * Electricity has a temporary effect in relaxing tbe muscles, and in
partial affections has cured by rendering the contractions less violent." Works of John
Hunter, edited by James F. Palmer, London, 1837, vol. i, p. 588.
John Hunter reeords four cases of Traumatic Tetanus; 1st, treated with Opinm, and
Bf^od'letting ; 2d, with Opium ; 34, Acetate of Lead ; 4th, AssafoDtidm and Opiom ;
each case terminated fatally.
Baron Larrey, who, without doubt, had a greater experience in the observatioo and
treatment of Traumatic Tetanus in different countries and climates, than toy other
military medical officer and surgeon, in direct opposition to the skeptical views of John
Hunter, and others, as to the value of remedies m this disease, lays great stress npun
the value of certain measures. Thus Baron I^arrey says, with reference to the locml
treatment :
" Experience proves that when tetanus is abandoned to the resources of nature, the patt^at
soon dies. The physician should hasten to counteract the symptoms presented by tbe disease.
The first object is to remove tbe causes of irritation, and to re-establish the tuppret9«^
excretions. This is to be effected by suitable incisions in the wound made before inilamitom*
tion takes place ; for should this be much advanced, incisions are useless and even dangerous ;
when necessary, we should include as much as possible of tbe wounded nervous cords mad
membranes, but incisions at the articulations are dangerous, and appear generally to increase
the symptoms of tetanus; I have seen examples of this. Caustic applications to the wo^nd «
may be made with advantage, on the first appearance of the symptoms, provided the •«■■»«
rule be observed as in the case of incisions. To these operations should suceeed bleedixi^ If
necessary, and the use of anodyne and emollient local applications, though these effects
generally feeble.
Internal remedies, whatever may be their properties, are almost always useless, bc^s^i
Treatment of Traumatic Tetanus. 341
the pfttieot in a short time after the appearance of tetanus, falls into a state of strangulation ;
but should this not take place in the eajlj stages of the disease, such remedies maj be
employed as physicians most confide in ; for instance, Opium, Camphor, Musk, Castor, and
other antispasmodics, given in large and gradnul doses." Memoirs of Military Surgery, yoI.
i, pp. 138-9.
According to Baron Larrey, mercurial frictions aggravated the disoase in Egypt ;
Cataplasms of tobacco leaves and alkalies, applied to the wounds, were productive of
no good effects ; and blisters applied to the throat did not arrest its progress. Moxa,
and the actual Cautery, although recommended by the Father of Medicine, were fol-
lowed bj the same results.
BaroQ Larrey not only proposed, but practiced amputation for the relief of Traumatic
Tetaous, believing as he did that, it is better to amputate the wounded limb as soon as
the symptoms of tetanus appear^ thin to relif on the uncertain resources of nature and
art to ^ect a cure. From his first series of cases, recorded in his Memoir on Trua-
matie Tetanus, contained '\\\ the first volunn of his Memoirs on Military Surgery^
Baron Larrey concludes :
Ist. "Thit of all the remedies propo:$cd by skilful pnictitioners, experience has proved to
me, that extract of opium, combined with camphor and purified nitrate of potassa, and dis-
solved in a small quantity of emulsion made from the cold seeds of sweet almond, and given
in strong doses acts most favorably, because the sick have a repugnance to all other liquids,
while they take this liquid with pleasure ; and that its effects may be seconded with venesec-
tion if neceasary, and by vesicatories under such circumstances as I have before mentioned.
2nd. ** That amputation performed at a proper time, is the most certain means of arresting
tetanus, when it is produced by a wound in the extremities.'' p. 15.3.
*
Id the second volume of his Memoirs on Military Surgery, Baron Larrey records
additional obiservations on Traumatic Tetanus, thus he says ,
** I have often removed the symptoms of incipient tetanus, by adopting such means as are
suited to remove its .causes, viz: by cutting the ligature of an artery in which a nerve is
incladed, and to which the patient refers all his pain, and where the nervpus irritation takes
iia rise. This division of the ligature arrested the disease in its forming stage, and expedited
the care of the woands. There is no dagger of haemorrhage if the vital powers be not debili-
tated, and there be no predisposition to adynamia. A few hours of direct compression, which
bring* the walls of the arteries into contact, are sufficient to induce adhesive inflammation,
as explained in the Memoir on Haemorrhage. In order to perform the delicate operation of
dividing the ligature of an artery, a grooved probe is to be introduced between it and the
artery, and the point of a very straight pair of scissors is to be passed down this groove to
cut the ligature. I have succeeded in this operation five times, • * *
Rpiapaatict of Cantharides applied to the wounds in which suppuration is suspended, and
the divided nerve irritated by contact of cold, moist air, will also prevent tetanus. When
these applications are made on the appearance of the first symptoms, the natural sensibility
of the diseased uerve, and the secretion of pus will be re-established. The cutaneous tran-
spiration is to be promoted at the same time by embrocations of very warm camphorated oil
ot chamomile, with the addition of tincture of opium, by covering the patient with flannel,
and by the exhibition of vermifuge medicines, if there be a suspicion of worms in the intes-
tines. I have used these remedies with success when cold has been the predisposing cause.
When I suspect the compression of a nerve, by the enlargement of the neighboring vessels,
or by the adhesion of parts of the cicatrix, I do not hesitate to apply the actual cautery until
I re«cb the points of the divided nerve, and sometimes I carry the cautery even to a greater
deptb. This application justly recommended by the physicians of antiquity, has produced
most surprising effects. By destroying adhesions and preventing the twitchings of the nerves,
it rrmoves spasm and irritation." Vol. II, pp. 300-301.
In his Sui^cal Memoirs, on the Campaign of Kussia, (rermany and France, Baron
larrey, states that after the battle of Dresden, (August 27th, 1813) :
'• Wonnds of the joints, and those complicated with fractures were thwarted shortly after-
wards by that sad affection tetanus, which we have so often observed, and almost always in
noist seasons or where the temperature passes suddenly from one extreme to another.
Among the means employed by us in its treatment, was the actual cautery applied to the
voaodi. This agent and the amputation of the injured limb, saved the lives of some patients,
342 Treatment of Traumatic Tetanus,
the historj of which cases I was not able to colleci in consequeoce of my bein;^ obliged to
follow the movements of the army/' p. 268.
Baron Larrey appears to have been the first surgeon to practice amputation for the
relief of Traumatic Tetanus : but, Mr. G. Hicks, surgeon of Baldock, is regarded as
the first to divide the nerves for the relief of Tetanus. He proposed to treat Hydro-
phobia, by dividing the nerves supposed to be acted on by the virus of the mad dog ;
and he instanced the following case of tetanus, in which this mode of treatment wai<
tried in 1797.
Case 60: Traumatic Tctaiuu cured bisection of the twrve^by Mr. G, Hick$^ 17U7.
A cooper was attacked with trhnius which appeared to come on gradually in the course
of a few hours, after a contusion of the palm of the hand. .Mr. Hicks saw hlra aboat three
weeks after the injury, at which time the Jaws had been completely locked for four days.
Observing at the seat of injury a tumor in a state of suppuration, be made an inctsion tbroagh
it, cutting down between the metacarpal bones with a view of ralievlng the nervons system,
by a division of the nerves affected. Opium was afterwards given in large doses, and the
next day the patient could open his mouth and swallow fluids with ease, the rigidity of the
mascles of the throat and face, being in a great measure relieved. London Med. and Pbv«.
Jour. Vol. XVII, p. 277.
Mr. John Hennen declares in his MilUary Su^rgtr^^ (London, 1821), 3d Ed. p. 241^ ^*
that he had never been fortunate enough to cure a case of Symptomatic Tetanus ; in
some instances of the Chronic species, however, he had effected, or witnessed relief: in
one instance in which a cure was effected by mercurial inunction, the patient expired
several weeks after of Mercurial Maragniiu : in another amputation of the wounded
limb relieved all the symptoms, but the patient died of a fever, which hung upon him
during the whole period of the complaint and carried him off in the sixth week. In
Mr. Hennen^s last case, venesection and the use of tobacco injection, (which brought
away enormous quantities of hardened fasces), after five days perscveranoe relieved all
the symptoms, and the employment of Ether and the Tincture of Opium in frequent
small doses, removed the occasional spasm that occurred, the bowels being carefully
watched. The disease lasted for seven weeks. But in another case precisely similar,
treated in the same ward, at the same time, on the same plan, and by the same medical
assistant, the usual fatal termination occurred on the 15tn day.
Whilst Sir James Macgrigor, was unable to say precisely the number of cas^s of
tetanus treated under the head of woundsy he states that there were some hundriHi
cases in the British armies, during the campaigns in the Peninsula of Spain and Pi^r-
tugal, which offered room for extensive trials of remedies. He gives brief historieBS nf
only six cases of tetanus which recovered, and after general observations upon the dif-
ferent remedies employed, concludes thus :
^' I am however, obliged to confess that little or no dependence is to be placed in %xi\
of the remedies, and I have to regret that the method of cure is yet to be discovered.
<* Judging from the very few successful cases, we may be disposed to trust principally to
blood-letting, purging, opium and digitalis. As the disease appears to terminate in frr^
sweating, in some of the few successful case?, Dover's powders may be useful, and the ve^t *>
able alkali and tobacco fume are deserving of farther trial."
With reference to Amputation, Sir James Macgrigor says :
<* Amputation as recommended by the Baron Larrey, totally failed in the fully formed «li«-
case: it was tried in many cases at Toulouse. Indeed I believe this gentleman's opinion it
altered since he published the result of his experience in Kgypt. I had soma coover^ntioi
with him on the subject, but I have been recently informed by Mr. Guthrie, that the B«rf>n
distinctly acknowledged to him, that the loss of the French army after the battle near Dreit«i<-n
was principally from Tetanus, when of course, this practice must have been fairly irirti
Medico Chirurgical Transactions, 1815. Vol. VI, p. 441i-4!)9.
Dr. J. H. Dickson. M. D., Physician to his Majesty's Fleet, after preneuCing sKioif
observations uu several very severe cases of Tetanus, which occurred in the woondtHl ff
Treatment of Traumatic Tetanus. 343
the BriUBh Forces, in the expedition against New Orleans, affirms that he was justified
in inferring :
**Tbat to the i m prove mentB in the medical and surgical treatment of wounds ; in cleanli-
ness and Tentilation, avoidin^^ at the same time exposure to currents of cold air, or sudden
changea of temperature ; in fine, to superior comforts, diet and accommodation ; but particu-
larly, to the greater attention paid to the state of the bowels, may be attributed the greater
infrequence of tetanus of late in the West Indies, when conipar(;d with former wars." Medico
Chirurgical Trans. YIII, p. 465.
Sir Qilbert Blane, says, that only three wounded men recovered in the whole fleet,
after the action of April, 1762. The wounded amounted to eight hundred and ten,
and sixteen of this number wehre destroyed by tetanus. Sir Gilbert Blane, expressed it
as the result of his experience, that the cure of tetanus, depends chiefly on the judicious
employment of Opium and the warm bath. He recommends that the opium be given
in moderate doses, often repeated, and he gives 93^, F., as the best temperature for the
bath.
]>r. James Carrie, in his Medical Reports, says that amongst the various remedies
which had been proposed in the treatment of Tetanus during the preceding thirty
years, only Opium, Mercury, the cold bath, and wine, seemed to be entitled to any reputa-
tion. In the use of the cold bath, Dr. Currie, appears to have been more successful in
Idiopathic than in Traumatic Tetanus. Mr. Benjamin Travers, on the other hand, in
his Further Inquiry concerning Constitutional Irritation, says that from the plunge of
the oold bath, he has seen the tetanic patient brought up a corpse, and has known an
hydrophobic patient expire in the spasm induced by the act of incising the wound.
Mr. Travers objects to opium, because it raises and swells the pulse, and for a time
at least augments the muscular energy, and in truth does not cease to do so until it
induoea a state resembling drunkenness, or congestive apoplexy. Antimony induces
nanaea and vomiting, purging and perspiration, and thus relaxes muscular power ; but
its eflTect is too indirect and uncertain, both as to its time and extent of operation upon
the nervous system, and too little controllable, within the limits desired, to recommend
itself to our selection in these cases. On the other hand, Mr. Travers advocates the free
and contioned use of the infusion of Tobacco, in the following manner :
**Tbe infusion of tobacco injected per anum, beginning with half a drachm of the dried
leafy to a pint, and increasing the strength to double, if indicated, may be employed with signal
effeet in calming tba apasm of Tetanas. It may be used twice or thrice daily with perfect
safety in the onset of the disease. It produces nausea, perspiration, and sleep, often of
boors continuance; but above all it diminishes its force and frequency if it does not arrest
the morbid action, and gradually restores the pliancy of the fixed and board-like muscles. To
eoaoteract its depressing effects, and indeed to support the patient, under the disease, indepen-
dent of all medicinal remedies, I give strong animal broths or jellies, and alcohol in the form of
brandy or wine, every hour or two ; and this I bold to be a not less important indication of treat-
ment. Patients bate been lost in Tetanus from want of proper nourishment and cordials, ofiener
than from want of proper medicine, pp. 30 1, 30G.''
Mr. Thomas Blisard Curling, after the examination of the records of 1 28 cases pf
Traomatic Tetanus, arrived at the following conclusions as to the treatment of this
diaeaae which I have condensed and consolidated from his Treatiiui on Tetanux.
Local Treaimenl, — Mr. Curling dismisses at once from the inquiry, the propriety gf
lunag the actual cautery, and other stimulating local means, to restore the suppurative
prooe» or healthy action, since such barbarous treatment is not sanctioned by experience,
and its utility is unsupported by any rational views of the pathology of the disease.
To prevent the propagation from the wound of the irritation supposed to be the cause
uf the disease, two plans have been adopted. 1st, Amputation or excision of the
woQoded part ; 2d, Division of the nerves proceeding to the seat of injury. In ampu-
tation many nerves are necessarily divided, and cases have been recorded in which Tetanus
was the soqncl of its performance.
Mr. Cfiriijig considers amputation as altogether so severe and serious a mode of
treaUog th^ clw?«t tho^ wft can scarcely ever be warranted in resorting to it, when the
344 Treatment of Traumatic Tetanus.
original wound is Blight, especially as if employed under the most favorahle circumstances
a successful issue can never be depended on . In chronic tetan us as patients usually recover,
it is certainly inadmissible, even when the wound is severe and in an unfavorable state*
unless its condition be sufficiently bad to demand the operation independently of the
spasms. Amputation can only be regarded as a justifiable proceeding after a severe injury
of the extremities, as a compound fracture or an extensive laceration, immediately that
there is the slightest indicatioh of spasms, for if delayed until the disease is more advanced
instead of proving beneficial, it will tend rather to aprgravate the symptoms and to render
the constitution less able to sustain the debilitating effects of the spasms. With reference
to the division of the nerves the same principle applies, for unless the operation be
performed very early, there can be little hope of a favorable result. When it is possible
to divide all the nerves proceeding to a slight wound, this plan is infinitely preferable to
amputation, since all the advantages of the latter may be obtained by an operatioD fiir
less painful, severe and serious in its consequences. Paralysis may be the immediate,
but is not likely to be a permanent result. This operation therefore may be regarded as
well worthy of a further trial.
Purgatives — As sources of irritation in the intestinal canal, and obstinate consti-
pation so frequently exist, too much importance cannot be attached to the employ-
metit of purgatives. A brisk Cathartic, by causing the expulsion of worma or unhealthy
fsDces, has produced almost immediate relief in the idiopathic form. One ^f the most
important consequences of the free operation of purgatives, arises from their ikToriog
the action of those remedies, which more immediately influence spasmodic contractions ;
indeed, until the bowels have been fully relieved, it is almost useless to resort to other
medicines. Those purgatives should be selected, which being nearly soluble, act
quickly and powerfully on the intestinal canal, as oil of turpentine, and crotoo oil,
especially the latter, since in addition to its active and rapid operation in eases of difli-
cult deglutition, a few drops upon the tongue, will generally be suiBcient to obtain the
desired effect. If any impediment to the evacuation of faeces is occasioned by spasm
of the spincter, or levator ani muscles, and if they are found firmly contracted, so
enema of an infusion of the tobacco leaf, containing laudanum, will most probably be
found successful. The action of the bowels must be steadily maintained thron^out
the disease.
Mercury. — Although Mercury has gained some repute, as a remedy in tetanua, the
evidence of latter practitioners, in regard to its influence in controlling the propress of
the symptoms is far from favorable. The constitutional effects of Mercuiy will not
arrest the disease, for patients have been known to expire with a stream of saliva
flowing from their mouths. Mr. Curling and others, have recorded casea, io which
extreme suffering was occasioned by the increased secretion- of saliva. Of 53 caacs in
the table of Mr. Curling, where Mercury was employed, 31 proved fttal. Of the 22
cases which recovered, in 20 Opium was combined with this remedy, and of the two
treated without it, in one tobacco injections were employed. In 11 of the cases in
which, neither Opium nor tobacco was resorted to, the Mercury being given alooe, or
employed in conjunction with some trival remedy, as the warm bath or blisten, afl
were fatal except one. Twelve cases of tetanus, consequent upon severe injuriea, are
related by Mr. Howship, in all of which Mercury was iiiUy exhibited. Two only
recovered, and in both of them it was given in conjunction with Opium. Aa the
symptoms may make considerable progress before the system is brought under itA
influence — as it can possess no specific power over the disease — and as debility '»
increased, the sufferings of the patient are seriously aggravated by the produdioii of
ptyalism ; in the pure traumatic form of the disease, the free use of Merooij mat K<
regarded as not only U8ele88, but exceedingly injurious.
Blood-Lettitig. — By cautiously analyzing the pathological characters of Tetaiiii^. it
has been attempted to establlHh a proposition of the highest import, in regard ta
the treatment of this disease, viz : that it u not estenHaUy an inflammatory ditmsr,
most cases of the traumatic form beingunaccompani^ with fobxite distaihaQoe, or with
Treatment of Traumatic Tetanus. 345
any symptoms indicating the necessity for active depletion. Aatoph logistic treatment
thcreibrc, is generally unnecssary for its removal ; but in these cases, where inflamma-
tion is the cause of tetanic irritation, which though rare in the traumatic. form, is a
frequent occurrence in the idiopathic, abstraction of blood may be highly beneficial.
With a view of removing congestion of the vessels of the medulla-spinalis, Mr. Swann,
and other practitioners, recommended the abstraction of blood in the course of the
spine. Numerous experiments and observations have shown that this state, not of con-
gestion, but of vascular excitement terminating in serous effusion, which it is contended,
is the effect and not the cause of tetanic irritation, is also a very frequent result of
excessive loss of blood ; hence, unless other circumstances indicate the propriety of
local depletion, such a practice should be adoped with the utmost caution, since in some
cases, it might aggravate, and in none is it likely to remove the disease. In traumatic
tetanus, occurring to a highly plethoric individual, with a hard and full pulse, but with-
out any symptoms of febrile disturbance, bleeding may perhaps be resorted to, with
advantage in the first instance. But at a more advanced stage of the disease, and in a
debilitated state of the system, even moderate bleeding is altogether inadmissible.
Although violent muscular action is maintained in an extraordinary manner for a con-
siderable time, yet great exhaustion is ultimately produced ; it is therefore always an
important object in the treatment of tetanus, to sustain the powers, so that the constitu-
tion may be enabled to withstand, both the debilitating effect of the disease, and the
depressing influence of those remedies best adapted to subdue the spasms.
Counter Irritation,^ Kither over the affected muscles, or in the course of the spine,
is of no service.
Varioua remedies^ as Cktrnpliory Miisk, Digitalis^ Stramonium^ Conium, ITj/oiciamu$j
Belladonna and Lead^ have proved utterly inadequate to allay the excitement in the
DcrvouB system, giving rise to undue muscular action.
Ouium.-^Or the numerous remedies that have been called in aid, in the treatment
of Tetanus, none have been more frequently, or more extensively employed than Opium.
And there is no question, that in many instances it has succeeded in allaying the
upasms ; but as it is resorted to, in, by far the greater number of tetanic cases which
occur, too much importance must not bo attached to its occasional success. Opium in
various forms, and in conjunction with other remedies was employed in 84 of the 128
cases of Tetanus in Mr. Curling's table, being more than two-thirds of the whole num-
ber. Of these forty-five recovered, of which ten were females.
In tetanus, as well as in hydrophobia and delirium tremens, there appears to be a
conventional license for the unlimited exhibition of Opium ; and yet the enormous
(loses in many cai^s exert not the slightest effects upon the system. Although in
Tetanus, the cerebral functions are undisturbed, yet Opium not only fails in allaying
^pasms, but is generally, e(|ually powerless as a narcotic ; whereas, in those cases in
which it controls the muscular contractions, its narcotic effects are invariably produced
at the same time. Morphia does not possess the constipating qualities of Opium ; and
in cases attended with difficulty of deglutition, its effects may be obtained by applica-
tion to the skin denuded of its cuticle.
Tobacco, — The earlier writers had great confidence in the efficacy of tobacco,
especially of the oleum tobacci, when applied externally to the neck and back. Tobacco
has two active principles, an essential oil and nicotine. According to the experiments
of Sir Benjamin Brodie, the former produces its effects on the brain, without directly
acting on the circulation. The latter influences the heart through the medium of the
nerves, rendering it insensible to the stimulus of the blood ; and it has been suggested,
that the spinal marrow is that part of the nervous syetem primarily affected. The
Hyinptoms occasioned by the influence of Tolwoco on the system, are extreme and alarm-
ing prostration, great reduction in the pulse, nausea, vomiting, tremor, syncope, cold
sweats, and paralysis of the muscles of voluntary motion. This state of prostration
liears some analogy to the state of extreme depression to which the spasms give place
just previous to death, after the more violent paroxysms of Tetaqtv*. But there is this
346 Treatment of Traumatic Tetanus.
essential and important distinction ; in the one case, prostration is occasioned by a sud-
den and powerful impression on the nervous system, which, if not carried too far, b
only temporary, the vital powers not being permanently impaired. In the ether, how-
ever, the powers of the system arc so completely exhausted, reaction cannot take place,
unless it be artificially excited, and very often, not even then. There is perhaps no
medicine, which tends so powerfully to relax muscular action as tobacco. Of nincU^t^n
cases in Mr. Curling's table, in which tobacco was employed, nine recovered. Of the
ten fatal cases, in several cases the remedy was either employed when the patient wa^
dying, or it was not fairly tried. Mr. Curling conceives that more has been adduced
in proof of the efficacy of tobacco, than can be adduced in favor of any other remedy
yet resorted to. He even goes so far, as to affirm, that he had not sucoeeded io
finding a single case, in which, being fully tried before the powers of the constitudoo
had given way, it has been known to fail. Many more cases have been cured by the
use of Opium, and for the obvious reason, that a far larger number have been treated
by it. Tobacco is a more certain and potent remedy than Opium, the latter hems, a
remedy that can never be relied on, having failed far oflcner than it has cured. Whilst
admitting that in its worst forms, Tetanus is a disease of too destructive a nature to lie
arrested by any treatment whatever, at the same time he held it to be the best remedy,
that the profession possessed at the time that he wrote his work, and a remedy which
will generally be found capable of diminishing the severity of the acute disease, and
often of subduing it altogether. The doses should be regulated by the age, habits,
and constitution of the patients, who, during its use, must be supported by a nourishing'
diet, tonics, wine and other stimulants. The carbonate of ammonia in particular, is well
adapted to counteract tho extreme prostration sometimes induced. At the commence-
ment, a scruple of the tobacjo leaf infused in eight ounces of water, will be enou^^h
for an injection, which must afterwards be increased in strength, in proportion to iu<
cflfects. A stronger infusion will be necessary for those who are accustomed to the use
of the plant as a luxury. Unless in Chronic Tetanus, baths impregnated with it, are
not only inefficient, but objectionable.
Antimany-^Autimonj being a remedy which diminishes the heart's action, and de-
presses the vital powers, has sometimes been employed for the relief of Tetanus. Of
ten cases in the table of Mr. Curling, in which antimony was resorted to, six were fatal^
but in these the disease was very acute. In the opinion of Mr. Curling, this remiHly
is best adapted to the more chronic forms of the disease, for although it has a dei^^ideii
influence in lessening muscular energy, its depressing effects arc too uncertain, and an.*
generally insufficient in power to arrest the course of the acute di.scasc.
Cold Affusion — It must be acknowledged that the evidence in favor of cold affu.<ion.
chiefly refers to cases of the idiopathic form of tetanus. With the exception of U>ha<x*«».
Mr. Curling knew of no remedy so well adapted to produce an impression on the ner-
vous system, of power adeqate to control the severe spasms of the disease, as cold affus^iiKi.
And he believed in the most aggravated cases, by perseverving in the applteatiou of it
until syncope or extreme depression of the vital powei-s is produced, the spasnus may U*
completely removed. Unless however, a powerful impression is made and kept up t*».r
some time, and the remedy repeated as soon as the spasms recur, it will prove ini'fft-* t
ual. The utmost care is necessary not to carry it so far as to take away all power *^i
reaction, and it may be desirable to administer brandy, or a diffusable stimulant duriiij
the application. The remedy pos8es.se8 this advantage, that other means fitted t<i rau^
the same effects, may be combined with it. Of twelve cases in the table of Mr. Curlinj.
in which cold affusion and other meatis were adopted, seven terminated favonJdv.
Ireatise oh Tetanus: PhxL, 1837, pp. 60-105.
The three objects of treatment upon which Mr. Lawrence placed reliance, wtn- :
first, venesection in the early st^vge, until the symptoms of general fulness of the v;i.M ti
lar system are removed ; second, the free exhibition of apeneuts, so as to remove oi>ti\* -
ncfis : and third, the cmploymeiit of opium for lessoning qj: controlling the very |iaiiitV.l
spasmg, lanott, January aOth, 1830, j>, 38i).
Treatment of Traumatic Tetanus, H47
Mr. O'Brien, has used the extract of hemp, (Hemp Reflin), in seven cases of Tetanus,
of which four were admitted in a hopeless state. He employed the remedy in ten grain
doses dLsBolved in spirit. The effect which he describes is almost immediate relaxation
of the mnscles, and interruption of the convulsive tendency. Of Mr. O'Brien's seven
cases, ft>ur recovered. In the Police Hospital of Calcutta, the late Dr. Baine, used the
remedy in three cases of Traumatic Tetanus; of these, one died and two recovered.
The preceding facts, says Dr. O'Shaughnessy, seem unequivpcally to show, that when
g;iven boldly, and in large doses, the resin of hemp is capable of arresting effectually the
progress of this formidable disease, and in a large proportion of cases of effecting a per-
fect cure. Lancety JS4O, pp. 539S40,
Dr. Marshall Hall, discarded the terms idiopathic and traumatic, and proposed in their
stead to divide tetanus into centric and eccentric. According to Dr. Hall, centric tetanus,
is that produced by disease within the spinal canal itself; eccentric tetanus arises prin-
cipally from a wounded, lacerated, or punctured nerve, and possibly from other sources,
as deranged stomach, deranged bowels, etc. Eccentric tetanus may therefore be both
traumatic or idiopathic.
The labors of Dr. Marshall Hall were important, in that they established correct
views of the essential nature and relations of tetanus. Thus he held that the influence
of the lesion of the nerve, is not only carried by exciter nerves to the spinal axis, and
reflected upon motor nerves, but it frequently pursues a retrogade course along the spinal
marrow ; a wound of the foot, not less than a wound of the hand leads to trismus. A
similar event occurs in experiments upon the decapitated turtle. If one of the lateral
nerves be laid bare, and pinched continuously, the muscla<) of the upper extremity as
well as of the lower arc forcibly contracted. This according to Dr. Marshall Hall, is
the very type of Tetanus. The treatment proposed by Dr. Marshall Hall however, con-
tained nothing new. Thus he says:
-'The principles of trcatmeat woald appear to be; I, to divide the injured nerve; 2, to
■ubdue the spasmodic affections bj such remedies as the Hydrocyanic Acid ; 3, to prevent
organic changes in the nervons system by depletion, general and local ; 4, to remove all
soarces of irritation as scybalae in the bowels, etc., and 5, to avoid all sources of augmented
spasm, such as shocks, noises, etc." Lectures on the Theory and Practice of Medicine.
I^neH^ February 14th, 183S, p. 69.
M. Matteuoot, appears to have been the first to recommend and apply the continuous
electric current in the treatment of Tetanus.
In a letter addressed to the Institute of France, M. Matteucci observes :
"That every natural philosopher who has made any experiments relative to the passage of
electric currents through the Itmbs of a frog, muat have remarked that the animal is seised
with a kind of tetanic convulsion, during which the limbs become rigid and inflexible. Volta
however remarked that by passing the current of electricity continuously, and in the same
direction, the contractions soon cease altogether."
Setting out upon this principle, M. Matteucci endeavored to apply it to the cure of
teCanos, and to discover how far the direction of the current, and the mode of intro-
<Juciog it might influence the muscular contractions. His first experiments were made
upon trogs, and from these, he concluded that the most advantageous method was that
of introducing the current in such a way us to determine the least possible contraction ;
he also found the tetanic state most readily overcome by the inverse current. Having
completed his experiments on animals, M. Matteucci looked forward with anxiety to the
time when he could apply the results to the human subject. An opportunity was at
l«»ngth offered by Dr. Farina, of Ravenno, who was called to attend a patient aflected
with tetanus, brought on by a gun-shot wound. The case was an unfavorable one, as
the muscles and tendons of the leg contained a great number of grains of shot, the
«-zciting cause of the tetanus being thus constantly in operation ; the remedy besides,
was not applied until ten days afler the reception of the wound, and at the very height of
the disease. The machine employed contained from 25 to 35 plates ; the electric ourrent
passed along the spinal marrow, from below upwards, for half an hour, without
348 Treatment of Traumatic Tetanus.
interruption ; it was repeated six times during ten days that the man lived. The
moment that the electric current was established the man became calm, to the surprise of
the numerous physicians surrounding him ; his muscles became relaxed ; the skin was
covered with moisture, and the circulation became tranquil. Such indeed was the effect
produced tha^ the patient constantly cried out for the electric pile. Unfortunately M.
Matteuod was confined to bed by a broken leg, and unable to direct the necessary obser-
vations ; the persons to , whom they were entrw^ted could not keep up the electric
current, even though the pile was renewed. Although the case finally terminated
fatally, the good effects produced wore so manifest, that M. Matteuoci looked forward
with confidence to favorable results, in future applications of the Continued Electric
Cfurrent in the treatment of Tetanus. Lancet, 1838, p. 350.
In his Report of seventy-two cases of Tetanus, occurring in Ouy*s Hospital, since the
year 1825, Mr. Alfred Poland has given i^ome interesting statistics, to which we have
before alluded. I will now record such facts as bear especially upon the pn^noeis and
treatment of the disease.
In thirty-two full years, there occurred seventy-two cases of Tetanus, in Guy e Hos-
pital, in 113,020, total admissions. There were sixty-two deaths in these seventy-two
cases of tetanus. Of the cases of tetanus, all had a co-existing or |previons lesion of
surface. The severity of the symptoms bore no relation to the degree of local injury.
In 86.56 per cent, tetanus occurred afler wounds of the extremities. The symptoms oc-
curred before the tenth day, in thirty-one cases in sixty-three ; between the 10th and
22d, in twenty-six cases in sixty-three ; above twenty-two days in six cases. The in-
terval preceding the attack did not determine the form of the disease, that is, that the
disease is sometimes of the severest and most rapid description when an interval of ten
days has elapsed. On the other hand, when the disease follows close upon the injury,
it IS for the most part uncontrollably rapid and fatal. As respects the mode of dyin^,
nineteen died during a paroxysm, with spasms and convulsions ; thirteen from asphyxia,
and suffocation, and ten firom exhaustion. In one case the heart's action continued for
some time after the patient had ceased to breathe. Of the sixty-two cases which ter-
minated fatally, thirty-two or 51.62 par cent, died' before the end of the fifth day. The
statement generally quoted in medical works, that if tetanus continue over a period of
twenty-two days, recovery is cer/aiit,was found to be incorrect; two of the cases at Guy's
were fatal, over this period, one on. the twenty-eighth, the other on the thirty-scoond
day. Ten died on the seventh, and eleven on the fourth day, while on no other
day did more than five die, and then it was on the third and sixth, or the days immedi-
ately preceding those of the highest mortality. With reference to the treatment
adopted : no benefit was experienced from local measures, which consisted in laying the
wound freely open, in amputation, in diviHion of the nerves near the scat of the
wound, in baths, and in applications of any description to the wounds.the spine, the
neck, spine and abdomen, and to the region of the diaphragm. The abstraction
of a tooth in order to administer food, in one c:uk;, was followed by immediate
death. In the constitutional treatment of two cases, those medicines which support the
system, and which would render the patient more able to fight against exhausting dificaMN
seem to have been most efficaccous. At all events, in the ten cases of recovery, quiniiM*
was given in seven, and in the others, wine, mush and tonics. Of the twenty-five ca^n^
in which quinine was given, seven recovered ; the doses were about one grain per hour,
given every third or fourth hour. Cannabi.H Indica and chloroform, remedies which are
in vogue in the treatment of tetauu.s in this country were of no service ; in moiit of the
cases in which chloroform was given, the disoitso was aggravated.
Dr. Jackson, (Indian Annals, October, 1853), has drawn up a careful paper on thi*
treatment of tetanus in the Native Hospital, at (Calcutta, with a view of showing that
great relief is afforded in that disease by the repeated inhalation of chloroform, aildtxl
to the internal administration of hemp and altn^ ; and in the latter stages, of quinia,
and generous diet ; and that many more ca.s4t8 of recovery haVe resulted from this plan
than from any other. It is worthy of remark however, that the same beneficial inHu-
Treatment of Traumatic Tetanus, 349
cnoe does not appear to be exerted in the cases of idiopathic tetanus, as in the trau-
matic form — this disease generally proving much more intractable. Only three cases of
idiopathic tetanus came under treatment at the Native Hospital during 1852, and they
all pioved fatal, whilst out of twelve cases of traumatic tetanus, there were seven re-
coveries and only five deaths. According to the old plan of treatment adopted in the
earlier part of the year, there yterejive out of seven admissions.
On the other hand, Professor Laurie, (Uiiisgow Medical Journal), has tried chloro-
form or ether inhalations in nine cases, all of which (except one of trismus) died. He
says:
"If no remedy jet tried bag douc good, niid ninny more have done linrm, how Are we to
treat tetanas? I reply negatively ; put the patient in a dark room, keep him absolutely quiet,
don't torture him with remedies which have been proved to be useless, give- him as much
nourishment as he can swallow, and trust the result to the power of his constitution. And
if the tpatmt are tevere alUviate them by chloroform y
Dr. Brcttou, (Philadelphia Medical Examiner), relatos a casj of traumatic tetanus,
which he considers to have been cured by chloroform inhalations. Mr. Harding,
( Lancet), speaks very warmly in favor of chloroform inhalations in tetanoid conditions.
l>r. Symes, (Dublin Hospital Grastette', details the particulars of a caso of traumatic
tetanus, in which chloroform inhalations were U3'jd with great su3C3S3. Rankin's
Abstract, 1854, p. 59.
Id a series of forty-three cases of tetanus occurring in various British Hospitals, and
reported in several numbers of the Medical Times and Gazette, 1854, chloroform was
tried in twelve instances, of which, eight died and four recovered. A writer in the
Medical Times and Gazette, June 17th, 1854, concludes after a review of these forty-
three cases,
Itt. ** That in a majority of cases, inhalation of chloroform may be practiced with safety,
as regards immediate consequences.
2d. " That it is always effectual in allaying spasm for the tims.
3d. *' That it exerts however, no preventive influence whatever, the spasms usually re-
turning with an increase of severity, shortly after its suspension,
4tb. '*Tbat its continuous administration over long periods of time, is not to be recom-
mended, since the patient sinks at least as fast, if not faster, than when the disease is allowed
to display itself.
5tb. " That it is of great benefit in certain protracted cases, simply as an alleviant of pain.
In Pome of these it will procure rest for periods, often of an hour or more after the suspension
of the inhalation, and acts altogether much more favorably than in earlier stages.
6th. *' That in certain protracted eases, it is of the greatest use, in enabling a patient
while in a state of half insensibility to take food, who would otherwise be unable to swal-
low.
7tli. '* That excepting for the two last named purposes, its use does not seem to be at-
tended by any commensurate benefit, while it may much interfere with the action of other
rrnedies, and may possibly be actively injurious itself."
The late Dr. Robert Bentley Todd* held, that the patholo^^ and clinical history of
tetanus, point out three objects, which the practitioner ou^ht constantly to keep in
view in it« treatment; viz: 1st. To support the .strength of the patient, so as to
oppose the exhausting effect of the convulsive paroxysms. 2d. To remove all possible
nrmrcoB of irritation, or of depreciation of the blood, by vitiated secretions, bad diet,
impure air. 3d. To diminish and reduce the exalted polarity of the nervous centres
to their normal condition, and if possible, to effect this by means which will not exhaust
or reduce the powers of the patient.
To fulfil the first indication, in addition to the various articles of food best adapted to
the aastmilating powers of the patient, administered in small quantities, and at short
intorrals, and also to wine or other alcoholic stimulants, the practitioner ought not to
^Medical Gazette, 1840, p. 7CG. Rankin's Abstract, I84fi, [p. 41. Clinical Lectures, on
Affections of the Nervous System, 1855, p. 276.
350 Treatment of Traumatic Tetanus.
•
withhold the liberal use of quinine, ammonia, iron, or other drugs, which czeri a tonic
power over the system in general.
In fulfilling the second indication, whilst the bowels are kept open, drastic pargattves
should be avoided ; too profuse sweating or diuresis should be guarded lagainst
*<To obtain the third object, namely : to reduce tbe polarity of the spinal cord, if at once
the most important and the most difficult. Tbn various sedative remedies, opium, bjrdrocyanic
acid, belladonna, conium, tobacco, have been fairlj tried and failed. Opium is not a sed-
ative to the spinal cord ; its use in tetanus may be laid aside, except in small dosea aa a
sudorific. In cold-blooded animals, it exalts the power of the spinal cord, and it is not im-
possible that in warm-blooded animals, it may have a similar tendency ; it is, therefore, a
remedy of little value in tetanus save as a sudorific, and in large doses it may be of an in-
jurious tendency.
" Neither is hydrocyanic acid a sedative to the spinal cord ; on the contrary, it tends to
produce epilepsy, and to excite the polar state of tbe cord, by induction from the brain.
Belladonna has a decidedly sedative influence, but it disturbs the action of the brain so much,
that it is not a safe or manageable remedy. The same may be said of conium. Tobacco
undoubtedly reduces the polar state of the cord, but it produces at the same time a state of
fearful depression. It is likewise an unsafe and not a manageable remedy. I have seen more
than one patient die, cured of tetanus, under this remedy.
'^ There are two agents which certainly exert a considerable power over tbe polarity of the
spinal cord, which have not yet been tried sufficiently fairly, and which I think fully deserve
to be put extensively to the test of experience. These are Cold and Chloroform. Of cold I
can speak favorably from my own experience; I have tried it by the application of ice in ox*
gullets to the spine, taking care to renew them frequently. • * * When cold liairly
reaches the cord, its influence is shown by a marked depression of the action of tbe hemrt,
which leads to general depression and debility. During the application of tbe bladders in
this way, ihcreased vigilance will be necessary in the administration frequently and at short
intervals, of nutritious and stimuliint substances.*'
Of the value of Chloroform and Ether, in the treatment of Tetanus and Tetaooid
affections, Dr. Todd confessed that he had had no experience, but he strongly advised
thier use iVom the results of experiments, which showed that these agents were capable of
exercising a most powerful controlling influence over the polar state of the cord.
The Crimean War appears to have added little or nothing to our knowledge of the
pathology and treatment of Tetanus.
The British Army during its service in Turkey and the Crimea, 1854-65-56, enjoyed
a comparative immunity from this disease ; only five cases occurred during the yearn
1854-5, viz: three at Scutari among the wounded, a fourth, apparently an idiopathic
case, was fatal on the 13th December, 1854 ; and a fiflh occurred in a patient who had
been a month and a half under treatment for dysentery, complicated with froit*btie of
the great toe, and ended fatally on the 20th February, 1855 — while daring the year
1855-56, only 24 cases occurred, viz : 23 in the Crimea, and one at home. One of tlie«o
Crimean cases followed frost bite, another was thought to be idiopathic and doc to
exposure to cold, but this was questionable, as the symptoms were consequent on an
injury of the foot; and the case which occurred in England, followed amputation f«»r
diseased bone, consequent on frost-bite.
This number is very far under what is believed to have occurred in any former catn>
paign, being (exclusive of the idiopathic cases, and those following frost-bite) 0.2 per
cent of the wounded. In the Spanish Legion, the proportion according to Mr. Aloock
Was 1.25 per cent, and in the Peninsula, the loss is known to have been very large froai
this cause, although the exact proportion cannot be ascertained. The causes of ihi«
immunity, notwithstanding the vust variety of wounds inflicted, the hardMhip0 and
fatigue endured by the tnmps, and the defective and improper kind of food so long wnfv.
plied to them, are not clear. The very simple mode of dressing wounds, univemlly
adopted by British Surgeons, may not have been without its influence ; and ponubly
also the universal practice of bringing the sides of the wounds in opposition by 80tnr\*.
position, etc., and not stuffing them with charpie, or other irritating subatanoea, under
the idea of favoring granulation, absorbing discharges, etc. The nearly total abtenee of
Treatment of Traumatic Tetanus.
355
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352 Treatment of Traumatic Tetanus.
336 tenninated .fatally ; of the 27 recoveries reported, the dieeaso is faid to have been
of the io-caUed "chronic form/' in 23 ; in the remaining four coses, the symptoms were
very grave. In two, recovery took place under the use of opiates and stimulants ; iu
two, after amputation of the wounded part. In the Federal service there was only one
recovery in every 14.2 cases ; and 92 per cent, of the cases terminated fatally, which is
very nearly equal to the mortality in the Confederate armies, viz : 91 per cent.
It is very evident, that during the Civil War of 1861-1865, in both the South-
ern and Northern Armies, treatment had little or no influence in lessening (he rate
of mortality.
In the Federal service, the great majority of cnscs were treated by the free u«e of
Opium combined with stimulants, and concentrated nourishment. Chloroform inhala-
tions were very generally employed during the paroxysms of spasmodic contraction.
Sub-cutaneous injections of the falts of morphia and atropia were frequently uK:d.
Cathartics, Quinine, Camphor, Cannabis Indica, Bromide of Potassium, Stijchninc,
Belladonna and Aconite, are mentioned amongst the remedies used. Cups, blisters,
turpentine, stupes and ice were among the applications made to the spine ; and fomen-
tations with Opium or tobacco, were in £cme cases applied to the wound. Amputation,
the division of nerves and the extirpation of neuromata in stumps, were the surgical
measures sometimes employed. The value of Nicotine of the Calabar bean, and of
Curare, as curative agents in Tetanus, was not tested. According to H. Demnc of
twenty-two cases of Traumatic Tetanus treated with Curare, eight recovered. Circular
Ko, 6*, War Department^ Surgeon Generars Office, pp. J^l, J^ii.
No light appears to have been thrown upon the pathology or treatment of Tranioatic
Tetanus, by the surgeons of either the Confederate or Federal Armies, during the recent
bloody gigantic and protracted Civil War.
Chloral Hydrate is at the present time on trialy as a remedy in Traumatic TeCanua
and convulsive diseases generally, and thus far, the results of its employment have on
the whole been favorable.
Dr. William MacLeod, Deputy Inspector General of Hospitals and Fleets, remarks
with reference to the action of Hydrate of Chloral in Paralysis of the Insane and i>tbcr
forms of Insanity, that the facts which he had observed forced him to conclude :
1st. That in Paralysis of the Insane, when the patients are destrnctire and Tioleni, tbe
judicious administration of Chloral acts as an excellent hypnotic by night, and soothing ageot
by day.
2d. That under its action the patients hare been free from destructive habits, and hare
gained in weight and strength.
3d. That in one case as much as 2,810 grains were taken during ninety-fire days, the
average taken being 30 grains, with no bad symptoms. In a second case, as much as 2.4^.%
grains, were taken during 122 days, being- at the rate of 22 grains daily; when the patienta
gave evidence of prostration. A third patient took 2,380 grains during eighty days, the daily
average being 20 grain?, wiih no bad symptoms. A fourth patient took 1,3G3 grains donr'i;
sixty-seven days, the average being 20 grains daily, with no bad symptoms. A fiflh patient
took 510 grains in twenty-four days, giving a daily average of 25 grains, with no bad synip*
toms.
4th. That under it the action of the bowels and bladder have improved.
5th. That in no case has there been a refusal of food ; on the contrary, the appetite of the
paralytic patients increased.
6th. That patients suffering frum abnormal sensation, derived much benefit from it.
7th. That in patients subject to hallucinations on hearing, with suicidal tendencies, it has
cut short the hallucinations.
8th. That in patients liable to hallucinations of hearing, and under their influence be covirg
noisy and excited, it has produced calm.
9ih. That in patients with a propensity periodically to maim and hurt tbemeelvea, tbe
disease has passed away under the influence of Chloral. * *
loth. In certain ca^es of melancholia, benefit was derived from its administration, a: i
convalescence advanced. ♦ •
nth. That the greater the disorganiEation of the brain and cord, (as judged by the sjmp.
toms, and especially by thermometric observations] tbe sooper dQes the system come uc^rt
the Chloral action. J'rariidoner, Aug,, 1870,
Treatment of Traumatic Tetanus.
357
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386 Treatment (^ Traumatic Tetanus.
by Dr. Brady, the symptoms appeared in twenty hours, and death followed in Hcvcnty
hours, and in another case reported by the same obserrer, the symptoms appeared ou
the following day, and the patient died in twenty-four hours.
At the same time, some of the severest and most rapid eases occurred, when an in-
terval of more than nine days had elapsed after the reception of the injury, as in cases,
100, 102, 115, 119, 122, 131, 135, 136, 138, Ui), 147, 148, 149, 158 159, 160, 170,
179, 193, 199, 211, 237, 244, 245, 282, 308, 355, 373, 382, 385, 380, 391, 392, 397,
404, 424, 431, 437, 438, 443, 446, 456, 458.
Afler a careful examination and comparison of the different methods of treatment,
recorded in the preceding table, whilst it will be found to be impossible from the heroic
use of the most powerful remedies and ])oi8on8, as well as from the constant interchange
of the remedies, without any apparent reason or system, to determine whether the relief
should be ascribed to one or more remedies, or to the natural powers of the patient,
which owing to the peculiar nature of the nervous excitement, resisted successfully the
action of the most powerful drugs and the effects of this terrible disease ; at the same
time, the table abounds with facts, illustrating the value of certain remedies and general
principles of treatment.
Case 263, treated by the injection of tartar emetic into the median vein, and case 394,
treated by sub-cutaneous injection of woorara, were evidently and directly destroyed by
the measures instituted by the attending phynicians.
Our knowledge of the therapeutics of Traumatic Tetanus, would be extended, if .it
were possible to classify with any approach to accuracy, the cases in accordance with
definite plans of treatment, or with the individual remedies employed, but fur the
reason juft assigned, this is to a great extent impossible ; but we may express the hopi*,
that the medical officers of armies and navies, and civil and military hospitals, will a^s
far as possible, institute definite plans of treatment, and test thoroughly by carefully
recorded observations, the relative value of those remedies which arc employed with
most confidence and frequency in the treatment of this disease. If such practiiiJ in-
vestigations be at the same time combined with careful obser>'ations on the symptonui
and pathology, it is but reasonable to believe that the doubt and uncertainty which h:i>,
throughout the entire history of Medicine, involved the therapeutics of this dreadful
disease, will be gradually, butsuR'ly dis.sipat4*d, and physicians will be enabled to adopt,
with some approach to certainty, that plan of treatment which will promise the highlit
and best results to the patient.
The following practical conclusions may be drawn from the precinling facts :
1. An imnortant advance in the trciitment of Traumatic letanus wtmld l)e made if
it were possible to institutt* efficient measures for the arrest of the disease in itM earlie^^t
stages. Lassitude, restlessness, great depression of spirits, an unea.Hy sensation about
the pnccordia^ cold chills, and an uneasiness about the throat, leading the patient to
imagine that he had caught cold, slight stiffness of the mu.Hcles of the jaw, and twitrli-
ings of the muscles of the injured limb, have justly been reganliMl as premonitory symp-
toms of this disease, and it is important that decided and efficient mciuturcH should Ik*
devised for the aversion or arrest of the atUu-k.
Kecently the following ca.se came under my treatment in private practice, in which
an opportunity was afibrded for the institutiou of mcasurcb designed to am*s>t the fiix
symptoms of Traumatic Tetanus.
•
Cabs 481. — A geDileman, age 36, whilst stooping down in his yard with a hcii io hU h.«i. j
which be had just caoght, was attacked by a spirited game cock, which drove one ofhi^Ion^.
sharp spurs into the posterior surface of the forc-nrm, in the muscular space bettrcen tli<
uloar and radius, just below the elbow-joint. The arm commenced to swell immedii&tc^x .
and in tweWe hours the patient suffered severe pain in the injured arm, with twitcbings of
the muscles. Upon the following day the nervous symptoms increased, with lassiindc, rest-
lessness and great depression of spirits. Tpoa the evening of the second day, the patuni
complained of uneasy sensations in the throat, with twitchings of the muscles of the ja»,
aroi and leg of the side upon iQchich the injury had been received. In attempting to walk th^
Treatment of Traumatic Tetanus. 387
spasms were so severe as to tarn the patieDt violently around, and almost to throw him
down.
The local application of the Tincture of Iodine, and the introduction of a tent smeared with
ludine ointment into the wound, (during this operation the patient fainted), established free
suppuration, and by the counter irritation of the Iodine relieved the pain in the region of the
nerves leading from the wound.
Hydrate of Chloral administered in doses varying from ten to thirty grains at regular
intervals of from one to four hours, relieved the spasmodic affection of the muscles, and full
doses of opium at bed time induced quiet sleep ; and under this treatment, at the end of ten
days, all symptoms of Tetanus disappeared.
A similar plan of treatment was successfully pursued by the author in the case of
hi.s own child, Fannie Polk Jones, set. four years, who was bitten June 10th, 1875, by
a j)et dog, just above the knee of the right leg. On the third day, alarming symptoms
appeared, as great rigidity of the muscles of the right leg and thigh, which extended
rapidly to the left lower extremity, causing firm flexion of the limbNS and preventing
locomotion. The sleep was disturbed, and the child emitted a piercing shriek when-
ever I touched the wounded leg. On the second night slight spasms were noticed in
the muscles of the upper and lower extremities, and during sleep the thumbs were
firmly flexed. I administered four grains of Calomel, and followed it with Castor
Oil in six hours, and thus evacuated the bowels. Tincture of Iodine was freely
applied to the wound, and followed with flaxseed poultices mixed with oil of Tur-
pentine and Laudanum. Laudanum and Bromide of Potassium were abo adminis-
tered internally after the bowels were evacuated. The poultices were large and renewed
every 4 or 6 hours. Under this treatment the spsuims entirely disappear^ in the course
iif 5 days.
The l(x»l measures which appear to bo most suitable for the arrest of Tetanus in
the earliest stages, are :
fi. Counter irritation, with the Tincture of Iodine and Ointment of Iodine applied
within and around the wound. This application should be followed by warm
[M)ultiees of flaxseed or bread and sweet milk, to which Tincture of Opium should
Im; added. The poultices will in like manner tend to promote suppuration in the
wound. During the past twenty years I have used with good results the Tincture of
IcMlinc as a local application to such wounds of the extremities as are known to be most
rrei|uently followed by Traumatic Tetanus, sus penetrating wounds of the hands and
ff«?t inflicted by splinters, glaws and rusty nails. When poured directly into the wound,
4*ven within a few momenta afler its reception, it produces no increase, but rather a
diminution of pain. The application should be repeated every day, or every other day,
:lm long as the wounds are painful and inflamed. In dissecting wounds also I have
found no agent su|)erior to the Tincture of Iodine for the arrest of the poisonous action.
In some caites a satunited solution of (Vrbolic Acid in Alcohol may be used as a local
applicaticm immediately t(» the wounded surfaces. An ointment composed of two
<inichms each of the Tincture of Iodine, saturated solution of Carbolic Acid in Alcohol,
and Tincture of Opium, mixed thoroughly with from ona to two ounces of Simple
( Vrate, has proved in my hands a useful application to wounds of this description.
Ad efficient sedative application to the surface of the injured extremity and to the
hack over the region of the spine, will be found in a liniment composed of e(|ual parts
of (-hloroform, (ium (Camphor and Tincture of Opium, mixed with from two to four
parts of Olive Oil. The Camphor should first be di.'^solved in the Chloroform and this
dilution mixed with the Tincture of Opium and Olive Oil. The injured limb may be
ntblied with this, and also enveloped in a piece of soil lint saturated with it.
h. The Carkful Rkmoval of all Foreion Boihrh from the Wound. — The
iiiifi«>rtance of a ^thorough examination of the wound and the removal of all foreign
Ii^Klies, was forcibly illustrated during the recent civil war, by the following cases, which
were treated in the General Hospital, at Charlottesville, Virginia :
In the first case, after death, a piece of the leather cartridge box was found buried
in the triceps muscle. The ball had passed through the arm ; the probe in like man-
388 Treatment of Traumatic Tetanus.
ner passed readily through from the point of entrance to that of exit, and hence the
extraneous body waH not discovered durin<; life. In this case the npasms appeared at
first to be confined to the muscles of. the arm, and Dr. Cabell at first supposed that it
was a case of ^' traumatic spasm." The spasms were confined to the wounded arm for
two or three days before they affected the general .system. The second case mani-
fested local spasms similar to those of the case just recorded, the spasius being confined
to the wounded limb. After the removal of a piece of cloth from the wound of the
leg, the patient recovered. It appears to l)e a fair inference that if, in the first case,
the piece of leather had been removed from the arm before tlie spasms became general,
the patient would, in like manner have recovered. Such cases support, in the clearest
and strongest manner, the theory that traumatic tetanus is primarily, in its earliest
stages, dependent upon local lesions of the nerves, the irritation being gradually propa-
gated to the segment of the cord with which the injured nerve is connected, and from
thence propagated to the ganglionic cells of the entire spinal axis.
c. Actual Cautery. — The application of the actual cautery to the wounded sur-
face appeared to be attended with beneficial results in certain cases of traumatic tetanus,
and Baron Larrcy was the most strenuous advocate for it» use. Causes 95, 96, 97, 98
and 99 illustrate the beneficial efi^ects of the actual cautery. It is probable, however,
that the Tineture of Iodine, and the saturated solution of Carbolic Acid in Alcohol will
accomplish as efficient and satisfactory results, and with less pain and inconvenience to
the patient. In case 342, the application of the actual cautery (a heated poker pres.sed
into the wound), was said to have been attended with a sensation of pleasure rather
than of pain, the patient exclaiming, '' What are you doing? Delightful ! You make
me feel as if I were in heaven ! "
d. Section of the Injured Nerve, Amputation, and the Application to
THE Wound or Cicatrix of the Actual Cautery, have, when employed in the
earliest stages, before the spinal axis has been seriously involved, been attended with
apparent benefit in arresting the farther progress of the disease.
Such measures are only valuable when the irritation is chiefly confined to the injured
nerve. After the irritation has been fully established in the spinal axis, it is doubtful
whether amputation, section of the nerve and the actual cautery will materially slier
the progress of the disease. Wo have carefully recorded the historical facts relating t4i
section of the nerves and amputation, as proposed by William Cullen and practiced by
U. Hicks, Baron Larrey and otheis. (See cases (iO, 91, 93, 94, 112, 118, 132, 137,
172, 178, 181, 228, 257, 2GG, 329, 338, 343, 345, 35G, 3G1, 3G7, 370, 371, 372, 3S0,
402, 447, 470J. In the employment of such measures, the physician must be gi>v-
erned by the general symptoms, as well as by the nature and position of the wound.
2. Absolute rest of the injured part; and quiet rest of the patient in a dark
n)om of regulated temperature. All draughts of cold air, and all extremes of heat and
c<ild, as well as sudden changes should be avoided. The strictest quietude should U*
insisted upon. If the patient has been accustomed to the use of tobacco in any ftMiu
or mode, it should not be discontinued. It is evident that in certain cases the seventy
and violence of the tetanic spasms and contractions, will preclude the use of T4>boci*«> iu
chewing or smoking.
3. The bowels should be kept open by efficient purgatives, as Croton Oil, CaloiD(4,
Castor Oil, Kpsom Salts, and the compound Cathartic pill of the Ignited States l*har-
maoopticia. The action of the purgatives may be promoted by the use of Knenui^
Infusion of Tobacco may with benefit be combined with the clyster. A simple, bat
efficient enema may be (juickly and extemporaneously prepared, by mixing one fluidoonct"
each of Castor Oil and Molasses, half an ounce each of common Salt and Sulphate of
Magnesia, and one drachm of Turpentine with one pint of tepid water. If the infusiun
of Tobacco be employed as the vehicle for the purgatives administered by the rct^tum,
half a drachm of the dried leaf, should be boiled in a pint of water and stmioed. Tht*
purgatives above indicated may be added to the infusion of Tobacco, or it may U*
udministeriHl alone. The iufitsiun of Tobaroo may l>e employed twice or three tiuie>.
Treatment of Traumatic Tetanus. 389
<lailj, but its effects should be carefully watched ; and its depressing action upon the
heurt and circulation generally, counteracted by stimulants and nutritious diet.
4. Thj strength oF the patient should be sustained throughout the disease, by simple
but nutritious diet, consistin}^ chiefly of milk, milk punch, beef tea,* e^g-nog, boiled
milk und rice, armw root and thick corn and rice ^rucl.
When Traumatic Tetanus is fully developed, the phy5<ician should ever bear in mind
the important facts, that the j;reatest sources of danjrcr are from sudden arrest of respi-
ration from spasm of the respiratory muscles and epiglottis, and iVoin the continuous and
progressive exhaustion of the powers, consequent upon the continuous expenditure of
the nervous and mubX*ulur forces, the loss of refreshing sleep, and the imperfect nutrition
of the body, consequent upon the great difficulty in many cases, of taking nourishment.
In those rapid cases which prove fatal, in the c*ours'j of from one to four days afler the
onset of the disease, the.ciuse of death is most generally anpht/xia ; and in every case
of Tetanus the favorable or unfavorable issue will depend to a great extent upon the set
of muscles involved. It should also be carefully borne in mind that the chances of
recovery increase with every day of prolonged life. The powei-s of the patient should
therefore, be continuously and carefully supported by nutritious diet, (administered
freely by the rectum in the form of beef tea, if the patient is unable to swallow), and
ulcobolie stimulants ; when asphyxia occurs, artificial respiration after the method of
Marshall Hall, should be instituted.
5. In the constitutional treatment of Traumatic Tetanus, thuso remedies should be
etuploycd, which exert the most decided sedative effects upon the spifud system, and
which promote in the most efficient and least injurious manner profound sleep.
The excitement of the nervous system may be controlled and subdued, and the tetanic
spasms overcome, and sleep promoted by the free and continuous use at short intervals
of such remedies as Opium, Morphia, Tobacco, Kxtiact of Indian Hemp, (Extractum
(*annabis Indicic), Calabar Bean, Sulphuric Kther, Chloroform and Hydrate of Chloral
and Bromide of Potassium.
It will be observed that Opium was used in conjunction with other remedies in the
majority of the cases recorded in the table ; and on this account it is difficult, if not
;i)>sulutcly impos.sible to estimate fully its value in the treatment of Tetanus. It cer-
tainly fails in many casjs to alleviate or to arrest the disease, and it may be a (|uestion
whcfhcr the enormous doses in which it has been used in the treatment of this disease,
may itot have increased the rate of mortality. Opium may be administered with good
fffects in conjunction with the Hydrate of Chloral, in doses varying from half to one
'jmin, every two, three or ftmr hours. The action of the solid Opium in pill is to be
preferred to that of the tincture or fluid extract, as it is more uniform, and diffuses itself
liver a longer period of time. The dose of the Hydrate of Chloral should be carefully
H'trulated in accordance with its effects, and the peculiarities of the constitution of the
Icitieut. In most cases from 10 to GO grains, at regular intervals of one, two, three or
f«»«r hours, according to the urgency of the symptoms, will be found to produce efficient
n'^ults. Bromide of Potassium has been combined with the Chloral Hydrate, with
apfK&rent benefit. Alcoholic Stimulants may be employed in conjunction with Opiuii),
Hydrate of Chloral, Chloroform and other remedies, with benefit, especially if given in
*«ufficiont quantity to produce sleep. Pure Alcohol, properly diluted, is perhaps, prefer-
al>le to the more common liquors vended in immense quantities and largely adulterated
with highly injurious and even poisonous substances.
We propose to consider briefly the therapeutic action in Tetanus, of those remedies,
which appear to fulfil the conditions indicated, in the most efficient manner.
The preceding record of 420 cases of Tetanus, arranged very nearly chroiMilogically,
nffurds oonclu.sive evidence that important advances have l>een made in the treatment of
Traumatic Tetanus; thus, if the table be dividcnl into two e(|ual portions in the first
:f 10 usuiOH recordtnl. the recoveries numlM5red 01 and the deaths 111), giving a per cent.
ofTflJ.O deaths, or one death in 1 .77 cases : in the second series of 210 cases, the recoveries
iiiiDiliere<l 122 ami llie deaths HS, giving a per cent, of 41.0 deaths, or one death in
2 3^ cases.
390 Treatment of Traumatic Tetanus,
la the first series of 210 cases which brought the clinical history of Traninatic
Tetanus down to or about the close of the year 1840, the chief remedies employed were,
Blood-letting, Mercury, Opium, Tobacco, Belladonna, Turpentine, Croton Oil, Tartar
Emetic, Camphor, Musk, Assafcetida, amputation, section of nerves, irritant and caustic
applications, blisters, actual cautery and cold affusion. The most valuable remedy in
this series appears to have been Tobacco administered in the form of infusion by the
rectum, its introduction into the mouth being most generally precluded from the nature
of the cases, and from the spasms which it is known to excite in some coses, when thas
administered.
In the seoond series, the most important additions to the remedies previously used in
the treatment of Traumatic Tetanus, were Chloroform,' Ether, Indian Hemp, (Cannabis
Indica), Calabar Bean and Hydrate of Chloral, and Bromide of Potassium.
Both series of cases include the records of Military and Civil Hospitals, as well as
those of private practice.
The diminished rate of mortality in Traumatic Tetanus appears to be referable chiefly
to the following causes :
1. Improvements in the Hygiene and sanitary condition of the sick.
2. Simplification and improvement of the local measures.
3. Increased attention to the support of the powers of the patients, by nutritious
dist and alcoholic stimulants.
4. The free use, at regular intervals and in accordance with the nature and severity
of the symptoms, of such remedies as Cannabis Indica, Calabar Bean, Chloroform and
Hydrate of Chloral.
Chloroform. — In the first case reported, wo w^ire led to attribute the favorable issue
chiefly to the Chloroform administered iatoriially. The Sulphuric Ether and Opium
were, without doubt, beneficial, especially as the strength of the patient was supported
by nutritious diet and stimulants. It would appear that Opium and Chloroform
mutually aid each other when given in conjunction in traumatic tetanus. The rosearchen
of Professor Claude Barnard, at the College de France, have shown that Morphia and
(/hloroform may be administered with benefit in combination or alternately. As it U
of the utmost importance that the strength of the tetanic patient should be maintaine^l
by every means, and especially by refreshing sleep, the physician should be careful («»
devise the most eflicient means for the furtherance of this end. Accordin<; to Prf>fti9sor
Claude Bernard, Morphia produces sleep, but at the same time it brings on a peculiar
state of excitement. If Chloroform is inhaled by an animal previously narcotised by
the alkaloid, only an extremely small dose is necessary to produce aniesthesia. On tho
other hand, the injection of a solution of Chlorohydrate of Morphia in an animal
which has been set to sleep by Chloroform, and is beginning to awake, restores insensi-
bility. This fact has been demonstrated by numerous experiments. In attempting U\
explain this theoretically, Profe.'^.sor Bernand admits that the sensitive cellule must U*
in contact with blood mixed with a certain quantity of Chloroform, in order that anaes-
thesia may take place. As the aniQsthetic substance is being constantly e1iminat4>d,
sensibility shows a tendency to recur, but Morphia prevents sensibility, just in tho
degree necessary for the production of aniosthesia by the Chloroform which is lefl. D.i
the other hand, if Chloroform protracts and re-establishes the somniferous acti«m of
Morphia, at the time when it ought normally to cease, it is because the sensitive irric^-
bility, which is the source of reflex action, being heightened by Morphia, placen th t>
animals in a condition of impressionability peculiar to Chloroform. The action, at omv
somniferous and exciting in Morphia, does not appear to Claude Bernard to justify tho
view of a double substance contained in the alkaloid, and producing thi.s two-fold eflPect :
he believes in the chemical unity of Morphia, and explains thi.s double effect by tw«i
stages of the same physiological action, which may vary in dunition or intonsily. and
thus produce certain difl^erenu'.s.
It will Im) found, uiHin examination of the preceding table, that (Chloroform was uj«h1
in the following castas: 2!l.% lilU, 295, 3(15, 308, 309, 311. 314. 317, 325. 331. 33:*
Treatment of Traumatic Tetanus. 391
334, 335; 336, 337, 350, 353, 354, 355, 357, 358, 359, 373, 378, 382, 383, 384, 385,
386, 388, 393, 395, 396, 429, 432, 434, 435, 438, 447, 452, 453, 457, 459. Of
these 45 cases, in which Chloroform was employed chiefly by inhalation, and in con-
janction with other remedies, 24 were cured and 21 terminated fatally. Even in the
fatal cases, the pain was relieved, and the severity of the paroxysms greatly mitigated.
This result would have been much more favorable if a large proportion of the cases had
not oocurred in military practice ; but notwithstanding this, the rate of mortality under
the use of Chloroform was les4 than 50 per cent., or more exactly, 46.6 per cent.
After a careful examination of the effects of Chloroform, administered in Traumatic
Tetanus internally and by inhalation, we have arrived at the conclusion that this agent
is far more efficient and safe when administered internally.
That Chloroform rapidly exhausts the powers of the nervous and muscular system
when administered by inhalation, and that this efifect is produced more rapidly than by
sub-cutaneous injection, was illustrated by a series of experiments which I instituted on
varioas animals, and from which I extract the following :
Experiment 186: Illustrating tlie Action of Chloroform on Warm-blooded Aninval^ hy
Sub' Cutaneovs Injection and Inhalation.
Aagaita, Ga., Jane 16, 1860 : Large, well conditioned cur dog. Temperature of Atmosphere,
70® F.; temperature of rectum of dog, 40°.GG C. Action of heart in a state of rest, 06 per
minute; respiration, 20 per minute. When first tied and secured for the experiment the dog
made violeot struggles; the thermometer was introduced into the rectum just after these
•truggtei, and indicated the temperature given above ; the dog, after being securely tied upon
the operating table remained quiet, and the thermometer in the rectum slowly descended
to 40^.62 C, and temained stationary at this point.
Two and a half fiuidounces of Chloroform were injected into the sub-cutaneous tissue of
the right thigh and fore leg of the same side. Simultaneously with the injection of the
Chloroform the dog commenced to struggle. During tlicsc struggles there was a rise in the
Ihermometer, and 25 minutes after the injection of the chloroform, the temperature of the
rectum was 41® C, showing a rise of U®.38 C. after the injection of the Chloroform. 40 min-
utes after the injection of the Chloroform, the dog was restless, barked and growled. Action
of heart increased, 120 beats per minute ; respiration 12 per minute, full and labored, nnd
occasionally stertorous. Temperature of rectum, 41®. 1 C. Chloroform to the amount of one
and a half flu idoances was again injected into the sub-cutaneous cellular tissue of the legs,
wiCboQt producing coma or any marked change. The dog was then released from the operat-
ing table; he rose and walked, and although weak and tremulous, appeared to have the
exercise of the cerebral functions. This appeared to be remarkable, as four fiuidounces of
Chloroform had been injected into the cellular tissue of the right thigh and leg.
One flaidounce more of Chloroform was injected into the cellular tissue of the fore and
hind legs, without producing coma, and the dog was still able to walk about ; he appeared
we«k, bat not at all insensible, and could not be induced to lie down. Occasionally there
was a sadden giving way of the legs, as if the dog would fall down, but this was momentary,
and the muscles appeared immediately to regain their strength. The temperature of the
rectum fell daring the last 35 minutes, 0®.'2 C, and now stood at 40®. 9 C. At this moment,
1h minutes after the first injection of the Chloroform, a sponge saturated with Chloroform
was held before his mouth ; the eflfects were almost instantaneous ; in less than one minute
be became insensible, notwithstanding that when the sponge was first applied his struggles
were of the most violent character. After the establishment of the coma, the action of the
be«rt was 112 per minute and very feeble ; respiration 50 per minute, quick and short; in 10
nioates after the commencement of the inhalation of the chloroform, the action of the heart
and the respiration had ceased; the temperature of the rectum had remained stationary
•luring the short period of coma, and at the moment of death stood at 4U®.9-C. The temper-
ature of the rectum commenced to descend a few moments after the cessation of the action
of the heart and lungs; the descent was very slow, almost imperceptible at first, and in 27
miontes after death, stood at 40®. G C; 75 minutes after death, temperature of rectum, 'AO^/J
r.: 195 minutes after death, 38®.4 C.
Autapty 195 mmulet after tleath. — The blood, after death, presented a cherry red color, and
coagulated perfectly after its abstraction, in two minutes, and the coagulum was firm. (In
trxposure to the atmosphere the blood rapidly changed to a bright arterial hue; under the
niftcroecope the blood corpuscles presented a normal appearance ; in some instances they
Assumed a stellate) 9hap^« Higor mortis complete. Interrupted mag;Qe(<)-elcctric currents
302 Treatment of Traumatic Tetanus.
lind no effect upon the voluntary and involuntary muscles. Muscles of nil parts of the l)u<l,v
of a deep red, purple and crimson color, and filled with blood ; when cut the blood pourt'd
from the cut muscles. Blood-vessels of brain filled with blood. No coagula were found in
the blood-vessels of the brain. Blood-vessels of messentcry filled with dark blood. Bladder
distended with urine. Mucus membrane of stomach and intestines redder than iKual.
Lungs considerably engorged with blood, but much less so than the lungs of a dog killed ai
the same time by a rattlesnake. The appearance of the mnscles of the dog killed by chloro-
form were in striking contrast to that of the dog killed by the poison of the rattlesnake,
which, although almost entirely bloodless, were of a dark purplish and bluish purple color.
Whilst the blood streamed from the cut surface of the muscles of the former, no blood what-
CTcr issued from the muscles of the latter.
Experiment 187 : Illustrating Action o/ Chloroform.
Augusta, (rd., June IGth, 1800. Subject of experiment, small kitten, two mouths old. Tem-
perature of atmosphere, 81® K.; of rectum of animal, 39^.4 C. Administered chloroform by
inhalation. The kitten became insensible in a few seconds. The temperature of the rectum
began to deseend immediately after the establishment of the coma« and in 4 minutes after th«>
first inhalation, stood at 3D° C. The action of the heart and the respiration ceased 4 minute*
alter the inhalation of the chloroform.
y.i minutes after death, temperature of rectum, 35^.2 C; 183 minutes, 31® C.
The microscopical examination of the blood after death, revealed no distinct alterations in
the blood corpuscles. The colored blood corpuscles in this young animal were distinctly
nucleated.
Exj^erhncntB 188, 189, 190, 191, 192, 19S, 194, 195, 196, 197, 198, 190, 200 :
repetition of preceding; czpcrimeDtB, with similar resalts.
When administered by inhalation, Chloroform is rapidly absorbed bjr the pulmonary
iiurface, enters the blood, and is conveyed in a very few moments to the ocntnil nervous
ganglia, and exerts an almost immediate effect upon the ganglionic cells. In moHt oase^,
when the inhalation ceases, the effects, when fresh air is freely supplied, pass off in a
comparatively short space of time. In some cases, however, obstinate vomiting, with
complete loss of digestive power, and great prostration of the muscular and nervous
systems, continue for periods of time varying from a few hours to thirty-six hours. In
experiments which I have instituted upon myself, with the inhalation of Chlorofunu.
the nausea, vomiting, and nervous prostration, has fVoquently continued for more than
twenty-four hours. In my own cuho, Chloroform, when inhaled, appears to produce
great irritation of the mucus membrane of the stomach, attended with the most dis-
tressing nausea, and th^ vomited matter consists of a clear acid mucoid fluid| o|\ca
discolored by bile.
When Chloroform on thj other hand is administered internally, it is slowly al»orlie«l,
and its depressing effects upon the ccrcbro-spinal nervous system, are less violent and at
the same time more lasting.
As Chloroform exeres a powerful sedative cfTeet upon the brain, induces auKsthoia
or insensibility to painful impressions, and if in sufficient quantity, deep sleep or coma*
with complete muscular relaxation, it is evident that it is eminently adapU^d to couo*
teract the state of ganglionic excitement of the spinal system with the greatly ezaQ;ror-
ated reflex actions, charncterlstic of Traumatic Tetanus. And it would appear that in
this disease, much larger doses may be borne with impunity than in any other nulad\ ,
with the exception, perhaps, of Hydrophobia and certain forms of Neuralgia, atieotlixl
with incessant psiin. In a case at Guy's Hospital, of painful neuralgia, more than i»n«*
pint of Chloroform was used in twenty-four hours. It should, however, be bom« in
mind, that this remedial agent sometimes arrests the action of the heart, or in 9i>nto
other manner suddenly destroys life ; and also, that when used freely by inhalation,
without proper attention to the admission of air into the lungs, it may accumulate in
the blood, and alho cause the accumulation of carbonic acid in this fluid, and thus.
gradually, but surely undermine the vital powers. And even in those cases, in which
Chloroform appears evidently to check the progress of tetanus, and to relax the muscU-^
we must administer it with due caution. It is desirable iu Tet^tuu^^ to presierve the
Treatment of Traumatic Tetanus. 393
struDgth by the most cificient and judicious means, on the ground, that every day of
prolonged life givc8 renewed hope of final recovery.
When given internally, in doses of from thirty to seventy drops, Chloroform appears
to produce no excitement of the brain, or increase of the action of the heart, but is
soilativc to the nerv^ous and circulatory systems, inducing a pleasant calmness with cere-
bral confusion and a feeling of drowsiness. When taken in a large dose, it appears to
affect the system like alcohol. In a case recorded by Dr. Alfred Swaine Taylor, in
which a man swallowed four ounces of Chloroform, he was able to walk for a considera-
ble distance after taking this dose, but subsequently fell into a state of coma — the pupils
were dilated, the breathing stertorous, the skin cold, the pulse imperceptible, and there
were general convulsions. He recovered in five days. (Med. Cfaz., vol. xlvii, p. 675).
M. Aran, has recorded a case in which a quantity, supposed to bo from eight to ten
drachms, was swallowed in mistake by a man ; the first symptoms were a burning sen-
sation, with inefTectual efforts to vomit ; in a few minutes afterwards, he was found with
his eyes glistening, his features animated, singing and talking incoherently, and unable
to recognize those about him. There were some convulsive movements ; the skin was
instensible to painful impressions ; sight was lost ; and the pulse was between seventy
and eighty. In the course of twenty or thirty minutes sleep ensued, which became
very deep, and was attended with insensibility of the surface, and complete relaxation ;
the respiration and circulation remaining normal. The sleep continued several hours.
Next day he could remember nothing of what had passed, and the unpleasant symptoms
gradually disappeared. (Bull, de ThC^rap., xlii, 29Gj. A private in a Cavalry regiment
in the l.'^nited States Army, swallowed nearly two ounces of Chloroform. He was seen
ten or fifleen minutes aflerwards ; he had already vomited, and was found insensible,
with stertorous breathing, and a pulse of about 60. The pulse became more feeble, the
breathing slower and the pupils more insensible to light. The surface became cold, and
fur a time he continued to get worse, the face becoming purple, while the pulse was
intonnittent and hardly discernible. Two hours and a half after taking the poison,
however, a gradual improvement commenced, but sensibility did not return until four
hoars later. For several days, he continued to suffer from great irritability of the
f<toiiiach, and eventually ho had an attack of jaundice. (Am. Jour. Med. Sci-, October
is:>7, p. 365).
Alarming symptoms and even death have been produced by much smaller doses. A
ludy swallowed half an ounce of pure Chlorofonu ; in five minutes she was quite insen-
r^iblc, generally convulsed, the jaws clinched, the face slightly flushed, the pulse full and
rather oppressed, and she foamed at the mouth. She vomited, and in twenty minutes
the convulsions had left her ; soon afterwards she had a relapse, and did not recover for
twenty-four hours. (Med. Times and Gaz., 1867, p. 615). In a case reported by Dr.
Taylor, a boy who had swallowed a drachm of Chloroform, lost all consciousness, in a
Mhort time became insensible, cold and pulseless, and died in three hours, quite calmly,
without a struggle, in spite of every effort made for his recovery.
If one drachm be the smallest dose which has been known to destroy life, and that
ill the case of a child only four years of age, it is evident that it is much less potent in
itM effects when administered internally ; for in one instance, the patient died in one
uiinutc, in which only tiO drops had been inhaled in vapor, and in another, so small a
quaDtity as fifleen or twenty drops, proved speedily fatal. These quantities are relatively
.-.inalK when it is remembered that the cohesion between the particles of Chloroform is
•w» feeble, that it yields a greater number of drops from a certain measure, than any
<»ther medicinal liquid ; one fluid drachm yielding on an average 240 drops. With the
cxoeption, perhaps of Prussic Acid, (^hloroform operating through the lungs, has
fletttroyed life more rapidly and in smaller dose than any poison known ; and from the
tact just recorded it appears to be at least tea timen more potent^ when administered by
iiihaktion than by the stomach. According to Dr. B. W. Kichardson, of London^ the
proportion of deaths from Chloroform will be about one in 1500 to 2000 cases of its
administration by inhalation. Dr. Kicbavdsou recognizes only one bodily conditioo^ an
fiO
394 Treatment of Traumatic Tetanus.
& distiDct source of increased risk in the administration of Chlorofunn by inhalalion ;
and that is, a heart with its right ventricle dilated, and attended with bronchial eoufrh
and dilatation of veins. Experiments have shown that the anaesthetic left the mnsclcsi
unaffected, and that its action is upon the nervous centres. (Lancet, June, 1870, p.
329).
In the treatment of such a disease as Tetanus, in which it is necessary, not only to
with caution, even in this comparatively harmless mode. It is now fortunate that a
comparatively soluble and tasteless subHtanee, capable of yieldinp; Chloroform by itn
decomposition in the blood, is within the reach of every physician for the effect ivo
treatment of Traumatic Tetanus. In the employment of Ohloroform and Chloral
Hydrate in Traumatic Tetanus, it should be borne in mind, that in the primary impn\<-
sions upon the nervous centres of animal life, sensibility to pain is aoolished before
consciousness, and a decided effect upon the ganglionic cells of the spinal cord may Ini
produced without any suspension of consciousness.
The vehicle in which Chloroform is administered in Tetanus should Imj carefully
selected, for if it be given in simple water, a portion sinks to the bottom of the vewM-l.
and when administered, makes a disagreeable impression, and also may excite spasms by
the sudden irritation of the fauces, throat and epiglottis. It may be administered in
the form of emulsion, the Chloroform being rubbed first with four parts of Almond or
Olive Oil, and then incorporating this mixture with water, by the intervention of
roucilagd of gum Arabic and sugar or syrup, in the ordinary form. ChIotX)fonD may
also be tuapended in water, by means of the yolk of egg, and syrup of Orgeat. (Syrupu.'^
AmysdalaB).
When one part by weight of Chlorofomi is mixed wiih eight parts of Alcohol, the
resulting solution forms stable solutions with water, wines or syrup ; and this mixture ii*
specially useful in Tetanus, as the alcohol is not contra-indicated. I have thas employiHl
Chloroform in the treatment of this disease, (ilyccrine also forms an admirable vehiclo
for the administration of Chloroform; a mixture composed of equal prts of each,
readily dissolves in water.
When used hypodermically, Chloroform (juickly allays pain, quiets spasms, and
induces sleep ; but the objection to this mode of medication is, that it tends to give riM.'
to local inflammations, attended with pain, redness, swelling, and tenderness on pressun*.
As a local application, and counter-irritant, applied fVccly along the spine. Chlomfonu
has proved efficacious in Traumatic Tetanus, and also in the Tetanus oY ncw-liorn
children (Trismns Nascentium.) In the cases demanding frequent local application «.
and especially in the Trismus of infants, it may be used advantagcoui<ly in (*ombinatiun
with Camphor and Olive Oil, thus: B. Chloroformi f ,^i ; Pulv. Camphoric ^ss; OU-i
Olivas fjiii: dissolve the Camphor in the Chloroform, and mix with the Olive Oil ; a>o
as a local application to spine and injured extremity, repeating at short interval;*, an^l
also applying by means of lint and flannel saturated with the mixture. •
Sulphvric Ether, — The tendency of (^hU)roform to depress the vital |>oweis, may in a
measure be counteracted, by combining it with Sulphuric Ether, for whilst this agent ai-t.n
in moderate doses as a diffusible stimulant, at the same time it has a similar efft^cl tt^
Chloroform, in producing Anai^sthesia, and relaxation of muscular sjiasm, and depi\t<si«in
of the reflex function of the spinal cord.
Sulphuric Kther in conjunction with other remedies was employed (chiefly bv inh^wf t
tion,) in cases 87 apd 88, 244, 248, 291, 292, 295, 299, 300, 301, 3u2, 303, 30S, 3ui».
330, 335, 453. Of lhe^» 17 cases, 10 were cured and 7 died, giving a mortality ••?"
forty^ne per cent, or one death in 2.42 ca.Hes.
Sulphuric Kther may be adminiiitercd in Traumatic Tetanus, either internally or l>\
inhalation. It ia well known that this agent is capable of prdducing complete paraljM^
of the nerves of pensation ; and this result i? especially valuable in the treatment . t
Treatment of Traumatic Tetanus. 395
•
Tetanos, in which disease, the slighteBt impression upon the nervoos system, even by a
touch or current of air, or a sound, is capable of exciting violent spasms.
In some cases of Tetanus, it is impossible from the firm closure of the jaws, and
from the excitation of spasms, by the local stimulant effects of Chloroform and Ether
upon the mouth and fauces, to administer these remedies internally ; and in such cases
^ood can be expected from these agents, by inhalation alone. When Chloroform has
been used, even after relief has been obtained from suffering, the patient has died from
nervous prostration, and as debility is one of the great dangers of Tetanus, it is best to
combine Sulphuric Ether with Chloroform, in order that the stimulant action of the
former may overcome or counteract the direct sedative or depressing effects of the latter.
Whilst the number of deaths caused by the inhalation of Sulphuric Ether, are much
less than those by Chloroform, at the same time, it is important, in the treatment of
8uch a disease as Tetanus, in which large quantities may be necessary to effect even an
amelioration of the symptoms, to remember, that this agent may cause death, by the
direct poisonous action of the absorbed vapor upon the nervous centres and heart, and
by improper seration of the blood, and the accumulation of impure blood in the brain
and heart, loaded with Carbonic Acid.
That Ether may prove rapidly destructive, by its direct action upon the nervous
.<iystcm, independent of its action upon the blood, is evident from the results of the
following Experiments, which I performed in order to compare the effects of this agent
with those of Chloroform.
Experiment 201 : Illustrating the effects of Sulphuric Ether hy Inhalation,
Aagusta, Ga., January 28th, 18GI. Large cur dog, subjected to inhalation of Sulphuric
Ether. The effects resembled those often observed in human beings. At one time the dog
growled, and barked, and endeavored to bite ; then he whined, and moaned, and struggled
violently. Although more than five fluidounces of Sulphuric Ether were poured upon the
sponge which surrounded the nose of the dog, during the space of one hour, coma was not
induced. The dilatation of the pupils was amongst the first effects produced bj the Ether.
After subjecting the dog to the action of the Ether fur one hour, he was released, and placed
upon the floor: he was unable to stand; endeavored to rise, and fell heavily upon his side;
all the muscles were in a tremulous motion, and when he wonld attempt to rise, his motions
appeared to cost him the exertion of all his strength, and after the most persistent effort or
series of efforts, having regained his feet, the muscles of the limbs would suddenly give way,
and down would fall the dog, as if struck by lightning. These effects gradually disappeared,
and at the end of one hour, the dog was able to get up and walk about. In the efforts to
rise, the trembling of the muscles, and the want of coordination of the muscular motions,
indicated clearly the action of the Ether on the motor cells and reflex function of the spinal
cord.
Kfffrtt on the Temperature.— Temperature of atmosphere 46° F. Temperature of rectum of
dog, before the inhalation of the Ether, .3i)°.6 C. The temperature of the rectum remained
sutionary until the pupils of the eyes were dilated, and then, in ten minutes after the first
inhalation, commenced very slowly to descend, and in fifteen minutes fell 0°.2 C, and in 15
minutef more lost 0^.2 G.
Notwithstanding the struggles of the dog, the temperature still continued steadily to descend,
and at the end of one hour after Uie first inhalation, stood at :i8°.G C, showing the loss,
during this time, of one degree centigrade. As soon as the inhalation of Ether was discon-
tinued, and the dog attempted to exert himself, the temperature commenced to rise, and in
4tx minates stood at 39° C, and in 19 minutes more, (25 minutes after the cessation of the
inlialation), the temperature of the rectum was 3!)°.4 C, and remained stationary at this
point uotil the dog completely recovered bis strength.
It \» worthy of note, that in the preceding experiment, Sulphuric Ether depresHed
tlu; animal temperature ; and lience this agent may prove of value in the treatment of
llitNMr ca.s*»H of Traumatic Tetanus in which tliere w a niarke<l elevation of tenip<*rature.
Ext^erimrni iii^i: lUusf rating the Effects of Sulphuric Ether, when injected into tlte
Blood.
Augnita, Ga., January 2Kth, 1 8« 1 . Injected into the jugular vein of a young, active, female
996 Treatment of Traumatic Tetanus,
proat, six flnlddraclimfl of Sulphuric Ether. In a few momentB after the injection of the
Ether, the goat struggled violently, and bleated, as if in great distress ; these straggles con-
tinued for three minutes, gradually becoming more feeble, nntil at the end of this time, pro-
found coma supervened.
Dilatation of the pupils was established before the supervention of coma. Death took place
in ten minutes after the transfusion of the Sulphuric Ether.
Fffectt an the Temperature. — Temperature of atmosphere, 46° F.; temperature of rectum of
goat, 39^.5 G.
The temperature of the rectum remained stationary during the struggles of the goat, and
after the establishment of coma, slowly descended, and at the moment that the heart ceased
to pulsate, and the respiration ceased, it was 39°.45 C, the loss being 0°.05 C.
After death, the temperature steadily but slowly descended, — in half an hour the thermo-
meter in the rectum indicated 39° C, showing the loss of 0°.45 C. in 30 minutes; 75 minutes
after death, temperature of rectum 38° C. The temperature of the body now began to descend
more rapidly, and in 25 minutes after the last observation it was 37° C. At this time, rigor
mortis was advancing, but not fully established ; 35 minutes after this observation (135 min-
utes after death), temperature of rectum 35°.6 C; rigor mortis progressing, but not fally
established. 135 minutes after this observation, and 270 minutes after death, temperature of
rectum 3l°.25 C.
Effects of the injection of Ether into the Blood. — The respiration became labored ; the action of
the heart was disturbed ; it beat rapidly but feebly ; these symptoms were simultaneoat at
least, if not anterior to the dilatation of the pupils and the shivering of the muscles.
Autopty 4} houre after death. — Blood-vessels of dura-mater and pia-mater of brain filled with
blood. Blood-vessels of brain and the prolongations of the pia-mater into the ventricles of
the brain greatly congested with blood. Blood in the veins of the brain presented a cherry
red, rather than a dark venous hue. The ventricles of the brain, as well as its substance,
emitted strong odors of Sulphuric Ether. Spinal cord not specially congested.
Mucus surface of trachea and bronchial tubes normal in appearance. The lungs presented
a purplish red color and mottled appearance, and were more dense and congested with blood
than is usual in death from mechanical causes. The fact that the blood-vessels of the langs
were congested with blood, was demonstrated, not merely by the color, but also by the fact
that they collapsed only partially when the thorax was opened. The lungs exhaled strong
odors of Ether. Muscular structures of heart normal in appearance. Firm, dark, almost
black coagula were found in all the cavities of the heart. The largest coagnlum, which was
about the size of a pigeon's egg^ in its largest portion, was found in the right aaricle, an«i
extended through the auriculaoventricular opening into the right ventricle, and also sent
branches into the vena cava and pulmonary artery. A small, flattened, dark purple coagn-
lum was also found in the aorta. These coagula ail exhaled Ether. Stomach, liver, spleen,
kidneys and intestines not at all congested, and perfectly normal in appearance.
There was no marked or unusual accumulation of blood in the large venous tranks. lu
these respects, as well as in several others, the effects of Ether were far different from thjft«
of Prussic Acid. In poisoning by this acid, the large veins are, as far as my experienov
extends, loaded with dark, almost blnck, uncoagulated blood.
The blood corpuscles of this goat, killed with Sulphuric Ether, presented, in many ca5«>5
marked alterations ; they were shrivelled in some cases, and in others stellate. Ether exhale«i
from the blood in all parts, and from all the organs and tissues. The color of the muscl<*«
was natural, and of a bright red, and pink, and purplish red after exposure to the atmosphere
It is worthy of note that, in like manner, the direct injection of Sulphuric Ether into
the blood caused a descent of the animal temperature.
The marked powers of Ether find Chloroform as' solvents of fats, without doubt, arc
active in the production of the peculiar phenomena induced by their intn>ductioD into
the circulation and distribution to the nervous elements. As the cerebro-spiiial an«l
sympathetic nervous systems are lar«:cly composed of fats, and of a peculiar phoBphorixtHl
lilt, it is possible that a portion of the peculiar phenomena resulting from the action t>f
Chloroform and Kther may be due to the direct solution or disturbance of the phy^u^l
constitution and chemical relations of the fats, and esi)ecially of the phosphoriied fat of
the ganglionic cells and commissures. As in the case? of (^hloroform, so also in tht*
action of Sulphuric Ether, it is far more potent when employed by inhalation. Half an
ounce of Ether, or even less, inhaled in the form of vapor, is capable of producing a
more powerful eff(rct on the nervous system than one or two ounces taken int4> tK**
stomach. The difference appears to be due to the jrreatcr absorbing surface eifJOJ«inl \*y
the lungs.
Treatment of Traumatic Tetanus. 397
As far as mj experience extends, no better combination for internal administration
has been proposed than that employed in the first case of Traumatic Tetanus, viz : equal
parts by measure of Chloroform, Ether and Tincture of Opium. Of this mixture, from
10 to 100 drops may be administered in simple syrup, in orgeat syrup, or in emulsion
with yolk of c^g, or in brandy or milk, or in any form of alcoholic stimulants, at regular
intervals, accordin;; to the effects, and the nature and urgency of the symptoms.
Chloral Hydrate. Wc have recorded a number of interesting observations and
cases in the historical notes upon the treatment of tetanus and in the table, showing
the value of Chloral as a producer of sleep, and as a valuable agent in the treat-
ment of Traumatic Tetanus and other diseases of the nervous system. - Chloral Hydrate
was employed in cases 401, 40:J, 405, 400. 407, 408, 409, 410, 411, 412, 413, 414,
415, 416, 417, 418, 419, 422, 478, 479, 480, alone and in combination with Bromide
of Potassium, and Extract of Culabar Bean. Of these 21 cases, only two terminated
fatally, giving a mortality of only 9.52 per cent., or one death 10.5 cases.
In the administration of Chloral, we are, in effect, employing Chloroform in a
pleasant and efficient form ; for M. Persouue has demonstrated by actual experiment,
that Hydrate of Chloral does not pass through the human organism without undergo-
ing a transformation, but that on reaching the blood it is separated into formic acid and
(Uiloroform, which latter substance is subsequently converted into Chloride of Sodium
and formiate of Soda, the products of its elimination. As a hypnotic, it appears to be
inferior to Opium alone; whilst at the same time it is superior to Opium and almost
every other drug, that in its sleep-producing action, there are no attendant symptoms of
cerebral oppression ; the sleep, though often prolonged, is light and refreshing, and no
unpleasant af\er symptoms are experienced.
These remarks apply only, however, when it is used in moderate quantities, for both
unpleasant and fatal symptoms have been produced by large doses; and in every ca.se
wo should administer it cautiously at first, beginning with not larger doses than from 20
to <)0 grains, separated at intervals varying with its effects. As a remedy for pain, it
should be borne in mind that it is far less certain and efficient than Opium and its pre-
parations. This fact I have carefully verified by experiments upon myself.
Chloral Hydrate may, in some cases, be combined with Bromide of Potassium with bene-
fit. The following formula will be found useful in the treatment of Traumatic Tetanus
and ccrebro-spinal meningitis : B Chloral Hydrate, ^iv ; Potassii Bromidi, Ji ; Syrupi
SimpHeis, f§vi ; mix ; tablespoonful every one, two, three or four hours, according to
the nature and intensity of the symptoms.
(jrotoa Ckhral Hydrate, sa fur as my knowledge extends, has not yet been
tf'in ployed in the treatment of tetanus, but its physiological effects would indicate that
it may prove equally as effective as (,'hlonil Hydrate. The relatively small dose of (he
(Voton Chloral Hydrate may also be regarded as favorable to its use in tetanus.
(*hloral is not suited to sub-cutaneous injection, for M. Laborde has shown that when
it is injected, even in weak doses, in animals such as rabbits or Guinea-pigs, it causes
lm*al irritation, gangrene, and more or less purulent infiltration.
Aiiffhol^ in large doses, (cases 109, 110, 111, 288, 472), produced effects in some
respects similar to those which characterize the action of C^hloroform, Hydrate of
(*hionil and Sulphuric Ether, viz: relaxation of the^musclcs and profound sleep. In
these 5 cases, 4 recovered and one terniinate<l fatally, giving a mortality of 20 per cent.,
or one death in 5 eases. There appears to be no question as to the value of alcoholic
>ttimulants in the treatment of this disease, as has been shown by the observations of
Turric and others. There appears to be, in the present state of our knowledge of the
therapeutics of Traumatic Tetanus, nothing to contra-indicate the use of Alcohol in
c-i injunction with such remedies as Opium, Chlorofonu, Sulphurij Ether and Chloral
Hydrate. Alcohol, in large doses, reduces the animal temperature, arrests to a certain
I'xtent the changes of the tissues, diminishes the motor and reflex powers of the Spinal
ford, prrimotes slei!p, and acts as a nutriment.
Opium. — No remedy has bet»n employe*! more frequently than Opium in the treat-
398 Treatment of Traumatic Tetanus.
ment of Traumatic Tetanus. An examination of the table will show, that in one fom
or another, and in various modes, it was employed in a majority of cases, even when
other potent agents were administered at the same time. Owing to the frequent com-
bination with opium, of one or more powerful agents and remedial measures, as Calo-
mel, Tartar Emetic, Tobacco, Calabar Bean, Indian Hemp, Quinine, Chloroform,
Amputation, Venesection, Blisters to the entire length of the spine, etc., it is impoesi-
ble to demonstrate, by actual statistics, the value of this drug. And it is a questi<^m
whether the immense doses in which it has been so of^en administered, may not have
been absolutely injurious ; and whether much better results would have b^n obtained
by a more moderate use of this powerful and valuable agent. It would appear from
the inseDsibility of many tetanic patients to the action of Opium in immense doees, that
a peculiar condition must characterize the cerebral nervous elements, as well as those ft
the spinal axis ; fur in those cases in which it controls the muscular spasms, its narcotic
effects are invariably produced at the same time. Such facts appear to support stronglj
the view which we have advocated, of the local origin of Traumatic Tetanus and the
progressive transmission of the irritation to the central ganglionic masses of the oerabro-
spinal nervous system, and at the same time to militate against the theory that taUnu'^
is due to some poison in the blood analogous to that of Hydrophobia. It has been
said by Dr. W. Hanna Thomson, of New York, (Am. Med. Times, Feb. 2d and 9th,
1861), that there is but little doubt that, were we not sure that Hydrophobia was the
result of a poisoned wound, we would, by the irritative theory of tetanus, he inevitably
led to ascribe the symptoms of rabies also to this mysterious but coDvenient irritation,
but the one preceding fact of a virus introduced does away with all diffculty towanL^
seeing in the strange nervous symptoms, not an irritation merely, bat the action of a
blood poison. The well known experiments of Magendie and Breschet prove that Hy-
drophobia can be as certainly communicated by injection of the blood of the rabid
animal as by the inoculation of saliva, and Hertwig, (Hufelands Journal, 1828), proved,
by his many excellent experiments, that not only portions of the salivary glands laid
on the wounded surfiice, but the blood itself, venous and arterial, are cajMible of com-
municating the infection. Dr. Thomson still further endeavors to establish the
hsematic pathology of tetanus by the well known fact, that we can produce somethinL'
very much like tetanus, at will, by charging the blood with a ready made poison. a»
Strychnine.
Whilst'admitting that there is an analogy, and a very striking analogy, between Hydro-
phobia, Strychnine poisoning and tetanus ; at the same time it mu^t be conceded, that a
mere analogy and similarity of prominent symptoms do not necessarily establish an identity
of origin. Such a mode of reasoning is plausible, but not conclusive. We can only account
for the arrest of tetanus in certain stages, by the application of the actual cautery to th^
injured nerve and surrounding parts, by amputation and by section of the injurvd
nerve, on the theory that the disease originates in the injured nerve or nerves, and i**
propagated along the nervous tracts centrifugally to the spinal axis. And the accuracy
of this view has been sustained by the pathological changes which have been frequentiv
witnessed in the injured nerves, and in the spinal cord itself. If the disease be maui-
festly due to the existence of a Materies Morbi, existing in the blood, and gencmt***!
in the diseased part, or in the system, under certain circumstances, the duty of tht*
physician should be to seek some remedy which would displace and expel the poL^un « »f'
tetanus from the blood, and he could best explain the curative effects of such an ai^otit
as Opium, by its power of neutralizing or eliminating the poison.
As no such poison has ever been shown to exist in the blood of the tetanic pati<-n?
and the phenomena of the disease, as well as the characteristic alterations are U*-:
explained without any such hypothesis, the physician acts most rationally and phil«*
sophically in the employment of those remedies and measures which arc capable «4
arresting, controlling and subduing the state of increased and exalted activity of i*i«'
nervous elements primarily involved.
While on the one hand, Opium is valuable in the treatment of Traumatic TeUnu:», t>\
Treatment of Traumatic Tetanus. 399
itH power of diniiinshiDg muscular force, and the suRceptibility of the cercbro-spinal
system to external impressions, and of rendering the ncr^'ou8 system insensible to pain,
and of producing quiet repose and profound sleep ; on the other hand, it may act
injuriously when given in large and repeated doses, by deranging the digestion and by
diminishing the biliary and intestinal secretions, and thus aggravating the constipation
characteristic of Traumatic Tetanus; and it may also induce a state of functional
derangement and irritation of the cord, analogous to that characteristic of Tetanus.
In order to avoid certain of these effects, Morphia, by sub-cutaneous injection, may be
advantageously substituted for the internal administration of Opium and its prepara-
tions.
Tobacco. — The delight and satisfaction with which Tobacco was hailed as a luxury
in Europe aflcr its introduction from America, about the year 1559, was only surpassed
hy the reputation which it speedily acquired as a medicine. Its value was loudly pro-
claimed as a panacea ; it was boldly asserted that the discovery of this herb alone, had
placed the moderns above the ancients ; and not only did physicians, like Magnenus,
give a long list of the diseases which it cured, but poets lavished upon it their choicest
epithets. Tobacco obtained the greatest fame as an external application to wounds ; to
ulcers and diseases to the skin. Used externally, it was the great remedy resorted to
by the nations of the Spanish Main for Tetanus, and in the Transactions of the Medieo-
diimrgical Society of Edinburgh two cases of fnsmitg are narrated by Dr. Anderson of
Trinidad, in which good effects resulted from its use in the form of baths ; four ounces
of the dried plant were boiled for an hour, in eight gallons of water, and then added
to impregnate the water of a tepid bath.
In the "" Trial of Tobacco" written by Edmund Gardiner, about 1648, it is said that
** the sufibmigation of tobacco being taken, is a good medicine for starkness or stiffness
of neck called tetanus, and for any pains or aches in the bcxly, proceeding of the cause
that tetanus doth«" Magnenus, Neander and others, held the same opinion, but it was
only of late years that it has been resorted to in the treatment of Tetanus. In this
diacaac it has been employed as an injection and highly extolled. Mr. Duncan, of
Grenada, published a successful case, thus treated, which was detailed in the 42d num-
b(T of the Edinburgh Medical and Surgical Journal, which excited considerable inter-
cut-at the time. In 1807, Dr. Iluggan suggested Tobacco tis a remedy in Hydrophobia,
and subsequently Dr. Clutterbuck, and Dr. Sigmond. actually employed it in the treat-
ment of this disease, with the effect of producing temporary alleviation of the spasms.
Lancet, May 13th, 1837, p. 253.
In the table we have recorded a number oP cases (125, 120, 132, 14G, 153, 157,
106,167,169,170,173,182,219, 220, 225,226, 234, 235, 240, 241, 276, 278,
289,) in which tobacco was employed alone, or in combination. In 23 cases, in which
this agent was thus used, 12 rccovert»d and 11 died, giving a mortality of 47.82 per
cent, or 1 death in 2.0f^ cases.
According to Mr. Travers, the infusion of Hobacco, injected \\qt anum, beginning
with half a drachm, of the dried leaf to a pint, and increasing the strength to double,
if indicated, may be employed with signal effect in calming the spasm of tetanus. It
may be used twice or thrice daily, with perfect safety, in the onsta of the disease. It
prodnoes nausea, perspiration and sleep, oilcn of hours continuance ; but above all it
diminishes the force and frequency, if it does not arrest the morbid action, and grad-
ually restores the pliancy of the fixed and board-like muscles. To counteract its dcprc^-
t*inp effect, and indeed to support the patient under the disease, independent of all medici-
nal remedies, Mr. Travers gave strong animal broths or jellies, and alcohol in the form
ui bnndy or wine, every hour or two ; and this he held to be a not less important indi-
cation of treatment, for patients have been lost in tetanus, from want of proper nouiish-
uient and cordials, oftcncr than from want of proper medicines.
The testimony of Mr. Curling jis to the value of Tobacco in the treatment of Tetanus,
is eciually cl<?ar and docided. Of nineteen eases, in the Tabic of Mr. Curling, in which
400 Treatment of Traumatic Tetanus.
Tobacco was employed, nmr recovered. Mr Curling concludes his observations u{h>u iLIk
agent, in the following manner :
" I conceive that more has now been advanced in proof of tlie efBcncy of tobaccOj than can
be adduced in favor of any remedy yet resorted to. I have not, indeed, succeeded in findinj; a
single casCi in which, being fully and ftiirly tried, before the powers of the constitution hud
given way, it has been known to fail. Many more cases have been cured by the u»e of opium,
and for the obvious reason, that a far larger number have been treated with it. Tobacco is a
more certain and potent sedative than opium, the latter being a remedy that never can be
relied on, having failed far oftencr than it has cured. Many appear to dread so powerful an
agent, as a remedy more dangerous than the disease ; but without resorting to so weak nn
argument, * Melius anceps remedium, qunm mulluui,' it may be justly alleged that only ihr
rash abuse, and not the judicious exhibition of tobacco, can afford ground for apprehen.^ion.
I would not say that tobacco is a remedy, which, even resorted to at an early period, nuU
employed with judgment, will always avail ; for I believe that in its worst forms, Tetanus i«
a disease of too destructive a nature to be arrested by any treatment whatever; but I hol«l
it to be the best remedy that we at present possess, and one which will generally be found
capable of diminishing the severity of the acute disease, and often of subduing it altogether.
"The doses should be regulated by the age, habits and constitution of the patient, who.
during its use, must be supported by a nourishing diet, tonics, wines and other stimulants.
The Carbonate of Ammonia, in particular, is well adapted to counteract the extreme provtra-
tiou Fometimes induced. At the commencement, a scruple of the tobacco leaf infused in
eight ounces of water, will be enough for an injection, which must afterwards be iocreasiui
in strength, in proportion, to its effects. A stronger infusion will be necessary for those who
are accustomed to the use of this plant as a luxury. Unless in Chronic Tetanus, baths im-
pregnated with it are not only insufficient, but objeelionable." — Treatise on Tetanus, p. 91.
31 r. Haughton recommends the use of Nicotine instead of the infusion of Tobacco, on
the ground that in the latter the alkaloid is combined with two or more vegetable oiL*.
the operation of which on the nervous system is unknown. He relates, (Dublin
Quart. Jour., Vol. 34, p. 172), two cases of traumatic, and one of idiopathic ieCanus
thus treated. In the first case, which proved fatal, the patient was nearly moribund
when the medicine was given ; it had, however, the effect of causing the immediate relax-
ation of the muscles of expression, of respiration and of deglutition, cessation of deli-
rium, and feeling of relief from agonizing pain, and a lowering of the pulae from 130
to 88. This case rcc jived 3 doses of one minim of Nicotine at intervals of two hottt>.
The second was the case of idiopathic tetanus ; it recovered. The dose was from half u>
two-thirds of a drop, repeated several times a day, so that in 11 days 44 drops were taken.
The effects noticed in this case were immediate relaxation of the muscles of the abdo-
men, back and diaphragm ; cessation cf delirium ; a slight tendency to increased circu-
lation, the pulse being f|uickened 10 beats per minute; profuse sweating, which exhaled
an intolerable odor of snuff, not of tobacco ; a tendency to deep sleep. The adducttir
muscles were not as easily brought to desiat from their spasms as the others, even when
the hamstring muscles gave way, the adductors refused. The third caac recovered ; the
Nicotine was given in donvn of 1 , 2 and 2} drops, according to the urgency of the teCanir
spasms. Afler the administration of the dose, in 3 minutes the spasm was gone, an«l
the muscles relaxed and profuse sweating accompanied by a Bmell of snuff, set in.
During the four days of treatment with this medicine, the patient received by the
mouth and rectum, altogether, 54 drops, equal to 32j grains.
Mr. Tyrrell as quoted by C. Handfield Joues, in his '^ Studies on Functional Nerroiu
Disorders," p. 253, r.'conls two well markcnl casts of Traumatic Tetanus, whirfa h»»
treated by the hwal application of Tobacco. (Med. Times and (jlaa., 18*>4, Sept. 24ili •
IJoth terminated succts.'^fully, Mr. Tyrrell arguo.*< that as Tobacco is of Hcnricc wh«ri
given internally, it should Ix^ more so in eccentric Tetanus, if applied locally, by par^
lyzing the nerves of the effected parts from which the irritation proceeds, and thu
removing the cause of the spasms. In the idiopathic form, Mr. Tyrrell pro|ifi0C8
remove the cuticle of the ^<kill by a blister, and to apply a strong solution of T<iba
to the denuded surfitw, and thinks tliat in this way, the coi^tl would more quickly »
Treatment of Traumatic Tetanus, 401
brought under the iufluencc of the remedy, and with less vital depression than when
it is given internally.
In one of the cases reported, a strong infusion of Cavendish Tobacco was applied to'
a blistered surface, 12 inches sc^uare at the back of the neck, as well as to the nose
which had been injured, and the patient was supported by clysters of Brandy, Ether,
Quinine and strbn<: Beef Tea, given every four hours. The treatment was begun on
the 22d ; on the 24th, ho was able to swallow, on the 26th, the neck which had been
rigid, was quite pliant. Delirium then supervened, but yielded to Quinine and Opium,
and in five to six days, the disease was at an end. Mr. Junior, as quoted by the same
authority, testifies strongly to the good elFect of Mr. Tyrrell's plan in a very interesting
case, which he has published in the Ed. Med. Jour., Feb. 1867. He used at first a
solution of Cavendish Tobacco of the strength of ^i\ ad Oj ; at a late date the strength
was doubled. The case was one of great severity, and the sufferings were extreme.
Within two or thrc2 hour.s aftir the application of the infusion to the wound, which
was large, the improvement was most marked. All the rigid muscles became to a con-
siderable extent relaxed, the mouth could be opened about half an inch, the paroxysms
were leas severe and freciuent, and a good deal of sleep was obtained. There were
many difficulties to be overcome, before the wound was healed, and recovery complete,
but the case terminated favorably in about two months. Mr. Junior says, there can be
no doubt that the recovery of the patient was due to the Tobacco stupes.
Bloodletting^ Calomel and Antimony^ are doubtful remedies in the treatment of
Traumatic Tetanus. The disease has been known to saper\'ene upon wounds, which
had been attended with the most profuse haemorrhages, and it has pursued its course
unchecked by the most energetic employment of blood-letting. If Traumatic Tetanus
be not an inflammatory disease in its inception, and if under all circumfitances, it is the
duty of the physician to preserve as far as possible the integrity of the blood, and the
proper nutrition of the body. Venesection should be employed with caution, and the
results carefully watched and recorded. Mr. Curling. Dr. Sandwith and others, have
recorded cases which were benefitted by free venesection, and the remedy appears to be
Kpeci^lly applicable to idiopathic tetanus. It is difficult however to form a just estimate
i»f this measure, as it appears to have been almost always used in conjunction with other
powerful agents, as Opium, Tobacco, Tartar Emetic and Mercury.
Beyond its purgative effects, and its power to regulate to a certain extent the secre-
tions of the intestinal canal, and its associated organs. Mercury appears to be of no value
in the treatment of Traumatic Tetanus, and the weight of testimony is against its
employment in such a manner as to affect the general system.
In fifty-three cases reported by Mr. Curling, in which Mercury was employed, thirty-
one proved fatal. Of the twenty-two cases which recovered, in one case it is mentioned
that although salivation was produced, the symptoms continued to increase, until the
noaotity of Opium was augmented ; in another case. Mercury was not resorted to until
tne diseaise had been established seventeen days ; and in still another ease, the patient
was improving before ptyalism was produced ; in twenty of these cases of recovery.
Opium was combined with the mercury ; and of the two treated without it, in one
Tobacco injections were employed ; six of these cases also were females. In eleven of
the cases, in which neither Opium nor Tobacco was resorted to, Mercury being given
alooe, or employed in conjunction with some trivial remedy, as the warm bath, or blis-
ters, aU icere fatal except one.
Twelve cases of Tetanus, consequent upon severe injuries, recorded by Mr. Howship,
in all of which Mercury was freely exhibited, two only recovered, and in both of them.
it was given in conjunction with Opium.
Baron Larrey found that Mercurial friction rather aggravated the symptoms in the
cases in which it was tried in Egypt. Sir James McGregor, in numerous triab of Mer-
I'UiT as a remedy, found it quite inert ; and he notices the case of a man who was seized
with Tetanus, whilst strongly under Mercurial influence) for the cure of % cutaneous
eruption.
402 Treatment of Traumatic Tetanus.
Mr. Mosely mentions that many people have been attacked in the West Indii^s uuJ»r
a coarse of Mercury, and expresses the opinion that it has killed more than it has curiHl
(Treatise on Tropical Diseases, p. 478.)
Dr. Wells has related three instances of the occurrence of Tetanus, during SaliTation
from the use of Mercury.
Sir Anthony Carlisle, informed Mr. Curling of two instances in which the disease
was developed in the course of salivation for another complaint. Dr. Thomson of
Jamaica, witnessed several cases which proved fatal when the full etfect of Mercury had
been produced; he observes that he ?as seen patients expire with a stream of saliva
flowing from their mouths. (Ed. Med. and Surg. Jour., Vol. xviii, p. 39.)
Mr. Maxwell has also recorded a case of Tetanus in a negro, which proved fatal after
the production of ptyalism.
Mr. Curling witnessed two traumatic cases, in which some ptyalism was produotil
without being followed by the slightest mitigation of symptoms. In both of thfui
extreme suffering was occasioned by the increased secretion of saliva. The mouth l)cin.;
closed by the spasmodic action of the orbicularis oris, to prevent the distressing constric-
tion of the throat, and the suffocating paroxysms consequent upon attempting to swallow
the saliva, the patients were compelled to keep their lips constantly apart with thiir
fingers. Treatise on Tetanus^ pp, 74, 7o.
The effects of Antimony, when introduced directly into the blood, arc shown in a
striking manner in case 263, of the table ; although its characteristic action was mani-
fested immediately, it exerted no influence upon the disease, the tetanic spasms conti-
nuing with unabated severity. The majoritv of the cases, in which it has bt-on
employed terminated fatally. Its power of diminishing and relaxing the muscubr
force, appears to bo dependent upon the nausea, vomiting, purging, and perspiratinu.
which it induces, and also upon its direct depressing effects upon the action of the
heart. Antimony is, when used freely, uncertain and uncontrollable in its action upm
the nervous system, and is liable when employed in -sufficient doses in Traumatic Tetanu>
to induce &tal prostration. In most of the cases in which it has acted beneficially, it ha>
been combined with Opium and Morphine, and it is but fair to attribute the g<» "^l
results chiefly to the latter remedies.
Quinine has been employed with a fair degree of success, more especially by Amorican
physicians, (see cases 347, 349, 351, 357, 384,) and of these 5 cases, only one pn)\«-<i
fatal. Other remedies, however, were employed in conjunction with Quinine. Farther
investigations as to the effects and value of Quinine in the treatment of Tetanus ar*
needed.
Woorara. The experiments of Sir Benjamin Brodie, in 1811, demonstrating^ th
action of Woorara upon the motor nerves, the application of the results of Profi.^'M.r
Sewell, at the Vetinary College, and the subsequent experiments of Mr. Morgan and of
Dr. Harley, not only anticipated the results obtained by the continental physioloin^t>«
but also led finally to the actual trial of this powerful agent in Traumatic Tetanu<%. Th«
application of Woorara to the treatment of this disease was based, not only up<>n .-\
knowledge of its physiological action, but also upon its antagonistic effects to tho arti6
cial Tetanus of Strychnine, and upon the results of its use in the idiopathic tetanu.^ <<t
the horse and ass. The superior value of Woorara to other narcotics, appears to con>:-*.
in its peculiar power of paralyzing the motor and not the sensory nerves, and it app^Mr*
that it might be so administered, as to destroy entirely the power of voluntary motiim
without impairing consciousness. In administering Woorara to animals laboring und>: r
Tetanus induced by Strychnine, Dr. Harley gj^vo sufficient to paralyze all the muscK -
except those of respiration. In this way he was able to allay the tetanic f^pasms withour
destroying the, intelligence, or arresting the performance of the organic functions. Ai;i
by continuing the thus moderated action of Woorara, until the kidneys had tinit* t..
eliminate the Strychnine from the system he had been able to save the life of the anim-l
According to Dr. Harley, the theory of its action in tetanus is much the same. Th:.i
is to say, you t^y to keep the spasms ftom killing the patient by their violence, until th.
Treatment of Traumatic Tetanus, 403
morbid state calling them into play has exhausted itself. According to this observer,
the chances of curing by Woorara, a patient laboing under Strychnine poisoning, are
natarally rouch greater than those of curing a case of Traumatic Tetanus, where the
morbific matter may go on increasing until its effects were more than sufficient to
cimnteract the influence of Woorara. This explanation of the failure of Woorara to
cure a certain, and that a very large proportion of cases of tetanus, does not appear to
k satisfactory, because it is based upon the supposition that a morbific matQriai is the
cause of Traumatic Tetanus, the violence and nature of the symptoms depending upon
the amount of the poisonous matter which acts antagonistioUly to such remedies as
Woorara. If this morbific matter really exists, it would seem to be entirely possible for
such an able physiologist as Dr. Harlcy, to demonstrate its existence by noting the
effects produced upon animals by inoculating the secretions of the wound, or of the
blood or juice of muscles, or of the urine and other excretions of the tetanic patient.
The failure of Woorara in the treatment of Traumatic Tetanus, may more rationally be
referred to its variable strength, no two specimens producing effects of equal degree to
it$ uncertainty when administered by the mouth, to its violent effects when inoculated,
ant] more especially to the fact, that in order to overcome tetanus it is necessary to give
an adfquate dose, and an adequate dose in severe cases would be such as absolutely to
arrt-st respiration.
Without tlie great&it precaution, the remedy will prove more dangerous than the dinecue.
Cases of tetanus have been treated by Woorara, on the continent by Vella, Manoe,
Cassaignac and others, and in England by T. Spencer Wells and others. In eight cases
of tetanus treated with Woorara on the continent and in England, five proved fatal,
and three recovered ; thus giving a mortality of 62.5 per cent.; and it should also be
(Stated, that the three cases which recovered under the use of this powerful agent were
•»f the chronic variety, whilst the five which proved fatal were of the acute variety.
It may well be questioned, if in view of such mortality, which appears to have been
influenced in a doubtful manner by the drug, whether it would be subserving the best
interests of those afflicted with tetanus, to rely upon so powerful and uncertain an agent,
instead of employing those which have yielded far better results.
An Italian Surgeon appears to have been the first to use Woorara in the treatment of
tetanus ; he employed it in three instances, applying the poison in solution to the wounded
part, and where no wound was present to a raw surface artificially produced by blisters.
In two of his cases the tetanus was acute and traumatic, but both died ; in the third
f-^se the disease was chronic, and recovery ensued. If these be added to the preceding
el^ht cases, we have four recoveries and seven deaths, in 11 cases treated by Woorara;
the four cases which recovered were chronic, and would most probably have recovered
without this drug, and the seven which terminated fatally were all acute.
According to H. Demme, of 22 cases of Traumatic Tetanus treated by Woorara,
■ Curare,) up to the year 1863, 8 recovered ; the mortality being 64.6 per cent. Busch
t'lnployed this agent in a certain proportion of the cases occurring afler the battle of
Koniggrats; the disease did not appear until the second week afler the engagement; —
Wore (^urare could be procured 9 patients died, a tenth was saved by the hypodermic
injection of one^fourth of a grain of Morphia, every two hours; of the remaining 11
cartes which were treated with Curare five died, one, however, of pysemia ; improvement
took place in all ; the duration of the successful cases was from 7 days to 4 weeks. He
ascribed its good effects to its preventing the cramp-like muscular contractions, which
react injariously on the spinal cord, intensifying its reflex excitability, and to the
aroidaooe of the excessive increase of temperature resulting from the powerful action
'>f the muscles. He prefers administering the remedy by sub-cutaneous injection, as
its operation is uncertain by the mouth. The dose varies according to the purity of the
preparation from grain ^^ to grain j^.
Woorara was employed in cases ^15, 316, 326. 394, 474, all of which, except one
proved fatal, and in case 394, the fatal issue was directly referable to the action of the
poison. Dr. Wm. A. Hammond and S. Wier Mitchell, in their important experiments
404 Treatment of Traumatic Tetanus.'
»
on the Woorali poison, (Am. Jour. Med. Sci., July, 1859, p. 13), found that in a few
minntes after the introduction of the poison through a wound, paralytic phenomena soon
became obvious, and the animal diea without preliminary spasm or convulsion, but the
heart, instead of continuing to act afler apparent death, had entirely ceased to beat, so
that it could not be excited by galvanism. They inferred that the action of the pouton
is directly and primarily on the heart, possibly on the ganglia contained in its tissue.
The capillary circulation was always arrested a minute or two before the heart's actioas.
which they ascribed to paralysis of the sympathetic.
Woorara has not, therefore, fulfilled the expectations of the physiologist and physician,
and has not increased our means of arresting or curing Traumatic Tetanus.
By a reference to the table, it will be seen that more favorable results were obtained
with Extract of Indian Hemp, (Cannabis Indica), and Calabar Bean.
ExJtract of Indian Hemp, {CantiabU Indica) , was employed in cases 269, 270, 271,
278, 279, 280, 282, 313, 319, 327, 346, 360, 361, 379, 386,431, 473,475,476,477 ;
and of these 20 cases, 12 were cured and 8 terminated fatally, giving a mortality of 40
per cent, or one death in 2.5 cases. Mr. 0' Brian used the resin of Indian Hemp in
seven cases, with the effect of producing almost immediate relaxation of the muscles'
and interruption of the convulsive tendency. More than on3 half, or foiir of Mr'
O'Brian's cases recovered. The late Dr. Baiiie used the remedy in three cases, two of
which recovered. Dr. I^ewis, (Edin. I^Ied. Jour., Aug., 1859), reports a case of Trau-
matic Tetanus in a lad, ast. 13, which tenuinated favorably under 4 grains of Indian
Hemp every three hours, the first being preceded by a full, free bleeding. No toxic
effects were produced, notwithstanding that the Extract of Cannabis Indica was con-
tinued at the same rate for throe days. Skues treated a girl tet. 9, suffering under
Traumatic Tetanus, with Indian Hemp, nouiishing soups and wine; she took from 4
to 18 grains daily of the extract, and was kept in a continual state of narcotism ; the
symptoms gradually declined in severity, and the patient was convalescent on the 13th
day. Dr. Famage treated two cases of Idiopathic Tetanus by Tincture of Cannabis
Indica, thirty minims every two hours, one of which terminated fatally and the other
recovered.
Dr. Charles D. Allen, of Glenariu, has recently reported a case of Traumatic Tetanus.
(British Med. Jour., April 4th, 1874, p. 450), which occurred in a lad aet. 11. who^
lefl hand had been crushed and lacerated by cogged-wheels. Tetanus appeared on the
18th day ader the injury and the amputation of the second, third and fourth fingen.
The spasms were severe, the pulse rapid — 140 per minute, the respiration 40, and the
temperature 103° F. Under the persistent use of Tincture of Cannabis Indica, com-
bined with solution of Muriate of Morphia, (one drachm each every two houn), the
violence of the symptoms gradually abated, and convalescence was established in two
weeks.
Extract of Calabar Bran was employed in the treatment of cases 398, 399, 402.
404, 414, 415, 421, 422, 423, 471 ; and of these 10 cases, 8 recovered and 2 termin-
ated fatally. In some of these cases, as in 414, 415 and 421, this remedy was em-
ployed in conjunction with the Hydrate of Chloral. The preceding cases yield a mor-
tality of 20 per cent., or one death in 5 cases.
In case 398, reported bv Mr. E. Watson, (Pratcitioner, 1870, p. 207), 2 grains of the
alooholic extract were administered at one dose, and at varying intervals, and 102(>
grains were given during 46 days.
In case 399, reported by Dr. W. Haming, (Lancet, 1869, p. 834), the Extract of
Calabar Bean was administered by sub-cutaneous injection, In 30 days, about tco
drachms of the Extract of Calabar Bean were injected, generally in quantities of one-
half grain. The antagonistic effect of the remedy upon the well marked tnsmos tod
opisthotonos was immediate and well marked. The arched back, painfulhr teo^
abdomen, quivering limbs, and anxious countenance, were generally relieved m fn^oi
five to ten minutes afler each injection, by comfortable decubitus, a feeling of drow<*}^
ease, and during the night by short snatches of sleep. In case 402, the extract tC
Treatment of Traumatic Tetanus. 405
Calabar Bean was administered, both bj the mouth and by injection. The extract was
«rivcn every two hours alternutely, by the skin and mouth, so that in every four hours
one grain and a half were administered, viz : one grain by the mouth and half a grain
by the skin. During the attack, the total amount of extract administered was 40}
grains by the skin, and 49) grains by the mouth, making, in all, 901 grains given in
10 days. The reporter of this case, Dr. A. Boutflower, (Manchester Med. and Surg.
Reports, 1S70, p. 52), was led to use this remedy from the effect which it possesses of
paralyzing the spinal cord, without at the same time depressing the action of the heart
to any great degree.
In case 471, reported by Mr. Ashdown, (Brit. Med. Jour., 18G3, March 21st):
Calabar Bean was administered both internally and by sub-cutaneous injection. The
patient was bled to a pint on the 2d day after the supervention of Lock -Jaw ; on the
following day he began to take t of a grain of the extract of Calabar Bean in one
flaiddrachm of water every half hour, and was supported with strong Beef Tea, Milk,
and Port Wine 8 oz., and Brandy 4 oz. On the next day, the dose of Calabar Bean,
and the stimulants and nutritive fluids were doubled, as the patient was much worse,
and the violent paroxysms coming on every four minutes. On the next day the state
was the same, and the Calabar Bean was ordered to be administered sub-cutaneously by
injection, gr. i of the extract dissolved in 18 minims of water, being thus given every
two hours. The effect of the first injection was very marked ; in about five minutes,
the legs which had been previously rigid and immovable, became flaccid and freely
movable by the patient, the abdominal muscles became less tense, and the aching of
the spine disappeared.
The pupils also contracted, and the pulse sank to 82. The effects lasted two or three
hours, and all the symptoms then reappeared. The injections were again continued
every two hours with similar effects. The pupils were much contracted, and the
patient at times was very delirious. As the injections occasioned much pain and
inflammation in the areolar tissue and the solution was found to be acid, a few drops
of Liquor PotasssB were added to it. This corrected the above-mentioned ill effects.
The injections were continued for nine days, when at the end of this time, the sever-
ity of the disease was evidently subsiding, and they were then replaced by suppositories
of the same extract, containing grain, 1^ to be applied every two hours. Morphia was
given with benefit every night. He took 12 eggs and 2 bottles of sherry in twenty-
four hours. In one month the malady was at an end.
Dr, John Cunningham, of Campbeltown, (Brit. Med. Jour., April 4th, 1874, p.
450), has reported a case of Tetanus, (Traumatic) occurring in a boy, aged 7, from
laoeration of the foot, which was cured by Calabar Bean. Dr. Cunningham adminis-
tered the Extract of Calabar Bean in solution, in amounts ranging from ^^th to ^th of
a grain eveiy hour.
Dr. Fraser has shown by valuable and elaborate investigations, that the active prin-
ciple of Calabar Bean qnicklv enters the blood, and causes muscular motion to cease,
and renders the entire muscular system limp and flaccid. It produces general paralysis,
and destroys all reflex action of the cord. Respiration under the influence of the
poison, grows gradually slower and slower, and at last ceases. Consciousness appears to
be preserved throughout. As muscular contraction can be easily and abundantly
excited by direct irritation of the muscles, afler the motor nerves have auite lost their
power to conduct impressions, it is evident that the poison has no influence on the
voluntary muscles ; paralysis is not produced by any changes in the brain, for ooncious-
iiefls is intact when paralysis is marked and progressing, and if the brain be removed
and the animal poisoned, the paralysis ensues as usual ; paralysis is not produced by
the action of the poison on the spinal nerves, for long after general panuysis is pro-
doccd, and even afler death, they conduct the motor impressions to the muscles ;
finally the paralysis depends alone upon the spinal cord, and is due to changes affected
in this organ by the Calabar Bean. The reflex functions of the cord are destroyed by
Calabar Bean, long before the spinal nerves lose their power to conduct.
406 Treatment of Traumatic Tetanus.
From its pbysiologicid action on the cord, Dr. Fraser recommonds the Calabar
(Ordeal) Bean, as an antidote to Strychnia, and he shows that it is superior to Curare,
as this last paralyzes only the motor nerves, while the Calabar Bean first paralyzes the
cord, and after some time, the motor nerves also.
Dr. Fraser has collected twelve cases of tetanus treated by Calabar Bean. Of these,
eleven only are useful in estimating the value of this drug, as the twelfth case was not
treated with Calabar Bean, until near its close ; and only one dose was given before the
patient died. Of the eleven remaining cases nine recovered, and of the two fatal c&se^,
in one the remedy was given in insufficient quantities. This drug should, aooording to
Dr. Fraser, be given at the very beginning of the attack, fur when muscles contract,
they beget a substance which excites muscular contractions, and at the beginnin<; of
tetanus, only a limited part of the cord or ganglia of the brain is involved, but speedily,
on the continuance of the disease, the whole of these structures are affected.
The extract of Calabar Bean should always be used in preference to the powder, a.s
it is the most concentrated preparation, and one on whose constancy we may rely. It
may be given in the form of pill, or of solution, and suspension m water (mixture),
or of solution in weak spirit of Sp. Gr. 0.920 (thirty-two grains to the fluidounce).
The first and last of the two forms are to be preferred, as that with water decompaHcji
in a few days. Tlie Extract may be administered by the mouth, anus, or snb-cutaneously,
In tetanus, the method by sub-cutaneous injection should be preferred. For an adult,
one grain of the extract by the stomach, or one-third of a grain by sub-cutaneous
injection, -will be generally sufficient to commence with : this should be repeated in two
hours, when its effects will usually have passed off, and the succeeding doses may be
modified according to the experience thus gained. When used by sub-cutaneous injec-
tion the dose of the extract should be carefully mixed with ten or fifteen minims t>f
water ; this mixture has always an acid reaction, which is sometimes so decided as to
produce slight irritation of the cellular tissue ; bnt this can be avoided by carefully
neutralizing the mixture with a solution of (Carbonate of Soda. When administration
by the anus is desired, suppositories, containing two grains of the extract, may be
made with Oil of Theobroma and White Wax. The remedy should be given at regu-
lar intervals in accordance with its effects.
Aconite was used in the treatment of Cases 2S8, 289, 318, 389, and of these four
cases, three recovered and one died ; a very favorable result. The physician in employ-
ing this valuable but potent agent, should remember that its success depends upon the
possibility of the heart being able to tolerate a sufficient amount to overcome the
excitement of the spinal centres. In Traumatic Tetanus, we have the local injury, fn»ni
which irritation is conveyed to the ner\'ous centres, including a state of hypenusthi^ia
or exalted polarity of these centres (the brain excluded,) derangement of nervous funo
tion, increase of irritability, and contracted and torn muscular fibre, the consequent
crushing of the sensitive nerves, and obstruction of the capillary circulation of the
affected parts ; followed by the consequent exhaustion ; death occurring by asphyxia,
by spasm, or by asthenia from exhaustion, or by syncope, from sudden cessation of the
heart's action. Aconite on the other hand, according to Dr. G. Smith of Hydcmdad,
alters the character of the local irritation, then abolishes it, the tingling being followtni
by numbness; it acts as a sedative of the nervous centres, (cerebrum excluded. -
diminishing their polarity, and inducing a state of ana3sthesij, impairing the excit**-
motor, vaso-motor, and voluntary systems of nerves, causing muscular weakness, partly>i*
of the diaphragm, suspension of spasm, paralysis of the capillaricH, and general exhaus-
tion, eventuating in death by asphyxia, from paralysis, or by syncope, from shoik. A*
no two states of the system can resemble each other more closely, than those dependent
upon Strychnine and Tetanus, and no two states of the nervous system are morv tb«»-
roughly antagonistic than those induced by Tetanus and Aconite.
Jieffadonna, according to Brown-St'iiuard, diminishes the reflex activity of the spinal
cord, by contracting its blood-vessels; but whether or not this be its nunlnt oftrrandt.
it appears to exert a direct sedative efft*ct upon the nerve cells. In case 2S1, ihc
Treatment of Traumatic Tetanus. 407
Kitract or Belbdoiiita certainly exerted beneficial effects. And it appeare from the
oWrvatioDS of Mr. Hutchinson, that in Tetaniui, large doaea of this potent agent may
bo administered without the niaiiifestatioii of dangerous symptoms, the enormous dose
of 5 grains of the extract being suscessfully administered ; and still farther that the
system appears to acquire a tolerance for the remedy, which necessitates its progreeaivo
incrcaae.
Farther observations, are necessary fur the establisbmcnt of the relative Talue of
Alropia and Strychnia.
The application of ice to the g/iinc, afler the method recommended by Dr. Todd,
protnisea to be of some use in the treatment of this disease ; we are however, without
ihe neccsauy facts to show the relative value of thi.<( measure.
Owing to the almost invariable presence of obstinate constipation in teLaous, pargalivi:*
have been recommended and employed by almost every physiciav and surgeon. The
weight of testimony appears to be in favor of Croton Oil, which recommends itself not
only on account of the efficiency and certainty of ita action, but also on account of the
facility with which it may be administered, even when the jaws are firmly locked ;
it being only necessary to place a drop or two of the oil upon the tongue.
Attaftxlida, Camphor and Afiisk, arc of doubtful utility in the treatment of Trau-
matic Tetanus ; and this observation applies also to the application of blisters over the
region of the spine.
In conclusion, in the present slate of medical knowledge, in the treatment of Trau-
matic Tetanus, the highest places must be assigned, and the greatest importance attached
to, the following remedial agents :
Chloral Hydrate.
Calalwr Bean.
l.'hlorofbrm.
Sulphuric Kthcr.
Cannabis Indica.
Tobacco.
Bromide of Potassium.
Opium.
Important advances in the Therapeutics of Traumatic Tetanus, will be made, when
in its treatment, all empirical remedies are discarded, and the attention of the entire pro-
fewion in concentrated upon two or more remedies, as Chloral Hydrate, Calabar Bean
and Bromide of Potassium.
OBSERVATIONS
ON
Cerebro-Spinal Menu
AND MORfi ESPECIALLY AS It APPEARED AMOMGST THE
SOLDIERS OF THE CONFEDERATE STATES ARMY
PURINQ THE
CIVIL AV^R OF 18G1-18G5.
OBSERVATIONS ON CEREBRO-SPINAL MENINGITIS; AND MORE
ESPECIALLY AS IT APPEARED AMONGST THE SOL-
DIERS OF THE CONFEDERATE STATES ARMY
DURING THE CIVIL WAK OF 1861-1865.
CIIAPTKR VI.
(»IISKBVATI0NS ON THE HISTORY OF CERKBRO-SPINAL MSNINOfTlS IN FORMER PERIODS.
HIKTuRirAL NOTK8 ON CERKBRO-SPINAL MENIN(;IT1S AS IT OCCURRED IN THE ARHIE8 OF THE
M>rTHERN a>NrEDEBACT DURINO THE WAR OF lH<Jl-186r>.
REi^rLTS OF THE EXAMINATION AND (CLASSIFICATION OF THE SICK AND WOUNDED, AND MORTl .
ARY RECORDS OF THE CONFEDERATE STATES ARMl'.
mRSERVATIONS of confederate SrKGFX)NS ON THIS DISEASE.
REPORTS RELATING TO A VERY FATAL MALADY WHICH (K^CU^t RED AMONG SOME OF THE TR0Ol*S
OF THE ARMY OF NORTHERN VIRGINIA, Sl'PPOSKD TO HAVE KEEN ('EREBR<KSP1NAL MENINGITIS.
•'REP<iRT OF SICK AND WOINDED IN TEN (y)MPAXIES, TWENTY-SECOND NORTH CAROLINA
KE(iIMENT, HT.\TIONED AT CAMP GREGG, NH\U FUEDERICKSIUrilG, APRIL, 1803, BY P. (JERVAIS
ROBINSON, srRGE<»N P. A. C. S."
-REW3RT OF W. D. MITCHELL, M. D., SENIOR srRGKON RHODES' BRIGADE, ARMY OF NORTHERN
VIRGINIA."
• REPi»RT OF J. T. BANKS, M. D.. SI ROEON THIRTEENTH RE(;iMENT GF/>RGIA VOLUNTEERS,
ARMY OF NORTHERN VIRGINIA."
••REPORT ON THE PRECEDING PAPERS BY Sl'RGEON R. J. BRECKENRIDGE, M. D., INSPECTOR OK
r\MPS AND HOSPITALS, ARMY OF NORTHERN VIR<JINIA.''
•EPIDEMIC OF CEREBRO-SPINAL 31ENINGITIS BY Sl'RGEON G. A. MOSES, OF MOBILE, ALABAMA/'
EPIDEMIC OF CEREBRO-SPINAL MENINtilTIS IN NEW ORLEANS, IH72, lH7:i.
Lord Bacon characterized Medicine as a Science which had been more pt'o/v^ued ihnn
liiboured, and yet more laboured than advanced, the labour having been rather in ciryle
than iQ progreasion. With much repetition there was but small addition. BacoR very
juAtly complained of the discontinuance of the ancient and serious diligence of Hippo-
crates, which used to set down a ^larrative of the special eases of his patients, and how
they proceeded and how they .were judged by reoovery or death. Therefore having the
example proper in the Father of the art, there was no need to bring a foreign example
of the wisdom of the lawyers, who are careful to report new cases and decisions for the
direction of future judgments.
Whilst it is true that facts lie at the foundation of all true advancement of medical
Mrieocc, and that as a general rule, the conclusions reached by any investigation will be
t nut- worthy in proportion to the number of carefully observed and recorded facts ; on
the other hand, it must be admitted, that the relationship of the oompUcated phenc-
mena of health and disease, cannot be discovered by observation alone. To the estabr
lishment of Medical Science, two things are requisite ; observation of things without,
and an inward examination, decomposition and analysis, and comparison of the results
of observation ; there must be both the exercise of the senses furnishing the primary
ideas, facts and phenomena, and the exercbe of the reasoning powers, determining in
virtue of their constitution and relations, through the senses to the exterior world, the
fixed relations or laws of the pathological phenomena.
In the investigation of the complicated chain of pathological actions, experiments
'412 HUtory qf Cerii>r<hS]nnal Mmngitis.
upon living animals, are of undoubted importance, in that they afford a oomparison
between pathological actions excited by unknown agents, and the phenomena manifested
by living animals, under the influence of well-known morbific agents and poisons.
Our discoveries therefore, in the study of disease, may be the result of a simple act
of consciousness, through an impression made on one or more of' the senses ; or they
may be conclusions established by the higher powers of the understanding dealing with
data, previously actjuired by the senses and perceptive faculties.
The differences of opinion amongst medical men, are due more to the extent and
character of their observations and studies, than to any real differences existing in the
subjects of medical research. Mental and moral peculiarities, as well as the different
objects for which the profession is followed, whether for the relief of suffering humanity,
or for the gratification of personal aggrandizement and ambition, determine to a great
extent those differences in professional creeds and practice which have led so many to
doubt the inspiration of the oracle, whose utterances arc found to be so changing.
It would appear to be impossible, but that the attention of observers should have
been arrested, at an early period by the bold and gigantic features of a disease, which
often attacks suddenly, without previous notice, throwing the system into great distress,
with violent pain and numbness in the head and limbs, convulsions, delirium, coma and
purple spots, upon the surface, and causing death within a few hours aller the fii>t
appearance of disordered action.
In attempting to determine the precise period of the appearance of Ccrebro-Spinal
Meningitis in the history of mankind, we are however met with numerous and insnr-
mountable difficulties.
Whilst there are passages in the writings of the Hebrews, and of some of the older
writers, as Homer, Herodotus, Ovid, Plutarch, Pliny and others, showing that pestilence
was both common and fatal in ancient times, and that the diseases which afflict modem
armies, were not unknown to the ancients ; on the other hand, the earliest and m<)!«t
celebrated writers, although embracing vast periods of time in their historical account^t.
give but few and imperfect notices of the diseases which scourged populous kingdoms,
and decimated immense armies and navies. The absence fVom the writings of the
ancients, of such minute descriptions of disease, as would enable the ph^'sician of
modern times to determine with some approach to accuracy the nature ana relations of
different diseases, is referable to several causes. In most cases their works were om*
jtends of the knowledge of their times, and embraced vast periods, and covered such an
innumerable number of civil, religious and warlike revolutions, that only the most
prominent events were recoorded. Such writings wci*e wanting in that personal and
actual observation, which could alone secure accurate dc^scriptions of diHcase. .\D<i
further, as such writers were busied, chiefly with t]ic origin, progress and decHoe of
states, with the civil and military achievements and intrigues of kings, princes, statt><
men and generals, the diseases and wounds of the common people passed almt^^t
unnoticed. The ancient kings, princes, statesmen and nobles, wore continually hattnt«*<t
with the terrors of poison, and the object of medicine wa.s rather to discover antidoti^
than remedies ; the different classes of mankind, were more widely separated, and tb«'
higher ranks took comparatively little notice of the destruction by pestilence ««f
thousands of slaves, or of the plebeian race.
Many populous nations of antiquity, were for ages, without any methodical rwonl*.
even of their civil, military and religious histories *, and many of the most important
events were preserved only in the dim and uncertain language of tradition.
Thus Justinian in his History of the World, extracted from Trogus Pompoiu*.
describes the Scythians, who were always regarded as very ancient, or of equal, if n»»i
greater antiquity than the Egyptians, as a people without landmarks, neither cultivatiin:
the soil, nor having any house, dwelling or settled place of abode, but being alwa}?
engaged in feeding herds and flocks, and wandering through uncultivated deserts. Thnr
wives and children were carried with them in wagons, which as they were covered with
hides, were used instead of houses, and protected them against the rain and oold ; th«>y
History of Cerebrospinal Meningitis. 413
were cUd in the skins of wild aDinials, as the use of wool and clothes was unknown to
them ; their food was milk and honey ; gold and silver they despised as much as other
men coveted them, and justice was ohser\'ed among them, more from the temper of the
people, than from the influence of the laws. They were a nation hardy in toils and
waifare ; their strength of body was extraordinary ; they took possession of nothin<r
which they feared to lose, and coveted when conquerors nothing but glory.
Many powerful kingdoms have been utterly destroyed without leavliiji any record
whatever of their literature and science, and their advancement in the arts may be
inferred only from the monuments which have resisted the ravages of time. We cer-
tainly have but meagre accounts of the history of the " antediluvians," and only allusions
to their progress in the arts ; and no account whatever is extant of their diseases.
Whilst we would infer from the " great age " attained by the *• antediluvians," and the
rapid multiplication of the race on the earth, that disease was rare, if not unknown, ut
the same time it must be confessed, that the closure of this immense period of time
against all investigation of the origin of diseases amongst animals and man, should
induce caution in those who attempt to define the period at which any particular disease
has arisen. We have a striking example of the manner in which entire nations may be
swept off by disease and battle, without leaving any trace behind them but their bonen,
rude earth monuments and stone implements, in the aborigines of North and South
America. The red men as a race, are cnaracterizcd by great energy, bravery and activity ;
they arc not strangers to the highest sentiments of humanity and religion, and they
developed both in North and South America, a civilization of a peculiar and in many
respects wondertul character. And yet whole tribes and nations have been swept off
by Small Pox, Syphilis, Whisky and the cruelties of their conciueroi-s, without leavinj^
a single written line to record their origin, religion, arts, wai*s or diseases.
Justin in his hi^itory of the world, although embracing a period of at least two
thousand years, mentions only casually the diseases which had distres-sed mankind.
Thus he simply records the fact that the famine which affected the retreating army of
Xerxes, produced a pestilential distemper attended with such dire mortality that the
ruads were filled with dead bodies, and birds and bciists of prey allured by the carcasses,
followed close upon the army. This author gives no account of the pestilence which
afflicted Carthage, seventy-two years af^er its foundation, notwithstanding tliat it was
so terrible as to lead to the establishment of the cruel religious custom of immolating
human beings ; in like manner, the pestilence which destroyed the army of the (\irtha-
geoiao General Hamilco, in Sicily, is not described, but simply referred to a pestilential
constellation, (pestilentis sideris,) although the entire city and country of Carthage was
overwhelmed with grief at the news of the calamity, private houses were closed, the
temples of the gods shut, all religious ceremonies intermitted, and business suspended.
In the curious notice of the Jews, by Justin, there is an allusion to Scabies and Lepro.sy,
as the cause of the expulsion of the Jews from Egypt, and the stringent laws of the
Hebfews against intercourse with the surrounding nations, is attributed to their rcmem-
braoce of the fact that they were driven from Egypt for fear of spreading infection. On
the other hand, Justin is much more explicit and full in his description of the circum-
(itaDces attending the diseases, wounds and mode of death of Alexander and other
distingoished personages.
Coroelius Nepos, in his Lives of Eminent Commanders, makes mention of disease
but 10 two passages ; in the former an allusion is made to the destruction of Dyonysius,
by some soporific potion administered by 'he physicians during his severe illness ; in the
latter, mention is made of a violent distemper of the eyes whicli afflicted Hannibal during
his naiurcb over the chain of the Appenincs, and which cost him the use of his right
eye.
Etttropius in his abridgement of Roman History, alludes to disca-^^cs and pe>tilence
only in the fifth chapter of the ninth book, where he states that the reign of llovtilianus
and Volusianus was remarkable only for a pestilence and for other discuses and afflictions.
We search ip vain, i^i the Historical works of Sallust. Florus and Vcllerius Paluculus,
414 History of Cerebrospinal Memngitis,
for any iDfonuation concernin*? the diseases and pestilence of the times of which thrv
wrote.
Tacitus, ID his Historical works, whilst describiug minutely the mode of death, thr
iutrigues and the poisoning of noted personages, gives nothing of the 8yniptoiu.< )»y
which we might recognize the terrible pestilence which devastated Renic, in the tinn'of
Nero. Tacitus describes this pestilence as sweeping away every living thing, witln.ir
any discernible derangement of the atmosphere, though the houses were filled with(li.-i<l
and the streets with funerals. Neither sex nor age were spared ; bond and frv^^ vivrv
snatched off indisciiminately, amidst the wailing of wives and children, who, wtiiUt
they were yet attending and lamenting the dead, were themselves stricken d«»wii ««nl
frequently burnt on the same funeral pile.
Titus Livius, the mo.st elegant of Koman Historians, whilst recording in his History
of Rome, the numerous and severe afflictions of this great city by pestilence, at the mm
time gives no such minute and accurate descriptions, as would enable the physician o\
modern times to recognize the true nature of the diseases. Rome, situ:ite<l in a low
malarious region, in the neighborhood of extensive marshes, was afflicted with pestilciicv
of a most malignant character as early as the ICth year from ltd foundation, and ll»^
years before the Christian era. Plutarch, in his life of Romulus sayp, that this plaini-'
killed instantly, without any previous sicknes.*?, and that even trees and cattle were ii"t
exempt from the malignity of its influence.
Thirty years after, in the 4(lth year of Rome, Italy was afflicted with .«*eveiv j>ejfhlr«j««-
of the nature of which we have no account, although Plutarch describes the in.'<titutiMii
of the Salii bv Numa on this occasion.
During a perio<l of five hundred and fourteen years, extending from B. (V lU'l tn 1»
C 120, Livy records no less than fifteen plagues, which afflicted U'»ni'\ and t»fh r
writers have still farther extended this number.
Whilst from some facts, mentioned incidentally, in the descriptions of Livy Mil
other historians, considered in connection with the topography and warm cllMut.' *>\
Rome, and the season of the year in which the diseases arose, we are \vi\ to r .uni
.sume of these plagues as of malarious origin, resembling in their symptoms and pMirn'--*
Billions, Congestive and Yellow Fevei-s, at the same time, the descriptions :ire x» z* n-
cral and indefinite in their character, that nothing more than mere conje:»tur<\> nu It •
formed as to the true nature of the diseases.
Herodotus whilst giving casual but valuable observations with reference to the .ir; oJ
Medicine amongst the Kgyptians and other nations, furnishes no detailed d.»scrintii«ii-
of either the nature or the origin of specific diseases ; and in like manner, thi; \v.»ik^
of Strabo throw but little light on the history of diseases.
When we turn to the writiuirs of those who have confined themselvivs st riot Iv i»
^ledicine, and attempt to determine the date of the origin of any special dl.se*is\ we ari
met with difficulties as great as tho.se encountered in the examination of the dt'Sv-ripriou
of dis<\ises by purely historical writers. ^lany of the most ancient and tvlehni-**!
medical writei-s did not busy themselves at all with inquiries into the histories of «l:--
eascs ; some simply recorded the facts and phenomena which passed directly under th*-..
own observation, whilst others simply reproduced, in new forms and in more ltiut.;
terms, the works of their predecessors, and immen.se chasms of timeexbt, in which m ♦
rec(»rd whatever has been preserved of the diseases which afflicted mankind. The ti:^*
body of doctrine in the history of medicine, is the collection of writings known unci •
the name of the Works of Hippocrates ; from the loss of the records of the e;irlier c i*..
tivatoi-s, the science of medicine mounts up directly to this source. In like manu< r
there exists a great gap after the writings of Hippocrates; the works from his tint " i**
the establi.shment of the school of Alexardria, and those of that school ii:<..*lf, haviu^
been completely lost, with the exception of some quotations and passages preserve --J i-.i
the latter writings. It apj>ears, however, that the Greeks received surgery, towtlu :
with the other branches of medicine, from the Kgyptians; and from some observatkuti^
made by the learned men of the Trench Expedition to Egypt, in ni)H, it u* evi«lt nt
History of Cerebro- Spinal Meningitis. 415
that in very remote times, this extraordinary people had made a great degree of pro-
;rress in the art of surgery ; upon the ceilino; and walls of the temples of Tentyra, Kar-
nack and Luxor, ba^so-relievos are seen, representing limbs that have been cut off with
instruments very analogous to those which are employed at tlie present day for anipu-
tdtiou. The same instruments are said to be again observed in the hieroglyphics, and
vestiges uf other surgical operations may be traced, which afford convincing proofs of
the skill of the ancient physicians in this branch of medical science.
We arc not to regard Greece as the birthplace of Medicine — we arc to look, rather, to
the early Egyptians as the first and most successful cultivators of Medicine. The
Itrlcsts of this ancient country, were a numerous and influential body, receiving for their
>upport about one-third of the whole income of the nation. Most of 'the Egyptian
priest*} were skilled in medicine, and, iw some suppose, practiced gratuitously among the
people. " Here," says Herodotus, *' each physician applies himself to one disease only,
aod not more — jill places abound in physicians ; some for the eyes, others for the head,
uihcrs for the teeth, others for the parts about the belly, and others for internal dis-
eases."
Pythagoras, who founded a great school of learning at Crotona, bctbre assuming the
bitoiness of teaching, spent much time in Egypt, and probably introduced much Egyp-
tian science and learning into his celebrated course of instruction at Crotona, where
medicine was first cultivated as a department of philosophy. From this school sprang
mme of the most distinguished physicians of that time, as Empcdocles, Alcmacon,
Democedcs and Acron, who flourished near a century before Hippocrates. Aristotle,
though not a practitioner of medicine, was of the family of -.-Esclepiadte, and was well
skilled in natural history, and the anatomy of the lower animals, as well as in the medi-
cal doctrines of his own and former times. Plato appears to have been well versed in
the principles of the medical art, and is said to have divided medicine into five branches.
Hippocrates, who is generally spoken of as the tather of medicine, was born as late as
the year 460 before the birth of Christ, and was, therefore, a cotemporary of Plato and
iSrjcrates, and lived more than a century afler the establishment of the celebrated school
of Pythagoras, and long after the foundation of the Temples of the ^Esclepiadae, devoted
to the sick, and containing numerous votive tablets, in which their diseases were
rec«>rdod. It is just to assume, therefore, that the history of medicine commences with
the Works of Hippocrates, only because of the loss of the works of the older Egyptian
and (rrecian writers, from whom Hippocrates drew his instruction, and a large portion
of his knowledge of medicine.
Rhazes, a Persian physician, who composed his works in Arabic, and who died at an
advanced age, about the year 932, and who, consequently, wrote near one thousand
yean ago, affirmed that the extent of medical science at his day far exceeded the bounds
uf haman life; and he goes on to say : ^' The authors who have improved this art are
not a few, but they are not to be comprehended within the compass of a few years ; a
thougand icriters, perhaps for a thousand years^ have been improving this art and pro-
fession ; and he that industriously studies those authors, will, in the short period of
life, find out as much as if he had lived a thousand years himself, or employed those
thousand years in the study of physic."
Now, this Rhazes is said to have been the ablest, and most distinguished physician of
his age; a perfect master of the art of healing, skilled in its practice, and thoroughly
'.rroanded in its principles and rules, so that pupils traveled from distant countries to
receive the benefit of his tuition, and his testimony, therefore, to the large number of
medical works extant at his time, is worthy of all credence. And yet, not half a hun-
dred of the thousand works to which he alludes, liave come down to the present day.
Not only have many of the works of the ancients been lost, but it would also appear
that amongst some of the greatest nations of anti(|uity it was impossible that any accu-
rate history of diseases could have been written, because of the absence of both medical
wiencc and of physicians devoted to the treatment of dise:ises. Thus, Herodotus
affirms that the Assyrians, even at the time of the greatest splendor and power of the
416 History of Cerebro- Spinal Meningitis,
Babylonish Empire, had no physicians, but were in the habit of exposing the Kick It
the market place, that they might confer about their diseases with the passing mnlti-
tude. If the passers by had themselves been afflicted with the same diieases as the
sick persons, or had seen others so afflicted, they advised him to have recourse to i\w
same treatment as that by which they escaped a similar disease, or as they had knowa
to cure others. Herodotus ulso relates, that amongst that nation of the Indians called
Padaeans, who were Cannibals, it was the custom when any one of the commuiiity was
taken sick, whether man or woman, for the nearest connections to put the sick per»oQ
to death ; and they justified this barbarous treitment on the ground, that if the sick
person wasted with disease, his flesh wouhl be spoiled. Those attaining old age, were,
in like manner, sacrificed and devoured. Herodotus adds that few amongst them attained
to the state of old age, for, before the limit of life waa reached, every one had been
destroyed in conscHjuence of some distemper.
The writings of Hippocrates, demand the first and most careful examination in all in-
inquiries relating to the history of particutar diseases, not only from the position which
they occupy in the history of Medical Science, but also, because, of all the ancient or
more modern authors, Hippocrates studied with the most particular attention, and
recorded with the most scrupulous accuracy the Natural History of Diseases*
In his work on Epidemics, Hippocrates states, that in Thrasus, afler a cold wet
autumn, during the winter, paraplegia or apoplexy set in, and attacked many, and some
died suddenly. He also describes this sudden and fatal form of disease, as prevailint^
as an epidemic, whilst the people remained free from other diseases.
Galen in his Commentary remarks, that those attacks of apoplexy were caased by
the cold winds of winter, succeeding to a humid autumn.
We have here a brief but pointed description, which applies more accurately to
Cerebro-Spinal Meningitis, than to any other form of disease.
This disease should not be confounded with the ardent fever accompanied with
^' plirenitis\ (delirium and coma), described by Hippocrates, and illustrated by nume-
rous cases. Hippocrates described the ardent fevers, which prevailed during the
autumn and early part of the winter, as characterized by acute fever, small, irregular,
rigors, insomnoleni;e, aberration of the intellect, thirst, nausea, circumscribed sweats
about the fore-head and clavicles, but no general perspiration ; much delirious talking.
despondency, great coldness of the extremitias. Paroxysms occurring on even day^ ;
and in most cases, on the fourth day, violent pains set in with cold sweats, the extn^m-
ities could not be warmed, but were livid and cold ; the urine was black, scanty, thin,
and the bowels constipated, and the patients died about the sixth day with sweats.
This description evidently applies to the higher grades of malarial fever ; the so-ca]le«l
Malignant, Remittent, Pernicious and Congestive Fevers. This view is still fkrtbiT
confirmed by a critical examination of the individual ca.ses. Those who have })rac-
tieed in malarious, hot, moist districts, similar to certain portions of Greece, will hare
no difficulty in recognizing the nature of the following case as described by Hipp«>-
erates.
Case J/S^: IWiu'cious Malarial Fever.
I<>asimus, who lived near the Canal of Bootes, was attacked with foyer after topper, ih'I
passed a bad night. The first day he was easy, bat in pain in the night. Worsa ia all re5*
pects on the second, and at night delirious. On the third day, restless and very delirioas. (*b
the fourth day, dangerously ill — no sound sleep at night, but dreamed and talked, and after-
wards appeared frightened and impatient. Early in the morning of the fifth day, cam* per-
fectly to himself, and was composed, but before noon, became so raving mad, ihat be cot"-
not contain himself. His extremities were cold and somewhat livid ; urine suppresMHl ; aii^:
about sunset he died. This patient's fever was continual, with sweats; belly tumiRed, distesil* 't
and painful; urine black and cloudy; bowels not bound; thirst perpetual { and before •>"
died, was strongly convulsed and sweated.
Hippocrates also described cases of febrile disease, characterized by the sudden oo-*<.
coma, delirium, and rapid fatal t^'rmi nation, which from the presence of jHmndiiU'
History of Cerebrospinal Meningitis. 417
swellingB, and tendency to putrefaction were evidently referable to the true Plague,
the Glandular PUjLgue of the Eatt
This great observer recorded fatal cases attended with delirium, convulsions and para-
lysis, which were examples of inflammation of the brain and spinal cord. In some of
these cases, the inflammation of the Brain and Spinal Cord, was evidently the result of
mechanical injuries, and the suppression of certain established discharges, as from the
ears and nose ; whilst others were examples of idiopathic inflammation of the mem-
branes of the Brain and Spinal Cord.
The following cases resemble more nearly Cerebro-Spinal Meningitis than any other
form of disease :
Ca8B 483. Asandrus was chilly, bad pain in his side and in his knees and thighs ; after
eating, grew delirious, and died in a short time.
Cabb 484. Polyphantus in Abdera, had a pain in his bead, accompanied with violent fever.
His urine was abundant, with thick turbid sediment.
The pa!n in the head not ceasing, medicines were ordered the tenth day, to produce sneez-
ing ; after which a violent pain in the neck attacked the patient. The urine was red and
turbid, like that of a beast of burden. He rambled like a man in a phrenzy, and died in
strong convulsions.
Casi 485. The domestic, Eualcides, weh affected in much the same manner. After passing
thick urine and suffering with pain in the head, she became phrenitic and died in strong con-
vulsions.
Casi 486. The Halicarnassian was attacked in the winter with a violent pain in the ear
and head. Bleeding afforded no relief. A phrenzy seized him and he died.
The compendious writers who followed Hippocrates, departed from his pi'ecision and
fulness, in the record of special cases, and their descriptions of disease, although often
el^ant and highly finished, were wanting in those bold outlines and in those striking
illustrations, which would enable the student to recognize such a disease as Cerebro-
spinal^ Meningitis, which possesses many symptoms in common with certain affections
uf the Brain and Spinal Cord.
If such elegant and renowned writers as Aretieus, and I'aulus ^lilgineta, were
ac^iuainted with the disease, they included its description under the head of Phrenitis
and Apoplexy ; but in our researches we have failed to discover in the general and
ix>mpendious descriptions of the older writers, following Hippocrates, a correct and
unmistakable portrait of the disease under investigation.
The absence, therefore, of correct descriptions of this disease, from the writings of
the various compilers of Medical Science, from the times of Hippocrates, to the estab-
lishment of Pathological Anatomy upon a Scientific basis, is no proof whatever, that
Cerebro-Spinal Meningitis is of comparatively modern origin.
During the middle ages, Europe was frequently devastated by fevers of the most
rapid and fatal character, often preceding and accompanying the glandular plague, which
were characterized by the rapid evolution of fatal symptoms, the presence of spots and
patechias, and by fierce delirium and profound coma. We recognize in the descriptions
of the most accurate writers of those times, several forms of disease, as Typhoid and
TyphoB fevers, Measles and Scarlet fever, Erysipelas, 3Ialignant Malarial fever, and
(*erebro-Spinal Meningitis; all of which were frequently confounded in a general
dcttcription of Putrid and Malignant fever and Pestilence ; and it is incorrect to assume
a^ some authors have done, that the Petechial and Spotted fevers, and the Black Death
of those days, were in most cases identical with the disease, which we now call Cerebro-
spinal Meningitis. Thus if we select such an author as the learned Lazarus Riverius,*
who wrote more than two centuries ago, and whose practice of physic reflected not only
*Tbe practice of Physic in seventeen several books, wherein is plainly set forth, the nature,
cure, differences and several sorts of signs, together with the cure of all diseases in the body.
Hy Nicholas Culpeper, Physician and Astrologer, Abdiab Cole, Doctor of Physic, and William
RowUnd, Physician. Being chiefly a translation of the works of that learned and renowned
Doctor, Lazarus Rirerius, sometimes Chancellor and Physician to the King of France, etc,
London, 1668, pp. 611, 613.
63
420 History of Cerehro- Spinal Meningitis.
•
not clear, that the disease described by Sydeoham, as ^^/ebris nova" was epidemic
MeniDgitis. The same obscurity hangs over the epidemics of spotted fever which pre-
vailed m Prussia, 1704, in England, 1710-1741, in Piedmont, 1720, in Edinburgh,
1733, in France, 1746, 1756, 1767 and 1758, in Vienna, 1758, in Naples, 1764, in
Tyrone, Ireland, 1765, in Tuscany, 1767, in Vienna, 1771 and 1772, in Cornwall,
England, 1758. The fever which prevailed in the French Fleet in 1758, according to
the description of Fousagrives, resembled more nearly a malignant Typhus ; although
possessing symptoms in common with epidemic Meningitis.
In 1788, during an epidemic of Typhus in Lyle, a disease appeared which was accom-
panied with tetanic convulsions and coma, the pia-matcr being chiefly involved. A
disease appeared at Geneva, in 1805, which resembled Ccrebro-Spinal Meningitis, in it<
sudden invasion, severe pain in the head, rigidity of the spine, occasional petechia;,
engorgement of the brain, and heavy mortality. In this epidemic one quarter of those
attacked died. The case which occurred at Strasburg the same year, appears from the
results of the p08t>mortcm examination to have been an example of inflammation of the
brain and its membranes.
It is impossible to determine the date of the iirnt appearance of this disease amon<:st
the European settlers of North America. Noah Webster, in his Hiatory of Epidemic
and Pestilential Diseages, alludes to sevcnd severe epidemics which were sudden in their
appearance and rapidly fatal in their effects, the nature of which cannot now be deter-
mined with absolute accuracy. Thus he says, that in the winter of 1697, a mortal
disease raged in the town of Fairfield, Connecticut, which was so general, that well
persons could scarcely be found to tend the sick and bury the dead. Seventy persoDH
were buried in three months, in this town, which contained less than 1000 inhi^itants.
Webster states, that in the same winter a deadly fever raged in the town of Dover, in
New Hampshire ; and he afiirms, that ^^ this disease was doubtless, that species of
inflammatory fever attacking the brain and ending in typhus, which has often proved a
terrible scourge to particular parts of America, during the rage of the pestilence in the
hist and of other epidemics in the country. We shall hear of it in the following cen-
tury, and especially in 1761." Vol. 1, p. 210.
Webster also records the fact, that in November, 1760, the town of Bethlehem was
assailed by an inflamnmtoryyerer with symptoms of typhus, which in the course of the
following winter carried off about 40 of the inhabitants. " The disease was extrenelj
violent, terminating on the 3d or 4th day ; in some cases the patient died within 24
hours of the attack. It seems to have been that species of winter fever, which ocean
in pestilential periods mentioned under the year 1698." According to Dr. Tnunboll.
of New Haven, the blood was very thick and sizy ; after issuing from the nose, and
sometimes from the eyes. The inflammation was violent and soon produced ddiriam.
The most robust bodies were most liable to the disease. A free use of the lancet in the
early stages of the disorder, was the only effectual remedy ; where the phyaicians were
afraid to bleed, the patients all died. This malady prevailed from November, 1760, t(»
March, 1761.
Spotted Fever, first excited attention and alarm in America, in 1806, at MedfieM.
Massachusetts. It appeared in Licthfield County, Connecticut, in April, 1807, and
continued in the towns of this State during 1808 and 1809.
In 1809 and 1810, it appeared in sevend towns in Massachusetts, New York, New
Hampshire and Vermont ; and in the latter State it continued during the winter of
1810 and 1811. The disease extended also to Canada, Pennsylvania, Kentucky, Noitk*
western Virginia, and finally to the Southern extremity of the United States. The
symptoms and lesions of the spotted fever of the New England, States, as deieribed
by Jackson, Warren, North, Hale, Fish, Miner and Gallup, demonstrate in the deaRoi
light that this disease was epidemic Meningitis, and not a continued fever. The valik'
of this demonstration is not at all invalidated by the fact, that lome of these obserr«r«
recorded amongst their cases, examples of Typhus and Typhoid fever.
Drs. Thomas Welch, James Jackson and John C. Warren, ia their reports U> the
History of Cerebrospinal Meningitis. 421
Maasachiifletts Medical Society, ia 1810, upon this epidemic, describe the iovasions of
the disease as sudden and Tiolent,
The following was given as a description of the disease as it occurred during this
epidemic :
*^ CdosuaI deadly coldness ; skin white as polished marble, and smooth ; countenance per-
fectlj placid, not one distorted muscle; pulse at the wrist imperceptible; motion of the heart
scarcely to be felt; respiration visible only by gasping, and that not frequent; and, as it
were, only a step between this imperfect state of life, and death."
The post-mortem appearances, as detailed by the committee, were characteristic of
epidemic Meningitis. In some instances of short duration, in which death occurred in
from twelve to twenty-four hours^ turgescence of the cerebral vessels was the only
lesion found, bloody points in the medullary substance of the brain, effusion of serum,
the arachnoid and pia-mater remarkably altered in appearance by the effusion of an
opar|ue substance between them, which the committee likened to coagulated lymph, or
semi-purulent lymph. This substance was frequently of the yellowish color of pus,
with a consistence between the tenacity of lymph and the fluidity of pus.
At other times, the deposit resembled well characterized lymph. There was some-
times adhesion of the hemispheres of the brain to the dura-mater and to each other. In
eveiy instance examined, the small vessels of the surface of the heart were beautifully
injected. Lymph was sometimes found on the pericardium, and the endocardium was
occasionally altered from its healthy texture. Traces of inflammation were less frequently
found in the pleurao. No marked, or characteristic, or uniform morbid changes were
discerned in the abdominal viscera.
Dr. Klisha North, in his ** Treatise on a Malignant Epidemic commonly called
Spotted Fever" published in 1811, describes several varieties or species of the fever.
Dr. North describes the milder form of the disease as resembling
"A mild Typhus, or the ferer attendant on Scarlatina; no petechias, but a red, fiery erup-
tion, or what is perhaps more common, no eruption at all ; pain in the head and limbs is less
serere ; less nnirersal agony of the system ; loss of appetite, nansea, but seldom vomiting or
purging ; no coma ; no delirium ; slight sore throat. This species or variety resembles the
Scarlatina."
Dr. Joseph A. (Jallup, in his ^^ Sketches of Epidemical Diseases in tlie State of Ver-
moni, from its first settlement to the year 18 lo^ has given an ezeellent description of
*' Sjiotted Fever,'' and records, as the result of his post-mortem examinations of the
brain, that
*' The blood-vessels in the brain, more especially the veins, are very turgid. The small
vessels are injected with red blood, which, in a state of health, are destitute of it. The mem-
branes of the brain exhibit different degrees of inflammation, according to the time of sick-
ness, and degree of local affection in the brain. Signs of inflammation are discernible in
almost the whole of the brain; the dura-mater adheres more strongly than natural to the
craoiam ; also the brain beneath often adheres to its meninges. An increase of serous fluid
is often discovered between the membranes, and the ventricles are more or less filled with the
same, as in hydrocephalus. The anterior and inferior parts of the brain exhibit the greatest
mirks of violence, and everywhere a remarkable pressure in the veins.*'
Dr. Thomas Minor, in the " Essays on Fevers and otiier Medical Subjects," pub-
lished at Middleton, Conn., 1823, has given illustrations of Spotted Fever, which he
call} also (Phrenitis Typhoides), and says that
"Spotted Fever appears to have its seat and throne in the brain, to belong nosologically to
the passive phlegmasia;. It is attended with no spontaneous reaction, but has the forming
and sappnratittg stages blended together. This is manifest by the greatest arterial debility,
typhoid delirium and convulsions, paroxysms of subsidentia, and in a word, by every symp-
tom which is known to indicate an extreme deficiency or exhaustion of the powers of life."
We shall have occasion to refer again to the descriptions of these and other American
422 History of Cerebrospinal Meningitis.
authors, as Dr. James Mann, who lias recorded observations upon thie disease, as it
manifested itself amongst the American Soldiers during the campaigns of 1812, IH]\\
and 1814, and we deem it to be unnecessary still farther to illustrate the nature of this
epidemic, which prevailed during the space of ten years, in various sections of thr
United States, by quotations from the accounts of Dr. South wick, of Albany, Dr.
Hunt, of the United States Navy, Dr. Robert Dunbar, of WiiKjhester, Va., Dr. John
Wilson, Dr. Utley, of Connecticut, Dr. Kercheval, of Bardstown, Kentucky, Dr. Ini
Bascom, of Grenville, New York, Dr. B. Vaughn, of Halloweli, Me., E. Martin, of
Maryland, Dr. Joseph Trent, of llichmond. Dr. P. HeHbrd, of jMiddleburg, Va., Dr.
E. S. Davis, of Milledgeville Ga., Dr. John Kerr, of Mis^sissippi, Dr. James Davis, of
Columbia, S. (\, Dr. Comstock and Dr. Hunting Shcrrill.
Cerebro-Spinal Meningitis' appeared 181G-17 in South Carolina and Massachusett:> ;
1818-1822, in Virginia, North Carolina and soma of the Western States, Pennsylvania,
Maine, Connecticut and Ohio; 1823, 1824, lS2r>, 182G, Connecticut; 182G, in New
Orleans and Fort Adams; 1827, Ohio; 1832, Connecticut; 1845, 184G, Illinois ,
1847, Mississippi, Tennes.sce, Missouri and Arkansas; 1847, 1848, Washington, D. i\:
1848, Montgomery, Alabama; 1841), Missi.ssippi; 1850, New Orleans; 1857, Now
York ; 1859, Virginia ; 181)1-1 8()5, Northern and Southern armies, Indiana, Tennt»sM'f,
North Carolina, lihode Island, Philadelphia, Ohio, Alabama, Georgia, New York,
Vermont, St. Louis, Missouri, Kentucky, Massachusetts, Washington, D. C.
It would be an error to suppose that no case occurred in the United States in thr
years ;iot mentioned above; for such a view could only be founded upon a knowledir*'
<»f the cases treated by the various practitioners of the entire country ; and it is wv II
known that the vast majority never report their cases to the public prints. It wuuM
apjKiar that cases occur every year in one part or another of the country, and as a goii-
cral-rule these have been reported to the medical journals only when several have
occurred in the same locality.
During this period, from 18()G to 18GG, including the American history «>f tin-
disease, it ajipearcd at various times, in different parts of Europe ; 1807, in Blackt*ti»!i.
near Ashburtcm, England, and in Briancou, Grenoble and Mayence; 1814, (irenobh- .
1S14, Mctz and University of Cambridge ; 1813-1815, Dublin, Ireland ; 1S17, G.r
many and Italy; 1S15, 182!5, Millbank Penitentiary, near Ijondon ; 132*J-'iO, Toulmi :
1837, Bayonnc.
M. Casimir Bronssais has given a statement of the different accounts of the di5k»:iM'
as it has appc^ircd in France, whicli have been drawn up chiefly by the army sur^'^^r.*
and ])hysicians.
First appearing at Bayonnc, Bordeaux and Rochelle, in 1837, and afterwanl."* at V«t-
saillfs and S|. Cloud in lS3i), it seemed to be fixed in the.*«c two latt<jr town> up t**
1812. From Versailles it launched off in one direction to (•aen and CherK»ur^, in
l!^lO and 18n,and in 18.31) and 1842. In a different dircH'tion it wjls met with .r
liaval. Mans. Chateau, (lonthier. Tours, Blois, and Joigny, in 1840-1841. Finalh \x
gained the neighborhood of Iiambouillet. During all this time, the dise;u<e, wich !*• u
exeeptions. :is in Landos and Laval, Rambouillet and Stnisbourg, was confiniHl t«i iIm
soldiers. \\i another <juarter of the kingdom, but still in the South, the dise;u*e In*.:, ti
at Narbonue and Foi.x. in tlie year 1S37, and thence, in 1838, broke ont in T*miI..o
but in the beginning of 1H:j1>, it showed itself at Nemis, where its at^cks wcr.^'i^inliiM'i
to the garrison. In the winter of 183I)-4(), it ap])eared at Avignon, and again in tlif
following winter. In this town the soldiers weie first attacked, but subse<juently M»ni«-
of the eivil population were suflerers from the disejuse. In 1840 it broke out at M«»iiii
lison, and at JiVons in the winter of ISH— 12. Finally it bninched off in another dint
tion to Pupigan in tlw winter of 1810— H, and seemingly retracsiHl it^ wuirsi^ Ui ai*!* ir
at Aigiies Mortes the following winter. In thi.** last town, no part of the civil |Ni|iir. i
tinn was exempt, <-hiMren suffering tMjually with the military.
Fpidemie .Meningitis has appearetl in other eountries besides France; illia.<U'»t.
uoticinl in different cities of Italy, during the winters of 1837, 183!>, 1840 aod Inu
History of Cerebrospinal Meningitis, 423
and more particularly in the kingdom of Naples, where the physician designated it by
the term Convulsive, or Apoplectic©, Tetanic Typhus, etc.; in Gibraltar, the disease
prevailed in the early part of the year 1844, but almost entirely among the civil popu-
lation ; 1840-1841), Algiers, from whence it extended towards the (Jrcat Sahara
Desert; 1843-1849, various portions of France; 1845, 1840, Dublin, Ireland; 1841),
Spain; 1846, 1847, Ireland; 1857, Sweeden ; 1845-1848, it prevailed with great
nialignancy in Denmark ; 1845-18G1, Sweeden and Norway; 18(50-1861, Holland ;
1860, Paris; 1863-1865, Germany.
It*is without doubt true, that it is difficult clearly to distinguish the characters of
many of these epidemics ; and the statements of those writ-ei-s who make no distinction
between Typhus and Typhoid fevers, and use the term Ccrebro-Spinal Meningitis as
synonymous with Spotted Fever ^ must be received with great caution ; and it should be
b*»rnc in mind, in such inquiries in the histories of these and related disciuscs, that it is
only since 1836, that pathologists have distinguished the characteristic lesions of
Typhoid fever, and established absolute and recognizable differences between this disca.se
and Typhus fever, and that the nature and pathology of Cerobro-Spinal Meningitis are
still matters of dispute with many pathologists.
We conclude from this very general outline of the history of Cerebro-Spinal Menin-
iritis :
1st. Cases of Cerebro-Spinal 3Ieningitis, appear to have been observed by Hippo-
t-rates.
2d. Ccrebro-Spinal ^leningitis has prevailed at various times, and in all countries,
and it appears to have been governed by no fixed laws as to duration, origin, locality
and climate ; its outbreaks have occurred simultaneously in the most widely separated
rountries presenting the most diversified conditions of .soil and climate, and it has
attacked alike the most salubrious and healthy towns.
3<1. Cerebro-Spinal Meningitis originates de novo, at the same time in widely scpa-
ratc<l centres ; and in its spread appears to be governed by no such fixed laws as regulate
the spread of special contagious forms of disease, as Small-I*ox, Measles and >Scarlatina.
4lh. The most fatal and wide-spread epidemics of (Vrebro-Spinal Meningitis have
(M'currcd in mid-winter, and no relationship can be traced between it5 origin and spread,
and miaBmatic exhalations similar to those which cause the various forms of intermit-
tent, remittent and congestive malarious fevers.
5th. In the irregularity and uncertainty of its origin and progress, (Vrebro-Spinal
Meningitiii resembles more nearly the Phlogniasi;i), lui i'neumonia and Pleuritis, and it
i\\ pears to be dependent more upon pre-existing states of the constitution and sudden
changes of the temperature, than upon the existence of any peculiar fibrile poi.son.
Cerebro-Spinal Meningitis, (Myelitis IVtechialis, (Y^rebral or Cerebro-Spinal Typhus,
.Mencgit*; Cerebro-Spinal, Fievre (\''rebro-Spinal, Typhus Cerebro-Spinal,) attracted my
att<Mition at an early period of the recent civil war, and I sought opportunities fur
ubsorving it« symptoms, and of gathering its history in various ])ortioiis of the Con-
f-ideracy, by an examination of the field and hospital rejxjrls of different departments,
and of the records of the Surgeon Geuenil's Office at Richmond, Virginia, and by j)er-
-»nal conference with surgeons in the field and hospital. The sudden ternn'nation of
the war, found my labors upon this disea-^^e, in an unfinished state: the value of all
facta however incomplete, which bear at all upon the nature of this obscure and almost
universally fatal di8eas<>, mther than the expenditure of health and .strength neeepsarily
re<|uirc<l in these investigation.*', have induced the record of the following observations.
Whilst I have made some research into the literature of Cerebro-Spinal Meningitis,
in the Southern States, it is not my intention to do nioiv than call attention to the first
author (as far as my information extends) who noticed this disease in the Southern
Atlantic and Gulf States.
liemard lionums, an enlightened observer, who spent several years in Florida,
pnbliiihed in 1776, a work, entitled **^l Concise Kaiural llUtoiy df Ensi and Went
J^r/ridaj containing ai» a^covnt of the Natural Prod'iice of all the Sovthem PartH oj
424
History (if Cerebrospinal Memngitis.
British America^ in the Three Kingdoms of Nature^ particnlarly the Animnl and
Vegetable, etc.,^^ in which occurs the following allafiion to a dLseasc resembling in ib<
Hcat, symptoms and rapid termination, Cercbro-Spinal Meningitis :
'* Id Georgia I saw one or two insiRDces of a disease among blacks, to which the people
give the odd name of the pleurisy of the temple, of the forehead, of the eye, and so on ; I am
lold they have a pleurisy for erery part of the head. It is riolently acute and, as I am
informed, proves sometimes fatal in ten or twelve hours time ; if immediately on its attack, a
quantity of blood is not drawn from the arm ; for the rest, this disease is treated like a
pleurisy, p. 249."
In the southern part of Georgia, in which Bernard Romans, made these observatiol)^,
recorded in his exceedingly rare work, ninety-nine years ago, the term Ilead Pfeurigy,
is sometimes at the present day, appli^ by unprofessional people, black and white, to
Cerebro-Spinal Meningitis.
During the months of August and September, 1863, 1 examined all the sick, wounded,
sanitary and mortuary reports on file, in the Surgeon GeneraVs Office in Richmond.
Virginia.
l^p to the time of this examination, Cerebro-Spinal Meningitis had not be^n entered
upon the reports of the sick and wounded as a distinct disease. The omission of thij<
disease from the official classification of diseases, issued from the Surgeon General^
Office, and according to which all returns from Medical Officers were made, was unfor-
tunate, as it was hence impossible to determine from these records, the relative fVequency
of this disease in comparison with other nervous affections, the rate of mortality, or the
effects of locality, season and climate. I classified and consolidated the following table^
of Nervous Diseases from the Official Reports of Medical Directors, on file in the Sur-
geon'Generars Office, Richmond, Virginia, August 186H.
lJUeati'9 of the Brain and NervouM System^ recorded in the Field ReporU of the Army of the Con/rdtr-
ate States of America^ during nineteen montftSy January ^ 1862 to July, 1863. CUua^ed and
Consolidated from Official Reports on jHe in the Surgeon General s Office^ War Departmfnt,
Richmond^ Virginia ^ August, 1863, hy jonrjih Jones, M. D. Surgeon ,- }*roriiional Army, C"«-
federate States.
MEAN rraXMoTH AKH T<
DISK AMES OF BRAIN
AND NERVOUS
SVh
TE5
1.
TAI. CAMt» PMXA40
> 1
1 '
<9 1
M
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7 12
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I 72y394; tl>>4»
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Total
il2.7K'
History of Ccrebro-Spinal Meningitis,
IHinUft of lAe J/rain a»d .Vfrrom .t^'lnH, rrcerdfd in the Jluipilal Kfporli 0/ l/ir Army nf Ihr Cvi-
/rdrraU Slattt of Amtrita, itiTiua ninttren monthi, Janaary, 1H03, (o j<i!y, 1803, CI<i-ified a»d
fhntolidaltd from Offleiat Rtporlt on liU in the Surgeon Gtneruft O^, War Dtpartmnt,
mehmond, Virginia. Awjutt, 1803, iff jaufph Jonm, il. It. Surg'on, Proviiional Army, Can-
ftderatt StaUt. •
DISKASES or THE BBAIM AND KERVLIU8 SVSTKU. iMD
■fiflP
z^
.* -
sH
»
-.t--
'T
,v.
i;-
!
HI
Ht
Mt^Iwi 1 w,ii,..'Li a ... ai A... li H) in I. II
.tprtl.IMi 1 K M 1 1, w .1 w .'.1 H ! ll«, M) -i «
Hmr, IMX -->. IT 4, ,-•' 4I ».1 7 40 K... T im (O 1:1 «t
Jaaa. WM.... ■!■ 31 ' i' ;l| S ai H H ' :i ... fl IKI l» i 1 •! >
Julf, 1M3 4i tt I i T| 11 « 1A «■ , T ], 3 IZ; .-•! I 1 r.
.Va Cerebra-Spioal MeningitiH did not appear in the ulattsificalion of the Medical
Dtrpartment of the ConfederHt« States, ihe cam» of this disease were most prububly
L'Dtered npoD the field reports and hospilal regiNU.'re, under several heads, but chiefly
under the head of Meningitis. Some ca.ses may have bt-cn recorded under the heads uf
Apoplexia, Cephalalgia and Cerebritis, but t.-ertiiin eunHidcralions, render it probable that
the lu^eat, numbers were recorded under the head of Meningitis.
Out of more than one million caseii of siukness and wounds eiitenMl ugmn the field
rcporta during nineteen months, January 1862, July. IStiS, only 47C cases of Mcnin-
(plis were recorded; and in nearly four-hundred thousand cases of disease and wuundu,
catered upon the hospital reports, during the same period, only 156 oases of Meningitis
appemred ; from these facta, therefore, as well as from extensive personal observation and
inijairj, I conclude that Ccrebro-Spinal Meningitis did not prevail to any great client
■moDgst the Confederate soldiers. In ita appearance among the armies serving in
different portions of the t^outbem States, its victims did not suiount to such a number.
ia any one district, aa to at all countenance the view that the disease posseaaed any of
the characteristics of a contagious fever ; and the disease daring the recent war, appeared
lu obey no well defined laws of climate, season, or of pKilogical and physical conditions.
The mortality records of the Confederate Army, were carefully examined with the
il<vign of determining the morl«lity produced by < V-rubro-Spinal Meningitis. During
ihe period of nineteen months, I found only one death recorded as due to this disi-ase,
and this occurred in the month of March, 1H02, and in the District of Aquia, coiu-
ntaoded by >lajor General G. W. Smith. The following table pteeenlH the number of
deaths from Meningitis, recorded upon the Field and [lot^pital Kepotts during tbia
period.
426 • History of Cerebrospinal Meningitis.
JJraths from Mniingitis in the Confederate Armt/^ durinfj ninetrm month*, Januartf^ 1M«;2, /« J«/y.
18tj;<. Field and IJos^nial Reports^ (JjntoUda ted from the (f/fifiai lirpnrt* otijiU m thr SnnffoH
(reneraV» Office^ War Department^ Richmond, I'd., Atif/ust, I8t>:5, % Joseph Junex, M, If. Sur-
tfeon^ Provisional Army, Confederate States.
1 K C
' W M
YKAR AND
' = 5
' as s •
iS " '
i 0 N T H .
1 ** -
, » IS 1
REMARKS
Jan'ry, 1862.. 16
'b deaths in Army of Potomac, Gen. Joseph K. Johnston.
8 deaths in Department of North Carolina.
1 death in Military Dist. of Ga. 1 death in Military Dist. of So. Th.
I death in Military District of Florida.
Fehr'y, 1802..' 4 4 deaths in Army of Potomac.
{1 death from Cerebro-Spinal Meningitis in Dept. of Aquia.
1 death, Meningitis, in General Hospital, Va.
] death, Field Reports, So. Ca. 3 deaths, Hospital Report:*, So. Ta.
April, 1802... 5 2 deaths. Mil. Dist., N. C. 3 deaths, Mil. Dist., Ga., So. (>. and KU.
\ftt» i«ro - / ^ death. General Hosp., Va. 1 death, Mil. Dist.. N. C,
May, 100. "^ \ 3 deaths, Mil. Dist., So. Ca., Ga. and Flu.
June, 18G2 ,
}32 deaths from Meningitis in General Hospitals of Virginin.
5 deaths. Mil. Dist. of So. Ca., Ga. and Fla.
I death, Army of the West. 2 deaths, Mil. Dept. of the Gulf.
\>uffutt 1862 7 ' i ^ deaths. General Hospitals, Va. 1 death, Dept. So. Ca., Ga. and Fla.
* "^ ' I I \ 3 deaths, Armv of the West, Gen. Bragg.
Sept. 1862....' 3 1 death, Army N. Va., (ien. R. G. Lee. 2 deaths, General Hosp. Va.
October, 1862 3 1 death, General Hosp. Va. 2 deaths, Dept. of the Gnlf,
i r 1 death, Gen'l Hosp., Va. I death. Mil. Dept. S. Ca., Ga. and Fl.i. I
Nov'bcr, 1862, 6 } death, Army of Tenessce.
(3 deaths. Mil. Dept. of the Gulf.
; r 1 death, Gen'l Hosp., Ga. 1 death, (len'l Hosp., So. rt\., Ga. and K)'
Dcc'ber 1862' 10 I ] ^ ^****>' ^^^J ®^ Tennessee, Gen. Bragg.
' I ' 2 deaths in army, serving in and aroand VIcksburg.
I I I 5 deaths. Army of Tennessee.
Jan'ry 1863..' 13 ' /^ deaths in Va.; 6 deaths in army, in and around Vicksborg. 1 dciilj
", I \ Army of Tennessee.
Fcbr'y 1863.. 15 ' i "^ deaths, Dept. N. C. 3 deaths. Army of Tennessee.
^' ", 1(7 deaths, Va. 4 deaths amongst forces serving in and around Vicksi^n^.;
6 deaths, Army of N. Va. 4 deaths, Gen'l Hospital, Va. 1 death. V.
Dist. S. W. Va. 2 deaths, Army of the Gulf. 7 deaths. Army of Trr.n.
1 deftth, Army at Mobile. 1 death, Vicksburg. 3 deaths, So. Ca.. lU
and Fla.
April 1863 ' 15 I J "^ <***tJ>»i ^'a- 3 deaths, Army of Tenn. 2 deaths, K. Tenn. I dta*:.
^ ^ ***! \\ Vicksburg. 2 deaths, So. Ca., Ga. and Fla,
Mav 1863 '8 ^ ^ death, Va. 2 deaths. Army of Tenn. 3 deaths, Vicksburg.
* ^* "'*' I \ 1 death, N. C. 1 death, So. Ca., Ga. and Fla.
June 1863 > 10 ' / 1 <^«Atb, Va. 5 deaths. Army in and around Vicksburg.
' '"l t U death, X. C. 2 deaths, So. Ca. 1 death, Army of the GuU.
July, 1863,,..: 2 i death, X. C. 1 death, Army of the Gulf.
March, 1863.., 25
Toul ;ia4
From the preceding table, it will be sceu^ that 194 tleatli.H wero nnronlod upon ii»<
Field and Hospital Roporb*. as due "to MeninptiH. Tho lar<?est number of demtofi fn'iii
this disease occurred in the month of July, 18G2, and 32 of the 41 doaths, ivconled x-
due to Meningitis during this month, occurred in the (icneral Hospitals of VirgiDM.
The number of deaths from this di.«ease in the General Hospitaln of Viruioia, duri!*^
July, 1862, very nearly equalled the number of cases repoirted.
History of Cerebrospinal Meningitis. 427
The large armies operating withia and around Yicksburg, lost 23 men of Meningitis.
io seyen months.
These cases show that, more than one-third of the cases reported as Meningitis ter-
minated fatally. Cerebro-Spinal Meningitis, was almost universally fatal amongst the
Confederate soldiers; we dbnclude therefore that only a portion of the cases of Menin-
ijitis, were truly Cerebro-Spinal Meningitis. Owing to certain causes the reports on file
at the Surgeon General's Office, were incomplete — this imperfection being referable
chieHj to sudden military movements, and the consequent loss or delay of documents.
Some idea of the imperfect nature of the reports, will be gathered from the fluctuations
ia the number of officers and man upon the field reports ; nevertheless the statistics are
accurate as far as the numbers, viz ; the m3an strength of officers and men, and the
diseaaes to which they were subjected.
A careful examination of the Sanitary, Medical and Surgical reports on file, in the
office of S. P. Moore, Surgeon General C. S. A., and in the hands of Surgeon F.
Sorrel, Inspector of Hospitals, disclosed the following interesting papers relating to
(-erebro-Spinal Meningitis.
As these papers possess historical, as well as medical interest, they are given in full,
as I copied them in the office of the Inspector of Hospitals, in Richmond, Virginia,
Auffust, 1863.
BEPORTS RELATING TO A VERY FATAL MALADY WHICH OCCURRED AMONOST SOME OF
THE TROOPS OF THE ARMY OF NORTHERN VIRGINIA, SUPPOSED TO HAVE BEEN
CERRBR0-8PINAL MENINQITIS.
/. Report of Sick and Wounded in 10 Companies 22d North Carolina Regiment^
stationed at Camp Gregg y near Fredericksburg ^ Virginia^ April, 1863, by P.
Gervais Robinwn, Surgeon P, A. C, S*
Attention is respectfully called to foar cases of MeDingitis Which occurred in this commaud
daring the month of April. They were all members of the same company, (Q).
(>f ihe three who died, J. P. Faison and Haywood Faison Were brothers, and of these H.
^Viliiams was a brother-in-law. These were conscripts, having been in camp about one
moQth previous to the appearance of this disease, and occupied the same tent ; the fourth
case, Uardee, who recovered, was an old soldier, having been in service since the commence-
uK'Dt of the war.
It is difficult to assign any special circumstance, or combination of circumstances, as caus-
iiiz this fearful maladj. The troops were at this time exposed to no influences other than
'tio>e ordinarilj incident to camp life, yet it is somewhat remarkable, that of the four cases,
ibree should have been of the same family.
Cask 487. J. P. Faison was taken sick on the 1 1th day of April. He complained of slight
betdache, but persistent, with a general indisposition to muscular exertion. Tongue rather
pile, but otherwise normal in appearance. PuUe 90 to 100, but not abnormal in force or
vuiume. Bowels somewhat constipated. Skin natural. B. Olei Ricini f.^ii.
April 12th. — In same condition, with some disposition to sleep; still complains of head-
ache, has had several evacuations from the bowels.
April i4tb, as there has been no abatement of the pain in the head, applied a blister to the
Q%pe of the neck.
April 15th. Died this morning about 6 o'clock.
As there were no symptoms of disease in this case apparently sufficient to account for death,
"r, iadeed, to enable us to form an idea with any degree of confidence as to the pathology of
the malady which ended so unexpectedly and suddenly, we determined to institute a post-
oortem examination.
1 confess myself, as well as my assistant, to have been completely deceived as to the gravity
of this case, and, indeed, we were inclined to suspect mallingering; I, however, withheld the
Mprtision of such suspicion, though another surgeon in the brigade, on whose judgment I
relied, concurred in my view of the case.
Aft the headache was the only persistent symptom, it was not unreasonable to look to the
briia as the Beat of the disease ; and on removing the calvarium and dura-mater, on the sur-
face of the brain were seen collected a yellow or light, straw-colored exudation, situated
between the arachnoid and pia-mater, which, on examination, appeared to be coagulable
428 History of Cerehro-Spindl Meningitis.
lymph. Oj puncturiog through the aracbaoid into the.^e patches, there escaped a thin,
serous looking fluid, the larger part of the collection remaining adherent to the iaclosing
membranes, but could be easily removed with the end of the scalpel ; at some few pointa, the
arachnoid and pi^-mater were firmly adherent. The latter membrane was more or less
injected throughout its extent. The ventricles contained no abnormal amount of fluid. Tbe
thoracic and abdominal organs were healthy, with exception of the summit of tbe right lung,
which was found to have been disorganized by old tuberculous disease.
As Watson remarks, such cases teach us that serions lesions of the brain can exist, and
even terminate fatally with scarcely a symptom of sufficient gravity to warrant eveo a sus-
picion of disease.
Cases 488, 489, 4l>(). — Of the other three casus which immediately succeeded this, the symp-
toms were well marked, and the disease readily recognized, they being ushered in by the
most violent paroxysms of mania, requiring the restraint of several attendants.
Post-mortem examinations were also made in the case of Haywood Faiton, and H. Wil-
liams, the appearances being much the same as those presented in the first case, except that
in the two latter cases there was greater evidence of disease, the effusions between the mem-
branes being more extensive, and the ventricles being in both ^distended with fluid. The
largest effusion in all these cases was to be found about the root of the spinal cord, (medulla
oblongata), and accounted for the mode of death, which was by a paralysis of respiration.
In the two latter cases there was considerably more evidence of disorganisation, which was
in accordance with the greater protraction of the disease.
The nsnal antiphlogistic remedies, such as purgatives, counter-stimulants to back of oeck
and spine, cold to head, stimulant injections, wore applied in the early stage, and stimulaou in
the latter, or that of collapse, but with very discouraging results, having lost three out of
four patients.
The question of venesection was duly considered, but it was concluded that in not one of
the cases was such practice admissible, they, like most cases of disease in camp, wanting that
<!haracier which a-ould ju-stify the abstraction of blood.
. P. r.ERVAlS ROBINSON,
Surffeon P. A, C\ X.
.A Rfport of W. I). MUchpfl^ M. D., *SV/i. Surgeon Rhodes Brigade,
HKADQrARTEHS ThIRD ALABAMA RbOIMSST. 1
February 2l8t, 1863. /
Suryfon Hunter Mr Guirf^ Medical iMrrrtor :
Sir : — I feel it a duty that I owe to those under my charge, as well as to my professional
reputation, when a disease of unusual fatality has made its appearance io camp, reBistantr
all those remedial agents dictated both by theory and what little practical experience I have
had, not only to report the existence of such, but to make such efforts as would oatarally
suggest themselves in the absence of all books of reference. * * •
The following case is one of six fatal cases which have occurred in my regiment, all simi-
lar in the symptoms, with a few triHing and unimportant variations.
It is well to remark, that in every instance the subjects have been robust, healthy men, and
in the prime of life.
Oasb 491. — Sergeant A. Oemeany, Third Alabama Regiment, aged 28 yearB, tall and robnst .
had been unusually healthy since his enlistment, nearly two years. On the moming of ihf
r»th of January, he was taken with a severe chill, attended with vomiting ; pains io tbe abdo-
men ; the bowels were constipated : be suffered during the day with severe headache and
piiins in the back and neck, the feeling of chilliness continued ; he was perfectly senaable
during the day, talked to his friends in a natural manner, and partook of food in the shape of
soup, at the dinner house ; he continued in this condition until about 10 o'clock p. m., when
a convulsion caused his mess-mates to call me to see him ; they had, up to this time consid-
ered his case as one of cUiil and fever, and paid but little attention to tbe matter; this eon-
vnlsion, which they described as exceedingly violent, and of nearly an half hour's duration,
were the first symptoms to excite their fears.
I did not see the case until after the termination of the first convulsion, but upos arriving
111 hi.f tent, found him in a condition very much resembling tbe state of collapse of Cholera
Asiatica, (stupid, could be aroused when spoken to in a loud voice, or when shaken, bet bi«
iinswers to questions when propounded, not very intelligible), aurface of body cold, and cov.
ered with bluish red particles, such as are Been in Hemorrhagica Purpura.
There were not at this time any symptoms of either paralysis or tetanua ; the poise wa«
full, but very slow, the pupil contracted, but responding readily to the action of light; tt.r
respiration wns labored, and there was a constant flow from the nostrils of a yeIlowit*i.
slightly ftrlid Huid. This ron«iitinn continued without the appearance of other symptom*
History of CerebrO' Spinal Meningitis. 429
until ftbout 1 A. M., whea a species of reaction ensued, severe and entirely uncontrolable.
(Expecting thiS) from the condition of the pulse upon mj first examination, I had made the
attempt, notwithstanding the appearance of collapse, thinking that the condition of the pulse
warranted me in this, to lessen the quantity of blood, by opening tbt Temporal Artery, but
the blood refused to flow, as it did also from the arm).
Convalsion, or, more properly, spasm after spasm, in rapid succession, ensued. The efforts
at respiration became painful to the beholder, muttering delirium followed, after about two
hoar's duration of this condition ; the intestines had remained cold during the whole of this
time ; respiration became less labored, the pulse was now fast and thready. At 8 o'clock the
next morning, I found the patient fast sinking, the mutterings had ceased, respiration was
slow bat not labored, the pulse very fast, but scarcely perceptible, the pupil preternaturally
dilated, and not responding to the action of light, sphincters relaxed, the entire surface of
the body cold, and the spots before spoken of v'ery much increased. With these symptoms
gradually increasing, the patient died at 9 o'clock.
In reviewing these symptoms, to find either a name for the disease, or to draw' some analogy
with some disease already named, 1 must confess that my efforts have been rewarded by no
conclusion at all satisfactory to myself.
Two diseases, Gerebro-8pinal Meningitis *and Typhoid Fever have elicited my attention, to
either of which I find many points of resemblance, though 1 roust say. many points of differ-
ence also. In my earlier investigations of this subject, I had almost yielded to a conclusion
that it was certainly Cerebro-Spinal Meningitis, but the existence of the disease as an epidemic,
and the absence of all pre-disposing and exciting causes, or rather such as in my opinion
woald be so considered, has caused me lately to lean very much towards the Typhus nature
of the disease. In this I am borne out by the existence of many cases of pain in the head
and back. Mild cases, (I think that many of the cases sent off as suspected 8mall-Pox come
under this head), resembling the symptoms wliich usher in the disease, also the existence of
many cases of low forms of fever, I am satisfied that the disease, be what it may, is epidemic,
and perhaps contagious.
Hoping that yoa will excuse any imperfections which may be apparent in the hastily pre-
pared paper, I would most respectfully ask your early action in this matter.
I am sir, very respectfully, your obedient servant,
W. n. MITCHELL,
Sen. Sur^.j Rhodes* Brigade,
P. S. I have seen in my Regiment, the 3rd Alabama, 8 cases perfectly well marked; six
(f*) were fatal.
;:t? [
'f. Report of J. T, Bank*y M. />., Surgeon Lkh Regiment^ Ga. Vols.
Camp Nkar Frbdbricksburg,
Med. Dep., 13th Ga. Reg., March 28th, 180:
Near Hamilton's Prossing.
Surffeon Hunter MeGuire, Medical Dirertar :
Sir. — The following description of the fifth case may be considered typical of them all, in
the main features presented by the cases in their short, rapid and fatal course. All were
stoat, healthy soldiers, three or four of them careless of protection, confident in their physicnl
^nilurance, and all inured to camp life ; ages from 19 to 27 years.
("asb 492. Thomp«on, Company F. 13th Ga., age 24, healthy and quite stout. Felt well
and ate a full meal for supper on the 13th inst., complained of feeling a little bad at bed-time,
when bis brother prepared his pallet, and he retired as he thought to sleep it off, but in place
of sleep, contlnned to complain until he was attacked with a chill, which lasted several hours.
Hit brother reports that he vomited freely while his chills lasted, but on close inquiry I learned
that he vomited only his supper. Called to see him at 4 a. m., 16ih inst. Chill had pas^^ed
off*, and fever rising, pulse 100, volume over natural, but soft and compressible. Skin warm,
face flushed with a slight purple tinge ; eyes injected and bathed in a profuse lachrymal flow,
mixed with macus ; pupil natural in size and action. Expression dull and dejected. Tongue
coated, white and moist; head easy; mind clear; respiration of a moaning character, but
full and easy when engaged in conversation, and without cough. Rowels acted well on pre-
vioas day. Pain very severe in both legs, and in them alone would he acknowledge to any
pain, bot so severe in them that he would often beg for something to ease them, saying they
would kill him they pained him so. Great thirst, gave him Opii gr. fs.. Calomel and Ipecic
aa, grains lii.
Called again at C o'clock, a. m. Condition same. I applied cups to nape of neck and drew
3 oxs. of blood, but stopped on account of depression. Learned that his supper was liberal,
and among other things ate freely of peas, and seeing no effects from the dose of medicine, I
determined to evacuate his stomach by means of a large warm draught with Ipecac, that I
might get rid of any offending matters, nron.<ie his liver to action and facilitate the subscqnent
430 History of Cerebro-' Spinal Meningitis.
absorption of medicine. The matter ejected was the fluid wbicb ihe patient had Just drunk,
with a little glairj mucus — no appearance of any bile.
Seven o'clock, a. m. A little change in the blush of his face, the purple tin^^e has increased
slightly with a little more depression in his circulation. (Quinine, grs. iv ; Camphor, gn. ri ;
Capsicum, grs. yi ; Calomel, grs. iii ; mix administer at once, and repeat every hour ; Mustard
Piaster over the entire length of the spine).
Ten o'clock, a. m. Circulation has failed; rapid pulse at wrist, can only be felt every 4th or
Tith beat. Cardiac impulse quite feeble. Continue treatment.
Noon. No pulsation at wrist; purple tinge of face increasing. Pain coutinues unabated.
Though pulseless, the patient is able to rise from his pallet, and with the aid of two comrades
walk out of his hut and evacuate his bowels. (Continue medicine ; repeat Mustard to spine,
also apply Mustard to abdomen and front of chest.)
Two o'clock, p. M. Purple tinge of face deepening, skin cool ; no redness of skin from
Mustard; pain in legs intense. No elTei't from treatment. (Continue treatment with 1 grain
of Sulphate of Morphia in next dose).
Six o'clock p. M., condition same ; no relief from pain by Morphia. Skin cold in the
extremities. Flush of face changed to a mottled, purplish hue. (Camphor and Ammonia
Julep, continue Quinine and Capsicum).
The patient continued to sink, and died at 1 1 o'clock r. m. His mind continued clear, and
he complained of the same pain rs long as h& could speak. Had two actions on his bowels
during his illness.
Pott'MoTtcm 12 Hours after Death — Kxtenuil Appearance. — Features very little changed, limbs
quite stiff and cold, some warmth of body. Skin discolored by the extravasation of blood.
Muscles over chest and in parietes of abdomen natural. Liberal supply of adipose tissue.
Abdominal Vucera. — No change in the peritonaeum. Small intestines a little injected. No
change in the appearance of the large intestines. Ccccum, ascending and transverse, colon
contained some fwcal mutter. Bladder full of urine.
Spleen almost twice its normal size. The comparative increase of weight of this organ must
have been greater than the increase of size, judging from its weight in handling it ; dark
color, friable, and bleeding very freely when torn.
Qall-bladder distended to a great size by yellow, healthy-looking bile — no obstrnctton to
its exit.
y^itcera of Chest. — Right lung, lower lobe, very much engorged, with some semi-organised,
plastic lymph over lower border, also some engorgement of posterior middle lobe; upper lobe
and left lung healthy.
Pericardium natural. No effusion in cavity. Heart increased in site about one-sixth.
Endocardium healthy. Each cavity contained a firm, fibrous clot, in si^e corresponding with
their capacities, and closely interwoven with the mitral and tricuspid valves ; veins emptying
int^ heart full of fluid blood.
Brain ami Mnnhranes. — A slight cloudiness of the arachnoid, with three small, opaque spots,
well defined, of the same membrane, ou the upper portion of the left cerebral hemisphere. In
the removal of the brain, about three ounces of blood escaped. No effusion in the ventricles.
Cohesive power of tissue natural ; color natural. Blood congested in the veins.
KemarkB. — The informatiou obtained in the examination of Thompson is both positive and
negative. Negative, in that no organic lesion was detected that can account satisfactorily
for the destruction of life. But slight information based upon positive phenomena wer«
detected, and they produced no symptoms during life to diagnose their existence. We bav«
positive information of great congestion of the liver and spleen. In the liver it is so great,
that the cohesive power of its tissue is greatly destroyed, and, when torn, bleeds freely i»r
dark, venous blood, indicating excessive engorgement in connection with its increased si/r :
and the corresponding augmentation of the spleen may account for the deficient capillary « \'-
culation, as well as the i^yatemic circulation. The heart thus robbed of a portion of it4
accustomed stimulant, must be correspondingly weakened in its action, which, in its turn of
cau-te and effect, niu^t add negatively to the coldness of the surface and defective circuUtiftn
in the extremities.' In the coiigeslud condition of the liver and spleen, they act as a reservoir
for the circulation, %vhich, peuned up in the carbonized state, must, (if the theory of rrfirt
nervous action be true), produce the toxical effect of carbonized blood on the brain.
In this we have a solution of the delirium, so common in these cases, and also the in<>.«n-
iii>r and irregular breathing, and in some casus the congestion of the lungs, the result of \Uk
impaired action of the pniMiuio^^a.^tric nerve in the carbonized state of the brain.
This condition lasting any considerable length of time, the nervous system is nece!(<Ar*i«
overpowered, and us power fails. co-existin>f with the congested state producing it, de<iru«-
tioii of life must be the result, ndtwith^^tunding no organic lesion may be detected sufficient !«.>
account for it. One of the functions of the liver, the secretion of bile, was still in action, a*
shown by the full gall-bladder — no organic legion existing, though greatly congested, £ulh-
cient to prevent it from performing its highest function.
History of CerebrO" Spinal Meningitis. 431
What Agencji if any, did the heart clots have in thia case? One interesting feature in this
case, and present in all the others, was the pulseless condition of the extremities so early in
the case, eren before the strength of the muscular sjstem had failed enough to prevent
rising and walking about in their huts. One of the cases I found pulseless when I iirst called
to see him, standing up by his fire, his comrades and himself alike ignorant of his danger.
May not these clots begin to form during the chill, under the powerful nervous depression
and congestion then existing, aided by the poisonous effect of the morbific agent in the foun-
tain of life, changing its chemical and reciprocal affinities ? These clots are said to form
mainly in death, and occupy the right side of the heart, but in this case, every chamber had
its corresponding clot. May not their occupancy of the heart, obstructing the circulation,
account for the constant failure of stimulants to arouse it, or increase its force when feeble
and failing ?
The condition of the brain and its membranes was not incompatible with mental action or
life, not congested enough to destroy its functions, and very little evidence Of intlamma^tion,
the slight opacity of the arachnoid being its only indication, and it gave rise to no symptoms
of its existence.
burgeon Jelks, of the 26th Georgia, assisted me in the examination, and informs me that he
lost six cases in his regiment last winter, while stationed on the sea coast of Georgia, quite
similar in general symptoms, duration and fatality. Of these he made two post-mortem
examinations, and found the same condition in both cases. One of the cases was placed in
hospital, smd treated by Prof. Byrd, of Savannah, Ga., who assisted in the examination of the
case placed under his care. In both of these cases Surgeon Jelks informs me, that the symp-
toms indicated the brain and its membranes as the chief source of trouble, both cases were
so diagnosed, the first by Surgeon Jelks, the second by Surgeon Byrd. In the examination,
lesis morbid action of the brain existed than in the case of Thompson, but, like his, presented
excessive engorgement of the liver and spleen.
All the cases in my regiment, so far as I can obtain definite information of others, have
been stout and healthy, with little or no premonitory symptoms warning them of their
danger.
What is the true nature of this disease ? I do not believe that any visceral lesion occurs in
these cases sufficient to account for its fearful destruction of life, though future investigation
may exhibit a constancy in morbid changes.
It cannot be Cerebritis or Cerebro-Spinal Meningitis. In the case of Thompson the lesion
was not sufficient ; nor arc the symptoms of its existence constant, in some cases no evidence
of undne action exists, and when they do exist, as in the cases of Surgeon Jelks, no lesion
was recognized by the scalpel. So too, the duration, symptoms and post-mortem phenomena
forbid the idea of Typhus.
From a close study of the cases that have fallen under my care, tl>e course which one of
them ran, the association of the disease, and the result of the examination, (abundant in
itseU, though needing repetition to give the evidence required for consistency), I am of the
opinion that the disease is a severe, aggravated form of congestion or Pernicious Fever.
The case referred to above is the fourth case of this disease occurring in my regiment.
His case lasted long enough to give some idea of the type. His chill came on in the evenio^r,
lasting forty or fifty minutes, and was follovred by a paroxysm of fever of ten or twelve hours'
duration ; then came a complete intermission, in short, an exact type of Intermittent Fever :
in the intermission he walked about camp.
His second chill came on at the same time, on the third day, same duration as the first,
same peculiar pain on one side of the face, but more intense. The chill was followed by a
little reaction of a few moments, when his pulse began to sink; in one hour the pulse was
extinct, and the patient died at the end of three or four hours from the appearance of the
chill.
Remittent and Intermittent Fever have been common in my regiment all the winter; an
intermittent type has been prevalent in nearly all cases of Diarrbwa, Dysentery and Infiuenza.
Our inlermittents bare been well marked, generally mild, and yielding kindly to treatment.
Id the last ten days they have increased in severity. Only one peculiarity has presented
itself in this disease — the majority of chills coming on during the night time. The pain in
these cases is in many respects like that of Dengue, but dissimilar iu everything else. The
post-mortem appearances of the liver and spleen are not new features in the course of Inter-
mittent and Remittent Fevers, and I feel quite certain that the fatality of the Congestive or
Pernicious Ferers, would be equally as great under similar circuinstaiu'cs.
Hut a devotee to a pt-rfect malarial theory, may object to this conclusion, on the ground
that malaria cannot exist on the snow-clad hills of our camps, so destitute of warmth, one of
the essentials for its production. My reply is — may be the nature essentially productive, and
modns operandi of this theoretical entity are yet unknown, and that facts should not be laid
aside because thereof.
The blood exhibited signs of disorganization in all the cases I have seen, by the purpura,
432 History of CerebrO' Spinal Meningitis.
sereral hours before death, io cases lasting ten or twelve hours. The pnrpora is evidenlly
the disorganized blood in the sub-cutaneous tissue, and it maj be that this disease-producing
element is a blood poison of some kind, like that of Scarlet Ferer, Small-Poz, Diptheria,
Cholera, etc., which, when imbibed sufficiently overwhelms the nervous system, changing
the chemical and reciprocal affiinities and tissues, and ending in the phenomena presented by
these cases.
I am, sir, very respectfullv, your obedient servant,
J. T. BANKS,
Surffeoriy Thirteenth Regiment^ Georgia VoU.
Hi'jHJi't un the Preceding Papers^ hy Surgeon R. J. Breckenridge, Inspector of OxmpM
and HospUaUj Army of Xorthern Virginia.
Office Medical Dirkctob Army op Nortueiiji Yiruiku, )
August 14th, 18(>3. I
Surgeon L. Guiitl, Medical Director Army of Northern Virginia :
Sir . — Having carefully considered the papers referred to me, from Surgeon Mitchell, Sen.
Surgeon Rhodes' Brigade, Snrgeon Banks, Thirteenth Ga., Surgeon P. G. Robinson, Tweoty-
second N. G. Regiment, bearing date, respectively, February 21st, March 28th, and April,
18(>3, all relative to a certain form of disease deemed worthy of special mention, — I respect -
fully return them, with the subjoined brief analysis of^ their contents, with my opinion of
the real nature of the cases reported.
This opinion, it is proper to add, was originally written on Surgeon Mitchell's paper sub-
mitted to me by Surgeon McGuire, some months ago, and now made the basis of this report —
and not upon a personal examination of any case, which, though aniiously sought by me.
wa^ unattainable, owing to the fact, 1st, namely, that none of these officers reported these
cases, until they had nearly, if not altogether, ceased occurring; and, 2d, that the most
sharply defined of these appeared to be too rapid in their progress to admit of the visit of
Surgeons at all remote from the scene of their occurrence.
The correctness of this opinion is not, to my mind, at all impaired by Surgeon Banks' paper,
which is most strikingly confirmed by that of Snrgeon Robinson.
Surgeon Mitchell had 8 cases, 6 of which were fatal, but he reports only one — that as tbe
type of them all. Snrgeon Banks does not state the number of his, nor their relative nor-
lality, but gives a history of Case No. 3, as typical. Snrgeon Robinson had foar caaes, three
of which were fatal. The case reported in detail was tbe least grave in its objective features.
but furnished, upon post-mortem examination, evidences as clear, though not so great, of its
true pathology, as the two others examined. It is greatly to be regretted, whatever may l«e
the reason, that these examinations are so seldom made in the army.
Surgeon Mitchell's conclusion is that these cases are essentially typhus in their nature.
Surgeon Banks thinks bis belongs to the class of '* Pernicious or Congestive Fevers," though
1 do not perceive the force of his reasoning, and cannot acknowledge that his conclnstoDs
lire justified by his own statement of the symptoms observed and pathological appearances
noted.
Surgeon Robinson's cases are demonstrably cases of Cerebro-Spinal Meningitis, as shown
by the scalpel. My conviction, however, is that but little importance is to be attached to the
idea of any family tenaency, evidently entertained by him, as a remote cause of this dis-
ease.
Calling your attention to the paper of Surgeon Mitchell, with its endorsement, to the paper
of Surgeon Banks, which is a special plea for the recognition of the disease as *'Perntcaou«
Fever," though his own cadaveric section fully recognizes the co-existent inflammation of the
t-erebral meninges, while the condition of the spinal is not even reported examined, and to the
close analogy of symptoms io some respects, in his cases, to those belonging to undoabtrd
cerebro-spinal inflammation uu tbe one hand, and Surgeon Mitchell's cases on the other ; —
and finally to the extraordinary corroboration of my views recorded last March, by the result
of Surgeon Robinson's post-mortem examinations, in all of which notable evidences of tbv
existence of this disease were found. I submit the following extract from my response to SSur>
gcon Mc(>uire*s endorsement upon Surgeon Mitchell's report, referring it toms for an expres*
sion uf my professional opinion upon the cases therein reported, as a statement of my Tiew»
upon this most interesting subject, repeating that they deserve farther consideration than
may be attached to a discussion based alone upon written reports, and not personal exaniii-
ation.
* * '^d. I think Dr. Mitchell is right in considering this disease either a Cerebro*Spii m\
Meningitis, or, on the other hand, an essential typhus.
As it has come under his observation, it is either epidemic or contagions, or both. So m
Typhus). It is rapid in its progress, more so than Typhus geoerally is. It tttmt tobsT« been
History of Cerebrospinal Memngitis. 433
attended by more spasms and conyulsions than usually belong to Typhus. While, on the
other hand, the spotted appearance of the skin, (undoubtedly I suppose the resalt of an effo-
sion of disorganized blood), presents a marked likeness to some cases of Typhoti and goes
very strongly to uphold their identity, still, as you justly remark, many of the symptoms are
wanting, so many that I am forced to this conclusion, either that this is anew form of *' blood-
poisoning," or that it is Cerebro-Spinal Meningitis.
Let me now give you my reasons for believing it to be the latter :
Ist. <^erebro-Spinal Meningitis, though an active and violent inflammation (more parti-
cularly of the Arachnoid,) yet has these features in common with Dr. Mitchell'i cases.
a. It is epidemic at times. No less than throe epidemics are recorded in France, Ireland,
and Gibraltar.
b. It is eitremely rapid in its terminaiinn, in its epidemic form, as will be seen below, and
it is fearfully fatal.
2d. There is a coincidence most remarkable, in all respects in symptoms. The notable
difference in epidemics, generally being tiiat the disease rarely attacks persons after puberty.
Vet Dr. Gilkrist in his account of the epidemic at Gibraltar, admits that a few over the age of
thirty were severely attacked; but on the other hand, the disease in Prance, attacked mainly
"Conscripts who bad lately joined their Rpgiroent."
3d. Now for the symptoms. The symptoms by which the disease commences are in general
ol a rery formidable character, and its accession is usually sudden, and quite unexpected ;
in the majority pf cases, the patient was in his ordinary health and spirits, up to the very
moment of seizure, and had experienced no premonitory symptoms to warn him of his danger.
In fonr of the cases in the South Dublin Fnion, the boys had eaten a hearty dinner, and
retired to bed in apparent health, when the disease all at once declared itself. In many
iostances it commences with severe pain in the abdomen, followed immediately by vomiting,
and not unfrequently by purging. In the worst cases, the symptoms are accompanied by
marked collapse, the extremities are cold and bluish, the pulse is at this time a mere thread,
and altogether the disease assumes very much the aspect of Cholera. After the lapse of a few
hours, reaction, more or less perfect ensues, the muscular system then presents characters
which may be considered almost pathognomonic. The muscles of the extremities, and those
of the neck in particular, become remarkably rigid, the head is drawn back upon the verte-
bral column, and finally fixed in that unnatural position ; no efforts of the patient can bend
it forward, neither can the attendants do so, at least by the employment of any justifiable
force.
The countenance at this period, often assnmes very much the tetanic expression ; twitcbings
of the muscles of the face sometimes ensue, the patient loses in great measure, the power of
moving his extremities, so that he is quite unable to assume the erect position ; the surface
becomes hot, the pulse feeble and frequent, from 120 to 140, the stomach often continues
irrit«ble whilst an insatiable thirst torments the sufferers, and the epigastrium evinces marked
tenderness upon pressure.
Symptoms of a still more serious nature quickly supervene ; the patient may be seized with
geuerai convulsions of a frightful severity, requiring personal retainment, to prevent him
from injury, or he may be in a semi-comatose condition, constantly moaning and grinding his
teeth, or even crying incessantly. Towards the close of his sufferings, he generally merges
into perfect coma, the pulse bocomes slow and labored, the powers of speech and deglutition
fail, bis stools are passed involuntarily, and death finally closes the scene. All this may occur
in a surprisingly short space of time ; some of the cases ran their course in forty-eight hours
and the greater number terminated about the fourth day, whilst some few were prolonged
even to a fortnight, or three weeks. Kxamples are on record of death from the disease io as
bhori a period as fifteen hours. Fatality in France, 80 per cent. The only statistics before
me give : army soldieri, 103 cases, 122 deaths ; not stated, 194 cases, 40 deaths ; civilians, 450
cases, and 20 deaths.
I do not see that the fact of there being '* blood-poisoning," at all interferes with the idea
of active, or even distinctive inflammation. Witness genuine Typhoid Pneumonia, or the
inflammatory ulceration of Typhoid fever, etc., etc. I suppose the truth to be, that it is not
a symptomatic fever, i. e. Cerebro-Spinal Meningitis followed by fever — but essentially Idio-
pathic, r. e. Cerebro-Spinal Meningeal Fever — an Idiopathic fever, (dependent if you please
upon serious lesions of the blood primarily,) the brunt of which is borne by the Cerebro-
."^pinal Arachnoid, like the glaudd of peyer in Typhoid, or the joints and heart in Rheumatism.
I am sir, very respectfully, your obedient servant,
R. J. BRECKENRID6E,
Stirffeon and Inspector of Camp$ and Hotpitak^
Army of Northern Virginia,
I>r Kubiii»oii published an account uf tlie four coycs of Ccrebro-Spinal MeniDgitiB
it'corded in hia report of »ick and wounded in 10 Compaaies, 22d North C&roliDa &^-
yt
434 History of Cercbro^Spinal Meningitis.
inent, previously given ia the Confederate States Medical and Surfrical Journal, Vol. ii,
No. 2, February 1865, p. 3H. The published account did not differ ia any essential
respect from the official report.
The following article by Surgeon G. A. Moses, of Mobile, Alabama, together with
the matter presented in this chapter, includes, as far as my information extends, overy
thing contributed by the Confederate Surgeons, on the subject of Cercbro Spinal Menin-
gitis, during the progress of the Araeric^in CUvil War.
Epitlnnic Orchro-Spiiud Mou'njitut^ hi/ Snrjf(ni G. A, Mosts, Molnh., Alfthama.
During my connection with the Army, my attention has heen at various limes, attrncte«l hy
n disease which had hitherto never come under my observation. It is that type of <*creliral
disease, known as Cerebro-Spinal Meningitis. It occurred I believe at Bowlinjj Green, dunn/
the winter of 18GI-1862.
In the succeeding winter, while the Army in the West, was at (Srenada, Miss., this diseaic
made its Appearance among the negroes employed upon the fortirication;^, and also amoiif,
plantation hands, in several adjoining counties. A^ain during the pa<t winter, I h:i\(*
observed it at this place, almost entirely confined to the blacks, both those employed by
(Jovernment, and others. Some cases have occurred Rmongf^t the citizens, principally in
children. The disease is marked by its rapid course, and fearfully frequent termination. I
have heard of but few rrporitd recoveries, and have seen none.
The first account* I find of a disease resembling this, but unnamed, dates in l.'Uo, wh«n
it appeared in France ; it is not again mentioned until l.'io:^. A disease almost similar appeart-d
in 1510 and 1517; after a very severe winter, (h^.'i'J) in Silesia, it carried offlarge numbor.*
of the population In 15S0, as.sociated as now with Otarrlial affections, it killed no less ili.in
10,000 persons in Home, I'i.ooo in Madrifl, and jtroporlionally large numbers in other ciiir*.
During the Civil Wars in France, DilO, Ozenaur says. ''The armies both Catholic and l»roif<-
tant, are decimated by a new disease," the subjects being attacked by "sudden and furln-*
pain in the head.'' It laRied more than three montb.^, and but few were saved. Sydcnli.iPi
reports it in UJ'Jl and h)t;4, as. -electing iheyoung and most robust >ubjecls and as pariakini.' 'i
the type of Typhus. In 17H8, during an epidemic of Typhus in Lyie, a disease appeari.l
more nearly approaching to the character of the present epidemic, li was accompiinied wif •
tetanic convulsions and coma, the pia-mater being rhietly involved. Not until IS::m, wa? »i<y
name given to this disease, when upon closer examination, were more fully vindicated ii< »•« «'
and nature. Of late years, it has occurred in many portions of the Confetlerarv. No sutlici«t.i
cause has yet been assigned for its appearance or cessation.
M. Toudes, in his valuable paper, has published statist ic> of attributable cause*, and as-'j""
the abuse of alcoholic stimulants as the chief — but of l.i»» crt.«es <|uot(d. in lou cases ii«i
cause is '* unknown. '
Ag it has occurred in the Army, it cannot be attributed to aleolnd, as among^it its \t«r.ii <»
this stimulant could but rarely be obtained. It a]>pears generally, if not universally, durin;:
cold, wet winters, along with severe types of pulmonary c<)mpljiint'«, and pa-^sea throu'jh t'"-
stages of all serous inflammations.
It is remarkable for the suddenness of its declaration, '\\< rapid develoj)ment and termin.«iii'r-
The subjects generally the young and most robust, arc to alt appearance in good h^^alth t
chill, or pain in the head, first attract attention ; in a \ery few Imurs the patient gn»W5» ^ii;- '
pain in the head appears to concentrate about the base, the neck becomes stiff, pain? are f' '•
in the extremities, or in the abdomen.
These signs increase until the muscles of the neck and back beeonie rapidly contrAtt*
giving almost opisthotonos; the smallest movement of a linger or toe. is attended with iuien--
pain; the pupil of one or both eyes is dilated or inactive, or their action is reverised; c» u »
occurs, often trismus ; the tongue until now moi>t and normal in color, or, a-* is more n-m
covered with a whitish fur, becomes dry, hard and swollen ; bowels obstinately con-stip-^'* '
pulse small and slow^, respiration labored, )>rofuse diaphoresis, and in a short time dii"
closes the scene, or the patient may have an iiiterinis>ion of the severe symptom* for twt]-. «
or twenty-four hours, the physician may hope until suddenly a relap-«e takes place. w»ih fa*«.
ending.
Treatment has been of but little benefit -everything has bem nconimended and tried, m ■»
poor success.
M. Kollet advised general blood-letting, b-eihes and cups to leii<.:tli tif spinal colimin r
actual cautery, with sinapisms, and bli>lers of Ammonia, co\ering the whole body. (Jris*' • *
in addition, recommends Mercury, (ianssauch trusts to t^iinine. Ch«iu(ratd to upturn iu i-fj
doses. They all lost from sixty to eighty per cent, of the caae*?. After the di^ea^c ha> l'- •
• Vid. Uutory of Ki>i«l«'in»r, (Vnlinh'^pinal Mtuitmlti" . Bil-lioti i|iii <lu Mi<l« < in Pim> tit U n, ^ i-l. ix.
History of Cerehro- Spinal Meningitis. 435
gressed to the extent it may in four or six bours, no medicine appears to act, Croton Oil failing
lo more the bowels to action.
The first symptoc of the disease, which attracts attention, appears g^enerally to indicate
not the commencement of disease, but its maturity, as in those cases which die in from ten to
Hfteen bours, with large effusion of lymph in the pia-mater. Insidious in approach, it declares
iiself at a time when interference is of no avail.
I am indebted to Dr. S. C. Young, P. A. C. 8., for information regarding the coarse of this
disease at Grenada, Miss. Of thirty-five cases which came under his observation, he know9
of no recovery; one was apparently imj»roving, when at the end of the third week, he was
taken from the hospital, some of the cases under his charge, lived twelve and fifteen days,
even longer. He thinks mercurials and stimulants promise the most success. Theory would
seem to approve his opinion, but the great difTiculty is to bring the patient under the influence
of the remedy. The disease as it has appeared in hospital here, runs its course with more
uniform rapidity than it has before done, no case having lived through the fifth day.
Like Cholera and Yellow-Fever, tiiis epidemic appears to tlepend on a specific poison,
excited by certain changes in the atmosphere. Experience has not advanced our knowledge
of the real cause or treatment of this most fatal disease, selecting as it does the hardiest sub-
jects in the Hush of strength and life, it baffles all our skill.
The accompanying notes in several cases which are types of all the others, will sufficiently
exhibit the symptoms, treatment, termination and pathological appearances.
The only change in the blood is an increase of the fibrin.
The cerebellum is more often and seriously affected than the cerebrum, being sometimes
softened, in its superficies, while the internal portion has a reddened appearance, the puncta
vao'culosa seeming larger and more numerous. This I judge to be a secondary complication.
The pia-mater is the membrane in which the disease finds its origin, and generally exhausts
its course.
NoTKS OF (^ASKS. ("asb 40.']. — March 24th, Alick, slave, aged about twenty-five years,
entered hospital at 10 a. m.; has felt unwell since yesterday ; quit work in evening. This
luoroing condition as follows: Pulse 04, soft, compressible and small ; tongue moist, of good
color, excepting a little whitish fur in the centre ; countenance natural; left lung congested,
a little crepitus ; some rigidity of posterior cervical muscles; bowels constipated. Prescribed
llydrarg: Chloride: Mit: pulv. Jalap^c aa grs. x., wet cups to chest; cold douche to head to
l>i; applied continuously for half an hour, and intermitted for some length of time, and so
alternately during day; whiskey 1 drachm, every half hour, as long as necessary to produce
effect. .^» p. M.; Pulse 80, very irregular, soft and quick; respiration 28; has been noisily
delirious and difficult to restrain in bed, since 1 p. jf. pupils largely dilated and inactive;
paiiisiag urine involuntarily ; spit out purgative this morning; skin of natural heat; cries as
though suffering ; continue whiskey and duuche.
March 2rith, 0 a. m. — Pulse i)\, small, soft and regular; respiration quiet and easy at 28;
pupilB contracted to a very small size and inactive ; deep coma; left side of face warm, right
Hide cool. Kody and extremities warm; diaphoresis; tongue dry, continued whiskey as often
as could be administered. 4 p. m. — Pulse 110, fuller and soft; left pupil acting a little less
promptly than normally ; right pupil still contracted and motionless ; face and skin same as
thii morning — not so much perspiration. Continued whiski*y. 0 p.m. — No change except
that respiration is somewhat quicker.
March 2'Uh. — Died at Gj a. m. ; Autopsy at 4 p. m, ; body still unusually warm, although
weather it cold; dura-mater healthy; on taking off this, the arachnoid is seen transparent,
except when underlaid by lymph deposit; blood-vessels much congested and very tortuous ;
each vessel carries in its track lymph, more anteriorly than posteriorly; base of brain a mass
of lymph, with some pus about the optic commi-ssure, across and around the pons varolii and
medulla oblongata ; arachnoid in some places bound dow'n by hands of lymph ; the deposit
enters the convolations, along with the pia-mater ; lateral ventricles contain turbid serum,
with fiakes of lymph. Spinal cord posteriorly covered with same lymph deposit.
Cabb 4U4, March loth.— Henry, slave, age 25; entered hospital .March 20th, Op. m. Com-
plained from the first of pain in the head, so intense thai he constantly emitted cries and
{(roans; pulse weak, at about 0<) ; tongue moist and white; pupils slow to act; had a chill
hefore entering hospital.
.March 11th. — Pain increased, no change otherwise; is taking 5 grains Iodide of Potassium
every hour. 12 m. — So noisy that he was moved to a detached room ; seems lo be suffering
int«*nBely ; still conscious, but no answers can be elicited. 4 p. m. Pulse somewhat increased
in frequency; tongue dry; puj>ils dilated and almo.^t inactive; coma commencing. l.Tth, 10
jk. M. — completely comatose ; skin moist and cool ; perfectly quiet: lying on the back for the
first time ; muscles of neck rather stiff; scalp blistered last night, and stimulants adminis-
tered ; pulse slow and feeble.
March 14th.— Died at 1 a. m.; Autopsy at 10; usual appearance of congestion and lymph
ileposii around aiachnoid and pia-mater; pacchionian bodies enlarged; Urge deposit of
436 History of Cerebrospinal Meningitis.
Ijmph and poi at base of brain, especially over pons varolii and medulla oblongata ; sub-
stance of cerebellnm reddened and slightly softened snperficialljr.
Casi 495. — March 19th\ 5 o'clock p. ji.; John, slave, age 28 ; has been sick for two days
before entering hospital, with Diarrhoea ; operations large and frequent; has taken three
grains of Opium.
March 20th, 9 o'clock a. m. — Bowels quiet, and moved since last evening; pulse 148, small
and soft ; temperature of skin natnral ; inclined to be stupid ; tongue dry and covered in
centre with a white fur ; pupils much contracted and motionless; complains of pain in bead,
and neck, and in extremities, especially in superior; ordered whiskey, i ounce every boar.
Died at half past four this afternoon. Autopsy: Dura-mater, in several places near pac-
chionian bodies, adhered to subjacent membrane, so that in uncovering the brain portions of
it were separated, leaving small, smooth, irregular cavities, as of a slough ; lymph deposited
along course of blood-vessels, and posterior to optic commissure ; no disease in spinal cord.
Case 496. — Reported by Assistant Surgeon J. H. Purifoy. Entered February 24th, with
some symptoms of Pneumonia, which endured for a day, before signs of Meningitis occurred,
when the case took the usual course of the above-mentioned cases, with one marked pecu-
liarity :
The pupils, after being dilated, became much contracted, and expanded upon the odmiMgion of
light. Death occurred on the fifth day. Post-mortem examination revealed : enlargement
and an appearance of red hepatization of the pituitary body, in addition to the usual
deposition of lymph, with some pus. This case was treated throughout with Quinine and
stimulants, irfter bleeding by cups to the extent of ten ounces. — Confederate States Medical
and Surgical Journal, Richmond, August, 1864, vol. i, No. 8, pp. 113-115.
After the clo8e of the war, articles and obsorvatiotis on Corehro-Spinal Mening:itL«
were published by several Southern phygieiaiiB, as Prof. E. S. (raillard, M. I)., Rich-
mond Medical Journal, Vol. 1, No. 3, pp. 204-212, Manh, 1866; William O' Daniel,
M. D.,of Marion, (ra., Atlanta Medical and Surreal Journal, Vol. 8, No. 1^ pp> 17*
18, March, 1867; James S. Dyer, M. D., of Ilartsville, Tennessee, Nashville Juamai
of Medicine and Surgery, June, 1867, pp. 472-478 ; Prof Juriah Harris, M. D.. of
Savannah, Greorgia, Savannah Journal of Medicine, July, 1866, p. 219; H. M.Law^on.
M. D , of Cuthbert, Ga., Med. and Sur. Reporter, August llth, 1866, p. 141 ; W. S.
Armstrong, M. D., of Atlanta, Ga., Atlanta Medical and Surgical Journal, June, 1866.
vol. vii, No. 4, pp. 145-151 ; W. C. Moore, M. D., of Atlanta, Ga., Atlanta Medics!
and Surgical Journal, January, 1H67, p. 4J)1 ; W. 0. Baldwin, M. D., of Montgomm.
Alabama, Am. Jour. Med. Sci., Oct., 1866, pp. 321-3:i8; J. AV. Moorman, M. D.. of
Hardingsburg, Ky., Am. Jour. Med. Sci., Oct., 1866, p. '6^6 ; J. H. Southall, M, D.,
of Little Rock, Aric., Rich, and Louisville Medical Journal, Aug., 1872, p. 138; John
L. Cook, M. D., Elizabethtown, Ky., Rich, and Louis. Med. Jour., Nov., 1872 p. SaS.
J. A. Larrabee, M. D., Louisville. Kentucky. Rich, and liouis. Med. Jour., Dec., 1873.
p. 764.
In like manner, various Northern and AVestern physicians have contributed to the
history of Cerebro-Spinal Meningitis during and subsequent to the recent war, as W.
H. Draper, Am. Med. Times, Aug, and Sept., 1864. AV. W. Gerhard, Am. Joor.
Med. Sci., July, 1863; J. B. Upham, Boston Medical and Surgical Journal, l^<>^i>
and Sept. 3d, 1874 ; J. S. Jewell, of Chicago, Report made to the Illinois State Mod-
ical Society, June, 1866 ; Chicago, 1866 ; S. G. Webber, Boylston Priie Essay, ltM>6.
reprinted from Boston Medical and Surgical Journal, 1866; L. Parks, Report of a
Committee of the Massachiutetts Medical Society, May, 1866, Boston, 1867; J. J*
Levick, Trans. Am. Med. Ash., vol. xvii, 1H66; Stills*, Philadelphia, 1867; Githens.
Am. Jour. Med. Sci., July, 1867.
The &ct» recorded by these and other ob.«»erver8, will be considered under the appn»-
priate divisions of this investigation.
Dr. S. 6. Webber, in his Essay, which received the Boylstou Medical Priue, W
recorded the following facts with reference to the prevalence of Cerebro-Spinal Mtfoio-
gitis in the Northern Army and States. The earliest records of the late cpidcBic art-
during the winter of 1861-2, when it was seen in the Army of the Potomac, and in
livingston County, Ind. In the fall of 1862, it appeared among the negroes v^*
were taken to Memphis, Tenn., )»y the Union onny, and one or two cases were
History of Cerebro-Spinal Meningitis. 437
with among the Union soldiers in the yieinity of Newhern, N. C.^ during the winter of
1862-63^ and spring of '63, it appeared in La Grange County, and other portions of
Northern Indiana, at Newbern, N. C., during January, February and March, and
during these months, and also April, at Newport. R. I., among the Midshipmen at the
Naval Academy ; in February and March it was seen at Philadelphia, and during the
latter part of the year at Cambridge, Ohio. During the two successive winters of
1862-63 and 1863-64, it was epidemic in Morgan County, 111. The year in which
Dr. Webber found the largest number of accounts of this epidemic was 1864. During
the winter of 1863-64, the negroes of Memphis were again vi.sit<?d by it, and during
the same winter and succeeding spring, Darwin, in the southern part of Clark County,
and York, in the Northern part of Crawford County, 111.; in the northwestern part of
Pennsylvania, and parts of New Jersey it was noticed during thin year, and also in
1862 and 1863; only a few cases occurred around New York. Daring January it
was in BratUeboro, Vt., during January and February in Philadelphia, and nt Benton
Barracks, near St. Louis, Mo. Durihg March it was seen in Brandon and St. Albans,
\'t., and Louisville, Ky., and during January, April and March, cases were seen in
Boston, Mass.; during May, at Chicago, at Lcland, and in Wiiliamson County, Ills.;
Daring the last part of July, three cases occurred at the Stanton General Hospital,
Washington, D. C. In October, Mechanicsburg was visited by it, and in November,
Marshall, 111., and during the latter part of the year, St. Pauls, Ind. Daring the winter
of 1864-455 a few cases were seen at the City Hospital, Boston; in January, 18(55, at
Greenwich, and in April at Palmer, Mass.; in the latter month at Kewaua, Fallon
County, Ind., and early in the year at Palestine, near Indianapolis, Ind.; in May, at
Nittaoy Hall, Penn. From September, 1864, to May, 1865, this disease appeared
among the troops on Gallops Island, Boston Harbor, Mass.; cases occurred in Boston
in 1866. — Boston Medical and Surgical Journal, vol. Ixxv, pp. 188, 181. In Phila-
delphia the epidemic appeared in 1863, and renewed its appearance annually up to
1867. During the same period it prevailed in certain parts of Maryland, Virginia,
North Carolina and other Southern States. In Mtissachusetts the disease appcarcMl
again in 1870, and the number of cases rapidly increased, until they culminated in the
somewhat extensive epidemic of 1873. — J. B. Upham, M. D., Boston : Med. and Surg.
Joum., Sept. 3d, 1874, p. 222.
During the winter of 1872 and Spring of 1873, Cerebro-Spinal Meningitis, (Kpidemlc
Meningitis), prevailed in New Orleans to such an extent as to attract some degree of
attenUon ; 79 whites and 41 colored (total 120), having fallen victims to this disease
in the six months ending June 1st, 1873. During this epidemic 1 ropeati'd the obser-
vations which I had made upon this disease during the civil war of 18H1-1S(;5, and
confirmed the conclusions which I had previou.sly adopted, viz : that
Ist. Cerebro-Spinal Meningitis Is characterized by true injlumnuttory symptoms,
via : Increase of fibrin in the blood, elevation of temperature, derangement of digcHtion
and aberration of nervous and muscular phenomena. Tnlike the true fevers, the blood
IS charged with fibrin, and fibrinous deposits are found within and around the iiiflanie<l
meninges of the brain.
2d. Po0t-mortem examinations in New Orleans confirmed my previous view, that
the disease consists essentially of an inflammation of the arachnoid and pia-niater of tlie
brain and spinal cord, and that in some cases the structures of the cerebro-spinal cen-
trefl may be involved in the inflammation.
3d. The fatality attending this disease must be referred to the character of the
organs involved, and also to the destructive effects cau.sed by the pressun; of the congn-
table lymph and efl'usion within the unresisting, bony cavity of tjie cranium and spinal
eavity.
4tii. The onset of the disease is in most cxses suddt>n, and eliaract4>rixed by chills
or chilly sensation, intense and excruciating pain in the head, and in the buck and
tniiscles of the lower extremities; V(»niiting ; cippressel aii'l lahore«l nspirallon, irre<.^u-
438 History of Cerebro- Spinal Meningitis.
Ur, feeble pulse, c<>Dvul,siv't:, muscular uiovements, jactit^lion, hy penes thesis, delirium
and ()pisthoMno:<.
'Hh. The duration of the disease is not Rovenied hy fixed laws, as in the idiopathir
fevers, as Wraoll-Fos, \'arioloid, Measles, Scarlet Fever, and Typhus and Typhoid
h'evers, but is govcrued by itie nature and extent of the primary and secondary IochI
lesions. In CHse!i in nrhifh the brain and spiniil i-unl arc greatly congested, the fsial
issue miLy OL-eur in a few hours, from delit:iont and perverted nervous supplii'S. and
arrest of resiiimtioti from the profound lesions of th^; ui-,>dulla oblongata. Many ca.'^^
may continae fur weeks and even months, nuuifiKtin;; various disturbances of the iiervi>u-
nnd muscular systems, attended with diily elevationH and depreiisions of tcm|H>ratur<'.
as in Typhoid Fever and jlospital liangrene. and fiually t«nDiDate fatally.
lith. It results, from the nature of the lesions in Cerebro-Spinal Meningitis. ni>i
only that the disea-sc may be of indefinite duration, but also that recovery in some cas<~
is more to be dreaded than death itself
The followin<r case, illuslrutin^ the preceding i!tatentcnt, came under my observiiiion
durin); the prosecution of my iu vest i<.Mt ions upon this diseaae, in 1872 mid 187'( :
C'(w ■i^f' : HiHKiruting llic I'tnunneat and Di»a*trous Effect* which mai/ rriiiti j'y.m
Iiijt'iinaiQfi'iii of the Mentnyei of the Brain and Spinal Con/,
l.'linrlcs ."^milli, n};c 21, native or Vicksburg, Mias, mulittlo. He is snid lo liave bctn i
Iipalth; cliilil nt (lie timi' of Ilia birth, and remainad so uaLiI be had attained the agf of nine
iiinnllis. At which lime lie was seized with violetit convulgions, dependral apparently uiion
iiiHaniiiinliDn of llie base of the brain and ipinal cord. The effei^ts of this disease were cuiu-
plcte [inralvsis of the nrma and legs, rigidilj of tie apine, pHral^Bls of Ui« tonguf , and arrr^ii
ft mental development. Tlie head nnd trunli of Charles ;Smith have attained the li/.t of th'<-r
iif n man, whilst llic arms and Ug^ are withered, contracted, contorted, and utterlv us«li-<'.
mid powcrlpsj, I'p lo the present lime. Charles Smith has remained iillerlj heljile-n. «n.|
emits only neak, inarlicutate sounds. During the past 2'> jeari, lie has remniaed more hrlp-
Ics.i thrill an inl'mit, and is onp of the ino^it aFHicted and pitiable objects thai I Imve r^r-
If ('erchro-S|iinal Meningitis lie related to the membranes of the brain, as Fli'uriii.- ir-
lo ihe invifltiiiK meiitbrane of the bings, it should be classiil with the fihtrgm-itui . iii
whieh there is an actual increase of the fibrin, and not with the jiyrexia'. in whuh tlii-
I'lemeiit is ilelicietil; and ia the character of the lesions of the cerebri i-spinal .lyMi'iii.
we have uii ex|)kii:ition of that striking and important fact, that amidst a niarL<"l
unifiirniily of svniptoms in diflureut eases, and in different epidemics, in various eoiin
Irii-s, and at various limes, the duration of the disea.<e isns indefinite aUhalof Pleiiiiu^
I^^^^^^^'i^^^CbT^^^H^m^
s^V
^/^ '
njyC*
•- %i^^
^-^* xj^ <l^'v><4i2^:^
_i— L -**-r«-«— ^
J^c^^
^**^»T» '
CHAPTER VII.
NATIRAL HISTORY OK CKREBKO-SPTNATi MKMNCITIS. CI1AN(JKS OK TKMI'KKATIKK, I'l LSK AND
KRSPIRATION. rATIIOUMJK'AL ANATOMY OK CERKHUOSPTNAh 31KNIN(ilTI.S.
PULSE.
Every variety of pulse has been observed in the same epidemic^ and even in the
>aiDe patient.
In eases which run a rapid course ^o a fata] issue, as a general rule, the pulse is
small, weak, thready, and intermittent, increasing in frequency until nothing ijut a
tn-mulous motion is felt.
In some cases it is full, tense and slow, and the frecjuency of the pulse is not a
pnpuiinent symptom of the disease ; in others it«» rate and volume are subject to repeated
\anatioDS, sometimes rising, during the course of a few hours, from .80 in a minute to
loO, and changing in the course ot an hour, and even in less time, from quick to slow,
and from strong to feeble, and vice versa.
\x\^ slight exertion, as rising from the recumbent to the sitting posture in bed, may
«lj»oble its frequency, and render it irregular.
It is evident, from the preceding facts and observations, that it is impossible to estab-
li>h a rule for the variation of the pulse in frecjueney and force, as we may do in certain
'ILv-ases, as Yellow Fever; on the other hand, the diminution of force and volume, and
fhe impairment of its tone to such a degree that slight causes produce extreme varia-
tii>os in its rate and rythm, indicating great diminution of the powers of the heart, are
1-haracteristic qualities of the pulse in (Vrebro-Sj»inal Meningitis, and distinguish this
•li^^ase from the essential fevers.
The enfeeblement and irregular action of the general capillary circulation in (Vrcbro-
Spinal Meningitis, is directly referable, not to a poison in the blood, but to the effects
ot the cbaracteristie meningeal inflammation, with its attendant congestion and cfTuxion
npon the vaso-motor and respiratory nervous centres of the brain, medulla oblongata and
spinal cord. No extended discussion of this subject is needed in support of the pre-
•fding proposition, as the relations of the circulation and respiration to the cerebro-
spinal and sympathetic nervous systems have been considered in the fii>it, third and
tl'urth chapters of this work.
KESPlRATIOiN.
A< a general rule, the respiration is embarrassed in relation t) the gravity of the case,
Slid the extent and position of the meningeal iufiamniation and fibrinous effusion. As
ill the case of the pulse, the respiration may be rapi<l or slow, without reference to the
othrr fiymptoms ; io general it is difficult, sighing, labored and interrupted, the uisjtinf-
f'on especially beipg laborious and prolonged. The distur])ances of respiratiun are to
1m' a-ferred to tl^ektame general causes as those of the capillary and general circulation,
viz: to the iqyojvement of the respiratory ganglionic centres, either directly or second-
440 Natural History qf Cerebro^Spinal Meningitis.
arily, by the prcHsurc upon the base of the brain, medulla oblongata and spinal oord,
induced by congestion and effusion. There are no facts to show that the respiratory
changes are caused by the presence of a specific poison in the blood.
TKMPEHATrRE.
In all the eases of Ccrcbro- Spinal Meningitis which I have observed, the temperature
is elevated above the normal standard, and is subject to diurnal variations, and in
sonic cases attained the degree of 107 F. In many cases, however, which recover, and
even in fatal cases, the temperature does not attain the high degrees which arc charac-
teristic of certain diseases, as Typhus, and Typhoid, and Yellow Fever, and Small Pox.
In the following fatal case, the temperature never exceeded 103° F :
C</^•e ^'W ; Cerebro^ Spinal MeningxtU,
Thomas UuDan, itt. 20, native of Ireland ; entered Charity Hospital, Ward 13, Februarj
14th, 1873. Comatose; neck and back stiff; opisthotonos. Under the use of purgatiTes.
Quinine, Opium, Bromide of Potassium, and Chloroform applied over spine, the patient recov-
ered sufficiently to sit up in the bed, but died suddenly in convulsions, February 26tb, on the
I'Jth day after enterin^c my wards.
The temperature in the axilla ranged from 100^ F , to 102° F.
In the following severe case of (^erebro-Spinal Meningitis, which recovered, the high-
est temperature observed in the axilla was 105° F.
Oise J^Oii : CerehrO' Spinal Meningitis,
Jot^tph White: occuiuilion. hotel waiter, (St Charles Hotel); age 19; native of New York,
liruught to Charity Hospital in a carriage a short time after complaining of being gick, Jan-
nary 4th. 1873. Whilst giving his name in the clerk's office, fell upon the floor in a ▼ioleoi
convulsion. Entered Ward Hi. I saw this patient shortly after his entrance ; the conyulBioii
was followed by delirium, and continual rolling of the body from right to left, the mascltrs
uf the neck and back being firmly contracted, and the head drawn backwards. Pupili greatly
dilated. Pulse moderately accelerated. Temperature high, but subject to marked oicilla-
tions. The patient could not be kept in bed without mechanical restraint, on acconnt of the
constant rolling and twisting of the body from right to left. I had to confine him ia bed« l»y
hi^rh boards nailed to the bed-post:*. A blister was applied to the back of the head, and over
the superior portion of the spine, and the bowels, which were constipated, freely opened by
Calomel; and Hydrate of Chloral, Bromide of Potassium, Quinine and Opium were freely
administered internally. An effort was also made to bring the patient under the inflaenee of
Mercury by means of the following: H. Hydrargyri Subchloridi (Calomel), "^i ; PoW. Ipecac
et Opii (Pulv. Doveri), »)iss; Quiniit* Sulph., ;^ss ; mix; divide into 10 powders; one puwdrr
every 4 hours. The ]>receding prescriptiou was repeated several times daring the active
Plages of the disease. On the 18th, the violent contortions of the body were lomewbat miti-
H;atcd, and the patient, although deliriou:*, was able to complain (when aroused) of inten^v
pain in the head.
Temperature, morning, HU®.! F.; evening, 105®; pulse, morning, 70; evening, lu4; respi-
ration, morning 'Jo ; evening 32. Jan. 14th, patient more ratioaal, but still bai opisthotOB«»<»
and complains of intense pain in the head, and is occasionally delirious and turns io beU
Temperature of axilla, morning, 1(m)® F.; pulse, 72; respiration, 24; temperature, erenin^.
1o:i; pulse, luti; respiration, 30. Continue Calomel, Dover's Powder and Qaiuine. IStli.
morning, temperature, 101°. « ; pulse, 8r» ; respiration, 21 ; evening, temperature, 104* F
H;th, mornini,', temperature 1()(>°; jjulsc, IS: respiration, 20; evening, temperature, 1<»3'.T
pulse, OH ; ropiralion 2o. ITth, patient says that he feels better this morning, and res ted
well during the night, still complains oC some pain in the head. Tempemtnre, morain^.
f»s^.'» ; pul.^e, IM); respiration, 2H ; evening, temperature, 104®.9; pulse, 80 ; respiration, '.>.
Hth, continues to improve ; morning, temperature, 98^.5 ; pulse, 80; respiration, 28 ; ereo-
in^, temperature, 9h°.:»; puli^e, 80; respiration, 24. 19th, patient complaias of seTere pain
in heaii.and along the spine; there appears to have been some increase in the local iaflamia^
lion, and this has been attended with a sudden rise of temperature, from 98^.5, on thee veain,r
of the isth, to 104° F., un the morning of the UHh ; the pulse also was increased to )00, ao j
the respiration to 32. I repeated the compound of Calomel, Quinine and Dover's Powder, an c
nibbed Croton Oil over the spine. These measures appeared to be prodnctiTe of good* The
Hydrate of Chloral and Bromi'le of Potassium were also repeated, ii^ doses Tarying from ^ to
Natural History of Cerebro^Spinal Meningitis,
441
34» jrraios of each, at iutcrvals of from three (o four hours. At 8 p. m., the temperature of the
axilla bad fallen to 101° F.; pulse, 84 ; respiratiou, 28. 20th, patient continues to improve ;
luorniog, temperature, 98°. 3 F.; pulse, 84; respiration, 24 ; evening, temperature, 101° ;
pulse, 84 ; respiration 24. From this date the temperature fell to the normal standard, and
exhibited slight diurnal oscillations ; the patient gradually regained the use of the extremi-
ties, the muscles of the trunk and neck gradually relaxed, and he was discharged, cured,
February :id. The disease continued unabated for 1(! days, and the patient was able to walk,
and was fully restored to health on the .'>uth day. Throughout the disease I endeavored to
maintain the strength, by milk punch and beef tea, and moderate quantities of alcoholic
sitimulants, administered at short and regular intervals.
The following table presents the oscillations of the temperature, and the pulse and res-
piration during 13 days — January 13th to 25th :
II .V T K .
TEMPERATURE.
P I' L S E .
RESPIRATION.
PAYS
OF I
IH.«*KAJ<K. 7 I — - -
Morning. Evening. , Morning. Ereniug. i Moniiog. , Erening.
Jaiiuarv
Aft
13th, 1873 8th.
14lh, •' iUh.
15th, •' nilh.
16lh, •» Uth.
I7lh, ♦* 12th.
18th, •♦ 13th.
lath, *• I Uth.
20tb, *' lath.
2Ut, " 16lh.
22d, '» 17th.
23d, •' 18!h.
24lh, - lIKh.
2.')th, '' 20th.
H)l°.
100°
101.8
100
o8.:i
104°
98. :{
I>9.2
jn).2
U8.5
1 F. 105°
105°
104
103.7
104.»»
98.5
101°
101°
99.«
99.0
99.2
9t».
98.5
70
72
85
7H
90
HO
1011
8!»
84
80
80
84
88
104
100
68
KO
80
84
84
80
80
8S
84
80
20
24
21
20
28
28
32
24
28
18
18
18
18
32
32
20
28
28
28
24
24
20
19
18
18
111 the following case, the highest temperature was reached on the 15th day of the
dittease, when the thermometer in the axilla stood at 105.3. This marked rise in
the temperature, as in the preceding can*, was preceded by a great aggravHtion of the
^ytuptoms.
L\i»f 'tO(f : Ctrebro-Sfunai M* iiiH(/l(U.
Telcr Harwasen, age 50: native of (Jerraany ; entered Charity Hodpilul. Ward 13, January
.'•»th, 1873, in a delirious state, with contraction of muscles of head and neck. Delirium,
wild, requiring mechanical restraint; bowels obstinately constipated; pupil:) contracted. 1
i au!(ed the bowels to be freely opened with Calomel ; applied a blister to the back of the
head and neck: and administered internally at regular intervals, Hydrate of Chloral, Bromide
of PotAasium, and Quinine and Dover's Powder. The intellect was gradually restored and the
( uotraction of the muscles gradually disappeared under these measures, and the patient was
.«blc to sit up in bed and converne on the 29th, 30th and 3l8t of January, and Istof February,
<»n the second of February he was seized with a chill in the morning, during which he became
iriteosible, with cold extremities, and the temperature fell to 09° F. The chill was followed
by high fever, the temperature of the axilla rising in the evening to 105.3 F. During the
(.bill, And subsequent fever, the patient was entirely insensible ; neck and back stiff; opistbo-
tooori; respiration labored and puffing; pnlsu small, thready and irregular. The patient
app«Ared to be in extremis. I repeated the blistei^to the back of the head and neck over the
r^ipoB of the spinal cord ; and administered the combination of Calomel, Quinine, and Dover's
Powder, as in the preceding case. During the period of great depression, I also gave freely
rftrboDAte of Ammonia and Alcoholic stimulantij. On the 3d, the symptoms were somewhat
iiQproved, and the patient frradually recovered cons^ciousness, and progressed with slight
•^•ccilUtionB of temperature, until the 11th, when there was a slight relapse, attended with a
ria^ of temperature. From this date, the patient gradually improved and was discharged
Hired, March 10th, 1873.
The following table present** the changes of tcuiinraturc during 21 days, January 25lU
• o February I4ih,
y\
442
Natural History of Cerebrospinal Meningitis,
PAY
TE1IPKR.\TVRE.
1
PAY
TEHPERATUBK.
I>ATE.
,
or
D
A T K .
or
1
DISEASE.
w
— —
PISKA.SE.
1
5
Morning.
Evening.
1
1
Morning.
Evening.
January
25,1
18'73..
103.2
, 103.5
Febr
'y
,4,
1873...,
1.'
9H..''»
10(1.9
t(
2«,
(>
102.4
, 103.2
II
^''^i
li
It;
98.2
99.5
tt
27,
II
• •
i
102.7
101.4
II
6,
i<
17
97.9
100.4
it
28,
11
*•
8
103.
102.8
li
1 ,
II
IK
97.H
99.2
11
29,
it
••
9
102.
' 103.
it
H,
II
19
97.8
99.2
(1
30,
(1
••
10
1 00.
102.
II
•*i
u
20
97.8
99. H
i(
31,
II
••
11
102.4
' 101.5
II
10,
i(
21
98.8
99. H
Kebry
I,
li
12
101.
101.2
II
ill
'1
22
98.7
lOl..*.
(t
2,
V.i
99.
106.3
it
*-•
14
23
98. 4
99.:;
ti
^.
II
••
14
100.6
, 102.
1
II
(1
13,
II
II [
2*
25
99.7
98.5
99. J
10<».
_. —
—
-
-
_fc
The following cases (501 and 502,) of Cerebro- Spinal Meiiingitii*, treated in ihv
Charity Hospital, illustrate the daily oscillations of temperature.*
Cabi 501. Cbrsbro- Spikal Mikikcitib.
Cakb 502. ('ERCBRO'SriNAi. Mr.KiN(:iTis«.
John Tompkint^ •^y^ 16 ytart.
Thomas Othtl^ A'jf, ItJ </ftfr*.
Pay
TEMPERA.
PATE.
or 1
Key
2
M.
B.
Dec.26,'72
101.
103.2
u 27, "
3: 99.
103.5
*» 28, *»
41 00.2
101.5
" 29, "
5
99.8
102.5
»* 30, *«
6
101.5
102.8
u 31^ u
7,103®
103.8
Jan. 1,'73
8
102.6
103.5
li «i II
9
103.
102.6
" 3, "
10
102.
104.4
It A II
11 101.8
103.6
♦* 5, •'
12 101.
104.
»* 6, "
13 101.
105.
II 7 <i
141101.
103.5
*' 8, '«
15 102.
103.
" 9, *'
16,100.4
100.
" 10, *'
1 I7;i01.5
1 99.
'* 11,**
is: 98.5
,103.
II 12, *»
19 101.
|102.
*• 13, »'
20 98.
' 99.
.1 ]4^i.
1 21 98.5
, 99.
•« 15, "
. 22
. 98.5
: 98.5
PULSE. RE>P'N
PATE.
I M.
88
62
82
lOlj
105,
102|
1041
104
108
94
108
95
110
98i
66|
94 j
102
100
82
84
84'
M. I E.
n.ii TEMPERA
or
Ffv
M.
K.
PI USE- RI>PIB N
100
64
92
100
100
96
100
108
104,
96
104|
98
108
90
88
86
» • • • • ■ •«
18 I)ec.2t;,'72
tt or 4»
- • »
II MU ((
......... ..t^i
ti •><) (t
-''1
•• ;{o, *'
'♦ 31, *'
Jan. 1/7:;
•I tt
•I
3, ••
6, ♦♦
^, •'
n I.
10, "
11,"
12, "
13, "
14,"
ij.
tt
•t
tt
t>
it
tt
ti
ti
it
tt
th
1 1
.*
.1
ti
1 100.
2 101.
3 100.5
4 lol.
5 101.2
6 lol.
T loi.ii
8 103.
9 102.2
10 101.5
u io;.8
12 101.4
13,101°
14 102.
15 102.2
16 101.2
17 102.2
18 100.
19 101.8
20 101.
21 101 2
22 99.
1»9.6 loo i»T
101.4
lul.L'l
101.0 I
I02.I
103.4
102.6
102.:.
102.
103.
98.J
104.
103.
102.5
102.
103.
102.
101.2
100.4
'100.4
100.
98.5
lofi
104
98
lot*
104
108
l(»2l
104
lot
102
120
110
104
84
9H
110,
112
102
98
100
I.
112
112
100
ii:>
120
118
116
im;
lo:«
120
110
ln^
I 0(1
104
84
104
^6
94
94
96
••«••■
In the following cases (503, 504,) which I have coDsoUdatcit from the clinical repiyrtC
of Dr. J. A. Lambee of Loui8vil]e, Kentucky, (Richmond and I^ouisrille Mtsiic.tl
Journal, December, 1872, p. 7(>4. (the hijrhcst point of teniporaturr n\ichiMl wa»* lOo"* F.
*The clinical record of these cases, was furnislied at my request, by Ur. Wm. .Martiii. ai
that time resident atudent in the Charity Hospital. Accounts of those cases hare beca pub-
lished by Dr. L, 8* McMurlry, (New Orleans Medical and SurgicaUoornal, January J8T4 .
Natural History of Cerebrospinal Meningitis, 443
Ccue 503 : Cerebro- Spinal Meningitis,
T. W., bright acdve boy, aet. 3 years and 2 months, March 23d, 1872. The mother stated
thai about two o'clock, the night previous, he alarmed her by acting strangely. He became
conscious after awhile, and complained of feeling sick. Pulse 125 per minute; anxious
expression ; jactitation of limbs, persistent vomiting of everything taken into the stomach,
and constant retching when the stomach was empty ; the eyes also were in constant motion,
the lids widely open. Physical examination of chest showed slight dulness, with bronchial
respiration over middle lobe of ri^ht lung; the condition of the other lung so far as any phy-
sical signs of pnenmonia were concerned, was good ; the most distressing symptom was the
persistent vomiting.
"^ March 25th. Passed a restless and uncomfortable night ; bowels had been moved ; vomiting
only partially cont;-olled, breathing hurried ; pulse 130. 3.30 p. m.; temperature in axilla 105^,
pulse 136 ; respiration 50 per minute. ^\^ graiu of Sulphate of Atropia, ordered to be given
every two hours by stomach.
10 p. M. There was present every evidence of the peculiar effect of belladonna — redness of
skin, dryness of mouth and fauces, with dilatation of pupils; temperature 103^.5, pulse 148|;
respiration 52. Ordered Atropine in same dose at four-hour intervals.
March 25th, 9 ▲. m. Pupils considerably dilated, mouth extremely dry, tongue constaDtly
thrown out for. water, which be drinks greedily, and occasionally vomits. Intellect seems to
be a little clearer ; when questioned makes an attempt to reply in a fretful manner ; pneumonic
signs better ; returning crepitation at base ; temperature 102°, pulse 38, and respiratioa 48*;
retains the Atropia, but vomits the water when taken in large doses*.
<> p. M. Temperature 104°, pulse 130, respiration 52. His words, if he says anything, are
incoherent; discontinue Atropia; has not slept a moment; ordered Bromide of Potassium
with Opium, for sleep.
March 26th, 9 a. m. Condition in no way improved ; has had no good sleep ; the right lung
is afcain beginning to do duty; temperature 103°. 5, pulse 144; respiration 148. To have no
medicine by the mouth, but ordered turpentine and Carbonate of Ammonia, with ^ grain of
Morphia per rectum, every 4 hours.
7 p. M. Sleeping, with fair pulse, less frequent respiration, extremities cool, but not cold.
March 27th. Slept well most of the night ; tongue not so dry ; no sordes ; temperature
1(»2, pulse 120, respiration 44; left knee swollen, hot and tender; abdomen much distended
and tympanitic. Ordered Tincture of Iodine to left knee; turpentine stupes to abdomen ;
bowels to be moved by simple enema ; beef tea often by the mouth.
March 28th. A remarkable change has taken place during (he last twelve hours ; he is per-
fpctly conscious, and has slept without the use of Morphia. Hands and feet quite cool com-
pared with the previous fever heat; temperature 101*. 5, pulse 25, respiration 40. Ordered
Quinine 2 grs. every hour, beef tea and a little brandy at suitable intervals.
March 29. Passed a good night by aid of Morphia, to procure sleep, and appears to be
somewhat refreshed and conscious ; respiration 32, pulse 18, temperature 103°. Ordered beef
tea with Quinine to be continued ; increase the nourishment.
March 30th. Temperature 103° ; respiration 24; pulse 108. Patient exhausted and weak;
tries to talk, but is incoherent. Carbonate of Ammonia, with Quinine and beef tea.
March 31st. Rested well and awoke clear as to expression ; cannot articulate his words
well ; complains when pressure is made over cerebral vertebra; ; body covered with herpatic
vesicles, eruption and sudamina.
April 5tb. Tongue appears moist, with aptbo: upon surface and edges ; temperature 104°,
puUe 120, respiration 28; left foot still swollen, eye looks better, pupils dilated ; takes cham-
pagne and ice eagerly , talks thickly, chewing his words so as not to be understood.
April 2 1st. During the interval between the 6th, has had again acute hydrocephalic symp-
toms, screaming, etc., followed by paralytic symptoms upon right side, the left being entirely
relieved. For six days past, has uttered no cry, and made no attempt to talk. At one time
be was unable to swallow any nourishment, but during the past three days, has taken egg-nog
and milk quite freely, when placed in his mouth, but manifests no desire for anything, swal-
lowing it mechanically when so placed. He does not yet articulate a sound, except when
his bead is raised from the pillow, the back of his neck touched, or he is turned in bed ; at
9iicb times he makes a faint noise, and his face bears an expression of pain.
April 30th. Emaciation of truuk and lower extremities, sunken belly, herpetic vesicles
over skin. Last night irrtgular spasms began ; at first consisting in slight trembling of upper
extremities, the hands* arms and face, being only affected. During the night spots appeared
over face, arms and trunk; some red, others of livid hue ; varying from the sise of a pea to a
aickle. He was unable to mak^ the slightest movement with the right leg, which was stiff
*nd rigid ; could not be bent or moved.
May 3d. Rested well all night, and looks better.
May 4th. Not so well, had a return of trembling, but no convulsion ; right pupil greatly
444 Natural History of Cerebro^ Spinal Meningitis.
dilated. Has not given any sign of consciousness, but lies like a piece of marble staiuarj ;
the skin for the most time of a marble whiteness, becomes suddenly suffused with a pink
color, which passes away. Several times his breathing during the last few weeks has become
so gentle and unobserved, that he was thought by his friends to be dead. There is complete
deafness and blindness.
May 15th. This is the eighth week of the disease, and from the last record, there has been
little or no change in the symptoms. He does not stir in bed, nor change position of bis own
accord. To day the right leg is stiff and motionless. A blister applied over the occiput and
back of neck drew well, and was filled with gelatinous matter. The pupil of the right eye is
dilated ; an examination of the retina by the opthalmoscope showed that it was of a deep red
oolor, and the vessels turgid ; the left pupil is fixed and too opaque by lymph to be examined.
He did not appear sensitive to the strong light ; but a slight contraction of the pupil was
noticed. The emaciation of the trunk and extremities is frightful ; the faqe docs not show
mnch emaciation.
May 30. Tenth week of illness, and 70th day after commencement of treatment. During the
past week, there has been more marked rigidity of muscle, the legs and arms, are as stiff an«l
immovable as marble; trembling spells become more frequent, and always accompanied by an
effort to move. During these spells, the face becomes quickly tinted, and then crimson, after-
wards deadly pallor succeeds. The emaciation is frightful ; his face which uotil now has not
participated much in the emaciation is slowly melting away. Although there is no pincbetl
expression or mark of pain upon his countenance as he lies unconscious and motionless, and
scrupulously neat in his snowy garments, h eis not unpleasant to look upon. The eruption up«»n
the scalp discharges some matter; a blister has since been applied. To-day his mother ga\e
him a strawberry; he ate it quickly and held open his mouth ; a piece of bread was given
him, and he spat it out; more strawberries were given and were eulcn by him. This is the
first taste and distaste he has shown.
June I5th. No important change.
June 29th. Thirteenth week, slight diarrhica ; same muscles contracted until their tendons
stand out upon the thin wasted limbs like strings; right arm and shoulder badly swollen.
Neither sees nor hears, nor is sensible to objects around him, although he is sensible to pain at
times. Bats well, even hastily of nutritious food, such as eggs, whey, sponge cake, etc., an«i
appears to like certain things, rejecting others, as soon as they are put into his mouth, t>iit
makes no sign of disgust at what he dislikes,. until it is in his mouth.
July 13tb. Sixteenth week; same, but more fretful from beat.
July 16th. Died this morning at 2 o'clock. Before he died he became opisthotonic ; hi«
back was a perfect arc, and his limbs were convulsed ; the rigidity of certain muscles ami »«•««
of muscles was the same in twelve hours after death as during life.
Ca»e iiOJf : Cerehro- Spinal MtningitU,
^SRgicGagan ; Irish girl, aged 13 years. Scrofulous nature, having suffered from bip-joim
disease.
April 20th. Complained of great pain in head, limbs and chilliness. On Thursday previous
to illness, she bad competed with some children in jumping ropes; had reached one-bundrrti
and fifty Jnmps without intermission, and being completely exhausted, she bathed her head m
cold water, and drank of the same freely. She retained the dorsal position in bed. and the
head waa observed to be buried backward in the pillow ; althougli no marked opisthotonos!
has characteristic eruption. Temperature of axilla 106, pulse fast and small, 140 per minute
April 22d. Appears easier, although in sound sleep ; answers questions very slowly ; int«>l-
lect not clear; temperature 105°, pulse 135, little fuller.
April 23d. Temperature 103. pulse I'JO, tongue dry, cracked and sore.
April 24th. Appears to be much worse this morning; complete opisthotonos; frequent
spells and screaming ; pulse rapid and feeble; temperature could not be taken; is eviden*.,t
sinking.
April 25tb. .Vo sleep, constant tossing about in bed, occasionally screaming : delirious
p. M. Appears to be worse ; low muttering, delirium; pulse 150 ; restlessness of limba.
May 4th. During the past week there has been but little change in the condition of the
patient except emaciation ; the pain continues in the head, and the rigidity of the neck also
is exceedingly feverish, but takes food and stimulants well ; tongue and lips now dean
asked for her breakfast this morning, aud ate with good appetite; the head is still dra«r
back, and the hands tremble considerably.
May 12th. End of third week; still lying conscious, feverish and fretful, with head drav-i
backwards; has become extremely emaciated; the sordes about the mouth and noae rcma i
and bleed considerably; tongue perfectly clean ; appetite good and even craving; di(ic^^t'or
perfectly performed; stool each day ; moves the right arm and leg with extreme difficulty
May 26th. Commencement or sixth week of the disease. Tetanic spasm and opiathoior.us
have entirely disappeared; abdomen sunken and Hat ; skin considerably discolored.
'. Natural History of Cerebro- Spinal Meningitis, 446
Jane 12th. Ha3 been sinking gradaally, with an exacerbation of all symptoms since last
record, vomiting at frequent interrals ; screaming ; opisthotonos retained ; extreme emacia-
tion and complete exhaustion, with coma at the last, from which she died at 2 o'clock in the
eighth week of the disease.
I have consolidated and condensed the fullowing cases, (505-554,) illustrating the
changes of the pulse, respiration and temperature, from the '* Notes of ninety-eight
cases of Epidemic Cerehro-Spinal Meningitis, treated in the Philadelphia Hospital,
( Blockley,) during the months of December, January, February and March, 18G7, by
\V. H. H. Githens, M. D., Am. Jour. :Med. Science, July 1807, pp. 17, IVJ.
Case 505. Age 47, male. Result^ death in two days. Symptomt^ delirium pain in head,
nausea, coma, eyes closed, pupils contracted, chest and abdomen covered with eruption of
small reddish brown spots, about one quarter of an inch in diameter: involuntary discharge?
in bed; skin dry.
Af^f, RetpiraUon and Tetnperature. Temperature of axilla, 101® F.; Pulse 126, very weak.
Head warmer than body; extremities cool ; face darkly congested. Corners of mouth drawn
down. Respiration labored and noisy; bronchial sounds, dry and metallic. Four hours
before death pulseless, and bronchial sounds so loud as to mssk sounds of heart.
Cask 500. Age 40, female. RetuU^ recovered in 10 days. Symptoms^ serai-comatose condi-
tion, but when called loudly would open her eyes, and turn her head slightly ; face darkly
congested ; pupils contracted ; chest, abdomen and thighs thickly covered with petechial
eruption; patient lies in bed in any position in which she is placed ; involuntary discharges
of urine and feces.
PuUe^ Respiration aod Temperature. Temperature in axilla on 2d day, 103° F.; skin dry ; head
warmer than b3dy ; extremities cool. No eahr mordazj the skin feels simply warmer than
natoral. On the 4th day, when there was a slight improvement of symptoms, and the erup-
tion was disappearing, the pulse was 140; small and thready: 5th day, pulse improved 120
per minute; 7th day pnlse full, 90 per minute.
Cask 507. Age 28, male. Retult^ recovered in 21 days. Symptomt^ pain in head, back thighs
and calves of legs; petechial spots over chest, abdomen, and thighs ; great muscular depres-
sion ; patient describes the pain in the head as resembling the compression of a band of iron ;
pain and tenderness in neck and along back; mind clear: corners of mouth drawn down ;
eyes widely open giving the patient a staring expression
PuUe^ Respiration and Temperature. 15th day of disease, temperature, 10 a. ji., 103® F., pulse
102, respiration 33; 6 p. m., temperature 103®. 5, pulse 100, respiration 34. 16th day, 6 a.
M., temperature 101®, pulse 86, respiration 36; 12 m., temperature 101®, pulse 72, respiration
28 ; 6 P. M., temperature 101®, pulse 76, respiration 32. 17th day, 6 a. m., temperature 101®.2.^>,
pulse 74, respiration 20; 12 m., temperature 101*', pulse K6, respiration 28; Op. m., tempern-
iiire 1 00®. 25, pulse 90, respiration 32. 18th day, 6 p. m., temperature 99®, pulse 84, respiration
2H ; ]2 M,, temperature 98®.75, pulse 84, respiration 24 : 0 p. m., temperature 98®.r), pulse 76,
respiration 24. 19th day, temperature 97®, pulse 70, respiration 28 ; 12 ii., temperature 96®.7r»,
pulse €6, respiration 28; 20th day, 6 a. m., temperature 97®, pulse ho, respiration 28 ; 12 m.,
temperature 98®, pulse 78, respiration 28 ; 0 p. m., temperature OH®..'!, pulse 86, respiration 32.
21 St day, 6 a. m., temperature 97®. 5, pulse 72, respiration 32.
Cask 508. Age 36, male. RfntU^ recovered in 16 days. Sffmptonut^ intense nervous excite-
ment, universal tremor pervading the whole body ; tongue tremulous; inten.se pain in head
located in occipital and temporal regions; unable to sleep by day or night; pupils small;
ronjonctiva injected ; eyes prominent and staring; hyper;rstliesia of skin ; respiration irrt*-
gulnr; abdomen, chest and thighs, thickly covered with reddish brown petechial eruption.
/VtM, Respiration and Temperature. 7th day of disease, 10 a. ii., tcnifierature 103®, pulse 126,
r«^spiration 36; 6 P. M., temperature 103®, pulse 112, respiration 28. Hth day, 6 a. m., tempe-
riiiure 101®.5, pulse 116, respiration 24: 12 m., temperature 101®, pulse 128, respiration 2H ;
6 P. X., temperature 103®, pulse 116, respiration 28. 9th day, temperature 102®, pulse 12<;,
respiration 32 ; 12 m., temperature 102®, pulse 130, respiration 36 : 6 p. m., temperature 102®. 5,
pulse 128, respiration 32. 10th day, 6 a. M.,^temperaturc 102®, pulse 124, respiration 40; 12
M., temperature 100®.5, pulse 134, respiration 28: 6 p. m., temperature 101®. 5, pulse 136, res-
piration 36. llth day, 6 a. m., temperature lOI®..'), pulse 140, respiration 28 ; 12 M., tempera-
ture 101®, pulse 140, respiration 32 ; 6 p. m., temperature 101®.'), pulse 120, respiration 32.
I2tb day, temperature 10l®.5, pulse 132, respiration 36: 12 m., temperature 102®, pulse 136,
respiration 36 ; 6 P. M., temperature 102® 74, pulse 140, respiration 36. 13tb day, temperature
M»2®, pnlse 106, respiration 32; 12 m., tcniperntiire 103®.2.'>, pul.se 120, respiration 32; 6 y.
M., temperature 102®, pulse 120, respiration 36. Uth day, 6 a. m., temperature 100®.2.^i, pulse
I«K, respiration 32; 12 m., temperature 10l®.:», pul.se IOM,*rospirntion 36; 6 p. m., temperature
l«»l®, pulse 112, respiration 24. 15lh day, 6 a. m,, temperature loi®, puNe 92, respirntiou 21 :
446 Natural History of Cerebrospinal Meningitis.
12 M., temperature 08^.5, pulse 108, respiration 28; 6 p. m., (temperatare 99<'.5, puUe 92,
respiration 32.
Cask 500. Age 43, male. Result, death in seven days. Stfmpioma. Expression stapid and
lieavy, petechial mottling on abdomen and thighs, on 5th day decided opisthotonos, inro-
luntary discharges from rectum and bladder, stupor.
IhiUe^ Respiration and Temperature, 3rd day of disease, 6 A. M., temperature 98", pulse 134.
respiration 28 ; 12 m., temperature 100°, pulse 130, respiration 32 ; G p. m.. temperature 101^.5,
pulse 132, respiration 28. 4th day, temperature 99°..'i, pulse 112. respiration 24; 12 m., tem-
perature 100^^.5, pulse 120, respiration 24; 6 p. m., temperature 9!>", pulse 128, respiration 24.
.Mb day, 6 a. m., temperature 99°, pulse 110, respiration 20; 6 p. m., temperature 99°, pulse
100, respiration 28. 6th day, 12 m., temperature 98°.5, pulse 104, respiration 28 ; 6 p. m.,
temperature 96°, puKse 112, respiration 24. 7th day, 6 a. m., temperature 92, pulse 102,
respiration 24.
Case 510. Age 52, male. RetuH^ death in 8 days. Symptotnt, diarrhcea, marked petechial
eruption, eyes prominent and staring, corners of mouth drawn down, active delirium on 4tb
day.
PuUe^ Respiration and Temperature. 3rd day of disease, 6 p. M., temperature 103°. 5, poise
120, respiration 40. 4tb day, 6 a. m., temperature 101°.5, pulse 108, respiration 36; 6 p. m.,
temperature 102°.5, puise 120, respiration 40. 5th day, temperature 101°.5, pulse 104, respi-
ration 32 ; 6 p. M., temperature 101° 5, pulse 120, respiration 40. 6th day, 6 p. m., temperature
101°, pulse 98, respiration 48. 7th day, temperature 101°, pulse 66, respiration 28; 6 p. m.,
temperature 101°3, pulse 142, respiration 32. 8th day, 6 a. m., temperature 100°, pulse 112,
respiration 48 ; 6 p. m., temperature 100°, pulse 152, respiration 52.
Cask 511. Age 51, male. R^ault^ recovered in 28 days. Symptoms, Severe headache,
chill, profuse petechial eruption, coma, subsultus tendinum, opisthotonos, hypersestbeaia,
sequlse, complete deafness and paralysis of left foot.
PuUe^ Respiration and Ttmperature» Pulse small and feeble, varying from 120 to 150. Tem-
perature, maximum 102°.75, minimum 97°.5, mean 100° F.
Casi 512. Age 45, male. Result^ death in 12 days. Symptoms. Severe headache, deliriun,
constipation, vomiting, opisthotonos, hyperiesthesia ; no eruption.
/'«iV, Rispiratim at I Tmp'ratire. Pnls3 strou]^ and irritable, 116 to 120; temperatnre,
tntximum 10.'}^ F., minimum loP.r>, m^ai 103° ; deUh on I2th day from choking up of broo>
chial tubes with thick mucns.
('a8r 513. Age 35, male. /2««a&, recovered in 16 days. 5yiii/»tomt, violent headache; no
delirium; constipation; severe and general muscular pains. The temperature ranged from
1>9° to 9.')° ; and the pulse from 90 to 62.
Cask 514. Aged 30, male. RewU^ death on 23d day. Symptoms. For the 6rgt fortnight
had all the symptoms of well marked Typhoid Fever, with the eiception of the eruption, which
was petechial in character, stupor and coma constant for several days before deuth. Tem-
lierature, max., 104°.5; min., 97°.7:» ; mean, 102°. 5; pulse, 88 to 134, barely perceptible.
(yA»R 515. Age 45, male. i?eitu//, recovered in 12 days. <Sym;>loiiM, violent headache ; no
delirium ; no petechia? ; some muscular pains ; severe headache ; slight opisthotonos, with
suhpuUus. Temperature, 99° ; pulse, 62-80.
<;ask 51G. Severe headache ; opisthotonos. Temperature, max., 102°.5 ; min., 98°; mean.
101°. Pulse feeble, 72-8»5.
("asi 517. Age 22, male. Result, iXtaWi on 21st day. Temperature, max., 104°.75; min.
J»7.°r. ; mean, 102°. Pulse 86 to 120.
(>*A8B 518. Age 20, male. Result^ death. Moribund when brought into hospital. Tem-
perature, 101° 10 lo;{°. Pulse lio to 120, feeble.
t'A.HK.'>]9. Age 23, male. Death 8th dny. Severe headache, opisthotonos, delirium, con-
junctiva congested. Temperature, 101° ; pulse, 100 to 110, feeble.
('ask 520. A^e 4r», muL*. Death 11 lb day. Severe headache, delirium, constipatioi.
hyperesthesia, opisthotonos, screaming. Temperature, 101°; pulse, 110 to 130, very feeble
Cask 521. A^e MTt, male. Cured in 7 days. Headache, constipation, itiflToess of back
Temperature, 100° F.; pulse, 7«I to 112.
Cask 522. Age 22, male. Recavered 14 days. Severe headache, muscular pains of head
and back, stiffness of le^^g and back. Temperature, 99° ; pulse 76 to 104.
Task 523. Age 43, mile. (\ir.*d 5 days. Constipation, headache, pain upon pre^^ure
over cervical vortebratr. Temperature, 100° ; pulse 76 to 112, feeble*
Cask 524. Age 5:{, male. l)«ath in 12 days. Severe headache, wild delirium, opistho-
touo4. Temperature, lol°; pulse, 74*to 130.
<>*ase 52r>. Age 21, male. Recovered in 14 days. Intense headache, bowels constipated.
muscular pains in back, slight opisthotonos. Temperature, 98° to 103°.5 : pulse, 92 to 14*;.
Cask 52<:. Age 26, male. Died on 10th day. (>oma, bowels constipated, opisthotonos
Temperatnre, ;»<;o to lo4° : pulse, 9K to 144.
(*ABE 5'J7. Age 54, male. Died 2d day.* Intense headache, constipation, opUthotoooa,
eruption. Teiiipeiature, 103"^.
Natural ffistory of Cerebro" Spinal Meningitis. 447
Case 528. Age 21, male. Recovered in 27 diiys. Slight delirium, Blight headache, con-
stipation. Temperature, 97° to 104°.5 ; pulse, 72 to 112.
Cask 529. Age 20, male. Recovered 15 days. Severe headache, stiffness of back, hyper-
sesthesia, erythematous eruption. Temperature, 96° to 104° ; pulse 72 to 106.
Cass 530. Age 44, male. Recovered in 8 days. Slight delirium, continued headache, con-
stipation, opisthotonos. Temperature 98° to 101° ; pulse 88 to 112.
Case 531. Age 26, male.' Recovered in 14 days. Active delirium, severe headache, con-
stipation, erythematous eruption. Temperature, 97° to 103° ; pulse, 86 to 120.
Ca8X 532. Age 21, male. Recovered in 17 days. Muttering delirium, severe frontal
headache, constipation, muscular pain in neclc, opisthotonos. Temperature, 97° to 104° ;
Pulse, 68 to 120.
Casi 533. Age 67, male. Recovered in 10 days. Headache, constipation, erythema and
petechise, congestion of conjunctiva. Temperature, 97° to 102°; pulse, 76 to 120.
Casb 534. Age 22, male. Recovered in 20 days. Delirium, headache, constipation, opis-
thotonos, hypersesthesia, eruption, erythema and petechia;. Temperature, 96° to 104°.5 ;
Pulse, 72 to 120.
Cask 535. Age 16, male. Recovered 5 days. Severe headache, constipation, vomiting,
muscular pains. Temperature, 97° to 103° ; pulse, 76 to 126.
Cask 536. Age 30, male. Recovered 22 days. Intense headache, constipation, opistho-
tonos, hyperesthesia, petechial eruption. Temperature 97° to 103° ; pulse 80 to 120.
("ask 537. Age 36, male. Death in 11 days. Constipation, muscular pains, hypersesthesia,
petechial eruption and erythema. Temperature, 94° to 104° ; pulse, 112 to 120.
Casi 538. Age 46, male. Recovered 8 days. Headache, constipation, muscular pains.
Temperature, 95° to 105°.25 ; pulse 68 to 96.
Tabi 539. Age 22, male. Recovered in 14 days. Severe frontal headache, muscular
pains, pain on pressure of dorsal vertebrae, congestion of conjunctiva. Temperature, 97 to
H»4° ; pulse 70 to 106.
Tase 540. Age 40, male. Recovered \4 days. Active delirium, severe headache, vom-
iting, muscular pains. Temperature 99° to 104°; pulse 80 to 130.
Cass 541. Age 21, male. Recovered 20 days. Headache, diarrhoea, vomiting, muscuUr
paiDi, petechial eruptipn.
Casi 542. Age 31, male. Recovered 28 days. Severe headache, coma, constipation,
muscular pains, deafness and loss of memory. Temperature, 99° to 104°. 5 ; pulse, 90 to 120.
Casb 543. Age 13, male. Death lOth day. Delirium, coma, injection of eye, petechial
eruption. Temperature, 104°.5 ; pulse, 120 to 140.
Cask 544. Age 27, male. Recovered 21 days. Active delirium, some frontal headache,
diarrbcBA, muscular pains, petechial eruption. Temperature, 98° to 103°; pulse. 00 to 120.
t*A8B 545. Age 30, male. Recovered 28 days. Deliriuni, severe frontal headache, opistho-
tonos, severe muscular pains, copious eruption, deafness. Temperature, 97° to 103° ; pulse,
1 20.
tUsi 546. Age 25, male. Recovered 21 days. Headache, delirium, diarrhcea, muscular
|»ains. Temperature, 98° to 104°.75 ; pulse, 136.
(*ABB 547. Male. Recovered 21 days. Headache, deliriuni, nausea, pain in muscles of
neck and back, suppuration of parotids. Temperature, 97°. 5 to 102°.
Cask 548. Age 60, female. Died 6th day. Severe headache, consiipation, opisthotonos,
liyper«8theeia, petechial eruption. Pulse 112 to 120.
Cabb 549. Age 36, male. Died 9th day. Severe headache, ooustipation, eruption of
erythema. Pulse could not be felt.
("abb 550. Age 57, male. Died in 60 hours. Severe headache, constipation, muscuUr
pains. Pulse 116 to 120.
Casb 551. Age 32, male. Recovered 18 days. Headache, muscular pains, opisthotonos.
Pulse 68 to 130.
Cabb 552. Age 25, male. Recovered 21 days. Active delirium, coma, muscular puins,
opisibotonoB. Temperature, 98° to 104° ; pulse, 80 to 130.
Cabb 553. Age 65, male. Died 9th day. Headache, constipation, petcciiial eruption .
Pulse 86 to 90.
Casb 554. Age 29, male. Recovered 21 days. Intense headache, constipation, muscular
|>minB, hypersBthesia. Pulse 86 to 1 40.
In luauy of the cases obflcrvod by Dr. GithcDH, the tempeniturc was lower than that re-
corded in typhoid or inflammatory diseases ; the obscrvationH were made at (I A. M., 1 2 M.
aud G P. M, dnily ; aud were taken as far as possible, in typictd Ciue.s. and in tlioso
where the tempertvturt^ was most elevated, and yet the averaj^c is lower by four or five
clegToes, than that qf iypj^ua Qr typhoid fevers, pneumonia, etc. In two cjses only did
the thermometer \V( the axil^ ]:eaoh lOn'^. In fifteen cases it was between 104^ and
448 Natural History of Cerebro-'Spinal Meningitis.
105° ; in twelve between 108° and 104° ; in seven between 102° and 103° ; in six
between 101° and 102° ; and in two it was below 100°; records being made in forty-
four cases. The numbers given are the liighcst point reached in each case. The differ-
ence in the temperature at the evening and morning obscrvationSi was not so marked
as in most other fevers, a fall of more than one degree being unusual, and frequently
there was no change. A regular and gradual descent, indicated the beginning of am-
valesccuce ; a rapid fall was the sure precursor of collapse.
The pulse varied from normal to 150 beats per minute in ten uncomplicated cascrt:,
and ranged as high as IGO in two cases in puerperal women , it was in aJl, very weak,
with a dichrotic tendency ; sometimes entirely imperceptible in the radial artery, and
always interrupted by a very slight pressure. It appeared to be the most deceptive
symptom, as no one would have suspected an inflammation of a high grade, with a
pulse, which, although, sometimes (|uick, was very strong, but always gaseous a\h\
ieeble in the extreme. Am. Jour., Med. Sci., July 1867, p. 38
Dr. J. Baxter Upham, of Boston, in his '' Additional Reflections upon the Late
Epidemic of Oerebro-Spinal Meningitis.*' states that in the replies to the circniar issaed
under the auspices of the Massachusetts State Board of Health, from about two hun-
dred physicians, representing seventy-two towns and cities, and containing the data,
more or less complete, of upwards of Ave hundred cases of disease, " the (empenture
is not given as often as could be wished, and when indicated, the period of the day, or
the stage of the disease has not been particularized. In several cases, however, a very
high temperature has been noted, as high as 108°. 25 by Dr. Wm, Read, and in ont»
instance (that of a boy eight years of age,) by Dr. Ira Russell, as high as 110°."
Boston Medical and Surgical Journal, vol. xci, 1874, No. 10, p. 226.
According to J. Tourdes, in the epidemic of Cerebro-Spinal Meningitis, observed at
Strasbourg, 1840 and 1841 ; at the onset there was no fever, even when the pulse wa.**
accelerated ; the temperature of the skin was natural, or sometimes even lowered ; and
there was always a complete absence of fever in cases which terminated fatally within
the first few days ; but when the attack was of more than a week's duration, a true
fever was lighted up which remained until ccmvalescence or death ; this fever was of
the continued type, but presented, marked and regular exacerbations, which took plai-c
in the afternoon along with an aggravation of the other symptoms. According to th«*
writer, the force of the fever, was sometimes, although rarely, inflaumiatory ; more
generally it was typhoid.
J. Burdon-Saudei*son. in his " Report of the Result of an Inquiry into the Kpidr>
mics of (Vrebro-Spinal Meningitis, prevailing about the liower Vistuta, London, 1SU5/"
states, that in adults the temperature varied from 1(H)° to 104°, and in children was
still higher. Exacerbations of Pain, were always accompanied with an increase of boat
oi' the skin, amounting to 2° or 3°.
Dr. Felix ^'on Niemeyer, states, that in the tirat stage of the disease, up to the third
or fourth da}', although the pulse may be over 120, and the respiration of 4t> p*T
minute, the biwlily temperature still remains proportionately low, or rises to 102** or
over.
Aci'ording to Zicros.>en's numerous ob.sorvations, the /fver has no regular course* .
very few temperature curves resemble each other ; sudden leaps, and exaoerbatioD? of
short duration ot)en occur; but generally a remitting type, with exacerbations of half .t
degree to a degree, is most frequent ; very high temperatures are almost exclusively
seen in severe cases that terminate fatally, in most cases the temperature beiu^ cot
al>ove 103°. The intermittent fever that occ;isionally accompanies the other symploiDH
during convalescence is regarded by Ziem^sen, as a re-absorbing fevtr^ while he refers
that occurring during the second week to an interrupted progress of the Meningitis.
The frequency of the pulse does not at all accord with the height of the fever.
According to Wunderlich, Epidemic (Vrcbro-Spinal Meningitis being obviously a fonn
of disease, which in spite of the actual identity of the anatomical lesions, may prcjvot
itself under apparently widely different symptoms, the temperature, may pursue Tmried
History of Cerebro^ Spinal Meningitis. 449
cotiiscs. From more than thirty cases ob5er>'ed by Wunderlich, it appears to this
accurate observer, that three special varieties of the fever course, can be particularly
dkinguished.
(a). In some vety severej and rapidly fatal cases, the temperature displays a similar
(Dursc to that of Meningitis of the convexity. Though not invariably very high at
the be^ioDing of the disease, it reaches very striking heights in the briefest time,
which persist continuously for some days, and rise just near death, and in the very
njoDient of death to quite unusual degrees, 42° C. (107°.6 F.) and more; and in one
r.»se, 43.75 C. (110.75) in dying, and may even rise some tenths higher after death
(three quarters of an hour afler death in the case just mentioned), it was 44°.16 C,
(111^48 F). Wunderlich also observed some fatal cases, in which the temperature
for some time was very moderate, and rose considerably all at once just near the end of
the diseage.
(l). On the other hand, relatively mild cases, exhibit only a fever of short dura-
tion, although there are sometimes considerable elevations of temperature (which con-
trast with the quick pulse), and the course is generally discontinuous. Recovery does
not take place by decided crbis, but generally happens, rather with remittent deferves-
cence (lysis); and the pulse then begins to quicken just as the temperature has become
normal or nearly so. Here and there cases occur, which after differverscing, and
apparently almost recovering^ relapse all at once, with a rapid rise of temperature, and
run a course like the cases marked (a).
(c). In contrast with these brief courses of fever with either very severe or slight
characters, we find eases, which are more or less protracted with a corresponding course
as to the fever. The height of the temperature in these may be very varied, and
indeed, exhibit manifold changes in the very same case, though, indeed, this chieflv
depends upon the varied complications which i^upervene in the shape of bronchial,
pnlmonaiy, and intestinal affections, and affections of the serous membranes. Some-
times the fever has the same duration, and the exacerbations of the temperature, the
'^me height as those of typhoid fever, and its curves, when projected, may greatly
roiembJe the latter ; but there is not the irregularity of abdominal typhus, and at the
W, the course is only that of the amphibolic period of that disease, or like that
which occurs ia very irregular forms of it. Fluctuations of considerable extent,
apparent improvements, and fresh and sudden rises of temperature are met with. Some-
times the course resembles the fever of phthisical patients.
Deffervescence may occur rapidly, but is however, for the most part protracted by
\\m. With a fatal termination, there may be either a rising or falling temperature,
according to the kind of case, and the various immediate causes of death.
Wunderlich has related at some length a remarkable case, in which both the course
rf the tempe^ture and the other symptoms, rendered the diagnosis doubtful for a long
time, whether he had to do with abdominal typhus or Cerebro-Spinal Meningitis.
Archiv der Heilkunde, iv, 271 ; v, 417 ; ibid, 1865, vi, 268.
On the Temperature in Diseases, a Manual of Medical Thermometry, by D. C. A.
Wunderlich, New Syd. Soc, London, 1871, pp. 388-391.
The important conclusion deduced from the preceding observations, is that :
The temperature in Cerebro-Spinal Meningitis varies in accordance with the extent
and character of the local inflammation, and does not manifest regular and defined
changes, aa in the essential fevers ; it is evident, therefore, that the febrile phenomena
<*f Cerebro-Spinal Meningitis are not to be referred to a definite poison acting primarily
ufion the blood.
BLOOD.
As far as my investigations have extended, the fibrin is increased, as in inflamma*
tions generally.
Ames states that the blood taken from the arm, aud by cups from the hack of the
450 Pathological Anatomy of Cerebro^ Spinal Meningitis,
neck, coagulated with great rapidity ; its color was generally bright, in a few cases
nearly approaching to that of arterial blood ; it was seldom buffed ; in thirty seven*
Cises in which it« appearance was noted, it was buffed in only four. Analyses were made
in four cases, the blood being taken, early in the disease, from the arm, and was the
first bleeding in each case. The first was from a laboring man, thirty-five years old ;
the second from a boy twelve years old, while comatose ; and the two others from stout
women, between thirty and tbirty-five. In the first analysis, Fibrin, 0.40 ; Corpus-
cles, 140.29. Second analysis, Fibrin, 5.20; Corpuscles, 112:79. Third analysis,
Fibrin, 3.64 ; Corpuscles, 123.45. Fourth analysis. Fibrin, 4.56 ; Corpuscles, 129.50.
Tourdes states that blood drawn from a vein was rarely buffed ; if a buflfy coat existi^^,
it was thin, and generally a mere iridisation upon the surface of the clot ; analysis fur-
nished the following results : First analysis. Fibrin, 4.60; Corpuscles, 134. Second
analysis. Fibrin, 3.90; Corpuscles, 155.54. Third analysis, Fibrin, 3.70 ; Corpus-
cles, 143. Fourth analysis. Fibrin, 5.63; Corpuscles, 137.84. Maillot gives as tbo
result of analysis in six cases, an increase of fibrin to six parts, and more in a
thousand.
It is evident, therefore, from these Quantitative Analyses, that the blood in (\*rebru-
Spinal Meningitis, represents the condition of this fiuid in infiammatory diseases.
PATHOLOGICAL ANATOMY OF CEREBROSPINAL MENINGITIS.
Near the close of the recent civil war, and shortly afler my return to Augusta from
the Army of Tennessee, a most favorable opportunity occurred for the careful invi>ti-
gation of the pathological anatomy of this disease. During the months of Jauuan*
and February, 1865, Cerebro-Spinal Meningitis appeared in one regiment of a brigade
of Qeorgia militia, which had been summoned for the defence of the city again^^t tbo
threatened attack of General Sherman. The brigade was camped on the Sand Iiill>.
about three miles from Augusta. The Third Keginiont of (icorgia militia, in wbivh
six cases of Cerebro-Spinal Meningitis occurred, were camped in a valley betweeo the
hills occupied by the remainder of the brigade. As far as my information exteiidHl.
the troopa camped upon the dryer and warmer hills escaped this dlsea^, Three of
the six cases died in camp, and the remainder were sent to the general hospitali* id
Augusta, and in like manner terminated fatally. The symptoms manifested by tht-SM
cases were clearly those of Cerebro-Spiual Meningitis; the finit symptoms whi<h
attracted attention being nausea, vomiting, diarrhiea and convulsions, followinl with
severe pain in the head, extending along the spine, alternate contraction and dilatation
of the pupils, deafness, low^muttering, spasms; delirium and eouia.
Case ooo : Cerehro- Spinal Aftmui^ilftt.
In the ease of Private Goosby, of Company J., 3d Regiment, Georgia Militia, aj»
28 ; the first symptoms noticed by the Medical Officers, were soreness in the eh*-*!
and cough, accompanied with pain in the head and back, aod with nausea and .-^liLlu
diarrhoea. This patient was sent to the 3d Georgia Hospital in Augusta, on the f<»lloii-
ing day, February 13th, 1865, and at the time of his admission was rational and com
plained of pain in the back and extremities ; the symptoms of C^erebro-Spinal dis^tiir
K»aiioe, progressively increased, and upon the next day, February 14th, delirium sol in
with iocontrollable restlessness, and loud cries and shrieks. In lucid intervals, au^i
when aroused from the delirium, the patient complained oT violent pain in the hwd
A large blister was applied to the back of the head and neck, and ten ounces of Wih-I
abstracted, and quinine freely administered at intervals. Thojsc mrasun^t^ appeanil t..
iJbrd some temporary relief, but the disoiise progressed gtoadily, the prominent muij
toBQfl being characterized by muttering, delirium, cnutraction of the pupik doaiiit^.-
rigid contraction of the muscles of the neck and Fpiue, slow pulse and imptdcd n-^i
ration aod torpid bow.(jk Peath occurred on the 25th of February.
Pathologieat Anatomy of Cerebro-Spindl Meningitis. 451
AUTOPSY EIGHT HOURS AFTBR DEATH.
Cerebro- Spinal Sjfstem. — After the removal of the Skull Cap, the dura-mater of the
bnin, presented a normal appearance^ there were no marks of inflammation, and no
effusion between this membrane and the arachnoid.
The arachnoid presented an opalescent appearance, where- it passed over the sulci of
the cerebrum and cerebellum.
The pia-mater of the brain, was greatly congested, and the larger veins and many of
the arteries were distended with dark blood.
The Pons Varolii, Medulla Oblongata, and Spinal Cord, were coated ^ith a firm,
llghtrgreenish yellow, wax-like fibrinous exudation ; large tracts of the cerebrum and
cerebellum were also thinly coated with this effusion, which also surrounded the Cauda
Ef{Qina and most of the roots of the spinal ner/es, up to their entrance within the durar .
mater of the Spinal Cord.
This exudation possessed various degrees of consistence, from that of a serous fluid
to a newly formed membrane, and dilQered in thickness, in different parts of the Spinal
The exudation at the base of the brain, where it covered the Pons Varolii, and
Medulla Oblongata, was of considerable thickness and firmness^ and extended laterally,
^.Tadualiy diminishing in thickness, to the convolutions of the cerebrum and cerebellum.
O^er the cerebellum and cerebrum, the deposit was much thinner and less consistent
than at the base of the brain, and around the spinal cord, and in many places it required
H<«e ioHpection of the pia-mater for its discovery.
\\ ben a section of the brain was made, so as to expose the ventricles, the third and
lateral ventricles were found filled, and even distended, with a light, greenish yellow,
'^mi-flaid exudation, resembling to the naked eye, pus. The optic thalami, and striated
Mies, as well as the walls generally of the lateral and third ventricles, were coated with
a layer of semi-organized plastic lymph.
The deposit was subjected to a careful microscopical examination. The points which
I dessired to settle by this examination, were :
1st. The nature of the effusion— whether pus? Or organ izable and ^' organizing '*
Wmph ?
2d. The extent of the action of the organizing force, in the plastic elements and
products of inflammation.
vM. What membranes of the brain and spinal cord were involved in the disease ?
^th. Whether the nervous structures, themselves, commissures, ganglionic cells, and
^onective tissue of the nervous elements of the brain and spinal cord, were involved
in the diseased action.
oth. Whether any of the effects and products of inflammation, could be detected
bj the microscope, in the nervous structures proper.
The following appeared to be the most important results of these labors.
I'nder the microscope, the exudation presented different stages of organization and
'lerelopment, from the simple granule, to the perfected fibre, and even fibrous tissue.
Although resembling pus, to the naked eye, the exudation possessed in its microB-
<^»pical characters, and structure, a higher organization, and the more solid portions
^tre rapidly passing into the state of an organized fibrous tiasue.
The first question was of great interest and importance, and was settled beyond all
i^Til and doubt. The effusion and deposit, was organizable, and ^'organizing" lymph.
The effusion resembled in its physical, chemical and miscroscopical properties, the
pb5tie lymph, thrown out in mechanical injuries, and in acute inflammation, pleuritis
itid peritonitis.
It is therefore incorrect to speak of the effusion in Cerebro-Spinal Meningitis, as Pus,
'r a Purulent matter. The effusion may in some cases degenerate, simply into puru-
ent matter ; but at first and in its essential nature, it consists of coagulable pbstio
TTao izable lymph, capable of conversion into fibrous tissue.
452 Pathological Anatomy of CerebrO' Spinal Meningitis.
Without doubt in many autopsies, superficial observers have been deceived by the
general appearance of the effusion, when seen by the naked eye.
I have embraced other and more recent opportunities of making carefnl examinations
of the brain and spinal cord in this diseaAe, and the microscopical characters of the
deposit was in all respects similar to those now recorded. The organizable effosion
presented various stages of cell devclopement, from the simple exudation corpuscles to
oiganiied tissue.
These facta struck mc as being of importance, in that they connected this disease,
with other forms of inflammation, as Pleuritis and Peritonitis ; and also explained the
great difficulties which lie in the way of recovery from an inflammation of the nutritive
membrane of organs essential to life, surrounded by a bony case. The present casC) had
perMSted for two weeks, and the results of post-mortem examination, indicoted that the
intensity of the inflammatory process had ceased, and much of the effused material was
becoming organized. The mere presence of the organizable and organizing material,
even after the subsidence of the active inflammation^ constituting ii» it were, the csseDcc
of the disease, from the very structure and functions of the cerebrospinal nervous syft-
tern, and its bony envelope must give rise to various morbid nervous phenomena ; and
when the pressure upon certain portions of the nervous system becomes sufficiently
great, produce irremediable disturbances in the muscles and organs supplied by the
parts chiefly affected, and finally cause death.
The more fluid exudation of the ventricles, consisted of a serous fluid, in which
floated numerous exudation cells, similar in all respects to those of ordinary inflammatory
processes, and larger than pus corpuscles ; free nuclei and granules were also present in
considerable numbers. Many of these inflammatory exudation cells, were much larger
than colorless blood corpuscles, and contained a number of nuclei ; the most common
form was the spheroid, but some cells, were seen floating in the clear liquid, of an oblong
rhomboidal and spindle shape. The more solid and organized portion of the exudation
lining the walls of the ventricles of the brain, contained larger and more fully developed
cells, many of which, appeared to be passing into the condition of fibres.
The firmer portions of the effused fibrous deposit covering the medulla oblongata,
pons varolii and spinal cord, were seen under the microscope, to be pissing rapidly int4i
the condition of fibrous tissue, presenting numerous cells in various stages of develt>p>
ment, forming fibres and coalescing, and interlacing with each other.
In the wax-like deposit, from the surface of the anterior columns of the medulla
oblongata, the exudation corpuscles, spindle-shaped cells and elongated fibres, were held
together by an amorphous matrix.
Careful microscopical examination failed to reveal any exudation corpuscles, in the
nerve structures forming the walls of the ventricles of the brain.
The structures of the medulla oblongata, pons varolii, spinal cord and spinal nenrei^,
were examined microscopically, but no exudation corpuncles were discovered within the
nerve structures proper. Exudation corpuscles were observed adherent to the neuri-
lemma of some of the spinal nerves, but none were discovered between the fibres or
nervous tubes of the spinal nerves.
No exudation was observed on the external portion of the arachnoid between ihi»
membrane and the dura-mater.
The arachnoid could be lifted off the exudation in many place*, in others it wai^
adherent Under the microscope the exudation corpuscles and elongated spindle-ahaped,
and branching cells and fibrils, were seen adherent to that surface of the aimdmoid,
which lies upon the pia-mater. The exudation appeared, therefore, to belong chiefly to
the pia-mater.
The absence of the effects and products of inflammation in the nervous stracturea, in
this case, is a fact of importance, in throwing light upon the sudden and apparratlj
rapid course of many cases of Cercbro-Spinal Meningiti.^. As long as the nervoos ele>
menta themselves are unaltered, it is not rcarfonahle to suppose that active nervous dis-
turbances would be manifested. It would appear (hat in these cases the effosiiA
Pathological Anatomy of Cerebro^ Spinal Meningitis. 453
progresBivelj increased until the pressure upon important nervous structures gave rise
to the disturbances of circulation, respiration, and muscular and mental action. The
presence of the effusion within the ventricles, distending them and compressing the
surrounding nervous walls, in like manner must have produced great derangement in the
actions of the brain.
Abdominal Cavity, I examined the Hver and spleen with great interest, to deter-
mine if possible, whether they bore any marks of active malarious disease.
The liver of this patient, during the earlier periods of his disease, was said by the
attendant physician to have been somewhat enlarged and tender upon pressure ; the
application of a blister over the region of the liver was thought to be necessary, and
was said to have relieved the engorgement of the organ.
Afler death the ligrgc lobe of the liver was more congested, and of a darker and more
purplish color than usual ; the small lobe of the liver, however, presented a normal
color and appearance. The inferior surface of the liver presented a slate color. Under
the microscope I discovered none of the altered colored blood corpuscles and dark frag-
ment« of haematin characteristic of Mularial fever. The liver contained grape sugar
which I have shown to be absent from the liver of Malarial fever.
The Spleen was somewhat larger than usual, and a little softer, but still very nearly
normal in sixe and consistence, and when cut and exposed to the atmosphere the spleen
pulp rapidly assumed the bright scarlet hue of the healthy spleen.
Under the microscope, the splenic mud presented the elements usual in healthy
spleens, and I observed none of the altered coloring matters, disorganized blood corpus-
cles, and dark red and black angular masses of haematin characteristic of malarial
spleens.
The microscopical characters of both the spleen and liver, were wholly different from
those of Malaria] fever, of even a few days duration ; and I felt convinced ' from the
results of this investigation, in comparison with the results of numerous similar exami-
nations in various diseases, that this patient had certainly not been afflicted with
Malarial fever for a number of years previous, and perhaps not during life.
The mucous membrane of the stomach was congested. in spots, and under a magni'
fyiog glass the blood-vessels of the highly colored and ecchymosed spots, presented a
beautiful congested arborescent appearance. The punctated congestions were most
namerons and marked in the cardiac portion of the stomach. Portions of the intestinal
canal were more congested than in health, the congestion being greatest in the lowest
portion of the ileum. This condition of the alimentary canal, was most probably the
rcflalt of the free use of purgatives.
The mesenteric solitary and agmiuatcd glands presented an appeanincc of health ; —
nothing unusual was noted in them.
Ojmmentary, The following points were established liy the iti vest igat ion of thin ca.sc
of Cerebro-Spinal Meningitis.
Ist. This was a typical case of Ccrebro*S[)inal Mciiingitis ; the di^sease was epidemic
in character, being one of a number of simultaneous cases ; and the period of death
waa deferred until all the phenomena had time for dcvch»pnicnt ; this then may Ik>
accepted as a type of the epidemic form of (ycrcbro-Spinal Meningitis.
2d. There was no complication with malarious disease.
3d. The products of the inflammatory action roH urn bled in all rcspcctK, those of
Plearitis and Peritonitis.
4tb. The inflammatory action appeared to be confined chiefly to the pia-mater,
involving to a certain extent, also the arachnoid.
5th. The nervous elements of the brain, spinal cord and cervical nerves (ganglionic
cells, commissures, nerve tubes and nervous connective tissue,) a[>pcared to be free from
inflarooiatory action.
Gth. If the nervous elements were primarily involvwl in Cerebro-Spinal Meningitis,
it would be impossible to explain the suddenness and violence of the symptoms^ and the
rapid fatal result in the absence of all lesion.s recognizable by micro.seopic investigation.
454 Pathological Anatomy of CerebrO' Spinal Meningitis.
On the other hand it can be readily conceived, that the inflammation of the nutritive
membrane and the coating of the most delicate organs confined in a bonj cane with a
dense exudation tending to organize itaelf progressively into more firm and resisting
structure, might give rise to all the phenomena of Cerebro-Spinal Meningitis. An effu-
sion of coagulablc lymph is just as capable of producing pressure and jderanged action
in the brain and spinal cord, as an effusion or haemorrhage of blood within the bony
case of the cei'ebro-spinal system.
7th. This case furnishes an explanation of the almost univereally fatal character of
Ccrebro-Spinal Meningitis, as well as of the tedious nature of recoveries from this disease.
Even afler the subsidence of all active inflammation in the meninges of the brain and
spinal cord, the most serious consequences may follow, and all the dangerous symptoms
and derangements in the most essential functions of life, may be kept up, by the mere
mechanical action of the organizable and organizing fibrous effusion. The period of
convalescence from this disease would depend, not only upon the amount of fibrinous,
plastic, inflammatory eff^iision, but also on the character and rapidity of the sabeequent
changes resulting in the formation of fibrous tissue, and in the gradual absorption of
some portions of the products of the diseased action.
8th. The disease appeared to have been produced, in this patient, by the same
causes which are active in the production of other inflammatory affections, as Pleuritui,
Peritonitis, Pneumonia and Acute Rheumatism, viz : exposure, cold damp weather and
the hardships of camp life.
9th. In its essential nature this case differed from a contagious malignant fever.
There was not a single fact developed by the post-mortem examination, which would
justify the classification of this disease with the pyrexiae. If Cerebro-Spinal McDiagiUi*
belongs to the class of febrile diseases, then Pneumonia, Plenritis and Acute Peritonitis,
should in like manner be stricken from the list of the phlegmasiae. Writers have been
led into error by attributing the mottled appearance of the surface and the changes of
the secretions, as well as the marked disturbances of the circulatory and respiratory
systems in (.Vrdbro-Spinal Meningitis to the action of a specific poison, " diMorgantziHg"
the blood. It is entirely pertinent to ask : If the blood is so disorganiied in this disease
as to allow of the effusions of disorganized blood into the skin, why should all marks
of disorganized blood and bloody effusions be absent from the structures moat inflamed
and diseased, the meninges of the brain and spinal cord? The fact is, that these dii^
colorations of the skin in most cases of this disease, are not due to actual effusions of
disorganized blood, but merely to irregular capillary action, and congestion dependent
upon deranged nervous action and circulation. It is oinnecessaiy in this connection, to
do more than allude to th6 effects of pressure upon the medulla oblongata, upon tfai^
functions of the circulation and respiration. And even if it be true that the blood \»
<li.sorganized in certain cases of Cerebro-Spinal Meningitis, such disorganization may bv
entirely explained by the derangements of the circulation and respiration induced by
the disturbance and perversion of the functions of the cerebro-spinal system.
lOth. Ccrebro-Spinal Meningitis being not an essential fever, but a local inflamma-
tion, the febrile phenomena being dependent upon the effects of the local lesions, it \s
not contiigious ; and therefore it may be treated in hospital wards, in contact with oth<?r
patients, and all hygienic efforts should be directed to its original oiusation.
Another case of Cerebro-Spinal Meningitis occurred shortly aft3r the preceding oo4-.
wliich afforded opportunity for careful post-mortem and microscopical examination.
Cn*e fiofi : Ccrebro-Spinal MeningitU.
Private 11. Powell, ('oropany D., 3cl Georgia Reserres ; age 20. PAtient brought \ti\o
Second Georgia HoApitnl, Augiists, (ieorgia, at 12 M., March 12th, 1865; inarticalate ; Ijinf
on his back ; neck curved back ; quiet irhen left alone, but crying out with agoov wbea
mored, particularly when the neck was disturbed and moved from its curved poiition; pul«f
small, about Oo heats per minute, and quite quick; eyes slightly crossed, pupils dilated, bat
mobile and seiisitivc to light ; hearing impaired and mind stupefied. The patient protruded
his tongue, when ordered to do so. The tongue presented a healthy appearance. The
Pathological Anatomy of Cerebrospinal Meningitis. 455
attendants who accompanied the patient from camp to the Hospital, informed the attendant
medical officer, Sargeon Joseph Ganabl, that the day previous, he was to all appearances,
healthy and well, but was stricken down at 11 o'clock that night, insensible and speechless.
The litter upon which the patient was brought to the hospital, was befouled with his faeces
and urine.
The patient was stripped, washed and put to bed, and -was visited again two hours after-
wards, and found still Ij'ing on his back, with neck curved, and body slipping towards the
foot of the bed ; these symptoms continued up to the period of his death. Although unable
to articulate freely, nevertheless he seemed to be sensible when aroused, and answered plain
questions. Upon one of the medical ofiRcers placing his hand upon the patient's head, the
latter threw bis hand around the nape of his neck to support the cervical spine and prevent
lateral motion.
The following prescription was ordered and persisted in with the exception of the Quinine ;
U. Quins 8ulph., grs. zx.; Hydrargyri sub-chloridi, grs. vi ; Potassse Nitratis, grs. xxxvi ;
Potassse et Antimonii Tartratis, grs. ii ; mix and divide into 12 powders, one powder every
hree hours. This combination of drugs was thought by the attendant medical officer to have
retarded the progress of the disease; the symptoms however continued much the same, (with
the exception of a diarrhoea, which was controlled by the Camphorated Tincture of Opium.)
until the afternoon of the 16th, when the patient became very deaf, and was unable to articu-
late or to protrude bis tongue. The next morning (March I7th,) the patient breathed in a
labored manner, with a wheezing sound, as if the bronchial tubes and air cells were full of
mucus, and died four hours after the morning visit of the attendant medical officer, apparently
from an arrest of the respiratory function. In artieulp'moriit, his face was covered with pro-
fuse perspiration.
The following post-mortem examination was reported under my direction by Assistant
Surgeon H. D. Schmidt.*
Pott-mortem Examination. Brain and spinal marrow, blood-vessels of the dura-mater and
pia-mater of the brain congested ; the veins of the pia-mater were distended with black blood.
The space between the arachnoid and dura-mater, was filled with a serous fluid ; and in the
spinal canal, the dura-mater was so much distended by this effusion, as almost to fill up the
whole canal. By making an incision through the dura-mater, near the termination of the
spinal cord, a considerable quantity of turbid fluid escaped. After the brain and spinal-mar-
row were removed, it was found that a considerable exudation of already organized Wmph
had taken place.
The fibrinous exudation covered the entire base of the brain, embracing the upper half of
the Medulla Oblongata, Pons Varolii, with the Crura Cerebelli, Crura Cerebri, Locus Perfora-
tus, Corpora Mammillaria, Tuber Cinererum, with its Infundibulum, Substantia Perforator
Media, extending to the fissure of Sylvius on each side ; and also covering the optic tracts of
commissure.
The Pituitary Gland, appeared to be entirely free from exudation. From the Pons Varolii,
and Medulla Oblongata, the exudation extended to the Cerebellum, for the distance of half an
inch or more, at the same time completely falling up the fourth ventricle, and thus pressing
upon the roots of the Pneumogastric nerves. Tbe deposit also embraced and extended over
considerable portions of the nerves which emerge from the brain at the above mentioned point?.
From the posterior columns, and restiform bodies of the medulla oblongata, the deposit
passed also to the cerebellum, extending for some distance into the valicula, and thus cover-
ing the inferior vermiform process.
The vessels of the Ependyma of the lateral ventricles were congested, and the ventricles
themselves contained a liquid exudation, which filled up the anterior and descending horns.
The substance of the brain appeared to be of the usual consistence; the gray matter of the
surface was a little darker than usual.
The spinal marrow was almost entirely covered by the exudation, especially that portion
of it between the cervical enlargement and medulla oblongata, and from the cervical enlarge-
ment to its very termination, embracing the Cauda Equina, the thickness of the exudation
upon the posterior columns, and extending to the antero-lateral columns, as far as the antero-
lateral fissure, amounted almost to one-fourth of an inch. Over the anterior columns, with
the exception of a few places, it was not quite so thick, being about j'^th of an inch.
The dura-mater of the spinal marrow was greatly congested, amounting in some places ewn
to inflammation ; in such parts this membrane adhered slightly to the arachnoid membrane.
The vessclsof the pia-mater were also distended with blood, and the membrane itself inHnmed,
•A f«»w inoothM iKtforo llio rly^'of thi* W«r, I ap|>lii'<l to Miiri;(>oii (iniiorul Moon-, .if tin* « oiiOmIiijiIc .\iiii>. iit
JMiuary iw».s to wUpvo Atwi'taut s?tirg<«on II. J». Schmidt, from dnty in thr roii«ti|if Huniiii, aful i» .iK«.iKii Imii lo
t\vty and«»rmy command ,'fii»ikij aMritnnt In the pru**H:utlon of tho invi-Atlfnitiotm «lurh 1 liinl n»«.hi« ud duiln»: llu-
«-Qtlr^ war.
Tbto rv'iunt wm rnnt^ by Surgeon Honcrml S, P. Moorr, and Dr. Schmidt rp\ o.iwl to m*- f*ir duty, tioar tho rU«.«
cf Jaaiurj, 1WI5. Th* ill>k«aUh of Awlitant Snrgoon Srhrotdt, ns \»HI on the i«udd»'n cloi-pof tin* «ar, imrliidiHl
titrndnl or •yatematlc lalx^r..
456. Pathological Anatomy of of CerebrO'Spinal Meningitis,
And adhering to the exudation. Bj microscopical examiDatioiii it was found that the exuda-
tion corpuscleB were lodged between the fibrous bundles of which the pia-mater \t composed,
and they were also detected in the neurilemma of the spinal nerves, to a distance of one-
fourth of an inch, outside the dura-mater.
The exudation was of such consistence as to bear cutting with the scalpel,; it consisted of
exudation cells, of various forms and sizes, in their different stages of development, as they
usually present themselves under like circumstances. Many of these cells were round, or
larger, or smaller, resembling those found in liquid lymph; but the great majority of them
had already become elongated and apindle shaped, and were bound* together by a granular
amorphous substance. The exudation almost everywhere, adhered very closely to the pia-
mater, and in most places also to the arachnoid, which fact, together with the pressure of the
exudation cells, in the meshes of the pia-mater, seems to indicate that the inflammatory pro-
duct was thrown out by both membranes, but chiefly by the pia-mater.
Thorax^ Lungt and Heart. When the cavity of the chest was opened, by carefaUy removing
the sternum, and the entire cartilages of the ribs, about half a fluid drachm of a dark brown,
very viscid matter, with a greenish tint, was discovered upon the anterior mediastinum, in the
cavity of the left pleura ; some of it was also seen to adhere to the parietal portion of the
latter directly opposite, covering a space of about four inches in diameter. In the latter
situation, this material was collected in masses in some places, from which it gradually sub-
sided into a thinner layer, to be lost at the limits of the area it occupied. The substance
Appeared as if it had been splashed upon the membranes. The dark viscid matter taken from
the cavity of the pleura, was found by Dr. Schmidt, upon microscopical examination, to con-
sist of cells containing large nuclei, and of a great number of granules. The outlines of some
of the latter were dark, but the majority were pale. The cells themselves were filled with a
yellow transparent material, of a slightly greenish tint, which assumed a lighter color by the
imbibition of water into the cells. These appeared to be altered cells of the epitheliaro of the
pleura, whose typical form they had retained, notwithstanding the alteration in size. The size
of these cells varied greatly, for while some of them were as large, or not much larger than
the normal epithelial cells of the pleura, others had attained a diameter of y^^ millemetres.
with a thickness of from jJHj^ to ^\l^ millimetres. By mutual pressure they bad assumed a
somewhat polygenal form, thus resembling hepatic cells. These elements were held together
by a viscid mucus-like fluid, which under the microscope exhibited a yellowish tint. Upon
chemical examination the dark matter gave the same reaction as bile.
The lungs were collapsed — a considerable portion of the posterior surface of the inferior
lobe of the right lung, was of a dark yellow color. The rest had the natural appearance,
with the exception of some portions, where the surface was elevated by emphysema.
Heart. All the cavities of the heart were fllled with coagula of black blood, extending
through the pulmonary artery and its branches.
Abdominal Cavity. The liver was considerably enlarged, and of a slate color, and the gall-
bladder fllled with very dark and viscid bile.
The spleen was enlarged and its capsule showed traces of former inflammatory disease, by
its thickness, and fibrinous deposits of considerable size. These changes in the spleen and
liver were not, as far as could be ascertained from the symptoms and the post-mortem exami-
nation, connected with the last fatal illness, but had existed perhaps for months previously.
The j^ueral results of the preccdiiij; post-mortem examiDation (Case 556,) ooiTespi>ti«i
with those of Case 555.
In the latter case there were no fact^j to show that the slate color of the liver and the
enlargement of the spleen, were marks of malarious disease, procediog pari-passu, with
the Cerebro-Spinal Meningitis. On the contrary, the thickened state of the capsule of
the spleen indicated that the lesion was of long standing. The Georgia reserves h»d
seen considerable service, and a lar^e proportion of the men had suffered with parozjnutl
fever. It is probable, if not absolutely certain from the nature of the cells, thai the
collection of viscid matter upon the pleura, was in no way oonnected with the diseft^
which caused death.
In the preceding ctiscs, the most prominent anatomical lesions were found in the
cerebrospinal ner\ous system. In Corebro-Spinal Meningitis, the pia-mater appoan to
be the chief seat of the inflammatory action, and the exudation of coagulable lym}4i :
it would appear however, from the results of post-mortem examinations, that the ai«cK-
noid and dura-mater, and even the structures of the brain and spinal cord maj W
involved. The character and extent of the inflammatory changes, will depend in ^eat
measure upon the leni^h of the disease. In those who ha^C died suddenly lAer a sbon
Pathological Anatomy of Cerebro- Spinal Meningitis. 457
illiic8:s ut' a tew hourst, we otVeii discover nothing more tliuii an intense injection of the
]iia-iuator, and of the subHtiinec of the brain and spinal cord.
I will proceed to compare the results of the investigations ju«t recorded with those of
various other observoi-s. who have ondoavorcd to iilustrato the pathological anatomy of
this disease.
I shall make no speeial selection <»f the eases and post mortem examinations, but will
endeavor to present an accurate and unbiassed view of the pathological labors which
throw any light upon the true nature and pathology of Cerebro-Spinal Meningitis.
The results of my investigations into the history of this disease in the Confederate
Army, have been presented in the preceding and present chapter, together with full
details of the symptoms and post-mortem examinations of the individual cases reported.
Dr. W. S. Armstrong, of Atlanta, (Jeorgia. has recorded observations upon the epi-
demic of Cerebro-Spinal Meningitis, which came under his observation at Mobile, Ala.,
during the winters of 18G3-G4, and 18()4-()5.
The symptom's which characterized the cases occurring in thisepidemic. either in the for-
mative or advanced stage, were of an equally grave import. Some patients were suddenly
attacked with coma, or stupor, so profound as to be with difficulty aroused, in the midst of
good health, after taking a hearty meal, or after a full day's work ; in other cases, vertigo,
l^aio in the head and cervical region, extendiu'^ along thcBpine, with lassitude and apprehen-
>ioa of impending danger, were observed ; in others, again, chilly sensations at intervals
«>f two or three hours, with cold extremities. ft>llowed by exacerbations of heat, flushed
face and increased pulse. IMirium, more or less wild, with a disposition forcibly to
leave the bed or room, was, in the outset, a prominent symptom. The condition of the
pulse was variable, usually ranging from ninety to one hundred, hardly reaching one
hundred and ten, unless just before the termination in death; on the other hand, it
occasionally sank to forty or fifty beat.-? per minute. Vomiting of bile and constipa-
lioD were usually, in the beginning, |>rominent symptonl^ ; the tongue was furred, and
as the disorder advanced, the teeth became coated with sordes. The urine was high
colored, scanty and often retained ; at other times, especially towards the cloee, it
passed involuntarily. Intolerance of light and sound, when present, appeared at the
I'arly part of the attack — the least ray of light being sufficient to cause spasmodic
closure of the eves and inten.se suffering: walking across the floor was excessiveW
auDoyiDg to the sufl'erer ; deafness and a genei-al indifference to surrounding objects,
was occasionally noticed.
The most prominent, and almost univn>ul ^»ymptoms. were puin in the head and
neck, accompanied by a tetanic rigidity of the cervical muscles, and of the large exten-
ts >r muscles of the Imck. This trouble, slight at flrst, increased, until the head was
drawn back on the shoulders, and no ordinary degree of force used by the attondants
eiiuld overcome it. The muscles of the back an«l lower extremities were occasionally so
iiiucfa involved as to produce complete opisthotonos. In connection whh this condition,
]iaraJyBis of the muscles of the face was sometimes present, as exhibited in depression
of the lower jaw, and protiusion of the cheeks and lips in expiration. Involuntary
twitchings of the mu.«cles. and want of prehonsicm also, often existed — the patient being
unable to drink without assistance. Strabismus, in one or both eyes, was met with in
-i jveral cases. The appearance of the pui>ils was not always the same, in the majority
of cases being dilated ; .sometimes one w<m o mtracted and the other dihited, and occa-
^ionaUy both were contracted. Pelirium was not common in the latter stages, before
coma set in, and was then of a low. muttering character. When coma came on, which
was usually about the fourth or fifth day, the pupils became widely dilated, the pulse
iHHtame more full, but it was never, as fur im the observation of Dr. Armstrong extended,
of a bounding character, as in coma from apoplexy. After the appearance of coma,
iiiv<iluntary dischaigt^ from the bowels an<l bladder were of fre<juent occurrence. Ster-
torous breathing was rarely pres4Mit, and until the fuma beeatne profound, the patient
cf)Dtinually t(»^sed from side to .side in bed, < ariying the ha^ds to t)ie head as if in
•^eat pain. ,\nother very common suuptom wos the hypeitest^csJa i>f tlie vb<>l^*
458 Pathological Anatomy of Cerebrospinal Meningitis.
nervouH 8y8tcm , pressure uj>oii tlie extrcuiitic^s, slight moving of tbe feet, or bend-
ing the toeS; causing the patient to cry out with pain. This exaltation of seuBibil-
itj did not appear at first, but towards the latter part of the attack. While ver-
tigo, pain in the head, intolerance of light and sound, deafness, stupor, ezalt4?d sensi-
bility of the nervous system, delirium and coma, were the usual symptoms by whicli
this epidemic was characterized, yet there were a few cases of an intermittent
type, accompanied by high fever, with pain in the head. Under the use of Qninia,
these symptoms would yield for a few days, and convalescence seemed to be established.
A recurrence of these symptoms would take place two or three times, when those mon*
violent, as extreme pain in the head and neck, rigidity of the muscles, etc., would
supervene, and declare unmistakably the formidable nature of the disease. The dura-
tion of the disease was variable, in some cases it destroyed life fn from twenty-four to
forty-eight hours ; but from five to eight days was the usual time ; during the winter
of 1863-64, it proved fatal sooner than in the following winter, — a few of the last
cases having lived from ten to fifteen days. The prognosis in this epidemic was unfa-
forable — in fact it was regarded as a death warrant to the subject ; and Dr. Armstrong,
notwithstanding that his observations were extensive among the soldiers and negn)
laborers in and around Mobile, never saw a single case recover. In the two varieties
of cases which were observed, a treatment, supposed most likely to succeed, was
adopted : in the one where [there was much febrile excitement, anti-phlogistics wen*
used ; in the other, and opposite condition, a supporting plan was followed, and both
alike with unfavorable results. Quinia in large doses, in previous epidemics, was found
to relieve a certain percentage of those attacked, but in this it failed in doses from a
f«cniple to a drachm. So likewise, Calomel was found to act beneficially in other epi-
demics, but at Mobile it failed even after its specific effects were produced.
Dr. Armstrong recorded four cases, illustrating the nature of this epidemic, and iu
the following cases post-mortem examinations were perfomied, which revealed th('
characteristic lesions of the brain and spinal cord :
CaseooT: Cerebro- Spinal Meningitis, Effusion of Lj^mph on Cerrhntm^ and at the
base of the Brain ^ Servni in lateral Vcntrichs.
Private, H. C, age about 40 years, was admitted into hospital, January ITth, Im>:». :^oiu<
six weeks ago, was exposed to the weather both daj and night in camp ; be had three chilU.
the last of which was congestive, and four days bad elapsed before consciousne^t returoeil.
In a short time he was convalescent. This history was obtained from a comrade. ]*re?eiu
condition : he complains of soreness from head to foot, has frequent rigors, and isi unable tu
express himself clearly ; pulse 90 ; tongue moist and furred ; bowels constipated. Orderc<t
a Cathartic and Qninia. Jaonary 18. — Pulse U3; bowels moved five times from purgative -
skin has been warm since admission ; pain in the head and neck. Ordered blisier to back u!
head and neck, repeat Quinia.
January 19th. — Pulse 90 ; pupils contracted : unconsciousness ; head drawn back from
contraction of muscles ; breathes through his mouth ; raises his hand to his head, as if in
pain. To have a blister to tbe head.
January 20tb. — No improvement; pulse lOO and weak. To have Cathartic aud Spirit.^ ot
Wine at short intervals. January 21st.— Pulse 120, and very feeble ; skin warm and per^^pif-
ing; comatose; opisthotonos, which began to develop itself yesterday, is very uiarkril
Died at II P.M.
Autopsy Janaary 22d.— Tbe anterior two-thirds of cerebrum superiorly, are covered w^u.
an adventitious deposit of lymph, of a greenish color, forming adhesions between th«*
arachnoid and pia-mater, and following the latter, as it dips down into tbe convolutions ot
the brain. The under surface of the anterior lobes, optic commissure, crura cerebri and pon«
varolii, are the seat of exudation also. ^Some pus {•« found at the medulla oblongata. Th;«
exudation is from one to two lines in thickness. The lateral ventricles are distended witU
effusion, which being drawn off, pus is found at the bottom. The choroid plexus is inject rj
The brain shows on section, no indications of softening, but appears henltby.
Case fh'iS : Cevfhro- Spinal Meningitis. Effusion of Strum in Arachnoid Sjtn/^ ,
deposits of lymph on Brain and Spinal Cord,
f fivate, \V'. V. V — Was admitted Janunrv KUli. i'^'.;.'*, at lo \ v.— Tulsr x. : vLin mtu* ^
pathological Anatomy of Cerebro^ Spinal Meningitis, 459
and cool ; pupils natural ; restless ; stares at his attendants ; makes no reply to questions
addressed to bim ; his cheeks protrude at each expiration. To have Quinia. January 20tb.
— Pulse 98 ; bad several actions on bowels; pupils responded to light feebly; both wrists
swollen and painful to the touch : notices what is going on in the room, but seems to be
unable to articulate. Continue treatment. January 21st. — His mind is clearer ; answers
some questions rationally ; for the iirst time be protrudes his tongue, which is furred and red i
took some nourishment ; bowels acted freely last night ; picks at the bed clothes ; has passed
no urine since yesterday ; one pint is drawn off. Continue treatment.
January 23d — Has been perspiring freely lor several hours ; delirious ; head is drawn back,
and to the right side; has had rigors since yesterday, at intervals; no action on bowels ;
drew off two pints of urine ; ordered head to be shaved, and a blister applied ; also a purga-
tive. 3 p. M. — Pulse 140 and irregular; pupils contracted slightly; right eye drawn out-
wards ; comatose ; no action on bowels ; drew tfff one pint of urine. Died in the early part
of the night.
Autopsy, January 23d — Effusiou of serum in the arachnoid cavity ; membranes very much
injected ; light deposit of lymph between the pia-mater and arachnoid, on the anterior sur-
face of the cerebrum, superiorly, eztensivel}' upon and around the optic commissure, over
the entire cerebellum, crura cerebri, pons varolii, medulla oblongata, and spinal cord through-
out its whole extent to the cauda equina. The nerves arising from the cord, on both sides,
were enveloped with this deposit also. At several points along the cord it had degenerated
into pus. The abdominal viscera, upon examination, appeared normal. The lungs were
healthy also. The right side of the heart was distended with blood, and the right ventricle,
contained a clot of fibrin, occupying half of its chamber.
Oiw5r)0 : Cerehro' Spinal Meningitis ; Deposit of Lymph^- Superiorly and ai the
Base of the Brain ; Serum in Arachnoid Cavity.
Private, W. J. H., was admitted on the 8th of December, 1864. The surgeon of his regi-
ment informed Dr. Armstrong, that he was found in bed this morning, apparently suffering
from congestive fever ; the attack came on while asleep. At the present time, he is uncon-
scious; pulse 119; pupils dilated ; skin cool. To have stimulants/ internally, and frictions
with Spirits of Turpentine ; also blister to head and spine.
December 9th. — Pulse 100, and increased in volume, but still not strong; teeth covered
with sordes. Continue treatment. December lOih.-^Pulse 120, and feeble; skin cool; coma-
tose ; died at 10 a. k.
Autopsy; December 11th .-^Effusion in the arachnoid space. On the anterior surface of
cerebrum superiorly, there is a deposit of adventitious membrane, also in its under surface
as far back as the crura-cerebri. The cerebellum below, has a deposit of the characteristic
greenish yellow appearance.
Dr. Armstrong also recorded a case of Cerebro-Spinal MeQingitis, in which the
diaeame made its appearance, whilst the patient was suffering from severe ptyalysm, from
Calomel, and proved fatal on the sixth day. Atlanta Medical and Surgical Journal',
X. 8., June, 1866, vol. vii, No. 4, pp. 145-151.
Dr. W. C. Moore, of Atlanta, Ga., recorded four cases of Cerebro-Spinal Meningitis,
one of which recovered, an<l three ternrmatetl fatally. The following is the record of
ih*» three fatal ca«<e8.
Cusf. /iaO : Cerehro-Spimd Meningitis,
Was admitted at Ocmulgee Hospital, Macon, Georgia, September 4th, 1864. He was under
tbe charge of a medical officer, who informed Dr. Moore, that he was received into the hospital
three days before, with congestive chill. Malignant, intermittent and remittent fever, was
then prevailing at Macon, among those not acclimated. The subject was a stout mulatto mau,
aged 30; apparently of a sanguine temperament, lie died three days after, with all the
symptoms of Cerebro-Spinal Meningitis.
AtUopty ttco hours aftrr death. Arachnoid congested with effusion of plastic lymph over
middle lobe, left hemisphere of tbe cerebrum, causing adhe«ions. Pia-mater greatly congested,
«>specially between the convolutions ; half pint of serum was discharged from ventricles, and
folds of arachnoid. Dura-mater congested at and near lateral and cavernous sinuses. 8ub-
ftance of brain apparently healthy.
Cane 501 : Cerebro-Spinal Meningitis.
Admitted and treate(| at same hospital as tbe preceding case. Subject, a stout black man,
4G0 Pathological Anatomy of Cerebro- Spinal Meningitis,
tkged abuut 25, of a strumous diathcsL't. Six days- prior to death, was admitted in hospiti!
with double pneumonia. lie continued to grow worse for three days, when he commenced to
complain of severe pain in the head, and in twelve hours was delirious, with great hyper-
esthesia, in which condition he died.
AtUopayfour hourt after death. All the membranes of the brain congested with effusion <.f
serum in yentricles, and between folds of arachnoid. (Jreai congestion of lateral sinuses tot
base of brain^ Both lungs in a state of red hepatization, except upper lobef, pleuritic adlie-
sions with effusion in pleural cavity.
CifSf 'Ifi.J : (\ rcbro-Spinaf Mrniiujitis.
Negro girl, aged ft, of strumous diathesis; was first attacked witli iutlucn/.a. in three orfuir
days became delirious ; on the fifth day after the supervention of the head symptoms, complex
rigidity of cervical and dorsal muscles, pupils of both eyes dihitcd, eyes injected, tcmperalur.
of skin normal. * "* Died on the eleventh day, after tlie supervention of Cerebro-Spvna
Meningitis. The following appearances are reported as having been disclosed by a po<'-
mortem examination: All the membranes of the brain congested, but no effusion of plA^t •
lymph. Found pus and serura in ventricles. Substance of brain softened, with partial «li--
organization about the base. (Atlanta .Medical and Suriricul .lournal, January, iHi;;. p;«
491-407.
Dr. Saofurd B. Hunt, in his report uu Cercbro-Spiiial MLMiiiigitis, publUhcil \\\ ili
Sanitary Menwira of t/ie United Sfftfes S'lfiitnty/ Commission, states as the re>iilt ol
his examiDation o^ sixty -eight autop.viics, rccnnlcMl by (\)nftMl5M*ate ami Federal Surireon-
and American Phvsieians. that ;
'• All present positive evidence, not only tliat the meninges of ilic brain and spiual cor
were the locations of inflammatory disease, but that the sufferers died from that inttammation
and not from any intercurrent or other disease, which might cloud the discussion of tin
essential cause of death*. The appearances in other organs were mostly negative. As mo^
of the patients had been healthy up to the hour when headache and nape-pain appeared, «••
we find their organs after death exhibiting trivial signs of disease." (.\fter accepting the resui!-
of the autopsy previously recorded, case 5.'»5, as conclusive, as to tlic pathology of Cerebri-
Spinal Meningitis, V. S. Sanitary Commission Medical .Memoirs, pp. :iy3-:iOH, l>r Hunt con
tinues) : " We are inclined, therefore, to believe that the only essential pathological conditio
of epidemic Cerebro>Spinal Meningitis, is that which its name indicates — an iufl immatioo (.-'
the meninges, especially of the pia-mater, and that it does not differ in character or tenden^ir
from ordinary phlegmasise of serous membranes. Its locality gives it a fatal tendency d*
seen in pleuritis, but not much exceeding that of peritonial inflammation.* *' Sontt^ty M^m^'**^'
Mrth'ml, pp. .381-01.
Dr. J. Baxter I'phaiu, in liis account ol* an epidemic of (V*rebro-Spinal Meninpti*.
which occurred in the winter and spring of 18(>2 and ISlio, in the camps in and aroun>i
Newbem, North Carolina, describes the usmU symptonis indicating legions uf th-
cerebro-spiDal nervous systcni; as sudden attacks of pain in the back part of the hea<l
excruciating pain in the back and limbs, sometimes accompanied with rigors, and n^u^.
and vomiting ; a peculiar stiffness of the muscles of the face and neck, convulsions an<:
coma. Post-mortem examinations revealed opalescence of the arachnoid, increas^xt
vascularity of the membranes of the brain and spinal cord ; large increase of serum in
the sub-arachnoid space, and in the ventricles oflimes turbid and mixed with floceii.-
of lymph, with an abundant exudation of thick yellowish, apparently semi-organ txei
lymph at the base of the brain and in the medulla oblongata. Dr. Upham also reconi-
passive congestions of the lungs, with spots of discolonttion on the lungs, reflemblinL*
pulmonary apoplexy ; in some cases, diffluent lymph in the pericardium, in othc^
instances sero-purulent fluids holding in suspension masses of flocculent lymph. In
some cases deposits of lymph were also noticed in the endo-cardium and the knee joinr^
(Boston Medical and Surgical Journal, xxxvii, April (>th, 18G3, It), 34, etc)
I have condensed the histories and post-mortem appearances of the following fiA«^ ••
oases of Cerebro-Spinal Meningitis, from the report of Charles M. Clarke, M. I)., ln»
Surgeon 39th Dl. Vol. Infantry, and Chief Opi»rating Surgeon 24th Army Coq-
(^Chicago Medical Journal, vol. xxiv. No. 1, Jan.. iStlT, pp. 1-14, pp. 103-1 12^.
Pathological Anatomy of Cerebrospinal Meningitis. -461
Citse '}^Ui : Cerebro- Spinal Meningitis.
Benjamin Hynian, private, Company F, lltb West Virginia Regiment; American by birth ;
age 20 years ; admitted to hospital February 20ih, 180.'>. On his admission he was iiercely
delirioos. Pnlse 80. Vomited a large quantity of dajk green matter. Pupils of eyes
slightly contracted ; tongue moist and normal ; skin dry and cold ; hands and feet of a pur-
pliih color; urine scant and high colored; bowels costive, 'ilst. Restless and wild ; no
sleep; pulse 120, very small and irregular. During ihc day petechia; of various sizes com-
menced to appear, chiefly on fore-arms and legs. No considerable change, with the excep-
tion of increasing weakness, until February 20th, when the pupils became dilated, and there
was a disposition to cough. The oelirium at this moment was more mild ; there was a dis-
position to sleep, and the patient lay comparatively quiet on his bed.
March 1st. Continues apparently tite same; dimness of virion noticed ; he is also becom-
ing quite deaf.
Patient gradually grew weaker, and died March 5th, !> o'cluek v. m. Just previous to deatli,
pustules of acne broke out, most ai>parcnt about the face and neck, but some few crops were
»ecn on the fore-arms and legs.
Sfclio Ciidav.y 17 hourt afUr dfath. — liigor mortis well marked. Body not emaciated.
Head. — Dara-mater greatly injected with both arterial and venous blood, and somewhat
thickened. The arachnoid had a shiny, opalescent look, and was noticeably thickened at
about the middle and on cither side of the longitudinal fissure. Pia-mMcr covered with
patches of lymph and pus. On removal of brain from the skull, a large quantity of serum,
ttaky with pus, escaped from the membranes of the spinal cord, and when the brain was
placed on the table, by slight ]iressurc, some six ounces of serum escaped from the mem-
branes and third ventricle. In the spinal canal, three drachms of thick, yellow pus were
found. Over the pons-varolii, optic tract, and the base of the cerebellum, a thick layer of
laudable pus was seen, and some was also found between the lobes of the cerebellum. The
lateral ventricle contained three drachms of flaky serum ; and in the anterior and posterior
corana there was one drachm of thick pus. The right lateral ventricle presented the same
appearance. Pus was also found in the third and fourth ventricles. The brain tissue,
especially the cervical portion of both cerebrum and cerebellum, was soft and puUaceous,
and easily broken down. The medullary portion did not seem greatly altered, although the
pnncta vasealos awere more numerous than usual.
Thoracic and abdominal organs healthy.
C'^'W ofj.!f : O'l'ehrO' Spinal Mr.ningitis.
Gaines Reynolds; private, Co. I, Hi>th N. V. Vols.; American; age 21 ycar^. Admitted to
hospital February 7th, 1865.
Was taken sick January 17tb, with chill, severe paiu in head, back, extremities, and the
surface of the body generally. Vomiting was an early and persistent symptom. A threaten-
ing collapse occurred about twelve hours from the seizure, in which the patient came near
dying. His eyes were red at first and discharged a little ; his hearing was very acute, and
the least noise disturbed him greatly. There was great sluggishness in urinating. The head
was disposed to be retracted. He was rational all the time, no convulsions, no delirium, no
paralysis. The pains gradually left him, and he was sent to the field hospital. The symp-
toms of this man on entering the hospital, were : iSlight pyrexia; eyes injected, looking like
a rase of acute conjunctivitis; pupils greatly enlarged; very restless in body, but evinced
no derangement of mind. He was not disposed to talk, but would answer questions correctly
nnd fully. Xo delirium throughout. The heat about the head was greatly increased, and
there was a constant desire to keep the head thrown back. This case passed on until G o'clock
f. H., Feb. 13ih, when he died comatose.
Sttlio Cadav,^ 2 p. m., Feb. 14th. — Uead. Kxtensive congestion of dura-mater ; some slight
adbetions between dura-mater and arachnoid. Od reaching the pia-mater, there was quite a
flow of floccalent serum, and on each side of the longitudinal sinus there was an extensive
eiudation of pus. On removing the brain, there was found, at the time the section was made,
a considerable flow from the meninges. There was a thick layer of pus over the whole of the
raednlla oblongata. On opening the membrane near the optic commissure, there were found
two ounces of serum.
The lateral ventricles and the fourth ventricle were full of turbid serum. The brain ti.Hsne
was softened throughout its whole extent. Upon examination of the cervical portion of the
t'ord, some pus was fonnd, and the cord was softened.
Ckfti, — Left lung covered with false membrane, and firmly bound down posteriorly ; pleura
also firmly adherent to pericardium. Left lung full of tubercular deposit, chiefly of the
miliary character. Right lung normal. Oreat hypertrophy of the pericardium on the left
482 Pathological Anatomy of of Cerebrospinal Meningitis.
r^ide : no effusion within it. There was an abnormal fattr deposit over the whole anterior
surface of the heart.
Abdomen. — Substance of liver cnj^orged ; gall-bladder greatly distended : spleen and kid-
neys normal.
Intutihei. — Omentum thickened and somewhat diseased ; transverse colon contracted to
one-third its normal si7.e ; ileum congested and coat thin, but not ulcerated. A lumbricoiii
worm was found in the jejunum. Descending colon thickened and constricted ; bladder di«-
tended with urine.
Citsc -Ifio : CercbrO' Spinal MeningitU.
Emory Wnlls; private, Company D., 39ih 111. Vols; American; aged 25 years. Ratered
hospital at Richmond, Va., June l4th, 180:i, at 10 o'clock a. m. Comatose; pupils largeb
dilated; tongue moist, but not furred ; pulse 140 to 150; great disposition to tonic spasms ;
head thrown back ; no apparent delirium; eyes congested and suffused; respiration re ry
rapid. This man was apparently well the day before his entrance into the hospital. No
change occurred, and he died at 11:30 p. m., June l.'ah, 13 hours and 30 minutes after hi?
entrance.
Autoptj/y 12 M., June IGth, 1865. — Body emaciated, rigor mortis not well marked.
IfeaH. — Dura-mater greatly injected with blood ; no special change in arachnoid^ but over
the entire surface of the pia-mater there was a large deposit of thick, yellowish pus. Braia
tissue proper infiltrated, greatly congested, and very much softened — a slight stream of waur
could wash it away. Pus found distributed in patches over the whole brain and in its sulci,
beneath the pia-mater. The right and left ventricles were full of bloody serum, which wa£
Haky with pus corpuscles. The third and fourth rentricles presented the same appearance
Medulla oblongata and cervical portion of spinal cord infiltrated with pns.
Thorscic and abdominal organs normal, with exception of kidneys, which showed a litt'.*
fatty degeneration.
Cn»i''*W: O'lebi'O' Spinal MeningitU,
Dennis Brow ; private. Company M, 4th Mass. Gav.; age 26. Entered hospital Fcbrnarv
19th, 1865. When first seen, was suffering with severe chill; delirious; considerable
dyspnoea, tongue red, with brown centre ; pupils natural ; skin dry and moist; pnlse icarcely
perceptible at wrist, very frequent and irregular, 120 to 150 ; eyes red and highly injccie«i
diarrhoea, with involuntary discharges from bowels ; [respiration short and quick ; respira-
tory murmur clear and distinct ; no cough ; very restless, with some tenderness over abdo-
men ; purpura hemorrhagica appeared in spots over the whole surface of the body ; iodit-
]iosed to talk, and it is with great difficulty that he can be made to answer questions. Is
good health up to the day before entering hospital.
February 20th, a. m. — Wandering of mind, and disposition to talk ; increase of purpura
over body ; breathing more natural ; pulse imperceptible at wrist ; skin cool and moi«t -
pupils enlarged ; vomiting ; diarrhoea ; whole surface of skin hypersesthetic. The patient
gradually sank, and died at 2:30 o'clock p. m.
AtUvpsy, 11 o'clock a. m., February 21st, 1865. — Brain, The dura-mater presented petechia*
discoloration over the whole of the superior surface, considerable effusion beneath it ; arach-
noid somewhat thickened ; pia-mater extensively congested with blood, with here aod there
a thick purplish streak, pus found in patches over the whole extent, lateral ▼entricles foil oi
bloody serum ; thick pus over optic tract; the cerebellum presented the same appearancM
there was pus in the fourth veutricle and in the spinal canal.
CSeat. — Right lung closely adherent to the pleura costalis ; and the pleura of both laodr^
presents a mottled appearance; lung tissue healthy; pericardium greatly congested aci
spotted, with thick, purple streaks of congestion. Pericardium contained two oubcos t*.'
serum, largely mixed with pus. The heart itself is mottled, and is covered with large palche«
uf pus, especially arouud the sinuses of the aorta. The muscular tissue of the heart con-
densed, cutting like cartilage. Left ventricle contained one ounce of thin, bloodj scruB.
Ahdomtn. — The liver, both externally and internally presents patches of congosiioa : a
small ulcer was found in the left lobe ; substance of liver greatly softened. Spleen oae-thi' i
liirger than normal. Kidneys normal.
InUMium. — The whole irart was covered with the hipmorrhagic spots : otherwise heaJiti
BlHiMer full of urine.
Cinif '1**7 : Cnrhro- Spinal Meningitis,
William .Statit'ii : Auieiican ; age 21 : private. Company C, 15th West Va. Vols. Adntttew
February 2i!th, 18tjr>. High fever; pulse 120; delirious and restless ; pupils coatrartei
Pathological Anatomy of Cerebro^ Spinal Memngitis. 403
couM not be aroused or made to understand anythiog ; petechial spots present over the
whole snrface of the bodj, but most marked over the chest and abdomen ; vomiting^ every half
hour. Died comatose at 12 o'clock noon, February 28th, without any change in the symp*
toms.
Autoptyf \0 o'clock p. M., March Ist, 1865. — Body emaciated; rigor-mortis well marked.
finun. — The pia-mater over the whole surface of the cerebrum, was covered with a thick
deposition of lymph and pus ; brain tissue greatly congested ; base of brain covered in patches
with thick yellow pus ; pons-varolii covered with pus in large quantity ; brain softened
throughout its whole extent, and the convolutions were full of serum and pus ; one drachm
of bloody serum was found in each lateral ventricle; the membranes of the cord were infil-
trated with pus, and some two ounces were collected in a cup, on section of the cord, through
the lower cervical region.
Cdsc i'ttlS : C^^rebrO' Spinal Mcnlngitiif.
F. M. Dwyre ; American ; aged 23 ; private, Company C. 0th Maine Vols. Admitted .Ian.
l.'ith. 1865, with high fever; pulse 120; severe pain in the back; tongue brown and dry ;
«ome epistaxis ; urine high colored, with thick phosphatic deposit ; eyes injected ; pupils con-
tracted ; the skin has a jaundiced appearance, and is dry and harsh. Soon after admission,
he became delirious, and so continued, without lucid intervals, until death.
For the first three days there was retention of urine. The catheter was used. The urine
was high colored; had a strong smell, and deposited a heavy reddish sediment. On the
fourth day the urine became more free, of light color, and passed naturally. The pupils
remained contracted ; some trismus manifest; also difficulty in deglutition.
Fifth day, some Jactitation manifest ; hearing and vision very obtuse. Patient continued
in about the same state, with no other very noticeable symptoms, until January 24th, when
he died.
Autopnff 12 o'clock M., 25th, 1865. — Body greatly emaciated, and the skin very yellow
throughout its whole extent.
Dura-maier intensely congested; pia-nmter covered with lymph, with here and there
patches of pui ; the cerebrum was considerably softened in places; large quantities of pus
were found covering the base of the cerebellum, medulla oblongata, and optic tract ; the
membranes of the cord were distended with serum, some pus also was found in them ; the
cerebellum was very soft, almost disorganized; the lateral ventricles were full of bloody
ftorum, with pus in cornua.
t'Aefl.^^Right lung healthy; left lung found to be undergoing hepatization ; lymph was
found inffused over its entire surface, and adhesions had commenced forming to the pleura
costalii.
Heart. — Some effusion in the pericardium, organ otherwise normal.
.I^dbmen.— Liver fully one^third larger than natural, and its entire surface beautifully mot-
tled ; the gall-bladder was quite empty ; substance of liver quite soft, and one could easily
push the linger through it. Spleen and kidneys normal. Stomach and transverse colon
inflated, Three inches of the ileum intussuscepted in one place, and four inches in another
The vessels of the whole intestinal tract were injected ; glands of the mesentery enlarged.
Otf^ ^00 : Cfii'ebro- Spina f Meningitis.
Josbna J. Drake; private, Company H, 199th Regiment Pa. Vols.; age 2G years ; American ;
entered hospital January I8tb, 1865. Tongue dry and brown ; teeth encrusted with sordei^ ;
pulte fnll and rapid, 120 in the minute; gteat subsultus tendinum ; furious delirium ; nii
occasional cough ; pupils natural ; urine scant and high colored.
The enbsaltns increased, with tendency to opisthotonos ; some epistaxis : eyes injectt-d :
coms-llke ttnpor.
Died January 2 2d, 8 o'clock p. u.
Auiapijf^ I o'clock, p. M., January, 23d, I860.
Body emaciated; some discoloration about abdomen ; the toes of each loot look blue.
Hrain. — Dnra-mater highly engorged ; some effusion between pia-mater and bruin; slight
exudation of the lymph over the cerebrum and some effusion in the convolutions, with cor-
puscles of pus : substance of cerebrum softened ; no effusion found in the ventricle? : ineni-
branes of the cord distended with serum; cerebellum covered with lymph : slight exudation
ii( puf, over optic tract.
Che$$, — Upper lobe of left Juog consolidated; lower lobe highly conjrestcil. Uij^ht Iimi-
shows a highly inflamed candilioWi nud on cutting into the ii3:«nc, pus exudes. llnut—Vi'Yx-
cordiam contains eiglit ounces of ?crum ; slight pericarditis nij^nilo^t : blond in ventricl<>
ooi coagulated ; the right auric.lo rf\i\t(\iu3 a fihrinon.s riot.
40 4 Pathological Anatomy of Cerebro^ Spinal Meningitis.
Ahdome/i. — Liver enlarged one-third ; gall-bladder enormously distended: substance uf
liver apparently healthy; spleen weighs 1.J lbs.; kidney, normal.
Cftsf r*7lf : O'i'f'fji'O'Sfnnul Mnttngitix.
Ptiviil Small, Co. I, Mth Maine Vols., agfcd Hi yeais, American. Admilled to hospital, 'lini.
iNth, 180.'). On admission there was well marked eruption of rubeola; skin hot and dr> :
pulse I '.Mi : some cough ; tongue red and dry, especially through the centre ; pupils natural
no delirium ; respiration very hurried, and patient seemed stupid. Tlia patient became 4cii>
rious ; pupils contracted ; tendency to opisthotonos. Died January 23d, at 9:30 a. m.
Sfctio Cadav^ 12 o'clock. M., January ^2:{d. Body extremely emaciated — rigor mortis wcil
marked.
/frfftn.— Membranes engorged with blood. Extensive deposition of lymph beneath arachnoid
membrane. iSulci of brain tilled with serum. Six drachms of serum found in left lateral
ventricle ; none found in the right. Cerebellum and pons varolii softened. Some pus found
around optic commissure. Pons varolii softened.
Chett, — Four ounces of serum in the pleural cavity. Lower lobe of right lung hepatized
false membrane is forming over posterior surfoce. On cutting into the substance of the loHcr
lobe, pus exudes. Left lung normal. //^r/rr.^Pericardium contains four onnces of scniui -
heart atrophied and the muscular tissue much softened.
Ahfhtmn. — Liver one-third larger than normal, and greatly congested. Intussusception ul
Ileum for eight inche.«, old in character. Whole intestinal tract engorged with blood.
Ctiat ./// ; CcrelfrO' Spinal MfningitU,
Arthur ^milh, aged 2::, pri\ate, Co. (r, 7th Conn. Vols., admitted to hospital, January tUh.
l^»;4 ; taken with a chill followed bv fever; complained of soreness throughout hia whole
body: vomiting. No change in symptoms, until just prior to death, when he became deli-
rious : pupils dilated and had tonic f]insm. Died comatose, 12 M., January 22d.
'Stcho Otf/ar, 4 p. ii., January 22(1. Body slightly emaciated; rigor mortis, but wtri!
marked.
Brain — Dura^mater distended uith serum; substance of brain greatly congested with
exudation of pus over its whole surface ; cerebrum softened ; cerebellum so very soft, tbat
a stream of water disorganized it : no effusion withiu ventricles; spinal cord congested.
Cfiett. — Right lung normal ; left lung congested; and lymph in upper lobe. Pericardium
contained eight ounces of serum.
Abdomen. — Liver hypertrophied : gall-bladder distended. Small iutestinei congested
patches of ulceration found throujrhout the whole tract of the ileum. Spleen somewhat
enlarged.
(us( '*].*: Oi'f'hroSjtuta/ MfningitU.
John Hughes, private, Co. <r. \:>H\\\ New York Vols., American, aged 24 ; admitted to bo>-
pital, December 22d, 18G4. Face flushed; respiration hurried, and talks incoherently — caoni>i
be roused; pulse 120 aud full: skin hot and dry: tongue slightly coated: fome disposition
to tonic spasm.
December 2:>d, coniinu<-s ulK'on^cious : some .opuFm of flexor muscles. :?emi-delirium
Pupil of eye contracted. Died December 24th, 10 a. m.
Striio Cadav. Seventeen hours after death. Body slightly emaciated, but presenti gu% i
muscular development. Uinror-mortis well marked.
Head. — Membranes of Brain present a highly congested appearance; Cerebellum inlenaiix
congested, and at its base the 9ub-araehnoid cavity was covered with a soft yellow exa<lalio.i
presenting every appearance of purulent matter. Cerebellum softened. On removal of th.
brain, a turbid stream, to the amount of one and a half fluidounces, wai found in the occ-
pital fossa, containing pus corpuscles. On the left hemisphere and near the IonfitaJ«i.a
^inus. the arachnoid ^\ns raised from the brain, by a collection of turbid tferun, about .';--
in «|uantity. Kach of the lateral ventricles contained one fluidrachm of milky tiruu.
.^^ftiual conl conl:e^te^^ tiironuhout its length, but no exudations were apparent.
Thoracic auM abdomin.ii organ.^ normal.
Of a*- 'il'i : (rit'fn'o-Sptuaf Mfntngifitt.
11. Manshur, pri\utc,Co. K, 2d X. H. Vol. Infantry. Admitted to hospital, Pebniaiy ••!
1H(;:>. This man bad been sick in the Regimental llospital, two weekg prior to hia rntr}
had chill followed by fever; al«o had diarrhcea. On day of bit admifaion, was delirici*.
j»upiN contracted; tontruc ijry and di-«colored ; respiration hurried^ pulte 13".
Pathologieal Anatomy of Cerebrospinal Meningitis. 4(i5
Februarj 7tti. CoDtiuues delirious; appears to be sufferiog greatly; bad several inToIun-
tary dejections from bowels during night ; some spasms of the muscles and disposition lu
trismus. February 9th. Pupils of eyes dilated; well marked tetanic spasm ; cannot force
open the jaws — well marked opisthotonos : abdominal muscles hard and rigid ; some appear-
ance of petechias over body ; hands and feet purplish in color, and very cold.
February loth. Died this morning.
Autopty 10 kourt nftrr death. — lirain. The membranes of the Brain, appeared distended and
puffed up with Huid, except the pia-mater, which was closely adherent to the brain; convo-
iittioos of the cerebrum were covered with lymph, and in some places there were large
patches of pus ; f,::;i. of flaky scrum found in each of the lateral ventricles; substance of
l>rain, much softened. The cerebellum presented the same appearances. Membranes of the
cord, inliitrAted with serum. Patches of ulceration in Ileum.
Cast' Jr.J ; CrrrbrO'Sffinai MeninyttU,
J. K. Spelieu, private, Co. II, ll)9ih Penn. VoU., AmericaUf aged 26 years ; admitted to
hospital, February 26th. High fever ; pulse 120 ; tongue furred ; skin dry and hot; respiration
hurried with considerable cough ; eyes injected and watery. February 27th. Complains of
tome pain and jactitation. March 1st, died.
Autopsy 24 hourt after death. — Body emaciated. Uij^ar-moriis well marked.
Brain.'^Otk removal of the brain from the skull, fgii. of serum was found in tlie occipital
fossa. Great effusion beneath the arachnoid, which was considerably thickened; pia-mater
rxtensively congested with both arterial and venous blood ; lymph found in abundance orer
whole surface of cerebrum and cerebellum, but no pus. No i$erum found in the ventricles ;
lirain tissue very much softened. Spinal cord not examined.
Clke$t. — Lungs normal; considerable effusion found within the pericardium; right auricle
nnd ventricle filled with coagulated blood ; large fibrinous clot found in left ventricle.
Liver and kidneys normal, t'^plocn atrophied. Intestines congested and spotted.
\\. \V. Uean, pri^ute, Co. C, iuh Maine Vols.: American: age 24. Admitted January 16th,
1^05, with what was considered a well marked eruption of rubrola ; slight fever; pulse 98;
severe cough with pneumonic expectoration ; severe pain in right side and considerable dysp-
iiira ; tongue red and dry. Kruption had mado its appearance three days before his
entrance. Made complaint of severe pain in his head and down his back. Pupils of eyes
natuml. The man became delirious on the third day after his entrance, and continued insen-
»ible until the date of death, which occurred January 3 1 si, at 3:30 o'clock, a. m.
Autopty, 2 o'clock, u. Body greatly emaciated ; ngor-mortis well marked.
Brain. — Membrane greatly congested and distended with serum ; arachnoid thickened :
pAtcbes of lympb over surface of cerebrum anil cerebellum. No effusion found in the ven-
tricles; some little pn.« found over tract of optic commissure. Membranes of cord infiltrated.
Brain tissue soflened.
C^«l.<— rpper lobe, and portion of lower lobe hepati/.ed (ri-d).
AMomen^-^XMtx enlarged one-third, and mottled.
Ciut M (j : Ci irh ro' Sjf iu u I Mtn utt/ it /n.
James Kirkpairick, ]irivate: Co. C. Ut'.Mh Pa. Vols. .\<Imltted to hospital January I'oih,
i«65. Died February 2d, 1865.
.4 u/o/iy, 12 hours after deaths /V/a/n.— Considerable effusion under the membranes, and
'lura-mater in a high state of congestion : arachnoid thickened. Over right hemisphere of
rerebrnm there was a large deposition of lymph ; pia-mafer thickened, and adherent in loroe
^•lacea to the brain. Pus found in .^mall quantities over optic tract. Ventriclet partly illed.
with turbid serum ; brain tissue Foft and cavity broken down ; spinal cord much congested.
Cf/Hf Jrr .• Orfbro-Spinal Mcningith.
.*^amuel Farnsworth, private, Co. H. loth N. H. VoU. Admitted to hospital, December
J I St, with marked fever ; pulse 120; tongue thickly coated : skin dry and burning; difficult
respiration : diarrha*a with involuntary discbarges ; severe cough with free expectoration :
* onMaot pain ascribed to back of head and neck; urine voided freely, but of da/k color.
T>ecember 22d, more obtuse, pupils natural ; pain in back rontinnes; discharges from bowels
• fiiite frequent ; December 24th, died ccmatose, at 10 p. m.
Stfdo Cadar., twelve hours after denlh. //rrr/N.^-Dura-mater intensely congested, with
pome effusion beneath it: some l^mph deposited over the lobes of the cerebellnyi ; vcptriclrs
dry; brain tissue poftened : meninges of cord congested throagli cervical regfo9«
Ckftt. — Double Pleuro-Fneumonin. Heart nonnal. Liver, splftv ffd l^idneys ^efltb^v
.t9
466 Pathological Anatomy of of Cerebro^ Spinal Meningitis.
Luring the months of January. February and March. 18G5. a large uumber of
cases came under the notioe of Surgeon Chns. >I. (^lark. at the field hospitnl of the
24th Army Corps, which at that time was located near Hutching s Run, Viiginui.
The troops were comfortably quartered about three miles back from Varioa Landin^:.
on the James River. The country was high and rolling, and heavily timbered. th«
soil being a mixture of sand and clay. The season had been remarkably wet, aod
intermittent, remittent and " ft/pho malarial " fevers were prevailing extensively. Thv
men were also greatly and continuously exposed to fatigue and excitement, there bciD<:
almost constant calls upon them for duty in reconnoitering, constructing carth-workh.
and fighting the enemy ; and Surgeon Clark considered that it was but fair to presume,
that the continual hardship and excitement that the men endured, and withal, coiisiderint:
that they were in a decidedly miasmatic region, were conditions that undoubtedly pre-
disposed to attacks of the malady. The enlargement of the liver and spleen, and the
ulcerations of the ileum in some eases, recorded by Surgeon Clark, without doubt,
hhould be referred to the preceding causes and not to the disease under consideration
It is a matter of regret that a full record of the previous history in each of the
forgoing cases (563-577), was not obtained, as it would not only have enhanced the
interest attaching to them, but would have been more satisfactory in a practical point
of view ; the results of post-mortem examinations, however, of those eases, folly aD<l
unequivocally sustain the view that Cerebro-Spinal Meningitis is essentially an inflam-
niatoiT disease of the Cerebro-Spinal Nervous System, and that it may be accomponietl
by inflammation of the Peri-Canlium) Pleura and Lungs.
In the epidepiic of Cerebro-Spinal Meningitis, which prevailed in Philadelpliia.
during the months of Pecembei^, 1866, and January, February and March, 1^67.
according to Dr. W. H. H. Githens, who recorded careful obsen^ations upon the casi^
treated in the Philadelphia Blockley Hospital, the post-mortem examinations reveale<l
!«imilar lesions of jthe Cerebro-Spinal System. The membranes of the brain were c<>u
gested, and serum was effused in large quantity in the sub-arachnoidean spaces, at the
bise of the brain, and within the membranes of the spinal cord. Fibrin waa deposit<^l
along the margins of the longitudinal fissure of the brain, about the commissuiv of the
optic nerve ; in fact, freely over all the base of the brain ; and in one case, it could hn
separated in masses weighing fVom three to five grains, from where it hnd firmly glued
together the two surfaces of the fissure of Sylvius.
The quantity of this deposit of fibrin, its color, eousihtence and strength of attach
meut, were influenced chiefly by two cases observed during life. In »ome ca^es, when-
the inflammatory symptoms were of an active character, as shown by the congestion ot
the face and eyes, the character of the pulse, and the violence of the delirium, death
occurred early ; and an autopsy showed little or no deposit of solid lymph, but a hr^-
<[uantity of serum, and in one case pus, in all the serous cavities connected with thv
brain and spinal cord, with turgesoence of all the vessels of the pia-mater and nervoa»
substance. If on the other hand, death did not intervene so quickly, there weri:
deposits of fibrin, becoming larger, firmer, and more adherent, in proportion to th«^
grade of inflammatory action, and the time allowed for its coagulation. These depoMt«>
were of the same character as those found in the cavity of the abdomen after an
attack of peritonitis. No particular lesion of the cord itself was noticed, the mem^
branes were congested, and there were sevei-al deposits of fibrin about the roots of the
spinal nerves.
The following cases with post-mortem cxaminatiou!<. arc selected from the report v\
Dr. Githens, in addition to those previously recorded.
Case 678 : CtrehrO'S^nnal Meningitis.
Julia Dilen, ait. 21 ; W4S delivered at full time, JaDuary 'J5ih, 1867, by meaus of forccp^^
Jan aary 30th. An eruption of an erythematous nature, appeared on chest with distio-*
•mption of a darker hue on abdomen and thififhs. Vonuting. no pain or tenderness lanerk .
hack, or stiffness of to.u^icleR anywhere
PtUh^^lj^dal Ahaiomy ^ CerebnhSpinal Memngitis,
After midaight, a hasmorrhage of about sttte^jflfei^lyt from uteraa occurred.
46?
Januarj Slst, ▲. m Vomiting and continued thirst, piPlsa 130, quick and weak.
10 p.m. Signs of cerebral disturbdnce; pain in the head with general uneasinessi and
▼omiting.
Febrnarj Ist, 10 ▲. m- Semi-comatose; evidently suffering great pain; face darkly con-
gested; pupils contracted. Pulse quick, 150 beats per minute. Later in the morning, coma
deepened; the eyes became dry and rolled upwards ; patient comatose, could not be aroused.
Died at 3 p. m.
Po^l'MorUm Examnation, eighteen hours after denth. Effusion of serum within the mem-
branes of the brain and spinal cord; deposit of fibrin along longitudinal fissure; congestion
of the membriines of the brain itself; softening of the brain substance, effusion of serum in
pericardial sack. Effusion of about sixteen ounces of serum into cavity of abdomen, with
deposit of coagulated fibrin in small amount on uterus, ovaries and descending colon.
Case 579 : Cerehro- Spinal MeningitU.
Mary Peterson, set. 45; temperate; first noticed in a collapse of three hours duration »
Symptoms were congestion of eyes ; the right pupil contracted, the left dilated and appeared
to dilate more under the influence of light. Coma, with labored stertorous respiration ;
apparently some headache ; constipation ; no eruption. Pulse 180, very feeble. Skin hot and
dry. Died in forty-three houn,
Pctl-mortem Examination^ revealed very extensive deposits of fibrin at base of brain; about
five ounces of serum at base of brain; spinal cord congested, with deposit of fibrin beneath
the arachnoid. A small quantity of pus around the cord in the cervical region.
Case 580 : Cerehro- Spinal Meningitis.
Wm. McAllister, 8Bt. 63 ; temperate; slight headache ; alternate constipation and diarrhcea ;
muscular pains in limbs and back ; slight petechial eruption ; brown, dry tongUe ; pulse could
not be felt; complicated with double pneumonia. Death on ninth day. Brain lesions were
very marked : large masses of closely adherent lymph at base of brain and on medulla
oblongata.
Caw 581 : Cerehro- Spinal Meningitis,
Anoie Fitzgerald, set. 20; temperate. Coma; severe headache; muscular pains in back;
pain on pressure, over dorsal vertebrae ; conjunctiva slightly congested ; thirst intense, tongue
dry, brown and furred in centre, but clear at edges ; pulse 90 to 160 ; skin hot and dry just
before death. Disease complicated by pre-existing pneumonia of right side ; puerperal convul-
sions. Death by exhaustion on eighth day. Autopsy revealed large quantities of tough
adherent lymph ; deposits at base of brain.
Case h82 : Cerehro- Sjnnal Meningitis,
Henry Saxe, set. 68. Muttering delirium ; intense headache ; constipation ; muscular pains
in neck, limbs and back ; slight opisthotonos ; petechial eruption ; marked congestion of con-
junctiva; severe thirst ; tongue dry and brown; pulse 90 to 120. Died on eighth day.
Large deposits of fibrin at base of brain. Am. Jour. .Med. Sci., July 18(i7, pp. 17, 34.
Dr. S. J. Webber, ia hi.«i Ensay on Cerebro-Spinal Meningitis, which received the
Boylston Medical Prize. (Boston Medical and Surgical Journal, vol. zxv., pp. 59, 61,)
affirms tbat the results of all careful observers, have shown that the principal lesions
are found in the brain and spinal cord ; the morbid changes varying from slight
increase of the number of hemorrhagic points, to extensive softening of the brain,
with effusion of lymph and pus beneath the membranes.
**Tfae Arachnoid in some instances has lost its transparency and become opaque, especially
at the vertex. Beneath it may h(* seen the vessels of the pia-mater enj^orged with blood, tbat
membrane being congested. Between the membranes, there is often an effusion of lymph,
pus or serous fluid, which may also extend into the ventricles distending them ; lymph occurs
more frequently than serum, and is deposited upon the under surface of the cerebrum, cere-
bellum, poos varolii and medulla oblongata, rather than upon their upper surface, and follows
the sulci, nerves and vessels, imbedding them in its substance. Pus is often found in the same
aituatioos. The lymph is of a greenish or greenish-yellow color, varying in amount from a
thin layer, to nearly half an inch in thickness and in consistency from a dense, almost fibrous
membrane, to a soft, sem>Uqatd substance. The veins and sinuses of the brain, «re distended
with dark fluid blood. The substance of the brsin may be natural in appearance, but it is
468 Pathological Anatomy of Cerehro^Spinat Meningitis,
often congested, the bsmorrhagic points being increased in numbers ; it maj be tofUned
almost to a pnB*like liquid. * * The same congested appearance and softening aro found
in the cerebellum, pons rarolii, and medulla oblongata. * * In the spine, a similar condi-
tion inaT exist, the membranes being congested, there being an elTn Rion of «ernm, Wmph or
pus, and the sub'stance of the cord being congested or softened.
The following is a very briof statement of the results recorded by Professor J. S.
JjBwell^ of Clucago, in his report on Cerebro-Spinal Meningitis, based upon the repon.«
of 200 Autqwies which he had collected from various sources. In this disease, post-
mortem changes are almost never absent from the ccrebro-spinal cavity. Both *hp
cranial and spinal dura-mater, almost never present well-marked evidences of structural
change, or of a firm exudation, on the free or serous surface. The arachnot<l also ha«
not often presented evidence of disease. The pia-matcr. unlik<» the two cerebro-spinal
investments, just mentioned, has almost uniformly presented the appearance of disesijc.
Rarely cases have occurred in which no evidence of structural change or exudation have
been observed, but not one where congestion has been absent. The rule is that it present*
the most indubitable evidences of disease. Thosp parts of it most frequently diseast**!.
are at the base of the brain, about the optic commissures : the interpeduncular 8pA>-<-
behind the ooumissttre ; the pons varolii and medulla oblong^Ua ; under surface of th<-
eerebelhim, and along the fissure of Sylvius. After this, the surface of the hemisphen-*'
is the most constant seat of disease. The congestion and the exudation when present
may occur uniformly over the surface, or, as invariably happens with the latter, is foun»l
along the course of the sinuses and blood-vessels, and large fis.sures. and along the ii«
suros between the convolutions. Next, the pia-raater of the cervical fwrtion of the c^ml
is mosi fircqucntly diseased, and of thus part and the medulla, the pnntevinr an^ptxt i-
most often diseased. M. Levy found in 4^ cjlm(\«. the postcricu part ulmo.Ht exclu'*ivc)\
siffected in 27 cases.
Xext in order, the lumbar and lower part of the dorsal roirioii;* are mast ufu»n affect*.**!
and lastly, the pia-matcr of the dorsal portion seems most frequently to be free fnun
disease. Sometimes cases have «iccurrcd in which the npiiial «»lomcnt has Imhmi ali«*cii!
but the converse has been exceedingly rare.
Except in some cases, where death has owurrcd either with i^xtrcni.^ suddenness. **'
in cases of long standing, there is found to be an incroas.' oi' the sulmrachnoid flni*l
(Specially at the base of the brain. In recent cases, it consists in a i-iuiple incrt-a*
of the natural fluid, but in most cases, it is colored yellowisli or nnldish by piu* or bloo«l
and varies in quantity from a few drachms to sc»venil ouiu-i^. It xaru^ in oon^i'<trn*
and has been found by M. Forget almast gelatinous.
Except in those cases where death seems to have taken placi; tov> soon to |H?ruiit of sm<-1i
a result, there has been found more or less plastic oxudatiiMi, most abundant, in sut'«
places as have been already indicated. Tl may be a soft, friable, pus-like layer, or ba^
a gelatinous con8isten<x;, or be firmer yet as coagulated fibrin ; it may bt! nearly tran-
parent, or have a grayish color, or may have a white or crciiniy appearance, or bo tinp-*'
various hues, by either pus or blood, or both. It m-iv v^nor a largi*. extent of surfiM*
or be disseminated in patches here and there. But it is always when present, fouu 1
along the course of the large vessels and the fissures, and about the roots of the nervc^
whether the cranial or spinal, the posterior roots of the latter in particular. It is, wh«».
present, on the surface of the pia-mater, but may be iiitiltrat>ed into it« fltructttnL\ •••
beneath it into the nervous substance for a short distance. It varies in thictncs^, fn •»
a mere film to a line or two, or more. Its consistence depends much t>n the dnniti "*
of the case, being most so, in cases which have some duration.
The ventricles of the brain have generally been observed, with more than the oomn'
quantity of fluid in them ; occasionally, the quantity has seemed to be normal. Il hi«
been fottod to vary from a small increase to several ounces, and in a case reported \>\
Dr. Reading, the quantity was so great the ventricles were raptured. M. Toudo^ su«
in 44 cases examined at Htrasbourg, 2(5 in which the ventricles were distended ; and u
44 cases examined by M. Levy, at Val de Grace, 18 presented distended ventrich-?.
RUhological Anatomy of CerehrO' Spinal Meningitis. 469
Xtemeyer mentions a case, where the ventrioles contained as much as six ounces of fluid.
The ventricular walls have heen found softened, and Allen npeak.s o? havin^^ seen ecchy-
moeed spots in them.
The Nervous substance in the majority of cases has boeu reported healthy ; occa-
sionally it has been seen paler than natural, more frequently it has beea seen congested
in various parts and degrees. M. Levy found in 44 cases injection of the nervous sub-
stanee, 9 times. SoJUning has occasionally been reported in chronic cases; Niemeyer
records it in 2 cases out of 15. One of those cases wa^ of 40 days standing, and
i>xhibited cheesy metamorphosis.
The spinal cord, is sometimes congested and softened.
No characteristic or uniform lesions have been observed in the lunp;s, heart, and
abdominal viscera. Report on (Vrobro -Spinal Mcninp:itis, rhieaj?o Medical Examiner.
ikitober 1866, pp. 609, 617.
As early as 1806, Drs. Danidson and Maun, tound adhesions of the cerebral mem-
braoes, in two out of five dissections, or *-a fluid resembling pus, both over the cere-
brum and ocrcboUum." In all the cases the encephalic veins were turgid with blood.
Drs. Thomas Welsh, James Jackson and John C. Warren, in their elaborate report
to the Massachusetts Medical Society, recognized the important distinction between the
appearances in two classes of cases ; in those which are fatal within the space of twelve
hours from the invasion, there is only excessive congestion of the large blood-vessels,
but in those which perish at a later period, they discovered other lesions which they
described as " more conspicuous in proportion to the duration of the disease." They
proceed to observe : ''The tunica arachuoides and the pia-matcr arc remarkably altereil
in appearance by the efl'usion of an opaque substance between them, which may bo
<*alled coogulable lymph or semi-pumlcnt lymph. This substance is frequently of tlu*
yellowish color of pus, with a consistency between the tenacity of lymph and the fluidity
of pus. At other times we see it possessed of the aspect of well characterized lymph.
The membranes at the ba.sc presiut the sanio appearances as at the vertex of the
brain. * ''
Dr. Joseph A. (jrallup, in his ** Sketches of Epidemical DLse:u»cs in the State of
Vermont, published in Boston, 1815,*' gives an accurate account of Ccrebro-Spinal
Meningitis under the name of Spotted Fever, and devotas an entire section to the
appearances after dea4h and on dissection. Dr. Gallup appears to have been fully
acquainted with the characteristic lesions ; thus he says :
** The blood -yesiels iQ the brain, more especially the veins, are very turgid. The small
vessels are lajected with red blood, which in a state of health are destitute of it. The mem-
braaes of the brain exhibit dilTereDt degrees of iDflammatioii, according to the term of sickness
and degree of local affection In the brain. Signs of iufiammation are discoverable in almost
the whole of the brain ; the dura-mater adheres more strongly than natural to the cranium ;
also the brain beneath often adheres to its meninges. .\n increase of serou^ fluid is often diit-
corered between the membranes, and the ventricles are more or less filled with the same, as
in hydrocephalus. The anterior and inferior parts of the brain cTliibit the greatest marks of
violence, and everywhere a remarkable pressure in the veins."
Dr. Gallup records the histories and Post-Mortems of several cases, illustrating fully
the symptoms, and the characteristic lesions of the Cerebrospinal System in this
disease, which at that time was called iSpotted Fever. He quotes a case from Dr.
Bowen of Reading, to show, ^* that actual inflammation exists in the head even to the
.^suppurative process.'' He describes the characteristic efl'usion of the pia-mater in sev-
eral cases, and calls it pus.' — Sketches of Kpidemic Diseases, in the State of Vermont,
etc., pp. 236-243.
After careful examination of the work of Dr. Hale on ** Spotte<l Fever," I 6nd that
* This Goramittea was appointed by the Counsellors of the Massachusetts Medical Society,
March 27tb, 1810, and their Report is given in the Massachusetts Medical Communicationi,
Vol. 2, Boston, 1813.
4?0 Pathologieat Anatomy of Cerehro^Spincd Meningitis.
this author had made no post-mortem examination himself, and appears to have been
iprnorant of the results obtained by other observers.
Dr. Job Wilson, in his lArork, published at Boston in 1815, not only describes the
nervous derangement observed during life, but also gives drawings representing the
appearances found afler death, in the brain and appendages.
Brs. North, Woodward, Fish and Miner,' all directed, in their observations upon
Spotted Fever published about this time, attention to the nervous disturbances, th^
persistent dilatation or contraction of the pupils of the eyes, various disturbances of
vision, drawing back of head, clonic spasms of the muscles of the neck, pain and rigidity
of the muscles, numbness or total insensibility and paralysis in various parts of the
lx)dy, .shifting pains and spa.<«nis, ansc^thesia and paralysis, and hypersesthesia of varioQ^
parts, blindness. deafnes.s. loss of sense of taste, spasmodic deglutition, and paralysis ot'
the pharnyx. The last named author, afler giving a case which he describes as stupi*!
iis a block, unconsciou.<% of any impressions on either of the senses, and so coDvnbe<l
that it rer]uired three or four men to hold him on his bed ; with eyes open and roUe^t
back so as to hide the colored part, and with teeth firmly clinched as in looked-jaw, and
with face, arms and legs, and body literally covered with spots : Dr. Miner remarks.
*' Spotted fever appears to have its scat and throne in the brain, to belong nosologicallj
to the passive phlegmasia;.''
Dr. 8. Ames, of Montgomery, Alabama, appears to have been the first author in thl«
(*ountry, who after an interval of thirty years accurately investigated and described the
symptoms and anatomical lesions of Cerebro-Spinal Meningitis. The admirable paper
of this careful and accomplished medical observer, embraced an account of eighty-five
cases, sixty-four of which were subjected to a r^ular analysis. According to Dr. Anie5.
250 cases occurred during the winter and spring of 1848, ip the town of Montgomen'.
Alabama, which had a population of about four thousand.
Dr. Ames considered the term Cerebro-Spinal Meningitis, not strictly applicable to
the epidemic described by him ; the symptoms and morbid anatomy of the malignant
forms especially, showing that the substance of the brain, if not the spinal marrow, wnf
almost invariably involved. He believed that there were good reasons for supposing
that the same was the case in the epidemic form of the disease, as it occurred in France-
Thus M. M. Toudes and Forget, mention the existence of hypereemia of the brain, in
every instance in which the condition of that organ is noticed. While the occasiooai
(observation of one of the products of inflammation, via : softening, and in all the fatal
cases the occurrence of symptoms, such as abnormal sensibility and muscular moti<m<*
delirium, coma, &c., which, being observed in a disease having a constaot excess of fibrin
in the blood, may be considered as unequivocal evidence of inflammation of the nerrou*
substance — at least, so long as there is no proof that simple meningitis can prodo(>'
them. The symptoms indicating serious and undoubted lesions of the brain and spinal
<H)rd, as described by Dr. Ames, were of the most unequivocal character — oepbal«#rii-
(some described the pain in the head as a continual, painful roaring, others as a fulaef*
and tightness, a.s thouiih a band were tightly drawn around the haul, or as if the ft^n-
liead, crown or sid<f«, were being crushed inwards ; a greater number described it »•
darting and thn)bbing, frequent shooting through the head from behind forwards, an*!
from side to side with a violence causing the patient to cry out); giddineas in the fir^
few hours of the attack ; injected conjunctivae, with glittering, wateiy eyes ; the pupil*
were dilated in seven out of forty-one cases, in the others they were either ooDtri<^<^l
or natural, in three cases they were insensible to light from coma, and in two wtth«mt
loss of con.Hciou.snes.< : double vision occurred in six cases, photophobia in six osne*. 'n
a number of others the ordinary light was disagreeable ; in one patient, the tense *'^
smell was lost in one nostril, in some cases there was spontaneous deafness, and io oin
case the deafness occurred three times on the second day, each time lasting about thrw
hmirs, with intermis.«<ion.s of about the same duration; stupor, amoimtiDg generanj t**
profound coma, which di<l not remit in the eases which proved rapidly fiital, but wbi«*k
in other cu.<«es alternated with delirium, and in favorable cases with lucid iot«mli
Pathologieal Anatomy of Cerebro- Spinal Meningitis, 471
tunic ooutraction of the U)u.scle8 of the back and neck, tonic 8pajjui» of the muscles )
and in some patients tremors, twitch in gs and perpetual motions of the limbs, in some
caaea trismus, in a few opisthotonos^ but in the majority the extremities of the spine
were thrown backwards till it was bent like a bow constituting opisthotonos ; general
convulsions in a number of cases; strabismus occurred in nine cases, an incomplete
{landysis of the right eyelid occurred in one case, and of one entiiH3 side of the body in
another ; pain in the' muscles in various parts of the body along the whole length of
tlie spine, and in the muscles and joints of the extremities, in some patients'; this pain
was of the acutest kind, and there was such a general morbid sensibility that the slightest
touch would make the patient start with a general spasm and scream out with pain ;
pressure applied to the cervical portion of the spine produced pain in the head, frequently
darting to the forehead, eyes and temples.
Dr. Ames drew up his account of the anatomical dutravter of this disease, fn.»ni
notes taken in eleven cases, and the following summary presents a general view of the'
results obtained by this observer.
Brain, — ^The dura-mater was the seat of abnormal vascularity in two eases. The
pia-mater exhibited abnormal vascularity in every case. The vessels carrying the con-
volntions were uniformly red, numerous, and large in size ; in several instances, many
of them were a line, or even more in diameter. In different subjects, spots of red
rechymosis were observed on the lateral walls of the third ventricle, the anterior wall
tif the fourth, and in the posterior horn of the left lateral ventricle. They were also
M'cn, in several cases, on the upper surface of the hemispheres, and on the cerebellum.
On cutting into the substance of the brain, besides the red points commonly present in
i-ases of congestion and inflammation, there was invariably found an infinite number of
red vessels containing, sometimes fluid, at others, coagulated blood. The gray and
Hhite matter had a pink color, dependent upon the presence of vessels that were sepa-
rately visible — which, although never entirely absent, occupied different parts in different
•subjects. In two cases, the medulla oblongata was spotted interiorly with dark, ecchy-
uiosed spots. Of these alterations, the cerebellum partook, to a greater or less extent,
in every case. Circumscribed portions of the membrane were softened in seven cases ;
in four, on the exterior of the brain, including the inferior surface of the cerebellum ;
and in the remaining three, on the floor of the lateral ventricle.
In nine cases, the brain itself was softened ; in seven, in some parts of the hemis-
phere, chiefly in the cortical ; in three, in the medulla oblongata and pons varolii ; in
five, in the fornix and septum lucidum ; in one, in the walls of th3 third ventricle and
(«anal leading to the fourth : in another, in the corpus callosum and outer semi-circular
rim of the lefl corpus striatum ; in another, in the optic nerves, the commissure, and
the tractus opticus ; in two cases, in the cms cerebri, and in one, in the cerebellum.
In ten cases, there was an efiiosion of yellowish colored matter, showing, under the
uiicroaoope, an abundance ot pus and lymph globules, on some portion of the membranes
uovering the exterior surface of the brain. In the greater number, enough of the
effiised lymph was coagulated to give some cohesiveness to the morbid product, but not
enoQgh to give it the appearance of an organized membrane. In appearance, it resem-
bled a very loose coagulum of fibrin. It was always found beneath the arachnoid mem-
brane In some cases it was so diffused as to look like a coating of cream upon the
hemitfpherea ; in others, it was confined, on the convex surface of the hemispheres, to
the oourse of the large vessels between the convolutions. At the base of the brain it
was in the greatest quantity, and met with most frequently about the optic commissure
— it was here never absent. In one case, it was found only at this point — the intersti-
i*ea of the convolutions being occupied by a serous fluid, eontainin<r a few pus globules.
It was found also on the corpora quadrigemina, the medullu oblon^rata, and around tho
third pair of nerves, where they penetrate the arachnoid membrane. Tho extorior sur-
faoe of the cerebellum was frequently the seat of this deposit.
In nine cases, there was an efiVision of fluid into the arachnoid euviiy. With this
eflfiuioD, ptw plobnlcs were mixed, i^i VJxrious proportions, in ever}' case in which tlipy
472 Pathological Anatomy of Cerebro^Spinal Memngitis.
were sought. la two cases, the eflusion consisted chiefly of pus, mixed with blood
globules. In the case in which the arachnoid membrane had a pink color, a small
quantity of the effused fluid, after standing a short time, coagulated. In one case, the
cranial portion of the arachnoid was the scat of an organised false membrane.
In four cases, a morbid effusion was found in the lateral ventridea; in one, it con-
Minted of a cream-colored layer, semi-fluid, on a part of the left corpus striatum ; in
another, there was about a drachm of a greenish colored pus ; in another, serum turbid
from flocculi ; and in another, serum mixed with pus and blood.
Concrete fibrin was found in the vessels of the brain, in several cases, via : In the
internal carotids, in two ; in the basilar artery, in one, and in the longitudinal sinus and
veins leading to it, in one ; the concretion in this case occupied the entire length of the
lai'ge vessel, and extended from it into the small vessels, from which threads of fibrin
were drawn out to the length of several inches.
Spmal Cord. — So far as the spinal cord was examined, the lesions, generally speak-
ing, were the same as those met with in the brain, in the same cases. The intenaf
vascularity of the pia-mater was always present, but the lympho-purulent deposit, and
the injection of the cord proper, were Ici^s common than in the brain.
In other parts of the body no Ic.^^ions were observed, which seemed to be other than
accidental, or particularly worthy of note, except those found in the digestive tube, and
mesenteric glands.
The abdomen was opened in fivt* lascs ; in all of them the mucous membrane of tht*
Htomach and ileum was reddened, thickened and softened to a greater or less extent. In
four cases, there were lesions of the agminatcd, solitary and mesenteric glands. The
solitary and agminatcd glands were enlarged, and in one case ulcerated. The meson*
teric glands were enlarged, red, and in one case softened.
Blood — The blood taken from the arm, and, by cups, from the back of the netl,
presented some physical characters, which, considering the nature of the disease, were
peculiar, and sufficiently uniform to assist in the diagnosis of some equivocal cases. It
coagulated with great rapidity. The seiTim Koparated from it very slowly, and in ^mall
(|uantity. Its color was generally bright — in a few cases nearly approaching to that o(
arterial blood ; it was seldom buffed ; in thirty-seven cases in which ita appearance w«.«^
noted, it was buffed in only four. The blood, an analysis of which is given below, wa>
taken, early in the disease, from the aim, and was the firet bleeding in each case. The
first was from a laboring man, thirty-five years old ; the second from a boy of twcJTt^
years old, while comatose, and the two others from stout women, between thirty ami
thirty-five.
roMPOMTloN OF IHK MMi(»l» IN (KKKDItO-MMNAl. MKN]NOlTl!<.
Specific Gravity of Defibriuated blood 1053.50
'» " Serum 1020.
Water TeT.SY
Solid Contents .232.17
Fibrin.. «,... 6.40
CorpuBcles 140.29
Solid Residue of Serum 85.31
New Orleans Medical and Surgical Journal, November, 1848, Vol. v. No. iii, pp.
295-328.
In those eu.scs of (Vrebro-Spiual MoniDgitis in which death occurs suddenly, aritkia
a nhort period aHer the first manifestations of nervous derangement, no marked lesoa
of the cerebro-spinal nervous system is found, beyond congestion. The ahseiiee of ike
deposit of lymph, and of the unetjuivocal marks of inflammation in the oei«faaro-^i»l
axis, led to many erroneous speculations, with reference to the nature of the diaaaae.
I>r. W. W. (ierhard, of l^hiladelphia, has recorded the following obaerratkm vpoa
this disease, which he teims Spotted Fever, and which he attempts to throw into tbf
ilaKS of essential fevers :
(2.)
(3.)
V-i.i
104G.
I04G.5U
1022.
1034.
813.83
796.07
tSi.Ji
186.17
203.83
212.6.i
5.20
3.64
4.5t>
112.79
123.45
12a.5<'
68.10
76.84
78.5:
PtUhologieal Anatomy of Cerebro^ Spinal Meningitis. 473
^' About the middle of last February, (1863), I was called to a case of a new form of dis-
ease.
'^ Ci.81 683. — The patient, a boj of sixteen years of age, was taken suddenly with intense
pain in the bead and back, with occasional delirinm ; there was also Tomitlng and nausea.
In the intervals of the delirium, he was dull and heavy, but able to answer questions cor-
rectly. On the second day, there was an eruption over the whole body, of spots varying in
size, from such as would be caused by the prick of a pin, to an inch or more in breadth.
These spots were of a dull red color, not in the slightest degree elevated, and rather resem-
bling eccbymoses, such as might be caused by the puncture of an insect, than a proper erup-
tion. There was no diarrhcea, moderate heat and fever ; the tongue was scarcely coated.
This patient died in four days from the attack, sinking into a state of coma.
**Cask 584. — A sister of this patient, aged twenty, was taken ill and died in twenty-six.
hours from the commencement. She was attended by Dr. Packard, and had an eruption
similar in all respects to that of the other patient during life. On examination, after death,
uo distinctive lesion was found.
'* A few days after these occurrences, 1 was called to the Falls of Schuylkill, five miles out
of the city, to see a number of cases of a new form of disease, which had excited much alarm
in the neighborhood. * * It was in that locality exceedingly fatal. * * Of the whole
number of thirty, ten terminated fatally. Tufortunately, no examination after death was
permitted in any of these cases, notwithstanding the most urgent entreaties.
" From an examination of the symptoms of a number of these cases, and comparing them
with the one I had already seen in Philadelphia, I was enabled to make out the character of
this affection, which, never having been met with before in Philadelphia, was entirely novel
to all our physicians. The disease is unknown in Europe, and is not even mentioned in the
complete work of Dr. Wood, or in any other one I believe, on the Practice of Medicine.
The only account of it to be found, is an imperfect description given of it by a number of
physicians in New England, where the disense appeared more than half a century ago, from
the year 1807 to 1B15 or 1810."
Dr. W. W. Gerhard, under the head of Anatomical LenionSj gives the report of the
ouly post-mortem examination of what he calls ^'Spotted Fever." which had come
directly ander his observation. Thus he says :
*' In a case in Montauk, a patient of Dr. Uhler, I was enabled to see the autopsy of the
whole body. The brain was found to be congested with blood, the veins containing an
unosaal quantity of it. At the base of the brain was an effusion of a few ounces of serum ;
the ventricles of the brain contained a moderate quantity of serum, but there was not a
trace of any lesion produced by inflammation."
No lesions of note were found in the other organs.
Upon this very slender foundation, viz : one post-mortem, by Dr. Packard, the sub-
ject having died in the first stages of the disease, twenty-six hours from the oommenoe-
ment, and one post-mortem witnessed by Dr. Gerhard himself, the subject being a
patient of another physician, and in a different locality, and the account, as recorded,
without any history of the case, this distinguished pathologist boldly announces the
theory, that Spotted Fever ^^ is strictly a blood disorder, unconnected with any structural
lesion/* Dr. Gerhard, by his own admission, was ignorant of the important and
thorough monograph of Ames, of Montgomery, Alabama, and he passes over the labors
of Drs. Danielson and Mann, Drs. Thomas Welsh, James Jackson and John C. War-
ren, Dr. Joseph A. Gallup, Drs. Hale, Wilson, North, Woodward, Fish and Minor,
with the remark that ^' (he only account of Spotted Fever, (Cerebro-Spinal Menin-
^tis), ^^ is to be found in an imperfect description given of it by a number of physicians
ib New England, where the disease appeared more than half a century ago, from the
year 1807 to 1815 or 1816."
Immediately afler recording the post-mortem examination above given, Dr. Gerhard
soys:
*' The anatomical leiions thus confirmed the conclusions at which I had already arrived
respecting the pathology of the disease. That is, that it is strictly a blood disorder, uncon-
nected with any structural lesion. The internal eccbymoses of blood are precisely similar
to the spotf on the skin,, and are evidently depending on the same cause. This fact estab-
lishes a wide distinction between them and those appearing in Typhn^ or Typhoid Fever^. as
well as the eruptions of the exanthemata.
474 Pathological Anatomy of Cerebrospinal Meningitis.
It requires nothing but actual observation to entirely dissipate all such Ideas. The dii-
ease belonjcs to the same class as other continued fevers, or exanthemata, but is just as dis-
tinct from Typhoid, or Typhus Ferer, as from Measles or Small-Pox. The two afreeiionsto
which it has the closest similarity, are the Petechial Typhus Fever, and some caligntst
varieties of Scarlatina.
Dr. Gerhard even goes so far as to congratulate himself in being thus able to " estab-
lish the character of another variety of febrile disorder." Thus he says :
"In the year 183G, I was first led to study the diagnostic characters of Typhus, and to Uj
down the distinctive characters separating it from Typhoid Fevers. (Am. Jour. Med. Sci.,
1837). These are now adopted by all the physicians of the French school, and by % large
number of English observers ; I could not help, therefore, regarding it a most fortunate cir-
cumstance, that accident had afforded me an occasion for establishing the characters of
another variety of febrile disorder, which, although not so common as either Typhus or
Typhoid Fever, is yet more fatal in its symptoms and course. These three varieties of fever
I regard as more distinct than many cases of Intermittent and Remittent ; although occs-
sionally the distinctive characters may be somewhat confused one with another, yet, on tbf
whole, they are so well defined, that no legitimate excuse can exist for confounding them one
with another. The diagnosis of the Spotted Fever is, however, much better defined thnn
that of Typhus and Typhoid, in all cases, fur sometimes these approach so nearly in their
symptoms, as to render the diagnosis of them very difficult." Spotted Fever occurring in (he
vicinity of Philadelphia, in the year 1863. Quarterly Summary of the Transactions of thr
College of Physicians of Philadelphia, 1862-I8G4, pp. 41-40.
Dr. Gerhard was evidently led into error as to the nature and characteristic lesions
of " Spotted Fever/' by making a hasty generalization upon the results of two po^t•
mortem examinatidns ; and it is verv evident that he had not critically examined the
authorities on the disease ; for if he had studied the " imperfect description given of it
by a number of physicians in New England/' he would have found that the theory !h>
recently and so warmly advocated by himself and other physicians of Philadelphia, that
Cerebro-Spinal Meningitis (" Spotted Fever,") is an essential fever, closely allied to
Typhus Fever, was propounded half a century ago.
Thus, Dr. E. Hale, in his History and Description of an Epidemic Fever, oummonly
called Spotted Fever, which prevailed at Gardiner, Maine, in the spring of 1814, in
his discussion of the nature of the disease, says :
''The whole inquiry, then, is into the nature and character of the fever as such.
"It has become customary to give the name T^hu* to all fevers in which prostration arid
exhaustion are prominent symptoms, however various these characters in other respects. If
this is to be regarded as a general distinction, merely expressive of the debility which accom-
panies fever, it obviously includes the disease which is described in the preceding pagrs.
But if Typhus is to be considered as a particular disease, the fever under consideration wu
not a Typhus ; for it did not exhibit the characteristic symptoms which belong to that dis-
ease. It had not the regular approach, nor the uniform appearance of Typhus. Its progre»i
was more rapid, its features more variable, its changes more abrupt, and its termination more
sudden.
"These are obviously characters of difi*erent diseases; and in practice, nothing can 1«
easier than to distinguish them. A very slight examination is sufficient to show that we hs%«
met a very different fever from that which has been so long known as Typhus.
" Yet this was a disease of debility, and of very great debility. , I am aware of the distinr*
tion between mere prostration of strength and debility. The fever under contidtrativa
exhibited them both, and in a very powerful degree. The strength was not only oppressed by
the impulse of the disease, but it was rapidly exhausted. To adopt the comparison of For-
dyce, the spring was not only overpowered, so as to prevent its action, but its elasticuy
speedily vanished under the weight which pressed upon it. * *
"I have thus applied to the epidemic under consideration, the distinction which Dr
Armstrong has adopted in his illustrations of Typhus. There are many points in which tbt
two diseases resemble each other, yet there are others, equally important, in which they ev.-
dently differ. Several of these have been mentioned. There is one other circnmstaoce «•'
difference, deserving of notice, which was omitted there, because its correctness may not p«r>
haps, be universally allowed, without further illustration. Typhus is everywhere detcnbe i
as a contagious disease, while the epidemic which has so extensively ravaged onr conntrv. :•
generally believed not to be rontagioivs.
Pathological Anatomy qf CerebrO'SpinalJfeningitis. 476
'' This ii fully mj opinion, and so generally is it established, that I should not think it ne-
cessary to say anything in its support, were it not that the contrary opinion is held by some
gentlemen for whom I have a high respect." Chapter vi, pp. 226, 227, 240.
Dr. Jewell and Dr. W. H. H. Githens, of Philadelphia, have recorded observatioDB,
which demoDStrate that the characteristic lesions of the cerebro-spinal system are pres-
ent even in those cases which terminate fatally in the first stages of the disease, and
within 48 hours after its onset.
Similar views to those advanced by Dr. Gerhard were advanced by the committee
appointed by the American Medical Association, (Trans. Med. Association, Vol. 17,
1866, pp. 33^-336), to report on " Spotted Fever," so-called.
Thos, the chairman of this committee, Dr. James J. Levick of Philadelphia, says :
'* A careful examination of the subject has left no doubt in the minds of the committee,
that the disease is essentially a ferer, not essentially an inflammation ; that local inflamma-
tions, when they do occur, are consecutire to the constitutional disturbance, are due to the
morbid condition of the blood, provoking exudation, and that their locality is determined by
Incidental circumstances. In the large majority of cases, the brain, with its appendages, is
especially involved. Next in frequency, in the order in which they are named, will be found
the exudations in the lungs, the peri, and eudo-cardium, and the synovial cavities. In some
epidemics there would seem to be a similar tendency to exudation in the lining membrane of
the larynx and pharynx."
After discussing the question of the relations of Cerebro-Spinal Meningitis with
Typhus Fever, the conclusion is reached, that :
^' Whilst holding the opinion that Spotted Fever is a distinct disease, due to a specific cause^
and having its own mode of invasion, phenomena and course, the committee wish again to
stale their conviction of its close analogy to Typhus Fever.
In the two instances reported by Dr. Levick, (Am. Jour. Med. Sci., July, 1864>
and July, 1865), one an adult female, and the other a child aged eighteen months)
l>oth of whom died in twelve and fourteen hours after the seizure, in the midst of health)
the cerebro-spinal meninges were filled with black blood. The account is imperfect)
l>ccause it is not stated whether there was opalescence or unnatural dryness of the
membranes, and the statement that ^' there were no traces of inflammation, and the
.Hubstanoe of the brain and medulla oblongata was natural in appearance and consis-
t4*nce," amounts to no more than this, that fibrinous effusion had not then taken place,
because a sufficient length of time had not elapsed. As congestion is an essential ele-
ment of inflammation, and, in fact, is its starting point, the cases of sudden death in
the first stages of Cerebro-Spinal Meningitis, in which the membranes of the cerebro-
spinal system have been found to be congested with black blood, furnish no grounds
whatever for tlie theory that the disease is an essential fever. If patients die in the first
or cougefttive stage of pneumonia, before any of the products of inflammation have
}>een formed, we are not justified by such superficial observation in classifying this
dlHcasc with the essential fevers.
Dr. J. J. Woodward, in a letter to Dr. L. Parks, quoted in the report of a Committee
of the Massachusetts Medical Socjpty, on Spotted Fever, or Cerebro-Spinal Meningitis, in
the State of Massachusetts, May, 1800, says, with reference to this disease, as observed
in the Federal armies during the civil war, 1861-1865, that
'* There were at leaat two classes of cases brought under the observation of this, the Medi-
cal Department of the army. In the first, the autopsy disclosed grave anatomical lesion of
the cerebro-spinal axis, accumulations of serum, sero-pus, pus, or tough, yellow lymph,
especially in the ventricles, about the base of the brain, and in the upper part of the spinal
canal. In the second class of catfes, no perceptible anatomical lesion in the cerebro-spinal
■ vis was observable. These two groups of cases rest upon equally reliable evidence, and are
not to be disposed of on the supposition that the latter represent merely an early stage of the
former, since it is to be remarked that both anatomical conditions appear to have been found
indifferently in protracted cases, as well as in those whish proved suddenly fatal."
476 Pathological Anatomy of Cerebro^ Spinal Meningitis.
After an extended investigation of the nature of Cerebro-Spinal Meningitis, as it
prevailed in the Confederate army and after the performance of post-mortem examina-
ttoBS, both during and subsequent to the war, in widely separated portions of the
Southern States, and after a careful examination and comparison of the labors of
American and European physicians, and of both Federal and Confederate medical offi-
cers, I have found no facts or observations to justify that portion of the statement of
Surgeon J. J. Woodward, which would imply that in a certain class of cases of Cerebro-
spinal Meningitis, however protract od, '^ no perceptible anatomical lesion in the cerebro-
spinal axis was observable/'
Until such a careful record of these cases hus been furnished, as will permit of care-
ful study and comparison, the preceding statement cannot be accepted as a basis for
generalization as to the nature of this disease.
Br. Meredith Clymer, in his chapter on Epidemic Cerebro-Spinal Meningitis, pub-
lished in the Third American Edition of " The Science and Practice of Medicine, by
William Aitken,'' pp. 492-505, holds a theory similar to that originally propounded
by Dr. Hale and others, and more recently advocated by Drs. Oerhard, Levick, Wood-
ward, and others.
As a result of his inquiries, Dr. Clymer is compelled to couclude]^that,
*^Tbe patbogenj of epidemic Cercbro-Spinal Meningitis is still unsettled. There is reasoo
to amj that it is not a Tariety of simple or ivliopathic inflammation of the membranes of the
brain and spinal-cord, nor of tjrphus fever, nor of pernicious paludal fever, but a BubstaDtive
disorder, consistent with itself in all material points, with constant symptoms, produced by a
constant cause, and hence entitled to be described and regarded as a distinct disease whose
proper nosological place is amongst general diseases, born of an external morbid poison; it mast
be owned that its pathogenic nature remains unknown."
Beyond the general statement of Dr. Woodward, Dr. Clymer adduces no facts to sus-
tain his hjTpothesis as to the nature of Cerebro-Spinal ^leningitis.
I have thus endeavored to present an unbiased account of the symptoms and patho-
logical lesions of Cerebro-Spinal Meningitis as observed by myself and other surgeons
of the Confederate Army ; and have carefully consolidated such a body of iacta and
observations, recorded by competent observers during the last half century, a.^ will
enable me to draw conclusions as to the nature of this disease.
PRACTICAL CONCLUSIONS.
Cerebro-Spinal Meningitis should be classed with the Phlegmasias and not with the
Pyrexiae.
The exciting causes, as far as known, the origin, progress and lesions and bloi"!
changes of this disease are similar to those of acute idiopathic Peritonitis, and Pleuritic*.
Pneumonia and Acute Rheumatism.
In Cerebro-Spinal Meningitis, as well as in Acute Pleuritis, Peritonitis and Pneu-
monia, the first symptoms are sudden, sharp, and grave, and the inflamed membniMA
and tissues, commence in a short time to pour out fibrinous inflammatoiy lymph, filM
with living exudation, granules and corpuscles capable of higher development aod
organization. The term ^^head Pleurisy" applied by the common people in some seotioRs
of the Southern States, to Cerebro-Spinal Meningitis, is by no means an inappropriate
term, as expressing the analogy which exists between this disease and Pleuritic infiam*
mation.
Without doubt one of the most potent causes of the variotis forma of idiopathic
inflammations is exposure to cold and the consequent arrest or perversion of the fuiicCai«
of the skin.
Inflammation of the Kidneys, Lungs and Pleura, appear to be caused not w nocb
by the degree of oold, as by sudden variations of temperature and moistare. It is wdl
known that Pneumonia often prevails as an epidemic over large tracta of oountir, aad
varies in its type, and in the rate of mortality, and in the rapidity of it4i progrem, wiik
certain atmospheric and climatic ohangt^s.
Pathohgiedl Anatomy qf Cerebro-Spinal Meningttis. 477
The term Epidemic, may with equal force be applied to Pneumonia as it prevails at
certain periods in the sub-tropioal and temperate zones of the earth.
All inflammations have been divided into two classes, vis ; extrinsic and intrinsic ;
the former term being applicable to all those cases in which an injury, either sustained
by the afiected part, or inflicted elsewhere, is the obvious cause of the morbid process ;
the latter to those inflammations which from the concealment of the cause have been
called Idiopathic. To the latter class must be referred Cerebro-Spinal Meningitis, Acute
Pleuritis, Peritonitis, Pneumonia and Nephritis and Rheumatism.
The production of Idiopathic inflammations by climatic causes and especially by sud-
den variations of temperature and moisture, may be referred to two causes.
Ist. It may be supposed that an impression received by afferent nerves distributed
to mucous or cutaneous surfaces is reflected to internal organs, causing primarily derange-
ment of nervous and vascular action ; and secondarily derangement of nutrition, secre-
tion and excretion.
2d. It may be supposed that sudden variations of temperature and moisture, may
induce the suppression or diminution of certain important excretions as those of the
rtkin and lungs, and induce the accumulation of certain noxious excrementitious matters
in the blood, which may secondarily not only alter the normal and healthy constitution
of this fluid, but also induce disturbances in the nervous supplies and oircuktion, and
nutrition of various organs. In this case the action of the external cause inducing the
alteration, perversion or suppression of certain important functions, precedes the earliest
sign of local disorder, and it is through the medium of the blood, or by the blood-ves-
sels that the offending materials act upon the nervous centres presiding over the circu-
lation and nutrition, and upon the internal organs. Inflammations thus induced have
therefore, much in common, with the so-called infective injiammationsj arising, as in the
case with puerperal peritonitis (^^^ puerperal /ever j'^) from the direct introduction into
the blood of poisonous material.
In Cerebro-Spinal Meningitis, the circulation of the pia-mater is at first accelerated
and increased, subsequently retarded and diminished, and the latter condition is
attended as in inflammation senerally of any organ or tissue, by exudation of liquor
sanguinis, and emigration of the white corpuscles (leucocytes,) from the blood through
the walls of the capilUiries. The subsequent changes, in the inflamed membranes and
textures of the Cerebro-Spinal Nervous System, all indicate increased activity of cell
life.
The local manifestations of inflammation in this disease are attended by a decided
increase of the fibrinous constituent of the blood, as in acute inflammations generally.
The tendency of those fevers, which arise from blood poisoning, as Typhoid, Typhus,
Yellow and Mdarial fever, is to degeneration and disorganization of the blood, and of
the secreting organs, and of the secretions and products peculiar to the disease.
Thus Malarial fever is characterised by a rapid destruction of the colored blood cor-
poscles, and by profound alterations in the liver and spleen, different entirely in character
from the morbid process denominated inflammation. * The malarial liver with its slate
color, with its altered bile, disint^rated blood corpuscles, flakes of altered hsematin,
and with its chemical actions so altered, that cellulose increases, and grape sugar dis-
appears, presents a very different condition from an inflamed liver.
The inflamed structures of the diseased liver, tend either to destruction and removal,
or to an alteration arising from the effusion and organization of plastic, inflammatory
lymph ; on the other hand some of the peculiar changes wrought by the malarial poison
in toe liver, may remain for months and even years. The enlarged, softened, disor-
ganised spleen, resembling a bag of soil mud, in malarial fever, is far different from the
hardened, inflamed spleen.
The deposit filling the glands of Peyer, and the Mesenteric Olands, in Typhoid fever,
although containing exudation corpuscles tends to degeneration and not to the forma-
tion of diatinct fibrous tissue, as in rlcnritis, Peritonitis and (!crebro-Spinal Meningitis.
In a word, Cerebro-Spinal Meningitin, like other acute inflammatory diseascfl, is cha-
478 Path4>logical Anatomy of CereirO'Spinal Meningitis.
»
racterized by an increase of fibrin iu the blood, and by the formation of deposits of
inflammatory lymph, capable of oi^nization into fibro-elastio tissue ; whilst on the
other hand, the true uncomplicated fevers, are characterized by a decrease of fibrin,
and the tendency to passive haemorrhages.
The ^ery diversity of the symptoms in Cer^bro-Spinal Meningitis, would iodicate
that the disease, is not due to any special poison, acting upon tbe blo«d, as in certain
well known fevers. Upon the supposition of a special blood poison, we cannot account
at all, for the fact that in some cases, the symptoms arc so obscure and light that the
nature of the disease is hardly suspected before death ; whilst in others, the disease w
announced with violent delirium and convulsions.
The diversity of the symptoms of meningitis has been well illustrated by the ca:4o.s
already presented, and especially by those recorded by Dr. P. Gcrvais Robinson, in the
paper given in the preceding chapter. The cases of Cerebro-Spinal 3Ieningitis reported
by Dr. llobinson, occurred in the same Company. The phenomena of the first ca.**e
were few, and very obscure, and not sufficient to lead to a just appreciation of their
gravity — the patient complained on the first day, of a dull constant hckdache, whieh
was persistent, and from which he could obtiun no relief; pulse not perceptibly abnor-
mal in rapidity, calibre or force ; the tongue presented no departure from a state of
health, and the only other symptom, besides the headache, which indicated disease, wa9
a constipated condition of the bowels. After the first twenty-four hours, there was
perhaps some disposition to drowsiness, from which however, the patient was easily
aroused ; there was at no time, however, delirium, and no variation in the size of tbe
pupil ; and up to the third morning there was so little apparent cause of disease, that
Surgeon Robinson was inclined to regard the complaint of the patient with suspicion a>
to his honesty. On the morning of the fifth day, he became profoundly coaudoM*,
and died the same day. An autopsy, a few hours after death, revealed an extensive
effusion of coagulated lymph between the arachnoid and pia-mater of the brain and
spinal cord *, the deposits or exudations of lymph were found in greatest quantity atM)at
the base of the brain, and around the medulla oblongata and commencement of the
cord.
On the same day that this soldier died, his brother complained of a dull and persisu>nt
headache, and in the evening became violent and suddenly delirious, and raved an4
struggled to such a degree, as to require the aid of three or four men to restrain him
The pulse was about ninety beats to the minute, full and strong, and the Uiwi !•*
closely constipated. By the use of cold water poured over the head in conMidenlM**
ciuantity, the more violent paroxysms were controlled ; and by the steady applicatiun *■(
wet cloths, in eighteen hours his delirium subsided, and reason was restorecL Th
Ixiwels were moved with Croton Oil ; and blisters applied to the nape of the neck an ;
spine, constituted the list of remedies used in this stage of the disease. Fmni iht*
time, until about the end of the fifth day, the disease appeared to be quiet and inac<i\t\
the patient being tranquil and c(uite rational, and partaking of such light noari<*hDi('i'
as could be procured in camp. During this period of intennission, there were no wry
remarka})lc symptoms of disease, the pulse being almost ((uite normal, the ton;?ie ai» t
.skin presenting no very peculiar or characteristic conditions, and perhaps the «mi!v
appreciable sign of any lesion of the brain was exhibited in the paralysis of the sen.v>r«
root of the fifth pair of ner\'es, thus destroying the sennibility of the fkce. Tow^ni*
the end of the fifth day, the functions of the optic began to be interfered with, ani
vi.sion became impaired, together with dilatation of the pupils Dr. RobinsiHi. aK •
observed, that during this interval, the sensibility of the jmrtio nuAiU^ was niii* '
inert^sed, the hearing unusually acute, and the patient's attention would U* altni(*<«^t
liy the slightent n<»ise, and he would even remark upon what was said in a h)w l^mo. a
84ime distjtnee from the bed. A part of this time, he could not re<.'«)gnize a watch li«*-«*
at his nose, nor feel a !<M;vere pinch of his cheek. From this he became much pn»e
trated. and sank into a stute of collapse, and stK)n profound coma supervening, ia tbi^
Pathological Anatomy of Cerebro- Spinal Meningitis. 471)
oonditioQ he continued until about the seventh day of disease, when death, apparently
dependent upon paralysis of the respiratory nerves, closed the scene.
The third case followed close upon the second, and was ushered in with the like
symptoms ; the patient first complaining of severe headache, succeeded by violent and
maniacal delirium, requiring physical force to restrain his muscular efforts. The courao
of this case was very similar to that of the preceding, with the exception of a varia-
tion in the paralytic phenomena. In this case, the por/ib mollis was affected intensely,
and the patient was quite deaf after the third day. The delirium subsided as readily,
and there was the same defective intermission in the march of the disease. In this
case, however, this intermittent stage was more protracted, and that of collapse followed
by ooma, came on about the sixth, and death about the ninth day of the disease.
Post-mortem examinations of the second and third cases, presented the same general
appearances as the first, except that in these, the lymph exudations were more extensive,
and there was much greater injection of the vessels of the membranes. In these two,
the lateral ventricles were filled to their greatest capacity, with fluid. The structures
of the Brain, in neither case presented any appearance of inflammation. The accu-
mulation of thick yellow lymph, was greatest at the base of the brain, the commissure
of the optic nerves, medulla oblongata, and commencement of the cord.
The hypothesis of a special poison acting through the blood upon the ganglionic cells
of the nervous system, will not explain in any satisfactory manner the preceding phe-
nomena, with their sudden and marked diversities and variations ; when we refer,
however, to the local manifestations and the pouring out of organizable lymph around
the delicate central nervous ganglia inclosed within a firm unyielding bony case, the
characters and diversity of these manifestations of nervous and muscular disturbances,
arc readily comprehended.
2, The Temperature in Cerebro-Spinal Meningitis, varies in accordance with the
extent and character of the local inflammation and the secondary results of the primary
diseased condition, and does not manifest regular and defined changes as in the essential
fevers ; it is evident, therefore, that the phenomena of Cerebro-Spinal Meningitis, arc
not to be referred to a definite poison, acting primarily upon the blood.
It is now well established that the thermometric phenomena of Yellow Fever, Inter-
mittent Fever, Snmll-Pox, Measles, Scarlatina, and Typhus and Typhoid Fevers, pre-
sent definite and charaoteristio changes, which may be represented by distinct curves.
In idiophatic inflammations, however, the temperature will vary as in the essential
fevers with the severity of the disease, but also with the stage of the inflammation,
and with the subsidence, or fresh accession of inflammatory action.
The fever accompanying acute inflammations, should be regarded as one of the results
of the inflammatory action, and not as the cause.
The fever of Cerebro-Spinal Meningitis, is the result or necessary companion of the
local inflammation in the Cerebro-Spinal Nervous System, and is not the came of the
h)cal inflammation.
I have observed many cases in which fevery viz : increased animal temperature,
increased circulation and respiration, and increased chemical change, directly resulted
from local inflammation.
The following case which I select from a large number, of a Himilar nature, observed
by myself, will illustrate the truth of the preceding proposition in a clear manner :
Gt$e 5S5 : Frost Bite, Gangrene of Both Feet; Amputation of both feet, recovery ;
the local injury and inflammation^ attended with great elevations and continual
fluctuations of temperature.
Joaqnin Gonzalles, age 42; native of Portugal; entered Ward 13, Charity Hospital, Nov.
•JHt, 1873, with Froit Bite of Both Feet. Patient gays, "that on the night of the ITlh of
Xovember, he was oi^^ l^untlag in the swamp, and that his feet were immersed in the cold
mad for several ^onrs. The plght was nnusaally cold for this latitude, (Louisiann), and the
inrfaee of the gro.i^nd was frozen. ()n the next day the feet were red and painful."
480
Pathological Anatomy of of Cerebro^Spinal Meningitis.
At the time of bis entrance, four days after exposure to the cold mud (Not. 3lBt), both
feet presented a deep purplish hue, and the toes felt cold to the touch.
The following table presents the record of the Pulse and Temperature :
DATE.
TXMPA.
M. £.
PVUK.
M.
E.
IH72.
,
Nov. 22
101.5 103.
120
108
• 2a
100.6 102.5
102
108
• 24
101.2 103.
108
•• 25
100.5 102.5
• 21;, 102. |iai.o 120
126
• 27'l01.4'lO2.
120
112
• 28,100.6 103.
llOtllG
• 20 '103. ,103.5 120,1281
•• 30
101. 1 102.5 116
112
Drc. 1
102. ,104. 112
112
•• 2
101. '104.8 112 120
• 3
102.3 102. 130,132
• 4
102.5y 105.81201 132
• r.'l04-« 100.0! 1361 102
■ 0 102. 105.O 112 114
• 7 la-./i lOTi. 1120
1
... ..
• 8 102.8 IW. 120|12Ci
• !»il03.2 103.5 126
108
• 10 102,0,105. 114
• 20 1(K). 101.5
• 21 101. 101.5
• 22 101.8 102.
I
• 23 101.8 102.
• 24 101.8 102. .
1
• 25 1101.5102.
• -29! 09.5 101.5
• 30, i«).5 101.8.
• 31 '100.7 101.
1873. 1
1
Jaq. 1
99. ■ 1
.. 2
100.4
• 3 99.
1
•• 4l 9J>.8' 1 1 1
•• 6
99.
;
1
REMABKS.
>, DATE. ! TniPA.
Half of Itolh feet including toes
blue and inclining to black.
[and inttomnia.
Complaina of groat pain in feet '
Feet gradually turning black,
eepecially about the toes. Tlie
toes are becoming dry and
shrivelled.
Patient compIalnH of conBtant
tingling and pain In the feet. ,
Sweats proftist'ly ; unable to
sleep.
Feet emit a foul odor, and have
been dressed with carbolic
ointment since Nov. 25th.
Distinct line of demarcation
fonning about middle of both
feet on the 16th day of ii\Jury. 1
Considerable discharge from ,
feet. Pulse very feeble. Pa-
tient frhivers and complains
of cold. Patient very weak. 1
, 1873.
'Jan. 7
• 9
' •• 10
•• 11
, •• 12
I •• 13
I •• 14
, •• 16
i •• 18
M. (|E.
100.2
101.
10t».
1Q1.2
101.2
102. •
101.51
99. '
100. ]
100. I
99.2
99. I
99.
PULSK.
BKMARK9
B.
98.31
Feb.
19
25 99.2 '
291 99. I 9f).2<
:«l 99. I 99.4
31 101.5; 101.
1
2
3
4
Bight foot ani|fttUled Jsu. U.
Ilad a chill at 12 ■. mi ib*
, 18th, followed by h^'f.
I Had another chill on tbt
12tb.
I,
.>
•• 6
7
•• 8
.. 9
• 10
•• 11
•• 12
• .13
•• 14
• 15
•• 16'
• 17
•• 18
Mar. 3!
• 4
• 5
•• 6
100. (101.
101.4 101.
101. 1101.4
101.4; 101.8|
101.2' 101.4
101. 101.2
101. 101-5
100. 90.
101. 101.5
101.
I \
101.5
100.
101.
102.
ioa5
101.5
101.4
102.21 101.
100.
104.
111.
101.5
103.'
104.
101.
104.
104.
104.
104.
105/)
106.
Left leg anpotatcd. Dr(*T»
ampntation, Tenpeim'e !•«■
Under the infloeiK* sf
Chlorofona, th« tespen*
ture fell In 1^ of an hour to
MP. In the e^eniDf W
same day the tevperatuv
vraa loio.
Piu borrowing nnder testtir*
and eanatng pnin
sloughing.
When this patient 'entered my ward, he was in such an exhausted and feeble state,
with rapid and feeble pulse, that it appeared almost impossible that his system ooold
possess sufficient strength to cast off the dead tissues. The treatment consasted ut
Quinine, Tincture of the Sesquichloride of Iron, nutritious diet, (beef steak, beef tea.
^^)fl boiled eggs, milk and bread,) with liberal supplies of Brandy and Port Wine. The
feet were dressed twice each day, with soft English Lint, coated with Caibolio Acid
Ointment, of the strength of one drachm of the saturated solution in Alcohol to the
ounce of Simple Cerate. Notwithstanding the excessive suffering, profuse sweats, and
the exhausting fever, induced by the, absorption of the gangrenous matters into the
blood, and the local inflammation around the dead tissues, the patient not only main-
tained his strength but slowly improved under the treatment instituted.
As soon as the line of demarcation had been established between the dead and livins:
tissues of the right foot, and the strength of the patient appeared to be sufficient to
withstand the shock, the right foot was amputated at my request by Professor Logan,
on the 11th of January. The shock of the amputation was very great and the tempe-
rdture sank down to a low figure, and the patient did not fully rally until alter the
lapse of several days. The lefb foot was amputated on the 8th of Febniary ; befofv
the operation the temperature of the axilla was 100^ F.; three quarters of an honraftrr
the amputation, the temperature was only 00^ F.; this reduction I attributed chiefly tu
the effect of the Chloroform. In the evening of the same day the temperatme had
risen to 101° F., which was about his average temperature, except when anfieiiog with
marked increase of the hectic fever. On the 13th, the temperature in the evemng was
104°, and this elevated temperature continued until February 22d, with slight daily
Puthologiccd Anatomy of Cerebrospinal Meningitis, 481
0!<cillatioii8. This rise was due to the formation of an abscess in the tissues near the
aokle joint. Ailer opening and evacuating the abscess, the temperature fell from 104°
to 100^. There was another marked rise of temperature on the 3d of March, the
thermometer in the axilla indicating 105^.5 F.; caused by the formation of another
abscess.
In this case, during a period of one hundred and ten days, the temperature ranged
from 99** to 105^.5 F.; the diurnal oscillations being always greater than in health, and
the marked elevations of temperature being connected with the nature and extent of
the local inflammation during the separation of the gangrenous feet, and during the
healing of the stumps and the subsequent formation of abscesses in the legs, near and
around the seats of the amputations. I have carefully preserved the feet of this patient in
the dry state, by means of certain chemical and organic substances, and it will be seen
upon iDspection of the specimens, which have not been altered in size, color or appear-
ance to any very marked extent, that the- separation of the gangrenous parts by the
!iatuni] processes had been almost complete before the performance of amputation. The
elevated temperature (with its marked diurnal oscillations), was attended by a rapid
pulse, rapid respiration and profuse sweats at night ; sleeplessness and intense thirst
aod great nervous prostration. The recovery of this patient was satisfactory and com-
plete, and at the time that the stumps had completely healed, he presented the appear-
anee of good health, and he was much heavier than when the feet were first frozen.
Without the liberal use of Alcoholic Stimulants, Nutritious Diet, Quinine and Ii*ou, it
is believed that the case would have terminated fatally.
This case thus susttiins the proposition, that the fever which accompanies acute
inflammation should be regarded as one of the rrsnlta of the inflammatory action and
not S3 the cause.
3rd. In Cerebro-Spinal Meningitis the pia-uiater appears to be chiefly affected, but
the arachnoid and dura-mater may also be involved in the inflammatory action ; whilst
on the other hand the nervous structures of the brain and spinal cord, appear as a
;;renenl rale to be free from inflammatory action. This absence of inflammatory action
from the brain and spinal marrow, affords an explanation of the fact, that the intellect
frequently continues to manifest its powers, undisturbed, for considerable periods of
time, and in some cases during the whole course of the disease, even when post-mortem
examination indicates the presence of profound lesions in the investing membranes.
If the nervous elements of the brain and spinal cord and cervical nerves (ganglionic
ceils, commissures, nerve tubes and nervous connective tissue,) are primarily involved
in Cerebro-Spinal Meningitis, it would be impossible to explain the suddenness and
violence of the symptoms, and the rapid fatal results in the absence of all lesions recogni-
zable by microscopic investigation. If on the other hand, it be true, that an effusiou
of ooagolable lymph is just as capable of producing pressure and deranged action in the
brain and spinal cord, as an effusion or haemorrhage of blood within the bony case of
the Ceiebro-Spinal Cavity, it can be readily conceived that the inflammation of the
natritive membrane, and the coating of the most delicate and important nervoiis
struetores, confined in a bony case, with a dense exudation, tending to organize itself
profi^ressively into more firm and resisting structure, might give rise to all the phenomena
of C!erebro-Spinal Meningitis.
-Itb. The derangements of the circulation and respiration, and of the secretions and
excrredons as well as of the nervous functions in Cerebro-Spinal Meningitis, may all be
referred to the local inflammation of the meninges of the brain and spinal cord.
The theoiy, that the febrile phenomena, the derangements of circulation and respira-
tioD, and the mottling and discoloration of the surface, are due to the action of a
distinct blood poison, is not necessary for the explanation of the phenomena, and is not
yiugtamed by the natural history of the disease. Derangement in the action of the
mednlla oblongata and of the nerves, given off from the base of the brain caused by
r he meningeal mflammation, and by the pressure of the products of inflammatory action
iu entirely sufficient to account for the derangements of circulation and respiration,
61
480
Pathological Anatomy of of CerebrO" Spinal Meningitis.
At the time of bis entrance, four days after exposure to the cold mud (Not. 31st), Uoth
feet presented a deep parpUsh hue, and the toes felt cold to the touch.
The following table presents the record of the Pulse and Temperature :
DATE.
TXMPA. PITUIK.
1
REMABK5.
i
1
r
DATE. 1 TCI
1
IPA.
KB.
FCLSB.
BEMARK0.
M. . £.
M.
K.<
1 U.
M.t K.I
IS7
>
1
^
,
1873. ' i
1
Nov
.22
ioi.r)|ioo.
120 108 Half of Xwih feet including toe« 1
Jan.
7 100.2'
1
■ •
•/3
100.6 102.01 102
108
blue and inclining to black.
••
9 101
■
*•
14 101.2 103. ;i08
••
10 100 1
~
2:» 100.5 102.6
••
11101.2 0S.3j i Right foi>taiu|Ni(aled Jan. 11.
••
2«i|102. iiaXo ,120 126
[and iDm>mnia.
••
12 101.2 I
• •
27 101.4 102. 120:112
Cuniplalnt* of great pain in feet
««
13 102. • ' '
••
28 100.6 lo:). llo'llGiFeet gradaalljr turning black,
14 101.5t t i
••
i'j'ioa. ,ia'i.-i 120,128
esp(>cially about the toes. The
^^
10 99. ; " ,
• •
:wioi. 102..->116 112
toe« arc becoming dry and
••
18 100. ' 1 Had a chill at 12 h. oti iU
1
1 1
gh rival led.
19 100. 1 1 , 18th, followed by f^vrr.
iJro.
1
102. 104. !ll2|112
Patient complalnD of constant
••
2.) 99.2 ' Had another chill on (k«
••
^
101. 104.81112 120
tingling and pain in the feet.
29 90. 1 99.2 > 12th.
••
a
102.3 102. ,130 132
Sweats proAiaely ; unable to
•M) 99. 1 99.4 1
• •
4
102Alft').8'l20 1.32
Bleep.
31 101.6 101. ' 1 1
• ■
.'> HH-m lOO..*), I36l 102 j Feet emit a fonl odor. and have
Feb.
1 100. |101. , • 1
••
IJ.102. 105.:i 112 114
been dreawed with carbolic
..
2 101.4 101. 1 ,
1
ointment rince Not. 25th.
••
3 101. 1101.4 1
••
7 lU-..'i Ift'.. !120
Distinct line of demarcation
4 101.4 101.8 ,
••
8 102.8 IW. 120 12<i
forming about middle of both
r. 101.2 101.4, '
••
!), 10:3.2 103..5il2ft 108
feet on the 10th day ofii^ury.
A Ull.
lOljJ
■ *
10!l02.nia\ ;114
Considerablo diNcbarge from
„
7 101.
101/)!
«•
20 KK). 101.:.'
f«*et. Pulao very feeble. Pla-
8 100.
90. ' ■
••
21 lUl. 101 .A
tient ^hiven and complains,
9 101. 101/)|
tLolt leg avpotatMl. Br fur*
• •
22 101.8 102.
of cold. Patient very weak.
10 ioi.5;ioi. 1
, amputation, Tempeim*» Kn*.
' Under tbo InflaeMo of
••
2a 101.8 102.
1
»•
11 100. 100/)'
•■
24 101.8 102. ,
••
12 101. lOlJV
Chlorofona. tbo teBipor»>
tore fell In % of aa boar to
WP, la tbo otoaiag of
••
2.'> 101..') 102. !
• •
.13 102. 101.4 I
■•
29 VJJhlOlJi
••
14 102.2 101.
1
• •
30 99..") 101.81
••
15 100. 104.
same day tbo tovpeimtoio
••
31 100.7 101.
••
10 104. 104.
' was loio.
1873. 1 1
•«
17 111.
104.
Jan.
1 9t». '
■•
18 101.5 104.
••
2 100.41
Mar
. 3' (106/)
Pua borrowing nad^r textnr*
■•
3, 9!».
•>
4 108. 106.
and oaualoc pabi and
■ ■
4I 99.8 '
«•
5 104.
aloughlag.
•■
Ci 99. 1
.1
»•
6 101. 1 i
When this patient entered my ward, he was in such an exhausted and feeble state,
with rapid and feeble pulse, that it appeared almost impossible that his syBtem oodd
possess sufficient strength to cast off the dead tissues. The treatmeot coDskted of
Quinine, Tincture of the Sesquichloride of Iron, nutritious diet, (beef steak, be^ lea,
Hofl boiled eggs, milk and bread,) with liberal supplies of Brandy and Port Wine. The
feet were dressed twice each day, with soft English Lint, coated with Carbolie Add
Ointment, of the strength of one drachm of the saturated solution in Aloohol to the
ounce of Simple Cerate. Notwithstanding the excessive suffering, profudk sweatSf and
the exhausting fever, induced by the. absorption of the gangrenous matters into the
blood, and the local inflammation around the dead tissues, the patient not only main*
tained his stren^h but slowly improved under the treatment instituted.
As soon as the line of demarcation had been established between the dead and livio^
tissues of the right foot, and the strength of the patient appeared to be sufieieQt to
withstand the shock, the right foot was amputated at my request by Profiessor Logan.
on the 11 th of January. The shock of the amputation was very great and the lempe>
rature sank down to a low figure, and the patient did not fully raUy until after the
lapse of several days. The left foot was amputated on the 8th of Febmary ; before
the operation the temperature of the axilla was 100° F.; three quarters of an bouraftcf
the auiputation, the temperature was only 90° F.; this reduction I attributed okieiy tu
the effect of the Chloroform. In the evening of the same day the temperatuie had
risen to 101° F., which was about his average temperature, except when snfiering
marked increase of the hectic fever. On the 13th, the temperature in the evening
104°, and this elevated temperature continued until February 22d, with slight daily
Pathological Anatomy of Cerebro^ Spinal Meningitis. 483
When it is evident that active inflammatory symptoms have subsided, the strength
should be supported by nutritious diet, and alcoholic stimulants judiciously adminis-
tered in small quantities, at regular intervals. The pain, and restlessness, and the
sleeplessness, and delirium, and the contractions of the muscles of the neck and beck,
should be treated by Chloroform administered internally^ in conjunction with Opium
and its preparations, by Hydrate of Chloral, Croton, Chloral Hydrate, and by Cannabis
Indica, Aconite, and Calabar Bean and Bromide of Potassium.
Counter irritation should be kept up along the back of the neck and spine, by blis-
ters, or by Croton Oil.
After the subsidence of the acute inflammatory symptoms, the convalescence will be,
in all cases where there has been an extensive efiusion of fibrinous lymph, tedious
daring the transformation of portions of the deposit into fibrous tissue, and the gradual
absorption of others. During these slow changes, the strength must be supported; and
active depletory measures employed with caution, as they may retard the reparative
process.
In instituting this vigorous plan of treatment, the physician should be confident of
the correctness of his diagnoiis, for such treatment in Pernicious Malarial Fever, might
be attended with serious results. When the disease is complicated with Malarial
Fever, Quinine should be administered freely, and caution should be exercised in the
ab^tTaction of blood.
482 Pathological Anatomy of Cerebro^ Spinal Meningitis.
and for the stagnation of the blood in the capillaries of the surface, and the oonaequent
mottling of the surface, as in Malignant Malarial fever. Not only is the fibrin increased
in the blood in Ccrebro-Spinal Meningitis, but marks of disorganised blood and of
bloody effusion.s, arc absent as a gonend rule from the structures most inflamed and
diseased, viz : the meninges of the brain and spinal cord, and in those cases in which
circumscribed discoloration of the membranes of the brain and of tlie pleura and peri-
cardium have been observed afler death, such appearances were evidently caused by
local congestions and pott-mortenh exudations of the coloring matters of the blood. And
(>ven if it should be true, that the blood is disorganized in certain cases of Cerebro-
Spinal Meningitis, such disorganization may be entirely explained by the derangementii
of the circulation and respiration induced by the disturbance and perversion of the
i unctions of the Cerebro-Spinal System. All the facts, however, point only to a want
of proper oxygenation of the blood, and to a tendency to stagnation of the venous blood
in the capillaries of the periphery. Petechial spots are absent in the majority of the
cases, and in many epidemics not more than 17 per cent of the cases manifest any
mottling or petechial spots of the sur&ce. In soldiers and in the poorer classes, whose
diet has consisted largely of salt food, the presence of petechial spots during the progress
of this severe disease, is largely due to the preceding scorbutic condition of the blood.
5th. An explanation of the almost universally iktal character of Cerebro-Spinal
Meningitis, as well as the tedious nature of recoveries from the disease, may be found
in the physiological actions of the nervous structures involved, and in the nature and
effects of the products of the inflammatory action. The prognosis of every well defined
case of this disease, must be doubtfU and unfavorable. Even after the subsidence of
all active inflammation in the meninges of the brain and spinal cord, the moat serious
consequences may follow, and all the dangerous symptoms and derangements of the
most essential functions of life may be kept up by the mere mechanical action of the
organizable and organising fibrous effusion. The period of convalescence from this dis-
ease will dep^d, not only upon the amount of fibrous inflammatory effusion, but also
upon the character and rapidity of the subsequent changes, resulting in the formation
of fibrous tissue, and in the gnuiual absorption of some portion of the products of the
diseased action.
6th. The treatment of Cerebro-Spinal Meningitis, based upon the preceding prin>
ciples, should be, in the first stages of the disease, entirely directed to the arrest or
modification of the acute inflammatory action.
As soon as the practitioner has convinced himself that the diseaso is Cerebro-8pinal
Meningitis, and not Pernicious Malarial Fever, the patient should be fV«cly bled, (in
the upright posture if possible), the blood being allowed to flow in a Ml stream until
the patient feels faint and exhausted ; from ten to fbrty ounoes of blood should be
taken, the amount bemg regulated by the severity of the oase, and the age, oonstituCion
and strength of the individual.
Gut-oups should be fVeely applied to the temples, to the back of the head and neck,
and along the entire r^on of the spine, and from four to eight ounces of blood be thu»
withdrawn over the wgion of the brain and spinal oord.
The bowels should be iVeely opened with Calomel, and, if neoecvary, with CtoC'Mi
Oil.
The back of the neok and head should next be shaved, and a blisti^^r applied over th«-
region of the cerebellum and back of the neck, and down the entire length of the v^^\
Over the spine, this blister should not be wider than from one inch to one and a half
inches.
Afler the firee evacuation of the bowels, Mercury should be given in small doecs^.
combined with Opium, with a view to mcrcurialiiation. The Mercury may be admi-
tageously combined with ]>over*s Powder and Quinine, as in the following fofBuU :
B. Hydrargyri Subohlorkli (CaJomel), 3 ss ; Pulv. Doveri (Pulv. Ipecac et Opii •,
3 ii ; QainisD Sulph, 3 i ; ^lix ; divide into 30 powders ; Sig : One powder everr tw**
or three hours.
Pathological Anatomy of Cerehro^Spinal Meningitis, 483
When it is evident that active inflammatory symptoms have subsided, the strength
should be supported by nutritious diet, and alcoholic stimulants judiciously adminis-
tered in small quantities, at regular intervals. The pain, and restlessness, and the
sleeplessness, and delirium, and the contractions of the muscles of the neck and back,
should be treated by Chloroform administered intemallt/, in conjunction with Opium
and its preparations, by Hydrate of Chloral, Croton, Chloral Hydrate, and by Cannabis
Indica, Aconite, and Calabar Bean and Bromide of Potassium.
Counter irritation should be kept up along the back of the neck and spine, by blis-
tere, or b}^ Croton Oil.
After the subsidence of the acute inflammatory symptoms, the convalescence will be,
in all cases where there has been an extensive efiusion of fibrinous lymph, tedious
during the transformation of portions of the deposit into fibrous tissue, and the gradual
absorption of others. During these slow changes, the strength must be supported ; and
active depletory measures employed with caution, as they may retard tne reparative
process.
In instituting this vigorous plan of treatment, the physician should be confident of
the correctness of his diagnoiis, for such treatment in Pernicious Malarial Fever, might
be attended with serious results. When the disease is complicated with Malarial
Fever, Quinine should be administered freely, and caution should be exercised in the
abstraction of blood.
<,II APTKIl VI I I.
OBSERVATION!! UN Tim KKI.ATKIXS llK rKHKBUHSPINAI, .VRMM
CASES OF CEBEBKO-SPINAL UENINlilTlS. WIIK'II riUJUIIHEll AT SAVANNAH,
AND MABCII, ima.
EFFECTH OF 11ERASGIOIBNT3 OK TIIK ni.iHH), AlttSIM! FRriM DKFKCTIVE ClBCILATiON ANI>
BlyPIBATIOK, I'POX THK MRUANS AMI TrsslKS. TIIK l>Kll.(M>KUESTl> OF THE rlBCl'LATlnS
AND BBBPIBATION. AND OP TIIK KKI'IIKTtllXfi AND E\(-Rh*TlilNS, AS WELL AS OF THK .IBETi'l-
Fl-NeTtONSINCKKKBBIHll'INAL MENtXtllTIS, MAV ALt. BK BEFKKKKDTIt TIIK UM'AL INFLAMMA
TION, OI'NaESTlllX, AND ALTKRATDiN OF THE MENtMIKS (KHI>KriAI.I.V THE PIAKATKRl AM'
BTBIICTDBF8 0FTHBBBAIN AND HPINAL C'llBD. rKBKBRll-iiPlNAL HKXINUITIS BEDEHBLBa IN IT>
OBiaiN AND PBOORESH. INFL.\NXATI>ltr DIMKASKA, AND HAS FltEVlTENTLV PHEVAILED AT TIO:
SAVETIMK. AND BERN INTIKATKI.V AAnwIATED WITH ISFMTKN!!\, CATARRH. AND PNRt-MoMi
THE CUANUEaur TBKPERATURK DI'RIM) THK PIIIHiRKSiliir i^KltKBKIk^PINAI. HRNlNUITIit. INKI-
I'ATB THE ACTIO!! OF TUB AUENT PRuDI'l-INIi TIIK DISK.UtK, DIRKLTLV UN THE CEBEBIU--
SPINAL araTEM. RATIIIRTIIAX UN THR BMNIII. TIIK IIINDITDIN of many patients Dt'RIN<l
CilNVALKSCENOB FIIDH CBREBRCMI'INAL HKNINOITIM, INDII'ATIH IN TUE CLEABKfT HANNEK.
THAT THE CRBBBRIkSPINAI. NKRVOi:S fYSTKM. IIAB BKEN INFI.AXED AND PABTfl OF TUR !<THrr-
TURKS P " " ~
My atteDtioQ was slron>;ly dircuUnl to lliu iui|)oiljint <juiu<lioii uf thu relslions of
(7erebn>-8pinA] Meningitis to Msbrial t'cver, by the exaiiti nation of several cues af ■
fatal form of disease, which oceurrud in the months of February and Much, 18i>^l.
unongBt the CoDFcdcrat« trooptt assembled fur the defence of SavaDnih, Oeorgia.
Daring the prosecution of investigations upon eainp diseases. amoDgst the Confederab.'
Troops, stationed along the coaat of Georgia, uiy friend and colle^rue Dr. H. y. M.
Miller, Chief 8uipcon of the District of Georgia, rojuesled me to examine some sudden
and severe cases of disease, which had occurred in the 32d Regiment of Georgia Vdna-
t«ers, at that time camped near the southern boundary of Savannah, at Camp William
DuDosn Smith.
Aocording to the testimony of Sur^on Hugh A. Blair, of the 'ii'id Regiment, bIuiM
the entire command, of an average mean strength of one thousand men, bad mffrred
with Malarial fever, and many of the men whom I saw upon rrgiinental parade, showed
in their sallow anaimic faoes, the cffccls of malaria.
In the hospital of this regiment, which was crowded with cases of Typhoid U:\fT.
pneumonia, and malarial fever, I obacncd three cases, suflcring with a form of diae*--^-
which had been sudden in its inception, violent in itjt syinptnni!), and reacmblinj; in ii>
main fektures, Cercbro-Spinal Meniogltii*.
In the latter part of February, a few days before my vi!>it, five ofthese cases had ooconx^l
and two proved fatal. Three of the five cases, commenced with strong convulsiAtL*.
followed in a short time by delirium. In four of the cases, the pupils were dila(«d ; and
the conjunctiva waa congcatcd in all. In one case the pupil was alternately dilated aixl
contracted. Pulse weak, but not specially acoelcraU^d. llcspiration apparently natnnl
at the commenoement of the disease, but gradually became stertorous aod im^lar
Coma rapidly supervened, and the patients died in from 12 to 18 bonis.
The three cases which I examined, presented an anicmic and sallow hue, as if th<-
patienlfl had been subjected to the prolonged aetion of malaria, and upon inqairy I
found that they had in each case xutfercd previously with chill and fever. ThcMc«Mr*
presented somewhat the Ryniplonis of Hi'vere oncn^ion of the brain ; the palienia Uj
Relations of CerebrO' Spinal Meningitis to Malarial Fever. 485
with the eyes open, without moTing or noticing anything pagsing around them, and
when the attempt was made to arouse them they gave little or no sign of intelli-
gcnoe. These cases terminated fatally in the course of a few days. It might with some
reason, be supposed that the continued action of malaria, had produced ch^inges in the
constitution of the blood and of the ccrcbro-spinal structures, and that at length during
the congestive stage of the disease, accompanied also by the action of cold, irritation of
the meninges of the brain and spinal cord was excited, and serous effusions took place
into the ventricles of the brain, and around the brain and spinal cord.
Similar cases occurred about the same timj, in the General Hospital in Augusta,
Geoi^; six cases, — the entire number proved fatal. All these were soldiers who
hid be3n suff'jring with milarial fever in Savannah, ani had been transferred in the
Utter part of the fall to Augusta. In each one of these six cases, the malarial fever
had not been arrested, and the patients exhibited its cifects in their pale, sallow, and
anaemic hue.
In most of the coses occurring in the General IIu:$pitaI of Augusta, the disease was
ushered in with an intense pain in one of the cye8< which wsis speedily followed by
coma and death, in from 18 to 50 hours.
Surgeon Blair, informed me that a cose similar iu sumc respects to those previously
described, occurred as early as September, 18G2. The patient had had chills and fever
tor some time, and looked sallow and anasmie. Had missed his chilli^ for several days, and
hid taken no Quinine for two days. On the 10th of September, 15 grains of Quinine in
three doses were administered early in the morning, the last dose having been taken at 8
o*clock, A. M. The Quinine had been given with a view to prevent the recurrence of the
chill as the patient appeared to be iu his usual health. At 1 o'clock P. m., whilst
attempting to put on his shoes, the patient suddenly fell, became insensible and never
rallied. In two hours he was jaundiced — even his tears were yellow, the pupils were
largely diUtcd, pulse not specially accelerated, but weiik. The patient died at mid-
night of the same day upon which he was seized.
KELATI0N8 OP CKRKBR0-8PINAL MKNINUITIH AND MALARIAL FEVER.
The following tables which I have consolidated from my kibors and investigations
concerning Malarial Fever, commenced in 1856, will furnish data for careful comparison
with the symptoms and pathological anatomy of Cerebro-Spinal Meningitis, as described
in the preceding chapter.
TABrLAR VIEW OF THE CHANGES OF THE BLOOD AXD URINE AND CIRCULA-
TION. RESPIRATION AND TEMPERATURE IN MALARIAL FEVER, DEDUCED
FROM THE STUDY OF MORE THAN TWO THOUSAND CASES, DURING A
PERIOD OF TWENTY YEARS— 1856 TO 1875 INCLUSIVE, BY JOSEPH JONES,
M. D.
CHAN6I8 OF THE BLOOD IM MALARIAL FftVIR. *
The maUriftl poitoo is capable of altering the constitutioa of the solids and fluids, and of
modifytog and altering the type, and progress, and effects of various diseases, even when no
njrnptoms of aberrated physical, chemical and nervous actions have been manifested, snfli-
cient to arrest the attention of the patient.
The eolortd blood corputciet are diminished during Malarial Fever ; the extent and rapidity of
the dimimiUon of the colored corpuscles correspond to the severity and extent of the disease.
The fixed saline constituents of the colored blood corpuscles, are often diminished in Malarial
Fever. The colored blood corpuscles are destroyed both in the liver and spleen. The col-
ored blood corpuscle! are more uniformly and rapidly destroyed in severe cases of Malarial
Fever, than in any other acute disease, with the exception, perhaps, of Pyiemia.
The Mpeeijic gravity of both the blood and serum is diminished during the active stages of
MaUirial Fever, and during the slow action of the malarial poison.
The miid matUra of the blood are more rapidly and decidedly diminished in Malarial Fever
than io any other disease. The color of the blood nod serum is altered ; in severe cases, the
48C Relations of Cerebro^ Spinal Meningitii to Malarial Fever,
blood, when first Abstracted, presents a dark purple, almost black color, and chaogea alowly
to the arterial hue when exposed to the atmosphere ; and in seTere cases it changes to a
cherrjr red color, and not to the bright red assamed bjr the surface of healthj, Tenons blood.
The blood of the liver and spleen, after death from Malarial Fever, presents a deep purple,
and almost black color, and does not change to the arterial hue upon exposure to the atmos*
phere. Serum golden colored in severe cases. The clot forms more slowlf, and is more
Tolnminous than in normal blood.
The fibrin is diminished greatly in severe cases of Malarial Fever; the dtmioution of this
element of the blood is characteristic, not only of Malarial Fever, but of all fevers ; whilst
its increase, on the other hand, is characteristic of the phlegmasia:. As a general rule, the
diminution of the fibrin in Malarial Fever, as in the pyrexiae, generally corresponds with the
severity of the disease, provided there be no inflammatory complication. The diminution
and alteration of the physical properties of the fibrin in Malarial Fever, to any great extent,
was always accompanied by congestion of the spleen, liver and brain, and serious cerebral
disturbances. The fibrin is not only diminished in malarial fever, but it is altered in iu
properties, and in its relations to the other elements of the blood, and to the blood-vessels ;
and in severe cases, heart clots (fibrinous concretions), are frequently formed before death.
The albumen is diminished during the active stages, but such diminution is not due to aav
loss of this element in the urine. As a general rule, albumen is absent from the urine in *
Malarial Fever, and when present, as in Malarial Hcematuria, it is accompanied with blood
corpuscles, and with casts of the tubuli uriniferi containing colored blood corpuscles.
CIIAMUKH OK Tni CIRCULATION, BBSPIRATION AND TBI1I*IRATI*RB.
InUrmiUeni Fever. — During the cold stage, (chill), there is a rapid, feeble pulse, rapid respi-
ration, and hot trunk, and cold extremities — the temperature of the extremities is reduced far
below that of the trunk, and even below the standard of health, because the circulation of
the blood in the peripheral capillaries is to a great extent arrested, apparently by the con-
traction of the unstriped muscular tissue of the walls of the minute arterioles. The diminu-
tion of the capillary circulation, and the reduction of the temperature of the extremities, pre-
cede the aberrated nervous and muscular phenomena denominated chill. This fact corres-
ponds with the changes in the constituents of the blood, and indicates that the first phe-
nomena of the cold stage are connected with derangements of the vaso-motor system of
nerves. As a general rule, the higher the temperature of the trunk during the cold stage,
the more rapid will be the equalization of the circulation and temperature. The severity of
the fever (animal temperature), which often reaches, in the hot stage, 107^ F., is by no meaop
an index of the character and severity of the subsequent effects. As a general rule, the
higher the temperature (within, of course, certain defined limits, not exceeding 102^ and
1 07^.5 F.), the more readily does the attack yield to treatment. The changes of the tempera-
ture in Intermittent Fever, arb characterised by abrupt elevations and depressions, so that
when the curves are projected upon a chart, they differ in the rapidity of the elevatioas anti
depressions from those furnished by all other diseases.
Remittent Fever. — The phenomena of the cold stage preceding the hot stage of Remitteai
Fever, are similar to those of Intermittent Fever ; the difference is one of degree, and not u(
kind ; the phenomena of the cold stage of Remittent Fever are more protracted than thoM o(
Intermittent Fever ; the sympathetic system does not so rapidly regain its normal action,
and the circulation in the capillaries of the extremities is not so rapidly restored in Remttteoi
as in Intermittent Fever. The alterations of the blood are more profound in Remittent tbtto
in Intermittent Fever, and therefore it results that the cold stage is more prolonged in Remit-
tent than in Intermittent Fever. The elevation of temperature corresponds more accurately .
with the increased actions of the circulatory and respiratory systems in Intermittent tban
Remittent Fever. Remittent Fever may be distinguished from Typhoid Fever by the greater
and more sudden elevations and depressions of temperature.
Chnge9tive or Pemiciout Fever. — The complete prostration of the muscular and nervous forrrs
the reduction of animal temperature, both in the trunk and extremities, the cold, clamn^
sweat, the rapid, feeble pulse, the rapid, thumping action of the heart, and the sudden inter-
vention of the most alarming cerebral symptoms, may occur gradually or suddenly, in etthrr
Intermittent or Remittent Fever, and may be induced by several distinct causes acting sinfly
or in conjunction. There is a want of coordination between the circulation, respiration an<J
animal temperature in Congestive Fever. The respirations are full, accelerated, anJ often
panting and heaving, varying from 30 to 50 per minute ; the pulse beats from 120 to !*><>» s»«l
feels like a delicate thread, and is often so small that it cannot be counted ; the heart tbuap^
irregularly and spasmodically, and rapidly against the walls of the chest, as in some rases of
narcotic poisoning ,* the circulation in the capillaries is feeble ; the temperatnre of the trank.
notwithstanding the full, rapid respiration, sinks below the normal standard, and the serftre
is covered with cold, clammy sweat.
Relations of CerebrO'Spinal Meningitis to Malarial Fever. 487
CHANGES or THE URINE IN MALARIAL FSVRR.
IniermHUni Fever, — The amount of uniie excreted durin{( the active stages, and during the
earlieft stage of the intermissioD, is less than that of health, and this dimiaution relates to
the water, and not to the solid constitnents. During convalescence, and especially under the
action of depnrants, the amount of urine is increased. The color of the urine varies from
light orange to deep red. During the active stages the free acid is increased, but diminishes
during convalescence. The urea is increased, during the active stages, above the standard
of health, and especially during similar conditions of rest and starvation. The uric acid is
diminished, both with and without the action of Sulphate of Qninta, during the active stages,
when the pulse is full and rapid, and the respiration full and accelerated, and the tempera-
ture elevated. As a general rule, when the fever declines, the uric acid increases above the
standard of health, both with and without the action of the Sulphate of Quinia. In some
cases the uric acid increased to four-fold the normal amount during convalesence. The urine
of the intermission of Malarial Fever, is characterized by heavy yellow deposits of Urate of
Soda and Triple Phosphates, the former in the form of granular and acicular masses, and the
latter as beautifnl prysmatic crystals. Phosphoric Acid is greatly diminished, and may even
entirely disappear during the chill and first stage of the febrile excitement. The phosphates
are more abundant in the stage of convalescence than during the active stages. The deposits
^so-called critical discharges),- so common during convalescence, consist chiefly of the Urates
of Soda, Ammonia, and the phosphates, most generally in the form of triple phosphates. The
Chloride of Sodium is abundant during the cold and hot stages. The Sulphuric, as well as
the Phosphoric Acid, is increased during the height and decline-of the hot stage. The urine
excreted during the fever is generally deficient in Uric Acid and the earthy salts, whilst its
acidity and power of resisting decomposition is greatly increased, and it will remain for a
great time without undergoing decomposition. On the other hand, during convalescence,
the urine rapidly undergoes change, and the deposits of the Urates of Soda and Ammonia,
and the precipitation of the triple phosphates, by the Ammonia generated during the
decomposition of the urea form the so-called critical discharges of Malarial Fever. Albumen
is almost universally absent from the urine of uncomplicated Malarial Fever ; it is present,
however, in that form called malarial hematuria, characterized by intense jaundice, and
congestion of the kidneys, and )»assive haemorrhages. In such cases the urine contains blood
corpuscles and casts of the tubuli-uriniferi filled with colored corpuscles.
The changes of the urine in Remittent Fever^ are the same in kind, but diflTerent in degree,
from those of Intermittent Fever. The urine is higher colored, more concentrated, and richer
in urea, Phosphoric Acid and Sulphuric Acid. If the case be protracted, the Chloride of
Sodium diminishes, as in Typhoid Fever. When the temperature falls below the normal
standard in the early stage of convalescence, the urea, as in the similar stage of Intermittent
Fever, decreases in amount. During the period of remission and convalescence, the Uric
Acid, which had suffered decrease in the active stages, increases above the normal standard.
The formation of deposits of the Urates of Soda, and of Ammonia, and of the triple phos-
phates, (critical discharges), in the urine of Remittent Fever, is similar in all respects, takes
place at analogoai periods, and is due to the same causes as in the urine of Intermittent
488
Relations of Cerebrospinal Meningitis to MalariaJ Fever,
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SelatioTis qf CerebrO" Spinal Meningitis to Malarial Fever. 497
TABULAR VIEW OP THE PATHOLOGICAL ANATOMY OP YELLOW FEVER AND
MALARIAL FEVER.
BY JOSEPH JONES, M. D.
The following comparison of the Pathological Anatomj of Yellow and Malarial Paroxysmal
FeTers eon tains the general oatline of the resalts which I have obtained by investigations
condacted in rarions parts of the Soathern States, and which were commenced in 1856. I
hare, upon several occasions, embraced opportunities of examining the bodies of those who
had died firom Yellow Fever and Malarial Fever, at the same time, as they lay side by side in
the Dead Houte, Snch examinations served to establish more fully the results of numerous
post-mor^m examinations of the subjects of each disease.
YELLOW rKVKB. MALARIAL FBVKR.
»
^^(eribr.— Generally full and not reduced in Exterior. — The general appearance of those
flesh; features may even present a swollen, who die from the effects of malarial fever will
bloated aspect. Skin of face and upper por- depend upon the nature and length of time
tions of trunk of a golden yellow color, and the effects of the disease. When stout
Dependent portions of body of a mottled pur- healthy men are suddenly destroyed by per-
plish and yellow ecchymosed appearance, nicious malarial fever, the body may present
Black vomit frequently oozes from comers of the fulness of health ; and in such cases the
the mouth, and trickles down the face and superiorportionsof the body may, as in yellow
neck. When the muscles are cut a large fever, present a golden yellow color, whilst the
quantity of dark blood escapes, which upon dependent portions present a purplish and
exposure to the atmosphere changes to a mottled appearance. The jaundice and mot-
bright scarlet hue. Putrefactive changes take tling of the skin, however. Is, as a general
place rapidly after death. In some cases of rule, present to a less degree than In yellow
Yellow Fever, especially when the functions fever. In cases of protracted bilious fever,
of the kidneys have been arrested for some the body is frequently emaciated. In chron-
ttme before death, the putrefactive changes ic malarial poisoning, attended with enlarge-
take place with great rapidity and energy, and ment of the spleen and cirrhosis of the liver,
sometimes even appear to commence before the belly and body and limbs generally are
death, the body exhaling a disagreeable odor, distended with dropsical effusion. The cut
surface of the muscles presents a purplish hue,
and the change to the arterial hue, upon ex-
posure to the atmosphere, is much slower and
less perfect than in yellow fever.
CertbrO" Spinal Nervous St/stem.^^St/mpathetie CerebrO' Spinal Nervout 8ff9tem-~'SympathHic
ServouM Syttem. — The post-mortem examioa- Nervous Sjfstem.^At far as my observations
tiODS of the brain, spinal cord and sympathetic have extended in Malarial Fever, the dura-
system have thus far revealed no characteristic mater was always normal ; the arachnoid
lesions to which the aberrated nervous symp- membrane pearl-colored, opalescent in some
tooas of Yellow Fever can be referred. Beyond cases, in others perfectly transparent and
coogestion of the capillaries of the cerebro- normal in appearance ; the blood-vessels of
spinal and sympathetic systems, which con- the pia-mater congested with blood, but
gestion appeared to be referable to the same always without marks of inflammation. Sob-
caase as that producing capillary congestion aracbnoia fluid in almost all oases clear,
in the internal organs, I have observed no transparent, and iu some cases of a golden
strnctoral lesion, as fibrinous effiision,hamor* color; the amount varied in different cases,
rhage, or softening of the eerebro-spinal and sometimes exceeding, but most generally fall-
syvpnthetio nervous structures. Chemical ing short of, the usual amount. Blood-vessels
analysis revealed the presence of urea, bile of the brain generally filled with blood. The
and leucine in the brain, and to the effects of structures of the brain appeared in acute cases,
tbeM labstances, as well as to the direct action as a general rule, to be unaltered either in
of the Yellow Fever poison, must be referred structure or appearance ; in chronic cases the
the aberration of intellect, the restlessness, nervous structures sometimes presented a
conrultions and com«, deeper and more grayish color, from the pres-
ence of pigment granules.
The structures of the brain and spinal cord,
in Malarial Fever, were therefore, as a general
rule, altered neither In consistence nor appear-
ance, and the same is true also with reference
to the sympathetic nerrons syitem^
498 Relations of Cerelrc^Spinal Meningitis to Malarial Fever. -
ffeart. — Pale yellow and brownish Yellow, Heart. — Normal in color, presents the deep
as if undergoing fatty degeneration; structures purplish red muscular appearance of the
of heart flabby and somewhat softened ; nume- healthy heart. Muscular fibres of the heart
rons oil-globules deposited within and around firm and of normal appearance under the
the muscular fibrillse of the heart. Cayities microscope. No deposits of oil in the mos-
of the heart, in many cases, filled with dark cular structures.
fluid blood; yellow fibrinous clots sometimes CaTities of the heart frequently distended
present. Blood contains abnormal amounts with dark blood. Firm laminated, fibriDoiis
of urea and extractive matters and ammonia, concretions very common : and in some cases
Fibrin of blood greatly diminished in amount, of Pernicious Fever, the formation of these
1 have determined, both by chemical analy- heart-clots during the cold stage withoot
sis and microscopical examination, that the doubt causes death, and renders Qnarailing
heart undergoes acute fatty degeneration in the action of remedial agents.
Yellow Fever. As far as my observations have The fibrinous concretions are not only at«
extended, the heart undergoes more rapid and tached to the carneas columnss and chords
extensive degeneration in Yellow Fever, than tendinee, and auriculo ventricular Tslves, but
in any other acute disease. The acute fatty they also frequently send forth long branches
degeneration of the heart in Yellow. Fever into the pulmonary arteries. The formation
should not be confounded with similar changes of these concretions is rare in Yellow Fever,
obserTed in spirit drinkers and in certain and when formed they are mnob smaller and
chronic diseases. softer than in Malarial Fever. The blood of
Malarial Fever contains more fibrin, fewer
colored corpuscles, and changes more slowly
to the arterial hue, upon exposnrs to the
atmosphere, than the blood of Yellow PcTer.
Lunfft, — Dependent portions greatly con- Lungt. — Dependent portions congssted with
gested ; otherwise normal. In some cases blood ; otherwise healthy,
circumscribed effusions of blood in textures
of lungs.
Stomach, — Mucous membrane of stomach in Stomach. — Mucous membrane often presents
many cases intensely congested, softened and a normal appearance ; sometimes ecchymoscd ;
eroded. Stomach often contains large quanti- rarely inflamed or softened ; sometimes dis*
ties of black Tomit. Reaction of black vomit colored with bile ; rarely contains black Tomit
often alkaline from the presence of ammonia^ (altered blood). Beaotion of mncons meoi^
resulting from the decomposition of urea, brane of stomach and intestines acid. The
eliminated by the gastro-intestinal mucous pathological alterations of the stomach, ob-
membrane. Anmonia and urea present in the served after death, do not correspond, as a
black vomit ejected during life, and also when general rule, with the severity of the lynp^
examined almost immediately after death. The toms, the vomiting and pain on pressure
presence of ammonia in the stomach and black during the progress of the fever. The iDjectio*
vomit was not the result of post-mortem putre- of the blood-vessels, and the mottled, parpUsh
factive changes. In many cases ammonia brownish red color, after death, appear to be
was present in such large amount, that when indicative, not of inflammation, but rather x>r
a rod, dipped in hydrochloric acid, was held stagnation and accumulation of the blood in
over the mucous membrane of the stomach, or the capillaries, consequent upon the disi«r-
over the black vomit, dense fumes of chloride bance of the relations of the blood to the
of ammonium were formed, as if the rod had capillaries. The distressing vomiting, so ofUn
been held over a bottle containing liquor am- a troublesome symptom in Malarial Fevcr«
moniae. Chemical analysis revealed the pres- appears to depend upon the contact of tba
ence of ammonia and also of urea in the black altered bile and the irritation of the nerrons
vomit. Under the microscope the black vomit centres, which supply the stomach with aer-
was seen to contain colored blood-corpuscles, vous force, by the altered blood and by the
and cells of the mucous membrane of the malarial poison.
stomach and broken capillaries. In some In cases where there has been chronic la-
ckses vibriones and fungi were numerous in flammation of the stomaob before the appe«r-
the black vomit ; in others they were absent, ance of the fever, and in cases of long slaadicg.
where the solids and fluids were permastat'.r
altered, decided lesions of itrneturt
found in the stomach. It may be asserl«ii.
however, that there is no constant or cbarmc-
teristic lesion of the stomach in MaUnal
Fever.
InUsUnes.^Ag a general rule dark-colored These remarks apply also to the small i«tes-
and distended with gas. In some cases th& re- tines. The mucous membrane freqae&t.y
action of the intestinal contents was stropgly presented a purplish, irregularly iaj«ctec
alkaline frgm the presence of ammonia. mottled appearance, especially after the ai-
'RelaHons of Cerebro^Spinal Meningitisjto Malarial Fever. 499
ministratioii of pargatives, and it vas fre-
quently observed that the injection of the
blood-vesselB was greatest in the dependent
portions of the intestines. In several cases
Brunner's glands in the duodenum were en-
larged and distinct. The solitary glands of
the small intestines appeared in many cases
enlarged and distinct. Peyer's glands were
uniformly free from any well-marked morbid
alteration. In some cases they were distinct
and well defined in their outline, and presented
a honey-comb surface, dotted with dark
points ; but they were always free from marks
of inflammation and even of irritation, and in
their pale, white color contrasted strongly
with the surrounding mucous membrane, dis-
colored with bile and often irregularly iigected
with blood.
Xfiper.—o Yellow color and bloodless, resem- Liver. — The weight of the liver is increased
bliog this organ in fatty degeneration, but in Malarial Fever above the standard of health.
firmer and denser in structure. Under the This increase of weight is due in part to the
raicroBcope, textures of the liver infiltrated stagnation and accumulation of blood in the
with oil; secretory cells of liver contain much capillaries and blood-vessels, and to the de-
oil. Theliverof uncomplicated Yellow Fever, posit of pigment matter in the structures of
as far as my observations extend, and accord- the liver. This observation applies to the
iog to the observations of Louis and many liver in the acute stages.
others, is of a bright yellow color. It is pro- In all the different forms of Malarial Fever,
bable that this color, as in the case of the intermittent, remittent and congestive, which
malarial liver, varies with the length of the bad continued longer than five days, and in
attack and the effects of previous diseases, which there had been no previous alterations
Thus, Dr. Samuel Jackson, of Philadelphia, of the structures, as in cirrhosis and fatty
foand the livers of those who had died in the degeneration, I found the exterior of a slate
early stages engorged with blood. The decoc- color, and the interior of a bronse color. In
tion of the Yellow Fever liver is of a golden that form of cirrhosis of the liver which is
yellow color, whilst that of the malarial liver directly induced by the prolonged action of
is of a brownish yellow color. The golden the malarial poison, the Tver is in like manner
yellow color of the Yellow Fever liver can be of a slate color upon the exterior, and olive
extracted both by Alcohol and water. The green within, and loaded with dark pigment
Yellow Fever liver is firmer and harder tban granules. The change in the color appears
that of Malarial Fever, contains much less to be very persistent, and in several cases I
blood, and is much less readily acted upon by have observed the liver to retain shades of
liquor potassss and acids. Liquor potassae light slate and light bronse several weeks, and
readily dissolves the Malarial Fever liver, and even months, after the relief of the attack of
the decoction presents the appearance of ve- Malarial Fever, the patients having been de»
noas blood, while no such effect is produced stroyedby other diseases or by violence. The
by the action of this alkaline solution upon liver, especially in the peripheral portions of
the Yellow Fever liver. the lobules, contains pigment granules, result*
Chemical analysis reveals the presence of ing from the alteration of the colored blood-
urea and fat in abnormal amounts; animal corpuscles and the hsematin. The pigment
starch and grape sugar are also present in the granules are frequently distributed uniformly
Yellow Fever liver. As a general rule grape through both the portal and hepatic systems
sogar is abstnt from the malarial liver. of capillaries. There is no accumulation of
oil globules, as in the Yellow Fever liver. If
Malarial Fever precedes or succeeds Yellow
Fever, the liver may contain both oil globales
and pigment granules.
The peculiar color of the Malarial liver can
to a certain extent be extracted by boiling-
water, and the filtered decoction presents a
brownish mahogany color, from the presence
of the dark coloring matters of the pigment
granules; the decoction of the Yellow Fever
liver, on the other band, presents a golden
color. The blood issuing from the cut surface
of the malarial liver presents a dark purplish
hue, and does not change to a brilliant scarlet,
as in the Yellow Fever liver. Upon chemical
600 Relations of Cerebro-Spindl Meningttis to Malarial Fever^
examination, the malarial lirer contidns animal
starch, but no grape-sogar ; the Yellov Ferer
liver contains both substances.
Oall Bladder.—'Tht gall bladder in Yellow Gall Bladder.— In most oases distended with
Fever is, as a general rule, contractedi flaccid, more than 1000 grains of thick, greenish bitck
small, and contains little or no bile. The bile, haTiog frequently a specific gravitj
amount of bile generallj does not exceed 100 ranging from 1030 to 1037. The bile b moro
grains. In Malarial Fever, on the other hand, abundant in Malarial Fever and is of a deeper
the gall bladder is, as a general rule, distended color, and frequently contains concretions of
with dark, greenish, black bile. In Yellow epithelial cells, from the coats of the gsll
Fever the vomiting is rarely bilious, unless bladder and biliary ducts, and casts of the
in the commencement of the disease ; and the biliary tubes. In thin layers, and when added
black vomit contains little or no biliary matter, to water, it presents a deeper shade of greeo.
The small intestines are rarely if ever dis- The Yellow Fever bile presents a golden color
colored by bile in Yellow Fever, whilst in in thin layers and when added to water.
Malarial Fever it is common to find the gastro-
intestinal mucous membrane discolored by bile.
Splun — As a general rule but slightly en- iS^^«n.— Enlarged, softened and loaded with
larged. In many cases normal in size and altered blood-corpuscles and pigment grana-
appearance. In many cases of Yellow Fever les; of a dark slate color upon the exterior;
the spleen is neither enlarged nor softened, the blood of the spleen does not change to
nor altered in appearance, either upon the the arterial hue upon exposure to the atnoi-
exterior or within. There appears to be no phere. In many cases the spleen is so toft
special alteration or destruction of the colored that it raptures when the attempt is made to
corpuscles in the spleen of Yellow Fever as remove it from the cavity,
in that of Malarial Fever. The enlargement
of the spleen in fevers does not, from these
observations, depend upon the diminution of
the fibrin, because this element of the blood is
diminished to a much greater extent in Yellow
Fever than in Malarial Fever, and at the same
time the spleen is enlarged to a great and
marked degree in the latter. Another fact
worthy of consideration in this connection is,
that in Yellow Fever the colored blood-corpus-
cles are not specially diminished in amount,
whilst in Malarial Fever they are rapidly
destroyed, and this destruction appears to be
greatest in the liver and spleen. In Malarial
Fever both these organs are loaded with the
altered blood-corpuscles and with the pigment
granules resulting from the alterations of the
colored corpuscles, whilst neither the spleen
nor the liver in Yellow Fever afford any
evidence of alterations of the colored blood-
corpuscles.
• Kidneys. — These urgans, as a general rule, Kidneyt.-^Ji ormtA in appearance and stroc
present a brownish yellow color, much lighter ture, except in malarial haematoria, when th«
than that of health. They, in common with textures are congested, and dark colored is
the heart and liver, contain much free fat. some cases. Occasionally slate-colored spots
When thin sections of the kidneys are examined appear upon portions of the kidneys,
under the microscope, the Malpighian cor-
puscles and tubuli uriniferi are found to be
filled with granular albuminoid and fibroid
matter, excretory cells detached, and oil-
globules. As far as my observation extends
these structural alterations of the kidneys
have escaped the notice of preceding obser-
vers. The importance of these changes in
the kidneys cannot be overestimated, for upon
them apparently depends the suppression of
the urinary excretion, which is an almost
universally fatal symptom. The changes in
the kidneys may depend upon several causes,
amongst which may be mentioned as of prime
Importance the alterations induced in the
Relations of Cerebrospinal Meningitis to Malarial Fever, 60l
albuDen and fibrin of the blood by the febrile
poison, and the congestion of the capillaries
induced bj derangement of the Taso-motor
system of nerves and by the altered blood.
Urmary Bladder. — As a general rule the Urinary Bladder, — Often distended, with
bladder contains little or no urine in Yellow high colored urine, free from albumen and
Ferer. The urine is of a light yellow color, casts. In malarial haematuria the urine con-
without any crystalline bodies, and loaded tains c.\sts and blood-corpuscles, and des-
with albumen, granular fibroid matter, urate quamated cells of the tubuli uriniferi. Casts
of ammonia, casts of the tubuli uriniferi, high colored, and often contain colored cor-
ezcretory cells of the kidney. In many cases puscles.
the urine is entirely suppressed for as long
A period as 48 hours before death. So long
as the kidneys perform their functions freely
and regularly the patient may recover, even
though black Tomit may have appeared, but
if the action of the kidneys has been arrested
by structural changes, death is inevitable.
After the careful study and record of the phenomena and patholo^cal anatomy of a
large number of cases of the various forms of malarial fever, I have reached the fol'
lowing general results.
GENERAL CONCLUSIONS CONCERNINQ THE RELATIONS OF THE MALIGNANT FORMS
OF MALARIAL FEVER TO CEREBRO-SPINAL MENINGITIS.
1. In many cases of Malarial Fever, various disturbances of the Cerebro-Spinal
Nervous System occur, as active delirium and Coma, which sometimes disappear, without
leaving any manifest alterations of function or structure ; and which are quickly and
eotirely relieved by the free and energetic administration of stimulants and Sulphate of
Quinia.
It is evident that in such cases, there is neither structural alteration, nor inflammation
of the Cerebro-Spinal Nervous System. The term irritation, even cannot with any pro-
priety be applied to such phenomena, if the term be used in its ordinary sense, as
related to inflammation.
2. In many cases of Malarial fever, which prove fatal, no lesions are discovered in
the cerebro-spinal structures, which will account for the symptoms during life, or for
the fatal termination. The truth of this assertion has been established by the post-
mortem examinations, which I have at various times published in the Southern Medical
and Surgical Journal, and in the Transactions of the American Medical Association.
The action of the malarial poison upon the Cerebro-Spinal Nervous System, in such
cttses, may be compared to that of a violent alkaloid, or even mineral poison.
It is well established that in death from various violent poisons, which produce great
distorbanoes in the functions of the nervous system, we are in many cases, unable to
discover any lesions in the structures of the Cerebro-Spinal Nervous System, which
eoald at all account for the nervous manifestations during the action of the poison.
Other causes and agents are also active in producing the nervous disturbances in
Malarial Fever, as :
(a.) Alterations in the physical, chemical and physiological properties of the blood,
iodaoed by the direct action of the malarial poison upon the blood. This action is
characteriied by alteration and diminution of the fibrin, by destruction of the colored
blood corpuscles, by profound changes in the relations of the blood to the absorption of
oxygen, and elimination of Carbonic Acid. The altered blood itself} independent of
any direct action of the malarial poison upon the nervous ganglia, may induce such alter-
Attons in the nutrition of the nerve stmcturcs, as to induce the most aggravated nervous
disturbances* It is probable also, that under certain circumstances, the altered products
and constituents of the blood in malarial fever and other diseases, may act as poisons to
the DctTous system.
S02 Helations of Cerehro-Spinai Meningitis to Malarial Fever.
(6.) Arrest of the fanctions of certain organs, as the spleen and liyer.
(c.) Retention of certain excretions, which should be separated by the liver, colon
and skin, in the general mass of the circulation.
(jd.) Re-absorption of the altered secretions and products of certain orgus, and the
toxemic action of these agents. Thus the re-absorption of the altered bile of malarial
fever, is attended with intense headache, vomiting and even delirium. The re-absorp-
tion of the large mass of altered blood, in the enlarged, softened spleen of malarial
fever, must be attended with injurious results.
3. In some cases of Malarial fever, the severe nervous symptoms remain ; stima-
lantfl and revulsives, and Sulphate of Quinia exert no effect in arresting the disease, or
in arousing the patient from the state of Coma, or in relieving the convulsions and wild
delirium.
Such cases may occur at any period of the year, in those who have been subjected
to the action of malaria, but as far as my experience extends, they occur most frequently
in the autumn and winter.
Cold appears to have much to do with the production and terihination of such cases,
as we shall endeavor to show.
Individuals, who have the " seedi " of malaria in them, may even remove to healthy
regions, and pass months with only an occasional slight chill, or headache, and then sud*
denly be seized with fatal symptoms, which appear to be referable chiefly to the Cerebro-
spinal Nervous System. In such cases in which the cerebro-spinal symptoms were pereiat-
ent, and terminated fatally, the true causes are found in the lesions of the blood, as well
as of the nervous stnictures. Even in those cases of Pernicious Malanal Fever, which
manifested during life symptoms similar to those of Cerebro-Spinal Meningitis, I have
failed to detect after death fibrinous effusions, coating the membranes ot the brun and
spinal cord ; but on the other hand, the ventricles of the brain, and the sub-arachnoid
space, were in some cases distended with fluid. It is but reasonable to suppose that
this effused fluid may, in some cases of malarial fever, caase death ; and at the aame
time, it is not necessary to suppose that this effusion or fluid, in and around the cerebral
structures, is due to the presence of inflammation. After the colored blood oorpasdca
have been destroyed, and the fibrin and albumen altered, and the blood thns rendered
watery and thus altered in its most essential, physical, and chemical and phynological
properties, by the rapid, or more slow action of the Malarial poison, it is evident that
an effusion of the watery elements of the blood is liable to occur from the blood-vesseli
of any organ and tissue, in which there is an active determination or congestion of blood.
A prolonged chill, in itself, or in conjunction with the action of cold, which still faitbcr
increases the internal congestion, may be attended with such efiusions ci the Uqoor
Sanguinis of the blood, as permanently to impede the functions of important organs.
In like manner, (as will be fully shown in the investigations on Pneumonia,) io the
case of the lungs, the irritation or inflammation of a comparatively snuU portion of ma
organ, in the body, upon which the malarial poison has exerted its characteristio efiwts.
may be attended with large serous effusions, not only from the parts immediately
involved, by the inflammation, but from surrounding parts. We may thus explaiB im
certain cases at least, the sudden supervention of symptoms of compression of the brain.
without any apparent inflammation of that organ, in those laboring under the aelioB of
the malarial poison.
4.^ The functional and structural derangements of the Cerebro-Spinal Nervont Sys-
tem in Malarial Fever, and under the action of the Malarial Poison, without thoaa
symptoms characterized as fever, are referable to several causes :
(a.) The direct action of the poison upon the nervous structures.
We have regarded the action of the malarial poison in most cases, as deprvninfr
and not inflammatory, and analogous in its action and relations to certain alkaloid
vegetable poisons. We must admit, however, that to determine accurately, the alten-
tions of the nervous apparatus, under the action of various morbific and remedial agenu,
it is absolutely necessary that the structures of the different parts of the nerroiia
Relations of CerebrO'Spinal Meningitis to Xalarial Fever. 508
ratuB, should be submitted to rigid Chemical and Microacopioal Analysis. Numberless
and almost insuperable difficulties, lie in the way of complete microscopical and chemical
analysis of the Gerebro-Spinal System. It is impossible to obtain the substances for
analysis, until several hours after death, and in substances so liable to change, important
alterations may take place, even in this short time. It is impossible to separate the
blood from the nenrous elements ; and the presence of a varying amount of blood, of
varying constitution, would of itself be sufficient to vitiate the results of every analysis
which had for its object the determination of the chemical changes, induced by a sub-
tile poison. Notwithstanding this imperfect state of pathological science, we may by
an analysis of those phenomena, which can be investigated, form at least a reasonable
system of belief. We will endeavor to do this.
As far as my observations extend, in most cases of malarial fever, the pathological
alterations of the brain and spinal marrow do not correspond with the severity of the
symptoms during life. The most universal phenomenon, appears to be the stagnation
and accumulation of blood in the blood-vessels and capillaries of the brain, and its
meninges, and especially the pia^mater. This accumulation of the blood in the vessels
of the oerebro-spinal system, appears to be due neither to inflammation nor irritation,
but simply to a stagnation of the blood, similar to the stagnation and accumulation of
the blood in the vessels of the large organs. Such stagnation of the blood signifies
clearly a depression, rather than an exaltation or irritation of the oerebro-spinal and
sympathedc nervous system. These views are sustained by the results of treatment.
In numerous cases, I have seen the wildest delirium calmed, the intellect aroused into
fall vigor, fVom the mostrprofound coma, and the most alarming cerebral symptoms vanish
under the free use of the Sulphate of Quinia. When Quinia was withheld, the effects
of the stimulants and sinapisms would be temporary ; whilst when it was administered
in sufficient quantities the restoration of the intellectual functions, and the removal of
cerebral symptoms were permanent. Now is this the action of stimulants or of Sul-
phate of Quinia, upon an irritated or inflamed brain ? These facts alone demonstrate
conclusively that the Cerebro-Spinal System, is not usually the scat of irritation, or of
inflammation in malarial fever, if we limit irritation and inflammation to the meaning
universally adopted ; and that if irritation and inflammation of the Cerebro-Spinal
System do arise in the progress of Malarial Fever, they are by no means universal phe-
nomena, dependent upon the definite and universal action of the malarial poison.
Nevertheless, the malarial poison does appear to exert a direct influence upon the
structures, and especially upon the sympathetic system. This influence is manifested,
not merely^in the disturbed cerebro-spinal functions, and in the disturbances of the cir-
culation and respiration, and in the disturbances of the muscular force generally, but
also in the derangement of the nutritive processes of the nervous structures. Thus
daring the chill, and earliest period of the hot fit, the oxydation of Phosphorous in the
nervous structures, iS either arrested, or is so mod^ed, that the products of this impor-
tant change do not appear in the urine; as the hot stage however, progresses, and
daring the active stages and changes of fever, the elements of the nervous system are
rapidly oxydised and Phosphoric Acid increases largely in the urine. Although the
increase of Phosphoric Acid, necessarily attends all active changes in the constitution
and stmeture of the blood, muscles and nerves, and is characteristic of most fevers during
the hot stage, still the preceding facts, compel us to admit one or the other of two
suppositions ; — the cessation of the excretion of Phosphoric Acid and its compounds,
and its subsequent increase during the different stages of malarial fever, is either due to
the direct acdon of the malarisd poison upon the Cerebro-Spinal and Sympathetic
Nenrous System ; or to the effects of the changes excited by the poison, in bringing
aboat that condition which we call fever, the results of the increased chemical changes
of fever, being manifested in the excretion of increased amounts of Phosphoric Acid,
and of all other compounds necessarily resulting from those changes in the structures.
(6.) The direct action of the malarial poison upon the blood.
The colored blood corpuscles are not only greatly and rapidly diminbhed. in Malarial
504 Relations of Cerehro^Spind Meningitis to Malarial Fever,
Fever, but they also often lose a portion of their mineral oonstituents. It is probible
that the colored corpuscles, taken collectively, perform the offices of an inuneoae
gland, for the elaboration of the mateiials for the nutrition of the muscolar and
nervous systems. The coloring matters of the serum are increased, and the color-
ing matters of the bile, retained in the blood of Malarial Fever. The retention of the
coloring matters of the bile in the blood, as well as the absorption of the altered bile,
must, as we have before remarked, produce disturbing and injurious effects upon the
nervous system. The constitution of the urine is greatly altered in the severest forms
of Malarial Fever, and some of its most important constituents, are either not formed
or, if formed, are not eliminated. The retention of such constituents as urea and
uric acid, as well as of the cxcrementitious matters in a partially oxydised form, in like
manner, must disturb the normal action of the nervous system. The fibrin of the
blood is altered, both in quantity and quality. I have frequently found fibrinous heart
clots, free from colored blood corpuscles, in fatal cases of Malarial Fever ; and theee
clots often extended long branches into the pulmonary arteries. The coagnlation of the
fibrin during life, signifies loss of vitalitv in the blood, and change of its phyn*
cal properties and relations to the containing vessek. The presence of these bodies
especially in the pulmonary arteries, deranges the action of the heart, and of the geo-
eral circulation, and in like manner deranges the respiration, and the absorption and die*
tribution of oxygen, These disturbances must necessarily be attended by similar dis-
turbances in the actions of the nervous and muscular systems. These profound altets-
tions of the blood must induce corresponding disturbances in the muscular and nervous
systems, and in all the organs and tissues which derive their nutrition from the blood.
The profound alterations in the constituents of the blood, must produce correspondiDg
disturbances in the general and capillary circulation, and in the chemical changes in
the capillaries and surrounding tissues, upon which depend the devslopment and buuq-
tenance of the physical, muscular and nervous forces.
5. As a general rule, the general and capillary circulations are greatly disturbed in
Congestive Fever. These disturbances are manifested in the quick, thumping action of
the heart, the small, feeble, rapid pulse, the panting, full respiration, the want of cor-
respondence between the temperatures of the trunk and extremities, the aberration of
the physical, chemical, muscular and nervous phenomena, and in the stagnation of the
blood in the different organs and tissues. The stagnation of the blood in the organs,
tissues and apparatus, is due to disturbances in the sympathetic and oerebro-spinal sys-
tem, disturbances in the general circulation, disturbances in the quantities and qualities
of the constituents of the blood, and arrest or perversion of the chemical changes of the
capillaries. It is well established, that the circulation of the blood through the ospil-
laries, depends upon the quantitative and qualitative physical and chemical relaiions of
the individual constituents of the blood to each other, and to the capillaries, and the
surrounding tissues ; and that disturbances of these relations will be attended by
arrest of the capillary circulation, stagnation and congestion of the blood, notwithstand-
ing that the generaJ circulatory apparatus mhy reoeive sufficient supplies of uerroos
furce, and perform its offices with sufficient vigor. When the genml ciieulstioii is
impeded, either by the direct action of the malarial poison, or by the altered blood
upon the fibres of the heart, or by the withdrawal or perversion of the nervoos fiuroe,
supplied by the sympathetic nervous system, or by the cerebrospinal nervous syrtea.
through the sympathetic, conserjuent upon the action of the altered blood, or of the
malarial poison, or of both, it follows, as a necessary consequence, that the intiodiiedott
and distribution of oxygen will be retarded, and the chemical changes in the ospOlsrM
impeded, and the blood will stagnate and accumulate in the capilhuies.
As chemical change is necessary for the development of muscular and nervons foree^
and for the manifestation of intellectual phenomena, whenever the normal <»>>f^iff4
actions of the blood are disturbed, aberrated nervous action, both in the oerebnH^HBal
and sympathetic nervous systems may result.
G. The treatment of the sudden and fatal form of Malarial Fever, the psthokgy of
Relations qf CerebrO" Spinal Meningitis to Malarial Fever. 505
which we have endeavored to unfold in connection with that of Cerebro*8pinal Menin-
gitis, should be conducted upon the same general plan, regardless of the period of the
year, and the length of time which has elapsed since the exposure of the patient to the
mabrious poison. Quinine, stimulants, and revulsives, are the main and essential reme-
dies in the malignant form of Malarial Fever, as has been well established by the expe*
rience of numerous practitioners. These remedies should be used immediately and
freely, regardless of the cerebral symptoms, and of the presence or absence of delirium
and fever. The greatest portion of tncso cases will be arrested, and the patient rescued
from the jaws of death, by the energetic use of Quinine, in doses varying fVom 5 to 15
grains every two or three hours, and by the free use of diffusible stimulants, as Alcohol,
Sulphuric Ether, Chloroform and Ammonia. If the sudden and severe symptoms are
not arrested by the ft*ee use of Quinine and stimulants, and the patient does not die, but
remains in a feeble, semi-conscious state, anti-periodics and stimulants should not be
abandoned, even though we may be convinced that serous effusion has taken place
around the brain and spinal cord, and in the ventricles of the brain. The anti-periodics
should be continued to ward off if possible the recurrence of the congestive stage, and
stimulants and nutritious diet should be given to support the strength, with the hope
that the effusion may be absorbed, and the impaired cerebro*spinal structures restored.
Iodide of Potassium and Iodide of Quinia, together with blisters to the back of the
neck and head have proved beneficial in cases which would have terminated fatally with«
out the use of these remedies. It is well established, that Quinine, with the various
preparations of iron, with nutritious diet, and attention to the state of the liver and
kidneys, and the use of such depurants as the acetates and citrate of potaasa and
soda, constitute the best remedies in the treatment of those who are thought to be liable,
from previous attacks of Malarial Fever, to these sudden congestive attacks. Arsenic
is. without doubt, a remedy of great value in obstinate oases of Malarial Fever, but its
administration will not always prevent the sudden supervention of fatal symptoms.
Arsenic should never supercede entirely Quinine and Iron, and during its use, due
attention should be paid to the functions of the kidneys and liver ; and it should be
remembered that whenever it exerts its local effects upon the stomach, in producing
nausea and vomiting, its constitutional effect in relieving the paroxysmal fever, is
greatly impaired, if not wholly lost.
7. In Cerebro-Spinal Meningitis, ou the other hand, although many of the symp-
toms resemble those of certaia forms of malignant Malarial Fever, the nature of the
lesions, and the entire pathology of the disease is different.
The changes of the blood, and of the liver and spleen, described as characteristic of
Malarial Fever, form no necessary part of the history of uncomplicated Cerebro-Spinal
Meningitis. The pathological phenomena are more complicated in Malarial Fever than in
Cerebro-Spinal Meningitis ; whilst the former disease is induced by a poison which alters
the chemical and physical properties, and physiological offices of the blood, and which
acts also upon the muscular and nervous structures, the latter consists essentially in a
violent inflammation of the meninges, and especially of the pia-mater of the entire
cerebro-spinal svstem.
Notwithstanding the essential differences in the characters of these two diseases, yet
in many cases, and especially in the first cases of an epidemic of Cerebro-Spinal Menin-
f^itifl, the physician is liable to confound the disease with malignant Malarial Fever.
This similarity of symptoms is due, rather to the fact that the manifestations of depressed
and abemted nervous actions are similar in many sudden and &tal forms of disease,
involTiog profound lesions of the blood and cerebro-spinal and sympathetic systems.
As &r as our knowledge extends, the main differences between Cerebro-Spinal Men-
tDgitifl and Malignant Malaria) Fever, appear to be as follow^ :
5f)6 Relations of Cerebro- Spinal Meningitis to Malarial Fever.
DIFFERENCES BETWEEN THE SYMPTOMS AND PATHOLOGICAL LESIONS OP CEREBO*
SPINAL MENINGITIS AND MALIGNANT (CONGESTIVE PERNICIOUS) MALARIAL
FEVER.
(a.) Cerebro-Spinal Meningitis more frequently commences with convulsions, and
less frequently with a well marked chill, in which there is an elevation of the teropcn-
ture oF the trunk, and a depression of the temperature of the extremities.
(b.) The temperature is not subject to the periodical elevations and depression':
which characterize Malarial Fever.
(c.) Contractions of the muscles, and pei-sistent dilatation or contraction of tin-
pupils of the eyes, are less frequent in Malarial Fever.
((/.) The pulse is more rapid, feeble, and irregular, and subject to greater hourly
variations, and the respiration is more rapid, irregular and panting in malignant Mala-
rial Fever, than in Cerebro-Spinal Meningitis, and at the same time the temperature i^
liable to greater variations, and the difference between the temperature of the tnnA
and extremities is greater, as well as the range of variations during the progress of tin-
disease.
(e.) The tongue is dr3'er, redder and more coated in Malarial Fever.
(/.) The bowels are not so obstinately constipated in Malarial Fever.
(g.) The complexion is more generally sallow and ana}mic in Malarial Fever. Jaun-
dice is much less frequent in Cerebro-Spinal Meningitis.
(h.) The alterations of the blood are more profound in Malarial Fever. In Cervhn*-
Spinal Meningitis the fibrin is increased, and there is no destruction of the bloo<l ci»r-
puscles, nor of the ferment, by which glucogene is transformed into glucose, as in Mala-
rial Fever; ond the tendency to passive haemorrhages is much less in the former dis-
ease.
(i.) The liver and spleen are univei-sally involved in Malarial Fever, whilst they
are frequently not at all affected iu Cerebro-Spinal Meningitis. The bronzed liver and
large, softened, disorganized spleen of Malarial Fever, will serve to indicate to tbr
pathological observer whether or not the epidemic of (Vrebro-Spinal Meningitis Im? coni'
plicated with the action of malaria.
(J) Even in the most sudden, and malignant, and rapidly fatal forms of Malarul
Fever, with the greatest marks of cerebrospinal disturbance, no organized or onraniu'
ble fibrous lymph is thrown out from the menjbrancs of the brain, and if effu^ion^
occur, the fluid thrown out is serous, or serum colored with bile, and more rarely with
the coloring matter of the blood. On the other hand, the effusion of coagulablc pla>t -
lymph is the characteristic lesion of Cerebro-Spinal JMeningitis.
(/:.) The nervous disturbances are more uniform and persistent in Cerebro-Spin il
Meningitis, and do not yield, as they do in Malarial Fever, to the free use of alcoh-'i
stimulants and Quinine.
It is not to be denied, that inflammation of one or more organs may arise in tb«
progress of an essential fever. Pneumonia is frequently excited during the ppr>gn^s • !
Malarial Fever, just as peritonitis may arise in Typhoid Fever from perforatioa «»f tK-
bowels; but we contend that when these inflammations arise during the projrress *•:
these fevers, they do not stand in the relation of an effect to a cause ; they ar« in r:*
manner cssontially and uniformly the rl^^ults of th*' action of the Malarial and Tyy-ho. 1
poisons.
We have also dwelt upon the important fact, that tlio delirium, coma, and imiml.ir
nervous actions which characterize the severer forms of Malarial Fever, Typhoid .i:» i
Typhus Fevers, are not due to an inflamed condition of the cerehro-^pinal norrou* *\-
t3m, but rather to impairment of the nutrition and action of the ganirlionic cells, uiid •••
the nerves generally, in consequence of the disorganization of the blood and nutrit.v
fluids, and in conse(juence of the retentit)!i of noxious products resaltins* from tV-
chemical changes excited by the febrile poison, and probably abo in cousoiiuont^ • •
the direct action of the peculiar poisons upon the nen'ous element.^. The dolinun> :
ISjfBcts of Gases on the ilood of Living Animats. 509
they do occur, are consecutive to the constitutional disturbance, are due to the morbid condi-
tion of the blood, provoking exudation, and that their locality is determined by incidental cir-
cumstances."— Trans. Am. Med. Ass., vol. 17, 1866, pp. 330, 333.
Dr. W. W. Gerhard, from whom Dr, Levick and other physicians of Philadelphia,
appear to hare derived their ideas as to the nature of this disease, from the result of
two post-mortem examinations of patients who had died suddenly in the earliest stages
of the disease, concludes :
**That it is strictly a blood disorder, unconnected with any structural lesion. * *
Although the proof of spotted fever, being a blood disease, is to my mind conclusive, it must
not be ascribed to an impoverished condition of this fluid, from innutritions or deficient food,
as none of the patients whom I saw, wdre in a condition of actual poverty, and a large majority
of them belonged to a class amply supplied with all the comforts of life." — Trans. College of
Physicians, of Philadelphia, 1862-4, p. 44.
The observations of Dr. Gerhard and Levick, upon the blood abstracted after death,
are not only absolutely wanting in both Quatititative and Qualitative data, but are also
valueless when compared with the results obtained by Ames, Andral, Gavarret, and
others. The same criticism will also apply to the observations of Dr. W. H. H.
Githens, of Philadelphia, and to those of all pathologists who have neglected the Quan-
titative Analysis of the blood during life, and based their observations upon this most
complex of sJl organic fluids upon the results of a superficial occular inspection of the
blood in the dead bodies.
But even granting that the blood is fluid and dark colored, with shrivelled corpuscles
in the large vessels after death, such facts furnish no proof that the disease is essentially
a blood disease, and no justification for the assertion that ^' the only constant pathological
lesion, is an altered state of the blood.'*
A large proportion of the cases of Cerebro-Spinal Meningitis, which terminate fatally
are destroyed by the derangement of the function of respiration, resulting from the
dcraogement of the nervous centres and nerves presiding over this function, cither by
a direct impairment of their functions, or by the pressure upon the nervous cells and
fibres, of the products of inflammation, poured out into the closed Cerebro-Spinal
cavity ; and in all cases of this disease, the blood may be more or less altered by the
imperfect elimination of Carbonic Acid Gas from the lungs.
In other words, after the establishment of inflammation within the Cerebro-Spinal
Cavity, in this disease, the impairment of respiration b such that Carbonic Acid accu^
mulates in the blood, especially as the disease draws nearer to a close, and this pobonous
gas exerts certain effects upon the blood.
I have performed a number of experiments upon the action of various gases upon the
blood of living animals, and have been able to show that Carbonic Acid Gas, whether
administered artificially, or simply allowed to accumulate in the blood of the living ani-
mal, acta upon the blood corpuscles, and alters their shape ; and that this is precisely
the gas which produces a crenated appearance of the colored blood corpuscles.
As this is a point of some interest to pathologists, as well as physiologists, especially
in its bearing upon the microscopical examination of the blood after death, we will
present an account of the experiments.
BXPERIMENTfl ON THK EFFRCT8 OF UA8ES ON THE BLOOD OF LIVING ANIMALS.
Carbonic Acid Gatt.
Experiment 203: Salt- Water Terrapins, (Emys Terrapin,) and Yellow-bellied Terrapins,
(fimys Serrata,) were placed in large receivers containing Carbonic Acid Gas. The animals
took long inspirations and eipirations resembling deep sighs. The noise made bj the passage
of tbe gas, in and out of their lungs, resembled that often made by human beings dying from
oarcotic poisoning, or congestion of the brain. The breathing of the terrapins became more
and more laborious and less frequent, occurring at intervals of from ten to thirty minutes, and
finally ceased in from ten to twelve hours.
The blood was of a much darker color than when the lungs were supplied with atmospheric
air, and resembled the venous blood of the mammalia; upon exposure to the air, tor a length
SlO Effects of Gases on the Blood of Living Animals.
of time, it became upon its exterior, of a red color. Tlie heart, and iolestioes, and luogs,
were engorged with black blood. The contractility of the muscles was destroyed.
The blood corpuscles had undergone remarkable changes. They were shrivelled ed*!
contorted, presenting innumerable shapes, and were entirely altered from the ordinary ellipsoid.
These changes had taken place in the colored corpuscles, in all the organs and tissues of the
body. The effects of the gas appeared to have been confined principally to the exterior wall
of the blood corpuscles, for when they were treated with Acetic Acid, the nuclei were brougltt
out unchanged. The urine of all these terrapins which were confined in Carbonic Acid Gas.
contained grape sugar, which is not normally present in the excretions of the kidneys of tbe*i'
animals.
These effects upon the blood cells are not so manifest in warm-blooded animals, on accoant
of the rapid manner in which they are destroyed by this gas.
Experiments illaUrating tJie Action of Carbonic Acid Gaa on Birds.
Experiment 204 : Augusta, Ga., February 18th, 18GG. A strong, active pigeon, was subjecioi
to the action of Carbonic Acid Gas, by introducing the head into the open mouth of a receiver
filled with Carbonic Acid Gas. After the first two or three inspirations, the action of tli^
respiratory muscles, became labored and spasmodic — the mouth of the bird was thrown wiic
open, and the muscles of the throat were convulsed. Immediately after the manifestation of
the effects upon the respiration, the action of the heart was greatly increased in foree^tlie
pulsations were so powerful, that the thermometer introduced into the rectum, wai violently
agitated by each impulse of the heart. The bird was killed by the Carbonic Acid Ga? in 1.')
seconds.
EffecU on Temperature, During the violent pulsations of the heart, the thermometer ro-i
0.05^ C, and after remaining stationary for a short time commenced to descend slowly, a*
soon as death took place, and in five minutes after death, fell 0.55 C: temperature of atmos-
phere, 10^ C; temperature of rectum before experiment, 42°. C; temperature of rectum j^i*'-
before the heart ceased its violent action, 42^.05 C; temperature of rectum 5 mioates a'^^^
death, 41°.5.j 75 minutes after death, 33°.; 120 minutes after death, 20° C; 285 minatcs afu:
death, 21° C.
Poet-Mortem Examination. 24 hours after death, the blood was fluid in the blood-ressH- «•'
the brain, liver, intestines, and of all the organs, and presented a dark, venous hue. Wtiti
exposed to the atmosphere, the blood changed to the arterial hue, and coagulated.
Experiment 205: January 19th, 1801. A strong, active Pigeon, was treated in a sicuja*
manner to that described in the preceding experimeut, the effects of the Carbonic Acid (ti*
were similar, with the exception that the temperature of the rectum did not rise, but «l)«-«'
descended during the action of the gas. Temperature of rectum before the administration «'
the gas, 42°.5 C; during the experiment, the temperature descended 0°.or> C, and stoo<l f
42°.45 C. at the moment of death ; temperature of atmosphere, 18°. 3 C; of rectum, one b<>> '
after death, 34°.; 85 minutes after death, 32° C. Pott-MorUm Examination, The appearar-^
were the same as those indicated in preceding Experiment 204 ; blood-vessels of organ) &••'
tissues filled with black, fluid blood.
ExperimenU 206, 207, 208, 209, 210, 211, 212, 213, 214, 215: Repetitions of Experiments -' *
and 205, with Carbonic Acid Gas, results similar. Blood-vessels after death, filled with bUt^'^'
fluid blood.
Carbonic Oxide Oa».
Experiment 21G: Effects of Carbonic Oxide Gas on Corn-Snake, (Coluber GulUtus.) Vt-
bank. Colonel's Island, Liberty Co., Ga., July 1855. An active Corn Snake, (Coluber Gui'**
tus,) was placed in a glass jar containing Carbonic Oxide Gas.
At first the efforts of the serpent to escape were unceasing and violent. GradualU -
respiration became |more laborious ; it gasped violently for breath ; its motions became s; ^-
modic and were succeeded by intervals of apparent exhaustion. It died forty-five m • '*
after its introduction into the gas. An examination after death, showed that the contra* *
of the muscular fibres had been destroyed, and that the muscles could not be excited by 4" •
ficial stimuli. The heart was the last portion of the muscular system to yield to the ac:
of the poison, it continued to beat feebly for a short time after the thorax was opened T.
blood from all parts of the body was of a brilliant scarlet color, and coagulated into a i\*'^
firm clot, which was unstable and dissolved again. After the dissolution of the fibnn. t
blood corpuscles settled to the bottom of the glass vessel, and the serum above was |>e^r'r:'
clear, and without any marked color. Under the microscope, the blood corpuscles preS'V*
no unusual appearance, when their broad surfaces were turned towards the eye ; when h '*
ever they were viewed edgeways, they appeared swollen, and the central nuclei, was much I"*
distinct than in their normal condition, being scarcely visible. Acetic Acid exerted its c^t*
racteristic action, first rendering the blood corpuscles dumb-bell or hour-gla«9 in sbap^ v ■
Effects of Gases on the Blood of Living Animals. 511
▼ieired edgeways, aad then rendered the exterior cell-wall transparent, and revealed clearly
the naclei. When the Acetic Acid was neatralized with diluted liquor potasssD, the cell-wallg
were again brought into view. Concentrated liquor potassa> dissolved the blood corpuscles,
with no immediate change of color. In a few moments however, the color changed to a
darker red, and gradually assumed a brownish yellow color, and became as usual ropy and
viscid. Vigorous streams of Carbonic Acid and of Oxygen Gases, passed through separata,
and the same portions of blood, produced no change whatever in the scarlet color, or form of
the blood corpuscles.
Portions of this blood were kept for several weeks, and they still retained their scarlet color,
and did not undergo putrefaction.
These reactions show that the change in the color of the blood was due, not to an altera-
tion of the forms of the blood corpuscles, but to a permanent chemical change in the color-
inji matter. Another effect of the Carbonic Oxide Gas, was to render the fibrin unstable.
This gas arrests oxydation and the rapidity of its action, shows the great importance of this
process. The vital acts are incompatible with the sudden arrest of the chemical changes and
metamorphosis of the elements of the solids and fluids. If however the process of oxydation
be slowly stopped, by a gradual diminution of the temperature of cold-blooded animals, the
vital force is not destroyed, although the mechanical functions may bo suspended.
Erptriment 217 : A Bull Frog, (Rana Pipiens,) placed in a receiver containing Carbonic
Oxide Gas, manifested similar phenomena as in the preceding experiment 216, but died in a
much shorter time, viz : 10 minutes. This difference appeared to be due to the difference of
structure in the integumentary systems of the ophidians and batrachians. The naked skin of
the frog absorbed the Carbonic Oxide Gas, more rapidly than the scaly integument of the
(serpent. The blood presented marked changes, viz ; a brilliant scarlet hue, and instability of
the tibrin.
Experiment 218: Action of Carbonic Oxide Gas on Kiny Snake^ May 30lh, 1861. Active King
Snake (Coronella Getula,) 3 feet in length, placed in a glass jar of Carbonic Oxide Gas, mixed
uith one third of its volume of atmospheric air. The reptile gasped for breath, and in a few
moments, the mucous membrane of the mouth, presented a beautiful pink color, showing the
absorption and eff'ccts of the gas. In 15 minutes the reptile appeared to be powerfully affected
and lay in a comatose state, from which it was with difficulty aroused. It gasped violently
and spasmodically for breath, once or twice each minute — the mouth was thrown open, and
the entire muscular system was convulsed, as it gasped. All signs of life were extinct in two
hours with the exception of a slow pulsation of the heart. The heart continued to pulsate slowly
and feebly for more than two hours after the thorax was opened, notwithstanding that
mechanical and electrical stimuli failed to excite contractions in the voluntary muscles. The
bl )od in all the organs and tissues presented a brilliant scarlet color.
Experiment 219; Action of Carbonic Oxide Gat on Pigeon^ 1861. The head of a large, active
Pigeon was introduced into a receiver containing a mixture of Carbonic Oxide Gas and
atmoipharic air. The action of the heart, after the first two or three inspirations, was
greatly increased in force. The action of the heart, was so great that the thermometer in the
rectum was violently agitated. In this respect the Carbonic Oxide Gas, resembled in its
excitant effect upon the heart of the bird, Carbonic Acid Gas.
The action of the heart gradually subsided during the last two minutes of life, and appeared
to cease altogether, before the cessation of respiration. Death took place in about 5 minutes
after the introduction of the head of the bird into the receiver. The temperature of the
rtrtom at the commencement of the experiment was 42^.75 C; temperature of atmosphere,
H^^ C; the temperature of the rectum commenced slowly to descend, from the commencement
of the action of the poison, and fell 0^.25 C, during the continuance of life, and at the time
uf death, the temperature of the rectum stood at 42°. 5 C; 48 minutes after death, 37^.33 C;
] ".:j minutes, 33®.; 318 minutes, 23°.5 (.'.
Immediately after the inhalation of tliegas, and before death, the mucous membrane of the
(Vcs and mouth presented a beautiful scarlet hue.
Poft'Mcrtem Examination. The skin of the most dependent portion of the body, presented a
beautiful, light scarlet color. The blood in the vessels of all the organs and tissues, presented
A brilliant scarlet color. No other change was observed, in the form of the colored corpuscles
tinder the microscope, except that they were more .swollen than normal. When kept for days
ih^ blood still retained itn brilliant color.
Kxpf'n'menf J JO : Act ton of (jarhonic Oxide Gait.
January IHOO. Strong, active Pi;;eon: head of bird placed in receiver, into which a stream
^f Carbonic Oxide Gas was ttowiug. The gas was almof^t undiluted, and its effects were
immediately apparent, and the bird died in a few moments. The mucous membrane of the
mouth and eyes, were changed almost immediately to a bright crimson hue. The bird died
I one minnte. Teinprrature of atmosphere, IH®,.*! ('.; temperature of
512 Effects of Gases on the Blood qf Living Animals^
inhalation of gas, 40^.Y C. Tiie temperature commenced to deicendi almost immediately after
death, and at the end of 50 minates, stood at 33^.8 C; 75 minutes after death, 32^.33 C\
Pott-Mortem Examination. Mucous membrane of the month, ejes, and skin of the moit
dependent portions of the body, of a beautiful, light carmine color. The blood in all tho
organs and tissues presented a brilliant carmine color.
Experiment 221 : Action of Carbonic Oxide Gas on Dog, large Bitch ; strong and io good
condition. Action of heart, 100; respiration 35 ; temperature of rectum, 40^.6 G. The bead
of the dog was placed in a receiver containing Carbonic Oxide Gas ; its effects were manifett
in 2 minutes ; the dog cried out as if in great pain, but there were no tetanic spasms and do
struggles. Both the respiration and the actions of the heart were diminished. The retpira*
tion was only 2 per minute. At the end of 4 minutes, the respiration ceased entirely. The
gas was then withdrawn ; the dog excited most probably by the atmospheric air, gasped
several times, stretched itself, voided feces, and manifested signs of recovery. 10 minote*
after the first application of the gas, and 6 minutes after its withdrawal, the respirations or
rather gasps, were 17 per minute; action of heart 48, irregular, spasmodic and forcible—
arteries beating strongly ; profound coma. Temperature of rectum, 40^.4 C. The temperature
commenced to descend as soon as the gas had produced decided effects. As soon as there
were signs of returning consciousness, the dog was again subjected to the action of the Car'
bonic Oxide Gas ; the same phenomena were repeated, the dog moaned piteously, the mucous
membrane of the mouth, tongue-, and eyes, assumed a brilliant scarlet and pink color, aod
profound coma, while slow action of the respiration was produced in 3 minutes, and in 0
minutes both the respiration and the action of the heart had ceased. Temperature of rectcn
40^.35 G. All signs of life extinct.
The chest was opened about a minutes after all signs of life had vanished — the cavities of
the heart were distended with scarlet blood. Vigorous artificial respiration was then insti-
tuted. The heart failed entirely to respond to either artificial respiration, mechanical stimuli,
or the interrupted electric current. Peristaltic motions of the intestines could not be excited
by any means, mechanical or electrical. The voluntary muscles responded slowly and feeblr
to the electrical stimulus. The muscles of all the organs presented a brilliant color, the
blood in all parts of the body presented a brilliant scarlet color. This brilliant color pre-
sentod a marked contrast to that of the blood of animals killed by various other gases, u
Chlorine, Carbonic Acid, and Per-Oxide of Nitrogen.
30 minutes after death, the blood in the cavities of the heart, was found to be coagulated
G hours after death, rigor mortis had not taken place, and the limbs were perfectly flexible.
£jq>eriment8 22.2, 223, 224, ^^o, 226, 227, 228, 229, 2S0, 231, 232.
RcpetitioDB of preceding Experiments, (216-221), illustrating the action of Carboolo
Oxide (las on living animals. The results were similar. By numerous experiments. 1
found that Carbonic Oxide Gas produced the characteristic brilliant scarlet or carmioe
color in the blood of all vertebrate animals — Batrachians, Ophidians, Cheloniuis, Sau-
rians, Mammals and Birds.
EXPERIMENTS ILLUSTRATING THE ACTION OP BIN-OXIDE OP NITROGEN (NITUK'
OXIDE NITROSYL,) AND PER-OXIDE OP NITROGEN (NITRIC PER-OXIDE, OR HI-
PONITRIC ACID.)
Kotperiment 223, January, ISdl,
\ Chelonian was placed in a glass receiver containing a mixture of Bin-Oxide and Per*
Oxide of Nitrogen. The first effects of the gas upon the Chelonian (Bmys Serrata), appeared
to be stimulating ; the force and rapidity of the respirations being increased. At the cxpin-
tion of 60 hours, although all signs of life had ceased, the heart still pulsated. The Tt§*t •
leading to the heart, as well as the cavities of the heart itself, contained much gas. Tm
cavities of the heart contained fibrous concretions, entirely free frpm colored blood cc:-
puscles. Clots of blood were found in all the large blood-vessels. The blood presented »
purplish brown and yellow color. The action of the blood was acid. Under the microsco^
the colored blood corpuscles were found to be greatly altered presenting contracted, shriw
ellcd, altered forms. All the organs presented a brownish color.
Eciienment 2'Vf : lUuKtcatiag thf. action of Bin- Oxide and Per* Oxide of Xitro^a
18(jL
Placed a Musk Tortoise (Sternothaerus Odoratus), in receiver containiDg a mixtare of B*e-
Oxide and Per-Oxide of Nitrogen. Life was oot destroyed until the expiration of 50 boor*
I
Effects of Gases on the Blood of Living Animals. 513
Ai the end of ibis time, its blood, aod organs, and mascles presented a similar brown and
purplish brown color, as in the preceding experiment (233). The blood corpasoles were
f reatlj altered in form and appearance under the microscope.
£jtperimeiU '2S5 : lUmtrating tfie action of Per- Oxide ami Bin- Oxide of Nitrogen
on Birds.
1861. Active Pigeon ; head of bird introduced into a receiver containing a mixture of
Bio-Oxide and Per-Oxide of Nitrogen. Immediately upon the inhalation of these gases the
effects were evident. Death ensued in &0 seconds. During the action of the gas, the tem-
perature rose 0^.05 C, remained stationary, and then slowly descended after death.
Temperature of rectum at the commencement of the experiment, 41° C ; at moment of death,
41^.05; 53 minutes after death, 34^.25 C; 72 minutes after death, 31^8 C; temperature of
atmosphere, 17° C.
The blood in the cavities of the heart, and in all the organs and tissues, presented a brown*
ish yellow color.
Experiment i^tif) : lUiutratiag action of Per-Oxide and Bin- Oxide of Nitrogen^
1860. Strong, active Pigeon ; head of bird introduced into a receiver containing chiefly
Per-Oxide of Nitrogen.
The effects were almost instantaneous, and death took place in 28 seconds. There appeared
to be no special increase in the action of the heart, which continued for a few seconds after
the cessation of respiration. Temperature of rectum before the action of the Per-Oxide of
Nitrogen, 41°.7 C; the temperature rose slightly during the action of the gas, and at the
time of death stood at 42°. 05.; temperature of rectum 55 minutes after death, 35°.75 C; 84
minatei after death, 33°.75 C; temperature of atmosphere 17° C. The blood in all parts of
the body presented the peculiar brown, and brownish yellow, and purplish color, as in pre*
ceding experiments.
Kxptriment 237 : HUutrating action of JJeutoxide and Per- Oxide of Nitrogen on
Dog,
1860. Stout, active, healthy, cur bitch ; head surrounded by a receiver, fitting closely
around the neck, and through the opening at the other extremity the gases were introduced.
The gases appeared to produce at first a stimulant effect upon the nervous system, and an
irritant effect upon the mucous membrane of mouth, eyes and nose, and bronchial tubes. The
struggles were at first very violent ; in a few moments, white froth issued from the mouth.
fo the coarse of 10 minutes, the breathing became laborious, the struggles ceased, and the
dog died, 20 minutes after the commencement of the experiment. Temperature of rectum of
dog, 39°.8 C; the temperature commenced to descend immediately after death, and in one
hour stood at 37°.5 C; in two and one-half hours, 35°.5 C; in 5 hours after death 31°.5 C;
temperature of atmosphere 17°.5 C.
Autopnf 22 houn after death. — Blood-vessels of brain, spinal cord, and of all the organs and
tissues filled with brownish yellow and purplish blood. Lungs presented a brown, mottled
color; bronchial tubes filled with frothy mucus. Muscles of the heart of a pale brown color,
loogs and all the organs of a brownish color. The liver resembled the bronzed liver of Mala-
rial Fever.
The blood was drawn half an hour after death. It was fluid — presented a dark brown
color, and coagulated immediately after leaving the body ; coagulum firm ; serum clear.
Toder the microscope, the blood corpuscles presented a swollen, almost perfectly round
•hap«.
Exposure to the atmosphere did not induce any special alteration in the brown and yellow
color of the blood. It was possible to distinguish at a glance, the blood of animals thus
destroyed from that of those which had been killed by mechanical means, or by Carbonic
Oxide Qas, or by Carbonic Acid Gas. When the blood was painted on stiff, white paper, it
retatsed its color, and at the end of 14 years it can still be distinguished from any other
dned blood.
ExperimenU ^dS^ ^*J0^ ^40^ ^it^ .iJ^ : Illustrating the action of Dentoxide and Per-
Oxide of Nitrogen,
The blood of five cats was carefully examined under the microscope, and the appearnces
noted.
These aniou^ls were then successively subjected to atmospheres of these gases, ia large
glass receivers.
514 Effects of Gases on the Blood of Living Animals.
Iq each case the animals struggled violently, and cried, the cries expreMiag great agony
nnd pain. Before death, they became jcomatose, the respiration spasmodic, and the month
Avns filled with froth. The time of death Taried from 2 to 10 minutes.
Blood drawn, both during life and after death, presented a dark brown appearance, whoUj
unlike healthy blood ; and the blood corpascles presented a swollen, altered appearance.
All the organs, as well as the muscular tissues, presented the usual brownish appearance.
Kxpenrntnts JJ^^i. '2U, ^4o, 246, 2^7, 2^8, 249, 260 : RepetUiom of preceding Experi-
meats on Various Animals, illustrating the effects of Bin- Oxide and Per-Oxiih
of Nitrogen.
KcHultH Bimilar to those jast recorded. In all eases, no matter what the char-
acter of the animal, profound changes were induced in the color of the blood and
organs, and this color was similar in all the various classes of animals.
EXPERIMENTS ON THE INHALATION OF CHLORINE.
Experiment 251 : Effects of CIdorine on Birds,
January, 1861. Large, active Pigeon. Head of bird held in mouth of glass receiver ecu-
taining Chlorine. The effects of the Chlorine gas were immediate, after the first inspirations.
The bird struggled violently. The action of the heart was greatly increased. The effects on
the temperature were marked and decided. Temperature of atmosphere 16^.5 C; tempera-
ture of rectum of bird before the inhalation of the gas, 41*^.9 C. The inhalation of the Chlo-
rine produced a rapid rise in the thermometer, and in 5 minutes stood at 42^.5 C. Durinf;
this rise in the thermometer, the action of the heart was greatly increased in number and
force. The thermometer was elevated and violently agitated at each impulse of the heart.
The head of the bird was held in the gas only a few seconds, just long enough to caase rev-
eral inspirations, and was then removed, and as we have said, in five minutes it had the effect
of causing an elevation of 0^.6 C. The temperature then commenced to descend, and at thf
end of two minutes stood at the original point, viz : 4l°.9 C. The bird was again subjected
to the action of the Chlorine gas, and the action of the heart, which had subsided with tht
fall of the temperature, immediately became violent, and the thermometer indicated a rise of
temperature, and in two minutes stood at 42*^.2 C. At the end of this time, which was joii 9
minutes from the first action of the gas, the bird gave a violent struggle and died. As soon
as death took place, the thermometer, after remaining stationary for a few minntet, ooin*
menced to descend, and in 50 minutes stood at 36** C.
This experiment confirmed the result previously stated, that Chlorlnn acts as a stimulant tu
the heart, and also increases the animal temperature.
Autopsy^ one hour after death, — The interrupted electrical current bad no efl\ect on the volao*
tnry and involuntary muscles. The blood was fluid, and presented a purplish brown color
but changed to the arterial hne when exposed to the atmosphere. Cerebro-spinal system
not specially congested. Cavities of heart filled with fluid blood, which did not Goagvlate
when removed. Longs presented a pale color, quite different from the brilliant bae of th«
lungs of birds. Haemorrhage had taken place from the mucous membrane of the mootb and
trachea. Liver congested. Under the microscope, the blood corpuscles in many tnstABcet
presented an altered, swollen and shrivelled appearance.
Experiments 252, 253, 254, 255, 2^G, 257, 258, 250, 200 :
Repetitions of preceding experiments with Chlorine on birds. Results similar to those
detailed in Experiment 251.
Experiment 261 : IHuttrating the effects of Chlorine Gat on Z>o^.— May 27th, 1861. Tonog.
bQt grown hound dog. Action of heart, 100 per minute; respiration 50 per mifiote; teoH
perature of atmosphere, 25® C: of rectum, 39^.7.
The first inhalations of the Chlorine, mixed with four times Its volume of atmospheric air.
produced violent struggles and cries, and the thermometer rose almost immediately to 39^.^*
C. Action of the heart 2 minutes after the inhalation, 1 13. The Chlorine excited the laliwy
glands and mucous membrane of the month violently, and the saliva poured in streams from
the mouth. This effect is characteristic of Chlorine, which acta powerfully npoo themncocf
membrane. Ten minutes after the first inhalation, the Chlorine was again administered, an*:
again excited violent struggles, and the force of the impulses of the heart was stUt fortber
increased. Action of the heart 114 per minute. As in the case of the action of Bromiac. t«
also in that of Chlorinei the pulsations of the heart were greatly accelerated In insplmtioB
but were diminisKed in expiration. The respiration was diminished in freqneacr, and hm ' >
l^eet$ of Gases on the Blood of Living Animals^ 515
minutes ftfter the inhalation of the Chlorine, it was onlj 18 per minute. The respiration was,
bowsTer, fuller and more labored than before the administration of Chlorine.
The Chlorine was again administered by inhalation, 35 minutes after the first inhalation.
Stru^ffles and loud cries were again excited. These struggles appeared to be due to the irri-
tatini^ effects of the Chlorine upon the fauces, and bronchial tube, and nose, and to spasm of
the epiglottis, and the consequent sense of suffocation.
After this inhalation, the action of the heart was 114, and respiration 16 per minute; tem-
perature of rectum, 39^.9 C.
Fifteen minutes after the ptccediog observation, during which time no Chlorine had been
administered, the action of the heart was 116, and the respiration 24 ; temperature of rectum,
390.5 C.
The dog was now removed from the operating table ; he stood up and walked with facility,
bnt appeared to be oppressed in his breathing ; the sounds of the longs indicated an accumu-
lation of mucus in the air cells of the bronchial tubes, and he gave repeatedly short, hoarse
coughs. The salivary glands and mucous membrane of the mouth and nostrils of this dog,
had been excited to a most profuse secretion, and at least one pint of mucus had been poured
out.
Six hours after the preceding observation, the dog still coughs occasionally, and walks
about. The excessive secretion of mucus has ceased. Action of heart, 140 ; respiration, 22 ;
temperature of rectum, 39*^.7 C.
Tbvnext morning the dog is active, but suffers with a slight cough, and mucus ralis in
breathing. Action of heart, 120 ; respiration 32 ; temperature of rectum, 40^.9 C. Under
the action of the Chlorine, inducing irritation and congestion of the lungs, the temperature
has, in 15 hours, risen 1^ C.
Twenty-four hours after the inhalation of the Chlorine, one fluidounce of a saturated
solution of Chlorine in water, was injected into the left Jugular vein. The dog remained
quiet for a few seconds, then cried out in great distress, the respiration ceased, but the heart
continued to act slowly. One minute after the injection of the Chlorinated water, and the
cessation of respiration, the heart still pulsates. The temperature commenced slowly to
descend, as soon ns the effects of the Chlorine, in reducing the respiration were manifest, and
now, 3 minutes after the injection, stands at 40^.5 0. A most copious flow of urine has taken
place. 7 minutes after the injection of the Chlorine, all signs of life are extinct.
The thorax was next opened, and artificial respiration instituted — the heart had ceased to
beat. The auricles, especially the right auricle, responded to the artificial respiration, and
commenced to beat slowly. The ventricles could not be excited to contract, either by me-
chanical stimuli, or by strong interrupted electrical currents. All the muscles of voluntary
motion responded to the electrical stimulus. The peristaltic motions of the intestines could
not be excited.
The pulsations of the auricles continued for 20 minutes after the institution of artificial
respiration ; after their cessation, the auricles were opened, and it was found that the blood
bad coagulated in the auricles, and in the right ventricle. This fact is interesting, as show-
ing the rapidity with which the blood will coagulate under the action of certain poisons »
Cavities of heart distended with black, coagulated blood. Liver of a deep purplish, slate
color, like that of Malarial Fever. 45 minutes after death, the muscles responded feebly to
the interrupted electrical current. The blood from all parts presented a brownish and
bleached appearance ; the muscles also presented a brownish, bleached appearance. Rigor-
mortis, two hours after death, well formed.
Experijnent 262: Action of Chlorine on Warm-blooded Animals. — January, 1861: Fine, large
cat, placed in a receiver, into which Chlorine was slowly introduced. The struggles of the
cat soon became very violent, and the actions of the lungs spasmodic. Froth issued from the
month. The period of excitement lasted 10 minutes, and was followed by a comatose condi-
tion, accompanied with spasmodic actions of the respiratory and voluntary muscles generally.
There were tremors of all the muscles. Death took place in 20 minutes.
AuUpsyt one hour after death. — Blood-vessels of the brain filled with dark purplish, brown
blood. The muscles presented a more dull, brownish, bleached color than usual, and pre-
sented a marked contrast to the deep colored muscles of animals killed by mechanical means.
After standing for more than one hour, the blood did not coagulate. The lungs presented a
brownish, bleached appearance. The bronchial tubes did not present any appearance of
marked congestion. AH the vessels supplying the bronchial tubes, 'and trachea, and air cells
were filled with brown, fluid blood.
The left cavities of the heart contained fluid blood. Tnder the microscope, some of the
colored blood corpuscles presented an altered, swollen appearance ; others wore normal.
ExperimenU 263, 264, 265, 266, 267, 268, 269, 270, 271 : Repetitions of preceding experi-
ments on warm-blooded animals — mammalia; results similar.
Bipermtnt 272 : Effectt of Chlorine Oat on Dog,^ViKj 8th, 1860 : Healthy, young dog. Tem-
perature of atmosphere, 26^ C; of rectum, 40^.75 C. The dog was introduced into a large
&16 ^eets of Gases on the Blood of Living Animals,
gliisi reeeirer, and subjected to the action of ChlorlDe gas ; the dog struggled Tiolentlj, tod
cried greatly during the action of the Chlorine. During these struggles, and during the
action of the gas, the thermometer rose, and at the end of 5 minutes, stood at 41^.6 C.
Death took place in 7 minutes. During the action of the gas, the tongue became Terj red,
and the breathing was spasmodic. 16 minutes after death, the thermometer indicated 41* C:
128 minutes, 37*^.9 C; 143 minutes, 37^.5 C.
AtUopiy^ 143 minutet after death — Cadaveric rigidity well marked. Powerful interrupted
magneto-electric currents passed in every direction through the nerves of motion and senis-
tion, and through the nervous centres and muscles, produced no effects upon the moscolsr
system. Blood-vessels of brain filled with dark, brownish colored blood. Lungs much cob-
gested ; liver also congested in yarious portions. Under the microscope, the blood corpviclei
were in many cases swollen, and in others crenated : they were especially altered in the
blood-vessels of the lungs.
JStperimetU 273: Injection of Atmofpheric Air into the Blood,-^\S60 i About one half ptot
of I atmospheric air was forcibly and rapidly forced into the left | jugular vein of an active
Scotch Terrier dog. The animal emitted piercing cries, struggled violently, andd ied in Icfs
than one minute from the commencement of the experiment. When the pipe was withdrswo,
air and blood issued with force from the vein. Temperature of atmosphere, 15® C; of rectom,
39.^6. The temperature remained stationary during the injection of the air, and commeoced
to fall immediately after the death of the dog, and one hour after, was 37*^.1 C; 95 Bsinotei,
36*^.26 C; 5 hours and 45 minutes after death, 28°.8 C. Rigor-mortis commenced one boor
and thirty-five minutes after death. 22 hours after death, temperature of rectum, 17^.1 C;
temperature of atmosphere, 14*'.4 C.
Autoptyf 22 hourt after death. — Blood-vessels of the brain and spinal cord greatly congeited
with blood, which contained numerous air bubbles. Lungs much congested with blood, asd
blood-vessels contained air. Heart contained air in all the cavities. The liver was congeited
and mottled, and the hepatic and portal blood-vessels contained numerous air bubbles. The
stomach and intestines, both upon the exterior and interior, presented a deep red, congested
appearance. The large and small bood-vessels and capillaries could be seen ramifying is
every direction, as if fully injected with red coloring matter. The blood was fluid in all the
vessels, and did not coagulate when removed from the body. When first removed from tb«
vessels, and whilst in the vessels, it presented the usoal venous hue ; but after removal sod
exposure to the atmosphere, it rapidly absorbed oxygen, and changed to a scarlet arteriii
hue. Microscopical examination revealed no alterations in the form of the colored cor-
puscles.
During the course of 48 hours, the coloring matters of the blood exuded through the coAt*
of the blood-vessels of the stomach and intestines, and colored the tissues of a uniform deep
arterial hue. To the eye, both the external and internal surfaces of the stomach and intes-
tines presented the appearance of the greatest congestion and marked inflammation.
In this experiment, a purely mechanical cause produced intense congestion of the blood-
vessels, and especially of the smaller branches and capillaries ; and on standing, the texteres
were uniformly discolored by the escape of the coloring matters of the blood. Similar phe-
nomena are witnessed in the bodies of patients who have died with various diseases, and aod^r
the action of such poisons as Prussic Acid and Cyanide of Potasiom, which induce congestion
of the internal organs. It is also evident that the appearances of congestion are gnttCj
increased by post-mortem changes. Such facts illustrate, in the clearest manner, the oecei-
sity of caution, when we endeavor to determine accurately the characteristic morbific eftcu
of diseases and poisons.
Experimmtt 274, 276, 276, 277, 278, 279, 280 : Illustrating the effects pf the mecbaaict'
injection of air into the blood-vessels ; results similar, as in Experiment 273. The appear*
ances of congestion of the various organs and tissues varied, in these experiments, witb tbt
amount of air injected, and the force used.
Experiment 281 : lUuatraUngtheeffecU of the Oontinuoiu Inhalation of Hjfdrogtn (Tot.— Havbask,
Coloners Island, Liberty County, Georgia, 1855 : A yellow-bellied terrapin, which bad btcs
placed in a receiver of Hydrogen gas, died in 10 hours. The blood corpuscles from all psr^
of the body presented an altered, shrivelled appearance, similar in all respects to that pro*
duced by Carbonic Acid gas. The simple exclusion of the atmosphere, and the sabstitatiot
of an inert harmless gas, produced remarkable alterations in the shape of the blood cor*
puscles. The urine of this chelonian contained grape sugar.
Experiment 282 : EffecU of Exclusion of Air on the J9^o</.— Maybank, Liberty Coaaty, 6«-
July, 1859 : Ligatures were passed around the trachea of yellow-bellied terrapias, (ib^
Serrata), and salt water terrapins, (Emjft Terrapin), The access of air to the lungs was tkti
completely cot off. These chelpnians gave signs of muscular contractility from 12 te •'*
hours.
In all cases, after death, the blood presented a dark purplish, almost black color, and vs*
^eets of Gases on the Blood of Living Animals. M
mach darker than that of reptiles in its normal condition. The blood coagulated when
abstracted.
The blood corpuscles, (under the microscope), had undergone important modifications*
Manj of them were shrunken, contorted and contracted ; others were swollen, assuming the
forms of spheroids, cubes and oToids. The nuclei, which were rendered distinct by the action
of Acetic Acid, in manj cases presented corresponding changes.
A stream of oxjgcn passed through the blood did not alter its color, and did not restore
the colored blood corpuscles to their normal shape. In every instance, the urine of these
chelonians contained grape sugar.
ExperimifiU 283,284, 285, 286, 287, 288, 289, 200, 291, 292, 293, 294 : Illustrating the efTects
of Nitrogen Gas and Atmospheric Air on animals in closed receirers.
I have also performed a nnmber of experiments on various animals, both warm and cold-
blooded, placing them in confined portions of Nitrogen and atmospheric air, in closed
receivers.
When an arrangement was made by which the Carbonic Acid Gas, Ammonia and organic
matters thrown off from the lungs, were absorbed, as fast as generated, the animals lived at
least five times as long as when they were subjected to the deleterious effects of the products
of respiration. The truth of this proposition was readily demonstrated, thus : Two birds, of
equal sise, and age and activity, are placed in two glass receivers (filled with either Nitrogen
or atmospheric air), of precisely the same capacity. lEiermetically seal up one of the birds in
its receiver. Invert the other receiver over the water bath, so that the feet of the bird shall
rest in the water. In the latter experiment the water will absorb the Carbonic Acid Gas and
other deleterious products from the lungs, skin, kidneys and bowels.
The bird hermetically sealed, will manifest, signs of poisoning in a few minutes, and will
die with convulsions in less than one hour. The bird confined in precisely the same amount
of atmospheric air or Nitrogen, in the receiver inverted over water, will show no signs what-
ever of derangement at the time of the death of the other bird, and will live for many hours.
A chicken (three-fourths grown, cock,) thus treated, during the winter season, lived for more
than six hours in a receiver containing less than one gallon of atmospheric air.
After deatli in all such cases, the blood presented a black, fluid appearance, and under the
microscope, the blood corpuscles frequently presented a crenated appearance.
The results of the preceding experiments sustain the view which I have advanced,
that a portion at least of the phenomena of Cerebro-Spinal Menin£;itis are due to the
(lUturtMtncefl of respiration ; which dbturbanccs result from derangement of the nerves
and nerve centres at the base of the brain, and are attended by the retention of a dele-
tcrioas gas (Carbonic Acid Gas), and other poisonous matters in the blood.
The mere inflation of the pulmonary apparatus with air does not constitute respira'
tion ; in this process there are changes involved, which are dependent on nervous
iofluence; and as the integrity of the blood de))cnd8 absolutely upon the proper per-
formance of the respiratory act, in all its manifold physical, chemical and physio-
logical relations, it is evidebt that when the nerve centres and nerves which control the
respiratory act, are suddenly and powerfully impressed by an inflammatory action, cer-
tain lesions of the blood must follow, in the relation of effects to a definite cause.
The results of the foregoing experiments clearly show that it is useless to attempt to
define the character of a disease, by a few crude observations on the blood found in the
vessels after death.
The nervous phenomena manifested during the progress of Cerebro-Spinal Meningitis^
as well as the constitution and appearance of the blood, and the results of post-mortem
examinations, do not sustain the proposition that the disease is essentially a blood
disease.
It is diflicult to find any poison which acts exclusively upon the blood, and in
attempting to select the best examples of diseases, produced by poisons, which are
known to act directly upon the blood, it must also be admitted that there is a class of
phenomena which may with much plausibility be referred to the simultaneous or con-
secutive action of the poisonous agent or agents upon the sympathetic and Cerebro-
spinal nervous systems.
For purposes of comparison, I have made selections from my experiments and original
observations and investigations, upon the action of three distinct poisons, which are
known to produce the most powerful effects upon the constitution of the blood, viz :
Bromine; the Poison of (he American Coppn'hend and RattUmahe. and Putrid
Organic Matter^
518 J^ects of Gases on the Blood of Living Animals,
Ejqferiment 295; Illustrating the action of Bromine. Augusta, Qa., February 4ih, 1861.
Active Female Scotch Terrier. Action of heart, 96 per minute ; action of heart increased
during inspiration, and diminished during eipiration. It was most rapid at the period of
complete inspiration, and slowest at the end of expiration. Respiration 10 per minute ; tem-
perature of atmosphere, 11^.1 C, of rectum of bitch, 39*^.05 0.
The dog was made to inhale the fumes of Bromine. The effects upon the animal were imne-
diate, irritating the lungs, eyes, and mouth, causing labored respiration, and most Tiolent
struggles, and loud cries. A profuse secretion of mucus took place from the eyes, month aod
nose, and bronchial tubes. The dog struggled violently, and the temperature rose 0^.3 C. in
5 minutes, and stood at 39^.35 G.
15 minutes after the commencement of the inhalation of the fnmes of Bromine, largely mixed
with atmospheric air, the heart gave 90 impulses per minute, and the respiration was 12;
temperature of rectum, 39^35 C.
30 minutes after the commencement of the inhalation of Bromine, the respiration is full aod
regular, but the action of the heart can scarcely be f^lt, and the temperature of the rectum is
slowly descending. The bronchial tubes and rectum, appear to be fast filling with mueai :
and loud rales may be heard, at a considerable distance, and the bronchial tubes appear to b«
contracted, the phenomena and sound resembling those of Asthma in the human sabjtec.
40 minutes after the first inhalation of the Bromine, the temperature of the rectum wu
39° C, showing a loss of 0.35 G. in 40 minutes. The temperature continued to descend for
several minutes, and after reaching 38^.9 0., it slowly rose during several minutes to 39® C .
and then again in 10 minutes fell again to 38^.9 G. The filling of the bronchial tubes with
froth, and the diminution of the action of the heart, are without doubt important cansei of
the fall in the temperature. The action of the heart is now so feeble that it is with diflcoltj
counted.
The dog was now loosed, one hour after the commencement of the inhalation — it was able
to walk about with perfect ease, and appeared to retain all its senses, with the exception of
sight, which was impaired by the local action of the Bromine upon the cornea, renderinf it
opaque. The skin of the face appeared to be greatly irritated by the Bromine as well u the
mucous membrane of the mouth and nose. The temperature of the body continued steadily
to descend, and the difficulty of breathing continued steadily to increase; and at the end of
five and one quarter hours, the respiration was labored and tuU, with loud rattling sounds in
the throat, and wheezing sounds in the lungs ; bloody froth issued from the mouth and nos-
trils ; there was a great tendency to sleep ; when aroused by shaking and loud talkinf,
attempted to walk, bat was unable to do so, the limbs being weak and tremulous, sat op iod
fore legs) for a few moments, and then fell over on the side, and appeared to be completflT
exhausted, and almost immediately relapsed into a profound slumber, with loud, har^'i.
labored breathing.
Action of heart feeble, determined with diflScnlty, 100 per minute. Respiration, 15 p«r
minute ; temperature of rectum, 34^.35 G. The temperature of the body has fallen 5** C. ^ince
the administration of the Bromine. Half an hour after this observation, the temperature of
the rectum was 33^.7 C., having fallen 0^.65 G. in this time. The extremities and surface of
the body also feel very cold. The loss of temperature appears to be due to three causes ; I't.
the local inflammation of the pulmonary apparatus, and the filling of the bronchial tubes an-i
air cells, with thick tenacious mucus ,* 2d, alteration of the blood ; depressing effects opor
the action of the heart.
At each inspiration there is a spasmodic contraction of the muscles of the neck, associate-l
in the act of inspiration. The contractions of the muscles of the mouth and nose, as well a»
the spasmodic action of the organs of respiration, indicate derangements in the respiraton
centres of the medulla oblongata, and evidence approaching dissolution.
The temperature continued to fall. The dog was kept under observation for about T boar«,
till 6 P. M.
During the remainder of the evening and night, the phenomena were noi observed ; — tbr
dog was found dead the next morning. Rigor-mortis complete. The temperature of the bod<
corresponded with that of sorrouading inanimate objects, and the atmosphere. It is probata
that the dog died shortly after the last recorded observation.
Autopty^ about 12 houra after death. — Brain greatly congested, with dark, almost black blood-
both arteries and veins appeared to be filled with blood, even the minutest vessels were dis-
tended with blood. The blood-vessels of all the membranes of the brain, were thus fi!!< ^
with blood. The muscles presented a dark purplish hue, and when cut, little or no blo<>i
escaped from them. The coloring matter of the blood appeared to have transuded tbroup*
the minute blood-vessels. The blood in the small vessels of the dura-mat^r, mrachaoid as'f
pia-mater, after exposure to the atmosphere, changed to a bright arterial hue. Microscopica'.
examination of the brain and spinal cord, revealed no lesions in the ultimate eltments.
The lungs collapsed but slightly, when exposed by the removal of the anterior wall of the
Effects of Gases on the Blood of Living Animals^ 519
thorax. They presented a bigblj congested appearance throughout. Mucus membrane of
bronchial tube of a deep red color, and greatly congested with blood. Bronchial tubes and
air cells contained much bloody froth.
All the cavities of the heart were distended with imperfectly coagulntcd, viscid, black, tar-
like blood.
The Vena Cava, and large veins of the abdomen, stomach and intestines, were distended
with black, viscid, tar-like blood. Liver congested in some parts and not in others, presenting
a mottled appearance ; gall-bladder filled with bile. The mucous membrane of the stomach
was of a nniform, deep reddish purple color, and appeared to be in a state of active conges-
tion. No blood was effused into the stomach. Mucous membrane of intestines purple, greatly
congested ; blood vessels distended with blood. The mucous membrane was coated with thick
bloody mucus, and when this was washed away, the surface presented a deep purple color.
It is possible that portions of the bromine may have been swallowed with the saliva and thus
acted locally ; it is also probable that the congestion of the alimentary canal was due to the
alterations induced in the constitution of the blood itself.
When the effused blood was examined under the microscope, it was found to consist of
altered blood corpuscles, resembling the coffee ground deposit of yellow fever black vomit,
together with less altered blood corpuscles, and acicular crystals, similar to those found in
such abundance in the blood.
Spleen presented a dark blue color, and appeared to be more distended with blood, and
iotier than usual. The blood of the spleen contained acicular crystals of hasmatin. Kidneys
congested with black blood.
The blood after its removal from the vessels coogulated imperfectly, and there was no con-
traction of the coagulum ; it had no consistency and the coagulnm was ruptured with gently
shaking the vessel, and not a drop of serum was separated, rpon exposure to the atmos-
phere the blood changed to a brilliant carmine hue, when spread in thin layers ; but in mass
it presented a black color, resembling tar in color and tenacity, and did not change to the
arterial hue even after 48 hours.
I'nder the microscope the colored blood corpuscles were swollen, and had a tendency to
run together, and form stars and acicular crystals. The blood contained numerous acicular
crystals of hiematin. These crystals increased in number and size, during the slow drying of
the blood upon the glass slide. The crystals in the blood in its natural state, when first
abstracted from the vessels were acicular and colorless. The crystals of hsematin which
separated in great numbers during the drying of the blood presented a deep brown red color.
Careful drawings of the appearances of the blood and of the organs specially affected, as
the lungs and intestines were made in this case, as they had been in the previous experiments
fur comparison.
It is worthy of note that the Bromine had acted powerfully npou the blood, causing altera-
tion in the form of the colored blood corpuscles, and the formation of acicular crystals ; which
differed materially from the crystals of haematin, which separated in great numbers, during
the slow desication of the blood.
It is also worthy of note that these alterations of the blood, were attended by passive
lia*morrhages from the intestinal mucous membrane, as in yellow fever.
RXPKRIllKNTti ON THE ACTION OF THE POIKON OF CERTAI.V AMERICAN OPHIDIANS.
ExpcntiieiiU icith the Poison of tJie American Ojppcrhanl ( Tngonoccphalas Contor-
trix — Holbrooh) .
Tbii reptile was first described by Linnseus, in the twelfth edition of his Systema Nulurap,
under the name of Boa Contortrix. The genus Boa, of Linnaeus, included all those serpents,
veooinoai or not, that had plates under the tail, as well as on the abdomen.
^nowywai. — Boa Contortrix, Lin., Syst. Nat., vol. 1, p. 373. Angkistrodoo Mokeson,
Bea«r., Tran. Amer. Phil. Soc, vol. IV., p. 381. Cenchris Mokeson, Daud., Hist. Nat. des
lUpt., vol. V. p. 358, pi. XL, fig. 3. Scytalus Cupreus, Rafin., Am. Jour. Arts k Sci., vol. I.,
p. 85. Scytalus Cupreus, Uarl., Med. k Phys. Res., p. 130. Ceuchris Mokeson, Uarl., Med. k
Pbye. Res., p. 128. Trigonocephalus Contortrix, Holbrook, North Am. Herp., 1838, vol. III.,
p. 39, pi. XIV. Trigonocephalus Contortrix, DeKay, Zoology of New York, Part III., p. 5:i
pi. IX., fig. 18. Copperhead, Vnlgo, Red Adder, Dumb Rattlesnake, Red Viper. Clinnckhond,
Copp«r-belly, Dead Adder, Bastard Rattlesnake.
The geographical distribution of the Trigonocephnlud is extended, Nuturulists having
ubaarved it npon the eastern Atlantic slope, from the western parts ol New Enp:land to the mid-
dle of Florida. Its geographical range extends from about 4.")® north latitude to the Gulf of
Mexico, whilst npon the west it appears to. be limited by the Alleghany Mountains. In tU«
520 Experiments on the Action of the Poison of American Ophidians.
Valle/ of the Mississippi, its place is supposed, by Dp Holbrook, to be tappUedbj the Toxioo-
phis Atro fiiscos, of Troost, which it resembles in habits. The motions of the Copperhead
are sluggish ; and when approached it prepares for defence, raising its head, throwing ont the
tongue, hissing and contorting, and flattening the head and body. The following is an accu-
rate description of this reptile, as given by Dr. Holbrook in his great work on North Americtn
Herpetology :
Charaeteri. — Head very large, triangular, covered with plates in front and on the vertex,
with scales behind, and a pit between the eye and nostril; upper jaw with poisonous fangg ;
body, thick, light hazel-nut brown, with transverse bars of dark brown, narrowest on the
mesial line, broader and bifurcating on the flanks ; tip of the tail coriaceous. — PI. 150, (}iHd.,
fol, 42, *c, 4.
Description. — The bead is very large, triangular, and broadest posteriorly; the mouth large,
with the upper jaw strong, and furnished with poisonous fangs; the vertical plate is regu*
larly pentagonal, with an acute angle directed backwards ; the superior orbital plates sra
irregularly triangular, with their apices turned inwards, and their bases outwards, projectiog
over the eye ; the occipital are rhomboidal, the frontal plates are large and quadrilateral :
the anterior frontal are of the same form, but smaller ; the orbital is large, triangular, with
its bases downwards and its apex upwards, and truncated. There are two nasal plates, tht
anterior quadrilateral, with its posterior margin hollowed ; the posterior trapezoid, with iu
anterior border lunated to complete the nostril. There are three posterior orbital platei
nearly of the same size, the upper one triangular ; the inferior orbital plate is single, long,
narrow, and lemi-circular. There are two anterior orbitals, the upper quadrilateral ; the
lower makes the superior wall of the pit between the eye and the nostril, which is completed
below by the second labial plate, and by a small plate that rests on the third labial. The
margin of the upper jaw is covered by semi-quadrilateral plates. The nostrils are large, late-
ral, and placed near the snout; the ejres are large, but do not at first appear so, from the pro-
jection of the superior orbital plates ; the pupil is elliptical, vertical and dark ; the iris bright
golden with a tinge of red. The neck ia greatly contracted ; the body is elongated, bat thick
to near the tail, and is covered above with rhomboidal scales, carinated, except those of the
lower rows, which are smooth and larger. The abdomen is covered with plates, the last one
of which is very large ; the tail is short, thick, conical, and ends in a horny tip.
Color. — The bead is a delicate light hazel-nut brown above, with the labial plates whitish ;
the gronnd of the color of the whole animal, body and tail, is of the same delicate hue, lighter
on the sides, where the scales are beautifully freckled with small dark spots. Behind the
occiput begins a series of transverse bars of dark brown, continued to near the extremity of
the tail. These bars are contracted along the vertebral line, but are broader and bifurcated
on the flanks. These bars are lightest on the back; darker at the sides, with their anterior
and posterior margins bordered with brown. The under surface of the whole animal is flesh-
colored, freckled with minute points of dark brown ; and a series of dark-colored tpota oo the
Abdominal plates, near their extremities, which then ascend, to ioolnde a scale or two on ths
flanks, and are so disposed that one spot corresponds to the point of bifnrcatioo of the trans-
verse dorsal bars, and another to the space between them. All these spots terminate at the
tail, which is flesh-colored below.
DiinentioM, — Length of head, 1 inch 2 lines; breadth of head, 11 lines; length of body, 2)
inches ; length of tail, 3} inches ; greatest circumference of body, 3} inches ; circumference
of neck, 1 inch 10 lines. In the individual described there were 150 abdominal plates, M
sub-caudal, and four pairs of bifid plates, or scales, near the apex. — [ AVtA ^Ri«rifaii Bcrft^
toloffy ,PhUa.f 1838, Vol. III., pp. 39-41.]
As a general rule, the Trigonocephalns Contortrix inhabits dark, damp, shady placet,
though it is frequently found in meadows bordering upon the low lands. The spccimeaf
which were used in the following experiments, were captured under the steps of a small negro-
house, situated upon a slight elevation in the neighborhood of an extensive martli. The
related species, the Water Moccasin ( Trigonocephalus Piscivorus), which is very abnadaat
in th*) low swampy regions of Georgia and Carolina, frequents the rice dama andswasspi, aad
is never seen far from water; and in summer numbers of these reptiles may be leen retticf,
in the low branches of such trees as overhang the water. The reptile is exceedingly daager-
ons to the unwary ; and is the especial terror of the negroes about the rice plantatloas, as it
is very sluggish in its movement?, taking no pains to avoid the descending foot of the passer
but attacks every thing that comes within its reach. From its habit of erecting ita bead and
opening the mouth for some seconds before striking, and from the white appearance of tbe
mouth, it has been called, on the rice plantations, the cotton mouthed moccasin. I once aav a
stout negro man who had been bitten by a large water moccasin. The symptoms of poieaning
were very marked. For hours the man appeared to be in extremis, notwithstanding the fre«.
scarification of the wound and the administration of large quantities of alcoholic sussttlaAis.
Beneficial results appeared to be derived by applying, chickens and f^ogt cut opea aUvtr u*
the wound. The entire leg and thigh swelled enormously, and the recovery was tedieat.
Experiments on the Action of the Poison of American Ophidians^ 521
The limb continaed somewhat larger than the sound leg for several years, and the roan com-
plained of pain in the region of the site of the poisoned wonnd daring certain changes of
the weather, and especially during damp «pells. Both species of the Trigonocephalus feed
upon frogs, mice, birds and insects. As far as my information extends, they do not, as the
king snake, feed upon other reptiles of the same genus and species. The copperhead is
regarded by the negroes with as much dread as the rattlesnake. It is, however, not so
abundant in the lower portions of Carolina and Georgia as the water moccasin and the
rattlesnake ; and instances of persons bitten by it are comparatively rare. DeKay, in his
Zoology of New York, says that the poison of the copperhead *' is considered as deadly as
that of the rattlesnake; and an instance is recorded, where a horse, struck by one of these
reptiles, died in a few hours." — [Part III., p. 54.]
IXPIBIMEXTS ON BITI OF COPPIBHSAD, (tBIGONOCBPUALUB OOMTOBTBIX.) .
Experiment No. 296. — Augusta, Georgia, May 12th, 1862. Subject of experiment, a fine
large black cur dog, half Hound and Pointer, (male). Temperature of rectum of dog, 103^.1 P.
temperature of room in which the experiment was conducted, 100^.4 F.; respiration of dog
panting, irregular, from the heat of the weather,* impulse of heart, irregular, about 90 per
minute. 1} o'clock P. M. Immediately after determining the temperature, the dog was
brought near the copperhead, which struck him twice on the foot of the right hind leg. The
moment that the fang entered, the dog emitted piercing cries, and appeared to be greatly
agitated, and the foot began to swell almost immediately.
The thermometer introduced into the rectum, stood at 104^.2^ F., and remained thus for
ten or fifteen minutes, and then slowly descended 0.2**, and remained stationary at 104® P.
This would indicate that the first rise was due partly to the agitation and struggles of the
animal, excited by the pain of the bite of the snake. Twenty-five minutes after the stroke
of the snake, temperature of rectum 104® P.; heart as yet not specially affected, although the
foot is greatly swollen ; thirty minutes after stroke of snake, ( 5 minutes after last observa-
tion ) action of heart 98 per minute, and somewhat irregular as before the experiment, being
affected by inspiration and expiration ; fifty minutes after stroke of snake, ( 10 minntes after
last observation, ) action of heart 110 per minute. One hour after the bite of the snake, tem-
perature of rectum still 104® P., the action of the heart appears to be diminished in force and
increased in frequency, being 124 per minute. The swelling is gradually proceeding up the
thigh, the limbs being greatly distended up to the knee-joint, and the lower portion of the
thigh is commencing to swell. A bloody terout fiuid novf istuet from the wound in eontiderabU
quanHtietf and (he fvidermit can be readily removed from all the region around the point where the fang
entered^ pretenting a red^ raw appearance. The swollen parte feel hotj and are teveral degrees warmer
than the sound leg. The dog is perfectly quiet, and, in fact, appeared to become so as soon as
the swelling commenced.
Two hours after the stroke of the snake, action of heart 156 per minute; respiration not
increased. Swelling of leg greatly increased, and extending up and involving the thigh : the
swelling increases in a decided manner, with defined borders. Blood and bloody serous fluid
continue to issue from the points at which the fangs entered : under the microscope the blood'
corpuscles of this fluid present a swollen^ altered appearance. The dog does not whine or cry, but
appears restless and sometimes groans, and pressure on the swollen leg appears to excite some
pain, as manifested by his whines. The temperature of the rectum still remains at 104®P.
When the dog is loosed, he runs about, with considerable life, on three legs, and during this
exertion there is a slight rise of temperature in the rectum, of one-tenth of a degree P. Action
of heart 150 per minute.
During the night the dog remained quiet, and next morning appeared much better. Swel-
iag in leg declining. Temperature of rectum next day, at 11 o'clock a. m., still 104® P. The ani-
mal appears to have regained his spirits. Right hind leg still greatly swollen, and several
degrees warmer than its fellow. Action of heart 120, in standing posture. On the following
morning May 14th, 11 a. m., dog seems lively, but the leg is still much swollen, and several
degrees warmer than the sound leg ; temperature of rectum 104® P. The leg is much swollen
and pits when pressed ; and pressure appears to cause pain ; the swelling extends to the
integuments of the belly and the sheath of the penis. Tongue of dog looks redder and
dryer than usual. The action of the heart in the sitting posture is 120 per minute, snd the
force of the heart has greatly increased. The wounds and excoriated places on the foot pre-
sent m much lighter color, snd appesr to be besling over. May 16th, 11a. m. — The dog still
continues to improve — swelling of legend penis greatly reduced ; temperature of rectum 103®.2
F. Dog appears to be much better ; action of heart 100® in sitting posture. Muscles of limbs,
aa npon yesterday, tremble occasionally. This dog recovered entirely from the effects of
tbe poison.
£rptrimtfit Ao. 2<j7<^Subjcct of ex|.friR:cnt a fine sclive 3 0UDg rock— temperature of anus
1I0®.3. Augusta, Ga., May 12th, 1862, 4 o'clock p. v. The copperhead used In the preceding
522 Experiments on the Aetion of the Pdison of American Ophidians.
'experiment was allowed to strike the cock upon the comb and head ; the reptile appeared 1o
be somewhat exhausted by striking the black dog in the morning. The strokes of the snake
appeared to excite violent pain in the cock ; he struggled Tiolentl^f and opened his wingi.
The rapidity and force of the action of the heart were increased during the strokes of tbe
snake, and during the struggles of the bird. During these violent struggles, and great agita-
tion, the temperature of the rectum of the cock rose ^^ C, and then fell again to the poiDl
whence it had started, being 110^.3 F.
Fifteen minutes after the strokes, the cock breathes rapidly ; the heart beats rapidly, and
with considerable force. Temperature of rectum still remains at 110^.3 F. The cock ww
again thrown to the copperhead, and several severe blows were inflicted about the head an<l
comb and leg, and the effects of the first strokes were thus increased.
At this time, the action of the poison resembled in some respects those of a narcotic ; the
cock appeared quiet and stupid, as if drunk ; but when aroused, opened his eyes and lockf*')
about, and attempted to fly and run with some activity.
Thirty-five minutes after the first stroke of the snake, the temperature of the rectnm still
remained at 110^.3 F., whilst the head, comb, and adjoining parts, as well as the regions
around the wounds in the breast, swelled greatly, and presented a dark purplish color, similtr
to that presented by wounds inflicted by the rattlesnake.
The effects of the poison resembled those of a narcotic — the bird remained perfectly still until
aroused ; it did not appear, however, to have entirely lost its reason, but was only stupid ■d'1
lethargic. The cock died during the night about 9 hours after the first stroke of the snake
After death, the tissues around the wounds inflicted by the fangs of the snake were foun<l to
be infiltrated with bloody serum and tenacious blood, which did not appear to possess th*>
power of coagulating. The muscular fibres, in the region of the wounds, which had been sob-
jecled to the direct action of the poison, were evidently in a state of softening and dlsorgno!-
sation. The bloody fluid issuing from the various cut surfaces presented a tenacious appear-
ance, and was of a dark purplish-brown color, and changed very slowly and imperfectly to *
lighter color when exposed to the action of the atmosphere.
The coloring matter of the blood-corpuscles had evidently been altered, and had escspcl
in many cases from the blood cells.
The infiltration of all parts around where the poison had been injected, and the flow of tlic
blood out of the vessels which had not been ruptured by the fangs of the snake, as well m>
the bloody color of the effused serum — all point to profound changes both in the blood an^i
in the capillaries and muscular tissues. A simple prick with a sharp instrument, like that o'
the fangs, certainly could not produce the pouring out of disorganized blood and bloo^
serum, through all the pectoral muscles. The blood and bloody tissues subjected to tbt>
immediate action ot the puison, remained black, and did not change, even after several boars
exposure to the action of the atmosphere.
The brain was not more congested with blood than usual, and the physical and microscopi-
cal examination failed to detect any alterations characteristic of the action of the poison on
the nervous structures. The spinal cord, in like manner, presented no special alteration^
Heart somewhat relaxed^ empty, and apparently softer than is usual with the heart of bsr -
The intestines, liver, stomach and spleen presented no special alterations, except that i '
liver appeared to be somewhat more congested with dark blood than uBual. The blood-n '•
puscles, under the microscope, appeared in many cases to be swollen and altered in shape
Experiment No, 298. — A portion of the dark, black and purplish-black flesh and blood, fr»->
the breast of the cock, killed by the stroke of the Copperhead, as related in the precf<li' .*
experiment, was introduced beneath the skin, on the side of a young kitten, three weeks •' '
and secured by a bandage. Twenty-four hours afterwards, the wound looked healthy, »'^>
the kitten did not appear to be at all affected. During the night, the mother pulled off t!
bandage and licked out the meat and blood. No injurious effects were observed from tb
action of the flesh of the cock.
Experiment No. 299. — Augusta, Ga., May 12th, 1862.— The Copperhead appeared to be tt.r-4
exhausted by its strokes of the dog and cock, and its poison appeared to lose its activity. *''
a fine large pointer dog, which was bitten on the foot and lip by the snake, at the coocla«i :•
of the experiments, was but slightly affected. The temperature of the rectum, which it '
before the stroke of the snake at 103°. I F., remained at the same point, and whilst therr v
some swelling of the foot and lip, it was comparatively slight. The action of the poisoi « .*
manifested chiefly in a tendency in the dog to sleep, and also in a slight ilicrease la tbf f*t-
quency of the beats of the heart. The effects were only temporary, and the dog recover* .'
entirely in a few days.
Experiment No. 300. — Augusta, Ga., June 5th, 1862.— The Copperhead used lo the preceJ ' :
experiments was allowed to rest for near one month, in order that it mig^ht accamalate »
stock of poison. The fine large black cur dog, which had been employed in the fir«t ex^r -
meats, and 'vltich at this time wa^ very fat and strong, was selected for the ^a). Tenpcr*-
Experiments on ths Action of the Poison of American Ophidians. 623
tare of rectum 103^.7 F. Actioo of heart 100 per minate ia staadmg posture (this number
represents the impulses of the heart against the walls of the thorax).
The copperhead inflicted several severe bites upon the fore-legs and nose of the dog. In
five minutes the effects were manifest. During the infliction of the wounds bj the snake, the
dog cried out loudly and shivered with paiu. In eight minutes the nervous system had given
waj entirely ; this loss of nervous power was ushered in by convulsive movements, the voiding
of faeces, dilatation of the pupils, laborious breathing and inability to stand, complete pros-
tration of the muscular system, frequent convulsive efforts to void fseces, and apparent loss of
consciousness. The temperature of the rectum during this period of twenty-five minuteSi
remained at 103^.7 F., and then rose to 104^ F. During the period that the thermometer
remained stationary, the breathing of the dog was stertorous ; as the heat rose the dog ap-
peared better, passed a great quantity of urine, and then the breathing became better. Up
t J this period, after the strokes of the reptile, the action of the heart could scarcely be felt.
One bour after stroke of snake, temperature of rectum 104° F. Action of heart so rapid and
f.'eble as scarcely to be felt, and it cannot be counted with accuracy. The dog appears a
little better, and notices when called. Two hours after bites of snake the action of the heart
c.in be felt with sufficient distinctness to be counted, and is now 160 per minate in the
r.'cumbent posture : the dog has again voided a large quantity of urine, and appears sensible ;
the respiration, which was before 48 per minute, is now 40, and is no longer stertorous; the
a:iimal raises his head and notices when called, and the pupils are less dilated ,' and when
rtised np upon the fore-legs, maintains his position and appears quite sensible.
June 6. — Next morning, dog looks badly — dysenteric flux from the bowels — bloody discharges
of altered blood-corpuscles,* having a dingy, dark, purplish look. Temperature of rectum
I )l^.3 F. Extremities feel cold. Leg much swollen — the swollen leg feels warmer than the
other extremities. Animal very weak and feeble. Action of heart 145 ; respiration '24. With
the diminution in the frequency of the action of the heart, and the diminution in the frequency
uf the respiration, the intellect appears clearer.
The evacuations of the bowels resembled in appearance tar, presenting a black color, and
cooiisting almost entirely of altered and partially coagulated and concreted blood.
When broken up and spread upon a glass slide, these tar-like excrements presented the
Hppearance of a semi-transparent bloody jelly.
Toder the microscope but very few blood-corpuscles could be seen, and these were altered
in «hape; it appeared as if the walls of the corpuscles had been dissolved, and the coloring
matters had discolored the thick mucus and thick serous, and exuded glutinous and fibroid
iHitters.
f Whether the destruction of the cell-walls of the blood-corpuscles occurred in the intestines
afier the passage of the blood out of the blood-vessels, from ruptured ressels, or whether
there were but few ruptures of the capillaries of the intestinal mucous membrane, but rather
it transudation of the altered blood with its coloring matter through the walls of the capilla<»
ries, was considered important to be determined. The large quantity, and the black color of
the intestinal discharges, led me to view them as of the nature of a hasmorrhage.
Aix o'clock p. M. — Action of heart 145 ; respiration 22. Dog very lethargic and feeble in
m )ttons, but perfectly sensible. Has discharged more of the tar-like bloody matter. Tem-
|i.r*iture of rectum 101^.4 F. The dog drank a large quantity of cool water, and in a few
moments the temperature fell to 100^.4 F., and remained at this point for three-quarters of
ai hour.
June 7, 2 o'clock p. M.-^Action of the heart about the same in frequency as on yesterday,
hut more feeble; the dog rose up to pass excrements, and the pulsations or beats of the heart
increased to 184 per minute. Respiration slow and regular as before. Temperature of rec*
turn 103^.1 F. — there has been an increase of heat. The dog still passes from the bowels
black, bloody, gelatinous, tar-like matter. The surface of the wound on the leg is of a dark
culor, and emits a dark colored serous fluid. The dog appears to be sensible, but is Tery
ii.uggish and indisposed to motion; drinks water freely, but refuses food— has refused to eat
cwc-r since the stroke of the reptile. Lips also much swollen.
]>uring the night this dog died.
Autopey 30 houre after death. — The fore-leg which had been struck by the copperhead was
iniiltrated with bloody serum ; all the fibrous tissues of the leg and thigh, beneath the skin,
up to the abdomen and beyond, were greatly infiltrated with dark, purplish-black serum.
Tndcr the microscope this presented numerous oil-globules and altered blood corpuscles,
miih ragged, star-like edges; long acicular crystals were also seen floating amongst the
ilfered blood corpuscles. The blood from the swollen, infiltrated cellular structures of the
head and nose, where the snake inflicted the severest bite, presented a peculiar appearance ;
thousands of small acicular crystals were mingled with the altered blood corpuscles, and as
the bloody serum and effused blood dried, the blood corpuscles seemed to be transformed
into crystalline masses, shooting out into crystals of hmmatin in all directions. The blood*
524 Experiments on the Aetion of the Poison of American Ophidians.
▼essels of the brain were filled with gelatiaous, coa2;ulable blood, which presented altered
blood corpuscles and acicalar crystals.
The muscular system everywhere presented a dark purplish color. The heart was filled
with coagulated black blood. When spread upon a glass slide, the blood corpuscles almost
immediately commenced to assume a crystalline form. Blood vessels of brain filled with dark
blood; membranes and structures of brain presented a normal appearance ; there were do
lesions of the brain recognizable to the eye. The exterior fibrous sheath of the spinal cord
presented a red appearance, as if the coloring matters of the blood had been effused ; slnic-
tnre of spinal cord natural; vertebral arteries filled with coagulated blood.
Stamack, — Mucous membrane of this viscus greatly congested — the stomach contained a
considerable quantity of bloody water.
Small JnUttmtB — Congested with blood, and presenting a dark purplish appearance. Some
portions were more congested with blood than others. The congestion was especially great
in the ilium, colon and rectum. The lower portions of the intestinal canal — the ilium, colon
and rectum resembled raw flesh, and contained the dark, tar-like, altered blood.
The p^totuum presented a purplish reddish color, as if saturated with the disorganized
blood. The internal coat of all the arteries was in like manner stained by the coloring mat-
ters of the blood.
The liver was congested with blood, and rapidly underwent decomposition.
iS^^en somewhat enlarged.
The fibrous tissue of the Inngs was infiltrated with bloody serum.
All the organs and tissues appeared to have suffered.
From the preceding experiments, designed to illustrate the mode of action of a poison about
which little or nothing was known, we conclude : —
1st. The primary and chief action of the poison of the American copperhead (Trigooo-
cephalus Contortrix) is upon the blood.
2d. The poison of .the copperhead is directly destructive to the colored blood corpuscle,
altering its physical and chemical properties and relations, and rendering it unfit for the per*
formanoe of its important offices in circulation, respiration and nutrition.
.3d. The poison of the copperhead appears to have an affinity more especially for the col-
oring matter of the colored blood corpuscles.
4th. Under the action of the poison of the copperhead the animal temperature is hot
slightly Increased, potwithstanding the profound changes inaugurated in the blood ; andaAer
the establishment and propagation of these pathological changes the temperature descends.
5th. The action of the heart is increased in frequency, and diminished in force, nnder the
Inflaence of the poison of the Trigonocephalus Contortrix. This increase in the rapidity of
the pulsations of the heart is not, as in the case of febrile diseases, attended by a marked rise
of animal temperature. The difference may be due to the peculiar and direct action of the
poison upon the colored blood corpuscles.
6th. In its action upon the cerebro-spinal nervous system, the poison of the Trigonoceph-
alus Contortrix resembles a mild narcotic — whilst rendering the animal sluggish and stopid.
it may produce death without the establishment of profound coma.
7tb. The profound alterations induced in the constitution of the blood by the poisoo of
the American copperhead give rise to passive haemorrhages into the cellular structures, sod
fh>m the intestinal mucous membrane. This phenomenon recalls strongly the passive bsmor-
rhages in certain febrile diseases, and especially of Yellow Fever. Some have supposed thit
the black vomit of Yellow Fever was the resultant of the effects of the preceding iouase
fever. Do not the present experiments indicate that it is rather the resultant of the actioo of
a poison upon the blood and gastric-mucous membrane ? We have here also an illustratioo of
the mode in which dysentery might be produced by a poison introduced into the blood.
JBiperiment 301. — Augusta, Oa., June 14th, 1860 ; fine fat, large cur dog. Temperaturv of
rectum 40^.2 C, temperature of atmosphere 79^ F. The dog was brought near an actirt
Rattlesnake, (Crotalus durissus) which struck him in the right foot, at twenty minutes ptit
ten o'clock ▲. m.
Five minutes after the stroke cf the snake, temperature of rectum 40^.2 C; action of the
heart 120 per minute; leg of dog trembles greatly, holds it up ; the foot is now swelliof
rapidly ; 15 minutes after the stroke of snake temperature of rectum 40^.24 C, there has beci
a slight rise of j^^^ in the last 10 minutes. Action of the heart appears to be a little (teller.
and is now 120 per minute. The dog was again struck by the Rattlesnake on the left foot, 39
minutes after the first stroke.
Ten minutes after the last stroke, and forty minutes after the first stroke temperature of
rectum 40^6 C ; respiration rapid and panting ; action of the heart appears to be rather filler
than at first. Ten minutes after this observation, (20 minutes after the second stroke, sad 5^
minutes after the first stroke,) the temperature of the body still continues to rise, aad tb«
thermometer in the rectum indicates 40^8 C. The right foot and leg li now much svollea,
Experiments on the Action of the Poison of Ameri^^an Ophidians* 525
and drops of bloodj seram of a dark parplish color, issue from the wouad, and the dog
occasionally gires convulsive movements.
Fifteen minutes after this observation (35 minutes after the second stroke and 65 minutes
after the first), temperature of rectum 41° C, temperature of surface of muscles of loins
37^.5 C Seven minutes after this observation, and seventy-two minutes after the first stroke,
temperature of rectum 40°.8 C; temperature surface of loins 37°.5 C. Eighteen minutes after
this observation and 90 minutes after first stroke, temperature of rectum 41^.23 C, tempera-
lure surface of muscles of loins 38^.20 G.
There appeared to be a great tendency to spasms of the muscles ; the slightest touch, and
especially the introduction of the thermometer into the anus, brought them on with great
violence ; whilst lashing the dog to a board the violent convulsions were excited, and the
temperature of the rectum rose from 40.8 to 41^.23 C. Ten minutes after this observation,
and 100 minutes after the first stroke of the Rattlesnake, temperature of rectum 41^.28 C,
temperatureof surface of muscles of loins 38^.6. Mucous membrane of lips and mouth injected
with bluod, and presenting a red appearance, much redder than normal. Pupils of eye
appear to be somewhat dilated, but they contract under the influence of the stimulus of
light. Respiration 140 to the minute, and panting; the rapidity of the respiration of dogs is
very deceptive, for the function of the skin is so sluggish, that when excited they are com-
pelled to make the lungs to a great extent do the office of the skin. The respiration of the
dog waA so rapid, that it was almost impossible to determine the action of the heart, on
account of the violent and rapid action of the diaphragm.
The dog was now released from his confined position, (tied down to the board,) and as soon
as bis limbs were free, he moved about with ease. He was allowed to remain at liberty lying
down for an hour, and then the temperature was determined. During this time he showed
DO signs of pain and no special drowsiness.
One hour and a half after the last observation and 190 minutes after the injection of the
poison of the rattlesnake, the temperature of the rectum had returned to the normal standard.
Temperature of rectum 40^.2 C, temperature of surface of muscles of loins 37^.2 C. Respi-
ration 24 to the minute; action of heart 152 per minute. The dog had some time ago a
copious evacuation of ordinary fscal matters, and now discharges fcctid bloody watery
stools. Six hours after this observation, and 9 hours and 10 minutes after the first stroke of
the rattlesnake, temperature of rectum 40^.2 C; action of heart 140 per minute; respiration
l^entle and natural.
June I5th, 10 o'clock a. m. — Dog appears well and hearty, with exception of swelling of
legs, temperature of r%ctum 40^.2 C; action of heart 120 per minute, the bloody discharges
from the bowels have ceased. This dog recovered entirely.
It is important to note in this experiment, the rapid rise of temperature induced by the
animal poison ; and the marked effects of the poison upon the blood inducing as in the case
of the copperhead, bloody discharges.
Eiperinuni 302 .* lUiutrating the action of the poUon of the American Raltleenake (Crotalus DuriS"
Mtu). — Augusta, Ga., June 15th, 1861 : Half grown cat was struck by a medium sized Rattle-
snake, which bad been exhausted by striking several times before. Temperature of rectum
of young cat, 38^.8 G. at the time that it was struck by the snake ; 7 minutes after, tempera-
ture 38^2 C.; 9 minutes after the stroke, 37^-8 G.; 30 minutes after stroke, 37^4 G.
One hour after the stroke animal apparently well, with the exception of some tremulonsness
of the muscles.
Temperature of the rectum 37^.8 G. During the first 30 minutes after the stroke the tem-
perature of the rectum descended 1^.4 G.; during the next 30 minutes it rose 0^.4 G.; and
contlnned to rise, and at the end of the next hour stood at 39° G, or 0°.2 G. higher than
before the introduction of the animal poison.
The young cat recovered entirely.
Kxperimcnt 303.* lUueiraUng the action of the poieon of the American Rattleenake {Crotalu*
DuriuuM). — Small, active bull dog pup, 2 months old. Temperature of atmosphere, 26^.11 G.;
temperature of rectum, 39® G.
A medium sized, dark-banded Rattle-snake, five feet in length, inflicted a wound with its
fitngs in the leftside of the neck ; the fang penetrated the muscles of the neck near the spine.
The bite of the reptile did not appear to excite any pain in the young dog ; he did not strug-
f^W or bark. The temperature of the rectum rose almost immediately after the injection of
the poison, and in three minutes the thermometer stood at 39^.4 G. Action of heart 120 per
minute. Respiration full, rather labored. The pup appeared to lose all muscular power
almost immediately after the injection of the poison, and did not once struggle or attempt to
ri^e, but lay quiet upon its side. 13 minutes after the stroke, respiration 24, action of heart
130, temperature of rectum 39°.26 G. At this time the pup lay in a profound coma. The
blood appears to be settling in the capillaries of the extremities, as thft feet present a purplish
appearance. Respiration spasmodic. Temperature of the rectum is gradually declining, and
has fallen 0^.12 G. during the last eight minutes.
526 Experiments on the Action of the Poison of American Ophidians.
Xineteea minateB after the iojection of the poison coma profound ; pnpils greatlj dilated ;
respiration 12 per minate and spasmodic ; the muscles of the month act spasmodically — the
mouth gasps conTulsively at each inspiration. Action of heart 130. The temperature of the
rectum stili falls gradually, and now stands at 39*^ G. 22 minutes after the injection of the
poison pupils greatly expanded, and do not contract when exposed to the action of the ligbt;
temperature still falling, and is now 38°.8 G. Respiration slow and spasmodic, in fact a
series of spasmodic gasps separated by long intervals. 26 minutes after the injection of the
poison, the respiration has ceased, action of the heart very feeble, 80 to a minute. Temperature
still falling, 38^4 G.
Twenty-eight minutes after the injection of the poison the action of the heart could not be
felt ; it bad just ceased beating, baring continued two minutes after the cessation of tbegrM-
piration. From the injection of the poison to this time, the mucous membrane of the mouth
and tongue did not present any special changes of color.
The temperature continued slowly to descend after the cessation of the action of the heart,
and 40 minutes after the injection of the poison, and 12 minutes after the cessation of the
action of the heart, the temperature of the rectum was 37^.6 G ; 167 minutes after stroke ot
reptile (139 minutes after cessation of action of heart), 31°.8 G. In the last 127 minutes {'1
hours and 7 minutes), the temperature of the body has fallen 5^.8 G.
Autopty 167 mntUet after the injection of the poieonj and 139 minutet after the eeeeaUon ^ thi
aeHon of the heart. — The interrupted magneto-electric current produced slight contractions ia
the muscles, showing that up to this time there had been some susceptibility to the electric
stimulus.
When the skin orer the region of the poisoned wound was removed, the cellular tissoe
was found congested with blood, and contained much dark purplish and black coagulated
blood effused into the cellular tissue — the blood-ressels and capillaries of the sarrouadiaf
skin were also greatly congested with blood. This effect is evidently due to the direct actioa
of the poison upon the blood and capillaries. By the peculiar structure and arrangement uf
the fangs and poison bag, during the stroke a continuous stream of poison is poured into
all the tissues through which it successively passes. This great pouring out of the blood ail
around the point at which the fang entered, was not due to the mere wounding of the vessels,
for the fang could not have been much larger than a large needle, and we know that the
puncture of a needle could not possibly have produced such effects in a few moments. That
it is due to an immediate effect of the injected poison upon the blood-vessels, appears to be
also proved by the rapidity with which the parts swell after a stroke by the fangs of the rat-
tlesnake. I have seen the swelling commence almost immediately after the injection of the
poison. The coagulated blood and effused blood was not confined to the cellular tissue, but
extended down amongst the muscles of the neck as far as the fang penetrated.
Head. — The blood-vessels of the dura-mater and pia-mater were filled with dark purplish
blood, which rapidly changed to the arterial hue after the removal of the sknll-cap. The
sinuses of the dura-mater contained well formed, dark purplish coagula ; all the large veini
also of the various organs contained dark purplish, coagulated blood.
Tharaz, — The lungs presented a deeply congested and mottled appearance. The right aori*
cle and ventricle of the heart were distended with dark purplish, almost black blood, and the
vena-cava contained dark purplish, almost black coagula. The blood from the heart, sad
from all the organs, changed readily to the arterial hue upon exposure to the atmosphere.
The coagulation of the blood in the heart and vessels in such a short period after death, is
interesting, as pointing to the effects of the poison directly upon the coagulating propertiei
of the blood.
Abdomen. — Blood-vessels of the liver filled with dark blood. Stomach and iolestioet
somewhat congested with dark blood. The mucus membrane of the intestines, and nor*
especially of the duodenum and superior portion of the ileum, presented a highly injected,
red, punctated appearance.
Under the microscope the colored blood corpuscles did not present any unusual appcsr-
ance.
Experiment 304 : lUueUating the action of the Poieon of the Dark Banded liaUUmakr.'^*^*
15th, I860 : Strong, active, well conditioned Gur Dog, Terrier blood predominating.
Temperature of atmosphere, 27® G.; temperature of rectum, 39*^.2 G. The dog was throve
into the box with the snake, and several strokes were inflicted by the reptile on diftrrnt
parts of the legs. The struggles of the dog were very violent during the strokes of the saskr.
and he sprang up several times out of the deep box.
In five minutes after the dog was removed from the box, (the strokes of the soake occsptrt
only a few moments), the dog gave signs of great uneasiness and pain.
Ten minutes after the strokes of the snake, the temperature of the rectum was 39°.^^-
showing a rise of 0^.6 G., in the short period after the introduction of the poison.
Seventeen minutes after the injection of the poison, and seven minutes after the last obstf'
vation, the dog fell into a profound coma.
Experiments on the Action of the Pdison of Ameriean Ophidians. 527
The temperature of the rectam rose daring the straggles and excitement, daring the injec-
tion, and just aAer the strokes ; and then just before the establishment of the coma, stood
•till ; and as soon as the coma was established, commenced slowly to descend. The action of
the heart and the respiration also diminished in frequency; the action of heart 100 per
minute; respiration 12 per minute. Daring the coma, or deep sleep, the thermometer de-
scended 0*^.2 G. The dog then revived, and immediately the temperature of the rectum com-
menced to rise, and 12 minates after the commencement of the coma, (29 minutes after the
bite of the snake,) the temperature of the rectum was 40^.2 C, and the temperature of the
surface of the muscles of the loins, was 36^.4 C.
The temperature of the rectum continued to rise during the succeeding eleven minutes, and
40 minutes after the introduction of the poison, stood at 40^.4 showing a rise during the last
eleven minutes, of 0°.2 0.; after remaining stationary for a few moments, it commenced again
to descend very slowly, and in fifteen minutes, stood at 40^.34 C, showing a loss of O^.OG, in
this period.
One hour and ten minates after the first strokes of the reptile, the dog was again thrown
into the box — his struggles were desperate and violent, during the renewed attacks of the
snake. During the struggles of the dog, and during the infliction of the bites, the tempera-
tare of the rectum rose slowly, and in fifteen minutes, stood at 40^.5 C, showing a rise
of 0M6 C.
The dog then as before, fell into a profound sleep, and the thermometer in the rectum com-
menced to descend, and in 15 minutes stood at 40o.4 C, showing a loss of 0°.l C. One hour
and a half after this, the dog was again subjected to the attacks of the snnke, and finding that
his strokes were rather feeble, and that it was probable that he was too much exhausted to
plunge his fangs to a sufficient depth beneath the skin, for the full effects of the poison, I
captared the reptile, extracted his fangs, and plaoged them into the muscles of the hind legs
of the dog.
Id these struggles with the snake, the temperature as upon the former occasions, rose and
stood at 40*^.6 G. As soon as the dog became quiet, the temperature of the rectum commenced
to descend, and in four minutes after this observation, (10 minutes after the third attack of
the snake,) stood at 40°. 4 G., having lost in four minutes 0^.2 G.; and in two minutes more
descended still farther to 40^.2 G. The dog appeared sleepy and stupid. The temperature of
the rectum remained stationary for a few minutes, and then commenced to rise, and in eight
minutes, (120 minutes after the third attack of the serpent,) was 40^.4 G. Dog appears
drowsy and indisposed to any exertion ; action of heart, 150 per minute; respiration 24-26;
left leg and thigh greatly swollen. Twenty-four minutes after this observation, and three
hours and twenty-four minutes after the first attack of the Rattlesnake, the dog vomited a
large quantity of frothy mucus, appeared to be very sick, passed a large quantity of natural
urioe, and then laid down with his eyes open, whining and groaning at every breath.
Two hours and six minutes after this observation, (5} hours after the first strokes of the
reptile,) lies in stupor, with eyes open, and snores as if in a deep sleep. Is very weak, and
when aroused is unable to stand alone ; respiration 24 per minute ; action of heart so rapid
and feeble that it cannot be counted. Even when the flesh is pinched and cut with a knitr,
the animal does not evince pain. Temperature of rectum, 40^.2 G. Sixteen minutes after
this observation the thermometer in the rectum, indicated 39°.8 G., showing a fall during this
period of 0^.4 G. Temperature of the surface of the muscles of the loins, 35°. 8 G., showing
a loss of 0°.6 G.
One hour and nineteen minutes after this observation, temperature of the rectum, 39°.6, and
that of the surface of the muscles of the loins, 35°.6 G. Action of heart 13 ; respiration II.
.Vfter considerable effort, thedog was aroused and stood up, and when led by a string, walked
slowly for one hundred yards, with great difficulty. During the night, no observations were
taken upon his symptoms.
* The next morning, June 16th, 24 hours after the first strokes of the Rattlesnake, the dog
appeared to be somewhat stronger ; but was still very weak and inactive, and presented as
upon the previous day, the appearance of a dog asleep with his eyes open. Action of heart,
120 per minute ; respiration 24. Temperatnre of rectum, 38°.5 G. There had been a fall of
I°.0 G., since the last observation. The dog lay with his eyes open, snoring, and at times
starting and jumping spasmodically. He was left alone for three hours, and at the end of
this time, was found dead and stiff. Rigor-mortis strong and well developed.
Auiopty 9bciU 4 hourt after death, Rigor-mortis complete. Temperature of rectum, 34° G.;
left leg greatly swollen, and upon dissection, presented a black purplish, and black appear-
ance, as if dark coagulated blood had been effused amongst all the structures. Wherever the
poison had been injected, the ssme deep black and purplish color of the structures were
observed.
Muscles generally presented a dark purplish hue, far different from the appearance in health.
Electric currents h«d no effect whatever^
528 Experiments on the Action ef the Pdison qf American Ophidiane.
BIood-TeaaelB of brain not congested with blood, Yenous blood^yesaela ronning along the
aidea of the apinal marrow diatended with black coagala.
Both the right and left caritiea of the heart were filled with dark purpliab, firm coagnU of
blood. The vena cara also waa diatended with firm, pnrpllah black coagnla of Tenons blood,
as in the previoua experiment.
Theae facta would aeem to ahow that the poiaon of the Rattlesnake promotea the coagulation
of the blood. Pruaaic Acid on the other hand, although acting in a few moments, on the
contrary deatroya to a great extent the coagulating power of the blood.
The right auricle and ventricle of the heart, contained nuroerona worma, aeveral inches in
length, and theae were anrrounded by a firm coagolum of blood. The lungs were greatly
congeated with blood, and collapaed but to a alight degree when the thorax was opened.
Blood-veaaela of atomach and intestines congeated. The mucous membrane of the atonacli
and intestinea, waa of a purpliah color.
The mucous membrane of the amall intestinea waa coated with a reddiah and purplish
bloody looking mucua ; — when this was scraped off, \h did not appear to be specially congested.
This corresponded with the appearances during life.
The rectum, both upon the exterior and interior, was of a deep purplish red and brovo
color, and the mucous membrane was covered with the same bloody looking mucus.
The liver presented a deep purplish, brownish color, in places inclining to the slate color.
Kidneys congested, omentum congested, and redder and darker than normtl.
Fore leg which was most swollen, was black as tar or pitch, and resembled in all respects
except in being much darker, the parts of animals dying within a short time.
The blood corpuscles from these portions appeared more altered than those from the blood
in other parts of the body, which did not present any very well marked alterations.
The dark purplish coagula changed to the arterial hue when exposed to the action of th«
atmosphere.
From the preceding experiments we conclude :
Ist. After the iojection of the poison of the Crotulus Durissus, (Rattlesnake,) tht*
temperature rises for a brief period ; but as soon as the poison has induced a decided
effect upon the ocrebro-spinal nervous system and heart, and coma has been established,
the temperature descends. If the animal recovers from this state of coma, the tem-
perature will apiin rise slowly and descend again, upon the supervention of coma.
We have in this rise of the temperature in the first stages, a phenomenon, similar in
some respects to that of certain fevers, with this difference, that it is less in amount
and duration.
2d. The Poison of the Crotalus Durissus (Rattlesnake^ acts as a local irritant upon
the capillaries, and as a destructive a^cnt on the blood and muscular structures, caustn;:
congestions and bloody effusions, and softening, and disorganisation of the muscular
fibres.
3d. The blood does not lose its power of coagulating, in every case of poisonin*: i»y
the Rattlesnake, but the clot is soft and voluminous, as if the fibrinous element of tl'c
blood had undergone some change.
4th. The colored blood corpuy^cles do not lose their power of absorbing oxygen, sad
change readily to the arterial hue, when exposed to the atmosphere.
5th. Whilst the microscope fails to reveal any marked or chanictertstio chancips in
the blood corpuscles, in the general mass of the blood, still its direct action on this flaid
is evinced not merely by changes in the coagulating power of the fibrin, but alsobj the
congestions of the organs, and the passive haemorrhage of the muoous membntoes.
6th. The Poison of the Crotalus, destroys by its direct effects upon the Cerebp>-
Spinal Centres, and by its depressing effects upon the sympathetic ganglia, and nvscaUr
structures of the heart ; and also by the changes which it induces in the oompositioo ot
the blood.
EXPERIMENTS ON THE EFFECTS OF PUTRID ANIMAL MATTERS.
In connection with the action of poisons, clearly of animal origin, is those of the
Trigonooephalus and Crotalus, it is important to remember that one of the most renark-
able phenomenon presented by animals into whose veins Magendie more than thiitj
years ago, injected putrid substances, was what is termed injlammatton of the inteiitiMs;
that u to say, exhalation of a matter, having the color of toathwgt o/JUJl
Experiments on Putrid Ammal Matters. 529
Varioos observers have pointed out the effects of certain animal substances in
raising the temperature when injected into the circulation.
Billroth and Hufschmidt, found that in all the cases in which putrid solutions or
recent pus were injected into the subcutaneous tissue, or into the blood, there was a rise
of temperature in the rectum, which was considerable even within two hours after the
injection, and reached its maximum in from two to twenty-eight hours ; that the mini-
mum exceeded the normal temperature by 1^.6 C. (2.88° F.,) and the maximum, 2^.2
C, (3^.96 F.,) and that if the injection was only done once, a rapid defervescence
generally set in, shortly afler the acme had been reached ; whilst on the other hand,
afler repeated injections death constantly occurred, generally with very high tem-
peratures.
C. Weber has determined by similar experiments, the heat producing and inflam-
matory effects of pus, of fluids from inflamed tissues, and of pyfemic and septicsDmic
bloody and even of the blood of an animal merely suffering from simple inflammatory
fever, when injected subcutaneously or into serous cavities.
Frese by numerous experiments, showed that the blood of animals suffering from any
kind of fever, induced a rise of temperature, when introduced into the circulation of a
healthy animal of the same species.
EXPERIMENTS UPON LIVING ANIMALS WITH THE BLOOD FROM THE HEART AND
THE BLACK VOMIT FROM THE STOMACH OF YELLOW FEVER CASES.
Eiptriment 305: With a small ^'subcataneoos" syringe, I injected beneath the skin of a
heAltbjr puppy, about thirty drops of l/lood taken from the heart of a yellow fever patient three
hoars after death.
No ill eiTecta were observed.
Experiment 306 : In like manner I injected beneath the skin of an active Guinea pig about the
same quantity of blood from the yellow fever heart.
The next day, October 16th, 1873, the Guinea pig appeared lively, and ate its food. October
I7tb, the animal appears sluggish and refuses food. October 18th — Animal feeble; moves
with difBcalty, and is evidently ill from the effects of the injection. October 19th, 5 a. m. — I
found the Guinea pig dead, cold and stiff*.
Ihttl'Mortem Examination — Body emits a disagreeable odor, cellular tissue of skin and sur-
face discolored and greatly congested around the point of the injection of the yellow fever
blood. Cellular tissue and skin softened in those portions around the area of injection.
Coder the microscope the fluid from these portions of the cellular tissue was found to con-
tain bacteria and revolving animalcule. Cavities of the heart distended with dark, almost
black, loosely coagulated blood. Blood changed rapidly to the arterial hue upon exposure to
the atmosphere. Tiider the microscope the blood corpuscles presented no peculiar alteration.
Kiver congested. The microscope revealed no accumulation of oil in the textures of the liver.
Liver cells distinct but pale. No bacteria, or animal or vegetable organisms, were observed
io the blood of the heart, or in the blood and structures of the liver.
Experiment 307 : Into the subcutaneous tissue of a large, healthy and active ipale guinea-
P<?» 1 injected about thirty drops of black vomit, taken from the stomach of the yellow fever
patient three hours after death.
The black vomit thus carefully injected into the cellular tistue caused the death of this animal in
aiz hours.
Fott-Mortem Examination. — Difl'used redness, and great capillary congestion of cellular tissue
beneath the skto. Congestion greatest in the immediate vicinity of the injection. Body emits
A fool putrid odor. Immediately around the point where the black vomit had been injected
dark blood had been eff'used, and the textures presented precisely the appearance of those
wounded and poisoned by the fangs of the Rattlesnake or Copperhead.
The cavities of the heart were distended with dark, loosely coagulated blood. No animal-
culifc, bacteria or fungi, or alga; discovered in the blood. Decomposition rapid ; and although
the animal was examined almost immediately after death, the odor was disagreeable and
resembled that of the black vomit.
Experiment 308 : I injected into the subcutaneous tissue of a large, healthy Guinea-pig,
about thirty drops of black vomit which I had preserved from a case of yellow fever, ejected
•bortir before death on the 0th of October, 1873, six days before the present experiment.
Death eaueed by the black vomit in six hourt.
I\tat"'Mortem Examination. — Results similar in all respects to those recorded in the preceding
ezi^nraent; intense congestion of cellular tissue around locality of iojection of black Yooit;
<7
530 Experiments on Putrid Animal Matters.
no animalcalue or regetable organiema in blood ; patrefaction rtpid and marked by fool odor.
Experiment 309 : I iojected into the Bubcataneons tissue of a Gainea-pig about thirty drops
of putrid blood, which I had extracted from the cavities of the heart of a subject who htd
died six days before, on the 9th of October, in a " congestive " malarial chill.
Death caused 6y the putrid malarial blood in eight houn.
PoH-mortem changes similar to those recorded in experiments third and fourth.
The preceding experiments are of importance in establishing the fact that black tromitf Idtf
from the etomach immediately after death^ or ejected during life in yellow fever, wiU, when iftfeekd wlo
the tubcutaneoue Unue, produce at deadly and as rapidly fatal results as putrid blood.
We deduce the following practical conclusions :
First. Black vomit, when absorbed into the circulatory system, may act as a deadly
SBPTIC POISON.
Second. As the capillaries of the stomach in yellow fever are often ruptured, and the
epithelium of the mucous membrane denuded, it is possible that in some cases the absorption
of black Tomit, especially after it has undergone putrefactive changes in the stomach, rasy be
an important cause of the fatal issue.
Third. If remedies could be used which would prevent putrefactive changes in the bUck
vomit and render it comparatively inert, a certain proportion of cases might be rescued,
after the appearance of black vomit.
The preceding experiments and reasoning led me to employ the sulpho cabbolats or
SODIUM, in doses of 20 grains, every 4 or 6 hours in the treatment of yellow fever.
I have used the eulpho carbolate of sodium in about forty cases of yellow fever, with satis-
factory results.
I find that it is readily borne by the stomach at all stages of the disease ; that so far from
exciting nausea or vomiting, it often modifies and arrests these distressing symptoms.
It appeared in some cases to arrest the decomposition of the black vomit. One case accom-
panied by a temperature of 107°. 1^, and attended with black vomit recovered under its u?f.
combined with ice water injections into the rectum.
At some future time we hope to present statements of these cases.
Davaine claims to have made the following discoveries : After injecting beneath the skin of
nn animars neck a single drop of putrid blood, the surrounding tissue became extensivrlr
infiltrated, and death soon followed with symptoms of septicaemia. The blood of this aoimnl
was then employed to inject other animals in a similar way, and was found to be more poisoo-
ous than the original putrid blood. A third and fourth animal was then injected, each witii
the blood of the preceding one, and in this way 24 in all were experimented on. The resulti
seemed to show that the toxic power of the septic material increases by dilution.
Strieker, in a series of experiments undertaken to test these statements, inoculated .***
animals with healthv, 23 with putrid, and 73 with blood diluted by transmission. Of the firii
series, 4 died. Of the second series 11 died. In experiments with diluted blood, when it bad
passed through 13 diflTerent animals, 53 of the 73 died. From this it appears that ereo the
very small amount of yn^^ of a cubic centimeter of poisonous material could cause deaf,
when injected hypodermfcally. Davaine's statement, that organisms form in the blood an i
increase by every transmission, was not sustained by investigation. Strieker found name ro't<
colorless bodies in the blood of these animals, but he did not regard them as organismSt l>-wL
ratber as proto-plasmic bodies.
The following facta he regards as ascertained :
1. That tranamission greatly increases the injurious and fatal action of the putrid matt* -
2. That the original disease was infectious, but that through inoculation it became contr.-
gioua.
3. That though it be not proven, yet it is probable that the special poison is a living con-
tagion {eontagium animatumj) for such rapid proliferation is only possible in organized materia i.
4. That the poison is diflfusible and is not destroyed by boiling {AUg. Wien. Med. Zmtmms-,
20, 1873 ; New York Medical Record, July 1st, 1873, p. 311.)
If it be true that the poison of yellow fever may be generated in human beings under r«'-
t$in conditions of the constitution, and more especially of the chemical and physical coa>! >
tution of the blood and of the nervous and muscular structures, when sobjected to i.r
combined influences of heat and crowding in an impure atmosphere; if it be still farther trur
that decomposition, both before and after death, is more rapid than in any other fora of
disease, and if this decomposition forms the most favorable condition for the rapid mnltipitc^a*
lion of bacteria and fungi, and other simple organisms; it is reasonable, in the light of ttc
preceding experiments of Davaine and Strieker, to suppose that these organisms may becoisc
carriers of the poison, and may constitute an important medium of its dissemination from the
original foci,
Magendie has shown hy actual experiments on living animals that an exM of
alkalinity ia (he blood, interferes not only with the freedom of the passage of this ^kpM
Experiments on Putrid Animal Matters. 531
througb the capillary vessels and dimiaishes the property of coagalation, but also, when
thus modified, the blood tends to penetrate the walls of the capillanes by imbibition,
and to produce those disorders in the mucous membrane, which have long been known
under the name of inflammation.
Magendie by injecting carbonate of soda, into the veins of animals, produced oedema
of the lungs, with its pathogmomonic signs, at the outset, and cadaveric lesions when it
causes death. Thus proving that when the blood becomes surcharged with an alkaline
principle, its serous matter increases in quantity, escapes from its vessels among the
lobular ramifications of the lungs, distends and bursts them, and carrying with it the
coagulable part, in a semi-liquid state, collects in irregular masses, which appear to be
formed in large measure of fibrinate of soda and potassa.
On comparing the disorders caused by spontaneous excess of alkalinity in the blood,
with those produced by injecting carbonate of soda into the veins, or by a frequent
repetition of blood-letting, Magendie found the sama symptoms and similar results.
If any substance possessing the property of combining chemically and of forming
salts with the fibrin, such as fibrinate of soda, potassa, or ammonia, be injected into the
veins uf a living animal, the fibrin will loose its coagulability, and this change affects the
blood generally, and although it may contain the usual proportion of fibrin, it becomes
unfit for circulation, and stagnates in the capillaries, and especially in the pulmonary
vessels, and local lesions, as apoplexy, haemorrhage, or hepatization follow.
Magendie has in like manner, tested the effects of defibrination upon the process of
inflammation during the reparation of wounds.
He selected a dog from whom he had successively removed several portions of fibrin.
A longitudinal incision was made through the skin, and some depth of muscle in the
anterior and middle part of the neck. The blood that escaped from the divided vessels
nppeared more liquid than usual ; it did not coagulate on the blade of the bistoury.
The lips of the wound were united by the twisted suture, and the animal lefl to him-
self. The animal survived the operation a few days only. An examination of the
wound afler death, revealed the absence of any real adhesion by coagulable lymph, and
the divided tissues were discolored, dry and hardly at all swollen.
The older writers were acquainted with the fact that alkaline salts prevented the
coagulation of the blood, and John Huxham in his Essay of Fevers, uses this fact to
explain the changes of the blood in Scurvy and Putrid Petechial Fevers.
It is well known that Tolatile alkali salts mixed with tbe blood, when just drawn, or rather
.ifter it runs from the vein, keep it from coagalating and hinder it from separatin^r into crasa-
mentoro and serum, as usual. The experiment is easy, and every one will find it true on
trial. This very adequately resembles tbe blood drawn from the bleeding scorbutics, and also
fruni most persons that labor under putrid petechial fevers, when the blood is drawn very
enrlj in the disease.
All humors of tbe body, actually putrified, become a strong Alkali, and putrid blood loses
its consistence, and soon after its color, running into a yellowish dark colored sanies. The
blood drawn in some greatly putrid petechial fevers, bath bad this appearance, and been
oliserved actually to stink as soon as drawn, as well as the urine, as soon as made ; so far was
the putrefaction advanced, whilst even life was still subsiding. Tbe surprisingly great aud
^\tQt*ij corruption of bodies dying of pestilential fevers with spots, shows this likewise ; I
have known such a corpn air as much, as they call it in seven or eight hours, as dead bodies
commonly do in seven or eight days, and to leak out a roost putrid taniu^ from all the outlets
of the body : which, by-the-bye, is a reason why persons dying of such fevers, should be
burted very soon.'' — An Essay on Fevers, etc., by John Huxham, M. D., 1757, pp. 50, 61.
Andral has shown that in the diminution of the fibrin, relatively to the Globules, we
must recognize the grand condition of the blood favorable to the production of hsDmor-
rhages ; and in his investigations he found the relation of these tWo factors so constant
that he found it impossible not to regard the one as the catise of the other.
In Scurvy the proportion of globules is natural, or varies within narrow limits,
whilst the quantity of the fibrin b diminished^ and its ooagulative quality is at the same
532 Changes of the Blood in Various Diseases,
time altered ; aod this condition is most favorable to the production of repealed aod
profuse hnmonhages.
The tendency of the formation of petechial and livid spots, during the progress of
malignant fevers, in the middle ages, is referable chiefly to the scorbutic condition of
most pallets, at those times, when salt meat constituted the chief nutriment during a
large portion of the year, and fresh vegetables were almost unknown. In this connec-
tion it should be remembered, that authors have declared, that they have found an
excess of alkaline matters in the imperfectly coagulated blood of persons who have died
of low-fevers or Scurvy, attended with livid petechise and spots. An analogous result
was announced by M. Fr^my and Andral.
Without doubt the supposition is correct that the peculiar hygienic condition of the
people of Europe, before the eighteenth century, caused them to be frequently attacked
with diseases, one of whose principal elements, it not their starting point, was a state of
dissolution of the blood. The dissolved and incoagulable blood, petechial and passive
haemorrhages, so constantly described by authors, in their histories of epidemic feven,
in the middle ages, are most philosophically referred in a measure at least, to the scor-
butic state of the blood of the patients, and to the bad ventilation and filthy habits of
the times. In the epidemics which prevailed in Europe during the middle ages, it wa9
common to observe gangrene, haemorrhage from various parts, extensive ecchvmosis, or
thousands of petechiae covering the skin, whilst the symptoms of Typhoid Fever, and
of the various contagious eruptive fevers, developed themselves with a high d^ree of
intensity, and the greatest rapidity. These affections were the external manifestatioa
of an internal condition of the blood.
Erasmus, the philosopher, who flourished towards the close of the sixteenth century,
wrote that in his day, the inhabitants of London, were every year, from spring to har-
vest, attacked by a malignant fever, which committed the greatest ravages in that city,
and especially amongst the poorer classes.
" The supply of water'* Erasmus says : "fails the inhabitants ; they have to seek it
at a great distance from the city ; the river water is carried on their backs, and is so dear
that the poor cannot procure enough of it to wash themselves, and keep their house»
clean. These houses are of wood, and very cold in winter, which makes it neoeasaiT
to fill the rooms with straw. But as this cannot be of^en renewed, it becomes spoiled
and very injurious."
Grant, who practiced medicine, and wrote towards the close of the last century, so^'
gested the inquiry, whether the peculiar hygienic condition of the people of Europe,
before the eighteenth century, must not have caused them to be frequently attacked
with diseases, one of whose principal elements, if not their starting point, was a state of
dissolution of the blood. It is certainly remarkable, that the observeis of preceding age»^
constantly speak of dissolved and incoagulable blood, in their histories of epidemics.
Huxham in his Essay on Fevers, has given a large number of observations, illas*
trating the great tendency to Petechiae and passive haemorrhages, in the feven of
those times.
Andral in treating of the changes of the blood in Scurvy, records the disappeatanrv
of this disease, and of the great febrile epidemics of the middle ages, and says :
*' We must therefore admit, that in consequence of the chang^e in the natur« of the M**
ences which necessarily act upon men, the blood which receives before the solida, the imprr«*
sion of the greater part of these influences, most present changes in its coostitntion proper*
tioned to those undergone by the agents which operate upon it. It would appear tbeo, that
there must have been a time, when a verj peculiar constitution of the blood engendered nmla-
dies, which in certain respects, may have differed from those now observed, and maj oo(
have required the same treatment. And thus it is that at different periods of the exlsteoce of
our race, and the diversity of influences to which it may be subjected, diseases of very di#K*
ent types may arise, and undergo changes in their essential nature, which are revealed to as
by the apeoific character of their symptoms.*'
Andral has likewise established this invariable law, of augmentation in the fibrift o^
Changes cf the Blood in Various Diseases. 533
the blood) in r^ard to every acate inflammation of the serous membranes ; and this
increase was very marked in a case of Cerebro-Spinal Meningitis, in which after death,
Andral found the Spinal Marrow surrounded in its whole ezlent, by a sort of purulent
sheath, the pus having infiltrated the pia-mater.
In the following case of soflening of the bTain, Andral, in like manner, discovered
an increase of fibrin.
Cask 632. — A womaQ was brought to the hospital, laboring under a recent attack of apo-
plexy. Her limbs were paralyzed and rigidly flexed. The patient was bled, and Andral was
surprised to find a larger quantity of fibrin in her blood (4.5,) than is usually found in simple
hsmorrhagrs. She soon died, and the autopsy disclosed in the right corpus striatum, and
H round a clot, a red softening of the cerebral substance of small extent, bat rery distinct.
Inflammation had then existed around the apoplectic centre ; the contraction of the paralyxed
extremities bad indicated it during life, and the excess of fibrin in the blood had added to the
value of the sign. It should also be remarked here, that if the excess of fibrin was small,
the inflammatory complication was also very limited.
In Tubercular Meningitis on the other hand, there appears to be no increase of the
fibrinous element of the blood.
Andral has given as the results of his investigations on the changes of the blood in
Tuberculosis and in Cancerous Cachexia, (Carcinoma,) that : So long as Tubercle and
Cancer preserve the character of hard masses without any inflammation around them,
an analysis of the blood, uniformly gives the normal quantity of fibrin ; but as the
soflening of these hard masses advances, and a process of elimination analogous to that
of inflammation, is set up around them, the blood becomes more and more charged with
fibrin ; so that the excessive formation of this principle is not due to the development
of the accidental production, but wholly to the inflammation excited by the latter, at
certain stages of its existence.
Andral has recorded the following remarkable case, in which tubercles developed in
the pia-mater simulated acute meningitis; but the qualities of the blood, even before
the autopsy, excited doubts regarding the existence of the latter disease.
Casi 633. — A seamstress, 24 years of age, entered the hospital of La Charite, May 27tb,
1841, complaining of having had a cough and shortness of breath for some time; she stated
that she suffered from continual headache; on May 18th, she met with a serious disappoint^
ment. and a few days afterwards her headache increased ; from that epoch she experienced
creeping chills. From May 23d, she grew more seriously ill ; on that day her headache was
unusually severe, and at the same time she had humming noises in her ears, intolerance of
light and bilious vomiting. From the 27th to the 30th of May, the symptoms of an acute
cerebral aflection grew more and more distinct. From May 30 to the day of her death, which
happened June 5th, she uttered piercing cries like those called hydrocephalic ; there were
delirium, strabismus, rigid flexure of the limbs ; distressing moans and convulsiTe movements
whenever the slcin of the trunk or limbs, which seemed to have its sensibility greatly exalted,
was at all rudely touched ; and towards the close tetanic rigidity of the neck.
At the autopsy the pia-mater was found thickly studded with tuberculous granulations,
which were collected most numerously about the fissures of Sylvius. In no other part, either
of the brain or Its membranes, was any appreciable alteration detected. Tuberculous granu-
Utions, similar to those which filled the pia-mater, were also found in the pleursB of both
sides, and in the peritoneum, both of which membranes were covered with them; both lungs
were filled with miliary tubercles. The only lesion revealed by dissection was the equal
development in all the great serous membranes, and in the lungs of small hard tubercles, with
no signs of inflammation around them. The anatomical characters of Meningitis were com-
pletely wanting.
When the analysis of the blood in th's case is examined ; at the first bleeding 3.0 parts in
the thousand, were found of fibrin, and at the second 3.4 ; so that the quantity of this con-
stituent of the blood did not exceed its physiological limits. During the life of the patient
this result was viewed with astonishment ; it seemed strange that in a disease which appeared
to be acute meningitis, the amount of fibrin should not be increased ; the autopsy explained
this anomaly and rather showed that the anomaly was only apparent.
Andral cites this case (633,) as the strongest evidence, that whatever may be the
534 Petechia in Cerehro^Spinai Meningitis due to the Local Inflammation.
extent or the rapidity of the formation of tubercles, it does not in the beginning, vi%-
ment the fibrin in the blood.
The changes of the blood in certain cases of Cerebro-Spinal Meningitis, may have
been the rwult and not the cause of the dberrcUed nervous actions. If this be tnie,
the petechia and ^ts, observed in a certain proportion of the cases, should not be
regarded as true cutaneous eruptions, like the cutaneous a£fections characteristic of the
exanthemata.
It has been said, that extreme agitation of the nervous system, may deprive the Uood
of its power to coagulate. According to several observers, a similar effect may be pro-
duced by a strong moral emotion, a concussion of the brain, the destruction of a certain
portion of the spinal marrow or a violent blow upon the pit of the stomach, affecting
the nervous plexus of that r^on. If facts of this class were appropriately verified,
they would doubtless be of the highest importance ; for they would show that the ner-
vous system exerts a powerful inflaence over the constitution of the blood, and thii
consequently a lesion of innervation may deteriorate the blood, just as an alteradoo of
the blood may modify the nervous action. Professor Bupuy announced, that by dividing
the pneumogastric nerves in horses, the blood of these animals lost its property of
coagulating; Dr. Mayer, on the other hand, having tied the pneumogastric nerves in
living animals, found that uniformly the blood had coagulated thronghout the whole
pulmonary circulation. These facts, as well as those relating to the effects of lightning,
excessive heat and excessive exercise in warm weather, require additional proof. If it
be true that the changes of the blood may be in accordance with the portion of the
nervous system affected, as in section of the pneumogastric and sympathetic, it may be
inferred that the changes of the blood in Cerebro-Spinal Meningitis may vajy within
certain limits with the portion of the nervous system chiefly involved.
THB DERANGEMENTS OF THE CIRCULATION AND RESPIRATION, AND OF THE S1CB^
TION8 AND EXCRETIONS, AS WELL AS OF THE NERVOUS FUNCTIONS IN CRRBBEO-
SPINAL MENINGITIS, MAY ALL BE REFERRED TO THE LOCAL INFLAMMATIO.^,
CONGESTION AND ALTERATION OF THE MENINGES, (ESPECIALLY THE PLA-MATEB)
AND STRUCTURES OF THE BRAIN AND SPINAL CORD.
The theory, that the cold stage, the febrile phenomena, the derangements of ctrcub-
tion and respiration, and the mottling and discoloration of the surface, are dae to the
action of a distinct blood poison which so alters the constituents of the blood that it
stagnates in the cnpillaries, and transudes through their walls into the surronndirc
tissues, is not necessary for the explanation of the phenomena, and is not borne out Ij
the natural history of the disease.
Derangement in the action of the nerves given off from the base of the brain and *•(
the medulla oblongata, caused by the inflammation of the pia-matcr, and disturhaoces in
the nutrition of the ganglionic cells, and by the mechanical pressure of the prodacCB cf
inflammatory action, are sufficient to cause the derangements of circulation and re^pi*
ration, and the stagnation and alteration of the blood in the capillaries of the sarfaci*.
and the consequent mottling of the skin as in Malignant Malarial Fever.
Not only is the fibrin increased in the blood in Cerebro«Spinal Meningitis, hot a*i
marks of disorganised blood and of bloody effusions in consequence of disorganivti-in
of the constituents of the blood, are absent from the structure most inflamed and
diseased, vis : the pta-mater of the brain and spinal cord. The appearance of tfh^^^o*
of blood and bloody serum, into the cavity of the cranium and spinal canal, deMribe^
by some observers, may be referred to the rough manipulation of the po6t-morte«
examination, and to post-mortem changes and exudations of the coloring matten • (
the blood.
The facts point chiefly to a want of oxygenation of the blood, and to a tendencj t.^'
the stagnation of the venous blood in the capillaries of the periphery, and noi to a di»-
PffteehicB in Centfro^Spinai Meningitis due to the Local Infiammatiem. 586
tinctire eropUoD, as in Typhus Fever, Measles and Scarlet Fever, nor to actual dfusions
of altered blood.
If it can be shown by actual experiment, that irregular capillary action and conges-
tion are dependent upon deranged nervous action, it is unnecessary in this connection
to do more than allude to the effects of pressure on the medulla oblongata upon the
functions of circulation and respiration.
Those writers appear to have been led into error, who attribute the mottled appear-
ance, and petechias of the surface, and the changes of the secretions, as well as the
marked disturbances of the circulatory and respiratory systems in Cerebro-Spinal Men-
ingitis, to the exclusive action of a fever poison disorganizing the blood.
In the first place, these capillary congestions, with their stagnant and dark blood,
cannot partake of the nature of a specific exanthemic emption, because they are found
in many cases in the mucous and serous membranes.
The " inflammatory " blood, whenever stagnant, from whatever cause, whether a
local injury, or from loss of contractile force in the capillaries, consequent on deranged
nervous action, would tend to throw out fibrinous effusions. Or perhaps it may more
correctly be expressed thus, the liquor sanguinis exuding from the stagnant blood
would contain a larger proportion of inflammatory lymph.
In the second place, the mottling and petechias of the skin are by no means present
in all cases of Cerebro-Spinal Meningitis. This has been in accordance with my expe-
rience, and many other observers have recorded the same fact. And in this connection,
it will be important to enter somewhat at length into a consideration of the character of
these congestions of the capillaries of the skin, as determined by the impartial state-
ments of the best observers.
Dr. E. Hale, in his description of the ^' Spotted Fever," which prevailed at Gardiner,
Maine, in the spring of 1814, thus draws a distinction between the spots or small
patches of a purple or livid color, which occurred most frequently in the fatal cases,
and an eruption or slight efilorescence of the skin, attended with redness, heat and
itching, which was a common symptom during recovery.
'* I bare hitherto «aid nothing of any spots upon the skin, although their real or supposed
Appearance has in manj places given a name to the disease. The reason is that I have very
little to say respecting them. In roost or all the fatal cases, just before death, small patches
of a purple, or rather livid color, were irregularly dispersed over the surface of the body.
They had a considerable resemblance, in their appearance, to small extravasations of blood
into the cellular membrane, and were probably produced by the stagnation of that fluid in
the small vessels of the skin.
In two or three other cases, spots somewhat similar to these, in their appearance, but of a
livid color, were discovered at an earlier stage of the disease. But they occurred early in
the season, and only where the fever had continued several days without any steps having
been taken for its removal. They disappeared as soon as the skin was excited to action,
either by friction or by internal remedies. I have never observed any tendency to the pro-
daction of these spots while the skin was moist, except in the fatal cases already mentioned,
unless the eruption formerly described as taking place during the convalescence, is to be
confonoded with them, and this was exceedingly dissimilar in its appearance." pp. 95, 96.
The observation of Dr. Hale, that these spots disappeared as soon as the skin was
excited to action, either by friction or by internal remedies, is highlv important, as indi-
cating that these spots were in no wise an eruption, but were proauced by the stagna-
tion of the blood in the small vessels of the skin. This explanation is sustained also
by the testimony of Dr Hale, as to the increase in the number and size of the spots in
the last moments of life, and in the article of death :
"The livid spots which had begun a short time before, increased at the moment of death,
and assumed much of the appearance of igcipient sphacelation, for which they were often
taken by the attendants." p. 109.
Dr. HalQ thua describes the eruption whi<;h sometimes occurred during oonvales*
oeDce;
536 PeteehicB in Cerebro^Spinal MemngUis due to the Local If\fiammation.
" After the epidemic seasoa had considerably advanced| aa eruption on the skin became a
Tery common symptom diiriDg recovery. It did not appear in bat few, if any cases, before
about the 1st of April, but after that time almost every patient was subject to it. It varied
in its appearance in different cases, but generally was a slight efflorescence on the skin,
attended with redness, heat and itching. 'Hie skin was very slightly elevated and uneven, but
commonly not pimpled. It subsided in two or three days of its own accord, leaving a branny
scale upon the skin from the desquamation of the cuticle.
" This eruption seems not to have been in any degree critical. It did not usually come on
until after the most severe symptoms of the disease had been relieved for several days, and it
was not attended or followed by any very observable additional amendment. Neither, on tl)e
other hand, did it appear to increase the fever, or in any way add to the sufferings of the
patients, eicept by the external heat and irritation, which were not often severe. It majr
perhaps be a question, whether the eruption is not attributable to the treatment, rather than
to the disease itself." p. 81.
Dr. Hale also describes a species of boil, or carbuncle, as another common aflection of
the skin and cellular membrane during convalescence.
" It did not commence until the cure was considerably advanced, generally several d*yi
after the eruption had disappeared, and sometimes not until the patient has so far recovered
as to have left his chamber. It was an exceedingly painful swelling, beginning in the form uf
a small pustule, which discharged a slight quantity of yellowish, ichorous fluid, and was sor-
rounded by an areola, which was of a bright red color, and hard ; the hardness extending
deep into the cellular substance, and attended by a burning, itching sort of pain. As tlie
inflammation rapidly extended itself, the centre became considerably elevated, and changed
to a deep purple, and almost black color. In a few days it ulcerated, and cast off a gangren-
ous slough, and then soon healed. The discharge from it was never very copious. These
tumors varied very much in their size, and in the extent of the inflammation. In some the
slough was not larger than a small pea, and the areolar not more than two or three inches in
circumference. In others, the slough was an inch or more in circumference, and the circle of
inflammation as large as a small plate." pp. 82-84.
Dr. Joseph A. Gallup, in his " Sketches of the Epidemic Diseases in the State of
Vermont/' states that the eruption, which had given the name to the disease, was not a
constant attendant, and he estimated the proportion of the cases which had distinct
crupdons, at about onfy one-sixth.
Dr. Eiisha North says that petechisd were by no means constant, and Drs. Thomx^
Welsh, James Jackson and John C. Warren describe the petechisa and vibice? n»
occurring ^^ in comparatively few cases of the disease. They are of worse portent in
proportion as they are more dark colored." According to these observers, they wen>
not always ibund in fatal cases, nor confined to such.
In fifty-seven cases, in which Dr. Ames, of Alabama, noted the state of the »k'w,
purple petechise, which did not disappear upon pressure, occurred in only one eas** ,
and an eruption around the mouth (herpes labialis) was observed in three cases.
Of the 96 cases recorded by Dr. Githens, ^^ thirty-six had marked petechial erup-
tions, not disappearing under pressure ; thirteen had mixed petechias and erythema ;
nine erythema and urticaria ; three had indistinct petechial mottlings ; and in thirty-
seven cases there was no eruption at all. If present, it usually appeared early ; it wa^
in many oases the first diagnostic mark ; and although showing, perhaps the oooditioo
of the vital fluid, it did not seem to have any reference to the degree of oerebrai
inflammation, or to the prognosis." Am. Jour. Med. Sci., July, 1867, p. 35.
Some observers, both in Europe and America, who have met this disease, have never
observed petechiao at all ; and most writers agree that they are not pathognomic, or of
any marked import
According to Dr. J. Baxter Upham, of Boston, Petechial spots were obserred io
only 65 cases in 315 cases of Cerebro-Spinal Meningitis. He oescribes the apott in
this limited number of cases, to have been generally of a haemic character, and to bsve
resembled those seen in the wont cases of Typhus. Boston Medical and Svi^icBl
Journal, vol. xci; Sept. 3d, 1874, p. 225.
We are in like manner justified in the conclusion that none of the other appeanaoiB
Relations of Cerebro^Spinal Meningitis to Climate. 637
and eruptions of tbe skin are characteristic or essential elements of Cerebro-Spinal
Meningitis, for in a large proportion of the cases, they do not appear at all, and many
other diseases present similar phenomena.
CKREBR0-8PINAL MENINGITIS, RESEMBLES IN ITS ORIQIN AND PROGRESS INFLAM-
MATORT DISEASES, AND HAS FREQUENTLY PREVAILED AT THE SAME TIME,
AND HAS BEEN INTIMATELY ASSOCIATED WITH INFLUENZA AND PNEUMONIA.
No less an authority than Dr. Nathan Smith, taught that " Spotted Fever '" resem-
bled epidemic catarrh, and in fact might be a variety of that disease. After a careful
examination of his " Practical Essay on Typhus Fever" we find that in this cele-
brated description, of what we now call Typhoid Fever^ no allusion is made to the
Spotted Fever, but his observations upon this disease will be found in his " Notes and
AddUum£' to the ''Treatise on Febrile Diseases, Etc, by A. P. Wilson Philip, M. D.,"
published in Hartford, Connecticut, 1816.
Dr. Smith, in his note upon Epidemic Catarrh, says :
** In my note on peripneumonia notha, I remarked that the catarrh assumes a great variety
of forms, and affected different parts of the body at different times. * *
*' A jndicioas physician has observed that the spotted fever, is a particular form of catarrh.
Id the winter of 1813, in that part of the country where the pneumonia typhoidia prevailed,
the spotted fever was prevalent at the same time among children. It was common for the
adaltfl in families to have the pneumonia; and the children in the same families to have the
spotted fever at the same time, which induced one to infer, that the two diseases were some-
how connected together.
In his note upon Peripneumonia Notha, to which he refers in the passage just quoted,
Dr. Nathan Smith, refers to the ancient origin or existence of this disease, pronounces
it a true epidemic, and shows that it belongs to the class of inflammatory diseases, and
is characterized by the inflammation of raucous and serous membranes, and the exuda-
tion of coagulable lymph.
In his comments upon Dr. A. P. Wilson Philips' description of Typhus Fever, Dr.
Nathan Smith presents the substance of his " Practical Essay on Typhus Fever,''
published ten years afterwards; and in the Notes on Petechial Fever, which Dr.
Philip considers immediately after T3rphu8, Dr. Smith takes the ground that the pete-
chial fever, as described by Dr. Philip, was only a variety of Typhus, and wholly dis-
tinct from the disease called Spotted Fever in New England. Thus Dr. Smith says :
*' Respecting the disease called Spotted Fever in New England, although the name may be
improper, as spots do not constantly appear, yet, by it we understand a disease of a peculiar
character, differing in several respects from any other. * *
*' I have mentioned in a note upon epidemic catarrh, some facts, which go to show, that
the spotted fever may be a variety of that disease. The following circumstances would lead
ns to believe that it depended on a peculiar morbid excitement of the capillary vessels in tbe
brain, which soon extended itself to this system of vessels throughout the body. Tbe disease
attacks suddenly. The arteries of the necic and temples beat strongly, the head is hot while
the pulse at the wrist is small, and the extremities cool. The functions of animal life are
HOOD impaired or lost.
** Severs! persons affected with this disease, who have recovered their health, have lost the
sense of bearing ; and others have been affected with blindness for several weeks. In one
case it affected tbe muscles of voluntary motion with tremors,.which has ever since deprived
the patient of the power of walking." " A Treatise on Febrile Diseases, etc., by A. P. Wil-
son Philip, M. D., etc., with Notes and Additions by Nathan Smith, M. D., Professor of
Physic, Surgery and Obsteterics, in Vale College," in two volumes. Hartford : printed by
Benjamin L. Hamlin, 1816, vol. i, p. 213-219 ; vol. ii, pp. 206-361.
Dr. Gallup considered the peculiar habit of the disease, called Spotted Fever, as
generally,
*• The offspring of cold climates, and cold seasons of the year. With a few exceptions, il
has broken ont in the coldeitt season?, and spread most alarmingly at such times in the differ-
ent places it has visited. The months of January and Februnry hate oftenett given rise to
538 Relations tf CerebrO" Spinal MeningUis to Climate.
It in point of seMonw hen it rages considerably ; it continues perbsps to tbe middle of the
month of May, and then passes off gradually like other epidemics."
This author affirmed that the most severe epidemic disease that had ever affliotod the
inhabitants of Vermont, the epidemic peripneumony of the autumn of 1812, and
winter of 1813, presented the general features of the disease, that bad been in tbe
State for about two years, called SpotUd Fever :
" The chief difference seemed to be, that now, the greatest force of local affection fell npoa
the longs. ♦ ♦
*< The chief difference seems to consist in the locality of the principal affection. In tbe
disease of 1810, '11 and '12, it was in the head ; in 1813, it was in the thorax. And these
circumstances go far in explaining tbe phenomena of the two diseases. Neither of tlie
diseases was strictly confined to one of these parts, or the other. When most in the
head, the diseased affection could be slightly traced in the thorax ; and when in the tbonx,
some could be traced in tbe membranes of tbe head." Loc. Cit., pp. 60, 70, 283, 284.
Dr. Ghillup also alludes to the fact, that the epidemic cause, affected both domestic
and wild animals, and a large number of Foxes and Souirrels died suddenly.
Dr. £. Hale, in his history of the " Spotted Fever, which prevailed at Uaidiner,
Maine, in the spring of 1814, in like manner, observed, that
" Tbe epidemic throogbont its whole course, was remarkably affected by tbe state of tbe
weather, and especially by any sudden change in the temperature. * * A few days of
unusual cold, seemed to render all the existing cases more severe, and at the same time, pru-
duced a greater number of new attacks ; while on the contrary, a change from cold to milder
weather produced a corresponding effect in mitigating the symptoms and lessening tbe
ravages oT the disease.*'
The disease commenced early in the autumn of 1813, in remote towns, and as winter
extended, the epidemic continued to spread over a larger extent of country. The firpt
case in Ghirdiner, to which Dr. Hale was called, was on the 11th of February ; through-
out the month of March, the Epidemic extended itself rapidly in all directions ; the
progress of the epidemic began to abate early in the month of April, and terminated
Its course in Oardiner, with the close of May. Manv of the writers who have recorder]
observations upon Cerebro-Spinal Meningitis, have failed to give careful records of the
weather and accompanying diseases, but in addition to the strong and clear testimooy ju5t
recorded, an immense mass of facts exist, to show that the disease generally, tf not
invariably, appears during cold, changeable and wet weather in autumn, winter and aprin;:
along mih some pulmonaiy oomplaints. t
It ai|peared in the Con^erate Army, at Bowling Green, during the winter of 186K
1862 ; in the succeeding winter it attacked the troops of the army of Northern Virgintt .
enoamped upon the snow*clad hills around Fredericksburg, and about the same time, it
appeaned in the Department of South Carolina, Georgia, and Florida, on the Atlantic
and Gulf Coasts, in the Army of the West at Grenada, Mississippi, and amongst the
negroes employed upon the fortifications, and also amongst the plantation hands, in
several adjoining counties; during the winter of 1863, 1864, it proved very fiita)
amongst the blacks at Mobile, and finally, it appeared in various parts of the Coofed-
erate States during the winter and spring of 1864-5. Some were disposed to ooonect
its appearance and spread, with the assembling of large armies, but its oocarrtort
amongst the citizens, in remote and comparatively isolated villages and towns, and it«
appearance also in the sparsely settled districts, at the same period of the year, wonM
indicate that the disease was due to a general epidemic influence. The fact that the
number of cases was relatively greater amongst the troops and negroes in service, »•
readily explained on the ground that these men were more exposed to cold and wet, and
at the same time subjected to those depressing influences, as scant diet, fiuigne and
mental anxiety, which render the system liable to the action of all epidemic inflneocea
The sick fuid mortuary reports of the Confederate Army, show that Pneomonk tad
Pleurisy und Qatarrh, were f^ more prevalent and seripDui in t^ux effi^ vmnpH cht
Relations of Cerebro^Spinal Meningitis to Climate. 539
soldiers than amongst the citizens. And there is no doubt, bat that the fever, which
appeared in, and spread from the large armies in Europe, following in their trains, and
spreading over the country, at various times during the last and present century, was
the true contagious petechial Typhus fever, and not the disease under consideration.
Cerebro-Spinal Meningitis accompanied with Malignant Pneumonia, prevailed in Ger-
many, in 1608 ; the epidemic of 1557, which prevailed in the environs of Poitiers, La
Rochelle, AngoulC^me and Bordeaux, commenced in the spring and was so destructive,
thit according to the expression of Coyttarus, the sick seemed to die rather from fear
than from the disease itself; the epidemic which showed itself in 1587, in Lombardy,
prevailed during the winter, and in the spring, it was complicated with pleurisy ; the
fever described by Sydenham, under the name of fehris nova, supposed by many to be
Cerebro-Spinal Meningitis, commenced in the month of February, 1685, aflei^ a severe
winter, and was at first considered by Sydenham to be the same as peripneumonia ] the
diseaae which appeared in a portion of the Army of Mont Blanc in 1814, prevailed
during the months of February, March and April, amongst the new recruits, who had
pzrbrtned very hard service, always in the snow, and exposed day and night to great
ftitigufi ; numerous other instances might be given illustrating the prevalence of this
disease during the winter and spring, as the epidemic at the Univerisity of Cambridge,
England, in 1815 ; that of Dublin, Ireland, and vicinity, during the winters of 1813,
14, 15; that of the galley slaves confined at Toulon, during the winters 1829-30 ; the
epidemics of England and France from 1832-1842 ; the epidemics of the United States,
from 1806 to 1866.
In the epidemic of Montgomery, Alabama, described by Dr. Ames, the disease made
its appearance early in February, was most prevalent in March, and disappeared as an
epidemic in the latter part of April.
Dr. W. Jewell, in his annual report on the Meteorology and Epidemics of Philadelphia
for 1863, describes the epidemic of Cerebro-Spinal Meningitis, as commencing in Feb*
ruory, and as being intimately associated with an epidemic Catarrh or influenxa.— '
TranMctioru of the ClUge of Physicians of PhUaddphia, 1862-186J^, p. 79, 80.
Dr. Levick, on the 6th of April, 1864, presented a paper to the College of Physicians
rif Philadelphia, in which he supports the view that the " Spotted Fever, '^ which had
prevailed in Philadelphia, was but a form of Epidemic Influenza.
Dr. S. Q. Webber, in his Prize Essay on Cerebro-Spinal Meningitis, after recording
m toy facts from various authors illustrating the effects of the weather, and of low damp
Httuations upon the origin and spread of Cerebro-Spinal Meningitis arrives at the fol-
lowing general conclusions :
'* Tb« influeDces, tbeD, which have been recognized as causes of this disease are nnusaal
Titigae, wbicb seems to have a pecalinrly powerful effect upon soldiers lately enlisted ; all
•Jtfbiliuting influences \ over-crowding in badly Yeniilated apartments ; want of cleanliness ;
Hudden variations of temperature, especially when combined with damp and wet weather;
« situation near marshes or considerable bodies of water and lack of proper drainage.
Contagion has but little influence, except as previously stated, under very favorable circum-
stances. Malaria has been mentioned by some observers, but if they mean that condition of
the atmosphere wbicb causes periodical diseases, and not a peculiar influence, suiffenerit upon
which this epidemic depends, there is no evidence of its existence.
Undoubtedly an epidemic condition of the atmosphere is the principal cause of this affoc*
tion. The other causes do not all exist at the same time, and sometimes none of them can be
iliscovered ; and again, most of them may co-exist without giving rise to this peculiar disease.
We mast then refer it to some hidden and hitherto undiscovered cause operating upon all and
prodacing the disease, only in those most susceptible to its influence, or who have been most
exposed to the pre-disposiog causes, and that cause has been called an epidemic condition of
the atmosphere, wbicb will answer well enough until its true nature is discovered. Whatever
this Inflnence is, it has frequently affected other diseases, assimilating them more or less to
this one.''
We have shown that the changes of the temperature during the progress of Cerebro *
Spinal Meningids, indicate the action of the agent producing the disease directly upon
540 Infiammatory Nature qf Cerebro^ Spinal Meningitis shown by its Mff^ts*
the oerebro-fipinal nervous system, rather than upon the blood ; io other words, the
changes of the temperature, are due rather to the lesions of the nervous system than to
the action of a fever poison upon the blood.
THE CONI^ITIONS OF MANY PATIENTS DURING CONVALESCENCE FROM CEREBRO-SPINAL
MENINGITIS INDICATE IN THE CLEAREST MANNER, THAT THE ClRRBRO-SPINAL
NERVOUS SYSTEM HAS BEEN INFLAMED, AND PARTS OF THE STBUCTTBIS
PERMANENTLY ALTERED, RATHER THAN THAT THERE HAD BEEN NOTHING
MORE THAN THE ACTION OF A SPECIAL POISON UPON THE BLOOD.
An explanation of the almost universally fatal character of Cerebro-Spinal Meningitis,
OS well as of the tedious nature of recoveries from the disease, may be found in the
physiological actions of the nervous structures involved, and in the nature and effects of
the products of the inflammatory action. The prognosis of every well defined case of
this disease must be doubtful and unfavorable.
Aside from the direct action of the morbific agent upon the nerve ganglionic ceDs
and commissures, it can readily be conceived, that the inflammation of the nutrittTe
membrane, and the coating of the most important and delicate organs confined in %
bony case, with a dense exudation tending to organize itself progressively into more
firm and resisting structure, might give rise to the phenomena of Cerebro-Spinal Menin-
gitia. ^ ... . . J
Even after the subsidence of all active inflammation in the meninges of the brain aod
spinal cord, the most serious consequences may follow, and all the dangerous symptoms
and derangements of the most essential functions of life may be kept up by the mere
mechanical action of the organizable and organizing fibrous efiiision.
The period of convalescence from this disease depends, not only upon the amount of
fibrinous inflammatory effusion, but also upon the character and rapidity of the subse-
quent chances, resulting in the gradual absorption of some portions of the products of
the diseased action.
Dr. Nathan Smith recorded the important observation, that in the Spotted Fever of
1813, several persons affected with the disease who recovered, lost their hearing and sight
and in one case the lower limbs were paralyzed.
Dr. Crallup appears to have been the first author who described a peculiar state of
chronic illness, often continuing for months and even years, and characterized by \x» ^*f
muscular and nervous power, pains in the head and various portions of the body %iA
extremities, inability to endure prolonged mental and physical effort which followed
Spotted Fever.
A careful examination of the full and accurate description given by Dr. GaUop, of
the " Segvelmof Spotted Fever,'' in the sixth section of his work, will show that the
symptoms which he describes, were ducr to the lesions of the oerebro-spinal nerroo?
system.
Dr. Gallup refers to an obstinate case of this kind, attended with pain in the head
(hemicrania) and tetanus, which finally ended in a state of deafness and idiotism.
Dr. Gallup also recorded the important practical observation illustrating the inflam*
matory nature of this disease, that:
'* AUhoogh there is a Rreat degree of debility in the organs of locomotion, a siaaU pQlx*
and a deficient circolation in the eztreme Tessels, the subjects of this disease bear btoediof.
puking, purging and moderate sweating to a great degree, without growing weaker or shovioc
many signs of increased debilitj. Not only this, but it is a fact capable of demoastrauoa.
that where these remedies are freely used the patient grows stronger, as soon as the fatifst
and immediate depression is over, which is only a short time.
"The circalation becomes more perfect, as is proved bj the warmth in the bands, feet, kt
le pain is mitigated, and by perseverance in the use of these means health is gradaall/
The
restored."
SpoiUd
Infiammatory Nature of Cerebro-Spinal Keningitis skown by its Sfffctt, Ml
until the cure was perfectlj completed, most persons were lubject to oocuional attaoks
of poin and numbness, either together or separate.
Many other observers have recorded cases of Cerebro-Spinal MeniDgitis, which ended
in paralysis, deafness and loss of vision ; thus, out of ninety-seven cases reported by
Dr. Githens, deafueu existed during and afUr oonvalescenoe to a greater or less extant
in fliiteen cases ; loss of memory was observed in seven cases, and purulent discharges
from the ears during convalescence occurred in three cases.
I have observed paralysis of the lower extremiues ; paralysis of the bladder ; paralysis
nf one or both upper extremities ; dcmentb, insanity, blindness and deafbesa, to result
from Cerebro-Spinal Meningitis.
Such results cannot be referred to the action of a distinct febrile poisoQ.
CHAPTER IX.
Whilst there exists do want of theories and pliiia of treatment, and oonfidsDce lo
specul remedies, unfortunate!; the attempts which have been made to nrge the olain*
of conflicting systems, have availed but little in the accurate determination of those
practical questions whiob involve the lives of a large portion of those afflicted with tbii
sudden and fBt«l form of disease.
It is cnstomary to dignify with the title Uxtentive Expcrieitee, the nse of one or
more remedies for a series of yean amongst a nnmber of patients, n^anllesa x\X the
fact, whether these remedies were selected as the result of education, ot of aoodent and
prejudice, or as the result of careful inves^gatioD and comparison of the reUtive eftrti
and value of diSerent modes of treatment.
The results are equally as bad, if not infinitely worse, when upon a few hurried and
crude observations, a theory is erected, intonded to express the pathology of discMe.
and a system of therapeutics invented to correspond with the notion of the nature of
the disease. Much truth may be evolved from the use of a limited mat«rift-medica ;
but a vast amount of error must neoessarily follow from crude and hasty pathotogiol
speculations.
In ffledioal science, as well as in sciences of more exact observation, do other vwlhod
except that of strict induction from well observed facts, will result in the ertablilhif >
of fixed and general priociples, which will express with truth the operations of natu*.
and enable man to guide and direct them ia fixed modes fur the aooomplishneat of
usefiit ends. Hypothetical discnssions of the nature of disease, and of the aetion of
remedies, apart fVom established facts, are worse than useless — they are puitiniT
injurious, in that they divert the mind from rigid experiment and fhim tba atrefiil
observation of nature. In therapeutics, we need above all thinn, rigid ofaaemtiaH w
the effects of the different agents, on the duration, progress, effects and teimtnatioB of
particular diseasee. In every inquiry in therapeutics, the physician should endnrar to
determine.
1st. The natural prt^iress of the disease when no remedies have beeo oaed: what is
the uatural history of the disease ; what are the tendencies of the disease — to reeovcfy
or to death ? The relstive mortality to the total nnmber of oases, snd to other dinsMM ^
when recoverr takes plaoe, what ara the antecedents and the immediate oaasesT Tkr
efllects of variations of climate, of previous habits, of diet, of age, as well as the ntent
and severity of the inflammation or disease should be accurately noted ; also ths tdeett
of various modes of diet and stimulation. The results of such iavestigotioos, will Ukw
a standard, by which the value of different remedies may be detormioed. Every om-
Bcientioas physician desires to dispense with all needless remedies: and if it wen povi-
ble to treat certain diseases by aUment alone, with more iucoeas than with dr^|^ it
would be the manifest duty of the medical attendant to conform the tnatment to the
established ooune of nature.
2d. Whether the remedies used, diminish the rateof mortality in partioulardiMMca,
and thns contribute to the safety of the patient.
3d. Whether the remedies abridge the ooune of the disease.
4th. Whether they lessen the sufferings.
Treatment qf CerebrO' Spinal Meningitis.
543
5th. Whether they leave an j injaiioiu resalts.
6th. The modes in which the remedies assisted nature in the relief of disease.
With a number of physicians, thus acting in concert, even if each one experiments
with and records his experience with only a single remedy, and that his accustomed and
faTorite one, it will be possible in the course of time, to determine with an approach
to accuracv, the most efficacious remedies and modes of treatment.
In Cerebro-Spinal Meningitis we have to deal with a violent form of epidemic disease
appearing suddenlv, and affecting immense districts of country, the natural progress of
which, especially m the first period after its appearance in any locality, is towards
death.
The sudden and rapid progress of the disease, is shown by the fact, that the most
fatal period is from the second to the fifth day, more than one-half dying then. If a
patient lives beyond the sixth day, there is some chance of recovery, lees than one sixth
having died after that time. The following tables illustrating the duration of disease,
were drawn up by Dr. S. O. Webber, from the records of 164 cases published in various
Medical Journals :
TABIiX I.
DURATION or FATAL CASES.
DCmATlOK.
No. of
Lrai thfto 1 day I 9
1 daj....
3 dllJ8.«
3 days..
4 days..
b days..
6 days...
7 dajs...
5 days...
10 days...
11 days..
U days..
18 days..
20 days..
23 days..
34 days..
30 days.
6
18
17
16
10
4
1
4
2
1
1
1
1
2
1
1
34 days I 1
36 days 1
56 weeks ' 1
SeTeral days I 1
Not mentioned 12
'I ••'
...
»• •
...
TABLE n.
DUBATION OF RECOVERIES.
TABLE III.
AGE AND POSITION.
OUBATiO!!.
3
4
5
7
days
days
days
days
10 days ,
13 days
14 days ,
16 days ,
17 days
20 days
21 days
23 days
26 days
28 days
30 days
36 days
37 days
40 days
48 days
50 days
58 days
Few days
6 weeks
18 weeks
10 weeks
4 months..
5 months
Not mentioned.
No. or
Cu«t.'
I
AOi. limitary
1
2
2
3
1
1
3
1
1
1
3
2
1
2
1
1
1
I
1
1
1
1
2
1
2
2
1
13
• ••
• • •
1 year..
IJ year,.
2 years
3 years
4^ years
5} years
6 years
7 years
8 years
9 years
0 years
1 years
2 years
4 years
5 years
6 years
7 years
8 years
9 years
20 years
21 years
32 years
23 years
25 years
26 years
27 years I
28 years'
29 years
30 years
31 years
32 years
34-40 ys
42 years
46 years
68 years
not sta'd
ToUl..
1
4
3
4
8
11
3
6
3
2
2
. ••
1
2
1
1
1
1
3
.. •
1
• • •
11
68
2
1
2
2
1
1
4
3
2
2
4
4
1
2
3
3
1
2
6
3
2
1
• ■ •
2
1
2
1
31
96
Total.
2
1
2
2
1
1
4
3
2
2
4
4
1
H
7
6
5
10
17
5
5
3
2
2
2
1
2
1
3
2
1
5
1
3
1
48
164
544 Treatment of CerehrO'Spinal Meningitis.
In rq;ard to the period of reoovery, it is not possible to give so precise informadon
as in the case of death. It will be seen from the 2d table, that health may be regained
at any period from the third to the tenth week.
Many of these cases from which these tables were oonstmcted, were not reported np
to the full restoration of health. Convalescence is usually slow and tedious, and as
soon as that was fiiirly established, the record ends. This may perhaps account for the
great difference in the length of the cases, some beine recorded until health was entirely
reestablished, and others only until convalescence. Table 3d gives a oomparattre view
of the ages of those who were attacked. This disease attacks most frequently youths
and those in good health, the very young, the aged and the feeble being less liable to
it ; and it will be seen, from the table, that from 15 to 21 is the most exposed age, one-
third of the cases having occurred during that period, and only five wero attacked who
were over forty. Males are more frequently attacked than females, the former furnish-
ing in these statistics of Dr. Webber, 114 cases, the latter only 36 ; sex not mentioned.
14 ; 67 cases, however, were soldiers and midshipmen in the academy at Newport ;
deducting these, we have only 47 males, and the dbproportion is not so marked, though
still noticeable.
Hirsh reports that of 391 fatal cases, 359 were under 15 years. Niemeyer found
that of 66 males, 20 died ; of 60 females, 18 died ; of 54 cases, from 1 to 5 yean of
age, 18 died ; 40 cases, from 5 to 14 years, 9 died ; 27 cases, from 15 to 23 years, 10
died ; and in 5 cases, above 23 years, 1 died. The mortality, although uniformly
appalling, is greatest at the beginning and diminishes as the epidemic progresses.
Among eighty-five cases recorded by Dr. Ames, there were twenty-two whites, vii :
five years old and under, one ; between five and ten, two ; between ten and twenty,
eight; between twenty and thirty, fAr^c ; between forty and fifty, <tro; over fifty,
three. Of the whites, ten were males and twelve females.
The blacks were sixty-three, viz : Under five years, one ; between five and ten, aur ;
between ten and twenty, fifteen ; between twenty and thirty, twenty-four ; between
thirty and forty, /ei»; bietween forty and fifty, j^ve; over fifly, f too. Of the blacks,
thirty-six were male9^ and twenty-seven Jemdlet, In the oases observed by Dr. Ames,
the mortality was confined to the malignant forms, and was about sixty (60) per oenu
In an epidemic observed by Left^vre, four-fifths died at the oommeiioement, and two-
thirds towards the end of the epidemic. Of 366 cases analysed by Dr. 8. B. Hoot.
the deaths were 243, and the recoveries 123, making the per centage of fatal cases 7U
per cent.
The following mortality table was drawn up by Dr. J. 8. Jewell from the monograph
of Mr. Broussais:
Nancj 8 deaths in
Le Mans 3
Anceois 4
Mont Brison 16
Poitiers.... 8
VerwiUef Ill
IVvlZ.. ...»•........•.«•• • ••.•............••*..•..•••• • •••..•.*•..••.•........«••..»•....... •. mA
I vrillKuBD .*•*.•• •.•......«..•...*......*•..«...•••.•.•.•*..•..•.....•..•....*.•.•.•.«•.. 40
Strasbourg (Mil. Hoip. ).......................... 108
Htratbonrg (Inhabitants) 90
Laval 44
Colmar...M...... m.... mm... &
Bayonne.M ^ m..^.... 21
AtKues Mort ^ ^ m... ...^^..^^...120
Thus, in 1035 cases, 592 terminated fatally, or 1 in 1.76.
Out of a total of 249 cases analyzed by Dr. S. 0. Webber, death oecunwl in 147.
and only 102 recovered. In the Sweedish epidemic, of 3051 penons atlaeked, 1387
died. Out of 161 cases treated in the Philadephia Blockley Hospital, dnriag the
ithi
I 10
a8 caiej
zrz \ in 3.5«»
ti
It
9
II
^ I in 3jm»
41
II
13
II
=3 1 in S.tMj
It
II
47
II
= 1 in tM\
It
It
10
II
= 1 in 1.:^
II
ll
20
It
= 1 in 2.5
t(
(t
227
It
= 1 in 2 <.*4
II
u
40
tl
= 1 in 1>;
IC
It
50
It
= 1 ta IT*
It
<l
184
It
=s 1 is 1 :••
II
tl
150
It
s 1 ia l.e^
li
ft
69
11
=r 1 is 1.56
(1
(1
7
(1
= lift 1-4*
II
C(
26
II
= lia in
CI
II
160
II
= llB 1.1.:
Treatment of Cerebro^Spinal Menmgitis. 545
months of Deoember, 1866, January, February and March, 1867, 43, or a little more
than one-fourth, died, and 31 were still under treatment at the time of the report.
During the recent civil war, the disease was very fatal, in both the Federal and Con-
federate armies ; it decimated one of the United States volunteer regiments in the
West ; in the first winter of its visitation at Memphis, there were no recoveries ; iu 35
cases reported by Dr. S. C Young, at Grenada^ Miss., not one got well ; Dr. Moses, of
Mobile, did not witness a single recovery, and heard - of but five ; and the mortality
throughout the Southern States during the war, has been variously estimated, from 60
to 80 per cent. In the Massachusetts epidemic of 1866, there were 278 cases and 170
deaths, or a mortality of a little over 61 per cent. Of 315 cases, selected from upwards
of 500 cases, by Dr. J. Baxter IJpham, which have been reported in Massachusetts
since 1870, 173 recovered and 139 died, the ratio of mortality being 44.55 per cent,
which was almost precisely the same as that of the 517 cases comprised in Dr. Upham's
recent report to the State Board of Health. We are at a loss to know upon what data
Dr. Alfred Stills, of Philadelphia, founds the statement, that '^ while ten epidemics in
various places, occurring between 1838 and 1848, presented an average mortality of 70
per cent, a similar number occurring during the decade from 1855 to 1865, give an
average mortality of about 30 per cent ; this remarkable fact would seem to indicate
a gradual decline of power in the epidemic cause.*'
As fiir as the preceding data, gathered from various observers, extends, there is no
ground for the adoption of the statement of Dr. Stills.''' On the contrary, there
appears to be no abatement whatever in the fatality of Cerebro-Spinal Meningitis.
We have endeavored to show, in the Seventh Chapter, that the treatment of Cerebro-
spinal Meningitis, based upon the principles established by the investigation of the
natoral history and pathological anatomy of the disease, should, in the first stages, be
directed to the arrest or modification of the congestion and acute inflammatory action in
the cerebro-spinal nervous system.
The sudden onset and rapid progress of the disease demand the most prompt and
energetic measures. The best means of modifying the congestion and acute inflamma-
tory action of the cerebro-spinal nervous system, are general and local blood-letting,
local counter-irritants, sinapisms and blisters, and the use of the warm water and hot
air baths.
Blood-Letting. — As soun as the practitioner has convinced himself that the disease is
Cerebro-Spinal Meningitis, the patient, as a general rule should be freely bled, (in the
upright posture if possible), the blood being allowed to flow in a full stream until the
patient feels faint and exhausted ; from ten to twenty ounces of blood should be taken,
the amount being regulated by the severity of the case, and the age, constitution and
strength of the individual.
Cut-cups may also be freely applied to the temples, to the back of the head and neck,
and along the region of the spine, and from two to eight ounces of blood should thus be
withdrawn.
The bowels should be freely opened with Calomel, and if necessary with Croton Oil.
If these measures fail to afibrd decided relief, the back of the head may be shaved and
a blbter applied over the region of the cerebellum, and back of the necx, and down the
entire length of the spine. Over the ppine this blister should not be wider than ftom
one to one and a half inches.
After the evacuation of the bowels, Mercury may be given in small doses, combined
with Quinine and Opium.
Free perspiration should be promoted from the very commencement of the disease,
by conducting the vapor of hot water into the bed, so as to keep the body immersed in
the vapor from the feet to the neck. The action of the skin and kidneys should still
farther be promoted by copious drafts of some hot tea, as sage tea, in which Bi-Car-
* Epidemic MeniDjciiis, or Cer^bro-Spinal Meniogitis, hj Alfred Stilts, M . D., etc. PhUa^,
18€7,p. 72.
546 Treatment of Cerebro-Spinal Meningitis.
booate of Potassa has been dissolved, in the proportion of one dracbm to the pint of
tea.
Cold cloths, wet with ice water, or bladders filled with ice, should be applied to the
head.
When it is evident that the active inflammatory sjmptoms have subsided, the more
energetic measures E^hould be abandoned, and the strength eupported by nutritions diet
and stimulants judiciously employed. The contractions of the muscles of the neck and
back, and the spaFms may be moderated, and sleep promoted, by such remedies as Calt-
bar Bean, Hydrate of Chloral and Chloroform.
Counter-irritation should be kept up along the back of the neck and spine by blisters
or by Croton Oil.
In some cases Quinine in large doses has acted beneficially as a sedative.
In many cases the severe pain will necessitate the use of Opium. This remedy, or
its alkaloid, morphia, may with benefit be combined with Hydrate of Chloral or Bromide
of Potassium.
Afler the subsidence of the inflammatory symptoms, the convalescence will, in all ci»cs
be more or less tedious, in which there has been an extensive efiusion of fibrinous ur
plastic lymph. During the transformation of portions of the deposit into fibrous tiivuc,
and the absorption of other portions, the strength must be supported, and the more
active depletory measures must be avoided altogether, o^ employed with caution, as thoy
may retard the reparative process.
As it is customary at the present day to decry blood-letting in this and in almost every
other disease, it is but just that we should examine the grounds upon which the merit
of this remedy rests in Cerebro-Spinal Meningitis.
The Confederate Surgeons who bled not at all, or but seldom, and who used Quinine,
Opium and Stimulants, lost almost every case of this disease.
Dr. Nathan Smith, in the Spotted Fever of his day, testifies, that ^' when to the uni-
versal torpor, which commenced with the disease, a high degree of excitement succeded.
blood-lettmg was practiced with good efiect."
Dr. Joseph A. (rallup has left important testimony to the value of blood-letting in
this disease ; and his observations are especially worthy of consideration, as he adopted
this remedy and used it freely, in opposition to the opinion of the profession and pabltc.
The entire observations of this intelligent physician ** on the Treatment or Methofim
Medendi of Spotted Fever,** are worthy of careful study, at the present time, when tho
mass of the profession condemn blood-letting, without themselves having given the
remedy a fair trial.
Some writers of considerable pretensions, who condemn bleeding in toto, in Cerebn^
Spinal Meningitis, do so entirely upon theoretical grounds, as by their own oonfeasion,
they have never used the remedy in a single case.
After illustrating hb method of practice by cases, Dr. Gallup* proceeds thQj< to dis-
cuss the value of blood-letting :
*' It will not be maintained that blood-Ictling is always ncccssarj or safe. It will oolr b*"
insisted on that it is often necessary and sonaetimes indispensable. * * Support and equal-
ize action when low, or depress and equalize action when high. Some cases I bare ne*.
where the most assiduous use has been made, from the beginning, of brandy, wioe, esfeore«
and essential oils, cayenne, camphor, ether, etc., internally, to support, and to equalise ac ^'^
externally, warm bathing, blistering, frictions with red pepper and rum, moderate and Urz
continued sweating, etc. By cqualiiingy it may be understood to divert the morbid act. ci
from the internal parts and important organs oppressed and agitated with pressure of bl k .
and membranous inflammation, to the surface and extremities of the body. If excitement *.?
kept up on the surface of the body, morbid action will spend itself partly there, and save t:r
more noble internal parts from destruction. It is presumable that the pressure of tbc b)c^'
and peculiar inflammation of the membranes of the brain, diminish the nervous tnerfj, ace
* Sketches Qf Epidemical Diseases, pp. 248^271,
i
Treatment of CerebrO' Spinal Meningitis. 547
maj b« ft CAQse of veakening the heart, and the rest of the sjBtem. So, taking some blood
oftimea actaallj gives strength to the action of the heart and system generally."
Dr. Ghillup states, that in tbe epidemic of 1811, he bled from one-half to two-thirds
of his patients, and that in not a single instance was there any reason to regret this
practice.
Dr. Ghdlnp recommended strongly, sweating, or the application of external heat, to
restore warmth and vigor to the surface, and relieve the internal congestions ; he gave a
preference to^the warm bath, but as this is often inconvenient, blankets dipped in water,
and applied over the whole body may be substituted.
Dr. Gallup affirmed, that in his section of the country, an almost certain fatality had
attended the use of Opium and Brandy in large quantities, and he recommended in their
.^tead, hot infusions of aromatic herbs, seeds and roots. With reference to Blisters, Dr.
Oallap says: "blistering ought to follow as soon as the patient has had warmth applied
In the first instance. It is of great efficacy in promoting excitement on the sarfaoe ;
the absorption of a safe stimulus from the flies, is supposed useliil, as also the mechanical
irritation upon the skin, helps to increase sensibility in lethargic oases."
Dr. Gallup disapproves of the indiscriminate use of emetics, and directs that cathar-
tics be used cautiously, as soon as the circumstances of the case will admit, as the
evacuation they produce, and the translation of excitement from the head they effect,
is often very useful in relieving the congestions in that part.
The results of this practice were most favorable, for we gather from the preceding
statement, that Dr. Gallup lost only two patients out of eighty-one decided cases, giving
a mortality of about one in forty, or 2.5 per cent.
Dr. James Mann, who served along the Canada border, as a Surgeon in the United
States, during the war of 1812,-14, in his ^'Medical Sketches or the Campaigns of
1812, *13, '14," has given an account of the "Epidemic Peripneumonia Notha," which
prevailed both amongst the soldiers and the citizens, and was apparently due to the
same causes, and was characterized by symptoms which in their sudden appearance, rapid
progress, and fatal character, resembled those of the "Spotted fever,'* which it had
succeeded.
The pen-pneumonia notka of that day occurred during, and subsequent to cold,
damp, wet, changeable weather, and is described as making its first attack with symp-
toms of uncommon coldness and torpor, which pervaded the whole system, without
those strong rigors observed in pleurisy, and intermittent fever, the heat of the body at
the same time, to the touch, was much below the standard of health ; during this state
iif torpor, an oppressed respiration with pain in the side supervened ; the first stage of
ciitig3Stion and depression was followed by reaction, and in the stage of febrile excite-
inunt, the heat of the body was never much above the standard of health. The pulse
during tbe cold stage was very small, and somewhat fuller than natural during the hot
stage, but except in very robust constitutions, it was not what might be denominated as
a hard full pulse. In many cases, the disease proved fatal in an incredibly short time,
and apparently in the first stage, and in some instances, in less than twenty-four hours,
lifter the first symptoms of indisposition supervened. Dr. Mann relates the case of a
r'oldier, attached to the hospital as a nurse, who complained that he had taken cold, and
that he felt an oppression at his breast; so little was his indisposition, that he went to
the lake shore, distant sixty rods, returned with two buckets of water, flung himself on
his bed, and died in six minutes, ;!pparently in a state of suffocation. There were other
instances of death almost as sudden. Upon inquiry, the patients said that they did not
MufiFer from extreme pain, but from a weight upon the chest, an oppression from an
inability to inhale the air, the lungs being so engorged as to be incapable of absorbing
or transmitting through its membranes, the oxygen of the atmospheric air, and the
poisonous carbonic acid gas of the blood. Fost-mortem examinations revealed engorge-
ments, congestions and inflammations of the lungs, even in those who had died in the
first stages, before the establishment of the febrile stage.
548 Treatment of Cerebro- Spinal Meningitis.
The biroDchue were charged with a mixture of blood and mucus. Where the disease
had been of some duration, adhesions of the lungs to the subjacent parts were noticed ;
the spongy texture of this viscus was lost, while it assumed in some measure, the solid
and compact state of the liver ; it was sometimes covered with a yellowish glutinous,
extravasated fluid, which adhered with some force to its surface. Dr. Mann describes
a remarkable, pale, pink colored sufiPusion over the whole face, distinct from the usual
febrile blush in the cheeks ; the appearance was similar to the sudden flush color pro-
duced by sitting before a fire, ader having been exposed to cold. This appearance was
most conspicuous on persons having fair and light complexions. A cough supervened
after the first twenty-four hours, in some instances, and when it was accompanied with
an expectoration, the pain in the side abated ; but if no expectoration accompanied the
cough, all the dangerous symptoms were aggravated.
Dr. Mann has recorded several observations which illustrate the close relationship of
this disease, with ^^ Spotted Fever ;^^ thus he states that during the cold stage, the
patients suffered with pain throughout the muscles of the body :
'* And in four or five instances, this epidemic made its assaalt upon the head, which bleed-
ing immediatelj relieved ; upon inqairy I found there was here no complaint whatever within
the chest. It was then prognosticated that in twenty-four hours, more or less, disease would
exhibit itself on the lungs. This prediction was fulfilled in everj instance when made. * *
In the campaign of 1814, there were a few cases of disease which assumed the form of
spotted fever, in which the brain seemed to be the seat of disease ; mental derangement
having been the most alarming symptom, without any pneumonic affection. The progress of
the symptoms was so rapid that no decisive mode of practice was adopted. All of them died,
within the first twenty-four hdurs, two of the number within six hours.
Dr. Mann has left most clear and decided testimony to the inflammatory nature of
the ^' Pneumonia Notha^ Pneumonia Typhoides^ Malignant Pleurigjf, Bilious Pneumo-
fita," which he considered in all respects similar to the Peri-pneumonia Notha^ des-
cribed by John Bell and other old writers ; and he has farther shown, that blood-letting
was the most efficient and valuable remedy.
In his remarks upon the treatment of the disease, as it prevailed during the campaign
of 1812, he says:
*' Without the employment of the lancet, other auxiliary remsdics proved ineffectual. The
bleeding should be small, and repeated, until the pulse becomes fuller and the heat of the
body is increased above the healthy standard, when the patient may bear a larger qaaatitv.
The patient sometimes fainted with the loss of eight ounces of blood at the first, who aabte-
quently was bled sixteen ounces, without auy collapse of the vessels. A fortanata use of
stimulants, in a solitary instance only, within my knowledge, proved successful, while their
indiscriminate use induced a most deadly practice. Such was the practice in the army for a
short period. Brandy, wine and soups, were the remedies administered io every form of tbeee
pulmonic affections. Prior to these potent stimulants, emetics, cathartics and blistera were
employed. The lancet was prohibited under every form of this epidemic.
*' It has been observed, the physicians, at the first appearance of this epidemic, doabted the
propriety of bleeding. Their doubts were removed by the superior success which followed
the use of the laucet, while stimulants proved fatal.
** This epidemic was considered by some typhoid, or asthenic. A typhus fever is always
accompanied with a prostration of the strength and low delirium. Will a disease ba consid-
ered typhus, when the patient is able to walk the room, and continue this exercise cren a
few minutes previous to death ? Is that disease typhus, which is relieved by bleeding? Thi«
form of the disease, in some cases demanded as many ounces of blood in the coarse of the
treatment as is often drawn from a person in severe pneumonia, accompanied with high
degrees of heat, strong arterial action and acute pain. Vet, in this disease, it was inexp«4icDi
to take more than two, four, six or eight ounces at once. The above quantities were takee
away every two,>foar or six hours, />ro re nata ; until permanent relief was procured. Some-
times after the first bleeding, the pulse became fuller, and the heat of the body increased
This favorable circumstance, however, did not usually follow until after the third or fourth
bleeding."
Treatment of Cerebro^ Spinal Meningitis, 549
Dr. Mann, in his acooant of tho winter epidemic of 1815, 1816, reaffirms his
views,*
Dr. Ames employed blood-letting in the beginning of the attack, frequently and
boldly, without regard to the state of the circulation, in the oongestiTe, as well as the
inflammatory forms of Cerebro-Spinal Meningitis. The quantity taken at one bleeding,
or at several, in quick succession, was sometimes very great, — on one occasion the
quantity taken at a single bleeding was forty-eight, and on another, forty-four and a half
ounces. In the greater number of -cases,^ the entire quantity taken from adults in one
day, varied from fourteen to forty ounces — in twenty-six cases the average was found
to be thirty ounces. The value of this heroic employment of the lancet was most fre-
quently observed in the inflammatory form, an improved state of the pulse, and relief
of the cephalalgia, being tho immediate consequence of the loss of blood. On the
whole, Dr. Ames believed that prompt and free bleeding in the early stages of both
the congestive and inflammatory forms was useful, in consequence of the time gained by
it for other remedies, which Dr. Ames conceived to be more obviously beneficial.
Mercury^ in tho hands of Dr. Ames, empbyed to produce its constitutional effects,
proved to be a more efficient remedy than blood-letting, both in the promptness and
permanence of its beneficial influence. If not always effectual. Dr. Ames considered
Mercury to be always safe, and the good obtained by it, to be more apparent, and quite
as permanent as that from all other remedies. In a few instances, however, salivation
induced early in the attack, and kept up for several days, failed altogether in producing
any perceptible influence, — in some cases, time was not afforded to effect salivation,
and occasionally, though rarely, the specific influence of the remedy could not be
obtained.
Biisttrt to the upper portion of the spine, were found, in mild and grave cases, seldom
to fail in removing, or greatly relieving the cephalalgia, even when bleeding had failed
to do so. In the malignant varieties also, the relief afforded by them was very great.
In the congestive forms, heat applied to the skin generally, mustard plasters and fric-
tions with oil of turpentine, were frequently beneficial.
Carbonate of Potaua was employed by Dr. Ames, with apparent benefit, in several
cases, and his experience with this remedy was such as to induce him to recommend it
to the attention of the profession. It was given to children in doses of from three to
"five grains, and to adults in doses of from ten to flfleen grains, repeated every two hours.
No case proved fatal in his practice, or, as far as he could learn, in that of either of his
professional brethren, in which it was freely and continuously employed. But it is to
be observed that, under any treatment, the mortality was confined to the malignant
forms of the disease ; that the remedy was given in but few cases of this kind, and that
other remedies of the most energetic kind were also administered along with it. The
powers of the remedy were exhibited in a much less equivocal manner, in the grave
and mild varieties. In many cases in which there were no febrile symptoms, properly
so-called present, the cephalalgia was speedily and permanently relieved, and in others
its administration was followed by a prompt reduction of the arterial excitement, and
the removal of intense cephalalgia, and other symptoms of head disease. In one
chronic case of the grave variety, in which the patient was fast sinking into a state of
dementia, convalescence began on the day that the medicine was first administered.
This man had been bled, salivated and blistered without benefit.
Qninine was employed by Dr. Ames frequently in the grave variety, to which it
seemed most applicable, and sometimes with partial sucoess. When the disease was
attended with a fever, which was regarded remittent, the meningitis appearing as if it
were engrafled on a remittent fever, Quinine occasionally arrested the paroxysms, but
more slowly, and with greater difficulty than in other fevers. In other varieties of
• Medical Sketches of the Campaigns of 1812-13-14; to which are added Surgical Cases ;
etc.; also an Appendix, by James Mann, A. A. S., Hospital Surgeon of the Army. 1816.
pp. U, 16, 17, 34, 125, 127, 305-317.
550 Treatment of CerehrO'Spinal Meningitis,
Cerebro-Spinal Meningitis, Dr. Ames oould not recommend thb remedy ; in sncb cases
its use, if not hazardous, never afforded much encouragement.
Dr. Ames used Emetics but little, but frequently employed Cathartict as adjuncts,
and to effect particular indications, but he did not rely upon them as curative reme-
dies. In two instances, a free catharsis, induced by drastic medicine, was evidently
prejudicial.
Opium was not considered by Ames as a safe remedy in the inflammatory nudigoaot
variety, nor of any use in the congestive malignant form ; in the other varieties of the
disease it was safe and valuable as an *anodyne remedy. — ^New Orleans Med. and Suig.
Jour., November, 1848, vol. v. No. iii, pp. 295-328 ; Am. Jour. Med. Sci., April,
1849, pp. 451-452.
Dr. Ames employed blood-letting much more freely than Dr. Gallup, and his snooeas
was not so marked. By a careful comparison of the testimony of these two observers,
it would appear that comparatively small bleedings, repeated at short intervals, if
sary, are more beneficial than these large evacuations which may in the congestive
depress the forces below the point of reaction.
Dr. Toudes, who advocated blood-letting, says, that to deny absolutely the utility of
bleeding, would be to fall into an exaggeration as false, as the unlimited oonfidenoe in
the employment of that remedy ; and notwithstanding the frequent inefficacy of bleed-
ings in the epidemic which he witnessed, he nevertheless concludes, that they rendered
more real service than other medicaments. In the observation of this physician, the
local abstraction of blood in the early stages of the disease, was in a number of eaaea
attended with good results, and followed by the happiest cures.
Casimir Broussais, considered bleeding as the only means of treatment during the
early stages, likely to be attended with success ; and Professor Forget strongly favored
general and local depletion, considering the latter preferable ; Matlot, Basseron, Corbin,
Maillot and many otner European physicians, have advocated and practiced free bleeding
from the arm, and locally by leeches and cups.
Dr. Robert Bums, of Philadelphia, who employed both local and general blood-lettinjr,
reports most favorable results, viz: nine recoveries out of 12 cases. The following is
his method of treatment.
" Th« treatment pursaed was the earlj abstractioo of blood geoerallj or locallj, accordinir
to circumstances, to relieve the brain and spine. Stimulating frictions to the whole tpiftal
column and extremities. Warmth to the feet, with sinapisms to different parts, to caotc
counter-irritation. Blisters sometimes, but seldom necessary stimulants. Diaphoretics when
feverish. The liver and bowels steadily acted on bj mercurial purgatives at night, and Castor
Oil next morning, and as soon as the violence of the symptoms abated, Quinia freelj admiais-
tered to the amount of eight or ten grains per day, for the first three or four days; tbis
however, to be varied according to circumstances. The nutriment, chiefly beef tea or eascncr.
barley, gruel, sago, and such other articles of a similar kind as best suited the disease, or
inclination of the patient."
Mr. Bums applied leeches freely to the back of the neck and temples. Dr. K. Oraeae^
of Bellefonte, Fa., has illustrated the value of blood-letting in a successful ease reported
in the Philadelphia Medical Reporter, May 7th, 18G4, pp. 277, 278.
We will examine briefly, in the next place, the testimony of some of the priiicipa]
American authors, who have opposed blood-letting in Cerebro-Spinai Meningitis.
Br. Hale considered the disease as a fever, adynamic in its character, oharacCeriied bj
great debility and prostration of strength :
'* The strength was not only oppressed by the impulse of disease, but it was rapidly
exhausted ; to adopt the comparison of Fordyce, the spring was not only overpowered, ao as
to prevent its action, but its elasticity speedily vanished under the weight which pressed spoa
it."
Acting on this hypothesis, Dr. Hale did not employ venesection in a single caaa, ihc
did he see any case in which it had been employed. He says :
Treatment of Cerebrospinal Meningitis, 551
" I vrta deterred from publishing it, by the fi^-eat tendency to debility which I witnessed in the
disease, as well as bj the reports which I hare heard of the disastrous effects, which were
said to hare followed its use in other places." And strangely enough, he adds : " The founda-
tion of these reports, or the accuracy with which they were related, it does not come within
my plan to examine here."
Dr. Hale, thas defines in general terms his mode of treatment.
"The first and leading object, always was to restore and continue in force the functions of
the skin. The second which was hardly less important, was to support the strength of the
patient. The remainder of the cure was effected by removing the great variety of occasional
symptoms which occurred. The means for accomplishing the two first objects, were pretty
uniformly the same in the several cnses. But for the last, the whole materia-medica presented
a field hardly enough variegated for the complicated and perpetually changing evils to be
removed." ♦ ♦
'* The treatment here described, was not such a course of indiscriminate exhibition of
stimulants, as those who disapprove of blood-letting and other copious evacuations in this
epidemic are supposed to have pursued, stimulants, it is true, were frequently administered,
and in some cases very freely ; but they were not prescribed without a rigid attention to
the symptoms which indicated, or which at least appeared to indicate them. The principal
reliance for the removal of the fever was upon a vigorous course of alteratives, aided by
the applicationof external warmth and moisture, and stimulants were chiefly given to
prevent and remove the prostration and debility which the fever generally produced." pp.
244, iii, 126-320.
The epidemic treated by Dr. Hale was comparatively mild, and wc are unable to
determine with precision the ratio of mortality, but from the statement of the author
the results of his treatment were fiivorablc, and he alludes to only seven fatal cases in
his practice.
Dr. Thomas Miner, held that :
** By an energetic exciting treatment at its access, this disease is frequently broken up
within twenty-four hours. When we fail in producing a revolution, and only make such iin
impression as to moderate the violence of the symptoms it usually continues seven, or in
some instances fourteen days, requiring the same course of practice according to the urgency
of the symptoms, as is demanded in the supporting stage of Typhus." — Eatat/a on Fevert^ p.
119.
According to Dr. Miner, '* Spotted Fever'* has ^'its scat and throne in the brain,"
and belongs ^* nosologically to the passive phlegmasia^ ;" and ^' no foreign author,*' he
confideotlj believed bad "ever described this disease." The work of Dr. Miner is
abeolutely devoid of all data, by which any judgment might be formed, as to the rela-
tive merits of his plan of treatment. To illustrate his views he records only one case,
and that a fatal one ; and yet this writer has been quoted by Dr. Alfred Stills, as an
'* authoritif " against blood-letting. Dr. Miner entered into no discussion whatever, as
to the merits or demerits of blood-letting in this disease, but simply advocated a stimu-
lant and supporting plan of treatment
The Committee of the Massachusetts Medical Society, charged with the inquiry into
the causes and history and modes of treatment of the epidemic of 1810, did not advocate
bleeding, as it was generally thought to be injurious; they recommended, however,
sweating by both internal and external means, and the judicious use of stimulants as cordials
and opium.
Dr. W. W. Qerhard,''' of Phildelphia, who held, as we have more fully shown else-
where a doctrine similar to that advanced by Dr. Hale and others, more than half a
centuiy ago, vis : that " the disease belongs to the same class, as other continued fevers
or exanthemata, and is strictly a blood disorder unconnected with any structural lesion,"
in like manner and upon the same grounds condemns blood-letting, although according
to his own admission, he had ^^ never practiced nor advised hlood-letting in any catted
Dr. Gerhard's plan of treatment was evidently founded upon his preconceived hypothesis
*Trans. Col Phya. PhiUd., 1864, pp. 48, 49,
552 Treatment qf Cerebro^Syindl MeningitiSi.
of the nature of the disease, and not upon the results of actual experiment and com-
parison of the different modes of treatment
Dr. Gerhard does not appear to have had any great success with his mode of treat-
ment for, of twenty cases alluded to in his paper, ten, or exactly one-half (50 per cent.)
died ; and in speaking of the success of the physicians of Philadelphia^ in the treat-
ment of the epidemic, he states, " that at leasi one case out of three or four has been
fatal," and, " at first, the mortality was much greater in several localities."
Dr. Geo. B. Wood, of Philadelphia, whilst expressing a more comprehensive theory
of the nature of the disease, in like manner appears to base his objections to blood-letting
exclusively upon hypothetical reasoning, and not upon actual experience with the relative
value of this reme^ly.
Dr. Wood divides the disease into two varieties, which he affirms are distinguishable
by the pred'ominanoe respectively of the features which have, in different places, gtveo
rise to the names of Spotted Fever, and Cerebro-Spinal Meningitis. The difference
consists^ in his opinion, in the more decided exhibition, in the one, of the characters of
a blood disease, as evinced by the early appearance of petechiae, and in the other, of
the symptoms of infiammatioU of the investing membranes of the brain and spinal
marrow. He admits that the two varieties are separated by no precise line, as thcj
run together by insensible shades ; but in their extremes they are strikingly different.
After careful examination of the entire article upon PetechicU or Spotted Fever ^ in
the work of the learned Dr. Wood, I have failed to find a single case, or practical
observation, illustrating, or supporting his system of treatment, which might, with truths
be styled the expectant plan of treating Cerebro-Spinal Meningitis.
The experience of certain European physicians, with reference to the value of blood-
htting, is more decided, and apparently based upon more reliable data ; and it must be*
confessed that the weight of this testimony is adverse to the indiscriminate employment
of this remedy. De Kenzi, Tourdes, Mottet, Lef^vre, Faure, Besseron, Corbin, Maillot,
and Laveran, have recorded observations illustrating the uncertainty of this as well a^
of all other remedies in the treatment of this disease. Dr. N. S. Davis, of Chtca<;o,
claims to have had good success, in the epidemic which prevailed in Chicago, in 187-.
by the employment of Calabar Bean and Ergot. A teaspoonful of a mixture comporH^d
of one and a half fluidounces of Tincture of Calabar Bean, and two and a halt iloid-
ounoes of the fluid Extract of Ergot, were given every two hours, by Professor Davt^.
CantharideSy in the hands of Professor Allen, of the Rush Medioed College of Chi-
cago, is said to have yielded f);ood results in the early stages, and in cases exhibicin*^
marked depression, even Strychnia has found advocates in Drs. Noble, Wales and
Palmer ; while the evidence as to the value of large doses of Quinia, combined with
Opium is conflicting. More recently Bromide of Potassium and Chloral Hydnte kavt:
found advocates.
Dr. Alfred Stills, has well said, that the difficulties involved in the questions which
have hitherto been discussed, and which refer exclusively to the history, phenooMna.
and nature of epidemic meningitis, are trifling in comparison with those that reftale u*
the cure of the disease *, these are partly inherent in the general subject of thertpeatio.
in which no problem whatever is susceptible of a categorical and permanent solauoo .
they depend still more upon the epidemic nature of the disease which gives a great
diversity of type.
<* These difficulties are further multiplied by occurring in a disease which ttaads alooe -.s
all other respects ; whose causes, phenomeDA and lesiions, in a word, whose lawa are specific
and whose varieties of type areas infinite as can be formed bj the combination, in constaati;
varying proportion, of a special disease of the blood deranging the molecular actions of tkc
economy, and an inflammation of the Cerebro-Spinal Meninges, and even of the subataocc
itself ot the great nervous centres. These reasons are sufficient to account for the diverfivat.
and often opposite methods of treatment which have been adopted and recommended br f>br-
•icians of equal sagacity, at diflcrent times and plftces." — Epidemic Meningitis, etc., p. 1 J4.
Dr. J. Baxter ITpham, in his recent fapor on the late epidemic of Cerplro-Spuial
Treatment qf' Cerebrospinal Meningitis. 553
.^[i-iiiii^itiij, ru«d bct'un: ihc MaSHacbuxcttii Mcdit^l Sociuty, June 2i], 1874, hm turcitily
illuMtnitcd the state uf doubt, hesilation and iibsolutc obscurity, wtiich churactcriKB thu
irentniunt of the present day.
Dr. Upham, however, iiotwithslandiii<^ the doubt and uncertainly, disclosed in thu
ri'plics to the Maasachusetta Board ui' Health, from two hundred physiciauH, reprcscnt-
iiii; wiveiity-scvcn towns and cities, and containing the data, more or leaa complete, uf
upwurds of five hundred cases of the disease, and giving a mortality of nearly onc-
liiiir of all the cases reported, concludes that " inmelhiiitf can be accomplinhed t'li ihr.
ii-iijf iif iTfalmenl." Thus he concludes his article with the following practical obeervu-
tii)nB, the spirit of which is similar to that of the views of Dts. Wood and Gerhard :
"Bearing in mind llic ewtnlial elemcDl of lUe diieaec, a morbid poison, acting primtkrily
unnn the riul fluid tod ■OeciiaKSccondaril}' and rApidljihe DieniDKCs ot the brain and apinal
ttinl, more eipeciallj' giving riie to svmptoms and pheaomena wbich itniulate while they are
nut identical irith InHammalory action in tbesB parta, and consequent eihaualion of tb* vital
(luncri and great ptrrerlion of Ibe nerve force, af manirealeJ in tlie irregular action of tlie
>ii-.iri, Ibe labored breatbing, tbe reatleasneas aad jactitation and extreme senailivencia of Ibc
niirr.ice ; remembering also the material lesions which are »a generally revealed oa pml-aoritm
inpprclion, tha indicationa for a rational treatment, ahould bs thete: —
-' 1. To huaband the strptigtb.
■• ■!. To combat the tendency to congrsLion of lb* brain and ipinal curd.
'■ J. To mitigate the intense pain.
■- 4. To calm the norvoua eicilemenl
'■ 5. To Douriah and support the syatem till the exuded morbid product! can be removrO
l>y tlie kindly otEcea of nature, and to minister, in the meanwhile, by all tbe ways at hand,
i.> iLe romfort and relief of Ibe patient." — Hoston Medical and Surgical Journal, Septenlier
,1.1, 18T4, p. 22S.
I huve thus endeavored to preectit a gcueral view of the various modes of treattnciil,
which have been proposed and practiced with the hope, that the reoord will prove of
permanent value ; and that whilst serving to direct the attention of physicians to the diffi-
culties of this subject, and the doubt and obscurity which involve the therapeutics of this
fatal form of disease, at the same time it may excite renewed interest in its thorough
invi-stigatioo.
The therapeutics of Cerebro-^pinal Meningitis will be advanced in tha future, by
i-uch a(.-curat« inveatignlions of the symptoms, (pulse, respiration. Temperature, nervouu
Hhd muMnilar phenomena, etc.,) (^emistry, (composition and changes at various sta^ti
..f tlie diiteasc, of the Blood, Urine and various scL-retions and excretions), Patholojiy
;iiid Therapeutics, in various countries and under various couditions uf climate, wit and
(ivcupatioD, u will permit of careful comparison and analyaix.
CLINICAL OBSERVATIONS
ON
CeRTJIII( DlSEjlSES OF THE LyMPHJITIC
AND
CIRCULATORY SYSTEMS,
AND OF THE
Liver and Kidneys:
ILLORTRATINQ THK
RELATIONS OF DROPSY TO VARIOUS DISEASES.
CLINICAL OBSERVATIONS ON CERTAIN DISEASES OF THE
LYMPIIATHIC AND CIRCULATORY SYSTEMS, AND OF THE
LIVER AND KIDNEYS, ILLUSTRATING THE
RELATIONS OF DROPSY TO VARIOUS
DISEASES.
CHAPTER X.
OB8EBVATI0NS ON OSMOSIS. PRKLIMINARY REMABKS C0NCKRNIK6 THR OBJSCTS OF THE
INVIWTKJATION. DEFINITION OF THK TERM DROPSY, OSMOSIS, END0SM0S18, EXOSMOSIS. IMBl-
HITIOK, CAPILLARY ATTRACTION, ABSORPTION, DIFFUSION. EXPERIMENTS ON LIVING ANIMALS,
ILLI'hTRATINU THE PHENOMENA OF OSMOSIS AND THR ABSORPTION AND ACTION OF SALINE
ITRJiATIVES.
PRELIMINARY REMARKS CONCERNING THE OBJECTS OF THE INVESTIGATION.
Ubefi'L results in cliuical instruction, may sometimes be obtained, by grouping
together the more important facte relating to some grave and striking symptom ^ and
by investigating the relations of this symptom to a large number of difleases. No
Mymptom is more striking or more uniformly grave, than dropsy, and as the practitioner
M otlen tempted to treat this distressing complication of a number of dissimilar diseases,
upon a uniform plan of routine practice, it was thought important to demonstrate ite
connection with various diseased states. We are thus enabled to group together many
of the most interesting cases of disease of the heart and circulatory system, and of the
abdominal organs.
Whilst the cases recorded are grouped, so as to illustrate one of the most striking
symptoms, common to a number of diseased states, at the same time, the facte and
eommentaricB will serve to illustrate many pointe in special diseases : and whilst we are
thus taught by experience, that oftimes no snuill difficulty is encountered, in determining
to which of ite many sources, a particular symptom, common to many diseases, should
\Hi referred ; at the same time we are impressed with the absolute necessity of acquiring
definite notions of the special disease, or condition on which the symptom depends.
It has been proposed to erase dropsy from the list of substantive diseases, and to
place it in the catalogue of mere symptoms, and connect it with the original maladies
upon which the effusions or accumulations of fluid depend. It would appear however,
that it is destined to be considered as a special disease or diseased state by systematic
writers, from the great difficulty experienced in many cases, of determining during the
life of the patient, the lesions upon which it depends, and also because to the practi-
tioner, dropsy is in all cases, something more than an effect or symptom of disease, as the
dropsical effusion may become the cause of other and mofft distressing symptoms^
eausiog, in some casen, extensive dcHtruction of ti.<viuo, and in others, embarrassing by
558 Osmosis, and the Absorption and Action of Purgatives.
its pressure, important functioDB, and evea extingaishing life ; and finaUj became the
removal of the dropsy, even when the original caose remains, may restore the patient
to a state of comparative comfort and health.
We do not propose to enter into an exhaustive consideration of all the canaes of
dropsy, but desire chiefly to examine the causes which have been illustrated by casea
actually observed and recorded in the practice of the author.
It may perhaps add something to the accuracy of the succeeding descriptiooa and
discussions, to recall the attention to the definition of certain terms employed by sys-
tematic writers.
Dropsy, (formerly written hydropsy, whence by contraction, dropsy): a morbid
accumulation of watery or serous fluid in the areolar tissue or serous cavities, arisio^
either from increased exhalation, or from diminished absorption, each of which condi-
tions depend upon antecedent states of disease. When limited to one part, the tern
ijBdema is employed, denoting swelling produced by the accumulation of serous fluid in
the interstices of the areolar texture, which swelling is soil, yields under the finger,
preserves the impression for some time, and is pale and withbut pun. When the
dropsy is extensive, the term anasarca is employed, and by some writers as ffynooymoiu
with general dropsy. When limited to the peritoneum, it is called abdominal jropay,
or ascites. Specific names are also applied, as descriptive of the sack, tissue or orgao
involved ; as when it affects the pleura, hydrothoraxj or dropsy of the chest ; when the
pericardium, hydropericarditisj or dropsy of the hearty when the arachnoid, hydrth
cephalusy or dropsy of the brain ; when the spine, hydrorachitis ; when the testicle,
hydrocele ; when the uterus, hydrometra; dropsy dependent upon diseasa of the liver,
hydrops hepaticus ; dropsy dependent upon disease of the kidneV) hydrops renalis.
During life, there is a continuous circulation of the fluids and elements of nutritbn.
not only by means of the heart and blood-vessels, but interstittally by a slower procesB
of osmosis through the walls of the blood-vessels and absorbents, and through the indi-
vidual constituents, the cells and fibres of the various organs and tissues. Althou^
not so rapid nor so manifest to the senses as the greater circnUtion, the constant and
slow interchange of the fluids of the body is of great if not of equal importance. The
fluid constantly secreted by the closed cavaties and interstitial tissues, is as constantly
re-absorbed into the circulation : when^ therefore, the serous fluid accumulates in the
tissues or cavities, without active inflammation, either the quantity of fluid secreted
has been abnormally increased, without a corresponding increase in the prooe» of
absorption, or it may be with an actual diminution of absorption,— or else the secretion
has continued the same as in health, whilst the absorption has been diminished.
OSSlOStS, (feNDOSMOSIS, EXOSMOBIS, IMBIBITION, CAPILLARY ATTRACTION, ABSORP-
TION, DIPPU8I0N).
It has been held by physiologists, that the lymphatic as well as the Uood-veMrl
8ystera, never terminate by independent extremities, but everywhere present a eon-
tinuous network ; and the teachings of both anatomy and physiology, up to a eoapar-
ntively recent period, appeared to establish the conclusion, that absorption is primarih
effected by the capillary attraction dependent upon porosity^ which characteriies lirins
OS well as inanimate matter. If it be granted that the whole vascular system, with th<>
exception perhaps, of that of the spleen, the medulla of bone, and some other smaller
tissues, is lined with a continuous membrane, it follows that no substance can eDl«r
(he blood-vessels, excepting in a state of solution, and that the process of reooof
absorption is one either of mechanical filtration, or of osmosis, including under thi«
term that of capillary attraction and diffusion. The fact that the pressure inside of the
vascular system, is everywhere greater than the pressure outside, renders it probabk*
that venous absorption is something more than mere filtration. The reaeaidica «^t
%^trickcr and others have shown that capillary vessels are composed of a delicate dnabl*^
contoured, dull nimnbrane) in which oval nuclei are imbedded* at tolerably regular iafrr
Osmosis, and the Absorption and Action cf Purgatives. 559.
vals. The parietes of these tubes arc therefore not structureless ; but granules arc
distributed through the capillary wall in a stellate manner, and in its general appearance^
it closely resembles protoplasm. It has not been clearly proved that the small, irregu-
larly shaped, dark, sharply defined spaces, observed within as well as between the cells,
after treatment of the capillary wall, with Nitrate of Silver, are actually spaces
(Slomata of Conheim). In order to understand the passage of the colorless corpuscles
through the vascular walls, in the process of inflammation, it is not necessary to admit
the existence of coarse spaces or openings {stomata), provided the capillary walls be
regarded as composed of a sofl material having the properties of protoplasm, and form-
ing an elastic and permeable membrane. If the openings in the capillary wall, were
reidly coarse, coloring particles of large size would pass through the vascular wall in
various regions ; but this never occurs. The colorless corpuscles on the other hand, by
reason of their softness and elasticity and living properties, not only accommodate thero-
dclves to the fine invisible pores of the vascular membrane, but also exert what may be
termed a digestive and assimilative action upon the capillary wall, similar to that
possessed by certain animals of a simple construction. The escape of the colorless
cirpuscle in inflammation must not therefore be regarded as a simply passive process,
like the flltration of a colloid substance, to which it was likened in the first instance by
Uering ; for this phenomenon can be influenced in the most various modes by the con-
tractility of the cells : everything, in fact, which favors or checks the active motility
and vital endowments of the colorless corpuscles influences their extravasation.
The serous or tissue fluid, with which, in consequence of the pressure under which
the blood courses through the vessels of the several organs of the body, the tissues arc
constantly permeated, requires constant renewal. Without a constant and rapid
exchange of this serous fluid, which to a great extent furnishes materials requisite for
the tissues and the preparation of the secretions, the composition of the various tissue
elements aronod which it plays, would be quickly and permanently altered. As soon
as the pressure of the fluid in the tissues, approximates that under which the blood
moves in the vessels, the passage of fresh serous fluid from the blood into the tissues
would cease. The constant escape of the serous fluid from the tissues, is provided for,
by means of the lymph vessels, which form a peculiar system, the rootlets of which are
distributed through the tissues, and which is related to the blood-vessels, in that it
indirectly withdraws from them the fluid they contain, and ultimately returns that fluid
to the blood-vessels by its terminal trunks.
It has thus been shown by physiologists, that the oricin of 'the lymphatic system is
in relation with the capillary vessels in which the blood moves under a considerable
pressure ; and that its termination on the other hand, communicates with the chief
venous trunks, and consequently with those parts of the vascular system in which the
blood pressure descends to its minimum amount, and in fact, almost to zero. The con-
clusion has hence been drawn, that the difference in the amount of these two pressures,
constitutes an essential factor in the production of the movement of the lymph : so
that the greater the difference, the more rapid is the movement : the lymphatic vascular
system therefore borrows its contents, as well as the impulsive force under which they
move, from the blood-vessel system ; and in so far it may be regarded as an appendage
of, or as an aoceasory dosed system to, the blood vascular apparatus. It is no longer a
matter of doubt, that the eapiUary lymphatics are lined by a single layer of flattened
epithelium, and that they also possess a special membrane, though not completely
homogenous and stouctureless as was formerly maintained, nor entirely closed. In some
lymphatics, openings of appreciable size, are known to occur, through which even
during life, small bodies may be absorbed into the interior of the tube. The openings
or itomata in the lymphatics, were first demonstrated by Professor F. V. Beskling-
hauaen, in the central tendon of the diaphragm. If milk, blood or fluids, which have
insoluble substances in suspension, be injected into the peritoneal cavity of mammals, a
beaotiftil injection of the network of lymphatics of the central tendon of the diaphragm
may be obtianef}. It has been shown by various experiments, that the openings by
562 Ogmasis, and the Absorption and Action of Purgatives.
precipitate thoB formed coniists of minate irregular granules. What bai changed the physical
form of this deposit? It has been accomplished, without doubt, by the action of the mem-
branes upon the chemical substances in solution passing through them.
Experiments an the Physical Influence exerted by Mucous Membranes^ removed/ram aU
vitality J on chemical substances in ^lution passing through them,
EscpenmenU 319-372 : I filled the intestine of a raccoon (Proeyon lotor) with a solution of the
chloride of calcium, whose specific grarity was 1031, and immersed in it a solution of the
oxalate of ammonia, haTing a specific grarity of 1007. In the course of an hour the exterior
fluids became cloudy, with a white precipitate of the oxalate of lime. At the end of two
days, a copious white deposit had settled to the bottom of the jar, which, under a magnifying
power of 210 diameters, presented the appearance of innumerable acicular, rectangular, and
irregular particles, often conglomerated together in great numbers, forming miniature repre-
sentations of plants with their branches and leaves.
Specific gravity of exterior fluid 1005.
The interior fluid was next examined, the intestine haying been punctured and its contents
carefully removed.
Specific gravity of interior fluid 1003.
This marked change of its specific gravity from 1031 to 1003, shows that a free interchange
of the fluids must hare taken place. The slight change in the exterior fluid, of 1007 to 1005,
is readily explained, when we consider the fact, that the exterior measured 12, whilst the
interior was only 4 fluidounces.
Within the intestines but a small deposit had taken place, in comparison with that of Uie
exterior fluid. Under the microscope this presented a magnificent crystalline appearance,
differing wholly from that of the exterior fluids, and also from that formed when solutions of
the chlorides of calcium and oxalate of ammonia are brought into immediate contact.
Amongst the crystals there were no less than seven well defined regularly formed varieties.
We recognize the octobedral and dumb-bell crystals, as the forms in which the oxalate of lime
almost invariably occurs in the urine, not only of man, but also of other animals, and even in
that of birds.
Does not this experiment indicate that the peculiar forms of the oxalate of lime, oocnrring
in urine, may be the result of the physical action of the basement membrane of the tubali
uriuiferi and its secretory cells ?
The tissues of the intestine were next examined.
The cellular tissue was not equally injected ; in some places there was scarcely any, while
in others there wsf#' a very abundant deposit.
In all places the mucous membrane appeared free from any deposit of the oxalate of lime.
It was found difficult, however, to decide this question by the microscope, on account of the
difficulty of separating the fibrous tissue completely, in which occurred a copious crystalline
deposit.
This is not the only instance ; out of numerous examples, we will select the following :
When the bladder of a raccoon ( Proeyon lotor) was filled with a solution of the bichloride of
mercury, and immersed in a solution of the iodide of potassium, a brilliant red crystalline
deposit of the blniodide of Mercury took place upon the exterior, whilst upon the interior a
light yellow mass of lozenge-shaped crystals of the protiodide of mercury was precipitated. In
this case also the mucous membrane appeared free from any deposit.
When the intestines of a raccoon were filled with a solution of the acetate of lead, and im-
mersed in a solution of the bichromate of potassa, the deposit upon the exterior consisted of
innumerable small, irregular granules, while that upon the interior consisted of bcautiAil,
stellate crystals.
When a sheep's bladder was filled with a solution of the oxalate of ammonia, and immcned
in a solution ot the (ihloride of calcium, no deposit took place in the exterior fluid, whilst a
precipitate of the oxalate of lime fell in the interior fluid.
Within the muscular and fibrous coats of the bladder this deposit presented the sane
Appearance. The fact that solutions of certain chemical substances will pass through a
mf mbrane in one direction, but not in another, might be illustrated by many examples.
The stomach of a raccoon was filled with a solution of the bichromate of potassa, and im-
mersed in a solution of the acetate of lead ; a copious deposit of the chromate of lead took
place in the exterior fluid, whilst none whatever occurred in the interior ; it retained its
natural color and appearance. The results were in all respects the same when the iattstiact
of this animal were treated in a similar manner.
When the stomach was treated in this manner, a deposit took place only upon the interior.
When the oesophagus of a large rattlesnake {Orotaiut AdawtanUus)^ was treated In a similar
way, only a small deposit occurred in the exterior fluid.
I filled the stomach of a raccoon, and a portion of the intestines of a large rattleenake with
Osmosis, and the Absorption and Action of Purgatives, 563
a eolation of the iodide of potass! am, and immersed them in a eolation ot the bichloride of
mercnry ; in both cases, a oopioas deposit occurred upon the exterior, whilst little or no pre-
cipitate fell in the interior fluid.
These facts are due to one of two causes. Either certain chemical substances in solution
exert an inflaence upon mucous membranes, changing their minute anatomical structure, and
thus destroying their power of carrying on the physical phenomena of endosmose and exos-
mose; or else mucous membranes possess a power of choice, as it were, dependent npon their
physical constitution, allowing one fluid to pass through in one direction, but not another
flaid, holding a different chemical substance in solution, in an opposite direction. When a
portion of the small intestine of a sheep was filled with a solution of the nitrate of lime, and
immersed in a solution of the oxalate of ammonia, a copious precipitate of the oxalate of lime
took place in the exterior fluid, which, under a magnifying power of 210 diameters, was found
to consist of innumerable octohedral crystals of different sizes, also a few dumb-bell crystals.
In the exterior deposit the octohedra were about one hundred times more nnmeroas than
the dumb-bell crystals.
In the interior fluid, a deposit of the oxalate of lime had taken place. The entire deposit
consisted of innumerable minute and delicately formed dumb-bell crystals, with here and
there an octohedral crystal. In the interior fluid, unlike the exterior, there were over a hun-
dred dnmb-bell crystals to one octohedral crystal. Minute octohedra, and delicately formed
dnmb-belis were found within the meshes of the fibrous tissue. By comparing this experi-
ment with the former ones, in which solutions of the same chemical substances were used,
we are forcibly taught the following laws :
1. Mucous membranes from the same relative parts of the bodies of different animals,
exert different physical influences upon the same chemical substances.
2. Mucous membranes from the same animal, but from different parts of the body exert
different physical effects upon solutions of the same chemical substances.
3. The physical influence exerted by the membrane is not the same in endosmose and exoa-
mose ; it differs with the direction of the current.
A very important question now presents itself for our consideration. May not this change
of form in the precipitates be due to the presence of some animal substance or fluid, as fibrin,
blood, albumen or serum, and not to the physical action of the membranes? To determine
this point, a series of careful experiments was instituted with the following substances :
albumen, fibrin, yolk of hen's egg, warm blood, cold blood, putrescent blood, warm serum,
cold serum, putrescent serum, and urine. In no case did the presence of these substances
produce a crystalline deposit of the oxalate of lime. Each experiment was performed in ser-
eral different ways, and under different circumstances ; sometimes the density of the solutions
of the chloride of calcium and oxalate of ammonia were raried, at others, the temperature
and conditions of the foreign body. But one result attended all these experiments — no crys-
talline deposit. In many instances we have mingled the interior and exterior fluids, in both
of which, crystals hare been produced by the action of the membrane, and in erery case the
precipitate of the oxalate of lime thrown down consisted of irregular grannies without any
crystalline form whatever. Does not this prove conclusively that the simple presence of the
different membranes did not cause the change of the physical form of the precipitate ?
The next question which presented itself was, whether dry membranes exert a physical influ-
ence upon substances passing in solution through them, capable of changing their physical
forms? To determine this point, we performed several experiments with dry membranes, with
solutions of the chloride of calcium and oxalate of ammonia, varying the relative positions and
densities of the fluids in each experiment. In no instance was a regular crystalline deposit
obtained. In only one experiment, two or three octohedral crystals occurred in the midst of
inillioDS of irregular particles.
All our experiments thus far prove that dry membranes exert little or no physical influence
apoD chemical substances in solution passing through them.
Oar next subject was to ascertain the influence of inorganic septa, during the endosmotic
Action. In our experiments we used thin vessels of baked clay. These were filled with a
solotion of chloride of calcium and immersed in a glass jar containing a solution of the
oxalate of ammonia. The relative positions and densities of these fluids were also changed.
In no instance did we obtain a regular crystalline deposit. So far, then, as our experi-
nents go, we are able to assert that inorganic septa do not exert a physical influence upon
chemical substances passing through them, capable of changing the arrangement of their
moteeales.
£rp(uiment upon the Phy$ieal Influence exerted upon Chemical Sub$lan€et in $olution^ a$ they pa99
through the cell walls of veyetablee. — I immersed the cut end of a stalk of Indian corn in a solotion
of the chloride of calcium, and allowed it to remain for 18 hours, at the end of which time it
was removed and placed in a solution of the oxalate of ammonia, in which it* remained for a
•inilar length of time. When thin slices of the corn-stalk were examined under a magnifying
power of 210 diameters, a crystalline deposit of the oxalate of lime was found to have takes
564 OsmosiSi and the Absorption and Action of Purgatives^
place within the hexagonal cells of the vegetable, differing widely from the deposit formed when
solutions of the oxalate of ammonia and chloride of calciam are broaght into immediate
contact. The precipitate thus formed consisted of irregular granules.
The crystals deposited within the cells of the corn, differed widely also from those formed
when the intestines of a raccoon or a sheep were filled with solutions of the oxalate of
ammoniai and immersed in solutions of the chloride of calcium.
I immersed sections of different lengths of the stem of a young and verdant bene plant, in
a solution of the acetate of lead, and then transferred them to a strong solution of the proto*
sulphate of iron. When thin sections were examined under the microscope, beautiful iquare
and lozenge-shaped plates had crystallized in all the hexagonal cells.
When the broad thick leaf of an endogenous plant was placed alternately in solatioos of
the same chemical substances, a crystalline deposit took place within its cells, which differed
in form from that within the cells of the bene plant. Different vegetables were immersed in
different chemical solutions, which, when mingled, produced a deposit of irregular granules,
and in every instance a regularly crystalline deposit took place within their cells.
U is unnecessary to do more than recapitulate the following results :
1. Cell-walls, like animal membranes, exert a physical influence upon the chemical tab-
stances held in solution passing through them. This physical influence is capable of altering
the arrangement of the molecules of the precipitate formed within the cells, to that the
precipitate which under ordinary circumstances consists of irregular granules, under the
influence of the endosmotic action assumes a regular crystalline form.
2. The cells of different vegetables, like different animal membranes, change in different
manners the arrangement of the molecules of the same substance.
It may yet be demonstrated, by experiment, that cells in the same plant, haWog different
offices, elaborating different products, exert a different physical influence upon the same che-
mical substance. Or, in other words, the cryst.illine deposit of the same substance, will vary
in physical properties with different cells.
Experiments determining/ the action of the ISalphate of Magnesia^ in ao/tf/tbn, wpoa
Living Animals.
Experimentt with a solution made of the ttrengtli of the ordinary purging dose^ one ounce of the
Bait to eight fluidounces of water. Kxperiment 373.. — 8 o'clock P. M., Sept. 5th, 1855. Made an
incision along the linea alba of the abdomen of a cat; drew forward the stomach ; passed a
ligature around the oesophagus, just above its junction with the stomach ; punotared the
duodenum; introduced the nozzle of a syringe, and threw into the stomach one flaidottoceof
the solution of the Sulphate of Magnesia. The duodenum was then tied between the iacisioa
Mud the stomach, thus inclosing completely the saline solution. The stomach and inteetines
were carefully returned, and the edges of the incision so closely sewed together that little or
lio atmospheric air could enter. Previous to the experiment, the cat had been starved for
more than thirty hours ; the stomach and intestinal canal were therefore completely enpty.
Specific gravity of saline solution, 1055. The next morning the cat appeared renarkably
strong. Upon pressing the abdomen, the bladder was felt, greatly distended with arise, which
had been excreted during the night, for the bladder was completely emptied during the
operation. By the exertion of pressure over the region of the bladder, its contents were
voided.
Sept. 7. The cat appeared strong and active, and passed about oae fluidoonee of clear
yellow urine. It continued alive aud strong, being able to walk about withoat aoy appareat
difficulty, until 1 o'clock p. m., of Sept. 8, when its throat was cut. The experineot lasted
:iixty-five hours, during which time the cat, of course, took no food or drink. The bladder
was distended with urine, which was collected and retained for future examioatios. Tuc
stomach contained one fluidounce and 2 j drachms, of a fluid almost transparent, baTing »
slightly turbid aspect. It was to a small degree ropy, from the admixture of macas, ti'C
presence of which was further determtned by the detection, under the microscope, of nan*.^
rous mucous corpuscles. Reaction decidedly acid, turning thick litmus blue promptly rri
Specific gravity, 1014. Compare thid with the original specific gravity of the siallne solaii«)&
1055, and we see at once that the greatest portion of the solution had been absorbed^ Tb^
contents of the stomach were next evaporated to dryness, dissolved in water, filtered aad
treated with the acetate of lead until a precipitate ceased to fall. The precipitate was next
treated with hydrochloric and acetic acids, alcohol and ether, to remove the carbMkAle ot
lead and all organic matter. It was next evaporated to complete dryness npoa the chloride
of calcium bath, and its weight accurately determined upon a delicate balance, capable of
turning to the thousandth part of a grain. A fluidounce of the original saline soletloB, sp.
gr. 1055, was also treated with the acetate of lead until a precipitate of the salpbate o€ lead
ceased to fall. This was dried and weighed in like manner. Knowing the amoBBt of ike
Sulphate of Magnesia contained in each fluidounce of the original solntion^ we are able, b«
Osmosis, and the Absorption and Action of Purgatives. 665
the applicEtioQ of the rule of three, to ascertain the amount of the Sulphate of tfagnesla
correBpondiHg to the sulphate of lead precipitated from the fluid of the stomach. The fol-
lowing are the terms used :
Weight of the precipitate of the sulphate of lead from > ( Its corresponding weight of the
one fluidonnce of original saline solution. / ' \ sulphate of magnesia.
{Weight of the precipitate of the sulphate of lead \ , f Its corresponding weight of the
from the fluid of stomach. / ' ( sulphate of magnesia.
Amount of the sulphate of magnesia remaining in solution in the stomach of the cat, grains
9.43.
Amount of the sulphate of magnesia in solution, absorbed by the stomach in sixty-five
hours, grains 46.09.
The intestines contained throughout their whole tract to the rectum, an orange-coloured,
tough mucus, which, iinder the microscope, was found to consist of mucous corpuscles and
epithelial cells from the mucous membrane ; also, large, irregular cells, filled with yellow
matter. The superior portion of the colon and rectum was filled with soft fecal matters, the
existence of which we have never noticed in a starving cat or dog not under the action of
medicines. According to our investigations in these cases, the excrementitious matters in
the colon and rectum are hard and comparatively dry. Their presence in this instance indi-
cated that a purgative eflTcct was produced by the absorption of the sulphate of magnesia
from the stomach.
The amount of the sulphate of magnesia contained in the urine was next ascertained.
Amount of the sulphate of magnesia excreted by the kidneys in the last twenty-four hours
of the experiment, grains 11.78. The former discharges from the bladder were not examined,
because they were voided suddenly, rapidly, and upon the floor. The urine examined was
remarkably rich in organic constituents.
The blood of the cat was next examined. The blood-corpuscles, like those of a dog which
was operated on in a similar experiment, showed the marks of inflammation by conglomerating
together in large numbers, resembling piles and rows ofcoins. The presence of inflammation
was further indicated by the amount of fibrin existing in the blood. Amount of fibrin in
1,000 parts of blood 7.0G. This is a much larger proportion of fibrin than usually exists in
the blood of cats and other animals in a normal condition. The parts in the region of the
wound bore the marks of inflammation. The lips of the wound had commenced to suppurate,
and portions of the peritoneum had adhered to the abdominal cavity by the ejection of
coagulable lymph. This was especially the case with the omenta.
Kxptriment 374. — 10 o'clock a. m., Sept. 4, 1655. ^lade an incision along the linea alba of
the abdomen of a dog; punctured the duodenum ; introduced the nozzle of a syringe ; threw
into the stomach one fluidonnce of the solution of the sulphate of magnesia ; and passed a
ligature around the duodenum, between the puncture and the stomach. A ligature was not
passed around the oesophagus where it joins the stomach. Specific gravity of saline solution
1056. The dog had been deprived of food and water for twenty-four hours previous to the
experiments, so that the stomach and small intestines were completely empty when the fluid
was thrown in. The bladder of the dog was emptied during the operation.
In the course of two hours, about one-half fluidonnce of bloody urine was discharged. At
fifteen minutes before 3 o'clock p. m., four hours and forty-five minutes after the performance
of the experiment, the dog vomited about one-half fluidounce of mucus and the solution of
the salpbate of magnesia. The mucus was completely incorporated with the saline solution,
so that the whole mass was viscid and ropy. At 5 o'clock p. m., passed one and a half fluid-
oQDces of clear urine. At 9 o'clock p. m., passed one-half fluidounce of clear urine.
On the morning of the next day, September 5, the dog appeared as strong as before the
performance of th) operation, and drank about one and a half fluidounces of water, which
was vomited up in a few moments. The water thus vomited contained but small traces of the
solpbate of magnesia. Although the dog vomited one-half fluidounce of mucus with the
solation, still more than one-half the original amount was absorbed, and acted decidedly upon
the kidneys. Three fluidounces of water were again drank by the dog, and again vomited.
At 4 o'clock p. M., the dog vomited two fluidounces of mucoid fluid. After this it devoured
with great greediness, the muscles of a young gray squirrel (Sciurus CarolinenM)^ cut into
small pieces. At 9 o'clock p. m., five hours afterwards, the greatest portion of the meat was
vomited, together with a fluid which contained mucus and gave a decidedly acid reaction.
This meat had been acted upon by the gastric fluid. The exterior of the largest, and the
entire snbstaoee of the smallest, particles presented a soft, white, gelatinous appearance, and,
when pressed, were easily crushed beneath the fingers. The dog refused to take any further
Donrisbment, and died in a few hours. Its bowels were moved shortly before death. Owing
to the time of its death, after midnight, we were compelled to defer our examination until
next morning.
The stomach was distended with gas, which probably was generated by the remaining par*
Ueles of meat undergoing partial fermentation after death. The blood-vessels upon its
666 Osmosis, and the Absorption and Action of Purgatives.
exterior were filled with blood. Its interoal macous coat was of a light purplish piok color.
The intestines were distended with gas, and contained a red, bloody riscid flaid, which, under
the microscope contained blood-corpuscles altered in shape, epithelial cells, mucous eorpttscles,
large ellipsoidal cells containing granules, and irregular cells containing orange-yellow matter.
Crystals, resembling the prismatic crystals of triple phosphate which occur in urine, werealM
present, in small numbers, in the contents of the intestines. The internal mucous coat was
very red in color. When the blood was examined under the microscope, the blood-corpuscles
were conglomerated together, indicating the presence of inflammation. The blood also con-
tained numerous minute worms, the larras of larger ones, several inches in length, which
were packed away in great numbers in the cavities of the heart, the larger blood -vessels
and in the structure of the lungs. It may be interesting to state that this dog was extremely
poor, a mere skeleton, and I found it impossible to improve his condition, although he was
liberally supplied with vegetable and animal food. And it is remarkable that tho docility,
courage, physical powers and tenacity of life in this dog did not appear to have been impaired
by its condition, induced no doubt by the presence of these worms in the heart, lungs and
blood-vessels.
Hxperimeni 375. — In an experiment upon the absorption of fatty matters, I operated upon a
remarkably large, powerful and intellectual pointer dog, which possessed the characteristics
of the preceding dog, a voracious appetite, without any lasting benefit resulting from the
consumption of enormous quantities of animal and vegetable food. His heart contained
numerous worms, several inches'in length, and exactly resembling those of this dog, (Ex. 374.)
With reference to the action of the gastric juice upon meat, we are aware that it conflicts
with the theories of certain physiologists. We have, however, enjoyed many opportunities
of demonstrating the fact that meat is digested in the stonxach. and not in the small intestines.
We have found in the stomach of an alligator, the bones and hair of an entire pig, without a
particle of meat upon them. In the stomachs of others we have found fish, anakea, crabs,
&c., in different stages of digestion ; some, like the meat in the dog's stomach, sligbtly acted
upon by the gastric juice ; others partially dissolved ; whilst of others little more than their
bones remained. These facts have also been verified by an examination of the contents of the
stomachs of snakes which feed upon mice and lizards.
We learn a practical lesson from this experiment ; the oesophagus should always be tied. If
this is not done, the animal is liable to vomit up the fluid injected into the stomach, and ve
will therefore be unable to ascertain the exact amount of the medicine absorbed.
By compariDg these two experiments, we are taught the following:
1. Solutions of the sulphate of magnesia, of high specific gravity, are capable, if
retained long enough, of being absorbed in the stomach.
2. After absorption, thev excite both diuresis and purgation.
3. The main channel for the elimination of the sulphate of magnesia is by the
kidneys.
4. Its elimination is accompanied by an increased amount of the solid constitoeot^
of the urine.
Several other conclusions are forced upon our minds, but we will reserve their czpn^
sion until after the completion of this series of experiments upon saline aolutioiis of
high specific gravities.
Experiment 37G; Ten minutes before 12 o'clock. May 25, 1855. — Opened the abdomiaal
cavity of a cat by an incision along the linea alba, passed a ligature around the «sopba|r«s
above its junction with the stomach, introduced the nozzle of a syringe into a small incisioa
into the duodenum, and injected one fluidounce of the solution of the sulphate of maffoesi*
into the stomach. A ligature was then applied to the duodenum, between the puncture sod
the stomach.
A ligature was next passed around the colon, just above its junction with the rectum ; thr
nozzle of the syringe was introduced into the puncture in the duodenum, and one flutdoaacc
of the saline solution thrown into the intestines. Lastly, a ligature was applied around the
intestine, a short distance below the incision, through which the solution of the suipbaieof
magnesia was injected into the stomach and intestines. The saline solutions were thus sepa-
rately and completely inclosed in the stomach and intestines, without any possibility of thrir
passage upwards or downwards. The stomach and intestines were returned to their natanl
positions in the abdominal cavity, and the incision carefully sewed up.
iSpecific gravity of solution of sulphate of magnesia 1053.
The specific gravity, as in all the subsequent experiments on living animals, was accnrstely
determined upon a delicate balance capable of indicating the weight of ^^v P*^ of a graia.
The length of the intestine inclosed between the two ligatures was three feel*
Osmdsis, and the Absorption and Action tf Purgatives. 567
As asuali the cat, before the operation, was kept without food or drink for twentj-foar
hoars. Daring the operation, which occupied ten minutes, one of the small arteries which
supply the intestines were cut, and speedily tied, with little loss of blood.
The bladder was coropletly emptied, and fecal contents discharged from the rectum during
the operation. Afterwards, several times, small amounts of urine were discharged, but no
fecal natters. At ten minutes after 8 o'clock p. m., eight hours after the operation, the cat
was examined. It was in an exceedingly feeble condition. The blood-vessels upon the
exterior of the stomach were injected and distended with blood.
Amount of fluid in the stomach one fluidounce and seven drachms. In eight hours it had
increased seven fluiddrachms. The fluid was without odor, and contained larfi:e quantities
of transparent mucus, which was so thoroughly incorporated with the saline solution, that it
poured like flaxseed tea. There were also masses of dense mucus floating about.
Under the microscope, with a magnifying power of 210 diameters, it contained raucous cor-
puscles and epithelial cells. The next morning numerous single cells, animalcules, were seen
sporting about.
In the denser masses of mucus there were several dark looking floccuH, which, under the
microscope, consisted of blood-corpuscles and coagulated fibrin. The amount of blood in
this state did not exceed one or two drops, and was, most probably, derived from the nozzle
of the syringe which came in contact with the bleeding edges of the wound in the duodenum.
When treated with heat and nitric acid, only a slight cloudiness was produced, showing the
presence of albumen in very small amount. It was without doubt, introduced into the
stomach in a manner similar to that of the blood-corpuscles.
Specific gravity of the fluid in the stomach 1026. The amount of sulphate of magnesia con-
tained in it, as ascertsined by the method described in the first experiment, was grains 49.5.
Amount of sulphate of magnesia which had passed out of the stomach, grains 6.02. Each
Huidddracbm of the original solution held grains 6.94 of the sulphate of magnesia in solution,
consequently about one fluiddrachm of the original solution had passed out of the stomach,
while six fluiddrachms of the fluid from the blood had passed in. The internal mucous coat
of the intestines was of a pinkish red color, the vessels which supplied it with materials for
secretion and nutrition being congested with blood.
EzammaUon of the Intettines. — The blood-vessels on the exterior of the intestines were filled
iriib blood, and the whole surface was reddened. This was not the case with the surface and
t>Iood-vessels of the adjoining intestine which was not filled with saline solution ; they pre-
sented a natural appearance. The internal mucus surface was reddened, and presented
numerous spots of a dark purplish-red color.
Amount of saline solution one fluidounce, seven drachms. The increase of the saline
fluid in the intestines was exactly equal to that in the stomach, notwithstanding that the
surfrtce exposed in the former was many times greater in extent than that of the latter.
The fluid was of a light red color, and its odor similar to that of the fecal matters of cats,
only considerably aggravated. The intestine included between the two ligatures, embraced
the jejunum, ilium, and the greater portion of the colon. Specific gravity of the fluid from
the stomach 1022.
Meat and nitric acid revealed the presence of albumen in minute quantity.
After standing for several boars, a light colored sediment settled at the bottom of the ves-
sel, which, under a magnifying power of 210 diameters, consisted of epithelial cells from the
roacous membrane, other large irregular cells, and a few crystals of the triple phosphate.
The supernatant fluid contained these in less quantities.
Amount of the sulphate of magnesia in the fluid of the intestines, grains 41.25.
Amoant of the sulphate of magnesia which had passed out of the stomach, grains 14.27.
Kach fluiddrachm of the original solution held grains 6.94 of the salt in solution, conse-
quently about two fluiddrachms of the original solution had been absorbed, whilst nine fluid-
drachms of the fluid from the blood passed in. In both the stomach and intestines the
•moont of the saline solution wss equal at the commencement and end of the experiment,
whilst the absorption had been twice as great in the intestines.
Experiment 377; ReptUtion ofErperitntnt 376: Secured in the stomach of a cat in the usual man-
ner, with ligatures around the oesophagus and the duodenum, one fluidounce of the solution
of the sulphate of magnesia. One fluidounce of the same solution was also introduced into
the intestines in the niual manner and secured with ligatures.
Specific gravity of saline solution 1055.
Operation performed at 12 o'clock at night. The cat nppeniid to sufl'er considerably
doriag the operation, but as soon as the wound was sewed np, it gave no indications of pain,
bot commenced, when stroked upon the head, a vigorous purring. The operation was con-
docted without accident, and only a ftw drops of blood from the cutaneous veins and arteries
were lost.
Preriout to the experiment, the cat wss kept withoat food and driak for thirty-six hours,
ibe stoDftcb and iotestines, therefore, were completely empty when the flaidt were introduced.
568 Osmosis, and the Absorption and Action of Purgatives.
Tbe cat was found dead at 9 o'clock a. m. next moTning.
The blood-y.essels upon the exterior of the stomach were congested with blood. The
internal mucous coat showed a high state of irritation, being of a purplish color. Several
small spots were visible of a deep purple.
The stomach contained one fluidounce, three dradn:?, of a light pinkish colored fluid con-
taining much mucus. Specific gravity 1G35.8. Heat and nitric acid produced onlj a slight
precipitate. Albumen was present in an fln:cnnt just sufficient to manifest itself in a feeble
manner, and was, no doubt derived frcm a drop or two of blood accidentally introduced dnnti?
the experiment. Under the microscope, the fluid contained nucleated epithelial cells frcm
the mucous membrane, also the mucous corpuscles.
Amount of the sulphate of magnesia remaining in the fluid of the stomach, grains 44.21.
Amount of the sulphate of magnesia which had passed out of the stomach, grains 11 31.
Each fluiddrachm of the original solution contained grains 6.94 of the sulphate of magnesia.
consequently one fluiddrachm and forty minims of the original solution, or three and a bslf
fluiddrachms of the fluid in its present state of dilution, passed out.
Examination of the Intestines. — The blood-vessels on the external surface of t|ie intestines
and in the peretoneum were congested with blood, and the whole surface was reddened.
The internal surface was coated over with light-yellow mucus and epithelial cells, ^hrn
this was gently scraped off, the mucous coat was found congested with blood, being of a pur-
plish-pink color, very deep in some parts, and in others lighter.
Amount of fluid in the intestines two fluidounces, four drachms. The fluid was of a yellow-
ish red color,. and contained a large amount of (hick mucus, epithelial cells, also granular
yellow cells. Its odor was fetid, extremely disagreeable and capable of nausating weak sto-
machs. Specific gsavity 1018.6.
When treated with heat and nitric acid tbe presence of altutften was promptly indicated.
It was present in considerable quantities. In addition to the cells atove mentioned, tbe
microscope revealed the presence of ionumerable crystals which pervaded the whole mas*.
and were visible to the naked eye as minute silvery particles. In form, the majority of them
were prisms, exactly resembling the prismatic crystals of the triple phosphate of lime,
ammonia, and magnesio, found in the urine of man and all animals. They were ineoloDe
in water.
A portion of the fluid was diluted with more than six times its volume of water, and allowtd
to stand for more than two weeks, and at the end of this time, they were unchanged in foim
or numbers.
They were insoluble in aqua'ammoniee and liquor potasree, and completely soluble iu nitiir,
hydrochloric, and acetic acids. These, and other chemical tests, prove these crystals to Ic
triple phosphate.
Amount of the sulphate of magnesia remaining in the fluid of the intestines, grains 25. 4S.
Amount of sulphate of magnesia which was absorbed, grains 30.04.
If the original solution was absorbed without dilution, more than four fluiddrachms pas<r«J
out of the intestines ; if, however, it was not absorbed until its present state of dilution, 3i>.( 4
grains of the sulphate of magnesia would have required an amount of fluid greater than tb«t
existing in the intestine. By comparing the effects produced by saline purgatives on tie
stomach and intestines, we see that, in equal lengths of Jime, the intestides absorb much more
rapidly than. the stomach.
In the stomach, 11.31, grains whilst in the intestines, in the same length of time, 30.C4 grairs
of the sulphate of magnesia were absorbed.
The inctement of the f uid in the stcmach was three fluiddrail ms, mhilst tbat of tbe intt?-
tine was twelve fiuiddraclms. Tbe effort to relieve the blood-vessels of their congestion. i>:
dilute tie saline fuid, rrd lerderits piopertirs hss irrifatirg by tbe ae'mixlure of dbcos
was four times gicater in the intestines than in the stomach.
By carefully censidfring end cempaiirg thcEe experimenlF, we arrive at the follcvbs
condusions :
1. The piimarj actirn of a soluticn of tbe sulphate of magneBia, of high spccifc
jrravity, is that of an irritant. The impression is transmitted to the nerves. Throw^li
their influence, blood is determined to the stomach and intestines. The blood-vesset
nre congested, absovption is consequently almost entirely arrested. The mncoiis ntin-
brane is excited to increased and rapid secretion of a watery mucous fluid. The objett
of this secretion are to unload the blood-vessels and dilute the internal saline solutioo.
and thus mitigate its irritant properties.
The saline solution is not immediately absoibed; it must be first prepared, asd fer
thiS; time is required. This first stage of the action of a saline pargative is analo^i:^
Osmosis, and the Absorption and Action of Purgatives. 569
to that of a blister, with this difference, that luucus and cxcreincntitious matters, instead
uf serum, are poured out.
2. Absorption of the saline solution, in an appreciable degree, does not take place
QDtil the blood-Tessels are partially relieved, and the fluid sufiiciently diluted.
The fact that absorption is arrested by a congested state of the blood-vessels, depends
almost entirely upon mechanical principles. If pressure be exerted upon a fluid con-
tained in a porous body, it tends to escape through the pores of that body. Water has
bcea forced through the pores of a thick vessel of gold. That pressure is exerted upon
the particles of the blood by some force, is seen in the fact, that the elasticity of the
reins, arteries and capillaries, has been overcome.
When the vessels are distended with blood, its flow is necessarily retarded, and, per-
haps, almost entirely stopped. This stagnation of the blood, also by a physical law,
prevents the absorption of the saline solution.
Motion of the fluid on one side, always promotes the passage through of that on the
other, because it is carried away into the general circulation as soon as absorbed, the
rapidity of absorption bearing a direct ratio to the miscibility of the fluids.
When the blood is at rest, the saline solution, which pAsses through the delicate mem-
brane into the capillary vessels, is slowly diffused, so that we have a saline solution of
almost the same strength, both in the stomach, in the intestines, and in the capillary
vessels. When two saline solutions, separated by a membrane, are of the same strength,
the endosmotio flow is not excited, because the end of all endosmotic action, the esta-
blishment of equilibrium, exists.
3. Living animal membranes, unlike dead animal membranes, do not allow the con-
stituents of the blood to pass indiscriminately through them, but select, alter, elaborate
and separate, certain definite materials.
The active agents in this process are the living cells, which exert a controlling
inflaence upon endosmose and exosmose. They elaborate and allow to pass through
their walb, only certain definite substances, the chemical characters of which depend
not so much upon the foreign fluid or substance, which excites the cells, as upon the
structure, functions and vital endowments of the cells. Hence the absorption and action
of saline purgatives in the animal economy cannot be exemplified, and its law deter-
mined by experiments performed with dead animal membranes. The question imme-
diately arises, how do cells which are mere sacs filled with fluid, accomplish these
powerful vital actions, elaborating materials often so complex in their characters, that
the most learned chemists are puzzled in their* analysis ? This is one of the most
important inquiries in science.
4. The congestion of the blood-vessels, and the increased flow of thin, watery, mucous
fluid cannot be caused indiscriminately by all fluids.
I inclosed common lard oil, in the usual manner, in the stomach and intestines of a
pointer dog, and also milk in the stomach of a cat, and allowed them to remain a length
of timo corresponding to that consumed in these experiments. In neither case were
the blood-vessels upon the exterior or interior of the stomach and intestines in tho
slightest degree congested, and there had been no flow of watery, mucous fluid.
5. The solntion of sulphate of magnesia, after its absorption, excites an increased
flow of the urine, accompanied with an increase of its solid constituents, and also pro-
daces purgation, attended with the excretion, by the intestines, of certain effete foetid
matters. The action is not confined to the kidneys and intestines, for the matters which
they eliminate from the blood, pre-exist in that fluid, and are simply separated by these
organs.
The saline solution probably acts chemically upon the effete products of the meta-
morphoses of the tissues, accelerating their breaking down and removal into the general
circulation, and final elimination from the blood. They may also excite the nerves and
vital forces which preside especially over the metamorphoses of the organic elements of
the body.
G. The absorption of saline substances, is much more rapid iu th<l s(<ou\ach, whilst
7*
568 Osmosis, and the Absorption and Aetion of Purgatives.
The cat was found dead at 9 o'clock a. m. next morning.
The blood-yessels upon the exterior of the stomach ^ere congested with blood. The
internal mucous coat showed a high state of irritation, being of a purplish color. SeTeral
small spots were Tisible of a deep purple.
The stomach contained one fluidounce, three dradn:?, of a light pinkish colored fluid con-
taining much mucus. Specific grarity 1C35.8. Heat and nitric acid produced onlj a slight
precipitate. Albumen was present in an smcnnt just sufficient to manifest itself in a feeble
manner, and was, no doubt derived frcm a drop or two of blood accidentally introduced dnrini;
the experiment. Under the microscope, the fluid ccntnined nucleated epithelial cells frcm
the mucous membrane, also the mucous corpuscles.
Amount of the sulphate of magnesia remaining in the fluid of the stomach, grains 44.21.
Amount of the sulphate of magnesia which had passed out of the stomach, grains 11.31.
Each fluiddrachm of the original solution contained grains 6.94 of the sulphate of magnesia,
consequently one fluiddrachm and forty minims of the original solution, or three and a half
floiddrachms of the fluid in its present state of dilution, passed out.
Examination of the Intestines. — The blood-vessels on the external surface of the intestines
and in the peretoneum were congested with blood, and the whole surface was reddened.
The internal surface was coated over with light-yellow mucus and epithelial cells. When
this was gently scraped off, the mucous coat was found congested with blood, being of a par-
plish-pink color, rery deep in some parts, and in others lighter.
Amount of fluid in the intestines two fluidounces, four drachms. The fluid was of a yellow-
ish red color,. and contained a Urge amount of thick mucus, epithelial cells, also granular
yellow cells. Its odor was fetid, extremely dissgreeable and cspsble of nausating weak sto-
machs. Specific gsavity 1018.6.
When treated with heat and nitric acid the presence of alLuiAen was promptly indicated.
It was present in considerable quantities. In addition to the cells atove mentioned, tbe
microscope revealed the presence of innumerable crystals which pervaded the whole vasr.
and were visible to the nuked eye as minute silvery particles. In form, the majority of them
were prisms, exactly resembling the prismatic crystals of tbe triple phosphate of lime,
ammonia, and magnesio, found in the urine of man and all animals. They were insoluble
in water.
A portion of the fluid was diluted with more than six times its volume of water, and allowed
to stand for more than two weeks, and at the end of this time, they were unchanged io foim
or numbers.
They were insoluble in aqua'ammoniae and liquor potasrie, and completely soluble iu nittir,
hydrochloric, and acetic acids. These, and other chemical tests, prove these crystals to be
triple phosphate.
Amount of the sulphate of magnesia remaining in the fluid of the intestines, grains 23.4^.
Amount of sulphate of magnesia which was absorbed, grains 30.04.
If the original solution was absorbed without dilution, more than four fluiddrachms passed
out of the intestines ; if, however, it was not absorbed until its present state of dilation, 30.<'4
grains of the sulphate of magnesia would have required an amount of fluid greater than that
existing in the intestine. By ccmparing the effects produced by saline purgatives on ibc
stomach and intestines, we see that, in equal lengths of iime, the intestides absorb murli mere
rapidly than the stomach.
In the stomach, 11.31, grains whilst in the intestines, in the same length of tiroe,30.C4|rraiBff
of the sulphate of magnesia were absorbed.
The increment of the f uid in the stcnach was three faiiddracl ms, mhilst that of the int<f-
tine was twelve flniddraclms. Tbe eCort to relieve the blocd- vessels of their congestion, to
dilute tl.e salire fuid, rrd nrder its piopcriieR Itss irrifatirg by the ae^mixtorc of Bntas,
was four limes greater in the intestines than in the stomach.
By carefully cciiFidciing sr.d ceinpaiirg these expcrimeDb, we arrive at the Mlovin^
CODCl 1181008 :
1.^ The pnmary actun of a Foluticn of the sulphate of magnesia, of high specif c
^nravity, is that of an irritant. The impreEsion is trannnitted to the nerves. Tkrov|cb
their influence, blood is determined to the stomach and intestines. The Uood-vcflsek
nre congested, absovption is consequently almost entirely arrested. Tbe mneons bmbi-
brane is ( xe itcd to increased and rapid secretion of a watery mueotui fluid. The oljertf
of this secretion are to unload the blood-veFsels and dilute the internal saline solndco.
and thus mitigate its irritant properties.
The Faline solution is not immediately alsoibed; it must be first prepared^ and Ar
this, time is required. This first stage of the action of a saline puigatiye « wniofudm
Osmosis, and the Absorption and Action of Purgatives. 569
to that of a blister, with this difference, that mucus and cxcrcmcntitious matters, instead
of scrum, are poured out.
2. Absorption of the saline solution, in an appreciable degree, does not take place
until the blood-vessels are partially relieved, and the fluid sufiiciently diluted.
The fact that absorption is arrested by a congested state of the blood-vessels, depends
almost entirely upon mechanical principles. If pressure be exerted upon a fluid con-
tained in a porous body, it tends to escape through the pores of that body. Water has
been forced through the pores of a thick vessel of gold. That pressure is exerted upon
the particles of the blood by some force, is seen in the fact, that the elasticity of the
veins, arteries and capillaries, has been overcome.
When the vessels are distended with blood, its flow is necessarily retarded, and, per-
haps, almost entirely stopped. This stagnation of the blood, also by a physical law,
prevents the absorption of the saline solution.
Motion of the fluid on one side, always promotes the passage through of that on the
other, because it is carried away into the general circulation as soon as absorbed, the
rapidity of absorption bearing a direct ratio to the miscibility of the fluids.
When the blood is at rest, the saline solution, which pAsses through the delicate mem-
brane into the capillary vessels, is slowly diffused, so that we have a saline solution of
almost the same strength, both in the stomach, in the intestines, and in the capillary
vessels. When two saline solutions, separated by a membrane, are of the same strength,
the endosmotic flow is not excited, because the end of all endosmotic action, the esta-
blishment of equilibrium, exists.
3. Living animal membranes, unlike dead animal membranes, do not allow the con-
stituents of the blood to pass indiscriminately through them, but select, alter, elaborate
and separate, certain definite materials.
The active agents in this process are the living cells, which exert a controlling
inflaenoe upon endosmose and exosmose. They elaborate and allow to pass through
their walls, only certain definite substances, the chemical characters of which depend
not so much upon the foreign fluid or substance, which excites the cells, as upon the
structure, functions and vital endowments of the cells. Hence the absorption and action
of saline purgatives in the animal economy cannot be exemplified, and its law deter-
mined by experiments performed with dead animal membranes. The question imme-
diately arises, how do cells which are mere nacs filled with fluid, accomplish these
powerful vital actions, elaborating materials of^en so complex in their characters, that
the most learned chemists are puzzled in their, analysis ? This is one of the most
important inquiries in science.
4. The congestion of the blood-vessels, and the increased flow of thin, wat3ry, mucous
fluid cannot be caused indiscriminately by all fluids.
I inclosed common lard oil, in the usual manner, in the stomach and intestines of a
pointer dog, and also milk in the stomach of a cat, and allowed them to remain a length
of time corresponding to that consumed in these experiments. In neither case were
the blood-vessels upon the exterior or interior of the stomach and intestines in the
slightest degree congested, and there had been no flow of watery, mucous fluid.
5. The solntion of sulphate of magnesia, after its absorption, excites an increased
flow of the urine, accompanied with an increase of its solid constituents, and also pro-
duces purgation, attended with the excretion, by the intestines, of certain efiete fwtid
matters. The action is not confined to the kidneys and intestines, for the matters which
they eliminate from the blood, pre-exist in that fluid, and are simply separated by these
organs.
The saline solution probably acts chemically upon the effete products of the meta-
morphoses of the tissues, accelerating their breaking down and removal into the general
circulation, and final elimination from the blood. They may also excite the nerves and
vital forces which preside especially over the metamorphoses of the organic elements of
the body.
6. The absorption of saline substances, is much more rapid iu the s^qmach, whilst
570 OsmosiSi and the Absorption and Action of Furgatives^
the effort at their dilution is very nearly equal in both, notwithstanding the disparity
between the surfaces exposed to their influence. The first fact is readily accounted for .
when we reflect that the oflice of the stomaoh is that of scoretion, rather than of absorp-
tion, whilst that of the intestines is the reverse. The fact that the stomach, with a
small surface, dilutes the saline solution as much as the intestines, exposing a mudi
greater secreting surface, proves that there is a regular standard, to which a dense saliufj
solution must be diluU^d before it can be absorbed.
Experiments with Weak Saline Solutions,
Experiment 378. — Opened the abdomen of a cat which had been starred for 24 hours, An-1
secured in its stomacli, in the usual manner, one fluidounce of a solution of the sulphate of
mnpncsia; one Huidounce of the same solution was also introduced into the intestines sod
secured in the usual manner, wil*h ligatures. Specific trravitj of saline solution, 1004. .'i.
The next morning, 12 hours afterwards, the cat was alive, and showed considerable life anl
strength. It was killed and its viscera examined. The blood-vessels upon the exterior of tt^c*
stomach were congested with blood, those of the pyloric extremity being more congested tb to
(hose of the cardiac portion. The stomach was next punctured, and its contents carcfu'Iy
removed into a graduated measure. It contained a large mass of dark beeswax, which ^ u
felt during the operation. Amount of fluid in the stomach, six fluldlrachms .ind twcu'r
minims. It had lost one fluiddrachm and forty minims.
The mucous membrane appeared congested with blood, being of a pinkish red color. aM
in several spots where the blood was much congested, was of a purplish scarlet color. Tj?
Huid from the stomach was of a reddish yellow color. Specific gravity, 1007.7.
The specific gravity had increased instead of diminishiu;;. This increment is, wiihu-.*.
doubt, due to the admixture of mucus. Under the microscop?, the fluid contained nucle.r' i
epithelial cells and mucous corpuscles. Meat and nitric acid gave a {flight cloudincsji. /•<:
sufficient to show the presence of the small amount of albumen which was introduce*! i-'^i
the stomach, in the blood upon the nozzle of the syringe.
Amount of the sulphate of magnesia remaining in the stomach, grains, rj.37.
Amount of the sulphate of magnesia which had been absorbed, grains, 1.20.
Each fluiddrachm of the original solution contained grains, 0.832, of the sulphate <'f
magnesia; consequently one fluiddrachm and twenty-eight minims of the original solui. i
must have been absorbed.
Kxamination of the Inteatinet. — The intestines presented a natural aprpcarance, and the h\o.-i-
vcssels upon their exterior were not congested with blood. The internal mucous coat pre-
sented also the same natural condition. All the saline solution had been absorbed. Ttj^
intestines contained thirty minims of a yellowish red, foDtid matter, which, under the micro-
scope, contained mucous corpuscles, epithelial cells, and other irregular masses.
The bladder, which had been completely evacuated during the operation, was about onr-
f. urth full of urine, and had been emptied during the night, showing that the kidnni
were acted upon. This experiment, like the preceding, demonstrates that solutions of :
sulphate of magnesia are more readily absorbed in the intestines than in the stomach.
In the stomach, one fluiddrachm and forty minims were absorbed, whilst in the iote»ii:i<s
in the same length of time, the whole amount of the saline solution had been absorbed.
Experiment 379. — A repetition of the latt Experiment. — Secured in the stomach of a cat, ia \'
usual manner, one fluidonnce of a weak solution of the sulphate of magnesia; also the s^^ "
amount of this saline fluid in the intestines. Specific gravity, 1004.5.
The cat remained alive, and showed considerable activity and vitality during the n .:' '
Towards morning, however, it grew feebler, and expired 13 hours after the completion ot t .
operation. The surface of the stomach showed very little more congestion than what « -^
natural. The mucous coat showed a slight congestion, being redder than usual, bnt far h*i
than the mncons membrane of stomachs which had been in contact with dense saline Si>«--
tions. Its fluid contents were transparent, and contained mucus. Amount, seven fir:-
drachms. It bad lost by absorption, one fluiddrachm. Specific gravity, 1008.
The increase in the specific gravity was, without doubt, due to the presence uf mi*. •■
When treated with heat and nitric acid, a slight, cloudy precipitate took place, showing t' *
presence of albumen in very small amount, the existence of which could be acconotc I for ' •
\\ie same accidents which occurred in other experiments.
Amount of the sulphate of magnesia remaining in the stomach, grains, 6.42.
Amount of th^ sulphate of magnesia which had been absorbed, j^j of a grain.
Each fluiddrachm of the original solution contained O.H32 of a grain of the salt . ci>'-*'-
quently, 0.390 of a grain of the sulphate of mngnci^ia had bcetv retained in the stomach, «
only pure water was abso,rhrd.
Osmosis, and the Absorption and Action of Purgatives. 571
Examination of the Intestines. — TbeiDtesiines contaiaed none of the saline solution, the blood-
resseli upon their exterior showed little or no congestion, and the mucous coat presented a
natural appearance. They contained, as in the former experiment, forty minims of a dirty,
yellowisb-red, semi-fluid mass, having an extremely fcetid odor, and composed of the same
elements, and resembled in all respects the contents of the intestines of the preceding cat.
The bladder contained one fluiddrachmof urine, which had been excreted during the night, for
it had been completely evacuated during the operation.
By comparing these expcrimentfl with those in which denss saline solutions were used,
wc arrire at the following conclusions :
1. The primary irritant efifect of a weak saline solution, is much less upon the
8tomach and intestines than that of a dense solution.
2. The congestion of the blood-vessels heing less, and the difference between the
relative densities of the exterior and interior fluids being greater, absorption is much
more rapid.
8. The stomach is much more readily irritated by a weak saline solution, and its
consequent secretion of mucus much greater than that of the intestines.
4. The relative absorbing power of the stomach is much less than that of the intes-
tines. This law holds good, both for dense and weak solutions of the sulphate of mag-
nesia.
5. After its absorption, a weak solution of the sulphate of magnesia acts principally
upon the kidneys, and promotes the breaking up and final elimination of effete matter,
it may also, but in a much feebler degree, cscite the depurative action of the intestines.
EXPERIMENTS UPON THE RECIPROCAL ACTION OF SERUM AND SOLUTIONS OF THE
SULPHATE OF MAUNESIA, THROUGH DEAD ANIMAL MEMBRANES.
Experiments on the reciprocal action of Scrum and dense Saline Solutions through
Dead Animal Membranes.
Szpa-iment 380. — In this experiment, the serous fluid from a hydrocele of the tunica vagin-
alis testis was used. When heated, or treated with acetic and nitric acid, the albumen was
coagulated in large quantities. Phosphate of soda, liquor potassa, and phosphate of ammonia,
produced no precipitate or perceptible chan;;e. These reactions should be borne in mind
during the subsequent examinations.
Introduced into nine inches of pig's intestine, one andahalf fluidounces of the serous fluid,
and, securing both ends, immersed it in a solution of the sulphate of magnesia, made in the
<>trcngth of one fluidounce of salt to eight fluid ounces of water. Specific gravity, 105G.
.""Specific gravity of serous fluid, 1021. Examined three hours afterwards. Specific gravity of
the exterior saline solution, 1049.
Heat and nitric acid threw down copious) precipitates of albumen, showing that the serum
had passed from the interior and mingled with the exterior fluid. Specific gravity of interior
lluid, 1035. Amount, one and a half fluidounces and thirty minims.
The serous fluid had gained by endosmose, thirty minims. The albumen in the serous
fluid was completely coagulated by heat, until nitric acid failed to give the slightest precipi-
tate ; it was then removed by filtration.
The presence of the sulphtite of magnesia in the fluid portion of the serum, thus freed from
albumen, was indicated by the precipitate of the sulphate of lead and magnesia, thrown down
hr tbe acetate of lead, liquor potaiisa*, and phosphates of ammonia and soda.
' In this experiment, the exterior fluid had lost in specific gravity 7 degrees in the thousand,
whiUt tbe exterior fluid had increased in amount thirty minims, and in specific gravity 14
decrees in the thousand.
The gain in the specific gravity of the serous fluid had been much more rapid thnn its gain
ifi amount. These facts render it probable that, after the endosmose of the saline bolution.
il.r> watery portion of the seruus and saline fluids must have flowe 1 back, leaving a certain
iiiiiotint of the sulphate of magnesia in a more concentrated form.
/•UperimeiU 381.— Secured in 12 iiuh<8of the colon of a sheep haxing the peritoneum on,
fine fluidounce of seium In ni the blood ol the pnme animal, and immersed it in a Foluiion of
tlif sulphate of mnpnefiia, made in the •strength of one fluidounce of salt to ei|rht fluidounces
»,r water; examined alicr 17 hour?. The interior saline solution was colored red. Amount
of serum, one fluidounce nnd ten minims. The exterior saline Folution ga\e indication.^ of
till* presence of albumen, nnd the clinnge m the s»picific gravities f'hoHcd that an interchange
'•^ the fluid had gone on.
572 Osmosis, and the Absorption and Action of Purgatives.
Eoper'ment 382. — The same leng^th of sheep's colon, and a saline solution of the same
strength were used, as in the preceding experiment ; the relative position of fluids, howcTcr,
was reyersed, the saline solution being in contact with the internal mucous coat. Amount of
solution of the sulphate of magnesia, one fluidounce. Examined 18 hours afterwards. Inte-
rior saline solution had assumed a pinkish color, and measured six fiuiddrachms, having lost
two fluiddrachms. The action of nitric acid and heat showed the presence of albumen. The
exterior serous fluid gave indications, with the appropriate chemical tests, of the presence of
the sulphate of magnesia.
Experimeni 383. — Repetition of experiment 381, using the same length of intestine and the
same relative position of the fluids ; specific gravity of the saline solution, 1053. Specific
gravity of serum, 1020. Examined after 17 hours. The interior serum measured seven fluid-
drachms, and had lost one fluiddrachm. Chemical tests demonstrated the presence of the
sulphate of magnesia in the serum, and that of albumen in the exterior saline solution.
Ezperiment 384. — Secured in 36 inches of the small intestine of a sheep, not deprived of
peritoneum, one fluidounce of the serum of the same animal, and immersed it in a solution of
the sulphate of magnesia. Specific gravity, 1053. Examined 17 hours afterwards. Amoant of
interior serum, one fluidounce ; it had not increased or decreased, and yet the characteristic
chemical tests gave unquestionable evidence of the presence of the sulphate of magnesia in the
interior serum, and of albumen in the exterior saline solution. Here cndosmose and ezos-
mose had been equal.
Experiment 385 : The same length of intestine, and the same fluids were used, but their
relative positions were reversed ; the solution of the sulphate oi. magnesia, instead of the
serum, being inclosed in the intestine. This then may be called the reverse of the last experi-
ment (384). Examined 17 hours afterwards. Amount of interior saline solution, seven fluid-
drachms. The greatest flow was from the saline solution to the serum, one fluiddrachm of the
interior having passed out.
By carefully comparing these experiments, we «ee that in four out of six, the greatest
flow was from the saline solution to the serum, although the specific gravity of the
former was much greater than that of the latter. In one of the other experimenta, the
endosmotic and exosmotic actions were exactly equal, whilst in the remaining one, the
greatest flow was from the serum to the saline solution, in obedience to the law slated
by numerous obs^nrers, that the flow is always from the less dense to the denser liquid.
This law does not hold good when a solution of the sulphate of magnesia and serum are
the fluids employed.
The relative position of the membranes exerte a controlling influence upon the paa^-
sage through of fluids. This fact has been almost entirely overlooked by obserrer*.
In experiments 380, 381, 383 and 384, the serum was placed in contact with the internal
mucous membrane, whilst the saline solution was in contact with the exterior serow*
coat of the intestine.
In experiment 380, the serous fluid gained thirty minims.
In experiment 381, the serous fluid gained twenty minims.
In experiment 384, the serous fluid had neither lost nor gained,
In experiment 383, the serous fluid lost sixty minims.
In experiments 382 and 385, the saline solution was placed in contact with the inlenial
raucous membrane, and the serum in contact with the external serous coat of lk«*
intestines.
In experiment 382, the saline solution had lost two fluiddrachms.
In experiment 385, the saline solution had lost one fluiddrachm.
When the mucous surface was in contact with the serum, the flow of the saline solu-
tion towards the serum was retarded, and that of the serum increased.
When the mucous coat was in contact with the saline solution, its passa^ ikn»Q^h
the membrane was greatly accelerated, whilst that of the serum was diminished.
The fact that solutions pass much more readily out of dead animal memhnin(», fntm
the interior to the exterior, might be illustrated by numerous examples. The rce^t < f
these experiments demonstrated conclusively that the laws regulating the action (»f alin^-
purgatives upon living animals, cannot be determined by experimenta pcrfomed with
dead animal membranes. In living animals their primary impression is always atl«tMK^I
with a rapid flow from the blcxHl to the saline solution, whilst the reverse toke^ |ilar«* irt
dead animal uienibrano.s.
Osmosis, and the Absorption and Action of Purgatives. 573
Experiments on the reciprocal Action of Serum and weak Saline Solutions through Dead
Animal Membranes,
Experiment 386 : Introduced one and a half fluidounces of the serous fluid from the hydrocele
of the tunica yaginalis testis, into 9 inches of pig's intestines and immersed it in a solution of
the sulphate of magnesia, having a specific gravity of 1010. Amount of saline solution, four
fluidoances. Specific gravity of serous fluid, 1021.
Examined three hours afterwards :
Specific gravity of exterior saline solution 1010.
Specific gravity of interior serous fluid, 1019.
Amoant of interior serous fluid, one and a half fluidounces and forty minims.
The serous fluid bad gained forty minims, and after the careful removal of all the albumen,
the appropriate chemical tests indicated the presence in it of the sulphate of magnesia. The
presence of the serous fluid was also determined in the saline solution.
Experiment 387 : The same length of intestine and the same fluids were used in this experi-
ment, only their relative positions were reversed, one and a half fluidounces of the saline solution
being confined in the intestines, and immersed in four fluidounces of the serous fluid.
Specific gravity of interior saline solution, 1010.
Specific gravity of exterior serous fluid, 1021.
Examined three hours afterwards.
Specific gravity of serous fluid, 1020.
Specific gravity of saline solution, 1010.
Amoant of interior saline solution, one fluidounce, and three fluiddrachms. It had lost
one fluiddrachm.
The appropriate chemical tests showed that there had been an intercliange of the fluids.
Experiment 3%% I Introduced one fluidounce of serum of pig's blood, into the intestine of
tbii animal, and immersed it in a solution of the sulphate of magnesia.
Specific gravity of serum, 1018.
Speeific gravity of saline solution, 1009.
Examined five hours afterwards.
Specific gravity of serum, 1018.
Specific gravity of saline solution, 1010.
Quantity of serum, one fluidounce, fourteen minims.
Chemical reagents showed the presence of scrum in the saline solution, and also of the
sulphate of magnesia in the serum.
By comparing these last experiments, the facts are demonstrated that the greatest
flow was from the saline solution to the serum.
The rapiditj of this flow was moderated by the position of the membrane.
In Experiments 386 and 388 in which the serous fluid was placed in contact with the
internal mucous membrane, the external saline solution in contact with the serous coat
of the intestines, lost in the first, forty minims, and in the last, fourteen minims.
^Vllen, however, the relative positions of the fluids were reversed, as in Experiment 387,
and the saline solution was placed in contact with the mucous membrane, the intornal
solution of the sulphate of magnesia lost sixty minims. In each experiment the greatest
flow was from the saline solution to the serum, but when the saline solution was placed
io contact with the mucous membrane, the flow was in one instance one-third, and in
the other nearly four times more rapid.
Out of 10 experiments with the serum of diflPerent animals, in which the relative
densities and positions of the fluids were varied, in only a single instance was the
greatest flow from the serum to the saline solution, and in this case the scrum was in
contact with the mucous membrane of the intestine.
From these facts, then, we are justified in laying it down as a general law, that with
dead animal membranes, the greatest flow is from the saline solution to the serum,
nigardleas of the strength of the saline solution, and this flow is greatest in the direc-
tion from the interior surface to the exterior of the membrane.
Does this physical law explain the action of saline solutions upon the animal economy ?
By no means. We have shown that when a strong saline solution is nsed, both in the
intestines and in the stomach, the flow is from the blood to the saline solution, and it is
not until that solution becomes diluted to a certain extent, that its absorption commences
in an appreciable degree. When, on the other hand, a weak saline solution is used in
574 Osmosis, and the Absorption and Action of Purgatives.
the stomach, it obeys the physical law laid down. In the intestines it is totally and
rapidly absorbed.
EXPERIMENTS ON THE RECIPROCAL ACTION THROUGH DEAD ANIMAL MEMBRANE8,
OF WATER AND SALINE SOLUTIONS OP DIFFERENT DENSITIES.
Experiments on the reciprocal action through dead Animal MemhraneSj of Water and
dense Saline Solutions,
Experiment 389: Introduced into eighteen inches of pig's intestine, bAviog the peritoneam
on, two and a half fluidounces of a solution of the sulphate of magnesia, and immersed it in
pure water.
Strength of saline solution one fluidouncc of salt to eight fluidounces of water, speci6c
gravity, 1056.
Four hours afterwards the amount of the saline solution was found, by measurement, to be
three fluidounces and forty-eight minims. It had gained four fluiddrachms and torty-eight
minima, speciflc gravity, 1040.
Specific gravity of the exterior fluid, which was originally pnre water, 1009.
The presence of the sulphate of magnesia was also indicated by all the appropriate chemical
tests.
Experimtni 390 : The same length of intestine, the same strength and relative posUion of Ibe
fluids were used in this as in the last experiment. The only difference was that the peritoaeam
was stripped off. At the expiration of four hours, the internal saline solution measured three
and a half fluidounces, having gained one fluidounce. Specific gravity, 1037. Specific
gravity of the exterior fluid, 1014.
This had a distinct saline taste, and, when treated with the appropriate chemical tests, the
presence of the sulphate of magnesia was promptly indicated.
Experiment 391 : Into eighteen inches of hog's intestine, with the peritoneum on, introduced
six fluidounces of pure water, and immersed it in a solution of the salphate of magnesia.
Specific gravity, 1056. Four hours afterwards the interior solution measured five fluidoonces
and fifty-three minims, having lost seven fluiddrachms and seven minims. Specific gravity,
lOlG. The appropriate tests showed the presence of the sulphate of magnesia. Specific
gravity of exterior saline solution, 1045.
Experiment 392 : Similar in all respects to the preceding experiment, except that the intes*
tine was deprived of its peritoneal coat. In four hours the internal fluid measured four and
a half fluid ounces, having lost one and a half fluidounces. Specific gravity, 1019. Specific
gravity of exterior saline solution, 1037.
Experiment 393 : Into eight inches of pig's intestine, having the peritoneum on, introduced
one fluidounce of a solution of the sulphate of magnesia, having the usnal specific gravity,
1056, and immersed it in pure water for seven hours. At the end of this time the interior
fluid measured one fluidounce, one and a half fluiddrachms. Specific gravity of exterior
fluid, 1008.
Experiment 394 : The same as the preceding experiment, except that the peritoneum wa«
stripped off. Examined seven hours afterwards. Amount of interior fluid one fluidounce,
one fluiddrachm. Specific gravity of the exterior fluid, 1005.
Experiment 395: Into eight inches of pig's intestine, having the peritoneum on, introduced
two fluidounces of pure water, and immersed it in a solution of Epsom salts. Specific graviix .
1()5G. After seven hours the interior fluid measured one and a half fluidounces, one fluid-
drachm and twenty minims. It had lost two fluiddrachms and forty minims. Speriflc
gravity, 1033. Specific gravity of exterior solution. 1030.
Experiment 396: Repetition of la ft experiment without the peritoneal coat, — After the same leoptb
of time the internal fluid measured one and a half fluidounces, having lost four fluiddrachms
Specific gravity, 1033. Specific gravity of exterior saline solution, 1049.
These experiments were repeated, and in every case the results were similar to th<t^^
above, and supported the following conclusions :
A mutual interchange of the fluid.s always took place, and the greatest flow was froa
the wat43r to the saline solution. The rapidity of the flow dcpeuded upon the positiuii
of the membrane. The flow wjis grentost from the internal mucous coat to the extoriur
The presence or absence of the peritoneal coat also modified the rapidity of the fl<iw
The endosmotic and exosmotic actions were most vigorous when the peritoneal coat «a^
:i})scnt. The nipidity of the inU^rchange of the fluids varied with the employment «»r
the int4'Htines of different animals. As a general rule, it was more rapid in tho inlcs^
tinos of the pig than in those (»f the sheep or cow.
Osmosis, and the Absorption and Action of Purgatives. 575
The following tablcB will illustrate these points :
Saline solution inclosed in intestines having the peritoneal coat on.
Sp. f r. of
•itcrior fluid.
Amonnt of fluid
iutrodnced.
Length of intcstlno.
Time.
Ainoant gn>In<^-
3 fluidounces.
4 »*
2J "
Sheep's 36 inches.
Cow's 12 "
Pig's 18 •*
Pig's 8 "
3\ hours.
4" u
4 '»
7
2 fluiddrachros.
2 "
4 *' and 48
IJ
1009
1008
Water inclosed in the intestine having the peritoneum ou.
Amount of flnid Length of intestine. Time. Amount lout i^p. Rr. of
Introdacrd. inUMior fluid ,
2 fluidounces Sheep's 24 inches. 3} hours. 3 fluiddrachros and 12 minims. 1010
2 " Pig's 8 " 7 " 2 •* 12 " 1033
G " Pig's 18 it 4 " 7 " 7 '* 1016
Saline substances inclosed in intestines deprived of the peritoneum.
Amount uf flnid Lcngtii uf inte«tiuc. Time. Amount gaiiKnl. Sp. Gr.uf
intvxidnced. exterior fluid.
24 fluidounces. 18 inches. 4 hours. 1 fluidounce. 1014
1 " 8 *» 7 " 1 fluiddrachm. 1035
Water introduced into intestines deprived of peritoneal coat.
Amonnt of flald I^ength of lntntln«. Tlm«. Amount lost. 8p. gr. of
introdacad. interior fluid.
ti fluidounces. Pig's 18 inches. 4 hours. 1^ fluidounces. 1019
•i *« Pig's 8 '• 7 " 4 ** 1033
Exjpcriments on the reciprocal Action through Dead Animal Membranes, of Water and
weak Saline Solutions,
Experiment 397 : Into eight inches of pig's intestine, having the peritoneum on, introduced
one flaidouDCe of common salt (chloride of sodium, made in the strength of one fluiddrachm
of mU, to four fluidounces of water, and immersed it in pure water. E.\aroined eight hours
Afterwards. Amount of the interior fluid, one fluidounce, forty minims. It had gained forty
minims. The exterior fluid showed the presence of the chloride of sodium by giving a preci-
pitate (chloride of silver,) when treated with the nitrate of silver.
Experiment 398 : Repetition of the last experiment in all respects, except that the peritoneum
was stripped off. Examined eight hours afterwards. Amount of interior fluid one fluidounce.
Specific gravity of exterior fluid, 1005. Here endosmose of the water had just equalled the
rxosmose of the salt. A copious precipitate of the chloride of silver upon the addition of a
solution of the nitrate of silver, demonstrated the presence of the chloride of sodium in the
irxterior fluid.
Experiment 399 : Introduced into six inches of pig's intestine, deprived of the peritoneum,
one and a half fluidounces of a solution of the sulphate of magnesia, and immersed it in
pure water. Specific gravity of saline solution, 1009. Examined four and a half hours after-
iVitrds. Specific gravity of interior fluid 1007. Specific gravity of exterior fluid, 1001.5.
Amount of internal fluid one fluidounce, seven fluiddrachros. It had gained three fluiddrachros.
Experiment 400: The same length of intestine and strength of saline solution were used,
hut the relative position of the fluids was reversed, the water being inclosed in the intestine.
Examined four and a half hours afterwards. Specific gravity of exterior fluid, 1007.5.
Quantity of interior water one and a half fluidounces, five fluid drachms. Specific gravity
1005. The internal water had gained five fluiddrachros.
Experiment 401 ; Introduced into twelve inches of pig's intestine, three fluidounces of a
folation of the acetate of lead, and immersed it in pure water. The intestine was deprived
of iti peritoneal covering. Strength of the solution, three grains of acetate of lead to
one fluidounce of water. Specific gravity 1005. Allowed to remain three and a half hours.
Amount of fluid in the intestine seven fluiddrachros, twelve roinim^. It had diminished
forty-eight minims. Specific gravity 1004. Specific gravity of exterior fluid 1002. The
Addition of a solution of the iodide of potassium to the external solution (originally pure
water,) wai attended with a distinct orange yellow precipitate of the iodide of Icad^ indicating
the presence of the acctMe of lead.
576 Osmosis, and the Absorption and Action of Purgatives.
By comparing these experiments, the fact is confirmed that in eveiy case there was a
reciprocal action and free interchange of the fluids upon opposite sides of the dead
animal membranes.
Upon a comparison of these experiments with those in which strong saline solntioni
were used; it will be discovered that the influence of the presence or absence of the
peritoneal coat, and of the relative position of the membranes, is not exerted in a defi-
nite manner when weak saline solutions are used. Also, that the reciprocal action of
water and weak saline solutions through dead animal membranes, is not governed by
the same fixed laws as the interchange of water and' dense saline solutions.
When compared with the experiments upon living animals, the fact is oondnsivelj
demonstrated that the laws which regulate the action of saline solutions upon livio^
animals, cannot be demonstrated or illustrated by experiments performed with dead
animal membranes.
The truth of this proposition is still further evident, when we consider the large
amount of fluids thrown into the alimentary canal during specific periods of time.
Thus the quantity of Gastric juice secreted, appears to be enormous. In dogs, the
daily quantity has been calculated by Corvisart, as one-twentieth, and by Lebmann, as
one-tenth part of the weight of the body. The latter ratio would give 14 lbs. in i
man of 140 lbs. weight, a quantity equal to rather more than 11 pints daily. That
this estimate, however large, is not extreme, is shown by the fact, that in a case of ga»-
trie fistula, in a woman, the estimated daily quantity was 30} tt»8. av.; the weight of
the body being 116 lbs. The quantity of saliva secreted in twenty-four hoars, by all
the glands, has been estimated at from 1 to 3 tbs. According to Kblliker, H. MiUler,
and other physiologists, the quantity of bile secreted daily in dogs with artificial biliary
fistulse, is about i ok. to every pound weight of the animal, or -^ part of ita weight.
This estimate if applied to a man weighing 140 lbs. would give 70 ois. or 4 lbs. 6 ox.
avoirdupois in a day, of which about Xth, or nearly 3 oz. would be solid noatter. Tht<
estimate is considered by some physiologists to be too high. Bidder and Schmidt,
calculate the daily quantity secreted by a man to be 56 ozs.; Nasse and Platner*s obser-
vations on the dog, would give a total daily quantity for man of 33) on.; whilst others
again have estimated it at only from 17 to 24 ozs. The quantity of pancreatic jnice
secreted daily in animals, varies according to different observers, fVom 15 to 35 graiiu
per hour for each pound weight of the body ; so that in a man weighing 140 lbs., the
(quantity secreted would be from 4} ozs. to 1 1 oz. per hour. The Pancreatic Socretioo* a^
well as the Gastric Secretion is probably not continuous, but related to the process of
digestion. From these fluctuations, it is impossible to estimate correctly the qoaotit}
formed daily; which has been differently estimated at from 7 ozs. to 16} lbs.
Whilst, therefore, discrepancies exist in the statements of diffiereut physiologists cud-
ccrning the actual amounts of gastric juice, bile and pancreatic juice secret»i durinc
Hpccific periods ; and whilst the collection of these fluids by the aid of artificial fistn-
lac in animals, is open to the objection, that the conditions, especially of the nerves
which govern the quantity of the secretion are not healthy ; and whilst objections maj
be raised against those estimates based upon calculations of the probable quantity, bj
collecting the juice for a certain time and multiplying the quantity thus obtained by a
number representing the whole twenty-four hours, on the ground of the intenDittencj
of the secretions ; at the same time it is evident that the total quantity of the digestm
fluids poured into the alimentary canal after taking food, is much greater than vaf
formerly supposed, and in comparison with the blood circulating in the body is rcry
great, and that the phenomenon of absorption by secretion in the living animal can be
only very imperfectly illustrated by experiments upon dead animal membranes.
In experiments upon membranes removed from the bodies of animals, it is abwIttteW
impossible to fulfill the conditioDs pcrfoimid by the constantly moving cnnvnts (•£'
blood, and by the nervous and muscular forces, and by the development, nutrition and
constant metamorphoses of the individual morphological elements. The important
phenomenon, first fully illustrated by Graham, under the term diafym^ vii : that
Osmosis, and the Absorption and Action of Purgatives. 577
various membranes and some porous septa, will allow only crystalloid bodies to pass
through, while the organic, or in the langaage of Graham, the Colloid substances are
retained, must also be modified by the constant changes taking place in living tissues,
and such modifications must be attended with corresponding variations of the osmotic
currents.*
* It it well known that ia the living animal, there is a prepondernDcc of the so-called
tndotmotic current, whilst there is little or no transudation, or ezotmont of albumen, the chief
nutritive constituent of the blood, except into the lymphatic system, which, as we hare seen,
has been shown by recent researches, to be possessed of distinct stomata. which anatomical
arrangement may be supposed to be adapted especially to the entrance of the albuminoid
serous fluid of the tissues. Albuminate on the other hand, is constantly absorbed in the ali-
mentary canal, and transformed into the albumen of the blood. Mialhe has given an expla-
nation of this remarkable phenomenon, by establishing the different endosmotic properties of
albumen and albuminosc. Recognizing the fact pointed out by Dutrochet, that albumen is
capable of inducing a more powerful endosmotic current, than almost any other liquid he
has shown, that it never itself passes through membranes, in the so-called exosmotio current ;
but that albuminoids, after transformation by digestion into albuminose, or albumen mixed
with gastric juice, pass through animal membranes with great facility. Such facts render it
evident that slight physical or chemical changes in the constitution of organic substances,
may be attended by the most marked changes in their osmotic powers.
No distinction therefore, can be drawn between the so-called crystalloid and the so-called
colloid bodiea based entirely upon their osmotic properties, as slight physical and chemical
changes may render the colloid as readily osmotic and difTu sable as the cryttdUoid.
The fact that all living tissues are capable of selecting and appropriating from the
nutritive fluids the materials necessary for the regeneration of their morphological con-
stituents, and that the secreting structures of glands select from the blood the materials
used iu the formation of their secretions, and that the nutrition of the tissues and the
character of the secretions may be modified through the nervous syetem, cannot as yet
be fully explained by physical experiments, although much light l^is been undoubtedly
thrown upon such phenomena, by the investigations of NoUet, Lebkiichner, Magendie,
Dutrochet, Parrot, Porrett, Fischer, Liebig, Mialhe, (f raham, and others. Some of the
modtflcations which absorption undergoes in the living economy, evidently, eau only bo
explained by the supposition, that the liquids and the substances which they hold in
solution, become for the time, part of the living structures, and partake of their pecu-
liar properties.
Derangements of the due relationship of secretion to absorption in the tissues and
cavities of the body, may depend upon —
Ist. Derangements in the nutrition of the tissues, leading either to an increase of
secretion or a diminution of absorption.
2d. Derangements or alterations of the blood, leading to derangement of the nutri-
tion of the tissues, with an increase of secretion or diminution of absorption.
3d. Derangements of the circulatory apparatus, attended with venous obstruotion
and oonoeition, increased serous efi'usion from the distended blood-vessels, and dimi-
nished absorption.
4th. Derangement of the functions of those organs, which regulate the amount of
the blood, as well as the constitution, by regulating the amount of the watery element,
and by the elimination of excrementitious materials.
It IS important that the student should bear in mind the distinction between tranBu-
dations and exudations :
Transudations are not, properly, liquor sanguinis, although derived firom the blood,
but consist of water containing more or less of the constituents of the serum of the
blood — the salts and albumen — without any appreciable amount of the fibrin or coag-
ulable element. They, therefore, preserve the liquid state ; and the act of transudation
relates chiefly to the physical properties of the tissues.
In transudation, there is no solution of continuity or rupture, the watery portion of
the serum of the blood simply percolating through the porous walls of the blood-vessels •,
73
578 Osmosis, and the Absorption and Action of Purgatives*
and transudation is usually the result either of a diminution of the albuminoid elements
and salts of the scrum of blood, or of undue hydraulic pressure, or of both causes
combined. Effusions, or exudations, devoid of fibrin and cytoblasts, and iocapaUe of
organiiation, when retained, are characteristic of dropsy. Occurring; upon mucous
surfaces which communicate with the exterior, they constitute fluxes.
Exudations contain, on the other hand, fibrin and cytoblasts or germ cells, and are
capable of coagulation and organization. Exudations are the result of inflammation,
whilst in true dropsy this morbid process is wanting.
Inflammation of serous membranes may be attended with more or leas effusion, but
the liquid is turbid from the admixture of coagulable lymph, and in this respect differs
from the clear serous liquid of true dropsy.
CHAPTER XI.
DR0P8T ARISING FROM DERANGEMENTS IN THE NUTRITION OF THE TISSUES, LEADING EITHER
TO AN INCREASE OF SEC^RETION, OR DIMINUTION OF ABSORPTION.
SUDDEN ACCUMULATION OF FLUID IN THE PERITONEUM. RESEARCHES OF ANDRAL, BECQUERKL
AND BODIER, ON THE CAUSES OP ACUTE DROPSY. CONSTITUTION OF THE BLOOD IN ACUTE
DROPSY. TREATMENT OF ACUTE DROPSY.
This divLsion is placed first, not only because it should include the most simple and
uncomplicated cases of dropsy, but also because the progress of pathological anatomy
and chemistry during the past thirty years, has greatly modified the ideas, formerly
entertained respecting dropsy, and the class of dropsies long regarded as idiopathic or
essential, has become so restricted, as almost to have disappeared from nosological classi-
fications. Some pathologists have so far restricted the causes, as to admit only two
f pedes of dropsy, viz : the so-called mechanical dropsies, the result of an obstacle pre-
sented to the flow of blood, whether in the central organ of the circulation, or in a
vascular trunk of a certain size ; and dropsies symptomatic of a special modification of
the blood, consisting exclusively in a decrease in the proportion of the albumen to the
The question involved in the preceding division, does not appear to have been definitely
settled ; and even in the apparent simple form in which it is now stated, important
questions relating to the process of secretion and nutrition, and the connection of the
blood with these acts are involved.
Cases of dropsy are not infrequently observed, both in hospital and private practice,
which are for the most part acute, and in which no trace of albumen is found in the
urioe, and the dependence of which, upon some alteration of the blood, or derangement
of the action of the kidneys, has not been fully established.
Sir Thomas Watson has described a form of dropsy, which he calls active aacUesy
where fluid is rapidly thrown out into the peritoneum and cellular tissue of the extremi-
ties, afler exposure to cold and wet, without fever, or any sign of inflammation, and
independent of any disease of the heart, liver or kidneys ; and where, after a short time,
the fluid is again absorbed. And he gives the following as a typical case of the phenom*
coa of active dropsy ; a laborer is engaged in some employment, which, while it
re(|uires considerable bodily exertion, and causes copious perspiration, necessarily
exposes him also to the influence of external cold and moisture ; he has been digging
(perhaps) in a wet ditch, in winter time, and he pauses to take his meal ; or he has
been unloading his wagon, and rides home, some miles, in a heavy rain that wets
him to the skin ; or he has been mowing in the heat of summer, and lies down to sleep
upon the damp grass. All these suppositions are derived from actual occurrences.
The perspiration is suddenly checked ; and in the course of a few hours he becomes
universally anasarcous. Sir Thomas Watson explains the sudden occurrence of dropsy
in such cases, by the sudden check of the exhalation of water from the skin and kid*
neys, lungs and bowels. But supposing the exhalation from one of these surfaces to
be much diminished, or to cease, without a corresponding increase of function in the
related organ, or in any excreting organ communicating with the exterior, then dropsy^
in some form or degree, is very apt to rise. The aqueous liquid thus detained in the
blood-vessels, seeks, and at length finds some unnatural and inward vent, and is poured
forth into the areolar tissue, or into the cavities bounded by the serous membranes.
580 Dropsy arising from Derangements of Nutrition and Absorption,
Dr. Charles Murchison, in his Clinical Lectares on Diseases of the Liver, Jaundtce
and Abdominal Dropsy, has recorded the following interesting case of what might be
termed acute dropsy.
Ga8I 634 : Symptoms of Colic^ followed by siyna of Fluid in the Peritoneum. — Edward, J ,
aged twenty-one, who had formerly been a printer, but had been working for six weeki
at a carrer and gilder's, was admitted into the Middlesex Hospital, under my care, on April
12, 1868. On April 6, he had been suddenly seized with severe pain in the abdomen and
retching. The pain had been voastant ever since, but had been also liable to some exacerba-
tions. The vomiting had recurred daily, but had not been so violent as at first. The boweli
had acted on the 8th and 10th, after castor oil and laudanum, i^hortly before his attack, the
patient had been suffering from gonorrhoea, and stated that some rears before he had a similsr.
though much less severe attack of abdominal pain.
On admission, the patient complained of constant pain in the abdomen, with frequent acate
exacerbations. The pain was increased by any movement, and there was also considerable ten-
derness over the abdomen, most marked over the caecum. The abdomen was distended ao<l
tympanitic, and the breathing was entirely thoracic. There was frequent retching of scantr.
bilions matter. There was a dark red (not blue) line along the margin of the gums. Tlie
tongue was moist, and only slightly furred ; there was thirst, and the bowels had not been
opened for two days. The pulse was 84 ; the skin was cool, and the temperature under tiie
tonffue 97**. There was no albumen in the urine.
The patient was ordered a warm bath, warm fomentations to the belly, an enema of three
pints of barley water with four drachms of tincture of assafcctida, and a grnio of opium erfrr
four hours.
The enema brought away two copious motions, but with no relief to the pain. On Apr>'
13th, a third of a grain of extract of belladonna was ordered every three hours, but next djr
the pain, tenderness and tension of the abdomen had increased, although the pulse was od'>}
72, and the temperature 97°. Ue was again ordered a grain of opium every four bourf. a
draught of castor oil and laudanum, and frequent cnemata. lie also continued taking <'i
grains of opium a day, until April 17th, and then thr^e grains until April 23d. Toder tb*.«
treatment the bowels were freely moved, and the paroxysms of pain became less severe; tiui
still he had occasional vomiting, the abdomen grew, larger and more tense, and on April H'lb.
there was unmistakeable evidence of fluid in the peritoneum. A thrill could be propagate-:
from one side to the other, on tapping, and where the patient was supine, there was dttlloe«$
on either flank, which varied with his position. He still had occasional paroxysms of pain
but no tenderness of the abdomen. The pulse, however, kept steadily at 72, and the tem-
perature rarely exceeded 98°. The signs of fluid in the peritoneum, with occasional s\\%t\
paroxysms of pain continued until May 4th. After this, the abdomen gradually becavt
smaller, and on May 18th, it had regained its nonnal size, and presented no sign of fluid, ac-i
the patient left the hospital free from pain.
The researches of Andral, Becqucrel and llodicr, render it probable that in tht^
cases of acute dropsy, there is odimes, if not always, in the early stages, a coogertioo "f
the kidneys, with the appearance of albumen in the urine.
Andral, after noticing the fact that sometimes individuals, who, after exposorr t««
some sudden cause of cold, are attacked a few hours after with anasarca, sUtes tJut.
after accounting for the dropsy, by supposing that the sudden suppression of the cuta-
neous function of transpiration rapidly produced a superabundant exhalation of seron
into the areola of the cellular tissue and the serous cavities, he was led to oondade tlut
this kind of dropsy was dependent upon derangement of the kidneys.
A young man, previously in good health, and strongly constituted, entered the h^
pital of La Charitd, with considerable anasarca and commencing ascites. He rdated t«>
Andral, that a few days before, being abed and asleep, some of his comrades ponn'vi
upon him a pot of cold urine, while he was in a state of perspiration. He got np
naked in order to pursue them, and was very much chilled ; he remained, said he^as tlion^^*
frozen. From the day following this occurrence, he began to peroeive a alight degree
of swelling, which rapidly augmented. The urine of thb patient was examined, and
found to be albuminous. Andral concluded from this, that the blood had been definveJ
by the kidneys of a certain amount of its albumen, and in this way aoooonted for tb**
formation of the dropsy. It is then vjwn the kidneys that the action of tke cM iii *
fallen. This dropsy was not, moreover, of long duration ; at the end of a ibita^t.tF«
cure was complete.
Dropsy arising from Derangements of Nutrition and Absorption. 581
Becquerel and Rodier, in their pathological chemistry, have given the results of the
analysis of the blood in eleven cases of acute dropsy.
The following is the historical resume, which these authors give to establish the
dependence of acute dropsy upon some alteration of the blood, although this depend-
ence was proved merely by induction.
^* Nine of the patients were males, and two were females. In all, the disease set in rapidly,
under the following circumstances :
*< In one case it followed a sudden suppression of the catamenia from violent emotion ; in a
second, it occurred at the fifth ^onth of pregnancy, but without any very appreciable cause ;
in a third, it followed an attack of scarlatina ; in four other cases, it followed a long expos-
ure to cold ; in another, it resulted from sleeping on the ground in the open air, during the
month of June; lastly, in three cases, the cause was inappreciable. In two of these latter,
the patients were sufferiug from a relapse of the disease.
** Of these eleven patients, nine entered the hospital before the fourth, or after the eleventh
day of the disease.
*' The primary phenomena were not the same in every case. In six, dropsy was the only
symptom ; in two, it was accompanied by fever ; in two others, there was likewise a slight
amount of fever, with vomiting and diarrha^a ; while in another, there was vomiting, coupled
with an attack of jaundice.
'* On the admission of the patients into hospital, the only marked symptom was general ana-
sarca of varying intensity, from slight, but diffuse pnffiness of the integuments, up to a con-
siderable infiltration of the sub-cutaneous cellular tissue. The skin was, as a rule, somewhat
paler than usual. The remaining organs, and even those which had been affected at the out-
set of the disease, were in a healthy condition. The feverish symptoms had likewise disap-
peared. In nine of these patients the urine presented no trace of albumen, either on their
entrance into, or during their whole stay in the hospital ; it was perfectly natural, moreover,
both OB regards quantity and chemical composition. In two cases, however, the following
phenomena were observed : In one man, who wa^ admitted on the fourth day of the disease,
a considerable amount of albumen was found in the urine on that and the succeeding day ;
on the sixth and seventh day it had gradually diminished ; on the eighth, it was barely dis-
cernible, and on the ninth day it had entirely disappeared. The dropsy, however, was not
removed until the seventeenth day. In the second case, admitted on the fifth day of the dis-
ease, a small quantity of albumen was found on the sixth and seventh day of the disease, but
none whatever on the eighth.
" Of these eleven cases, nine were cured, and two left the hospital relieved. In none did
the disease last longer than a month.
" Ao analysis of the blood was made in each of these cases, and the mean results thus
obtained, will be found in the subjoined table :
Analytis of 1000 Grammet of Bloods
Moan. Maxinra. Minlm*a.
Specific gravity 1045.84 1053.20 1037.65
Water 830.Y8
Caobales 104.58 134.88 70.10
Solid matters of the serum C1.87 65.C2 57.24
Fibrin 2.07 4.10 1.25
Analytit of 1000 Orammes of Serum.
Mean. Maxim'a. Miolm'a.
Specific gravity 1022.G1 1024.28 1020.05
Water 928.47
Albumen 58.52 03.18 51.12
Extractive matters and salts i 13.01 17.14 7.74
*< The fflobules are less liable to decrease than in cachetic dropsy ; they nevertheless fell, in
one case, to 70, and in another to 72. In three cases they were about 120 per 1000 ; in three
others, between 100 and 120 ; and in five cases, between 100 and 110.
" The fibrin underwent a marked diminution in two cases only, viz : between 1 and 2 per
1000 ; in six cases it varied from 3 to 6, while in three others it rose above 3 per 1000.
" T%e albumen of the terum was always diminished, and in some instances this diminution was
considerable ; it ranged from GO to 66 in four cases, and from 55 to 60 in six others, while in
one case it fell as low as 51.02.
" It 11 almost needless to add that the specific gravity of both the blood and serum was
always fonnd to have fallen below the standard of health.
682 Dropsy arising from Derangements of Nutrition and Absorption.
" Sach, theni is the history of acute dropsj. We have now to interpret and explain its
attendant phenomena.
'^ At first, two prominent facts present themselres to our notice ; the one being the dropsy,
and the other a modification of the blood, consisting in a decrease of the albamen, and of the
specific gravity of the circulating fluid itself.
*' What is, then, the correlation of these two facts? Upon which of the two does the other
depend, or are they independent of e:ich other? To answer such questions, is somewhat more
difficult than might be a priori imagined. If, in fdcc, we admit that the alteration of the
blood precedes the dropsy, bow are we to explain the decrease of the albnmen in those cases
where there has not existed (as in cachetic dropsy) any material appreciable cause, toaccooot
for the impoverishment of the vital fluid ? This difficulty, howeverj is not insurmoantablef
and the following simple explanation may perchance prove satisfactory :
'' Of the eleven cases quoted above, two were admitted before the seventh day of the dis-
ease.
" What, then did we find in these two cases? An expiring albuminuria, if we may be per-
mitted to use such an expression. On admission, u certain amount of albumen is foond in
the urine, its decrease is watched, and about the eighth day it is found to disappear entirely.
In such a case, the modification of the blood admits of easy explanation.
*' It is evident, in fact, that the following sequence of events took place : These two indirid-
oals, whether under the influence of cold, or some other cause, were attacked with a certaie
amount of congestion of the kidney. This congestion was manifested by the escape of albu-
men along with the urine, which lusted as long as the congestion itself, viz : seven or eigbt
days, and then ceased. Under the influence of this escape of the albumen, the proportioe
of that element naturally existing in the blood became diminished, the density of the serum
fell, and dropsy was produced. But the change in the composition of the blood, when once
effected, lasts for some time after the disappearance of the albumen from the urine, and as
long as this change exists, so long will the dropsy likewise exist. Had these two patients
not been seen until the eighth day of the disease, no albumen would have been found in the
urine; the diminished amount of that constituent existing in the blood, together with (b«
dropsy, could alone have been discovered, and their correlation would have been lost.
'* In these two cases this solution of the problem would appear simple and rational, nor do
we think it can well be contested. But will it hold good with respect to the remaining oioe
cases? We think it will ; and we adroit the same, by iuduction it is true, bnt yet upon c(r>
tain plausible reasons, which are the following :
1. As these nine cases were not admitted into the hospital until after the seventh dtj of
the disease, we may readily conceive the albumen to have disappeared from the urine f^rt'
vious to admission.
2. The symptomatic expression of the disease was the same in every case. In several of
them its onset was marked by a combination of phenomena sufficiently characteristic of
acute congestion of the kidney (active hyperiemia).
3. The modification of the blood was the same in each of the eleven cases.
4. The progress and duration of the disease were likewise identical in each.
^' We may now, therefore, offer the following summary of our theory ; for however rational
and satisfactory, it is still but a theory :
** Under the influence of some cause or other, congestion of the kidney is produced. Tl>c
congestion is indicated, along with other symptomatic phenomena, by the escape of a certain
amount of albumen with the urine; this, ere long, diminishes the natural proportion of tbr
albumen of the blood, and the latter condition in its turn gives rise to a greater or le»$
degree of dropsy. We may here observe that, when this decrease of the albnmen takr«
place rapidly, dropsy is produced with greater facility and with less diminution on the pari
of this constituent of the blood, than when it occurs in a chronic form. But the congestion
of the kidney is generally of much shorter duration than the modification of the blood amI
its consecutive dropsy ; it disappears therefore long before these latter phenomena, and if
the patients are not examined until a certain time after the onset of the disease, they aloof
are observed, the escape of albumen with the urine having altogether ceased.
*' If the theory which we have thus propounded be the true one, it would leem adfisable i?
designate the disease in question, as congestion or active hypersemia of the kidney, ratbrr
than as acute dropsy from decrease of the albumen of the blood. We do not, however, dects
ourselves authorized to make such a change, being unable, as yet, to elevate our bypothesi«
to the rank of a positive fact, at least in the majority of cases."
These investigations of Bcc4|uerel and Rodier, conducted in the spirit of Philosophic
incjuiry, are of great value, in establishing the connection of acute dropsy with conp(»'
tion of the kidneys. It would be more reasonable to suppose that the acoonpinjini:
dropsical effusion was as much the result of the non-eliminatioD of the elements of the
Dr(^y arising from Derangements of Nutrition and Absorption. 683
urine, uid the retention of the watery element, ne the mere loss of albameo. I have
witnessed the Huperveotion of acat« dropsy id patients who were exposed to cold,
during convalescence from chicken pox, measles and scariatina, within two days after
the cause which produced congestion of the kidney, with almost complete cessation of
its action. In such cases, ihe two or three ounces of urine excreted during the tweoty-
four hours, although loaded with albumen, were not sufficient in quantity to mate-
rially affect the composition of the blood. The most sudden case of acute dropsy, that
I have ever witnessed, was attended with almost complete suppression of nrine, as the
result of exposure to cold during conralesoence from variola ; and nremic coDVulsions
of the moat violent character supervened.
The retention of the urea, and water Dortnally excret«d by the kidneys, appears to
be connected with the dropsical effuaion, even more intimately than the loss of a small
amount of albumen.
The treatment of acute dropsy should be based upon an accurate koowledgo of
theprevioui state of the patient and the amount and composition of the urine.
When the kidneys are congested, and the urine is scant and loaded with albumen, and
the patient suflers with fever, general uneasinesa and gastric deraogement, both general
and local blood-letting may be practiced with benefit.
Leeches and cut-cups over the region of the kidneys will prove beneficial in relieving
the coDgestioa. After the albumen has disappeared from the urine, and in those cases
in whi(£ its presenoe has been never detected, blood-letting is not indicated.
The diet shauld be light but nutritious, and composed largely of vegetable and farina-
ecooa artides.
Various measures may be instituted to procure the removal of tha effused fluid ; as
purgatives, hot air baths, diuretics and stimulating frictions.
When the kidneys are congested, tiimulating diuretics should be avoided, and the
taline dinretlca sbonld be employed. The bitatrate of potassa ( cream of tarUr ),
employed in the proportion of one ounce dissolved, or rather suspended in one pint of the
infusion of juoiper berries ( juniperi fhictus ), may be administered during the twenty-
four hours. If the gentle stimalant effect of the volatile oil and resin of the juniper ber-
ries be contra^ indicated, the cream of tartar may be given suspended in one pint of water.
A wine glasainl of this mixture may be taken every two or threa hours. Afler the
relief of the kidneys, and the establishment of the excretion of the urea in its normal
amount, good diet, together with tonics, especially cinchona and the v^tablc bitters,
may be employed to restore the blood to the normal standard.
C H AFTER XII.
]>R01>MY AKISING FROM DERANGEMENTS OR ALTERATIONS OF THE BI/KiD, LEADING T«i
DERANGEMENT OF THE NUTRITION OF THE TISSUES, WITH AN INCREASE OF SEURETIUN oB A
DIMINUTION OF ABSfJRPTION. EFl'ECTS OF THE PROIA^NGED ACTION OF THE MALARIAL POlSti.N
IN DERANGING THE CONSTITUTION ;OF THE BLOOD, AND IN INDUCING DROPSY. CONSTITirrHiX
OF THE BLOOD IN MALARIAL FEVER. CONSTITUTION OF THE BLOOD IN MARSH CACHEXIA.
TREATMENT OF DROPSY ARISING FROM THE A<mON OF THE MALARIAL IH)ISf)N.
The prolonged action of the malarial poison, not nnfrequently induoea such changes
in the composition of the blood and sach derangements of the liver and gpleen, as to
lead to the effusion of serous flaid into the areolar tissue and peritoneum. The changes
of the blood induced bj Malarial Fever, appear to be the cnief cause of the dropsici]
effusions, although in some cases this symptom may be attributed to the mechanic^
obstacle, offered by the enlarged spleen and liver. Several well marked cases of dropsy
resulting irom the prolonged action of the malarial poison have been from time to time
presented to the Medical Class of the University of Louisiana, in which no albumen
could be detected in the urine, nor any diminution of this secretion, nor any very great
enlargement of the liver and spleen. Such cases were uniformly characCeriied by a
sallow, anssmic complexion, and watery blood, poor in solid constituents. The effects
of the malarial poison in altering the composition of the blood, are shown in the fol-
lowing table (page 585), embodying the results of my investigations :
The effects of the malarial poison upon the blood, are rendered manifest, by a con-
parison with the following typical formula of the constitution of the blood.
Physiological limits of the variations of the constituents of the blood as established
by the researches of MM. Becquerel and Rodier :
IN 1000 PARTS OF BLOOD
The water, may vary, , from T60.00 to 800 o«».
The specific grayity may yary " 1055.00 to 10«3.«h^.
The globules may yary <* 120.00 to 150.0t».
The fibrin may vary *^ 2.00 to 3.5<*.
The solid matters of serum may yary ** 90.00 to 105.<><>.
The saline constituents may yary *' 4.00 to 10.(>^.
IN 1000 PARTS OP SBRUM.
The specific gravity of serum may vary from 1027.00 to 1032. •'wi.
The water of serum may yary " 880.00 to 900.<mi.
The solid matters may vary *^ 100.00 to 120.<«»-
The albumen may vary " 70.00 to d«> ■••■.
The following is the typical formula of the constitution of the Blood in health.
adopted by MM. Becquerel and Rodier.
ANALYSIS OF 1000 PARTS OF BLOOU
Specific gravity of blood 10€(> •»•.•
Water ., Tei.v
Globules \%h.w
Albumen 70.ct>
Fibrin « 2 ^0
Fatty Matters, Extractive Matters and free Soils 10 •«»
Phosphates « o ^hi
Iron, , „,...,„.., "35
Dropsy arising from Alterations of the Blood.
585
^
p «*
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CungcHtivo Fevor.
Malo.
Congestive Fever.
Male.
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10 days* duration
at time of analysis.
Male.
Remittent Fever uf
16 days* duration
at time of analysifl.
Male.
1 1 Remittent Fever of
2 weeks' duration.
1 1 Male.
I ! Remittent and Ty-
i; plioid Fever of 11
I days' duration at
|i time of analysis. M.
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of fi weeks* dura-
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Intermittent Fev'r
of 2 weeks* dura-
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lysis. Male.
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Intermittent Fever
'' of 12 days* duration
at time of analysis.
Slale.
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586 Dropsy arising from Alterations of the Blood.
ANALYSIS OP 1000 PABT8 OP BBRUU.
Specific gravity of serum 1028.00
Wftter 9«8.f«'
Albumen 80.oy
Extractive Matters and free Salts 12.00
The following results are established by this comparison :
1. In Malarial Fever the specific gravity of the blood and serum is diminished.
The specific gravity of the blood ranges in this disease from 1030.5 to 1042.4, and
the specific gravity of the serum from 1018. to 1023.6.
In health, on the other hand, the specific gravity of the blood varies from 1055. to
1063., and the specific gravity of the serum from 1027. to 1032.
2. In Malarial Fever the colored blood-corpuscles are greatly diminished.
In health the dried corpuscles may vary from 120. to 150. parts in the 1000 of blood,
and the moist blood-corpuscles from 480. to 600. In Malarial Fever, on the other
hand, the dried colored corpuscles range from 51.98 parts to 107.81 ; and the moist
blood-corpuscles from 207.92 to 323.63.
The careful comparison of these analyses of malarial blood with each other, reveak
the fact, that the extent and rapidity of the diminution of the colored corpuscles, cor-
responds to the severity and duration of the disease. A short but violent attack of
congestive or of remittent fever, in its severer forms, will accomplish as great a dimioa-
tion of the colored blood-oorpuscles, as a long attack of intermittent fever, or the
prolonged action of the malarial poison.
3. In Malarial Fever the relation between the colored corpuscles and liquor nDgoinis
is deranged.
Thus in healthy blood the relative proportions of moist blood-oorpuscles in the lOiHI
parts and liquor sanguinis, may vary from 480.00 to 600.00 of the former, and fW)m
520.00 to 400.00 of the latter ; whilst in Malarial Fever, the globules vary from 207.92
to 323.63, and the liauor sanguinis from 792.08 to 676.37.
4. The Fibrin of the Blood is diminished to a marked extent, in s6me oases of Malarial
Fever, and is altered in its properties and in its relations to the other elements of tb«
blood, and to the blood-vessels.
5. The Organic matters of the Liquor Sanguinis, and especially the Albumen, in
diminished in Mahurial Fever.
Thus the solid matters of the serum may vary in health, from 90.00 to 105.(K»:
whilst in Malarial Fever, they vary from 62.78 to 80.22 parts, in the 1000 parts of
blood.
It is chiefly to this latter change, vie : the diminution of the albumen of the bloixl
in Malarial Fever, that the dropsical effusions are to be traced. The other changea of
the blood, without doubt, lead to congestions of the liver and spleen, and to dmogf-
ments of the capillary circulation and nutrition of the organs ana tissues, but a carefnl
examination of those diseases as ansemia, chorea and pycemia, in which the colored
blood-oorpuscles are greatly diminished, will show that this cause alone will not iodocf
dropsy. In the watery state of the blood induced by the action of the paludal poison,
comparatively slight obstructions of the circulation in the spleen and liver might lead to
dropsical effusion.
It would appear also, that from the derangement of nutrition caused by the action of
the malarial poison upon the blood and nervous system, that certain effete products arr
not sufficiently and properly eliminated, and then as in the case of urea, may be active
in the production of dropsy.
MM. BecQuerel and Bodier have demonstrated that in that peculiar condition of the
system called marsh cachexia, accompanied by a remarkable decloration of the skin,
and not unfre(|uently by dropsy, and produced by the long influence of malaria, ther?
is the greatest decrease of both the albumen and the globules ; as is well shown bj th^
following analysis of marsh cachexia.
Dropsy arising from Alterations of the Blood.
587
AnalytU of 1000 parts of Blood in Afarth Cachexia.
A man, ag«d
SO, nuOieiiDR from
Marah CmehexU
aad Oea'l Dropij.
A man, afffid' A mao. a^vd
4S, sufferiag from 48. aulfeflof from
Manh Cachexia Manh Cwshexla
aad Oco'l Dropav. iaad G«n'l Dropaj.
Specific Gravity
Water
Moist Globales
Solid Matters of Moist Globules
Water of Moist Globules
Solid Matters of Serum
Fibrin
1035.40
869.34
268.40
67.10
201.30
61.10
2.36
I
1040.00
853.75
407.48
101.87
305.61
41.84
2.54
I
1034.06
869.71
269.12
67.28
201.84
59.88
3.13
A man, aged I A man, a««d
as, ittirerlag from 1 18, raiferiac from
Marth Cachexia .Manh Cachexia
and Oen'l Dropay. and Oen'l Dropajr.
1033.85
875.67
224.88
56.22
168.66
63.83
4.27
1040.57
846.31
378.88
87.22
251.66
62.32
4.15
Analytis of 1000 ParU of Serum in Manh Cachexia.
Specific Gravity
Water
Albumen
Extractive Matters and Salts...
1020.37
936.40
55.68
7.92
1016.40
953.29
37.26
9.45
1021.61
930.08
50.20
13.72
1024.15
926.75
60.20
13.05
1023.56
922.98
63.25
13.77
The mean composition of the blood in marsh cachexia may be represented thus :
Anvlytie of \Q00 parte of blood {mean composition of in five cases of Marsh Cachexia.)
Specific gravity 1036 76
Water 962 38
Moist globules 303 76
Dried residue of globules 75 95
Water of globules 227 82
Solid matters of serum 57 79
Fibrin 3 39
Mean composition of 1000/>arto serum.
Speeific gravity 1021 22
Water 935 10
Albumen ; 53 32
Extractive matters and salts .t..^ 11 58
The following interesting remarks with reference to the cause of the dropsy, are made
by MM» Becquerel and Rodier :
"The dropsy has been attributed to the mechanical obstacle afforded by the enlarged con-
dition of the spleen, so common in these cases. We do not deny the possibility of such a
sequence ; but it is certain that in many instances, we fail to discover such an amount of
splenic enlargement, as would suffice to eiplain the occurrence of an increasing and general
anasarca. In only one of the preceding analysis of the blood, in marsh cachexia, did we
notice a marked degree of splenic enlargement ; It was, however, insufficient to account for
the serous infiltration. * * * # ♦
**It is in this disease, therefore, that we meet with the greatest decrease of both the alba-
men and globules. It nuiy be taken as the type of cachectic dropsy.
'*How now, are we to account for so great a change ia the composition of the blood ? W^e
nre driven to adroit a poisoned condition of thi.4 fluid, produced either by the absorption
of the marsh miasm, or by repeated attacks of the peculiar fevers to which this miasm gives
rise?"
The indications in the treatment of dmiMy ari.sing from the action of the malarial
fioiaon, are :
Ist. The removal of the cause, giving rise to the phenomena of malarial fever, and
causing a simultaneous decrease of the globules and albumen, with congestion of the
liver and spleen. The patient must be removed from the influence of the paludal
poison. In many cases, even after the removal of the patients to elevated, healthy non-
luiaamatie regions, the attacks of ague wiil recur again and again with obstinacy.
5D0 Dropsy arising from Alterations of the Blood.
and diureliet. Gustavc Brok, native of Finlandf age 67 ; tea-faring man, has always enjoyed
good health up to the time of his residence in Louisianai six months ago. Commenced work on
the Railroad at Bloomficld, in a sickly malarious locality, and was seized with chills in the latter
part of July, 1870; and suffered with a paroxysm (chill and fever) every other day, until he
entered the Charity Hospital, (ward 25, bed 308,) November 24th, 1870. Swelling commenced io
lower limbs a short time before entering the Hospital, and increased rapidly until the abdomen
became distended with fluid, and the features of the face were bloated. The complexion was
sallow and jaundiced. It was observed that the swelling was always greatest in the right leg.
Liver somewhat enlarged, and sluggish in its action. Spleen greatly enlarged and indurated
Under the use of mercurials, (Blue Mass,) and Quinine, followed by Tartrate of Potossa,
and Iron, and the mixture of Quinine, Chlorate of Potassa, Hydrochloric Acid and Tinctore
Muriate of Iron, this case progressed slowly but favorably; and on the 23d of Febrnarr,
1871, every vestige of the ascites, anasarca and a^dema had disappeared, and the complexioa
had assumed a clear and healthy appearance. Throughout the attack the nrine was free from
albumen, although at times, and especially during the paroxysms of the chill and fever, which
recurred several times, containing biliary matters and presenting the usual changes charac-
teristic of malarial fever.
We observed that the absence of albumen from those cases of dropsy which were clearlr
referable to the action of malaria, was a most favorable symptom.
During the months of November, December 1870, and January, February and March 1871.
I treated in wards 24 and 25, Charity Hospital, 180 cases of disease, and of this number, more
than one-half, or 114, were suffering with the various forms of malarial fever, (Pernicious
Remittent, Intermittent, and Chronic Malariail poisoning.) Of these one hundred and fcar-
teen cases of malarial fever, one tenth were suffering with anasarca. Treated npon the
principles just indicated, the entire number, including the fourteen cases complicated witb
anasarca, ascites and ucdema, were relieved and were discharged cured — no death occnrred
We attributed this favorable result to the persistent use of purgatives, diuretics. Iron and
Quinine ; as well as to the fact that in this series of cases, the liver, and kidneys were nca
seriously involved. We have from time to time, in both civil and military practice obserrei
a number of cases of anasarca acccompanying the prolonged action of the malarial poisoc
and apparently dependent upon the alterations which it induced in the liver and spleen.
which were only temporarily relieved by treatment, and which finally terminated fatally.
In such cases the liver as well as the spleen presented an altered and indurated appearance
and in a certain proportion also, the kiducys were involved.
"'Case 63G : Chronic Malarial Poisoning^ with Ateitet and General ^notarra.— Victor Sievtui.
nge 52, native of France; admitted ward 13th, bed 189, Charity Hospital, December IMii.
1872. Patient gives the following history : about nine months ago, May 1872, io IIUdoi*.
was attacked with Intermtlient fever (chills and fever,) which continued about six Booth*-
Three months (October 15th,) before entering the Chanty Hospital, he left Illinois and can.*
down the Mississippi River to New Orleans, and while on the boat, was again attacked t%
chills and fever, and he observed that the chills were accompanied and followed by swellic;
of the abdomen and lower extremities. Was also greatly exposed on the deck of the steamt;
to cold which seemed to induce the first chill.
On the third day of the voyage down the Mississippi, the patient noticed that his feet an !
legs began to swell ; the swelling gradually progressed upwards, until the abdomen becanr
involved. After his arrival in New Orleans, on the 30ih of October, there was no re^Ur '«
in the attacks of fever, which assumed in turn, the quotidian, tertian and quartan typ^^
Kntered the Charity Hospital, and was so much relieved by the treatment with Qniniae. Irot.,
and Bitartrate of Potassa, that at the end of three weeks, he left and endeavored to follow L.*
occupation (Veterinary Surgery.)
At the end of twelve or fifteen days, the chills and tever returned, and the swelhog of t '
abdomen and lower extremities appeared agnin, and increased rapidly.
Entered Ward 13th, December 11th, 1872; pule, sallow, anaemic; face presents a s wo.*- f
bloated appearance; abdomen greatly distended with fluid; veins upon the walls of T'
abdomen, present a full distended and arborescent appearance ; lower extremities swollen ai. i
distended to such an extent, that the patient walks with great difficulty, and in fact i* cum-
pelled to lie in bed. Pulse accelerated and feeble. No appetite. Great depression and f''>—
tration. At times the patient cries, and says that there is no hope for bis recovery.
Ten grains of Sulphate of Quinia, and twenty minims of Tincture of Opium. (Landan'jT
were administered this day, and repeated again on the 12th. On the next day, December !.>.'
1 administered 5 grains ot Sulphnti' of Quinia, every two hours, until the patient bad takrc .
grains. These measures arrested the chills for a short period. As the dropsical effasion « «•
increasing, I determined to employ a combination of diuretics and purgatives. A pu« >
composed of forty grains of tlowcrs of Sulphur, one ounce of Bitartrate of Potassa. a: >
twenty grains of pulvori/o<l Jnlia]!, was mixed with half a pint of water, and adminifirr- i
Dropsy arising from Alterations of the Blood, 591
morning and erening. These powders produced free action on the bowels and kidneys, and
were repeated daily. Throughout this case the urine teas free from albumen.
December 18th. Patient has complained of a troublesome cough for several days, and to
relieve this I ordered a mixture, composed of three drachms of (chloride of Ammonium, three
fluidounces of Syrup of Squill, and two fluidounces of Syrup of Wild Cherry Bark, (Prunus
Virginiana ; ) teaspoonful whenever the cough was troublesome. The Chloride of Ammonium
was given for its alterative effects, which experience has shown, are often of value in the
peculiar state of the blood, liver and spleen, characteristic of the prolonged action of the
malarial poison. The squill was given for its expectorant and diuretic effects : and the Wild
Cherry for its sedative and tonic effects.
December 19th. Ascites greatly diminished ,* lower extremities not so tense ; patient says
that be is much better. R. Quinias et Ferri Citratis, four drachms ; Acidi Citrici, one drachm ;
Aquse, Menth, Pip, six fluidounces ; mix, teaspoonful three times a day.
December 20th, m., temperature axilla 100° F.; s. 100°.; 2l3t ii., 99°.7, pulse 88; 22d m.,
100.7. Patient had a chill at 11 a. m., December 22d ; during the chill the temperature of the
axilla was 101°. 25 P.; whilst that of the hand was only 91°.5 F. I have observed that in many
cases in which the action of the malarial poison has been prolonged, the rise of temperature
in the trunk is not so marked as in cases in which the paroxysmal disease has been recently
developed.
B« Quinise Sulph, one and a half drachms; Ferri Sesqui Chloridi, one fluidounce; Aqus
DistillatO}, eleven fluidounces ; mix ; tablespoonful in wineglassful of water every four hours;
suck through glass tube.
December 23d if., temperature 100°.5 ; 24th if., 100°.5. December 25th, had a chill at 8
A. M., which was followed by high fever. Ordered a powder composed of three grains of Sul-
phate of Quinia, one grain of Powdered Camphor, and one grain of Capsicum, to be given
every three hours, and continued until ten powders have been taken. December*26th m., 98° ;
27tb M., 97°; 28th, 98°. December 28th, had a chill at 8 a. m., followed by fever. Repeated
the Qoinlne, Camphor and Capsicum powders. Daily observations upon the temperature
showed that it ranged from the 28th of December to the 20th of January, 1873, from 98° F.
to 99^*5 F. During this period the patient was kept upon the Citrate of Iron and Quinine;
the bowels were occasionally moved by Blue Mass combined with Quinine, and also by Mag-
nesia and Bitartrate of Potassa. The improvement of the patient was marked, up to the 20th
of January, when the temperature rose to 101° F., and reached 103°.4 F. on the 21st. This
was the last paroxysm of fever. Quinine was freely given at this time, and the solution of
Citrate of Iron and Quinine continued. The patient made a complete recovery, and was dis-
charged on the 3d of February, in apparent health ; all marks of the ascites and anasarca
had disappeared, and the complexion presented the clear, rosy tint of health. This patient
haa visited me at various intervals, up to the present time July 1875, and presents the appear-
ance of health, and says that he has had no return of the chills and fever or dropsy.
Cabi 637 : IntermttUnt Fever; General Anasarca^ Resulting from the Prolonged Action of Malaria. —
Patrick Flavin, age 46, native of Ireland. Entered ward 13, Charity Hospital, February
12tb, 1873. Has been working in swamps and been exposed to cold and wet. Sallow, jaun-
diced, anaerolcal hue ; excitable, feeble pulse ; ordinary temperature but slightly elevated
above the normal standard, but subject to oscillations much greater than those ordinarily
observed in health. Had chills at various times, and on the 13th of February, the day after
bis entrance, the temperature rose after the chill to 103°.8 F.
On the 14tb, 16th, 17th, 18th and 19th, the temperature oscillated between 99° and 100°.8
F.; and on the 20th, rose after a chill to 102° F.
I attributed the ascites and anasarca in this case, {etpeciaUy as in the preceding case^ the heart's
action was normal^ and the urine entirely free from albumemf) to the effects of the malarial poison
in impoverishing the blood, and inducing obstructions in the portal and splenic circulations.
This patient was treated with entire success, upon the same general plan as that pursued
in the preceding case, (Victor Sievaux.)
Casi 638 : Intermittent Fever ; Chronic Malarial Poisoning ; enlargement of Liver and Spleen ;
Anmmia; Anasarca. — Noah Wilkinson, age 13, native of Georgia ; laborer. Entered ward 13,
bed 189, Charity Hospital, December 3l8t, 1874. Had suffered with chills and fever, for more
than 12 months. Whilst passing through New Orleana with his father and mother, on the
way to Texas, suffered with a paroxysm of fever, and was brought to the Hospital. His
father and mother were in like manner brought to the hospital sick, and both died ; they were
not however under my care. Noah is pale, sallow and dropsical. Features of face, present a
bloated, sallow, anieroic appearance, but little difference in color being observed between his
pale lips, gums and tongue, and his face and hands. Hands swollen, bloodless and semi-
transparent. Belly distended with dropsical effusion. Lower extremities and scrotum cede-
matoas. Says that be lived in a low, damp, malarious locality in Georgia, and suffered with
chdu und fever for more than twelve months.
Qnioine with veyeral Qf the standard preparations of Iron, as the CitratQ of Iron and
592 Dropsy arising from Alterations of the Blood.
QuiniDe, Precipated Iron, Tincture Sesqui Chloride of Iron, were administered persisteotlj at
regular intervals ; the bowels were occasionally moved by a mercurial, (either Blue Mass or
Calomel,) and the action of the kidneys was promoted by the daily use of the Bitartrate of
Potassa. A combination of Tincture of Quassia, Tincture of Rhubarb, and of Gentian and
Cinchona, was also employed as a tonic and antiperiodic.
The patient improved slowlj' but steadily during the month of January, 1875, the pulse
ranging from 60 to 70, and the temperature varying from 99 to 99.5 in the axilla, the anasarca
disappearing, the complexion assuming a clearer and more ruddy hue, and the general health
and spirits improving.
On the 10th of February he was seized with violent convulsions, attended with rapid tumuU
tuous action of the heart, elevation of temperature and coma. The convulsions commenced
at 3 A. M., February 10th, and continued at intervals of 15 minutes, for 30 hours. Dnriog
the convulsions every muscle of the body was thrown into violent action, consisting of
numerous short jerks ; the head was moved rapidly from side to side ; the face became of a
deep purple ; the veins of the neck were greatly distended, and the action of the heart was
tumultuous and powerful ; one pupil was dilated and the other contracted.
At 8 A. M., the pulse was 136, temperature of axilla 103.5 F.; 5 p. if., pulse 140, respiration
56, temperature of axilla 106^.75. I applied a blister 2 by 4 inches to the back of the neck, ice
bags to the head, sinapisms to the extremities ; opened the bowels with purgative enema, and
administered iuternally, freely Calomel and Quinine. Oil of Turpentine was also applicU
locally over the region of the lungs, as the patient appeared to suffer from oppression in
breathing, and percussion revealed dullness. After the evacuation of the bowels, Qninine
was administered by enema together with diluted brandy ; and large doses of the Bromide of
Potassium were administered internally at regular intervals during the night.
The blister drew well ; the bowels were freely evacuated, and the following morning, Feb*r
llth, the patient appeared to be more quiet, the convulsions were not so violent and recurred
at much longer intervals : 8 a. m., pulse 144, respiration 48, temperature of axilla 104^ F.;
8 p. If., pulse 130, respiration 36, temperature 104°. 5 F. The patient has continued to improve
during this day, and has taken Quinine, Beef tea and milk punch by the mouth.
February 12th, rational ; no spasms ; complains of severe pain in the muscles of the body,
and especially in those of the arms and chest. Eight a. m., pulse 116, respiration 36, tempe-
rature 101° F.; 8 p. M., pulse 120, respiration 36, temperature 105*^.75. During the night a
marked remission of the fever took place, and the next morning, February 13, the pulse was
08, respiration 28, and temperature of axilla 101° F. The fever returned, however, again on
the 14th, but without the convulsions; 8 a. m., pulse 128, respiration 44, temperature of
axilla 104° ; 8 p. if., temperature 103°. The patient suffered with a cough dependent Qpoa
bronchial irritation, also with fever, the tongue being heavily coated with brown for and red
at the tips and edges. He sat up for the first time, on the 17th.
The pulse continued up to the 2d of March, to range from 90 to 120. Marked rises of
temperature were noticed on the 18th and 20th of February; the following observations were
made upon the variations of temperature. February 15th, if. 100.5°, c. 102°; 16th, m. 101°,
B. 102°; 17th, if, 101°, E. 102°; 18th, if. 101°.5, R. 102°.25; 19th, M. 101°.5, ». 101°.5 ; 20lb,
M. 103°.6, K. 101°.25; 21st, if. 101°.5, «. 102°; 22d, M. 10l°.5, B. 99°; 23rd M. I0l°.5, i.
101°.5; 24th, if. 101°.5, E. 101°; 25th, sr. 101°, E. 101°; 2eth, H. 104°, s. 104°.25: 27lh, M.
101°, B. 101°; 28th, If. 101° F., E. 101°; March 1st, M. 102°, b. 101°. The parozjeval
character of the disease was clearly shown by the variations of temperature, and the spinas
appeared to have been directly caused by the action of malaria, for they were relieved nnder
the combined action of quinine, counter-irritants, purgatives and stimulants.
Under the persistent use of Quinine, Iron, Tincture of Bark, and small doses of Arseoioai
Acid, this patient slowly improved, and was discharged on the 1st of April, 1875.
The urine was free from albumen, thoughout the preceding cases.
Case 639 : Intermittent Fever ^ Chronic Malarial Poisoning ; Ansmia; (BdHna of Ixncer JSHrtmuUf,
T. Mc, age 25, native of Ireland, laborer, entered ward 30, Charity Hospital, November 29tb,
1874. Has been working in the swamps and has had Malarial Fever for three months, with
little or no treatment. Liver and spleen enlarged ; annmia ; marked cedema of lower extresni-
ties ; scrotum swollen and pits upon pressure. No albumen in urine. Under the persisleei
use of Quinine, Iron, Quassia and Bitartrate of Potassa, recovered, and was discharged Dec.
3l8t, 1874.
Case 640 ; Intermittent Fever ; Chronic Malarial Poisoning ; Ansemia ; (Edema of Lomrr Ertr^
tnities and Scrotum.— ,]. 0. P., age 24, native of Ireland, laborer, contracted Malarial Fever in
swamps ; entered ward 29, Charity Hospital, November 29th. Liver and spleen enlarged :
pale, sallow complexion ; anamic ; has suffered with chills and fever for two montbs; lower
extremities and scrotum greatly swollen. Albumen present in small amount in nrine. Ian«
proved rapidly, on the treatment with Quinia, Iron, Bitter Tonics and Tartrate of Potassa ;
discharged December ITith.
Case 641: Intertnitient Fever; Chronic Malarial Poisoning; Enlarged S^ltm ; Anmm^: jlee«
Dropsy arising from Alterations of the Blood. 593
»<trca. — (». M., age 23, native of Germany ; entered ward 29, Charity Hospital, Norember 3uili,
1674. Hag been working in swamps and marshes, and has sufTercd with chills and fever for
two months. Spleen greatly enlarged ; pale, sallow complexion ; anaemic ; lower extremities
and scrotum oedematous. Improved under a treatment similar to that instituted in the pre-
ceding case ; discharged December 21st.
CasI 642 : IntermiUeni Fever; Chronic Malarial Poisoning ; Enlarged Spleen ; Anemia ; (Edema
of Scrotum and Lower Kxtremitiea. — J. S., age 31, native of Ireland, laborer; entered ward 13,
Charity Hospital, Dec. 3d, 1874. Has suffered with Intermittent Fever for six weeks ; spleen
enlarged; anaemia; ccdema of scrotum and lower e.xtremities ; urine slightly albuminous.
I'ader the treatment specified in the preceding cases, restored to health and discharged Dec.
(?A«l 643 : Intermittent Fever ; Chronic Malarial Poi$oning ; Enlarged Spleen ; Ansemia ; Ana-
Marea. — Daniel Gary, age 31, native of Kentucky, laborer. Has suffered with chill and fever
for three months, whilst working in malarious swampy region, and during this time has had
little or no treatment. Entered ward 20, Charity Hospital, Dec. lOtb, 1874 ; sallow, pale,
slightly jaundiced complexion. Anaemia; spleen enlarged; lower extremities and scrotum
(edematous ; belly distended ; countenance presents a swollen, bloated appearance ; anasarca ;
no albumen in urine. Improved under treatment, and was discharged January 31st, 1875.
Cask 644: Intermittent Fever ; Chronic Malarial Poisoning; Anxrnia; Anasarca, — J. McGinty,
age 30, native of Ireland, laborer; entered ward 30, Charity Hospital, Dec. 28th, 1874 ; spleen
enlarged; anasmia; anasarca; no albumen in urine. Improved under treatment with Quinia,
Iron and Bitartrate of Potassa, and Tiuc. Quassia and Cinchona. Discharged February 7th,
1875.
Gasis 645^53.— Similar to preceding, and relieved by similar measures.
Cask 656 : Persistent Intermittent Fever : Anmmia and Anasarca. — John Hirscher, age 32 ;
native of Germany ; contracted malarial fever in the swamps of Louisiana. Entered Ward 30,
C. U., October 8tb, 1874, with fever and anasarca.
So albtimen in urine. Heart and lungs normal. Treated with Quinine, Iron and Bitartrate
of Potassa. Recovered.
Ca8I 657 : Intermittent Fever^ and Chronic Malarial Poisoning. ^-F rank Leonard ; native of
Pcnniylvania ; laborer; has suffered with intermittent fever for about one month. Entered
Ward 30, C. H., Nov. lOth. Lower extremities, scrotum, and penis distended with dropsical
effusion. Pale, lallow-anaDmic ; great deficiency of red corpuscles, ^^o albumen in urine. Heart
normal.
Kecovered under the usual treatment with Quinine, Iron and Bitartrate of Potassa. Dis-
charged November 25tb.
Cab I 658 : Intermittent Fever ; Chronic Malarial Poisoning ; Anisarca. — Circumscribed deposits
of yellow pigment in skin. Aniemia.
Thomas McElroy, age 30; native of Ireland. Brown hair, brown eyes, Entered Ward 30,
il. 446, C. U., Nov. I5th, 1874. Has had chills and fever, with little or no treatment, for
nine weeks. Features swollen ; pale, sallow and swollen, with several brownish yellow spots
These spots, which vary in size, from half an inch to three inches in diameter, are found upon
varioai portions of the body. »Somc effusion in abdominal cavity. Lower extremities u)dc-
matons. Heart normal. No albumen in urine. Recovery under Iron, Quinia and Bitartrate
of Potassa, and natritious diet, slow, but complete. Discharged Dec. 24th.
CAiiB659: Intermittent Fever of Two Months; Aiuenia ; Anasarca; Enlarged Spleen. — James
Brown, age 25 ; laborer ; native of Ireland. (Contracted malarial fever whilst working iu
swamps and low grounds on Mississippi River, in the month of August. Entered W« 20, B.
422, C. H., Nor. 17th, 1874. Pale anaemic, with loss of muscular and nervous power. Great
«pdema of lower extremities. Xo albumen in urine. Heart normal. Under the usual treatmcjt
with Qainine, Iron and Bitartrate of Potassa, recovered, and was discharged Dec. 9th.
Ca8I 660 : Intermittent Fever ; Amtmia ; (Edema of Lower Extremities ; Enlarged Splecn.^^
Thomas Reid, age 30; native of Ireland; laborer. Entered Ward 30, C. H., Nov. I7tb, 1874-
Has suffered with intermittent fever for " several weeks," during which time has had little or
no treatment. Pale, sallow complexion ; anaemic ; lower extremities much swollen. No
albumen in urine. The usual treatment with Quinine, Iron and Bitatrate of Potassa, resulted
in the removal of the effused liquid, and the improvement of the blood, and the establishment
of health, and the patient was discharged Dec. 3d, 1874.
Casi 661 : Intermittent Fever ; Chronic Malarial Poisoning ; Enlargement of Liver and Spleen ;
Ansemia; Diarrhoea; (Edema of Lower Extremities. — J. M. Budge, age 30; native of Florida;
pedler. Has suffered with malarial fever 5 months. Entered Ward 30, C. H., Nov. 17th,
1874. Pale, sallow hue ; anaemic; liver and spleen both enlarged; lower extremities greatly
swollen ; pitting deeply upon pressure. No albumen in urine. The persistent use of Quinine,
Iron and Bitartrate of Potassa removed the malarial disease, restored the constitution of the
blood, and relieved the dropsical effusion; patient discharged, Dec. 30th, 1874.
Cask 662 : Intermittent Frver ; C^hronic Malaial Poisoning ; Enlarged Liver and Spleen; Antemia ;
594 Dropsy arising from Alterations of the Bhod.
Antuarca, — 1(. 8., age 56 ; native of Coonecticat; sailor. Kntered Ward 20, C. H., Not. 33.
Hub suffered with malarial fever for three months. Pale, sallow complexion; anaemic; liver
and spleen both enlarged. General anasarca. No albumen in urine. Patient died on the
24tii, the day after his entrance into the hospital. Death appeared to be directly caused by
the profound lesions of the blood, liver and spleen, due to the prolonged action of the
malarial poison.
Cask 603: Malarial Fever; Ansemia ; Anasarca; Coma. — , Entered Ward 13, C. H.,
Nov. 17th, 1874. Patient entered in an insensible condition. Temperature of axilla, 104^ F.
Nov. 18th, morning;, temperature of axilla, 103° F.; evening, 104**.5 F. Nov. 19th, moraiiij;,
temperature of axilla, 106° F.; died shortly after this observation. Quinine in large doses was
administered by enema, and sinapisms applied to the extremities, but without any beneficial
results.
Cask 664 : Pertutent Intermittent Fever ; Chronic Malarial Poitoning ; Amcmia ; General Ana^
sarca ; Coma ; Death with High Temperature; Pigment deposited in Brain^ TAver and Spleen, — Emanuel
, Carnerio ; native of Portugal, age 13. Entered Charity Hospital, Ward 30, bed 449, Oct. 3«i,
1874. Has had intermittent fever for four months, and has had no medical treatment. Pale,
anaemic, sallow, yellowish green complexion ; abdomen, scrotum and lower extremilici dis*
tended with serous effusion. Scrotum about three inches in diameter, semi-transparent; pits
upon pressure ; serous fluid confined chiefly to the cellular tissue. Urine entirely free from
albumen. Appeared to improve upon Quinine, Iron and nutritious diet. The dropsical cfl'a*
sion was reduced to a marked extent by the Bitartrate of Potassa. Heart and lungs normal.
On the 3d of November the patient suddenly became comatose. The coma was attended with
violent and rapid cardiac action, and a marked rise of temperature. On the morning of the
second day, one and a half hours before death, the thermometer in the axilla indicated 107°.j
F. Quinine and counter-irritants had no effect, and the patient died comatose, November 5th,
1874.
Pott'mortem Examination^ six hours after death. — Brain congested ; gray matter dark blui:ih
color; structures of the cerebrum and cerebellum loaded with dark pigment granules, depos-
ited chiefly in the walls of the smaller blood-vessels and capillaries. Under the microscope,
the course of the smaller blood-vessels in the cerebral substance could be readily traced
everywhere, by the vast number of pigment granules. Liver, slate on the exterior, and
bronzed within, and loaded with black pigment particles, which were deposited in greateft
numbers in the portal capillaries in the periphery of the lobuli. Spleen enlarged and loaded
with black pigment. Heart normal ; muscular structures, under the microscope, normal.
Blood very watery, and deficient in colored corpuscles.
Cask 665: Chronic Malarial Poisoning; Ascites; Anasarca of Lower Extremities: Ohstimaf'
Diarrhofa ; Ansemia ; Sudden a4xmmiUaUon of Fluid in Right Pleura ; Side punctured ^ and refievedo*
1 1 gallons of Serous Fluid ; Sudden Death ; Pigment in Liver and Spleen. — Thomas Kagan. ac*
47 ; native of Ireland ; laborer. Entered Charity Hospital, Ward 13, bed 183, Nor. I7th, 1874.
Height six feet; brown hair, brown eyes. Has suffered during the summer and aatnna with
malarial fever, contracted in the swamps of the Mississippi river. Pale, an»mio ; lips an J
tongue have but little more color than his sallow face. Abdominal cavity distended wiib
dropsical effusion ; lower extremities also greatly swollen, presenting a semi-transpareat
appearance, and pitting upon pressure. Has suffered during the past five weeks with coo-
itant diarrhoea. Diagnosis : Chronic malarial poisoning ; portal and splenic obstmctioai
anaemia ; ascites ; anasarca ; chronic dlarrhcsa. Prognosis unfavorable.
Quinine, Iron and generous diet induced some improvement, and the dropsical effotioa wa*
controlled to a certain extent by the Bitartrate of Potassa, employed in purgative and diarrtir
doses. But the diarrhoea was troublesome, and with diflBculty controlled. When, by tbc o*e
of Sub-Nitrate of Bismuth, Opium, Ipecac and Astringents, the diarrhoea was cheeked. tb«
dropsical effusion rapidly accumqlated. When the diarrhcca was uncontrolled, the effuirU
liquid diminished, but the strength of the patient was sensibly and steadily reduced. Thf
respiration varied from 20 to 24 per minute, and the temperature either remained at the oor-
mal standard) or was occagionally, in the evening, slightly elevated, ranging from 99^ F to
101^ F, Bepeated examinations of the urine revealed the absence of albnmen.
Whilst endeavori(ig to enrich tl^e blood, which was, to a marked extent, deficient in red
corpuscles, and at tl^e same time to control the diarrhoea and promote the free action of tb«
kidneys, the patient appeared not merely to hold his ground, but even to improve »low!%,
when, after a cold spell of weather in the early part of January, on the 1 1th, the patiett
complained of ser^e pain in tl\e right side. Up to this time nothing, abnormal whatever hiJ
been noticed, eitKer in the lungs or heart.
Auscultation and percussion revealed the presence of a large amount of serous fluid in tl*
right pleuritic oayity. The liquid was suddenly effUsed, and accumulated with such rapiditr
as to produce a marked increase ojf the right side, anteriorly, posteriorly and laterally : an i
at the same tim/e the lung was pressed upwards and interiorly towards its attachment to thf
right bronchus. Great dyspnoea superyoQcd ; the patient was compelled to sit up night sad
Dropsy arising from Alterations of the Blood. 595
dtLj, The lips and hands presented a purple appearance, and the respirator j sounds were
heard only in a circumscribed space, between the second and fourth ribs on the right side ;
whilst the left lung was normal in its actions, with increased resonance. A blister 6 by 8
inches, over the seat of the pain on the right chest, produced some temporary relief; Squills
Digitalis and Quinine, with purgatives, in like manner produced only temporary relief. On
the 16th of January, the right pleural cavity was evacuated, by means of the aspirator, and
I) gallons of clear, serous liquid was drawn off, with great temporary relief to the patient.
The serous liquid rapidly accumulated in the right. pleural cavity, with a return of the dis-
tressing symptoms, and when it was deemed necessary to repeat the operation for the evacua-
tion of the pleuritic effusion, the patient died suddenly in bed, on the 31st of January, 1875.
Po9t Mortem Ezaminalion — Six hours after death. Exterior. — Abdomen distended, lower
extremities greatly swollen ; right side of chest very prominent and flat upon percussion.
Thorax, — ^Left pleura and lung healthy. Heart normal ; right pleura distended with about
one and a half gallons of clear, light yellow, serous fluid, entirely free from pus. Delicate
membranes were observed attaching the surfaces of the walls of the thorax and lung,
especially around the seat of the puncture. These membranes were of great delicacy and
beauty. Their cohesive power was so slight as to be readily ruptured upon the slightest
touch. Right lung contracted and compressed into a small mass, which presented a carnified
appearance when cut open.
Abdominal Cavity contained more than one gallon of serous liquid similar to that found in
the right pleura. Lymphatic glands of mesentery enlarged and hardened. Mucous mem-
brane of ilium and colon greatly congested and ^^ inflamed.'* Gall bladder filled with gall
stones. Liver enlarged, slate colored on the exterior, bronzed within ; and under the micros-
cope, lo&ded with black pigment matter deposited chiefly in the Portal Capillary network upon
the periphery of the lobuli. Liver cells pale, with comparatively few oil globules ; many of
the liver cells contained dark pigment granules. Spleen enlarged and loaded with black pig-
ment particles.
Careful microscopical examination revealed no structural alterations in the muscles of
the Heart. Malarial fever p'roduces no alterations in the muscular structures of the heart.
Yellow fever on the other band produces profound alterations as I have before shown.
The following cases recorded by Frcrichs, in his work on Diseases of the Liver, are
iini>ortant in the light which they throw upon this comparatively obscure and imperfectly
understood complication of Malarial fever.
(Usi 66G : Tertian and Quotidian Intermittent of three months* duration ; Anasarca ; Ascites ,*
iHarrhcea ; Death from Exhaustion ; Atrophied Pigment Liver ; and Pigment Spleen. — A boy 10
years of age, who had been much neglected, and who, for three months, had suffered almost
uointerrnptedly from Intermittent fever, at first of a Tertian, and afterwards of a Quotidian type,
came to the hospital at the beginning of May, 185.5, with a pale, anaemic countenance, and
suffering from profuse watery diarrhcra. The spleen was moderately enlarged. No hepatic
dnllness conld be detected in front ; in the axillary line it amounted to 2 centimetres (J inch).
The lower part of the abdomen contained a considerable quantity of fluid, but there was
scarcely any obvious oedema of the feet. The evacuations by stool, which occurred six or
eight times in the course of the day, were then of a grayish-yellow, and without any traces
f>iiher of blood or dysentery exudations. Pulse 90, and small ; no elevation of temperature.
Appetite slight* The urine, when treated with heat and nitric acid, exhibited scarcely any
turbidity.
The attempts to check the exhausting evacuations by means of Chloride of Iron, Nux
Vomica, etc., and to counteract the anaemia by means of a regulated diet, proved fruitless.
After three days' stay in the Hospital, the boy died.
Autopsg. — Considerable Ascites ; slight Anasarca. No important changes in the organs of
the cranial or thoracic cavities. The mucous membrane of the stomach and intestinal canal
pale, at some places oederaatoua ; the serous membrane of the small and large intestine exhi-
bited here and there livid spots, — the remains of ecchyraoses. The kidneys were normal,
with the exception of a few isolated pigment-granules in the glomeruli.
The spleen was large, firm, congested, and densely infiltrated with black pigment.
The liver was very small and atrophied ; numerous deep depressions were seen upon its
outer surface. Its parenchyma was congested, brownish-black, and of lenacions coasistence.
Yellow sixe injected into the portal vein passed along very incompletely : in thin sections of
the injected tissue, the ramifications of the portal vein, as far as their entrance into th«
lobules, could be seen to be much enlarged, and at some places, unequally so. Black pig-
ment waa observed in the interior of the capillaries, only a few of which were injected; a
large number of them appeared to be no longer permeable. (Diseases of the Liver, New
»Syd. 8oc., 1860, vol. i, p. 258).
Cask 667 : Persistent and oft-recurring Quotidian fnl^rmittent : Hydrtemia ; Anasarca ; Ascites;
596 Dropsy arising from Alterations of the Blood.
Pro/tue Diarrhasa ; Death from EzhauHion: Atrophtf of the Liver ; Bloeking up of the CapUlarif*
with Pigment. — Mrs. M., aged 26, before she came to the Hospital, on April 27th, 1855, had
suffered for several months during the winter from intermittent ferer. This farer continued
for a long time after the patient's admission, and did not permanently disappear until after
the repeated administration of large doses of Quinine. The patient became gradaallj
reduced to an eitreme degree of anaemia, to which general anasarca and ascites were super-
added, and which rapidly increased to a critical degree, under the additional operation of
persistent and profuse diarrhoea, (to check which, the vegetable and metallic astringent^,
particularly the Muriate of Iron, were employed without efffct). Death took place six week?
after admission. Neither albuminuria, nor derangements of the sensorial functions, which
before admission had accompanied intermittent ferer, were observed at any time during tlie
patient's stay at the Hospital.
Autopgy. — There was nothing abnormal in the brain ; the lungs were anaemic and collapsed:
and there was a moderate amount of effusion in the pleural cavities. The heart was nnrmnl.
The abdominal cavity contained several pounds of clear, serous fluid.
The liver was small ;* it weighed 1.7 kilogr, (I lb. 8} oz. av). and was thus less than one-
half the normal weight; at the same time it appeared shriveled and tenacious, (welk u. zabe).
and its parenchyma was congested and dark. Uuder the microscope, numerous flakes of
pigment could be seen in the capillary vessels, some of which were remarkably large. The
ramifications of the portal vein were greatly enlarged as far as the periphery of the loboies,
but attempts to inject them proved very unsuccessful. A large proportion of the capillaries
contained pigment, and were from this cause, impermeable b}* the injection. The sorrouad-
ing hepatic cells were either atrophied or filled with fat; at some places, lardaceoas matter
(Spftkttoffe) was observed. Sugar could not be detected in the liver.
The spleen was smallf , firm, and colored brownish-black, owing to dense accumolationf of
pigment; its capsule was thickened. The kidneys were normal, except that isolated pignrni
granules were seen in the glomeruli. The mucous membrane of the intestine was pale and
nederoatous ; in the sigmoid flexure there were a couple of superficial catarrhal ulcerations.
The origin of the atrophy in this case could not be traced with certainty. The plgmeot
flakes and granules, which not unfrequently are found !n the spleen in the course of severe
intermittents, and from this organ are transmitted into the portal vein partly, and pass to
through the capillary network of this vessel, and parti}" owing to their size, remain firmly
impacted in it, and give rise to occlusion ending gradually in obliteration. The obstructed
flow of blood entails an arrest of the secretion, and destruction of the glandular cells. Ucca*
sionally it happens that large clots are swept along into the vessels of the liver; scar- like
depressions are then produced at these parts of the surface of this organ to which the obstruc-
ted vessels lead. (See Diseases of the Portal Vein.): pp. 259-261.
Cask 668 : Pernstent Intermittent Fever ; Anttmia and Hydrtetma ; Exhau^ng Diarrk*ra, it*«/^
hut little Bile in the Stoolt ; Death under Cerehral symptoms: Fatty Degeneration of ike Ltf*^ :
Small Lardaeeout Spleen; A limited Cancerous Ulerr in the Qerum, — I. Palltska, aged 31, during
July and August 1853, was treated in the Clinique for Anaemia, without benefit. He wa« .t
large, broad-shouldered man, of a pale, waxy countenance, and complained of remarks Mr
weakness, accompanied by wandering pains and deranged digestion.
At the origin of the aorta, there was heard a systolic bruit, which was propagated into tli^*
carotids; lungs healthy; spleen and liver of normal size; the tongue slightly coated: lb"
bowels were moved two or three times in the day, and the stools were of a pale color ; Qne**
had a specific gravity of 1012, and was free from albumen. I'nder the use of the preparatioo*
of steel, the etherial tincture of the muriate of iron, the lactate of iron, etc., the appetitr
Increased ; but the paleness, the feeling of weakness, and the other symptoms of aavmia
remained unchanged, notwithstanding a full diet. The patient left the hospital, and did nui
return until the 16tb of February, 18:>4. The nn»:raia had now increased to hydrrmia
anasarca and ascites had supervened ; there were from six to ten pale stools daily ;* a teadi-r
induration, which, however, was not very accurately circumscribed, could be felt upon pal-
pation in the cascal region ; urine 1007, pale and without albumen ; blood drawn off by a
cupping glass showed no increase of the white corpuscles. Vegetable and mineral astringvoi*.
nux vomica, etc., were administered in vain to check the diarrhoea. On the eveniog of thr
25th, loss of consciousness set in suddenly, the Rpeech became stammering, tha featores di«-
torted, and the eyes fixed and staring ; pupils dilated ; pulse slow and thready ; the rc«p:-
ration slow and feeble. On the 26th he died.
AtUopsy. — The contents of the cranial cavity presented nothing abnormal. The hroni*.-
were empty, and the lungs were ncdematous ; the heart appeared unchanged in its mttsr*'!*'
tissue and valvular apparatus. About lour pounds of clear serum were found in the abdon •
•Tlio right lolw wiw :.»,; ini-hoM Ioiir, mi.l 4 linNuI ; tho l«-n, 4 l.y I' ,' ; tli« tliicknnwanioiintM !•> i iiif Iir«
til iiMB'^iinsl ;t iii<lif<« in h-ii^Mh, J'^ in ttri'Hilili, an«l 1'.^ •» tliirkn.-i*'*. It^ w.'iKlit luniHuiUHl Im m 11 kikic«-» •
avoiiil )
Dropsy arising from Alterations of the Blood. 59?
nftl caritjr. The mucous membrane of the stomach and of the small intestine, as far as the
ilio-cscal ralve was pale. The caecum over its greater extent was firmljr adherent to the
fossa iliaca, and its mucous membrane was partialljr converted into an ulcerated surface of a
dirty-gray, ragged character ; the walls of the caecum presented a pulpy infiltration about five
lines in thickness. The lower portion of the intestinal canal, as also the retro-peritoneal
glands remained intact.
The spleen was slightly enlarged five inches long, and three in breadth ; its consistence was
firm, and its cut surface glistening.
The liver was of normal size ; its surface was smooth, and its margins sharp; the secreting
cells had an irregular outline, and most of them contained no nucleus, but were filled with
fine granules and drops of oil. and some of them also with brown pigment. The gall-bladder
contained a small quantity of yellow mucus, and in the gall ducts within the liver, were
liggregated masses of cylindrical epithelium of a gray color. The liver contained no sugar,
but large quantities of leucine and tyrosine.
The patient attributed his illness to an obstinate intermittent fever, from which he had
suffered during three months, 2^ years before his death. The altered condition of the spleen
and liver, which must be regarded as constituting the starting point of the aniemia, appa-
rently dated from that period. The spleen which was scarcely enlarged, was in a state of
lardaceous degeneration, and the liver was affected with fatty degeneration, such as we find
as A final result of infiltration of the parenchyma with albuminous matter, in consequence of
malarious poison, constitutional syphilis, etc., which may or may not be accompanied by larda-
ceous degeneration of the spleen, kidneys, and lymphatic gland. The tunctions of the liver under
these circumstances were in a great measure destroyed, and the results, which the suspension
of these functions entails upon the entire system, ensued.
The limited cancerous deposit in the caecum, which did not make its appearance until the
symptoms of anaemia had already existed for two years, might have contributed to expedite
the death from exhaustion, but could not be regarded as the cause of the poverty of the
blood, pp. 309, 311.
Cask 669 : PenuUnt and ofi'reeuning Inter miUent Fever ^ ulUmately of a quartan type ; Album-
nuria of a high grade ; fibrinous catUf with pigment in urine. ; (Edema ; Rapidly supervening Ascitet ;
Tapping after the inefficacious employment of steel and purgatives ; Return of the Fever ; Paroxysm
of two day's duration; Death from exhaustion; Pigment in the Spleen; Occlusion of the Hepatic
Capillaries ; Atrophy of the Liver ; Accumulation of Pigment in the Kidneys ; Consecutive Pneumonia .
Doroth Scheimer, age 28, a laborer*s wife, was in the clinical ward, from the 17th May to the
31 St July. She had suffered repeatedly from intermittent fever of various types, and during
last winter, from an almost uninterrupted quartan fever. At the time of her admission, the form
of the fever was double quartan. Fur fourteen days the patient had observed oedema of the feet,
and a remarkable diminution in the secretion of urine ; the urine was turbid, greyish-yellow,
and contained an enormous number of fibrinous casts, which were partly covered by black pig-
meut granules and cells. By boiling, the urine was converted into a solid coagulum. The
region of the kidneys was tender upon pressure. The spleen extended about 4 centimetres
1 } ittchs beyond the margin of the false ribs. The blood drawn off by means of a cupping
glass (care being taken to avoid the admixture of any foreign matter,) contained brownish and
black pigment masses, in the form of scales (Schollen) and cells.
After taking a drachm of Quinine, the attacks of fever ceased. Tbe characters of the urine,
however, did not alter, and it continued scanty ; there was repeated vomiting of a greenish
mucous fluid, without any headache or darkening of the countenance. Was ordered lemon
jiiic«. The quantity of urine diminished somewhat, the vomiting ceased, and the appetite
improved. Was ordered lactate of iron. The ccdema of the feet diminished, but ascites
became rapidly developed to such a degree as to interfere with respiration. Colocynth,
gamboge and similar purgatives were of little avail against the dropsy ; the energetic employ-
ment of these remedies only gave rise to derangements of digestion, vomiting, etc., so that it
did not appear advisable to persist in them.
On the loth of July, twelve pounds of clear serum were drawn off by the tapping. The
volume of the liver, which could now be determined with greater accuracy, was ttlightly
diminished.
On the afternoon of July 12th, there was an attack of fever, — rigors, heat, and sweating:
the fever did not return on the i3th.
On the night of the 14th, after the usual interval, notwithstanding the employment of
quinine, the paroxysm again made its appearance ; the pulse continued very frequent, rose to
140, and was scarcely perceptible, without one being able to detect any cerebral disturbances,
dyspnoea or physical changes in the heart or pericardium. The pulse continued frequent from
the evening of the 14th to the morning of the Uth, when it suddenly sank to 86. No fresh
attack of fever took place ; the pulse remained to the last varying bntwecm 80 and fio, but the
ascites rapidly increased, and the ccdema of the feet spread to a renuirkable extent. The
598 Dropsy arising from Alterations of the Blood.
patient became rapidly prostrated ; and, after a protracted asfooy, death took place on the
31st, without any cerebral symptoms.
Autopit/^ Aufftul Itty 12 hours after death. — No remarkable alteratioD was observed in the
skuIUcap, meninges or substance of the brain, either in their amount of blood, color or eoa-
sidtence. The mucous membrane of the air-passages was pale ; the left lung wai oedematons
superiorly ; infcriorly, it was inBltrated, but only to a slight extent with soil exudation ; the
pleura, at this place was covered with a thin layer of gray, flaky exudation. The right tang
was hypostatic posteriorly, and emphysematous along its anterior margin. The pericardium
contained about three ounces of clear serum ; the muscular tissue and ralrular apparatus of
the heart were normal. The blood in the right auricle was firmly coagulated.
The ccsophagus was pale. The mucous membrane of the stomach was ecchymosed at tome
places, and, around the pylorus was of a slaty, gray hue. The lining-membrane of the bowel
was pale superiorly, and in the large intestine was (Edematous, and at some places the larger
vessels were injected. The fseces were yellow. The pancreas and mesenteric glands were
normal.
The spleen was enlarged, but flabby and shrivelled ; its capsule was thickened, and its
parenchyma was tenacious (Zahe), and of a bluish, gray color.
The left lobe of the liver had a broad atrophied rim ; white traces of obliterated vetseb
could be seen in its serous covering. The parenchyma had a smooth surface on aection, was
somewhat friable, and of a grayish-brown color. The entire volume of the organ was
diminished. The gall-bladder was found to be adherent to the stomach and colon, and was
greatly distended with a green, mucous, somewhat albuminous, bile.
On microscopic examination, the usual forms of black pigment could be detect«d in the
spleen, in the blood of the portal vein, and in the capillaries of the liver.
The kidneys were of normal size ; their surface was smooth ; their capsule firmly adherent :
and their cortical substance grayish yellow, soft and friable. The microscope shoved the
existence of pigment in the glomeruli, as also in the vessels of the cortical substance, and
occasionally, also in the interior of the urlniferous tubes.
The mucous membrane of the bladder was ecchymosed ; the urine was scanty and albu-
minous.
The genital organs were not altered to any great extent ; there was a cryst the siie of a
haxel-nut in the right ovary, pp. 348-350.
Cask 670: Intermittent Fever, of a Tertian and Quotidian Type^ lasting for Sewn Weeks: Imtf
tmal Catarrh ; IIydr«mia ; Anasarca ; Improvement under Preparations of Stetl ; Relapse ; XaptJ
Increase of the Dropsy ; Unconsciousness ; Death ; Pigment in the Spleen and lAver^ wiihami any
Implication of the Brain or Kidneys. — Franz Krocker, age 45 ; a worker on the roads. Came to
the hospital on the 1st November, 1854. For seven weeks he had suffered from an intermit-
tent fever, at one time of a tertian, and i&t another, of a quotidian type ; and four weeks
before, anasarca had made its appearance. The spleen was found to be considerably enlarged.
extending about three inches beyond the margin of the false ribs ; the heart and lungs were
normal ; there was no albumen in the urine ; the bowels were relaxed, and the motions thin.
After the arrest of the fever, by means of Quinine, the patient's condition improved ; ander
the use of nutritious diet, wine and the preparations of Iron, the anasarca receded, and the
diarrhcca abated, until the 8th of November, when the temperature became elevated, the pal ■«''
rose from OG to 100, and dyspnoea, with sibilus and rhoncus in the air-passages, and acaic
headache, made their appearance. At the same time, a copious efl'usion of fluid was dctert^J
ill the abdominal cavity, and, soon afterwards in the pleural sacks likewise. Although th>*
change in the patient's condition did not in any way resemble a fever paroxysm, yet, consid-
ering the uncertain character presented by the malignant forms of fever, recourse wms bad to
Quinine. The patient, however, rapidly collapsed ; his color became earthy : tomnolcacc sn
in, and on the 14th, he died.
Autopsy J twenty-four hours after death — The body was greatly swollen from dropsy. The
meninges and substance of the brain contained the normal amount of blood. There was t.^
alteration in the color or consistence of the brain, and no pigment in the capillaries ot the
cortical substance.
The mucous membrane of the air-passages was slightly reddened, and covered with grai
mucous. Several pounds of scrum were found in each pleural cavity. The lungs were
an;i*mic, and of a dirty, gray color, with emphysematous margins superiorly; inferiorly, llf}
were com])ressed and non-crepitant.
The ])ericardium contained a pound of clear serum; in the heart, there was loosely coa^n*
lated blood, in which pigment was found in tolerable quantity. The muscnlar tissue and
valvular apparatus of the heart were normal.
The peritoneal sac contained many pounds of clear serum. The stomach and tnte«tinjil
canal were pale, but in other respects healthy. The spleen was very large, its capsule «*•
tensely distended; its parenchyma was soft, and of a dark, grayish brown color.
The liver was shrivelled up at its margins; the serous membrane along the anterior rim «»f
Dropsy arising from Alterations of the Blood. 599
the left, as well as of the right lobe, was opaque, from recent exudation, and covered with
pale red, newly formed vessels. The hepatic tissue was of a dark, grayish-brown color, and
uf soft consistence. Here, as well as in the spleen, there were large masses of pigment.
Bile, thin, pale and albuminous.
Kidneys ansmic.
Urinary bladder and prostate, normal, pp. 250-352.
(A Clinical Treatise on Diseases of the Liver, by Dr. Fried. Thcod. Frerichs. Trans, by
Charles Morcbison, M. D., London, 1860, Vol. L)
Several cases, similar in all respects to those just recorded,* have come under our
observation, following protracted intermittents, and consc(|Ucnt upon the prolonged
action of the malarial poison.
These cases were characterized by a pale, sallow, anaemic, unhealthy, jaundiced hue.
The lips and mucous membrane of the mouth and ton^e was bloodless. Microscopi-
cal and chemical examination showed the absence, or rather great diminution of the
colored blood corpuscles, without any abnormal increase of the colorless corpuscles, and
thus we were enabled to distinguish the cases from Leukocythsemia. Irregular and de-
ranged action of the liver was inferred from the jaundiced complexion, which presented
more of a greenish hue than in acute jaundice. The muscular and nervous forces were
greatly depressed, and the general condition that of mental and physical weakness, with
aversion to all exertion, and absolute depression, and abject apathy. In most cases, the
patients were afflicted with a continuous and uncontrollable diarrhoea, which could not
be reached by remedies. Notwithstanding the continuous diarrhoea, the extremities
became ocdematous, and serous fluid was thrown out into the abdominal cavity. Even
in the most extreme depression and exhaustion, the features and limbs presented a
swollen, puffed and bloated appearance.
The post-mortem examinations revealed, as in the preceding cases, enlargement and
induration of the spleen, with induration, and pigmentary infiltration of the liver.
By numerous post-mortem examinations, we have established the fact, that in acute
cases of malarial fever, (Congestive, Remittent and Intermittent), an immense number
of colored blood corpuscles are destroyed iu the spleen, and perhaps also in the liver.
In iuch cases, the enlarged spleen resembles a soft bag of diffluent, purplish, red and
black mud. Under the microscope, this mud is found to consist of colored blood cor-
puscles in various stages of decomposition.
If the views of Frerichs, with reference to the subsequent pathological effects of the
decomposiog blood corpuscles, and resulting pigmentary matter, be correct, we must
h)ok to the changes of the blood in the spleen as the primary cause of this form of
malarial dropsy.
Frerichs assumes that the c:ipillarics of the splenic artery pour their blood into a
Kystem of large sinuses, whence it pa8.scs into the efferent veins ; even in the normal
state, the blood which has flowed rapidly through the narrow capillaries, would pass
more slowly through the ample channel of the venous sinuses, and not unfrequently
would stagnate in some places so that conglomerate masses of blood corpuscles would bo
formed, which gradually might be transformed into pigment. In the intense congcs-
tioo, which experience shows attack the spleen, as a consequence of intermittent
fever, these stagnations are very great, and would lead to considerable accumulation of
pigment According to this view, the pigment would arise from the stagnation of the
blood in the venous sinuson of the spleen; the dub and spindle shaped pigment
cells are the epithelium of the lining membrane of the sinuses infiltrated with the
decomposed red matter of the blood, the globular pigment cells are colorless blood cor-
puscles, infiltrated with molecules of coloring matter, and the pigment scales are the
broken up fragments of the coagulum and colored corpuscles.
Frerichs is unable to explain, by this theory, why the formation of pigment is either
absent, or less marked in many otner congestions of the spleen, in Typhus, I^o^mia,
and simple Intermittent Fever ; and wl^ it is that the metamorphosis of the blood pig<
PMnt into melanotic matter, app<irently takes place much more rapidly here than at other
dOO Dropsy arising from Alterations tf the Blood.
places. Ho guggcsts that the acid character of the splenic pulp must cxcrcifie an im-
portant influenoe over the metamorphosis of the hlood pigment.
The effects of the morbid process taking place in the splenic pulp during the action
of malaria, are of a complicated nature, aid we shall, upon this division of our investi-
gations, notice only those which throw light upon the obscure and fetal form of dropc^y.
The destruction of large numbers of the blood corpuscles o^Dtrlbntes, in tbe first place, to
the production of a state of the blood like that of chlorosis, which usually soon makes iti
appearance in the course of intermittent fevers. This effect upon the general mass of the
blood is aggravated byttie interruption of the important blood-forming function of the spleen
which takes place at the same time. It is a difficult matter to determine to what extent each
of these agencies is calculated to act ; the loss of blood corpuscles, however, most be pro-
portioned to their destruction, and consequently, to the quantity of pigment which has been
formed.* An increase of the colorless corpuscles, as a consequence of the disease of Iho
spleen, is not observed ; in most cases the examination of the blood has shown no remark-
able deviation in this respect.
The pigment originating in the spleen, passes first with the blood of the portal vein into
the liver. It is here that the first functional derangements are observed. One portion of tbe
pigment passes through the capillaries unarrested, and enters the general circulation; tbe
larger particles remain impacted in the capillaries of the portal vein, and obstruct the circo-
lation of the blood through these vessels. The accumulation of pigment is sometimes seco
to take place chiefly at the periphery of tbe lobules in the interlobnlar veins ; but at other
times it extends throughout the entire capillary vascular system, and penetrates into the
interior of the lobules as far as the central veins. The derangements of the circuUtioa and
their consequences vary according to the quantity of the large pigment scales and cells.
These derangements manifest themselves first in an abnormal secretion of the liver. Tlu«
bile is usually secreted in large quantity, and we have repeatedly found in it considerable
quantities of albumen ; leucine can always be detected in the hepatic parenchyma ; its
saccharine constituents, however, are unchanged.
Extensive capillary stagnation gives rise to obstruction of the circulation of blood in the
roots of the portal vein, which manifests itself in various ways according to its intensitr.
Sometimes we see exhausting hsemorrhages from the gastro-intestinal mucous membraoc,
coming on in intermittent manner, or more frequently profuse diarrhceas, occasionally asso-
ciated with vomiting, etc., acute serous effusions into the peritoneal sac, together with bluodr
suffusions of the serous membrane, constitute another result ; while at the later period,
chronic atrophy of the liver, with its train of consequences, may make its appearanea.
The next organ, in point of frequency to the liver, which undergoes important organic an!
functional derangements, is the brain. Numerous particles uf pigment which have passfj
unarrested through the vessels of the liver and of the lungs, accumulate in the narrow capil-
larics of this organ, and particularly in those of the cortical substance. * « «
The third organ in which wc observe abnormal conditions of structure and functions in
melansniia, is the kidneys. The larger pigment cells and scales which enter thete organs
along with the arterial blood, not unfrequcntly become impacted in the capillary coils of th«
Malpighian bodies ; and by altering the pressure of the blood, give rise to derangemeots to
the secretion of urine, which exercise a powerful influence over the further progress of tli«
disease. Albuminuria makes its appearance to an extent which varies with tbe quantity uf
pigment found in the kidneys. In the cases where the fever has presented a distinctly inter-
mittent type, and where, as in quartan fever, the intermissions have been of considerm^if
duration, we have observed during each paroxysm a great increase of the albuminoat co&-
tents of the urine, and during the intermissions, a marked diminution, or a complete dKH*-
pcnrance of them. The albuminuria is frequently simple, and the process may last a loo;
time without leading to intimate structural changes in the kidneys. But in other casrs.
fibrinous matter passes off in the urine along with the albumen; I have repeatedly obsarvtd
fibrinous casts, including pigment masses and granules of the tame nature as those foaad la
the blood ; I have met with cases in which bloody urine was excreted. Complete tupprtMioi.
of the urinary secretion is of frequent occurrence. In cases when the secretion of albomra
and fibrinous matter has lasted for a long time along with intermittent ferer, or after iti
cessation, and ultimately hns led to a fatal termination from exhaustion, alterations of com-
parative insignificance have been found in the kidneys. Numerous flat, scarred depretaMn«
have been observed on the outer surface of the organ, but no distinct grannlatioos. la aomc
cases there has been lardaceous degeneration.
With the exception of the liver, the brain, and the kidneys, in no other organ or tissae eta
* The lo(« in tUfK ^ny mny l>o ronotdernMo. Occaf«ionany tbe organ, which la almoct l^ck tnm tb»
of Mood » a>nBiUenib)y nilai(;ril, UiuuniekiMl in i{« voDoieteuco, «nd, at some puis ioflltrated with txXtv
, t/lood.
Dropsy arising from Alterations of the Blood. 601
aoj remarkable change of Btructure, or derangement of fonciion be obeerTed. It is true
that we can detect pigment throughout the entire capillary vascular system, so far as this is
filled with blood, but accumulations of this pigment, and occlusion of the capillary vessels,
are only wont to take place to any extent where the smallness of the capillaries, or the pecu-
liar nature of their distribution, impedes the free motion of the pigment scales. * *
The peculiar colour of the skin which is produced by the quantity of pigment in the blood
contained in the vessels of the cutis, is of importance in diagnosis. In the slighter grades of
melana^mia it is ash colored ; in the more intense forms it is dirty, grayish brown, and some-
times deep yellow brown. In most cases, a few drops of blood obtained by scarification of
the skin suffices to show numerous particles of pigment under the microscope. (Clinical
Treatise on Diseases of the Liver, by Dr. Fried. Theod. Frerichs, New Syd. Soc. 1860, vol. 1,
pp. 322-332.)
The most striking objection which meetfi us, in Attempting to account for the changes
in the liver and the dropsical effusions in certain cases of Malarial Fever upon this
theory of Frerichs, that the pigment granules are the active agents in causing occlusion
of the smaller capillaries, and local congestions and structural alterations, is that both
the spleen and liver may be loaded with pigment granules, without any degeneration or
hardening of these organs, and without even any marked derangement of health.
Two oases have come under my observation, where death was produced suddenly in'
/uU healthy by causes other than those producing the accumulation of pigment granules
in these organs, and in which there was no relation between the fatal issue and the
pre-existing action of malaria, to which the patients had been subjected for varying
periods.
The following are the cases :
Cabi 671 : Augnsta, Ga., July 1862. An active, strong, athletic, well formed and healthy
mechanic, was assaulted by two ruffians, as he was peacefully going to his work. One of the
rnfians presented a double-barrelled shot gun, which the mechanic seised with both bands,
and attempted to wrest from his antagonist ; one barrel of the gun was discharged within
four inches of the left thigh. The discharge of the gun was not attended by immediate loss
of power in the limb, and the mechanic struggled tor a few moments and then fell. Upon
examination it was found that the linen pants were not destroyed over the region of the dis-
charge ; whilst the cotton drawers were burned ; a circular wound was discovered about two
inches below Ponpart's ligament, on the anterior surface of the thigh. Blood oozed from
this wound, and the skin was extensively ruffed up towards the abdominal cavity. The
probe failed to pass into the wound for any distance — no shot or balls were found, and there
was no well defined track indicating the passage of any hard body through the muscles of the
thigh. Upon examination of the gun it was found that only one barrel had been discharged,
and that the other barrel contained two loads of shot. The condition of the wound there*
fore, as well as the fact, that two loads of buck«shot were found in the other barrel, proved
that the injary to the thigh and surrounding parts were due to the explosive force of the
gunpowder alone, discharged within a few inches of the thigh.
The patient remained insensible a few moments after bis fall, but soon recovered his senses.
After reaction took place, the patient appeared to be doing well, but in the course of the
succeeding night (the deed was perpetrated at 1 p. m., in the day,) he manifested symptoms of
great uneasiness and prostration.
The next morning his countenance was pale and sunken— pulse small and threaded, with
complete suppression of the urinary secretion. At 1 1 o'clock p. v., the patient was apparently
calm, mind clear, with the exception of a slight failure of memory with reference to the
length of time which had elapsed since the infliction of the injury. Expression of counte-
nance calm ; features sunken, face deathly pale and fore-head bathed with cold clammy sweat ;
pulse could scarcely be felt, — a mere thread, beating IGO times in the minute; in a few
moments the pulse disappeared from the wrist, whilst my hands rested over the artery.
Extremities cold, and the cold creeping up slowly but steadily, towards the trunk ; breathing
labored ; action of heart rapid and thumping. He was at this time under the action of Castor
Oil administered a few hours previously ; had an action from the bowels during this exami-
nation, but passed no urine. The kidneys appear to have been torpid since the reception of
the injury. The left thigh in the region of the wound was much discolored ; blood trickled
from the wound continuously. Patient complained of no pain in the wound ; and during an
examination, in which pressure was quite freely exerted upon the surrounding parts, did not
complain of any pain. When the surrounding parts of the thigh were pressed, air issued
from the wound, and it appeared to have been driren in amongst the muscles. Abdomen
distended to a small extent, especially in the region of th^ bladder. Percussign showed tfa^^
7«
602 Dropsy arising /rem Alterations of the Blood.
this distention of the abdomen was due chiefly to the presence of fluid. The catheter Intro-
diiced into the bladder failed to bring off any water, and hence, it was concluded that the
fluid was within the flbdominftl.envitjr and amongst the surrounding tissues. Lower portion
of abdomen discolored.
It was evident that the life of this patient was fast drawing to a close, and in order to fulfil
the demands of justice, he was informed of his true condition, with a request that he should
narrate all the circumstances of the assault upon him, as a dying man, in full knowledge of
the approach of death. He received the announcement with surprise, and said that he fell
well, and as far as his feelings were concerned, felt that he would soon be entirely restored to
health.
After calmly giving his testimony, he bade us good night, saying that he wished to sleep ;
the powers progressively gave way, and at I o'clock a. m. in the morning he died.
The body was examined by myself in the presence of the Coroner's Jury, 10 hours aAer
death, on the 16th of July, 1862.
Auioptifj 11 hours after death. Exterior ; height, 6 feet ; weight, about 175 pounds, strong,
full, well developed muscular system.
External wound elliptical ; 4 by 3 inches in length, and superior border 2 inches below
Poupart's ligament: extensive discoloration of inner half of left thigh, and of a large portion
of the scrotum, and lower portion of abdomen. The discolored skin of the thigh, waa of a
deep red color, as if saturated with blood. The wound was carefully examined and dittected
^Vhen pressed, numerous air babbles, having an offensive odor issued from the wound. The
muscles around the wound were extensively lacerated, and air Issued from amongst their fibres
and from the blood-vessels supplying them. No passage through the muscles could be found ;
and the wound did not penetrate into the abdomen — this fact was determined beyond m\\
doubt, both from the thigh towards the abdomen, and from the cavity towards the thigh. The
peritoneum, lining the lower portion of the abdomen, over the seat of the wound, was eotire.
Abdomen. — When the abdomen was opened, the liver presented the true tlaie and bronze tolor
of malarial fever.
This patient was cut off in perfect health, and th.it in a very healthy month of th« year,
and it is evident that he was not suffering from the immediate action of malaria. Upon
inquiry I found that he had suffered with bilious fever, eight years before to PhiladeU
phia, and after his removal to Augusta, had chills and fever several years in succctaioa, had
chills and fever last fall. This change in the color of the liver was therefore not recent^ but
of long standing. This case illustrates the great importance of knowing the previous historr,
when we attempt to decide the true nature of pathological alterations.
The intestines were greatly distended with gas, and in many parts were discolored with
extravasated blood. The color was especially discolored and injected upon the left tide. The
walls of the abdomen especially upon the left side, were infiltrated with blood ; blood waa
also effused into the cavity of the abdomen. The cellular tissue surrounding the left kidney
was infiltrated with blood. The left kidney was greatly congested.
Spleen enlarged, but of normal consistence in texture. It was not softened, as in recent
cases of malarial fever.
This case appears to have been destroyed by the great shock to the sympathetic nerroai
system and the consequent arrest of the function of the kidneys. The symptoms daring the
last hours of life resembled those of congestive fever.
The liver presented a slate and olire color upon the exterior ; and a brooxe and olire grrea
color upon the interior surface. The structures of the liver were firm ; there was no special
enlargement of this organ.
Numerous particles composed of conglomerated altered blood corpuscles, and pigmeoiAry
matter, and of coloring matter of the blood corpuscles, were found scattered thronghoal the
structures of the liver. These pigmentary granules were especially abundant in the saost
deeply colored portions of the liver. It will be seen that these altered blood corpoaelcs. as
well as the masses of pigment matter, resemble the altered masses of pigment and conglo-
merated blood corpuscles characteristic of the Black Vomit of Yellow Fever.
The spleen was enlarged to twice its natural siie ; but was not softer than nsual ; the moi
of the spleen preyented very much the same appearance as the blood and jnioes of the liver
in like roanneif nnmeroKS dark red, bright red and black masses of altered corpusclea, and of
pigment of the blood, were discovered in the mud of this organ.
Casi fits ; Appear0nce presented ky the lAver^ and blood of the I Aver ^ of a Mulatto Jfiwt, mlU •*■ rf
very suddenly — «o tuddeuly oi to exrite tuepioions of Poitoning ; HiHory of the Case. — Reaidei»< •
near graveyard, Angnata, Ga., December, 1861. He had been up all night fiddling ml «
" ball," at one of the diireputable houses on the outskirts of the town. He is aaid to linvr
taken nothing during tlpis time, but a glass of beer. Shortly after drinking this, he eoaplaint^l
of feeling very unwel^ and was ciirried home. Complained of a burning sensation and cra»T»
in his stomach and bowels ; had a copious operation ; laid down, and then in a few moaea:*
afterwards, got npof the stool to bare a second operation, when be fell forwards and died
dropsy arising from Alterations of the Blood. 603
almost immediately. These facts were communicated to me bj my colleague, Dr. L. D. Ford,
who was called Id at tlie Coroner's inquest. At the post-mortem, no special examination
was made of the brain and spinal cord. No definite information was gtren me with reference
to the appearance presented bj the alimentary canal.
The lirer presented, upon the exterior, a dark slate, and bronze, and purplish color. The
interior presented a dark, olive, bronze color, and the blood presented very much the color
of the lirer, and also represented the color of the blood of malarial fever. Portions of the
liver presented a mottled appearance — a mixture of the bronze, olive, Spanish brown and
purplish color of the liver of health. The appearance of this liver is interesting, as resembling
closely the darker shades presented by the liver in malarial fever. I was unable to ascertain
definitely whether the patient had at any time suffered with malarial fever ; it is, how-
ever, highly probable that he had so suffered, for his house was in a malarious district, and
within a half square of the graveyard. Being a barber by trade, and having his shop near
one-half mile distant, he must have been much exposed at night. This condition of the liver
does not appear to have affected his health, as he was of a full habit, and very active. Be-
sides, death occurred i n the winter season, and if this state of the liver was the result of
malarious influence, the effects must have been of long standing.
It ifl evident, therefore, from the preceding cases, that the slate and hronze pig-
mentary liver of malarial fever may he present, without heing attended with any dis-
turbances of health, such as those described by Frerichs, and referred to by him to
the injarioufl action of the pigment matter.
The dropsy of the malarial fever is, without doubt, connected with the changes of
the blood induced by the malarial poison, and also with the structural alterations of the
spleen and liver ; but that the alterations of the liver depend primarily, or wholly, or even
in great part upon the mere stasis and alteration of the blood in the spleen, is hot yet
fully established, and it is very evident that the malarial poison exerts a direct destruc-
tive action upon the colored corpuscles both in the spleen and in the liver and kidneys.
In attempting to determine the effects of malarial fever in the production
of hardening and cirrhosis of the liver, we must, in every case, eliminate the
effects of intemperate habits, in altering the structures of the liver, either before or
during the existence of malarial disease. By careful histories of oases, I have been
enabled to show that a large proportion of the cases of malarial fever, attended with
induration of the liver, occurred in those addicted to the inordinate use of ardent
spirits.
Ths effects of hsemorrhage, in producing dropsy, were well illustrated by the fol-
lowing case, which recovered under my treatment, in Ward 24, Charity Hospital.
Cass G73.— John M. Rose, age 32 ; native of Maryland. Admitted into Charity HosptUl,
Ward 24, bed 3C9, January 10th, 1871. Belly greatly distended by effusion into abdominal
cavity. General anasarca, greatest in lower extremities. Sallow, malarious hue. Veins of
abdomen turgid and arborescent. Portal circulation evidently embarrassed. Patient well
built; weight 170 pounds ; dark hair, dark eyes and dark complexion. Has generally enjoyed
good health, with the exception of occasional attacks of chills and fever. Served in the Con-
federate army during the American Civil War, and, with the exception of diarrhoea of three
weeks* duration, was never sick.
Daring 1866 and 1867, lived in Arkansas, upon the Arkansas River, and during this lime
fiuffered severely with chills and fever. Has been running upon Mississippi boats during the
past four yearii. Twelve months aaro was attacked with a severe htemorrhage from the
stomach; vomited blood and passed blood by the bowels; could not account for the attack,
as he felt perfectly well, and was engaged in chopping wood with an axe at the time. Did
not lose his appetite, and did not quit his work, but for the space of only one week, on
account of the general debility caused by the hemorrhage.
Patient says that he lost at this haemorrhage *' about one gallon of blood," some of which
was bright red, and other portions appeared black. Had no dropsical swelling after this
attack. The complexion became sallow after this haemorrhage, and remained so up to the
present time. At the time of this htemorrhage, was not, (and had not been for soine time),
snfTering with malarial fever.
Recovered his usual strength, and remained well, and without any disease whatever, until
three weeks ago, when, on the 28th of December, 1870, whilst performing the duties of fire-
man, apon one of the .Mississippi steamboats, wan attacked suddenly with giddiness, faintness
and sickness at the stomach, and in " ten minutes, vomited about two quarts of blood." The
first portions of blood were black, the latter portions fluid and bright red, and clotted slowly.
604 t)ropsy arising fl'om Alterations of the Blood.
Was attacked in the middle of the night, shortly after partaking of food. Became very weak,
and vomited again, half an hour after, and threw np about one quart of blood in three hoars
After the first hemorrhage. The blood was warm and fluid. Vomited again daring the
morning, abont one quart of fluid blood. The patient supposes that he lost, in the coarse of
a few hours, about one gallon of blood.
The strength was greatly reduced by these haemorrhages, and two days afterwards the
extremities and the abdomen commenced to swell, and when he came under my treatment, on
the 19th of January, were greatly distended, with embarrassed respiration.
Mercurials,' in the form of Calomel and Blue Mass, combined with Quinine, were persist-
ently used, in conjunction with Cream of Tartar.
The dropsical effusion slowly and steadily disappeared, until the abdomen attained its nor-
mal proportions; and the patient regained his usual health. After the disappearance of the
dropsical effusion, the liver was found to be somewhat enlarged, whilst the spleen was decid-
edly enlarged, forming a bard, well defined tumor, eight iucbes in the longest diameter.
Throughout the disease the urine was free from albumen.
After the relief of the dropsical symptoms, and the regulation of the liver and boweli,
great benefit was derived from the Quinine and Tincture of Muriate of Iron mixtare, and
the patient was discharged at the end of two months, in his usual good health.
Cask' 674 : Prolonged Action of Malarial Poison ; Hmmorrhagt from Stomach and BomtU :
Anasarca and Ascites. — William Woods, age 22 ; admitted Dec. 1st, 1874, Charity Hospital,
ward 30. Blue eyes, light hair, native of Pennsylvania ; served in Federal Army ; had syphilis
about three years ago. Had chills and fever, for the first time, about four years ago. Dariog
the last summer and fall has been working in the Mississippi swamps, near Baton Rouge, La.,
and was sick with Malarial Fever about three months. On the 14th of November, 1874, was
suddenly seized with vomiting of blood, and lost about half a gallon of blood or more daring
three days. Also passed a considerable quantity of blood by the bowels. Commenced to
show signs of anasarca immediately after the loss of blood. When this patient came under
my treatment he was in a state of extreme anaemia, the fingers appearing bloodless and almost
transparent, and little or no difSerence being manifested between the color of the lips and
gums and tongue and the sallow anssmic face ; distinct anemic murmur in heart ; belly grc*tly
distended with fluid ; lower extremities distended with fluid ; urine clear, light coloreid ; low
specific gravity, and entirely free from bile and albumen ; no enlargement of liver detected.
IHaffnosis: dropsy resulting from prolonged nctiou of malarial poison and haemorrhage from
stomach and bowels. Prognosis doubtful.
The following is the general outline of the treatment instituted in this case.
The bowels were moved occasionally by blue mass and the compound cathartic pill.
From 5 to 20 grains of Quinine were given daily, for a period of 10 days.
The Bitartrate of Potassa was administered as a diuretic and gentle purgative, one ounce
Uiixed with a pint of water, being taken each 24 hours.
Various preparations of Iron, as the Citrate of Iron and Quiuia, precipitated Iron and
Tincture of the Sesquichloride, were continuously and persistently given in the nsnal doses,
three times a day. Nutritious diet was ordered.
Under this treatment the dropsical effusion was entirely removed, the complexion improved,
assuming a healthy, ruddy appearance, the strength returned, and the patient was discbarged
February 7lh, 1875.
Cancer may give rise to dropsy from its general effects upon the oonstitation of the
blood \ but thifi condition must be distinguished from the ascites or watery, effoaion intn
the peritoneal cavity, which arises from cancer of the liver, the effusion in this affectioa
being due to chronic peritonitis, extending from the liver over the peritoneam, and nne-
times also, but more rarely to occlusion of the trunk or large branches of the portal veiD.
In 31 cases of cancer of liver observed by Frerichs, the peritoneum contained lar^
quantities of fluid in 18 ; of 60 observations recorded by other authors, ascites
sent in 30, in 19 it was absent, and in 11 cases no mention is made of it.
CHAPTER XITI.
DROPSY ABISINQ FROM DERANGEMENTS OF THE CIRCULATORY APPARATUS, ATTENDED WITH
VENOUS OBSTRUCTIONS AND a)N0ESTI0N8, INCREASED SEROUS EFFUSION FROM THE DISTENDED
BLOOD-VESSELS AND DIMINISHED ABSORPTION.
CARDIAC DROPSY RESULTING FROM STRUCTURAL ALTERATIONS OP THE HEART AND LARGE
BUMiD-ViaSSELS. CARDIAC DROPSY; DILATATION OF HEART; DEATH. CARDIAC DROPSY. DILATA-
TION or HEART; GENERAL ANASARCA; DEATH. DILATATION OF CAVITIES OF HEART: UNIVER-
SAL DROPSY. ARTICULAR RHEUMATISM: VALVULAR DISEASE. ANEURISM OF INTERNAL ILIAC.
ANEURISM OF DESCENDING AORTA. ANEURISM OF AS(^ENDING AORTA. ANEURISM OF ARCH OF
AORTA. ANEURISM OF ARCH OF AORTA AND ASCENDING AORTA; DlL.\TATION OF HEART.
TREATMENT OF CARDIAC DROPSY.
Under this head may be classed Cardiac dropsy, resultiDg ^m structural alterations
of the heart and large blood-vessels ; and Hepatic dropsy, resulting from certain diseased
states of the liver, and sometimes accompanied by enlargement and induration of the
spleen.
CARDIAC DROPSY, RESULTING FROM STRUCTURAL ALTERATIONS OF THE HEART AND
LARGE BLOOD-VESSELS.
In the first stages of heart disease, the constitution is as a general rule unaffected, and
apart from certain local phenomena and physical signs, and slight dyspnooa and palpita*
tioD, the general health appears good.
Owing to the continuous disturbance, however slight, at first, of the circulation and
respiration, the dyspncoa and palpitation increase, the nutrition of the body is impaired,
the general health progressively deteriorates, and a slight amount of oedema appears in
the longer extremities.
As the disease progresses there is not only a progressive aggravation of the affection
of the heart, but also, as a direct effect of the disturbances of the respiration and circu'
lation, a great increase of dyspnoea and dropsy.
In the last stage of cardiac disease, in which the patient is doomed to speedy death,
the countenance assumes a yellowish white, cachectic appearance, and the dropsy in
many cases beoomes general.
Although cardiac dropsies appear in most cases to be preceded immediately by venous
congestion, we should not refer the dropsical effusion to this cause alone, for it t^pears
to be referable, to a certain extent at least, to the progressive alteration of the blood and
derangement of nutrition caused by the disturbance in respiration and circulation!
The blood is not properly oxygenated, the carbonic acid is not properly eliminated, and
the organs and tissues are not only supplied by an imperfectly elaborated blood, and
that too in an irregular manner, but the office of important organs, as the kidneys and
liver, is in turn deranged.
This symptom of taurdiao disease is usually, therefore, of late occurrence, making its
appearance almost invariably about the ankles and feet, as slight oedema, and by slow
degrees ascending towards the trunk, and ultimately involving the upper extremities
and fiice. The anasarca commencing in the feet and gradually proceeding upwards^
precedes the ascites, and even when the belly becomes swollen, the swelling of the legs
IS large, and out of all proportion to the ascites.
Aooordiog to Dr. Walshe, dropsy, sequential to heart disease, occurs in the following
sitoatioDs, enumerated in the oraer of frequency with which they severallv suffer ; the
Bab<ciit«Deoiii cellular tissue; the pulmonary parenchyma; the peritoneal and pleural
606 Dropsy arising from Derahgemerds of the Cireutatory Apparatus.
sacs ; the pericardiam ; the cerebral and spinal arachnoid and Bub-arachnoid spaces ; the
tunica vaginalis ; the joints and the eyeball, especially the aqneoos chambers. But id
the last three situations, dropsy is excessively rare.
Dr. Latham has justly observed that the first appearance of the dropsy, marks an
eventful period in the progress of cardiac disease. It indicates that a new law takes
effect in the circulation, and gains the mastery of the law of health, which has hitherto
been able to retain the watery elements of the blood-vessels, now the serum escapes and
accumulates in the areolar tissue of the body.
The forms of valvular disease, as laid down by pathologists in the order of the fre-
quency in which dropsy is met with, are : (1), Considerable contraction of the left
auriculo-ventricular orifice; (2), Dilatation of the auriculo-ventricukr orifioe, with
hypertrophy and dilatation of the right ventricle ; (3), A state of the mitral valve and
orifice permitting free regurgitation ; (4), Considerable contraction of the aortic orifioe.
As a general rule, cardiac dropsy supervenes earlier, the earlier that venous congestion
ensues. The establishment of a varicose condition of the blood-vessels in the air-voBieles
of the lungs, essentially aggravates the dyspnoea. When the dropsy is carried to great
amount, erythema, erysipelas, and even sloughing are prone to occur ; the ikin enicks,
the serous fluid oozes more or less copiously.
Dr. Walter Hayle Walshe, in his valuable " Practical Tteatise on the DtMeoieM of ike
Heart and Great Vessels,'^ gives the following important observations upon the nature
and causes of dropsy and serous flux of cardiac origin :
(a.) St/atemie Form,
Dilatation was formerly regarded as the condition of the heart mainly inducing the iraport«nt
class of dropsical symptoms. This opinion discountenanced by M. Brouillaud, who aooght to
establish valvular obstruction as their sole efficient cause, was restored to favor by Hope and
M. Andral — the former of whom indeed went the length of teaching that pare hypertrophy,
also, was capable of generating dropsy. Of late. Dr. Blackiston has brought together a body
of evidence calculated to show that the systemic vessels do not become loaded in cases of
dilatation, unless there be co-ezistent tricuspid regurgitation. Still more recently Or. H.
Douglas has defended the original thesis of our forefathers. It becomes necessary for me tu
express an opinion on this "vexed question" of the mechanism of cardiac dropsy; let me
commence by throwing into a series of propositions such inferences as flow directly from facta
that have fallen under my own notice.
1. Mitral regurgitation or obstruction, or aortic regurgitation or obstruction, may tererally
exist, and, for a lengthened period, without systemic dropsy supervening. 2. Mitral regnrgv-
tAtion and aortic regurgitation may co-exist for years, and yet no dropsy occur. 3. Both
of these propositions hold good, whether notable hypertrophy do, or do not, exist behind the
obstruction. 4. Simple hypertrophy of the left ventricle may reach the highest point without
systemic congestive effects of kind arising. Dr. Hope, at is well known, maintained the
reverse, holding that pure hypertrophy, if protracted, will produce general dropsy ; but he
gives no cases demonstrating the facts, and the motives of his belief are, as far as be shows,
totally speculative. And a priori views are not so completely in his favor as he appears in
imagine; when he talks of the "increased force of circulation surmounting the natural tonic
power of the capillaries," he forgets that that very tonic power may have increased ^en>«j«v
with, and in consequence of, the growth of the hypertrophy. The question is one of obaerrn*
tion ; and I have stated what 1 have actually seen in persons who had not been redaoed by
treatment to a state of anaemia. 5; Dilated hypertrophy, even of the left ventricle may U»t
for years without any such effect, provided the dilation be not in notable excess. 6. The
heart may be in a state of advanced fatty metamorphosis, the pulse feeble and infrequent, tbe
encephalic and respiratory functions exhibit the singular perversions attending a high degree
of the disease, the entire organism betray functional languor and inactivity, nnd yet even tbe
praeiibial integuments fail to pit in the least under pressure. 7. Or the heart may be soA a»d
flaccid and the pulse persistent, frequent, feeble, and irregular in force and rythm, and yet no
systemic congestions occur. 8. The natural relationship ot width of the arterial orifices, and
also of the auriculo-ventricular orifices, may be materially perverted, without the least sys-
temic dropsy arising, until the closing days of life. This is seen, for instance in cyanotic
cases where the aorta and pulmonary artery are transposed in origin, the relationship of the
great veins to the two sides being normal. Similar evidence is often afforded by caeca ol
aneurism of the arch of the aorta with an orifice more or less widely dilated, bo as to exceed
that of the pulmonary to variable amounts. 9. Tricuspid regurgitation where the right vrn-
It iclo is in a state of dilated hypertrophy, as shown during life, by swollen and pnlfaliU
Dropsy arising from Derangements of the Circulatory Apparatus. 607
Jagnlar veins, which fill from below and as shown after death bj actual examination, does not
necessarily produce dropsy. Besides if tricuspid regurgtation sufficed unassisted, on
mechanical principles to produce systemic dropsy, why should not constriction of the pulmo-
nary orifice, so frequent in cyanosis, habitually engender it.
These propositions are, I believe, incontrovertible ; they are the mere general expression of
facts which are perpetually occurring. I cannot, then, see how the conclusion is to be avoided
that something beyond and in addition to any one, or any group, of the cardiac conditions
referred to, is required in order, as matter of necessity, to entail the occurrence of dropsy. I
can scarcely suppose the unwarranted assumption that, were life sufficiently prolonged, these
conditions would of themselves suffice for the purpose, would be seriously urged in rejoinder.
And again, the existence of some acting cause beyond, and independent of the heart, is farther
shown by the facts : that there is no direct relationship between the amount of heart disease
and of dropsy; that dropsy comes on suddenly sometimes from extraneous causes, the state
of the heart remaining, as far as ascertainable, in precisely its previous condition ; and that
dropsy diminishes and increases, comes and goes, either spontaneously or through the influ-
ence of treatment, while the organic changes in the heart remain permanent and unmodified.
We must not, however, run into the opposite and equally erroneous extreme of wholly
ignoring the direct influence of organic changes of the heart and its orifices. Two cardiac
affections are, as matter of experience, frequently associated with systemic dropsy — namely,
dilatation and tricuspid regurgitation. And it is certainly so rare for either of these states to
exist for any length of time without the surpervention of such dropsy, that any hypothesis
explanatory of cardiac dropsy, must look to these states as forming important links in the
chain of causes.
A share in the direct mechanism of systemic dropsy being thus conceded to structural
change in the heart, the question next arises what is the nature of the influence, independent
of that organ, which completes the causation. Local conditions in the heart we admit estab-
lish a difficalty in the systemic circulation ; what influence actually and directly leads to the
dropsical ezosmosis ?
This influence seems a compound of conditions, favorable to transudation of the serosity of
the blood, in that fluid itself, in the walls of the capillaries and venous radicles, and in the
receiving tissues.
Firity as concerns the blood, the influence of an impoverished state of that fluid is too well
known to be for a moment contestible. Experiments on animals prove that if the veins be
more or less loaded with water, they yield this in the form of dropsical elTusion. The a*dema
and sometimes extensive anasarca of spansemia ; the slight codema attending the hypnosis of
protracted convalescence from various acute diseases ; the various dropsy of uremia — are all
illustrations in point. Obviously morbid states of the blood, when of the proper kind of
themselves, alone suffice for the production of dropsy ; look at the sudden anasarca of acute
Bright's disease, or of an acute recrudescence in the chronic affection, while the heart, liver
and longs, may be texturally sound. Secondly^ it is readily conceivable that the variable
density of texture of the walls of the vessels may promote or restrain the process of flltra-
tioo. TMrdl^f cases occasionally present themselves, in which dropsy supervening from
diseased heart, fails to affiect portions of the body, noted under ordinary circumstances, as the
earliest and readiest sufferers — for instance the lower extremities. 1 have observed this where
the legs had been the scat of erysipelas and subcutaneous inflammation prior to the occur-
rence of the cardiac dropsy ; the chronic anatomical change in the cellular tissue in such a
caa« possibly acts as a barrier to its reception of serosity from the vessels.
It may no doubt be argued a priori^ that dilatation of the heart occurring as a primitive
disease through simple weakness, or following actual structural alteration of the texture of
the organ, will occasionally prove the efficient cause of dropsy, even admitting the necessity
of blood change, just contended for. It may bo urged that when the heart is so affected, the
necesaary vii a (ergo in the circulation is wanting, and capillary stagnation must eniue — and
that this very stagnation, becoming habitual may modify the qualities of the blood, land im-
pair tba nntrition of the walls of these vessels through the strain they suffer. But plausible
tboagh this argument may be, I believe as matter of experience, that the necessary change in
the composition of the blood is meanwhile really worked out by other and more effective
agencies.
Long since Lower showed that local dropsy might be produced by ligature of veins; and
the occurrence of serous effusion from local obstruction of vessels of that class is clinically
well known. But here are instances of sudden and limited obstruction ; they are evidently
not logically comparable with cases of slow and centric obstruction. And even where the
difliculty in the way of the returning blood is purely local, it does not necessarily follow that
transudation shall occur from the communicating venous radicles, although the evidences of
changed condition of these vessels be structurally obvious. Thus in case of aortic aneurism
pressing one or both innominate veins, Ike capillaries of the base of the neck may dilate in such
maoncr as to prodpce nptable general s\relling at the spot, yet not a particle of <cdema bQ
difctrnible.
608 Dropsy arising from Derangements qf the Cirenlatarg Apparatus.
(h) Visceral and Tntra-Serout Form.
Puhnonary adema is chiefly connected with disease, constrictive or regurgitant, of the oriflca,
sometimes with dilatation of the left ventricle, rery rarely with hypertrophy of the right'
Aadtes arises especially from general dilatation of the heart and tricuspid regurgitation ; and
these are the conditions mainly observed, as antecedents to all the other Tarieties of dropsy
enumerated.
B. — Cardiac Flux.
(a) The intestines become the seat of serous flux in some rare instances of certain forms
of heart disease. Watery diarrhoea thus induced may be wholly spontaneous, or the original
excitant of the discharge mny have been some hydragogue purgative, the influence of which
holds on. " « #
(b) I believe that in some of those cases, where vomiting forms so obstinate a symptom of
chronic heart disease, the immediate cause of the nausea is the presence of an irritating
watery secretion from the gastric surface. It is never very copious.
(c) Watery flux from the kidneys, though on the whole not very rare. Is uncertain in its
occurrence, doubtful in its mechanism, and cannot be said to belong to any particular cardiac
affection. For my own part I have seen passing attacks of hydruria more freqvently in con-
nection with different forms of dynamic disturbance, than with any specific organic disease.
* * Here the rationale is the same as in the case of hysterical diuresis ; and so long as the
immediate mechanism of the latter continues in its present obscurity, we must remain in
ignorance of that of the former.
Albuminuria occurs every now and then in cases of cardiac disease, especially of dilatation
and tricuspid insuflSciency, the tendency of which is to congest the viscera. The cortical and
tubular substances remain tcxturally sound. The character of this form of albuminous Dm
are as follows : it is a passing phenomenon, sometimes disappearing spontaneously, sometlmea
yielding to treatment ; the albumen is always small in amount; the specific graTity of the
fluid never falls very low, its color remains unaffected and its smell wholly free from thai
whey-like odor to which I long since drew attention as notably significant of Bright's disease,
A few casts of the latter occasionally appear.
The researches of pathological chennsts have shown that in the early stage of orgiaoic
heart disease, marked merely by the local phenomena, a few physical signs, and a flight
amount of dyspnssa and palpitation, the proportion of water increases, and the specific
gravity of the blood consequently diminishes ; the globules decrease somewhat, their
mean being represented by 125 ; the fibrin remains unchanged ; and lastly, the albu*
men contuned in 1000 parts of scrum undergoes a trifling diminution, proportionate to
that of the globules, its mean being represented by the figures 71.05.
As the disease progresses, the physical signs be<x)me more clearly defined, the local
symptoms more marked, and the general health begins to fail, and the oonstatation to
evince signs of deterioration, and the face becomes anssmic, and the lower extremitiea
slightly cedematous, the specific gravity of the blood and serum becomes lower, the pro.
portion of water increases, the globules undergo still further diminution, their memo
being represented by 117, the fibrin augments in many caaes^ and lastly, the albovcfi
decreases, like the globules, its mean proportion in lOOO parts of serum being 66.21.
The dropsy is indicated at its onset by a decrease of the albumen of the blood.
When the disease has reached an advanced stage, with severe palpitation and
dyspncea, considerable serous infiltration invades the pleural and peritoneal cavities, as well
as the sub-cutaneous cellular tissue. Under these circumstances, the blood, for the no^
part, undergoes groat modifications, of which the following is a general outline :
The amount of water is greatly increased, whilst the specific gravity and solid mMU
ters of both the blood and serum are proportionally diminished. The blood globules
and the albumen, and especially the latter element, undergo very oonsiderable decrease.
The decrease of the albumen of the serum is consecutive to the dn>pay, only takiog
place when the latter becomes well marked. The decrease of the albumen has been
referred to the impoverishment which the blood undergoes, by reason of the loaa of
ssrum, constituting the dropsy. 6ccqu3rel and Bodier very justly oonduded, frooi
their analysis of the blood in cardiac dropsy, that, when the blood has become impov*
erished by the occurrence of mechanical dropsy, it is probable that infiltration
with increased rapidity, and that the serum, even more watery than heretof)re,
with greater facility, under the influence of two causes actii^g ii) the same direeCioD, vis :
Dry>8y arising from Derangements of the Circulator]/ Apparatus. 609
the iiDpediment to tbo ciroulatioD, and the dimiDutioo of the solid matters of the
senim.
The following oases of cardiac dropsy, have been selected from those observed in our
wards in the Charity Hospital.
Organic diaeases of the heart and great vessels, although constituting, relatively, a
small proportion of the diseases treated in military, civil and hospital practice, at the
same time, the ratio of mortality is comparatively great.
Thus, in a total of 2380 cases of various diseases, which I treated in the Charity
Hospital, daring a period of 45 months, the total deaths were 235. During this
period, 41 cases of organic disease of the heart and great blood-vessels were treated, with
14 deaths, giving a mortality of 34.14 per cent., and a r§tio of one death in 2.95 cases.
The following are the cases and results, as entered upon the Case Book : Organic Dis-
ease of Auriculo Ventricular Valves, with Hypertrophy and Dilatation of Heart, 9 cases,
3 deaths ; Organic Disease of Auriculo Ventricular Valves, with Dilatation, 5 cases, 2
deaths ; Hypertrophy, 1 case : Hypertrophy, with Dilatation of Arch of Aorta, 3 oases,
1 death ; Dilatation and Fatty Degeneration, 3 cases, 1 death ; Fibrous Concretion,
right side, attached to Chordse Tendinoe, and CamesD Columnie, and Tricuspid Valve, 1
case, death 1 ; Palpitation and Irregular Intermittept Action of Heart, cases 4
Aneurism of Ascending Aorta, 2 cases, deaths, 1 ; Aneurism of Ascending Aorta;
Arch of Aorta, and Descending Aorta, 3 cases, 1 death ; Fatty and Calcareous
D^eneradon of Coats of Aorta and Semilunar Valves, with Dilatation of Left Ventri-
cle and Auricle, 1 case, death 1 ; Insufficiency of Mitral Valve, with Dilatation of Left
Auricle and Ventricle, cases 6, deaths 2 ; Insufficiency of Aortic Valves, 3 cases, 1
death.
Casi 675 : Cardiac Dropty ; Hypertrophy of Heart : First ttayes oj CirrhoM of Liver, — la this
case, the ttudenis were enabled to watch the gradual progress of the disease to a fatal issue,
and to observe the gradual aggravation of the heart symptoms and the origin and increase of
the general anasarca.
James Duncan, age 30 years : height five feet, nine inches ; weight 135 pounds; dark hair,
bine eyes, dark complexion ; native of Ireland ; six years a seaman, and fifteen years a boat-
man on the Mississippi river. Twelve years ago he had several attacks of chills and fever ;
again, six years ago, and finally, during the fall of 1868.
Eighteen months ago, the patient says, that he was working in the hot sun, and drank large
qnaotitias of cold ice-water, when he was attacked suddenly with an affection of the heart,
which lasted several days ; six months afterwards was attacked in a similar manner, and spit
up blood.
Habits intemperate at times ; previous to the late civil war, drank regularly, but not to
intoxication ; entered the Southern service, and drank but little during the war. Since the
war, Qsed alcoholic stimulants freely to relieve the pain in the region of the heart. At first,
the stironlaata gave comfort, and he consumed large quantities, even to intoxication.
Shortly, however, before entering the hospital, the stimulants appeared to aggravate the diS'*
ease, and the patient gave up steady drink. Suffered severely the week before entering tbo
hospital.
Admitted into the Charity Hospital, ward 18, bed 267, March 9tb, 1869. At this time, the
patient was suffering with great pain in the region of the heart, soreness and pain in the
epigastric region, and along the abdomen in the region of the liver, extending on either side,
to the hypochondriac regions. Bowels irregular and constipated. Appetite pretty good,
patient indisposed to exertion, but not confined to bed.
Treatment consists in the administration, three times a day, of ten drops of Tincture of
Digitalis, and the same quantity of the Tincture of the Sesqui Chloride of Iron.
April 5th, 1869.-— Patient takes gentle exercise during the day, walking around the ward
and hall, but suffers debility from muscular exertion ; came under my treatment at this time
and the following results of physical exploration were then recorded :
Auscultation and percussion revealed enlargement and dilatation of the heart; the dull
space over the region of the heart being at least twice as large as in health. The beat of the
heart is lower down and more to the right than normal ; and the impulse, as communicated
to the hand placed upon the wall of the thorax, is different from that of health, giving the
impression of the impulse of a large, soft, quivering bag, against the thoracic walls. The space
of the walls of the thorax against which the apex of the heart is propelled, appears to be at
least three times the ordinary size of health. The first sound of the heart is entirely altered
10 \Drop8y arising fronv Derangements of the Circulatory Apparatus.
beings converted into a load, blowing sound, macb more distinct upon the left sldOi and over
the region of the left fttiriculo-ventricQlar valve, near the junction of the cartilage of the
fourth left rib vith the sternum. This loud cardiac murmur was beard at the apex of the
heart and along its body, becoming most distinct over the region of the auricalo-Tentricalar
vah-es, in the middle of the sternum, in a line with the articulation of the cartilages of the
fourth ribs with the sternum, and gradually diminishing towards the base, and becoming qniie
indistinct over the position of the semilunar valves of the aorta and pulmonary arteries near
the junction of the third ribs with the sternum. At the apex of the heart, the second sonnd
was beard with difficulty. At the base of the heart, or rather about the region of the arch of the
aorta and the arch of the pulmonary artery, above the line joining the cartilages of the third
ribs with the sternum, the first sonnd was beard with difficulty, or rather it became indistlDCt.
The second sound of the heart was loud, sharp and metallic, with a slight roughness prolonged
in the direction of the aorta. Some dullness upon percussion over region of lungs. No
physical signs of either tuberculosis, or pneumonia, or of pleurisy, were detected. Tba con*
gestion of the lungs was referred to mitral regurgitation. The veins of the neck (external
jugulars), gave a distinct venous pulse.
The liver was enlarged, and tender to the touch. Slight effusion into the abdominal eavitr,
and oedema of face and extremities, especially marked in the feet and ankles, complexion sal-
loi|, wax-like, with slightly jaundiced hue. The yellow, jaundiced hue was especially dis-
tinct in the tyti. Urine scanty, high colored, high specific gravity, and loaded with biliary
acids. The urine contained no albumen or urinary casts.
Bowels irregular, most generally constipated. Appetite poor; tongue coated with whitish
colored fur. Pulse feeble, 80 per minute ; respiration 22 ; temperature under axilla in the nom*
ing, 99^ F. Sp. gr. of urine, 1023.
The diagnosis established by this examination was —
Enlargement and Dilatation of Heart.
Regurgitation of Blood from Auriculo-Ventricular openings.
Roughness in the Aorta, beyond the Semilunar Valves.
Congestion of the Lungs and Venous Pulse, in consequence of Regurgitation of Blood
through both Left and Right Auriculo-Ventricular openings.
Absence of Active Inflammation or Tubercles from Lungs.
Cirrhosis of the Liver in the early stage, in which the organ is increased in siza.
The patient was treated with small doses of Calomel and Sulphate of Qainia, with occa-
sional saline purgative, with no perceptible benefit. The heart trouble inereased, the
spitting of blood became quite common, and the oedema of the extremities, and dropsical
effusion steadily increased. Tincture of Wild Jessamine (Gelseminum Sempervireas), waa
also effectually tried, as well as Tincture of Digitalis, but without any perceptible beneficial
effect, and in fact the latter remedy appeared to do harm rather than good, by its depresainf
effects upon the action of the heart, and its debilitating effects upon the nervous system.
Nitro-Muriatio Acid administered internally, and also in the form of foot-bath, appeared to
afford more relief.
The failure of strength appeared to be quite gradual, and the patient finally became moch
swollen, the effusion in the abdominal cavity increased, the venons congestion became mor«
marked, with distinct pulsations of the jugular veins and blue lips ; the difficnlty of respira-
tion became so great, and the action of the heart so irregular, that the patient eonld aot
rest at night, and was compelled to sit up in bed. The forces failed progressively, and he
died on the 15tb of June. The following is a tabular statement of the ipore important sy«ip«
(oms;
Dropsy arising from Derangdrnents of the Circulatory Apparatus. 611
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612 Dropsy arising from Derangehients of the Circulatory Apparatus.
The forces progrestivelj failedi although the patient was able to converse wheo propped op
in bed, almost up to the last moment of life, and died saddenlj at five a. m., Jane 25tb.
The P&9t'Mortem Examination was performed six hoars after death.
Exterior, — Surface of a yellow jaundiced hue and with dark mottling of blood in the depen-
dent portions. Abdomen and lower extremities considerably swollen from serous effusion.
When the thorax was opened, the lungs did not collapse to any marked extent. The longs
were greatly congested with blood. The marks of the haemorrhages were visible In varioas
portions of the lungs. The effusions of blood had transformed the pulmonary tissue into a
dark, liver-like, hard substance.
The lungs contained uo tubercles, were not softened, and gave no evidence of pulmonic or
pleuritic inflammation.
Heart, — The pericardium was adherent to the sternum upon the anterior aspect.
The heart as it lay in its natural position, presented an enormous size, and was distended
in all its cavities with black fluid blood.
The heart contained at least one pint of black fluid blood, and it appeared as if tha patient
bad died from the want of power in the walls of the heart to contract upon the blood ditteodtng
its cavities.
The left auricle and ventricle were enormously dilated ; the right auricle and ventrida were
also dilated, but not to so great an extent. There was an appearance of partial fatty degene-
ration in some portions of the heart, and the muscular structures generally of the heart were
softer than normal.
The auriculo^ventricular, and aortic and pulmonary valves, were not thickened nor altered
In structure, with the exception of some insufficiency of the mitral valve. The anricnlo-
ventricular openings, however, were so much altered, in being greatly increased in site, that
the valves were insufficient.
The length of the heart after being placed in alcohol, and after considerable contraction,
was six and a half inches, the breadth five inches, and the circumference eleven and m half
inches.
The walls of the aorta and pulmonary artery, beyond the semi-lnnar valves, were ronghcned
by calcareous and osseous deposits. These deposits accounted for the rough sound sacccedtog
or rather flowing from the first sonnd.
lAvery cirrhosed, enlarged, with some fntty degeneration. Surface of liver presented a yel-
lowish brouEcd mottled color.
Microscopical examination, revealed increase of fibrous tissue, and oil globules, together
with numerous fragments of hamatin. The masses of haematin scattered through the testoret
of the liver, gave the dark mottled bronsed appearance, and were most probably deposited
during the previous attacks ef Malarial Fever.
KiduerS) congested, but normal in structure.
In the preceding case, the dilatation of the heart appeared to have been dae io a
manner to the same causes which induced softening and fatty degeneration of the nos-
cular fibres of this organ and of the cells of the liver.
In the following case the symptoms of heart disease, although severe, have been
relieved partially or mitigated by treatment.
Case 676: Daniel Dunn, aged 46 years; height five feet six inches; weight 176 Bm. ib
health ; large, well developed chest and limbs, large head and intelligent coantenoaee ; dark
hair, dark blue eyes aud dark complexion ; native of Ireland ; occupation fireman on iteoasbip
Has no hereditary tendencies, and has always led an active life; served in the Soathera arsy
daring the recent war, and was wounded five times; left legfractured by Minnie boll; fletk
wound of posterior portion of upper third of thigh, flesh wound of right hip, another woaod
on the Instep, and still another on the anterior part of the thigh, two inches below Poapart t
ligament. Had repeated attacks of intermittent fever, during 1857, 1858 and 1859, and was
affected with sunstroke on the 4th of July, 1863.
During the summer of 1868, suffered with pain in the region of his heart, ntlnaded wnk
anasarca, pain in the head, loss of muscular power, and difficulty of breathing. Adaitted
into Charity Hospital, October 19th, 1868. At the time of his admission was softriag wiik
anasarca, cephalalgia, muscular debility and irregular and Imperfect action of the heart.
The treatment consisted of tonics, nutrition, diet, and the free use of diuretics. Under thit
treatment his general condition improved.
At the time this patient came under my treatment in March, 1869, his complexion was solW*.
anemic, and of a yellow, wax-like hue. Temperature normal; pulse 76; mtpirmtion 2j,
Lower extremities oedematous. Some oedema about face and upper extrcaitiet. rriaory
secretion abundant. Patient complains of pain in his head, and of wtokncts upon nay
unusual exertion. Action of heart abnormal, a murmur being heard with the first sonnd.
Dropsy arising from Derangements of the Circulatory Apparatus. (>1^
having its mAximnm inteosity at the position of cardiac impulse. The anasarca has been greatly
reduced bj the persistent use of diuretics, and especially by the cream of tartar and Juniper
berry infusion and mixture. Tincture of bark and preparations of iroUj and especially the
tincture of the sesquichloride, appear to have been most beneficial in maintaining the strength
of the patient. The following obserTations gire a correct view of some of the leading symp-
toms in this case. April 7th, 9 ▲. m., respiration 20; temperature of axilla 98°; tongue
clean, bowels regular, complexion sallow, anemic, urine abundant, oedema of extremities and
of face ; spirits good, assists in nursing the patients. April 8tb, 9 ▲. m., pulse 86 ; respiration
22 ; temperature of axilla 98«.5, sp. gr. of urine 1020. April 9th, pulse 92 ; respiration 21 ;
temperature of axilla 99^.5; urine abundant, one hundred and forty ounces (140 ozs.) being
passed during the last twenty-four hours; sp. gr. 1010. The urine was carefully tested upon
this occasion, as it had been upon others, for grape sugar and albumen, but no traces of these
substances were detected. April 10th, 9 ▲. m., pulse 92; respiration 21; temperature of
axilla 99° ; urine excreted during twenty-four hours 100 flutdounceg, sp. gr. 1010 ; no grape
sugar nor albumen. April Uth, 9 a. m., pulse 88 ; respiration 22 ; temperature of axilla 98°.5 ;
amount of urine 100 fluidounces, sp. gr. 1010. April 12th, 9 a. m., pulse 88 ; respiration 22;
temperature of axilla 98°.5 ; amount of urine 100 fluidounces ; sp. gr. 1010. April 13th, 9 a.
M., pulse 88; respiration 20; temperature of axilla 98°.5; amount of urine 100 fluidounces;
sp. gr. 1010. April 14th, respiration 20; temperature of axilla 98°.5 ; amount of urine 100
fluidounces; sp. gr. 1010.
At the time of the entrance of this patient into the hospital, the anasarca was
Tcrj great and troublesome, but it yielded and was held in abeyance by the action of
diuretics.
Neither albumen nor grape sugar were detected in the urine.
The dropsy in this case appeared to be the result of the cardiac disease, and the
annmio state of the blood.
Cabi677: Diiatation of Heart ; General Anasarea ; Death. — Hannah Clark, colored woman,
age 40. Entered ward 34, bed 517, Charity Hospital, September 19th, 1869. Patient lies on
her back utterly prostrated, with apparent complete muscular and nervous exhaustion.
Universal anasarca; abdomen and extremities, and head swollen from dropsical effusion.
Action of heart very feeble ; impulse of heart can scarcely ba felt. Great dullness upon per-
casaion over region of heart; and the area of dullness at least fonr times as great as that
nsual in the healthy thorax. Dullness upon percussion over both lungs ; dullness most
marked over the lower dependent portions of lungs. The dullness is so great over the lower
portions of the thorax as to indicate pleuritic eff'usion. Upon auscultation, the sounds of the
heart are indistinct and feeble. Diagnosis : dilatation of both sides of the heart, and general
dropsy as the result of cardiac disease.
The patient is evidently in extremis. Oppression of breathing so great that the patient is
unable to articulate with any force, and it is difficult to understand her broken sentences.
Patient died September 21st, two days after her admission ioto the ward.
Auiopty twelve houre after Death.
ISderior.-^Trunk, abdomen and extremities greatly swollen. Areolar tissue everywhere
iofiUrated with serous fluid. On opening the cavity of the thorax, a large amount of serous
flaid filled the pleura, and occupied a large portion of the space usually filled by the lungs.
The right Inng was compressed into a mass not larger than a man's hand, and presented a
bepatised appearance, and apparently had lost the power of dilatation. The left lung was
also compressed into a comparatively small space, but was readily dilatable when removed
from the pleural cavity. The heart was enormously enlarged, measuring seven and three-
tenths inches in length, and fifteen and a half inches in circumference, as it lay in the thorax
with the auricles and ventricles immensely distended with black blood. The blood was par-
tially coagulated, and the coagnla were readily divisible into two portions, the one ordinary
blood and formed post-mortem, and the other light yellow, fibrinous, and formed ante-mortem.
The fibrinous clots were to a great extent, stripped of colored corpuscles, and adhered
closely to the valves and chordss tendinoB. The walls of the heart were thin and not hyper-
tropbied.
The edges of the mitral valve were thickened and from the deposits of calcareous or osseous
matter ; or rather from the deposit of fibrin in some preceding attack of rheumatic endocar-
ditis, which had been gradually transformed into an inorganic hard mass.
Spleen, liver and kidneys, healthy in appearance. Intestinal canal also normal in appear-
ance. Some small loose fibrinous clots floated in the serous fluid of the pleura and perito-
nenm ; and a small patch of fibrinous exudation was observed on the surface of the descending
colon, in the Inmbar region.
614 Dropsy arising from Derangements qf the (Hreulatory Apparatus.
The origin of the cardiac disease and the supervening dropsy appears to have been
the deposit of fibrinous matter upon the auriculo-ventricular valves in some former
attack of rheumatism, thus causing aariculo-ventricular regurgitation.
Casb 678 : Dilatation of Cavities of Heart; Univertal Dropty ; Death. — John WiUoo, aegro
man, aged 57, stoat, well-bailt man, native of Virginia. Admitted to Cbaritj Hospitali ward
No. 32, September 2d, 1868.
Patient says that be has always enjoyed good health up to December, 1868, when be was
seized suddenly with palpitation of heart, and great difficulty of breathing. Has been ad-
mitted sereral times into the Charity Hospital, since this date, suffering with palpitatioa of
the heart and dyspaoea. As soon as some slight improvement took place, nnder rest and
diuretics and tonics, the patient would ask to be discharged.
At the present time, September 2d, the patient suffers with great dyspnoea, pain in the region
of the heart, dry backing cough, general anasarca, which however is less in the right arm and
head.
The apex beat of the heart is just below the nipple ; space of percussion dallneu over
region of the heart greatly enlarged. First sound of heart prolonged and attended with a
distinct regurgitant murmur. Second sound normal. Diagnosis-^Dilatation of both sides of
the heart, with auriculo-ventricular regurgitation. General dropsy and dyspnoea coaseqoent
upon heart disease. No albumen or bile was found in the urine. Diuretics and tonics
were administered, with only temporary benefit, however, as the anasarca increased as well
as the oppression of breathing; the lower extremities became immensely distended; the
patient was unable to lie down, and finally died twelve days after his admission, on the 14th
of September.
The post-mortem examination revealed a similar condition to that described in the preced-
ing case No. 677. Universal anasarca — liver and kidneys and intestinal canal healthy. Heart
greatly dilated and distended with black blood. The dimensions of the organ were fnlly
equal to those given in the preceding case. The mitral valve was thickened with otseoms
deposit.
The auricles and ventricles were greatly dilated, and the auricular ventricular openiag fo
much enlarged as to render the valves insufficient, and to allow regurgitation of the blood,
during the contraction of the ventricled.
The following case illustrates the fact that we may have decided evidenoe of iDsufi-
ciency of the aortic valves^ without dropsical efiusion.
Cask 679: Articular Rheumatitm^ with dtrangemtnt of Second Sound of i7carr— 'Wm. Rog«rs>
seaman, aged 21 years, stout, well formed man ; admitted into Charity Hospital, ward No. 11*
bed 154, January 20th, 1870, suffering with chronic rheumatism, affecting chiefly tbe npper
extremities. Patient states that seven years previous to the present attack, be was cooflacd
to his bed six or eight weeks by rheumatism. Which affected chiefly tbe apper extreattics.
Tbe attack was brought on by exposure. Two years afterwards he had a second attack, which
was confined to the parts and joints of the lower extremities ; and at this time be aaffered
severe pain in the left side, which his attending physician pronounced to be dae to plea-
ritis, with palpitation of the heart. The present attack came on in November, 1869, with
pain in the wrists, joints and hands, and finally affected tbe shoulder joints. On percnssioa
the heart appears to be hypcrtrophied ; and upon auscultation the second sound it eatirely
altered, being converted into a prolonged, blowing sound, heard loudest at tha base of the
heart over the aortic and pulmonary valves, and is transmitted up as high as tba point of
bifurcation of the common carotid artery. The sound is loud and distinct. The patient was
placed on a mixture of Wine of Colchlcum, and Solution of Iodide of Potassium, so com-
pounded that eight drops of the Wine of Colchicum and five grains of the Iodide ofPotassiam
should be administered three times a day. Iodine was also used locally, and the parts
covered with cotton and oil silk. Under this treatment the patient steadily improved, aad was
discharged from the ward on the 26th of February, 1870.
It is worthy of note in this connection, that the most extensive anearLsm may exist,
without the production of any dropsical effusion. If the aneurism presses upoo one or
more of the large veins, it may, by its mere mechanical pressure, cause saoh a ooojcea-
tion as to lead to cedcma of those parts from whence the obstructed vein should remore
the bl(x>d.
It is also worthy of note that in the cases of aneurism, which I have examined in
the Charity Iloapital. there was most generally more or less fatty degaoentioo of tW
arterial coats, in various portions of the circulatory system.
Dropsy arising from Derangements qf the Circulatory Apparatus. 615
Case 680 : Aneurism of Internal Iliac,
Thus io the case of a large aneurisiii of the internal iliac, which filled the entire
pelvic fossa on the left side, xneasuring eleven inches in the longest diameter, and six
and a half inches in the short diameter, the heart b partially degenerated into fat and
the entire aorta is dilated, with thickened, d^enerated, roughened walls.
Cass 681 : Aneurism of Descending Aorta; Absence of (Edema; Great Emaciatifm ;
Death,
The hodj of this man, aged sixty, af^er death, presented no marks of dropsical
effusion, and was greatly emaciated. The descending aorta was dilated into a large
aneurism having an hour-glass contraction in the middle. The long diameter of the
aoeurismal tumor was six and one-half inches and the transverse diameter four inches.
The vertebral column had been eroded and absorbed upon its anterior surface, by the
pressure of the tumor, and adhesions had formed between the walls of the aneurism
and the diaphragm. No dropsical effusion was discovered in the areolar tissue and
serous cavities after death, and none had been observed during his residence during the
past three months.
Cass 682 : Aneurism of Ascending Aorta ; sudden rupture of Aneurismal Sac
within the Pericardium ; Hatmorrhage — Death, Absence of dropsical effusion,
A young woman entered the Charity Hospital, complaining of a pain in the region
of the heart; the general health appeared to be good — complexion clear and limbs
round and firm. This patient died suddenly a short time afler entering the hospital.
When the cavity of the thorax was opened, the pericardium was found to be filled with
blood ; the amount of which was about one pint. No blood was effused exterior to the
pericardium, and there were no marks of dropsical effusion in any of the serous cavities,
nor of oedema in any of the extremities. Death in this case appeared to have resulted
from the sudden compression of the heart, by the blood effused into the pericardium,
rather than from the amount of blot)d lost. As is well known that portion of the
aorta which arises from the lefl ventricle, behind the sternum, opposite the third inter-
costal space, and passes from left to right, the ascending portion of the arch, coming to
the right of the sternum, between the cartilages of the second and third ribs, is within
the pericardial sac. The ascending aorta together with th^t portion of the arch from
which the carotid, innominate and subclavian arteries are given off, was enlarged or
dilated to more than twice the normal diameter, and a diverticulum or pouch from the
unearismal dilatation was sent off, downwards from the arch of the aorta, and rested
against the auricle. The rupture took place at the most dependent portion of this
division or diverticulum from the dilated aorta, just where it rested upon the auricle.
la the case of aneurism of the femoral artery operated on by Dr. Warren Stone, Jr.
and which terminated fatally from hsdmorrbage and pyaemia, I found the artery for
some distance above the seat of the aneurism in a state of fatty degeneration. Wc
can seo in such a case, the cause of failure in the operation of ligation of the artery
for aneurism. The ligatures out through the soflened and degenerated arterial coats,
and hiemorrhage occurred ; compression had been previously tried without success. It
in probable that in such cases, the results of compression would be rendered unsatisfac-
tory fnm. the degeneration of the coats of the artery.
In the three following cases, no dropsy and no tendency to it was at any time
obaerved.
Cabi 683 ( Antwritm of Arth of Aorta^ involving alto the Atrtndiny Aorta ; Abtence of Dropti^
tal Swelling ; Death. — Michael McCann, male, age 35 years ; height 5 feet 6 inches : weight 120
ponnds; dark brown hair, grey eyes, dark florid complezioo, sharp feat ares ; native of Ire-
land ; has been twenty years in New Orleass; occupation, day laborer ; had syphilis ten years
ago, which the patient says affected him for several months; had yellow fever fifteen years
a^o ; apd chillt and fever in the sammor ^p^ths of 18C8.
616 Dropsy arising from Derangements of the dreukxtory Apparatus.
Admitted into the Chiirity Hospital Noyerober 14, 1868, tuffering with pain in right arm,
extending up along the side of the neok and head, and attended with diffiouUj of deglutition.
Patient sajs that he suffered with pain in the right elbow joint, in August, 1868, which lasted
three months, and then shifted to the right shoulder joint, and from thence passed to the head,
with which he still suffers. Before coming to the hospital, was treated with local applic*-
tions and liniments, without any perceptible benefit. For four or fire weeks after entering the
hospital, the patient could not lie down hy day nor by night, on account of the great oppres*
sion of breathing, and a most troublesome cough, and sensation of choking, In the recambent
posture. He lost fiesh, bis weight being reduced from 155 in health, to 120 pounds. The
treatment has consisted ohiefiy of anodyne, sub-cutaneous injections of Morphia and Atropia,
At night; Iodide of Potassium, as an alteratire, and Tincture of Sesqui-Chloride of Iron, as
a tonic. The pains are relieved by the sub-cutaneous injection of Morphia and Alropia, and the
patient is unable to sleep without tliem.
April 3d, 1869 : Condition of the patient much the same as when he entered the hospital.
Constant cough and constriction about the throat. The patient coughs and clears bis throat
in a peculiar manner, as if a tumor was pressing upon the bronchial tubes. General appear*
ance favorable ; patient is not emaciated or swollen. Skin dry and warm, tongue reddish
upon surface. Suffers with pain in head, and neck, and upper part of right side of thorax.
Pulse strong, but differs in character and intensity in the two arms, 70 per minute \ apex beat
of heart visible one inch below its natural position. Pulsation very marked and forcible over
the upper portion of the sternum, producing a loud impulse against the walls of the ehott,
over the intercostals of the first and second ribs, immediately to the right of the steranm,
where the sounds are loudest. There is also flatness, on percussion, over the infra-clavienlar
region, on right side of chest, where the sounds of the heart are heard with the greateat inten-
sity. Temperature j>f axilla variable, ranging from 98^.5 to 100^.5 F. The respiration varies
from 18 to 22, an«iis natural, with the exception of some prolongation of expiration and
inspiration, and a peculiar sound, as if the bronchial tube was preued by a tumor. The con-
stant cough, and peculiar clearing of the throat, in like manner indicates the presence of a
tumor pressing upon the wind-pipe. There is also difficulty and pain in deglutition.
These symptoms led to the conclusion, that this patient was suffering with an anenritm of
the aorta, involving the ascending portion, the arch, and probably also the upper portion of
the descending aorta.
April 6th : The heart is beating tumultuously, the apex sound being much more diatinot
than the sound made at the intercostals of the first and second ribs. The pulse in the right
arm is weaker than in the left. When the patient raises the right arm and attempts to grasp
the bed-post as high up as the arm can reach, standing with his back to the bed and throw*
ing the hand a little backwards, as well as upwards, he experiences numbness, also a tendencj
to faint.
May 6th : There appears to have been a gradual change in the position of the seppoeed
anenrismal tumor in the chest ; careful and prolonged examination revealing a more tavinU
tuous and powerful impulse against the supra-clavicular region of the left side. The sab*
clavian artery of the left side appears to have suffered dilatation, as it is of great sixe, and the
column of blood is thrown with great power and a marked thrill through its dilated valla,
with every impulse of the left ventricle. On the other hand, it is remarkable that the carotid
artery on this, the left side, can scarcely be felt, being exceedingly small in ontliae andfoebie
in beat. In fact, it is almost impossible to feel the beat of the carotid, without the most per*
sistent and careful examination. As the carotid and sub-clavian are given off separately
from the arch of the aorta, on the left side, we are forced to one of three conclusions : either
the carotid on the left side has been partially occluded by fibrinous matter deposited mloog
the walls of the aneurism, or the tumor presses upon it in some manner, so as to diiialeh iu
column of blood, or the aneurism does not extend much beyond the junction of the left smb^
clavian. The third supposition is excluded by the previous history of the case. It would
appear that this tumor was slowly shifting its position to the left of the vertebral colaae
It is well known that the soft parts become incorporated with the anenrismal tamor. ani
even the vertebrae are absorbed by the constant pressure, as was teen in the ease of tbe
aneurism of the descending aorta, previously described. The diagnosis of aneeriaai of tbe
arch of the aorta, appears by these signs, and especially by the movable nature of tbe ta«ior.
to be still further confirmed.
May 30th : Under nutritious diet, and moderate purgation, and the persistent use of Iodide
of Potassium, alternating with the Tincture of the Sesqui-Chloride of Iron, the conditio* of
this patient has somewhat improved ; at least he has certainly *' held his own."
Patient does not snffcr any pain of consequence ; heart is not so forcible in its aettoo ; iUw
left radial pulse is still stronger than the right, whilst the beat of the right carotid is aaci
more powerful than that of the left, which can scarcely be felt. Dullness opon perc«saioa,
with bronchophony extending from the left border of tU9 sternum, to the middle of rigki
Dropsy arising from Derangements of the Circulatory Apparatus, 617
claTicle, thence downwards^ to midwaj batween clavicle and nipple, thence Inwards to left
border of sternnm, thence upwards to starting point, making an area of marked dullness and
bronchophonjf of about four inches in diameter.
Jnne 0th : Patient is suffering more than usual pain in head ; and neck and supra-clavicular
spaces have a full, swollen appearance. The patient also suffers pain in the middle and upper
portions of the thorax, in the region of the aneurismal tumor; he complains of a smothering
iensation In the throat
June 2l8t : Condition of the patient good ; complexion that of health ; appetite good. Im-
pulse of heart qnick and powerful, two and a half inches below left nipple. The apex of the
heart aots as if it was thrust directly forwards against the walls of the thorax, making a
defined beat. The beat of the heart gives the impression of a tumor above, which forces the
heart downwards, or rather, from which the organ recoils.
Left supra-clavioulsr region prominent, a powerful pulsation synchronous with the con-
traction of ventricles of heart being evident to the eye, and also to the touch, above the mid-
dle of the clavicle. Left carotid artery can scarcely be felt in its beat. The first sound of
the heart is heard at the apex, mingling with the powerful blow against the walls of the
thorax ; the second sound is not distinct, and there appears to be a third sound, which may
be due to the pulsation of the aneurism, together with some clicking, thrilling, rushing
sounds of low intensity. Marked dullness in both supra-clavicular regions along the bor-
ders of the sternum, and over the sternum, for two inches below the nipple. Distinct metallic
click or thrill over upper portion of sternum.
The air is drawn in and expelled from the bronchial tubes with difficulty, as if the wind-
pipe was compressed. Difficulty of deglutition continues, solid food appears to be arrested
about midway in the oesophagus, or rather, at the upper third of the sternum.
This patient continued under my treatment until the first of November, 1869, when a
change occurred in the wards, and he passed into the hands of Professor Bemiss. Up to this
time, the patient had maintained apparently a stationary position ; the most marked symp-
toms for the worse was the stridulous breathing and sense of suffocation.
The patient continued much in the same condition, with a gradual aggravation of the dis-
turbance of respiration, and finally died on the 10th of April, 1870. We are informed by/
Professor Bemiss that up to the time of death there was no dropsical effusion.
A post-mortem examination was held by Dr. Bemiss, and he kindly presented the heart and
aneurismal tumor to my pathological collection.
The heart was enlarged, and dilated, and fatty, degenerated, and flabby. All the cavities
were dilated, but the dilatation was greatest in the left ventricle. The arch of the aorta
was dilated into a large aneurismal tumor, thirteen inches in circumference, and contained a
large laminated fibripous mass, eleven and a half inches in circumference. Portions of this
fibrinous clot were evidently of recent formation, and contained coagulated blood. The
ascending aorta was greatly dilated, the dilatation commencing at the junction of the
aorta with the heart, and gradually increased upwards to the aneurismal tumor. The diame-
ter of the ascending aorta, just before it passes out of the pericardium, was three inches.
The pericardium was thickened. The semilunar valves of the aorta, as well as those of
the pulmonary artery, and the tricuspid and semilunar valves, appeared to be normal in
structure.
The result of the post-mortem confirmed the diagnosis twelve months before death, vis ;
Aneurism of arch of aorta.
The wind-pipe was compressed into a flattened, ribbon-like tube, and the mucous membrane
presented a thickened and highly congested appearance. The aneurismal tumor pressed upon
the lower portion of the wind-pipe and upon the bifurcation of the bronchial tubes.
Casi 684 : Aneurism of Arch of Aorta; Great Opprtition of Betpiration ; Ab$ene€ of Dropsical
Sw^llmp ; />«aM.— William Willoughby, aged 36 ; height 5 feet 3 inches ; weight 147 in health ;
auburn hair, gray eyes, fair complexion ; native of Canada ; seaman by occupation. At
eleven years of age suffered with chills and fever, which continued seven years ; had yellow
fever in 1858 ; had two falls on ship-board, when intoxicated ; these falls were from consii-
erabla heights, but no ill effects were noticed. About five months before entering the hos-
pital, was in the habit of using his shoulders in pressing up heavy weights, and after strain-
ing, felt pains in the region of the heart ; about a month afterwards began to suffer with pains
across the thorax, in right arm, and on side of neck and face.
Admitted to Charity Hospital, February 3d, 1B69, suffering with pains in the thorax, right
arm, and in side of neck and face, and after remaining in ward 21 for one month, a tnmor or
swelling, with a livid snrface appeared, extending from four to six inches across the thorax,
in A line with the second rib ; this remained for several days, and then slowly subsided. At
the time of bis admission, the patient weighed only 125 pounds. He suffered with great
oppression and difficulty of breathing, and was unable to sleep at night in the recumbent
posture. The treatment consisted of sub-cutaneous injections of h!ulphate of Morphia and
Atropia. Rest at night could be procured only by these injections. The effects of tl^Q
78
618 Dropsy arising from Derangements of the Circulatory Afparatus.
Atropia were almost immediately manifest, in the rapid dilatation of the pnpiU of both
eyes.
April Ist : The patient came under my treatment and obserTation at this tima. Says that
lie does not suffer so much pain. General appearance that of health, with clear, florid com-
{•lexion ; no oedema or dropsical eflTusion in any part of the body ; his countenance, howeTer,
wears an anxious, and, at times, distressed and oppressed look ; weight 125 pounds, appetite
fair; bowels regular ; skin soft and natural ; tongue clean ; pulse 88 ; suffers with cough and
oppression in breathing. Apex of heart displaced, two inches below, and to the left of the
nipple ; action of heart strong ; pulsations very marked over the sternum, and Tiaiblt at the
apex. Great difficulty in the deglutition of solid food, from the pressure of the aneurtsmal
tumor upon the oesophagus, with a sensation as if the passage of the food was interrupted
about the centre of the sternum. Respiration 19 per minute and embarrassed, with cough
when lying upon back. The cough and clearing of the throat is peculiar in its character,
giving the impression of great constriction of the wind-pipe and the bronchial tabes, and
the sounds are heard as if they proceeded directly from the upper third ot the aterouB.
Pulse feebler in the right, than in the left arm.
Diagnotit, — Aneurism of Arch of Aorta.
May 12th : Complains of pain in side of neck and head, and over the sternum ; difficulty ia
respiration very marked, and amounting to decided dyspnoea, especially when attempting to
assume the erect position. The least particle of phlegm in the trachea, gives much trouble
and distress until removed. Clears his throat in a peculiar manner, as if the bronchial tubes
wtfre compressed. Great difficulty in the deglutition of food.
Impulse not so marked over sternum, as if the tumor was imbedding itself in the posterior
walls of the thorax, and against the vertebral column.
May 25th : Pain not so great, but general appearance less favorable. Hypodermic injectioo
of Morphine and Atropia administered last evening, and the patient is this morning in a ner-
vous state ; pulse 96 ; temperature of axilla 101^.75 ; pulse in right arm very indistinct.
May 31st: Bronchial rales over both lungs; rales and vocal resonance more marked over
right lung; these physical signs appeared to be clearly referable to the pressure of the anea«
rismal tumor upon the trachea and bronchial tuhes.
The sternum appears to be more prominent upon the right side ; spex of heart still further
displaced to left of nipple ; sounds at this point apparently normal, though with less force
thnn before, and the sound heard over the base, viz : the second.
The bronchial rales are unattended with much expectoration, and it appears as if the nucos
is with great difficulty expectorated through the compressed bronchial tubes.
June 10th : Symptoms greatly aggravated ; great difficulty of deglutition ; great oppression
in breathing, with prolonged, wheezing inspiration and expiration, as if the air passed throogU
the compressed bronchial tubes and trachea with great difficulty. The patient, althoogb
oppressed, distressed and weak, still moves about the ward and hospital.
When the ear is placed against the walls of the chest, the sounds of the voice and of respU
ration appear to issue directly out over the space of at least five inches in diameter, aa if the
sonorous vibrations were transmitted directly through a tumor. Percussion revealed dulU
ness over the sternum, and over the greater portion of the clavicular and infra-claTicalar
Spaces. The form of a tumor and its position, may be made out with great cleamcsi. by
combining percussion and auscultation. The {liagnosis is especially aided by causing tht
patient to speak when the ear is applied to different portions of the thorax. The poaition of
the tumor may be made out by auscultation and percussion on the back, as well aa upon tbe
front of the chest.
When tbe patient coughs, the sounds are transmitted, almost like peals of distant thunder,
to the ear applied over the walls of the chest just above the tumor. The loud bronchial raU*,
heard most distinctly over all the upper portion of the lungs, appeared to be due solely to tb*
pressure exerted by the tumor.
The patient is evidently near his end, and at this examination the opinion was expres5«4
that his life would terminate suddenly from suffocation in the course of a few days.
During the night of tlie 13th of June, the patient was seized with great difficulty of re«pi-
ration, became bUck in \\t face, struggled violently for breath, and died suddenly from tbe
effects of the compression pf the bronchial tubes, or arrest of respiration.
This patient had friends, who carried off his body before a post-mortem examination cou!4
be made. This was greatly to be regretted.
It waa clearly sbowi;^ in the peceding oaseg ^so, that the most extenuTe aneonsms
are not necessarily s^^^nded with dropsy.
Casi 065 : Aneunsm of Attending Aorta and Arch of Aorta ; Dilatation of left VemirteU ; 5w-
den Death ; Ab$ene^ f^f Droptieal J^tuion or (Edema. — Moone^, age 56, native of Ireland, tal-,
Dropiy arising from derangements of the Cireidatory Apparatus. C19
well formed man, entered the Charity Hospital, ward 16, bed 150, Janaarj 16tb, 1870. Has
been in this hospital several times before.
At the time of my examination, January 18tb, the patient presented well developed limbs.
Suffered with great oppression in breathing, loss of rest, and almost complete prostration
after making any effort. I attempted to examine this patient, but be suddenly became greatly
oppressed, his lips and hands turned blue, and the patient appeared to be dying.
The results of this imperfect examination, were dullness upon percussion, over and around
the apace normally occupied by the heart, for an area, the diameter of which was at least
•even inches transversely, and eight inches laterally ; the apex beat of the heart was at least
two inches below its normal position ; great oppression in breathing, inspiration and expira-
tum prolonged, with a wheezing sound, as if the air was passing through a greatly constncted
trachea. It was necessary to prop the patient up in the sitting posture before an open window.
The symptoms of enlargement of the heart and aneurism of the aorta were well marked.
This patient died auddenly next morning. ,
The post-mortem was performed eight hours after death.
The exterior was full and without marks of oedema.
When the cavity of the chest was opened, the heart was found to be enlarged, with all the
cavities distended to their utmost capacity with dark fluid blood. The ascending aorta was
greatly dilated, the dilatation commencing at the heart, and increasing rapidly upwards, and
just after emerging from the pericardium, th^arch of the aorta expanded into a large aneu-
riamal saC) six inches in diameter. The arteries given off from the arch of the aorta were
greatly dilated, and the innoniroate artery, was, at its junction with the aneurismal tumor, as
large as a healthy aorta. The pericardium was adherent to the heart, this adhesion appeared
to have been of long standing, and was probably coincident with the changes in the semilunar
valves. The heart measured in its longest diameter, seven inches, and in its short diameter, six
inches. The semilunar valves of the aorta were thickened, adherent at certain points and
insafficient. The aortic regurgitation accounts for the great dilatation of the left ventricle.
As far as we could learn, this patient had suffered with deranged action of the heart and
oppression of breathing for more than six months, and he referred the first distressing aymp*
toms, to the lifting of a great weight.
We shall consider in the next place, briefly the troatment of cardiac dropsy.
TREATMENT OK CARDIAC DROPSY.
When dropsy depends* upon serious organic lesions of the heart and large blood*
Tessek, treatment should be regarded ss chiefly palliative ; the physician may relieve
certain symptoms of the most grave and distressing character, and relieve intense
suffering and thus prolong life, for a considerable length of time ; but the cure of the
disease, is in many cases out of the question, as it is impossible either by drugs, diet or
mechanical means to restore the enlarged, dilated, degenerated heart and insufficient
valveS) to the normal state*
Cardiac dropsy supervenes in most cases, afber the forces have been depressed, and
the blood rendered watery ; venesection therefore as well as drastic purgatives should be
used with great caution. Local blood-letting (cut cups over the region of the heart
and kidneys) may accomplish good results by relieving congestion and promoting free
diuresis.
It b well known that diminished fullness of the vascular system promotes the absorp*
tioo of serous effusions ; when therefore obstruction to the circulation of the blood
through the heart, co-exists with pulmonary congestion and anasarca, and at the same
time, the general vigor is as yet unimpaired, the abstraction of a moderate quantity of
blood, affords relief to the over-loaded blood-vessels, and congested lungs, and facilitates
the action of hydragogue remedies.
Bitortrate of Potassa, the Compound Jalap Powder, Gamboge and Elaterium, are
peculiarly valuable, from their certainty of action as hydragogue purgatives.
From one ounce to one ounce and a half of the bitartrate of potassa, in eight ounces
of water, taken in two doses, at an interval of two or three hours, forms one of the most
effective and safe purgatives.
The extract of Elaterium may be administered in doses of from one-sixth to one-half
of a grain. Caution, however, must be employed in the use of the Extract of Elate^
^20 Dropsy arising from Derangements of the Circulatory Apparatus.
rium, on acoount of its intense activity, and occasionally depressing effects. A bolus of
the following composition has been recommended and employed with success by various
physicians : B. Pulveris JalapXy Pulveris Khei., Pulveris Scammonii &&, gr. y ; £la-
terii, gr. ss; Bitartratis Potassse; Sulphatis Potassse, &sl, ^ss ; Syrupi Zingeberb;
quantum m§uxi ut fiat bolus. It is an observation of long standing, that in the exhi-
bition of remedies, more decided and beneficial effects may be obtained by combiniog
several analogous remedies in small quantities, than by giving a single one in a lar^
dose.
In cardiac, as Hk other forms of dropsy, the urine is almost always scanty, and the
progress of the effusion frequently bears a direct relation to its diminution ; the atten-
tion therefore should be strongly directed to the secretory function of the kidneys, u
affording the most probable channel for the relief of the disease.
Although sometimes uncertain in their action, diuretics upon the whole prove mo3t
effective in the control, moderation and even complete removal of dropsical effosiooi
As far as my experience extends, the Bitartrate of Potassa or Cream of Tartar, n
the best diuretic, and I have relieved many cases of dropsy by this remedy alone.
When used as a diuretic, from half an ounce to one ounce and a half should be sus-
pended in a pint of water, and the mixture should be taken in wineglassfnl doses even
two or three hours so that the whole may bo administered during the twenty-four
hours. The bottle containing the mixture should be always most carefully agitated, as
the cream of tartar is almost insoluble, and ialls to the bottom of the vessel upon stand-
ing. When the digestion is impaired, or should dyspeptic symptoms be induced by the
cream of tartar, we should employ as a vehicle for the salt, an infusion of juniper
berries or wild carrot seed, and some aromatic, cardamom, fennel or ginger may be
added.
It would be foreign to our purpose to cuter into any recapitulation of the obserrations
tnade at the bedside with reference to the various diuretics, and we shall simply name
those of the most undoubted efficiency ; such as :
Acetate, Nitrate and Citrate of Potassa ; Acetate of Ammonia ; Iodide and Bromide
of Potassium ; Nitric Ether ; Squills ; Digitalis ; Yeratrum ; Colchicum ; Tobacci) ;
decoction of Sooparium and of Chimaphila.
Squill as an active diuretic has enjoyed a high reputation with the profession, and it
appears to be peculiarly useful in dropsy of the chest, with scanty high colored and
unooagulable urine, which deposits a sediment on standing. It should be used at short
intervals and in such doses as to produce nausea, and the patient should be subseooeotly
kept just within the nauseating point. In cases which demand the mercurial inflaence.
the squill may be advantageously combined with calomel. Small doses of Blue I^IK
occasionally at bed time, will frequently promote the action of .diuretics.
Diaphoretics are much less efficient than diuretics, and cathartics; beneficial r0alt»«
however, may be obtained by the free diuresis excited by the vapor or hot air bath.
When drugs fail to control the dropsy, mechanical means become neoeasary for ooii-
trolling its influence ; such as tapping, puncture with a sharp lancet and aeap«iietorv
Owing to the danger of the sup3rvention of erysipelas, incisions should be made with
great caution, and whenever practicable, puncturing with the needle should be preferrvd.
the point of the needle should merely penetrate the true skin , the punctures shonKi
vary in number from twenty to fifty or sixty, according to the part or the extent of thr
effusion, and they should be at least half an inch asunder.
When the blood is anaemic. Iron and the bitter tonics, and nutritious diet riioold be
employed.
Experience has established the tact, that no advantage arises from the denial of water
to dropsical patients.
In some cases attended viith great debility, spirituous liquors, in moderate ammsnt.
are indicated ; hard cider and gin, are amongst the best forms of alcoholic stimnlaat*.
Of course, the results of treatment will depend, in a great measure, upon the extc'Ot
and character of the organic lesions.
CHAPTER XIV.
HEPATIC DROPSY, ARISING FROM SOME OBSTRUCTION TO THE CIRCULATION OF THE BLOOD
THROUGH THE LUVER. CIRRHOSIS, FATTY DEGENERATION, AND ATROPHY OF THE LIVER.
DROPSY RESULTING FROM OBSTRUCTION OF THE PORTAL CIRCULATION IN CIRRHOSIS OF THE
LIVER.
DROPSY RESULTING FROM CIRRHOSIS OF THE LIVER AND CARDIAC DISEASE.
TREATMENT OF HEPATIC DROPSY.
HEPATIC DROPSY, ARISING FROM SOME OBSTRUCTION TO THE CiacULATION OP THE
BLOOD THROUGH THE LIVER.
T|IE distingabhing characters of dropsy, from diseases of the liver or portal vein, as
laid down by systematic writers, are :
Ist. In uncomplicated portal obstruction, the dropsy commences in the abdomen,
and the legs are only affected secondarily and in consequence of the pressure of the
ascitic fluid on the inferior vena cava. When the affection of the liver is complicated,
with heart disease, the ascites may bo preceded by dropsy of the legs.
In cardiac disease, on the other hand, anasarca commencing in the feet and gradually
proceeding upwards, precedes the ascites ; and even when the belly becomes swollen,
the swelling of the legs is out of all proportion to the ascites.
2d. No signs of dropsy in the face, arms, or upper part of the trunk, are observed
in dropsy arising from obstruction of the portal system ; whilst in that form of the
disease which is dependent upon structural alterations of the kidneys, codema of the
face and arms is a very common symptom even in the early stages.
3d. Dyspnoea, never precedes the hepatic dropsy, although it may accompany the
aerotts effusion when great ; from the pressure of the fluid interfering with the action
of the diaphragm and abdominal muscles ; in cardiac dropsy, on the other hand, the
dyapnoaa precedes the ascites, and is distressing out of all proportion to its extent. In
cardiac dropsy, from the congestion of the lungs and imperfect aeration and circulation
of the blood, there is more or less lividity of the lips, face and extremities, whilst this
symptom is not characteristic of uncomplicated portal obstruction.
4tb. If there be no concurrent disease of the kidneys, albumen is absent from the
urine, except in those cases, in which the ascites itself, when extensive, may, in conse*
qnenoe of the pressure of the fluid on the renal vein, lead to the appearance of albumen
in the urine. The albumen, however, disappears upon the withdrawal of the pressure,
as in the operation of paracentesis. The absence of puffiness of the face, or pitting of
the upper extremities, and of granular, fibrinous, and oil casts from the Urine, will still
furUier distinguish hepatic dropsy, from that dependent upon alteration add degene-
ration of the kidneys.
5th. The ascites occasioned by portal constriction, is still further dbtinguished, by
enlargement of the spleen, enlargement of and tortuosity of the superficial veins of the
abdomen, haomorrhoids, gaatrO'^enteritis and hasmorrhages from the stomach and bowels.
Eolargement of the superficial veins of the abdomen, however, is not in all cases a cer-
tain indication, as the same appearance is sometimes observed in cardiac dropsy and in
renal dropsy, as the result of the pressure of a large quantity of ascitic fluid upon the
inferior vena cava ) but in such oases, there will be usually also a varicose state of the
TeiDS of the 1^.
It is important that we should consider briefly those morbid ootiditiond of the liver,
62^ Dropsy frdrn bbstruettdn of Circulation of Blood through Liver*
which give rise to dropsical effusions, in connection with those diseased states of this
organ, which seldom or never gives rise to this symptom.
In waxy, lardaoeous or amyloid degeneration, the liver undergoes greater enlargement
than in any other disease, excepting perhaps, cancer ; the enlargement being often so
great as to fill up a large portion of the abdominal cavity. The enlargement being
uniform in every direction, the form of the organ is not essentially altei^, the outer
surface is smooth, and the lower margin more rounded than natural, regular and free
from all indentations. In rare cases, this change may co-exist with cirrhosis, or with
syphilitic gummy tumors, and then the organ may present a nodulated surface, and
this complication may be attended with ascites.
In like manner when accompanied with waxy degeneration of the kidneys, dropsy
may result from the derangement of the excretory function of these organs.
In those cases of waxy deposit of the liver, which have come under the observation
of the students of the Medical Department of the University of Louisiana, the state-
ment of pathologists has been verified, that there is but little tendency to obstruction
of the portal circulation ; and consequently ascites, and enlargement of the subcota-
neous veins of the abdominal walls, are not common phenomena in its clinical history.
The absence of ascites in waxy liver, has been accounted for by the fiu^t, that the
branches of the hepatic artery, and not of the portal vein, are implicated in the disease.
In some rare cases of waxy liver, ascites results from the pressure of enlarged waxy
lymphatic glands in the fissure of the liver, upon the trunk of the portal vein.
In fatty liver, the enlargement is due to the accumulation of oil, as has been well
shown in the post-mortem examinations, and in the specimens of fatty liver mounted io
alcohol. In fatty liver, as in the waxy disease, the enlargement is uniform in every
direction, and without tumors or nodules upon the surface, and the natural form of
the liver is but little altered ; there is no ascites or enlargement of the superficial veins
of the abdomen, the secretion of bile is not arrested or impeded, and jaundice is not a
symptom, and as in waxy liver, throughout the progress of the disease, pain is absent
This degeneration of the liver is often accompanied by similar changes in other organs,
and more especially the heart and kidneys. Fatty d^eneration of the heart is evi-
deuced by the feeble cardiac impulse, faint cardiac sounds, slow or quick, feeble and
irregular radial pulse, attacks of vertigo, syncope or pseudo-apoplexy, and dyspncn on
slight exertion. When fatty degeneration of the liver, is attended by Aitty degeoera*
tion of the kidney, there will be a tendency to general anasarca ; the urine is dimin*
bhed in quantity, oftimes turbid, and contains albumen and casts of the tubuK ttrioilcn*
containing oil globules.
In simple hypertrophy of the liver, attended by an increased sixe of the lobules,
and by an increased size or number of the secreting cells, without any altentiou of
structure, the enlargement is uniform, and rarely great, and is not attended by any
prominent symptoms nor by dropsical effusion.
Whilst the enlargement may be very great in hydatid tumor of the liver, ascites,
oDdema of the lower extremities, enlargement of superficial veins of the abdomen, and
haomorrhoids are not dbtinguishing charactera ; and as the hydatid tumor rarely inter-
feres with the functions of the kidneys, those of the urine so oommon in waxy and
fatty enlargements, are absent ; in rare cases, however, the kidneys also may be the eeat
of hydatids) and dropsy may arise from this cause, or from the pressure of the hytiatid
tumors upon the portal trunk j or from the bursting of the cyst, or through the super*
vention of peritonitis.
Ascites rarely results from mere congestion of the Hver, unless this dqieod ou
meehanical obstruction of the circulation m the heart and lungs.
In the venous engorgement of the liver resulting from mechanical obstmetion of the
cardiac circulation from valvular disease of the heart, the primary enlargemeot of tlie
liver gives place after a time to an opposite condition of contraction, atrophy of tlie
central portion of the lobules, being induced by the pressure of the oonstantl j dnieoded
veins. The congestion of the liver dependent upon cardiac disease, induces u fotm of
Dropsy from obstruction of Circulation of Blood through Liver • 623
granular liver very different from true cirrhofiis, where the atrophy oommencee at the
circum/erenoe of the lohulet.
The diseases of the liver which most oommonly give rise to portal obstructionj with
ascites, are, according to those pathologists who have had the most extensive opportu-
nities of observation: 1. Cirrhosis and other forms of chronic atrophy of the liver ;
2, cancer of the liver ; 3, pcri-hepatitis ; 4, thrombosis, or obstruction' of the trunk of
the portal vein.
We shall confine our observations to the first and most common cause of portal
obstruction and ascites ; viz : cirrhosis of the liver.
Cirrhosis of the liver is most common in those countries, where the drinking of
alcoholic stimulants prevails, and the disease can almost always be traced to the abuse of
strong spirits ; and hence the name ffin drinker's liver.
Most observers have noted in the early stages of true cirrhosis, a temporary conges-
tion and enlargement of the liver, apparently caused by the irritant effects of the
alcoholic stimulants.
The lobules of the liver have been described by Malpighi, Kiernan, Miiller, Leidy,
and others, as isolated from each other, and each invested with a layer of areolar or
fibrous tissue. In the pig, in which these lobules were first noticed, and in the Polar
bear according to Miiller, and in the Octodon Cummingii, according to Hyrtl, the
lobules are invested by fibrous tissue, but in the liver of the human subject, and in
that of the vetebrate animals generally, the lobules are not separated from each other
by a fibrous partition, and there is no areolar or fibrous tissue or prolongation of 01b-
80D*8 oapaale between them or in their interior. Yogel, Henle, Bowman, and Beale
have fiiiied to detect any fibrous tissue in the interlobular fissures of the normal human
liver.
In cirrhosis of the liver, on the other hand, there is a remarkable development of
fibrous tissue in the parenchyma of the liver ; and the individual, secreting segments
become prominent or even form isolated lobules. The increase of fibrous tissue in the
cirrbosed liver, may be manifest to the eye, and especially when slices of the organ are
subjected to the action of a stream of water, and gently mashed between the fingers.
The character of the fibrous tissue may be determined by microscopical examination.
Cirrhosis of the liver is of slow development and progress. The whole structure of the
liver la not pervaded with fibrous tissue in a few days. It is reasonable to conclude
with Dr. Budd, that the remarkable changes in cirrhosis, are mainly the consequence
of adhesive infiammation in the areolar tissue about the small twigs of the portal vein,
and 10 the areolar tissue of the portal canals, by which serous fluid and coagulablo
lymph are poured out.
la this stage the liver may bo enlarged. The serous part of the effusion is next
absorbed, the lymph contracts, becomes converted into dense fibrous tissue, which divides
the lobular substance of the liver into well defined masses, and gives great density and
toughness to the organ. Finally, this fibrous tissue compresses the small twigs of the
poitjJ vein and the small gall ducts, and thus impeding the escape of the bile, and the
flow of blood induces great atrophy of the original hepatic tissue, and causes by a depri-
vation of the blood and the admixture of this dirty white fibrous tissue, marked changes
in the color of the liver.
In cirrhosis, the normal, dull, reddish brown color of the liver is altered to a bright
canary yellow, sometimes to a brownish or greenish, and occasionally to a reddish color.
A section of the liver, upon a general view, presents the grayish and yellow color of
impure beeswax.
Owing to the contraction of the or^n in the latter stages, the outer surface presents
a granular or nodulated character, which has given rise to the designation, " hob nail
liver,** The yellow color of the organ is also due to the large amount of yellow pig-
ment contained in the secreting oella, and hence the term cirrhosis. The capsule is also
aometimes thickened and adherent to the surrounding parts.
In the firm, tenaoeous, granular liver, resulting from the congestion caused by
624 Dropsy from obstruction of Circulation of Blood through Uver.
obetructed cardiac oiroulation, and which has fVequentlj been mistaken for cirrhosis, the
depressions, however, correspond to the centre of the lobules, whereas, in true cirrhosis,
they are at the circumference.
Ascites, resulting from portal obstruction, is met with ohener in cirrhosis than in any
other disease of the liver. The fluid in the peritoneum, is a clear yellow, serum, rich in
albumen, and without any blood or inflammatory products. In consequence of thd
congestion and distention of the veins that return the blood irom the intestines and
peritoneum, the serous portion of the blood transudes through the walls of the vessels
into the peritoneal cavity, and when once ascites appears, it persists and gradually
increases ; and when the amount of the effused fluid ie large, it may compress the
inferior vena cava and iliac veins, and thus produce secondary oedema of the legs, but
it is a peculiarity of dropsy from uncomplicated portal obstruction, that the ascites
precedes and preponderates over dropsy elsewhere. A large accumulation of fluid in
the peritoneum may also interfere with the action of the diaphragm, and cause embar*
rassment of respiration, but it is distinguished from the ascites caused by cardiac
disease, by the fact that the clyxpncta follows and never precedes the ascites. Pressure
exerted on the renal veins by a large quantity of fluid in the peritoneum, may also
embarrass the action of the kindeys, and lead to the appearance of albumen in the urine,
independently of any disease of those organs, the albumen disappearing from the urine,
afler the removal of the pressure by the operation of paracentisis.
The following cases will illustrate the characters of dropsy resulting ttom porta!
obstruction :
Gabs 686 : Dropsy retuUing from obttruetion of the portal cireulaUon in Cirrkotit 0/ tMs Iawt.^-^
This case illastrates in a striking manner, the effects of obstruction of the portid circulation,
in the production of ascites, and of serous effusion into the cellular tissue of the lovtr
eztremitiei.
S. McL-^-, native of Rapides Parish, Louisiana; lately a resident of Catahoula Parish : bai
been engaged in farming during the past two years ; age 35 ; height six feet ; blue eyes, dark
hair, dairk complexion, thin beard; no beriditary tendencies,* up to the present attack bat
enjoyed good health with the exception of occasional attacks of chills and ferer. Patient
saya that he has used ardent spirits in moderation, and never to excess, except upon one occa-
sion when he had an index finget shot off.
Patient states that three months since, was seized with violent abdominal pains, eitendiDg
from the umbilicus to the pubis, and attended with griping. A few days afterwards wasseite^
with violent vomiting and ejected a large quantity of blood (*' an ordinary blue bucket fall " :
the vomiting and loss of blood was attended with great exhaustion ; four days afterwards,
there was a repetition of this attack, attended with vomiting of blood.
Two weeks afterwards an increase in the size of the abdomen was observed, attended with
swelling of the lower extremities. Purgatives and diuretics were administered ; the patient
remembers that Eleterium was used which appeared to be productive of no beneficial efSects.
Three weeks since his lower extremities began to ulcerate, and the ulcerations 'nvolved tJb*
subcutaneous areola tissue, and ragged indolent ulcers appeared.
This patient was admitted into the Charity Hospital, ward 19, bed 284, on the 13tb of Apr.:
1869, in an exhausted, restless state; abdomen greatly distended; lower extremities <»deiDa«
tous and ulcerated. Auscultation and percussion revealed no disease of the heart and lun;^
The lungs and diaphragm were forced upwards by the effusion in the cavity of the abdomea.
the heart also appeared to be pressed upwards and forwards.
The sounds of the heart were unusually distinct and abrupt, and sharply defined, but ct>
enlargement, dilatation, degeneration or valvular disease could be discovered. The laiifs
were resonant; the respiration was more frequent than usual, from the abdominal pr^ttor^.
but there were no signs of obstruction in the pulmonary cirenlation ; no pleuritic effusior«
and no tubercular deposit.
The abdomen was enormously distended with dropsical effusion, and the veins of the abdo-
minal parieties were enlarged and filled with dark blood, and presented a distiDCt arbore^cea:
appearance upon the abdominal parites. The lower extremities were greatly swollen, and the
legs ulcerated, with thickened, indurated discolored integument. The general complcxMa
was sallow and cnormic. The urine was scant, high-colored, and loaded with biliary acii;
The swelling was circumscribed by the superior wall of the abdominal cavity, and in llact, ty
the diaphragm. All above this was of the normal appearance, and the faee, aad arma, aai
thorax, were thin and wasted, almost skeleton-like, wb.Ust al.l b.elgw the diaphragm was tvoN
leu and infiltrated with serous fluid.
Dropsy from obstruction qf Circulation of Blood through Liver » 625
The mUoWj Jaundiced hue ; the prewnee of the conttiiuenta of bile in the urine ; the limitation of the
twelUng to the abdominal cavity and lower extremitiet ; the abtence of all organic diaeaee of the heart
and lunge ; the abtence of albumen and of fibrinous cattefrom the urine ; the abdominal dropsy ^ and the
congestion of the venous system of the abdomen and lower extremities , all sustained the diagnosis ^ that
this was a ease of Girrbosis op thr Livbr, in the latter stage of contraction ^ unattended by disease of
the heartf lungs or kidneys.
The bowels were opened with two Compound Cathartic Pills, and the patient was placed
upon the diuretic mixture composed of Cream of Tartar oz. i, Juniper Berry Tea (Juniper
Berries oz. 1, boiling wat«r f. oz. xvi; after cooling strain) f. oz. zri; to be taken in wine-
glassful doses during the twenty-four hours.
April 15th — Temperature of axilla, 97^ ; it is of importance to note that the temperature
is below rather than above the normal point. This depression appears to be due to the
obstruction, in the portal circulation, caused by the cirrhosis and contraction of the liver,
and also to the interference of the circulation and respiration from the abdominal pressure.
This observation, as well as others, confirmed the accuracy of the diagnosis, as to the
absence of tuberculosis, and also confirmed the view that the affection of the liver was of long
standing, and in the stage of contraction.
Only eight ounces of urine were collected during the twenty- four hours ; specific gravity
1030; high colored, loaded with biliary acids; upon standing let fall a copious deposit of
orates, which disappeared when the urine was heated, and yielded a large crop of crystals
(lozenge-shaped) of uric acid.
The diminution in the amount of urine appears to be due in a manner to the pressure of
the flnid distending the abdomen, and also to the small amount of nourishment taken, the
ao»mic state of the blood, and the depletion of the serous or albuminoid elements of the
blood.
April 16th. — During the night the patient was aroused about 1 o'clock a. m , with violent
retching and vomiting, and ejected a greenish black matter in sufficient amount to fill an
ordinary wash basin. This afforded some relief, but the patient was considerably depressed.
Iq two hoars the nausea retdrned, and the patient vomited a similar amount. The matter
was 80 disagreeable in its odor, that vomiting was excited in his nurse while removing the
matter from the ward.
Twenty-two ounces of urine were collected. Specific gravity, 1030, high colored; bowels
free. Appetite poor.
April 17tb.— The nausea, with occasional efforts at vomiting, continuing, the Bitartrate of
Potassa and Infusion of Juniper Berries were discontinued. No appetite. Bowels free.
Seven and a half fluidounces of urine collected ; high colored and loaded with biliary acids
and orates. Ulcerations of the lower extremities improving under the use of Carbolic Acid
ointment. Patient restless and unhappy. It has been necessary to administer Morphine each
evening to produce rest. Tincture of Cinchona, of Gentian, and of Rhubarb, in proportion
of two parts of the former to one of the Utter, have been given, properly diluted, in wtno-
glassful doses, as a tonic and gentle laxative.
April 18th. — Symptoms the same ; the distention of the abdomen has progressively
increased. Only four finidounces of urine collected during twenty-four hours.
April 19th. — No change; distention of the abdomen so great as to embarrass in the most
distressing manner the action of the heart and lungs.
It was determined to tap the patient upon the following morning. Sixteen and a half
oances of orine were collected; upon careful testing no albumen was discovered; urine high
colored and loaded with urates and biliary acids ; specific gravity, 1030.
April 20th. — Operation of paracentisis performed midway between the anterior superior
spinous process of ilium and umbilicus; three and a half gallons of serous fluid were drawn
oir, which presented a light golden yellow color. Specific gravity of serous fluid 1009, and
upon the application of heat, the coagulated albumen filled about one-fifth of the test-tube.
Tbe patient expressed great relief. Percussion revealed no enlargement Qf the liver, bat an
actual diminution in tbe volume of this organ. After the application of the bandage around
tbe abdomen, the patient was put on stimulants and nutritious diet.
Seventeen ounces of urine collected, high colored, loaded with urates and biliary acids ;
free from albumen; specific gravity 1027.
April 2Ist. — Condition of the patient apparently improved by tbe tapping; appetite good ;
swelling rapidly subsiding from the lower extremities, and ulcers healing. Twenty-four fluid-
onnees of urine collected ; high colored ; specific gravity 1027 ; no albumen.
April 22d. — Patient perspiring freely ; previously the skin had been dry and harsh. Serous
flaid gradually accumulating in the abdomen. Appetite good, spirits cheerful, bowels regu-
lar. Trine presented similar character.
Tbe patient was placed upon a gentle course of mercury, one grain every four hours and
on the 27th bis gums were slightly touched ; the abdominal swelling, however, went on
steadily increasing. The patient continued to lose strength^^and the accumulation of serQt\^
626 Dropsy from obstruction of Greulation of Blood through Idver.
fluid in the abdominal cavity continued until the distention was as great at before the flri)
trtpping, bedsores began to form on the 29th, iind a persistent diarrhcca set in, which was not
arrested by astringents.
The patient becamq delirious ou the night of the 30th, and lay in a semi-comatote state,
and passed his urine and excrements in bed; and gradually sank by almost imperceptible
stages, lying for two days in a state which could with difficulty be distinguished from actual
death, and finally died at 4 o'clock, p. m., May 3d.
The pott-mortrm performed twelve hours after death, revealed the following points :
Upper extremities, head, neck and thorax, greatly emaciated, merely the skeleton with the
skin stretched over; abdominal cavity and lower extremities greatly swollen and distended.
The abdominal cavity contained near four gallons of serous fluid.
The lungs were healthy ; without tubercles, or adhesions, or any marks of inflammatory
change.
The heart was normal in size, with no lesions of the valves; the pericardium, however,
was adherent, and this adhesion of the serous membrane of the heart, throagboat iis entire
extent, accounted for the more distinct sounds of the heart.
The liver was greatly contracted, hardened, and of a slate color ; and the spleen alao was
enlarged and hardened, and of a similar color with the liver. The kidneys were congested
but healthy. No derangement beyond congestion of the blood-vessels was discovered in the
kidneys.
The liver was cirrhosed, hardened and greatly diminished in size ; the weight being only
twenty-four ounces ; the length ten inches, and breadth four and a half inchea, and greateit
thickness two and a half inches. The liver had lost the appearance of divisions into lobolei
upon the exterior, and resembled an elongated flattened spleen.
The color of the liver was slate on the exterior, and a mottled olive green yellow and
bronze within.
The peculiar color of the liver appeared to be the result of the previous attacks of malarial
fever, and the slow action of the malarial poison. Under the microscope, the fibroua tissue
was found to be greatly increased, and the dark masses of altered haematin were scattered
throughout the structures, giving to the organ, its peculiar malarial hue. The liver cat like
leather and wasUrm and bard.
The spleen was enlarged and iudurated and had lost the natural splenic mud Weight uf
spleen; nine ounces; length, six inches; breadth, three and a half inches; thickness, one
inch. Spleen cirrhosed like the liver, and cat like leather. Contained numeroas mas?es of
hsmatin and altered blood corpuscles.
This then was a case of undoubted induration and contraction of the livor, oQacciim'
panied by disease of the heart or kidneys ; but attended with the marks of pre-oxi5t-
ing malarial disease.
The relations of the action of the malarial poison, to the induration and oontracCiuQ
of the liver, are of the most important character, and demand further icvoeitigatioo.
The question is, whether the effects of the malarial poison were merely coDcunmt
with, or subsequent to, the establishment of the cirrhosis, or whether they caused the
peculiar state which lead to the throwing out of the fibrous matter, and the 8ub6e<|ttcnt
contraction and induration of the organ.
This case resembles the chronic atrophy of Frerichs, or the red atrophy of Rokitani4T.
in which there is no nodulation or granulation of the outer surface, and not ncccayarily
any thickening or adhesions of the capsule. The liver affected with the chronic atn>phy
of Frerichs, like that of the ca.se now under consideration, presents a dark-brown. <)r
bluish-red color, firm consistence and homogeneous appearance, with little or no io«i:-
cation of a division into lobules ; the .secreting cells being smaller than natoiml ao<i
loaded with dark-brown pigment granules. In like manner, the atrophy of the (»r^:ao
is general, and as in the present case it has been known to weigh only tvcvity-four
ounces. But the most important anatomical character of chronic atrophy, \n said to U-.
the destruction of the ramifications of the portal vein, the branches of which tetmiittte
in club'Sbaped extfcmities, so that the organ cannot be minutely injected from the por*
tal vein.
Pathologists describe this cconparatively rare form of liver disease, as being occa5k>o-
ally seen in conneotion with simple and cancerous ulcerations of the stomach and iotee-
tines, or with a deposit of blood pigment in the minute vessels of the liver, in the bodiefr
of persons, who have suffered long or often from intermittent or remittent (evenu
Dropsy from obstruction of Circulation of Bipod through Liver. 627
It 18 well known that both the liver and spleen are congested during; the cold stages
of intermittent and remittent fever, and during the action of the malarial poison^ either
in its most active manifestation, or in the state of chronic malarial poisoning, the colored
blood corpuscles are destroyed in large numbers both in the liver and spleen.
It is reasonable therefore to refer the induration and atrophy of the liver in this case,
in its first origin, to the action of the malaria.
In five cases observed by Frcrichs, cirrhosis of the liver was preceded by persistent
intermittent fever, a coincidence which has been repeatedly mentioned by other obser-
vers. Frerichs states however, that on the whole, granular infiltration of the liver is
a rare lesion in individuals who have died from the cachexia of intermittent fever, and
he had more frequently found either simple chronic atrophy or fatty, and occasionally,
colloid infiltration. It would appear therefore, that other agencies must co-operate in
the development of cirrhosis in intermittent fever, and the precise nature of these agen-
cies is obscure. In an extensive series of observations on malarial fever I was unable
to connect cirrhosis of the liver directly with the action and effects of the malarial poison,
for many stout, athletic men, who were suddenly stricken down afler a short illness of from
one to four days, a few weeks aft^^r onterini; fur the first time in their lives, a malarial
region, presented marked cirrhosis of the liver. For in such cases, the disease was clearly
referable to some antecedent cause. And in such investigations it should be borne in
mind that a certain amount of cirrhosis may exist for a length of time, without any per-
ceptible impairment of health ; and without incapacitating stout laboring men from the
daily performance of their arduous duties.
The three following cases of cirrhosis of the liver, recorded by Frerichs, are worthy
of notice, inasmuch as they were preceded by obstinate intermittent fevers ; in one of
them not one of the causes existed which are wont to give rise to cirrhosis ; in the two
others, the abuse of spirituous lifjuors, etc., could not with certainty be excluded :
Case 687 : PersitUtU Jntfrmittent Fti\r ; Irregular llahils of Life ; (Sastric Catarrh ; Slti/ht Jaun*
dtre ; Cachexia; AacUts ; rararentisia ; Collapse. — Death. Autopay. — Fioelj -granular Cirrhosis
of LiFer; Splenic Tumor with slight pigment deposit; Catarrhal Tumefaction of the 5Iucou8
Membrane of the stomach ; Cicatrices in the Duodenum ; Typhus (sic) Cicatrices in the
lleMm.
Cabb €88 : Rosin* Fritze, aged 2S, was a patient in the Clinical Department of AH Saint's
nospiul, from the 14th of April to the 2<Hh of May, 1857.
Vp to the beginning of ISri?, she had been at service in the country, working in the room*
log in the bouse, and in the afternoon, out of doors, and she had then been in the habit of
drinking from one to two glasses of brandy daily. During the previous summer and autumn,
she had suffered first for six weeks, and afterwards for four, from a tertian intermittent fever,
for which she had been treated in the Ohlau Infirmary. During January and February, she
seemed to have led a very irregular course of life. The patient stated that for four weeks
before admiuion, her appetite had failed, and she had been troubled with a feeling of fullness
in Ibe right bypocbondrium and epigastrium, and during the same period she had observed a
swelling of the abdomen, and a pale, yellow tinge of the skin. Three weeks before, her feet
had become swollen.
The patient was jaundiced, and remarkably emaciated ; the skin was everywhere dry, Hs-
sared, and covered with branny scales; there were extensive ascites, and likewise slight
enlargement of the veins upon the abdomen. The lower extremities were moderately cede-
matoni ; the upper were free from oedema.
PercQSsioa of the chest presented nothing abnormal ; loud, sibilant, and moist rales were
Aodible over the back part of both lungs ,* the patient complained of a troublesome, dry cough.
Heart normal.
The hepatic dullness was completely absent at the epigastrium ; in the right mammary line
it commenced at the sixth rib, and extended downwards about 4 centimetres (1.57 English
inch); but the percussion tone was nowhere completely dull. The splenic dullness com-
menced at the eighth rib, but its lower margin could not be defined, owing to the ascites and
the nedematous condition of the integuments. The abdomen was greatly distended by a large
quantity of liquid and gas, but was nowhere tender. The tongue was coated yellow and dry.
After the administration of Tincture of Colocynth. the bowels were freely moved ; the stools
were of a brown color. Trine scanty, scarcely 3U0 cubic centimetres, (10} fluidounces), in
th« day, dark, reddish-brown, dense^ with a reddish sediment of urates, and a small quantity
of bile pigment; it was free from albumen. Pulse 80.
628 Dropsy frdni dbstruetion of Circulation of Blood through Liver.
On the 19tb, paUe 84 ; respiration 22. The ascites and dyspnoea were rapidly increasiDg ;
less jaundice; urine more scanty, only about 200 cubic centimetreSi (about 7 flatdounces), in
24 hours, turbid, neutral and rapidly decomposing. The sediment contained a large quantity
of globular lithates, also triple phosphates, and a few small octohcdres of oxalate of lime.
The patient complnined of pricking pains in the liver, and was very morose. Was ordered
Infusion of Rhubarb.
On the 22d, pulse 84 ; respiration 24.
On the 30th, pulse 100 ; respiration 26; headache and bilious vomiting. For eight days,
the jaundice had been diminishing, but the ascites had increased. The dyspntra was more
urgent, the secretion of urine had almost entirely ceased.
On the 6th of May, paracentisis was performed, and about five pounds of a bright yellow,
perfectly clear fluid were drajtvn off from the abdomen.
On the 6th, pulse 90; respiration 26; had slept well. A large quantity of sernm wai
flowing from the punctured wound. The region of the liver was tender when toncheil.
Stools Tery scanty ; no urine passed. * *
On the 16th, pulse 100 ; increased tenderness of the abdomen. Since the day before, the
wound had completely closed, and the abdomen had rapidly increased in size.
On the 1 7th, pulse 96; bilious vomiting, increasing collapse.
On the 19th, pulse 100; abdomen greatly distended, but not very tender; frequent vomit-
ing, and coldness of the extremities. The vomiting returned during the night, and, oo the
following morning, the patient died rather suddenly.
Autopsi/. — Body extremely emaciated ; no jaundice ; no oedema of feet. * *
Four pounds of yellow, tolerably clear fluid in the abdominal cavity. Hpleen 5} inches
long, 3} inches broad, 1 inch thick, flabby, reddish-brown, and infiltrated with bluish-black
pigment.
Kidneys anaemic and of normal consistence.
Liver small and shriveled. A tight-luce furrow was observed on the right lobe. The par-
enchyma presented everywhere a granular character, and a dense, firm, leathery consistence.
The granulations varied in size, from a pin's head to a linseed, and were separated by corres-
ponding narrow rims of areolar tissue. The bile was scanty and pale, and contained a large
quantity of mucus.
Ca8bG89: IntermiiUnt Fever of tevfH montfu^ duration ; Aactict ; Ilydrftinia ; Amuarta ; DtatK
from (Edema of the Lungs, Autopsy. — A moderately enlarged pigment-spleen. Cirrhosis of tl>e
liver. Mucous membrane of the stomach and intestines, and likewise the kidneys, normal
Cask 690: Old Pleuritic Exudation; Persistent Intermittent Fever: TuhereU of both Lun^ ,
Ascites ; Bronzed Skin ; Small Liver ; Dyspeptic Symptoms. Autopsy, — Firm adhesions of PI ear*.
Tubercle of the lungs. Cirrhosis of the liver. Super-renal capsules normal.
Spleen of moderate size, tolerably firm, and dark brown. Liver very small, nniformlr
granular, firm, tenacious, and of a yeliowish brown color. Two concretions of a nolberrr
form in the gall-bladder. Supra-renal capsules in every respect normal, The cortical sob-
stance of the kidneys presented several cicatrix-like depressions, but in other respect*
these organs were healthy. (Clinical Treatise on Diseases of the Liver, Vol. ii. pp. 63-69).
Cask 691 j Dropsy resuUiny from Cirrhosis of the Liver and Cardiac Disease. — ^This case of the
stout seaman, William Woods, who died in ward No. 18, a few days after coming under mr
treatment, presents several points of interest, and the dropsical effusion in the cavity of the
abdomen, and into the cellular tissue of the face, and upper and lower extremities, were dec
to both cardiac disease and cirrhosis of the liver. The following outline of this case will serve
for comparative deductions :
William Woods, aged 47 ; dark hair, dark complexion ; in health, a large, powtrftt), stoat,
athletic man ; ship carpenter by trade ; has been sick about two years ; says that bis disease
commenced whilst working in the water; has always used ardent spirits daily, io large, cr
rather pretty free quantities. .
Entered the Charity Hospital November 9th, 1868. At that time the abdomen wm nach
distended with serous effusion, and it has been necessary to tap the abdomen upon teverm^
occasions, and several gallons of water have been drawn off.
When this patient came under my treatment, in the month of March, 1869, tha complexiea
was of a wax-like, unhealthy, jaundiced hue ; the features of the face were swollaii and IiTii
from venous congestion ; the abdomen was distended with dropsical effusion, and theextressi-
ties were ocdematous. Patient feeble, but able to sit up and walk about a litUe. Great
obstruction of venous circulation ; veins of neck distended with black blood. Lips livii
Arteries in all parts of the body, where they could be carefully examined, greatly ealarg^i
and tortuous, with a powerful beat. The column of blood is sent out with great force frota
the heart, giving a powerful beat to the arteries, which appeared to be nnivenally eoUrp-:
and degenerated. This degeneration of the arterial system is still farther shown by tb« *^' •
senilis. Great oppression in breathing. At times the restlessness and oppresaion Tery gfv-^
Patient cannot lie down with comfort, but requires to be propped up in bed. Percav '.»)
Dropsy from ohstruetton of Circuiation of Blood through Liver. 629
aad aasenltation revealed dallnesa in the lower dependent portions of the langs, and greater
flatneM over the chest than in health ; there were no symptoms of pneumonia, or pleurisj, or
of phthisis, and the dallness was referred wholly to the obstraction of the circulation. Heart
greatly enlarged, with a powerful beat. The dullness, upon percussion, extends from the
Junction of the second rib with the sternum, to the lower edge of the seventh rib, and even
beyond the right border of the sternum. The region of dullness, indicating the position of
the enlarged heart, is eight inches in the longitudinal, and about six inches in the lateral, or
transverse diameter.
The first'sound of the heart is entirely altered to a low bellows sound, terminating abruptly
by the powerful closure of the pulmonary and aortic valves. Both sounds of the heart are
merged into one — a powerful, low, blowing sound, with a sharp, loud termination, thus:
TC-n-CHUCK. The sounds of the heart resemble those made by an ordinary steam tug. The
sounds of the heart are heard with great distiuctness along the track of the large arteries,
and especially of the carotids.
Abdomen greatly distended with serous effusion. Liver apparently diminislied in size and
hardened.
Derangement of the liver is evidenced aside from the ascites, by the yellow jaundiced hue
of the complexion, and the great amount of bile in the urine. CKdema of extremities. Bowels
constipated. Appetite poor. No marked febrile phenomena. Patient dull and lethargic, but
calm and sensible.
The diagnosis of this case was :
Hypertrophy and Dilatation of Heart.
Universal Degeneration and Dilatation of Arterial System.
Great enlargement of Aorta.
Cirrhosis of Liver.
The dropsical effusion was referred directly to these causes.
The patient continued to grow worse; treatment was onlv palliative, and he died on the
27th of March, 1869.
The Pott'tnortem Examinaiionj performed six hours after death, revealed enormous hypertrophy
of the heart; this organ was eight inches in the longest diameter, and six and a half inches
In transverse diameter, after being emptied of the dark venous blood which distended its
cavities, and after being preserved in alcohol. During life, when distended with blood, its
dimensions were much greater. All the cavities of the heart, but more especially the left
ventricle, were dilated, and the auriculo-ventricular openings were greatly dilated. No
thickening of the auriculo-ventricular valves was observed.
The valves of the aorta and pulmonary arteries were somewhat enlarged and perhaps dege-
nerated, but no deficiency or adhesions or calcarious degeneration were observed.
Aorta and pulmonary artery ; but especially the former, degenerated, roughened and dilated.
The dilatation of the aorta amounted in the ascending portion and arch almost to an aneuritm.
The arteries were universally dilated and degenerated in their structure, and appeared in a
great measure to have lost their elasticity. Microscopical examination show^ed that this dila-
tation and loss of elasticity was due to the conversion of the unstriped muscular fibres into
fat. The liver presented a rough hob-nail appearance upon its exterior; it was contracted,
diminished in size ; the capsule was greatly thickened, and could be pealed off, and the struc-
tures were cirr hosed.
Kjdneys congested, but healthy in structure — no degeneration or alteration of secretory
tex tares.
Spleen somewhat enlarged.
TbiB liver, as in all the other patients who had been exposed to the malarious climate of
the Missiiaippi valley, presented a darker color than usual in cirrhosis, and also gave evi-
dence in the dark grannlar masses of the preceding destruction of the colored blood cor*>
paacles.
The dropsy in the preceding case was clearly referable to cirrho.sts of the liver and
cardiac disease.
Cass 692 : CtrrhoM of Liver; Chronic Dyunter^f ; Awitea. — John t. Rwing, age 39, native of
Mississippi, Brakesman on Railroad.
Sntercd Charity HospiUl, ward 13, bed 198, August 17th, 1872; died February 22d, 187.3.
Cause of disease, exposure to wet and cold, especially at night, combined with the habitual
and excessive use of alcoholic liquors. Father and mother of patient healthy, up to the time
of their death) from Typhoid Fever, in 1869. Light blue eyes ; light brown and brownish red
hair and beard ; florid complexion ; height 6 feet, 9 inches ; weight in health 175 lbs.; enjoyed
good health np to January, 1872. The only serious disease with which he has suffered wss
the 8mall-Pox. In January, 1872, suffered with severe pain in region of the liver, cramps in
the abdomen and diarrhoea ; continued working however, until the Ist of June. Dropsical
639 dropsy from obstruetion of Circulation of Blood through liver.
swelling commenced about the 1st of Juljr, and the patient entered the Charity Hospital of
New Orleans, on the 17tb of Augast. Has been in the habit of drinking strong ardent spirits,
(Whiskey and Brandy); bis custom for several years, has been to take from one to three
drinks of (raw undiluted) Whiskey in the morning, before breakfast. The dropsical eflTntioo
into the abdomen rapidly increased after his entrance into the hospital. Was tapped, Sept.
26th, October 8th and October 15th. Abdomen distended with dropsical effusion. Veins of
abdomen distinct and arborescent in appearance. Lower extremities distended with flaiJ.
Skin over legs covered with a scabby eruption. The dropsical swelling of the abdomen is
definitely and abruptly bounded by the diaphragm above. Face, chest and arms, without anv
oedema, but thin and wasted. Action of heart feeble, but regular: no eardiae deranffoment.
Upon percussion and auscultation the lungs also are found to be healthy. Respiration some-
what embarrassed, and difficulty of respiration, increased by exertion.' The embarrassment
of respiration appears to be due solely to the pressure of the fluid in the abdomen, which
forces the diaphragm upwards. Urine high colored from the presence of bile. Carefal che-
mical and microscopical examination of the urine, demonstrated the absence ot both albanen
and casts and cells of the tubuli uriniferi. Kidneys apparently healthy, and performing their
normal functions. Bowels loose ; actions often attended with pain, straining and roncous
discbarges streaked with blood.
The results of the preceding examination lead me to exclude the heart, kidneys and lungs,
from any connection with the dropsical effusion, and accordingly the following diagnoMu:
cirrhosis of the liver and chronic dysentery ; anasarca of lower extremities and ascites of
abdominal cavity, caused by the portal obstruction ; prognosit unfavorable; life may be pro-
longed by treatment, but there is no chance whatever of recovery.
October 17th, I introduced the trochar and canula within the cavity of the abdomen, and
drew off four gallons of clear, limpid, light yellow, serous fluid. Specific gravity of seroas
fluid from cavity of the abdomen 1007.5. Microscopic examination revealed the pretence of
numerous colorless blood-corpuscles and exudation spindle-shaped corpuscles. The seroa»
fluid from the abdomen was coagulated, both by boat and the mineral acids. Upon analysn
1000 parts of this serous fluid yielded 19.5 parts solid residue, of which 9.9 parts were drie*l
albumen, and 8.7 parts salts and extractive matters. Bach pint of the dropsical tloid yielded
C3.() grains of dried albumen ; each gallon 508.8 grains, and the entire quantity of flnid coo-
tnincd in the cavity of the abdomen (4 gallons,) yielded 203.*}. 2 grains of dried alboaien.
Reaction of serous dropsical fluid, alkaline. Upon standing, a few small fibrous fiocculi sepa-
rated. The putrefactive process was slowly set up, and a number of vibros and fungi were
developed.
The 2036.2 grains of albumen contained in the whole amount of dropsical effusion, corres-
ponded to the serum of 28,891).84 grains of blood, wh' h equals the albumen of the serum of
4.12 pounds Troy of blood.
The strength of the patient appeared to be increased by the tapping and the removal of tie
dropsical effusion ; the tension being thus removed, and the lungs and heart being relieved o(
the pressure. A tight bandage was applied around the abdomen.
After the tapping, the dropsical effusion rapidly disappeared from the lower extremities, «Qd
the abdominal cavity commenced to fill up rapidly, and in 24 hours a perceptible nccQmoUtip>>
of fluid had taken place.
The pulse ranged from 100 to 1 10, and the temperature oscillated daily, between lOO^ K.
and 101° F.
The dropsical effusion accftniulated so rapidly, that it was necessary to tap the |»atieaias«'i>
on the 2Gth of October, 9 days after the last tapping.
October 26th, a. m., abdomen enormously distended; diaphragm pushed upwards; breatbiof
embarrassed, action of heart feeble and irregular, mind wandering. I introduced the trochar
(paracentisls,) and drew off 5 gallons of light yellow serous fluid. The walls of the abdonra
were somewhat thickened, especially the peritoneal coat ; and there had been some tendenets
of the abdomen, after the last tapping.
Specific gravity of dropsical fluid 1007.0; reaction alkaline. Under the microscope tite
fluid contained colorless blood-corpuscles ; 1000 parts contained dried solid residue 17.6 partt
dried albumen 8.8 parts; extractive matters and salts 7.1 parts.
The entire amount of fluid from the abdomen (5 gallons,) contained 3190 grains of dnrd
albumen.
The relief from the tapping was only temporary ; the effusiou disappeared from the low^'
extremities, and increased rapidly in the abdomen. The application of a tight baodafe aroaed
the belly, appeared to exert but slight influence in preveAting the return of the drop«*c*i
effusion.
1 determined to attempt the reduction of the dropsical effusion, by exciting lbs kidoett \^
increased action ; and accordingly on the 27th of October, commenced the adminiatimtiua at
regular intervals of 4 hours, of a powder composed of eight grains of powdartd Sqntll, oe»
and a half grains of powdered Digitalis and three and a half grains of Nitrato of Potash
The sixth of a grain of Sulphate of Morphia, was also administered at bed time.
Dropsy from obstruction of Circulation qf Blood through Liver ^ 631
October 30tb. Patient very weak ; delirious; dropsical eflruston increasing rapidly; urine
high colored, free from albumen, but loaded with bile and urates : urea in normal amount.
The Digitalis, Squill and Nitrate of Potassa were abandoned, and the patient placed upon a
purgative mixture, composed of one ounce of the Bitartrate of Potassa, three-fourths of an
ounce of Washed Sulphur, and twenty grains of powdered Jalap. This powder was mixed
with a cup of water, and administered twice a day, in the morning and evening.
December 10th. The purgative powder has produced free action on the bowels, and also
increased the flow of urine ; the patient has improved, has gained some strength, the intellect
is clear. The dropsical effusion has slowly decreased, and it has not been necessary again (o
resort to the operation of paracentisis.
When the action of the powders have been too great upon the bowels, only one-half or
one-fourth of the quantity specified above was administered twice a day, and sometimes the
medicihe was intermitted for 24 and 48 hours.
The actions on the bowels are attended with straining and pain, which symptom appears to
be referable to the chronic dysentery, with which this patient had suffered for 12 months,
before entering the hospital.
The entire amount of fluid removed from the abdomen by tapping has been 128 pounds;
and upon careful analysis, I found that this amount of serous fluid contained an amount of
albumen, which was equal to that contained in the serum of about 17 pounds of blood. As
the whole amount of blood contained in the body of a man uf this size, might be estimated
at about 24 pounds, it is evident that from the 26th of September, to the 26th of October,
(one month,) the greater portion of the albumen of the blood, that is an amount of albumen
nearly equal to that contained at any one time, in the whole mass of blood, had been effused
into the cavity of the abdomen.
Under the systematic employment of the Bitartrate of Potassa, Sulphur and Jalap, the
dropsical effusion, was not only kept from accumulating, but was entirely removed ; and to
such an extent that the lower limbs presented a shrivelled appearance, and the abdomen
reduced very nearly to the normal size in health.
When necessary, opiates were given to induce sleep, and the diet was nutritious ; soft boiled
eggs, mntton and beef, milk, rice and bread.
The Chronic Dysentery however, and the constant pain attending the action ot the bowels,
slowly reduced the strength of the patient, whilst at the same time, the digestion and assimi-
lation of food, were imperfectly performed, and the patient died December 30tb, 1872.
Autopsy 12 hours after death.
Kxterior. — Face, neck, arms and thorax greatly emaciated. Abdomen, flaccid and greatly
reduced In size in comparison with its former dropsical condition. Lower extremities nearly
normal in size and but slightly swollen.
Thorax, — Muscles normal in color ; adipose tissue completely absorbed ; pericardium and
heart, normal in size and position ; heart normal in all its parts. Pleura and lungs normal.
Lungs without structural alteration or congestion.
Abdominal Cavity, — When the abdomen was opened, abont thirty fluidounccs of yellow serous
fluid ponrcd out. Surface of the peritoneum, rough and nodulated from the effusion of coa-
gulable lymph. The fibrous nodules of the peritoneum varied in size from I to ^^ of an inch
in diameter. Sub-acute inflammation had evidently been excited in the peritoneum by
tapping.
AUmentarff Cmal. — Stomach, normal. Jejunum and Ileum, somewhat congested, but
healthy. Mucous membrane of large intestine studded with the cicatrices of old ulcers.
Some of them appeared to have completely healed ; in the rectum however, some of the ulcer-
ated surfaces presented a brij^ht congested appearance and appeared to be in a state of active
inflammation.
Lieer. — Color of liver yellow ; surface nodulated and irregularly contracted. Weight of
liver, 2 pounds and eleven ounces. Liver contracted and cirrhosed, the hardening being most
marked in the Portal system of Capillaries bordering the individual lobuli. WhiUt the portal
periphery of each lobulus was hardened, the interior was sorteoed, and contained much oil,
within and around the hepatic cells. Under the microscope the excretory cells of the liver
were filled with oil globules, and the oil was greatest in the centre of the lobuli in the meshes
of the hepatic capillaries. Gall Bladder contained 1050 grains of bile.
Kidneys healthy. Spleen normal.
The diagnosis was fully sustained by the post-mortem examination, viz: Ctrrhosis of Liver
and Chronic Dysentery.
CaSI 693: Enlarged nodulated Litter; Cirrhosis and TaUreular Deposit; Ascites; Jaundice. —
Ab Choo, Chinaman. Admitted to ward 30, bed 449, Charity Hospital, November 2ath, 1874.
Died December 10th, 1874. Diagnosis: Cirrhosis, and Tuberculosis of Liver. Prognosis
ttofavorable.
Patient says that he has been sick for several months. At the period of entrance the patient
presented a golden hue, the sclerotic conts of the eyes being tinged of a deep yellow. Abdo-
032 Dropsy from obstnietion of Circulation of Blood through Liver.
men distended with dropsical efl^ision. Lirer greatly enlarged, extending some 3 tnchei
below tbe border of the false ribs. Urine loaded with bile and orates. The urates were in
such abundance, that upon the addition of Nitric Acid, a heavy deposit resembling that canted
bj albumen, toolc place, but this was cleared up bj heat.
When pressure was made over the region of the enlarged lirer, tbe surface was felt hard
and nodulated.
Patient died December 10th.
^ Autopsy 6 hours after death.
Liver greatly enlarged; of yellow color, with nodulated, irregular surface. Weight of
liver 10 pounds. The entire organ was filled with hard circumscribed tubercular masses,
varying in diameter from \ of an inch to H inches. Under tbe microscope tbe nodalsr
masses consisted of granular matter, small cells like those characteristic of tubercle, liver
cells filled with oil, oil globules, and fibrous tissue.
Case 694: Congenital Enlargement and Cirrhom of Liver ; Ascites; Fever, and pertiaUni Jentndiee :
Passive Htemorrhages into Cellular Tissue ; fatal result. — Infant daughter of Doctor ■ of Nev
Orleans, born January 6tb, 1874; labor natural; at birth the child appeared to be healthy,
nursed well, and slept quietly. During the course of the 2d week, when light was admitted
into the room, the infant was observed to be of a deep golden jaundiced hue. It was probable
that the jaundice existed from i)irth, bnt it was not previously noticed because light bad been
excluded from the room. A few small dbses of calomel were administered, but no appreheo-
sion was felt by the parents, as the iofant appeared to be healthy in all respects, with tbe
exception of the universal jaundice.
I was called in consultation about tbe middle of March, and upon careful examinattoc, fouod
the liver to be enlarged and indurated, the surface extending below the ribs, presenting a
hard nodulated feeling when the hand was firmly pressed against it so as to displace the fluid
which had been elTused into the abdominal cavity. Tbe liver extended across the epigattrian
and encroached upon the left hypochondriac region ; and on the right side it projected aboal
three inches below the border of tbe ribs.
Diagnosis ; Cirrhosis and Enlargement of Liver.
Prognosis unfavorable. I expressed the belief that the disease was necessarily fatal ; that
sooner or later Ascites would appear and increase to a distressing extent ; that the blood
would be gradually and profoundly altered by the retention of bile ; and that treatment conld
only be palliative. Notwithstanding this condition, the child ate well, slept well and developed
about as rapidly as other children of the same age.
About the end of the third month, the child began to suffer with fever and acute paroxysm
of pain, which were most marked at night. The fever seldom, if ever entirely intermitted,
and at times, the temperature was very high. The pain at times was agonising; the nttl«
patient would scream, struggle, pull its hair, and bite its fingers and try to tear off its clothes.
The urine was highly charged with bile, but at the same time the discbarges from tbe boveli
presented the normal color. Quinine, used by itself, and in combination with calomel, ap-
peared to exert no influence upon the paroxysms of fever. A course of Iodine and Iodide of
Potassium in like manner, appeared to accomplish no beneficial effects. At night the cries of
the child were so incessant, and the pain and agony so great, that such sedatives asTtnctare of
Opium, Bromide of Potassium and Hydrate of Chloral were employed at regular intervals, and
oftimes in relatively large doses. At times very large doses of these agents were neceasarv
to induce short periods of rest. The intellect of the child, however, continued bright, and
the appetite good, and the digestion apparently unimpaired. Liquid continned to accunalaie
in tbe abdominal cavity, and about the first of the eighth month, the ascites had increased to
such an extent, as to greatly distend the belly, forcing up the diaphragm and impeding re9-
piration. However, by the persistent and free use of the Bitartrate of Potash, in pargatiT»
and diurectic doses, the eflfusion was so far reduced and controlled, as to obviate the seces-
sity of the tapping.
About the beginning of the 9ih month, haemorrhage occurred from a slight abrasion «.r
ulcer on the frffrnum of the tont^ue, which continued at intervals of a week, and was res-
trained by the local and internal use of the Tincture of tbe Sesquichloride of Iron. There
supervened a general haemorrhagic condition. Hsmorrhagrs took place in the cellular txsss'
beneath the skin, in the legs, arms, body, head and face. The position of the local bstmor*
rhages were indicated by circumscribed, hard, dark colored, elevated tumors of varions fire*.
from one-half an inch to three inches in diameter. A free hemorrhage into the cellalor
tissue occurred (suddenly in the left cheek. Blood was poured out into the tissnes, ontii t^^
whole side of the face and the mouth was distorted. The whole cheek, both within (aioeot.f
surfoce) and without, presented a purplish, almost black color. The diameter of this (••(
appeared to be about three inches. The haemorrhage into the cellular tissue of the left chrtk
occurred seven days before death. A hx*morrhage of about equal amount occnrred in the
cellular tissue of the right side of the head, above the temple.
Ivighteen hours before death, a violent fever supervened, attended with cough, and great
Dropsy from obstruction of Circulation of Blood through Liver. 633
opprestioD of breathing, and finally, with stupor. Before death, the child vomited blood,
and large quantities of bloody mucus issued from the mouth and nostrils.
The preceding case is of interest, as illustrating the effects of the bile upon the blood
in inducing passive haemorrhages in the cellular and muscular tissues, and from the
mucous membrane of the mouth and stomach.
The effects which were slowly induced in this case, are rapidly manifested in severe
cases of yellow-fever, in which, in addition to the action of a special fibrile poison, and
the rapid and marked elevation of temperature^ there is also induced intense jaundice.
Wo will consider briefly in the next place :
THE THEATMENT OF HEPATIC DROPS V.
The treatment of dropsy arising from portal obstruction, must depend, not only
upon the cause of this condition, but also ijpon the various complications, as cardiac
and renal disease. The preceding cases illustrate in a dear manner, the fact, that
dropsy may be referred in the same case, to several causes, as cirrhosis of the liver, and
cardiac disease ; it is therefore absolutely essential that the physician, should, as far as
possible, clearly recognize in each case the cause or prominent cause of the dropsical
effasion. It would bo foreign to our purpose, to discuss the mode of treatment appli<
cable to all the diseases of the liver, which may give rise to ascites ; and our effort will
be to indicate briefly the mode of treatment of that form of dropsy illustrated by the
preceding cases, viz : ascites arising from cirrhosis of the liver.
Cirrhosis of the liver is at the outset obscure and insidious, and is slow in its progress,
often extending over several years: the physician therefore rarely has an opportunity of
treating the disease at its commencement. When, however, the existence of the disease
is indicated by the symptoms of disordered digestion, loss of appetite, flatulence, irreg*
ular action of the bowels, pain after food, dull pain, with slight tenderness in the right
hypochondrium, and slight enlargement of the liver, occurring in a person addicted to
spirit drinking, attention should at once be directed to the habits and diet of the
patient. Alcoholic stimulants, and rich, indigestible, stimulating food and condiments,
should be interdicted, and the patient confined to spare, but nutritious diet, consisting
of such articles as milk, eggs, and farinaceous substances, with a moderate allowance of
meat and fish. In order to avoid the occurrence of delirium tremens, it will be neces-
sary in some cases in which the habit of taking large quantities of alcoholic stimulants
has been fully established, to reduce the amount gradually. The bowels should be kept
freely open, by saline purgatives, and occasional doses of blue mass and calomel ; and
the general health preserved by regular exorcise in the open air.
If the pain and uneasiness, in the region of the liver, is well marked, sinapisms,
leeches, dry cups and cut cups may be used over the affected organ, with benefit,
If the liver still remains enlarged, after the subsidence of pain, the alterative effects
of Iodine — either locally, in the form of the tincture or ointment, over the region of
the liver, or internally, m the form of the Iodides of Potassium and Iron, or of Lugol'a
Solution should be carefully tried. If these measures fail in reducing the liver^
recourse may be had to the mineral acids, the Hydrochloric, Nitric and Nitro-muriatic
Acid, internally, and to the Nitro-muriatic acid bath'^.
When the stage of contraction of the liver sets in, as evinced by diminution of the
area of hepatic dullness, jaundice and aHcites, there appears to be no known treatment,
which will restore the liver to it.s noimal condition, or remove the obstruction to the
*Tbe Xitro-muriatic Acid Bath is prepared by addinfi^ two ounces oT strong Hydrochloric
Acid, and one ounce of strong Nitric Acid to two gallons of water, at 98® F. Deep, glazed,
earthen or wooden vessels should te used, and the feet and legs are immersed in the hath,
whilst the thighs and right side are sponged with the acid solution. The patient should re-
iDaiD In the hath from half an hour to one hour. The hath thus prepared should Ve renewedt
at leait every third or fourth day.
79
634 Dropsy from dbstmcticn of Circulation of Blood through Liver.
portal circalation. In this stage the efforts of the physician are directed chiefly to the
relief of symptoms, and the support of the patient's strength, in order that life may be
prolonged to its farthest limit.
The diet should he nutritious but not stimulant, alcoholic stimulants should be
entirely prohibited, or used only in cases of emergency and with ^eat caution ; the
digestion should be improved by such tonics as Quinine, Gentian, Xitro-muriatic Acid
and Strychnia; and the bowels should be kept open, whenever sluggish, by mild pur-
gatives.
The ascites should be treated by diuretics and purgatives. A pill composed of half
a grain of powdered digitalis, one grain and a half of powdered squill and two grains
of blue pill, has been administered with benefit in cases of ascites, dependent upoa
hepatic disease, two or three time dailv.
The diuretics and purgatives previously recommended in the treatment of cardiac
disease may be employed. As a rule, however, the ascites slowly increases, and sooner
or later it is necessary to resort to the operation of paracentisis ; this should be delayed
as long as possible, for notwithstanding the temporary relief afforded, and the increeed
action of the kidneys, the fluid usually collects again rapidly, and the patient is
exhausted by the great drain of albumen from the blood.
CHAPTER XV.
WATEKT BLEHEHT, AND BY THE ELIMINATION Of ^XCHEHENTITIOUU HATBRIAL.
Ai^IMNQ raOM DI!}EA8Ea OF TUB KIBNEV. DROPSY BESITLTINO FBOM BRIOHTB DISEASE Olf
THE KIDNEY. BBIOHT'S SISEAHE ur KIDNEY. ANASARCA. TREATMENT Ur DBUPSV ABISINQ
FBOM DUEASE UK KIDNKVK.
The kidaeys not only r^ukte tba uuiuuut of thu watury uluuieut uf ihii blood, but
they also eliminate certain nusii>us subalancus, resulliu<; from the luetamorphoaiB of the
tissues, and the chemical changes involved in the generation of the physical forces ;
any arrest or alteration or suppression of the action of these important organs, must,
therefore, be followed by an aooumnUtion of the watery element, and oerlain excremen-
titioofl matteis in the blood, derangement in the processes of absorption and eshaUtiun,
and disturbance of the sympathetic and ccrebro-spinal nervous system.
It has been estimated, upon reliable data, that the amount of water taken by an
adult, in twenty-four hours, is. on an average, from ooe-half a fluidonnce, to six-tenths
or eevea-tentht of an ounce for each pound avoir, of body weight ; a wan averaf;iog
] 40 pounds, will therefore take about seventy Ui ninety Buidouncee daily, and in ordinary
diet, about twenty to thirty ounces of this are taken in the so-called solid food, and the
remainder is drank as liquid of some bind.
But the amount taken, varies within wide limits, in different circumstances, and
firoro individual peculiaritioa ; some men take only sixty ounces — others as much us
one hundred and twenty, or even more ; more water is consumed in a dry than in a
moist climate, and durin); great exertion, than during a period of rest. The mean
amount of water excreted through the kidneys by different male adults, varies fVom
thirty-five to eighty-one fluidounces a day. The variations in the amount of water
exctet«d by the kidneys, will depend upon the varying quantity introduced into the
system; and upon the varyin;; quantity eliminated by the skin, lungs and bowels.
It results, from the preceding calculation, that the kidneys alone eliminate, during
the year, in adult men, on an average, from eight hundred U> eighteen hundred pounds
of water. This great and continuous circulation of water through the living being is
cmential to the existence of life, and the performance of the various functions. Thus
daring the development of heat, and of the forces which work the animal machine, a
portion of matter is chemically altered, decomposed and broken up into simpler forms ;
if these matters, as urea, uric acid and carbonic acid and urate of ammonia be not con-
tinuously removed, ill-lieaUh, and Gnally death, will result. To accomplish the con-
tinuous removal of the various useless and noxious substances, there is first, the almost
universal solvent, water; second the circulatory apparatus, in which these substaaoea
are received, and by which they arc distributed ; third, special organs, as the lungs and
kidneys, which separate these matters from the blood, and cast them out of the circle of
living molecules. Wc are thus enabled to understand the reason why general dropsy
so rapidly and so surely suporvenss, when the function of the kidneys is arrest«a or
materially impaired.
An additional cause of dropsy is also known to exist iu certain diseases of the kid-
neys, vis : The constant loss uf albumen by transudation through the capilUries and
<33t) Dropsy arising from Lesions of the Kidneys.
excretory tubes of these organs, and the consequent derangement of the oomposition of
the blood.
The diseases of the kidneys, which are almost universally attended with dropsy,
are: —
Congestion, and acute inflammation of the kidneys^ occurring as a sequel to scarla-
tina.
Acute nephritis, caused by exposure to cold or wet.
Acute Bright's Disease (^'' croupous nephritis.") The course of this disease is always
acute, and terminates either in recovery or death, in most cases, within a few days. It
is a frequent complication of scarlatina. Post-mortem examination shows the kidneys
to be congested, enlarged, with the urinary tubes filled up and occluded with an extra-
vasation, consisting of a coagulating exudation containing epithelial cells and blood cor-
puscles.
Chronic Bright's Disease, ('^ parenchymatous nephritis.") The pre-disposing causes
of Bright's Disease, are, cold ; incautious exhibition of certain irritating diuretics, as
cubebs, copaiba and oil of turpentine ; the abuse of ardent spirits ; the alcohol eltmiiH
ated with the urine acting locally upon the structures of the kidneys, the disease appear-
ing almost as frequently among hard drinkers as cirrhosis of the liver ; tedious suppu-
ration accompanying caries and necrosis of the bones ; the conditions of dyscrasia*
occasioned by gout, rachitis, scrofula and malarial cachexia.
In the 8o^calied large white kidney, the cortex is pale and hypertrophied, and the
uriniferous tubes crammed with granular epithelium. The large white kidney u oflen
merely an advanced stage of acute nephritis*, but it may alw be developed independently,
as the result of chronic inflammation.
In the fatty kidney, the organ is large and pale, and the Hccreting cells loaded with
oil ; and the observations of pathologists render it probable that this stage is preceded
by the stage of exudation, characteristic of the large, white kidney.
On the other hand, in the two common forms of chronic kidney disease, character-
ized by the contracted, granular, or gouty kidney, and the waxy, or amyloid kidney.
anasarca rarely shows itself, except shortly before the fatal termination.
Dropsy arising from renal disease, has the following distinguishing characters.
The anasarca of the sub-cutaneous areolar tissue, is general from the first, and moet
generally noticed first in the face ; fluid is also almost always efiused into the pleunr.
pericardium and peritoneum. The urine is scant, turbid or smoky, containing lar<^^
quantities of albumen and sometimes blood ; also renal epithelium and casts of the
uriniferous tubes, varying in their character, according to the particular disease of the
kidney. The countenance is swollen, heavy and pale, with a peculiar wax-like appear-
ance. There is a tendency to nervous disturbances, convulsions, loss of memory, rest-
lessness, delirium and coma. The digestion is derantrod, with dry tongue, fcetid bresth.
and obstinate vomiting.
In the production of the anasarca, which accumpanios and funiis a prominent symp-
tom in certain diseases of the kidney, several causo.s are in operation.
Ist. In the acute affections, when dropsy comes on rapidly in a few boon, and k«
almost the first indication of the disease, this symptom is most probably prodooed by
the retention in the blood-vessel system, of the water, urea and salta, which shoold be
eliminated in the form of urine. The anasarca comes on before any great anKmDt of
albumen has been thrown oflF from the blood by the kidneys ; the blood ia still rich in
this constituent, and the change in the blood results rather from a relative inerene in
the watery clement, and the retention of those noxious compounds, as urea, which
should be continuously eliminated. The circulation of the blood through the eapilla-
ries, depends, not alone upon the continuous action of the heart, bat also vpoo th«
relations of the blood to the capillaries and to the organs and tissues through which it
circulates ; whatever, therefore, alters the constitution of the blood, deranges the capil-
lary circulation, by deranging the chemical affinities of the blood and tissaee, and by
deranging the action of those portions of the nervous system which preside over and
Dropsy arising from Lesions of the Kidneys. 637
regulate the amount and charaoter of the capillary circulation. If water be injected
into the blood-vessel system of living animals to an extent greater than that which may
be readily and rapidly overcome by the kidneys, congestions of important organs, and
serous transudations will speedily result. Whether the view be held that urea, as urea,
acts as a poison, or it be maintained that the poisonous effects resulting from the injec-
tion or retention of this substance in the blood, be due to certain changes of the chemi-
cal constitution in the urea, in consequence of which it is converted ioto a more active
substance, viz : carbonate of ammonia ; the cause of the anasarca is, with equal justice,
traced, in part at least, to the paralyzing or deleterious influence of certain excre-
mentitious matters upon the nervous system, heart, smaller arteries and capillaries.
2. In chronic Bright's Disease, in addition to the retention, to a great extent, of
the watery element, and the consequent distention and relaxation of the swollen arterial
branches and capillaries, and the retention of the poisonous urinous excrements, there
is a continuous and great loss of albumen, which results in the production of a thin,
poisoned blood, and the consequent derangement of the nutrition, circulation and func-
tions of the organs and tissues. The researches of Gregory, Bostock, Christison,
Andral and Gavarret, Becquerel and Rodier, have shown clearly, that a diminished pro-
portion of albumen, and a consequent decrease in the density of the serum, constitute
the leading changes of the blood in Bright's Disease, and from which may be deduced,
in part at least, the pathogenesis of the dropsy developed under such circumstances.
The diminution of the albumen, as well as the extent of the dropsy, bear a relationship
to the duration of the disease, being much less in acute than in chronic Bright's Disease.
The diminution of the proportion of albumen in the blood, is scarcely perceptible in the
acute stage, before the fourth day. A great change takes place in the blood in chronic
Bright's Disease, its mean density falling from 10t>0 to 1045.6 ; the globules fall like-
wise, whilst the fibrin is somewhat increased ; the serum likewise undergoes a consider-
erable change, the mean specific gravity being represented by 1021 ; and the albumen
being so much diminished, that its mean is represented by 55.
The three succeeding cases illustrate the effects of cold in producing those changes
in the kidneys, which lead to the establishment of this form of dropsy.
Ca8B 695 : Bright'* Diseate ; AnoMorca ; AteUe$ ; Ezciiing Cause of Ditease, Gold and Exposure,
— Clemens Schwercr, age 48 ; native of Germany ; occupation, seaman. Has always enjoyed
good healib up to bis present illness. Entered Ward 25, Cliarity Hospital, January 11th,
1871. About tbe 1st of December, 1871, took cold on ship-board, after being wet by a cold,
driTing rain. Soffered with diarrhcea at this time, and two weeks after taking cold from the
wetting and exposure, noticed that bis extremities, especially his legs, were swollen. Suf-
fered with dull pains in the bead and in the small of the back, and observed that the urine
became very scant and high colored.
At the time of his entrance into tbe Charity Hospital, the face was puffed and swollen ; the
extremities, especially the legs, were cedematous and greatly distended with serous effusion.
Tbe arine was scant, high colored, and loaded with casts of the urinary tubes, and albumen.
Under tbe use of Cream of Tartar, Juniper berry tea, and Extract of Squill, tbe dropsical
effaiioii was completely removed; the limbs and face returned to their normal size, and the
arioa became abundant and light colored, and the amount of albumen diminished greatly.
Daring the night of the 5th of February, however, the patient slept with the window at the
bead of bis bed raised; a sadden cold change occurred during the night, and upon the next
day I found the nrine scant, and loaded with blood — in fact, when passed, it resembled, to
the naked eye, fluid blood. Both chemical and microscopical analysis showed that the urine
consisted, to a large degree, of blood.
Counter-irritants were applied to the spine and over the region of the kidneys ; the diet
was reduced to farinaceoas articles; the patient was rigidly confined to bed ; tbe function of
tbe skin was promoted by the hot air bath ; and tbe function of the kidneys was excited
feotly by Cream of Tartar, administered in flaxseed tea, conjoined with the Extract of Squill.
ha effects of the congestion of the kidneys, consequent upon the action of cold, was almost
immediately evident, in the return of the oedema.
Tnder the measures just indicated, the patient improved steadily, and on the 23d of Febru«
ary, the urine was free from blood, and presented the normal, light yellow color. This
patient improved steadily, and on the Ist of April was discharged at his own request.
CasB 696 ; Drapnf Ariiingfrom Bxposurt^ Chid and Alcoholic Drink^^^^Henry Neimer, Batcher |
(S3B Dropsy arising from Lesions of the Kidneys.
age 32 ; native of German j. Has lived in Loaisiana 17 years, and followed the oceupaiion of
butcher. Has never had malarial fever. Has been in the habit of rising at 2 o'clock io the
morning, and has been much exposed to wet and cold. Has been in the habit of drinking
alcoholic stimulants freely. Had an attack of anasarca with ascites, in November, 1870, and
after remaining in ward 22, Charity Hospital, for 1 month, was relieved to a considerable
extent, and went out and renewed his old occupation; bat the dropsy retarned again upoo
exposure, and he re-entered the Charity Hospital, ward 24, on the 14th of Febmary, 1871.
The bowels were regulated by gentle purgatives, and the kidneys excited by Sqnill and
Cream of Tartar, and the condition of the blood was improved by Quinine and Mnriated
Tincture of Iron ; and this patient was discharged from the Hospital on the I3th of April.
Cask 697 : Ana*arra ; Aaci(et ; resulting from Cold and Abuse of Aleoholie Stmmlants, — Tbomai
Moran, age 38; height, 6 feet; native of Ireland; has lived in Louisiana during the last 2*;
years, running on steamboats on Mississippi and its tributaries. Had chills and fever in Id^I.
and bilious fever in 1863, and chills and fever again in 1867 and 1868.
Served in the Confederate Army, and lost a finger in the service, and had bilious fever
which affected him for about 5 months in 1863. Habits at times irregular and intemperate.
"When on a spree would drink two or three bottles of whiskey during the 24 hoors.'* Haf
been in the habit of taking four or five drinks daily.
Has had three attacks of dropsy; first attack eighteen months ago, took cold at night
whilst watching on the levee of this city — got wet in the rain, and the wind changing saddcal?
to the North, and the temperature becoming suddenly cold, he was thoroughly chilled.
(Kdema followed by general anasarca and ascites, commenced a few days after the exposure to
the cold rain, and continued five weeks. Patient says that during this attack he bad oo regu-
lar medical attendance, but took on his own account salt and oil ; and under this regalar
purgative, the dropsical swelling progressively declined and disappeared. Daring this Mtack
he did not intermit daily work. The second attack occurred six months after, in the month
of July, 18G9; cold was in like manner the exciting cause; was acting as a butcher, and
carried his meat around to the markets at night, and took cold after being exposed to a coo!
rain all night. The swelling in this attack lasted two months, and he had no medicine, except
that which he took himself, viz : Castor Oil, Epsom Salts and Lemonade.
The third and last attack occurred about the 1st of July, 1870; worked in an ice bouse;
entered the cold ice chamber whilst in a profuse perspiration. The sudden check of perspi-
ration was followed by dull pain in the region of the kidneys, and the lower extremities coo-
menced to swell two or three days afterwards.
Entered ward 25, bed 374, Charity Hospital, February 1st, 1871 ; abdomen greatly disteodcl
with dropsical effusion ; blood-vessels of surface of abdomen prominent and arborescent ; drop-
sical effusion into the abdomen, bounded very distinctly by the diaphragm ; face and apprr
extremities emaciated as well as the thorax ; lower extremities and scrotum, and penis, dis-
tended with the dropsical effusion. Urine high colored and loaded with biliary matters aai
albumen. No disease of heart or lungs.
Diognosis : Cirrhosis of Liver ; Bright's Disease of Kidney. Dropsical effusion clearly refrr-
able to both the Liver and Kidney diseases. This diagnosis was confirmed not only by the pres-
ence of biliary matters and albumen in the urine, but also from the unsattsfactory effects of
both purgatives and diuretics in the treatment of the case. These!agents hardly restraiaed thr
dropsy within its original limits, and at the end of three weeks I found it necessary to tap the
abdomen. About IJ gallons of serous fluid were drawn off with temporary relief. When I
resigned the word, at the close of my regular annual term of service, on the 16tb April, th t
patient was in pretty much the same condition.
Case 698 : Dropsy resulting from Bright* s Diseate of the Kidneys. — Frederick Uayer ; aged r: •
years ; height 5 feet 7 inches; weight 160 pounds; light, sandy colored hair; blae eyes, f^T
complexion; native of 4Sweden ; laborer by occupation; has generally enjoyed good be«li>i
with the exception of chills and fever in tbe last two years.
Admitted March 21st, 1869, to Charity HospiUl, ward 29, bed 422; cede ma of theIo«tr
extremities; scrotum and penis greatly distended with serous effusion; some effasiea it
abdominal cavity ; face puffed ; complexion sallow and wax like ; action of heart somewhat
irregular, with a slight murmur in the first sound ; slight cough attended with pain, rtfcrrei
to the precordial region ; cough most troublesome during the night ; very slight expectora-
tion ; percussion sounds over lungs duller than in health, indicating oedema of those orgaa*.
with some pleuritic effusion. Pntient has a large and well formed chest and there are t ^
symptoms of tuberculosis. No enlargement of the heart was detected, and the cardiac anr-
mur was referred chiefly to the aoKmic state of the blood. Bowels regular. Tbe rfjay*-^*
that this was a case of Brioht's Diseasb, was still further confirmed by an examination of t»e
urine. Heat and nitric acid showed the presence of albumen in the nrine and casts of i^ •
urinary tabes of the kidneys were detected in moderate abundance under the microscope
The bowels were opened freely with Compound Cathartic Pills, and tbe attempt wat made
to excite and increase the action of the kidneys, by the Cream of Tartar and Jnniptr Berry
Dropsy arising from Lesions of the Kidneys, 039
mixture previously described. Under this treatment the urine increased in amount, the pulse
became regular ; the tongue cleaned ; the bowels were moved regularly every day ; and the
patient became more active and cheerful, and there was a marked diminution of the anasarca.
April 3d. — Amount of urine passed f. ozs Ixxvi ; pale yellow ; speci6c gravity, 1013 ; upon
application of heat, the albumen, after coagulation, filled one-fifth of the test-tube.
April 4th. — Pulse 76 ; respiration 20; tongue clean, appetite good ; bowels regular; sallow,
unhealthy, wax-like complexion. Amount of urine passed, f. ozs. Ixxvi ; specific gravity,
1013, amber colored*; contains casts of tubuli uriniferi and albumen. Under the use of the
Cream of Tartar and Juniper Berry tea, the swelling is slowly diminishing, and the general
condition of the patient improving.
The patient under the persistent use of diuretics and gentle purgatives and simple but nutri-
tfoos diet, slowly improved, and left the hospital at the end of April ; the swelling bad not
entirely disappeared, but the patient left of his own accord.
My attention was again called to this patient in the month of August, 1869 ; he had returned
to the hospital in a most distressing condition, with general anasarca, and the abdomen
enormously distended with dropsical efTusion. The scrotum was so greatly distended that
the skin burst, and from the cracks the serous fluid issued.
The patient was not then under my treatment, and I was not informed what measures were
instituted for bis relief, beyond the free use of squill and calomel. The patient died about
the middle of September; no post-mortem was held as his friends claimed the body.
Case 699: Dropty ruulting from BriphVs Ditease of the Kidnryt. — John Shone. The patient
gave the following history: Was admitted to Charity Hospital in 1858, with what be terms
swamp fever, and was discharged in one week, after which time was attacked with dropsy,
and then entered the Marine Hospital, where he remained three weeks. The dropsy was
relieved, and be enjoyed good health for the space of two years ; at the end of which time he
began to be afflicted with periodic headaches and vomiting.
Entered the Charity Hospital, on the first of February, 1869, and was treated for albumi-
nuria, and left of his own accord, on the 16th, and returned again on the 5th of March. The
patient appears to have been benefitted by a mixture composed of Tincture of Sesquichloride
of Iron, Digitalis and Nux Vomica. Purgation is said to have given the greatest relief to the
pain in the head and vomiting.
Came under my treatment in ward 18, bed 264, on the 26th March, 1869. Age 26 ; height
five feet eight and a half inches ; weight in health one hundred and eighty-five pounds, at the
present time one hundred and seventy-two pounds ; has a large and well proportioned frame ;
color of hair red and sandy; eyes blue; complexion in health florid; native of Germany;
seaman; has no hereditary tendencies as far as known.
Complexion sallow, and of a waxen hue; bowels constipated, except when moved by pur-
gatives; skin soft and moist; tongue red around the edge and tip ; pulse regular ; impulse of
heart regular, but a murmur is heard over the region of the aortic valves, synchronous with
systolic impulse of the heart ; respiration natural ; temperature of axilla 98^.5 F. The
features are full, swollen and oedematous, and the cheeks hang in a dead flabby manner, and
the expression of the countenance is heavy, though not disagreeable, and there is no expres-
sion of pain or distress. The cellular tissue generally of the body, and especially of the
lower extremities, is a*dematous and pits when pressed, and the pits formed by the pressure
of the fingers remain for a great length of time. The urinary secretion is abundant, and
cootAins both albumen and casts. The patient suffers, periodically about every seven days,
with attacks of severe headache and vomiting. The patient was placed upon the Cream of
Tartar mixture as a diuretic, and the bowels kept open by the compound Jalap powder mixed
in molasses.
May 30th.<^The condition of the patient much the same ; his spells of vomiting have not
recurred so frequently ; sufiters with considerable dyspnoea during the spells of headache and
vomiting. The amount of albumen has decreased somewhat, ranging from one-eight to one-
twelfth in moist volume. The patient is still taking the infusion of Juniper Berries and Cream
of Tartar, together with the Tincture of Muriate of Iron.
June 22d. — Patient suffering greatly with dyi^nosa ; pale, anaemic ; action of heart tumul-
tuous ; great difficulty in filling the lungs ; the left lung is dull upon percussion, from the
diaphragm or borders of the ribs upwards to the nipple, between the fourth and fifth ribs.
Upon careful examination of the patient in the sitting and recumbent posture, it is evident
that a considerable amount of fluid has been effused into the pleural cavity of the left lung,
compressing and embarrassing its action. Right lung more resonant than left, but there is
evidently some effusion upon this side also. Dullness upon percussion, over region of heart,
greater than normal. Action of heart irregular, and sounds indistinct; blowing sound with
the fint sound, whilst the second sound is prolonged. Serous efl'usion in abdominal cavity,
with tenderness in epigastric and hypochondriac regions.
Tlie following table will present in a condensed form some of the chief pymptoms :
640
Dropsy arising from Lesions of the Kidneys.
DATE.
e
1
1 •
1 •
a
1 i
o '
TO
1 Q
April 1st, 18G9, 9 a. m. 72
" 2d, •' ,721
3d, 1869, 5 p. M.'72{
4lh, 1869,9 a. M.I70
6th, " 70'
Cth, " 80
7th, '* 82
8th, " 82
8th, 1869, 6 p. M.'86'
9th, 1869, 9 a.m. 83'
10th, " 88'
12-13 88
14th, 9 A. M 90
13-16 90
17-20 '8O:
2l8t, 9 a. M '90'
22d, " 90'
24-25, " 8O'
26th, <' 82
27th-MBy l8t 80
May 2d-9th 82
" 11-15 82
" 16-24 82
•* 26-30 80!
June 6th i80'
u
<(
It
<i
(I
i<
((
C(
((
(<
((
l(
i<
u
(t
i(
t(
l(
18
18!
18!
18
22
e 2
"^3
aiABACTEBS OF UBINIC,
F.
98.5
98.5
99.5
98.
99.5
99.
99.2
08.5 I
' 100.5 '
' 100. j
, 99.5
09.
00.
00.
09-100
, 09.2
100.7 I
100.5
100.5
100.5 I
ICO. .
99.5-10
90.
90.
99.5
Am't in
M hrs.
lO OSS.
C8
110
110
150
45
72
75
75
100
I 100
83
80
85
75-85
65
50
GO
60
80
100
70
35-75
40-50
35-65
40-65
Sp. Or.
1010
1010
1010
1010
1014
1013
1012
1012
1010
, 1010
1010
1010
1010
1010
1010
1014
1010
1010
1009
1009
1010
1010
1010
1010-1012
1012
BEMABK&
Color. lAlbu
j ID«D.j
reddish
yellow
amher
pale
yellow
t
In bed and snffering with
headache.
Headache.
M
1
K
I During night headache.
f
1
I
t
I
1
1
i-yV Headache and dyspoota.
On 20th, headache aoii
vomiting.
Do. do.
Do. do.
Headache.
In conjunction with Dr. B. A. Pope, this patient, together with several other cases of Brigbt'f
Disease, under my treatment, were subjected to a careful examination with the ophtbalmr'-
scope; the characteristic alterations of the retina indicative of Bright's Disease, were dit-
covered, although they were absent in other cases of this disease ; thus showing that tbf
ophthalmoscope is incapable of indicating the disease in all cases.
This patient left the ward for another on the 23d of June, and passed from my care tnJ
treatment.
I was informed that afier the transfer, the diuretics and purgatives were discontinued. a.-)i
the dropsy rapidly increased, and the patient died about the middle of July.
In this case, the dropsical effusion was restrained wilhin certain limits by thejudidoc*
use of diuretics and purgatives, and as soon as they were discontinued, death speedily ea-
sued.
Casi 700 : Dropty Resulting from Bright' a Diaeate of Kidney. — Charles Daley, age 60, height '
feet 5 inches, weight in health 140 lbs.; left leg shorter than right, from having had compoan^
fracture of both tibia and fibula; the patella is now quite prominent; black hair, hasci eyes.
florid complexion in health ; native of Ireland, laborer; no constitutional tendencies as frr as
could be gathered ffom statements concerning the health and diseases of hit relatives; bai
never had syphilis or scrofula ; has been in the habit of drinking whisky freely, at tines t*'
excess, for forty years ; has enjoyed pretty good health, with the exception of a spell of ch:.
and fever about five years ago.
Was admitted to the Charity Hospital on the 15ib March, 1869, ward 29, bed 429, wi'L
general anasarca and with albuminous urine. The anasarca appears to have come oa gra<
dually.
Complexion sallow, and of a \^ftxy appearance. Features swollen. Trunk and extremii'**
L'dematous ; pressure causes pits which disappear very slowly. Appetite and spirits vtr?
IV
good, but muscular and norvous forces depressed. Diagnosis; Bright's Disease of the k<--
nevs.
The patient was placed upon the Cream of Tartar and Juniper-Berry Tea, Tincture of tke
Sesquichloride of Iron and nutritious diet, and the bowels were kept gently open by sal re
purgatives.
March 30tb. — Patient appears to be improving; the amount of urine hat incrttfed; the
complexion is somewhat clearer, and the anasarca has disappeared to a considfrablt extet:
I>r^sy arising frm le$ian$ tf the Midrn^^
641
W#ifht it the prelent time About one huadred and tweaty poandd. Patient cheerfiil, with
a good etvrefifoQ of eyei , but it rerj weak aod oonllned to bed most of the time. Bowels
regular; skin Softer and more moiit. Tongne natural. Urine loaded with albumen and
ciitf.
iht following table will exhibit some of the more prominent symptoms :
S5S
PATK
April 1ft, 1869, 9 A.M...
" Sd, "
9d, IS6S. 6 P. A...
4th, ues, 9A.M.
5th,
«th,
7lh,
Sw, 1S6S, 6 P. Mm.
Sth,lSeB.9A.M..,
u
H
n
H
M
•I
- 10th.
't.
•
• 1
18
75
75
18
75
18
75
18
98
25
• ••
•«•
••,•
• •■
■ ••
•••
• ••
••■
• ••
• ••
98
26
2
5
•g,
M
!98,
83^5 97.5
99.5
Iftft
• ••■•« J VO«
'97.5
t«« •• •
1005 1
98^1
98U>I
Sftllow.
feftturef
•WoU«B.
•t.
GHAEAGTSBt OV UBIIIE.
ABl>t of I
Urine In
M konn.
I r. ot.
Speolio Color of
Ofnnty UrlBC.
AssoRMAL Coxtrrrosxit.
I
Confined
tolMd.
Lies on
btch.
• ••
•« t
i
52
IOCS
S4
1010
30
1010
ao
lOM
32
1010
40 J
1010
lis
1006
3R
MIO
95
•»•»••
S
loia
11
1025
Tellow
AlbaiMiL
Catttof TttbuU Vriotferi.
H
«»
M
•i
April lOtb.— Lungs dull upon percussion, and there is a decided htoreaso of heat tvety day
towards night. The urinary secretion progreisirely decreased, and with this decrease the
swelling increased in the cellular tissue and abdominal carity.
Ob the 12th of April, the patient got out of bed, and passed a portion of the day on the
gallery In the rear of the ward. The day was damp, rainy and cold, from this exposure the
patient contracted a serere bronchitis, which seemed to prostrate him grOsrtly, andThe grada*
Allyjgrew worse, and died on the 5th of May. Death was preceded by ooaTUMoas aad c6ma.
Toe post-mortem examination revealed adheiions of the lirer, stomach, heart and Tnngs to
their respective serous carities and membranei ; the lirer was congested ; spleen aortoal ;
longs contained miliary tubercles ; kidneys in a itate of fatty degeneration.
Oasi 701 : Drcp9if ruMng from Brighi'% JHteoie of the Kidn^9.^o}sn Crowley, s^cstfAA ;
aatire of PennsyiTania ; age 37. No hereditary tendencies can be traced. Bad syphilTs
iwelTe years ago ; the disease is said to hare yielded readily to treatment, and disappeared in
three weeks. Well made, muscular man, with full, well developed chest ; blue eyes, fight
rellow hair. During his sea-faring life has been in the habit of using strong aleoboUc stimu-
lants freely. During a portion of his life has acied as fireman on board steamship, and whifst
perform^Bg his duty, would frequently be exposed to sudden chaiftges of teitoperatvre, and to
wet and cold, and at inch times would indulge freely in atcoholvc stittnifhivts. Xi^oyed good
health up to the last twelve monthi, when he was shipwrecked, and remained In the water
some Bine hours, and contracted a severe cold, from the effects of ^hleh the patient baf suf-
fered, in the way of a ilight cough, up to the present time.
Sntered Charity Hospital, ward No. 13, bed 199, December 8tb, 1869. features of face
swollen ,* slight serous effuiion in abdominal cavity ; lower extremities oedematons, pitting
on pressure ; scrotum swollen ; complexion has a tallow, wax*like appearance ; nr^BO albu-
naiaous, and, under the microscope, loaded with casts of the tubnii uriniferi. ITpotk: ansculta-
tlon, snb-crepitant rales are heard in the anterior portion of the ri|^t lung, referred to chronic
irritation of the bronchial tubes ; no signs of tubercular deposit were discovered. The heart
sounds are not altogether normal, and the soft murmur was referred to the ansmlc condition
of the blood. Liver slightly enlarged. Excretion^if kidneys angmonted ; the Amount Of arjue
passed daily ranging from eighty-eight to one hundred and eleven ffuidonftc^s. of low specific
gravity, ranging from 1 008 to 1 009. Patient says that during the last three weeks he has been
easily ^tigued, and during the last twelve months, has suffered with pain in his back, in the
region of the kidneys, but has been following bis usual occupation to within the last month.
Temperature of axilla 98^.8 P.; pulse 72 ; respiration 18. Amount of urine passed during
tbe last 24 hours 88 fluidonnces; sp. gr. 1009. When the urine was subjected to the action
of heat and nitric acid, the moist, coagulated albumen filled one-fSfth of the test-tube. ¥he
psrtiant was placed upon the Cream of Tartar, and Juniper berry tea, Tincture of Ses^fui-
chloride of Iron and simple but nutritious diet.
December 18th. — The apex beat of the heart is most forcible to the left ef nipple ; percus-
sion also renders it probable that tbe left ventricle is bypertrophied to some extent. Auscul-
tatiOB over region of heart reveals a soft murmur, heard loudest over base of the heart during
aeeond sound ; it is also heard at apex, with loss of murmur over body of heart, the sound
beiBg transmitted along arch of aorta, but not from apex towards spinal cofnmn. The veins
o/the upper portion of (be c^ept are somewhat enlarged and congested, fstl^flt suffers t1t¥
642 Drcpsy arising from Lesions cf the Kidneys*
coQgh and oppressioa of breaihiog after exertion . The respiraUon is proUiifed with conaid*
arable ronchus, with a few sibilant rales. The lungs are duller upon percuss ion than to
health, and there is some effusion in both pleura. The dullness upon perentsion appears to
be due in part, also especiallj in the infra-claTicular and clavicular regions, to oedema of the
pulmonary tissue. The cardiac murmur is probably due, not only to the ansmic stata of the
blood, but also to fatty or calcareous degeneration of the aortic ralres, permitting some
regurgitation of the blood into the left ventricle. The urine contains albumen in abundance,
with casts of the tubuli urinlferi. The amount of urine passed during the twtnty-four hours
has ranged from sixty to one hundred flnidounces. The temperature of the axilla ranged, in
the morning, from 09° to lOO^' F., and in the evening, from 9S^5 to 101^
Under the use of the diuretics and gentle purgatives, the anasarca has slowly diminished,
and the patient oppears to be more comfortable. There are times, however, when the nerrons
system is much disturbed, (headache, restlessness and dilatation of the pupils), apparently
from the retention of the constituents of the urine.
Dec. 20th. — In addition to the preceding treatment, the warm bath at bed-time, and the
steam bath, (prepared by beating a brick and pouring water over it while nuder the bed
clothes), were ordered ; and as a tonic and gentle stimulant, a tablespoonfhl of Hnxhass's
Tincture of Bark, three times a day, one hour before each meal.
Dec. 21st. — In order still further to act upon the skin and kidneys, Syrup of Squills and
Syrup of Ipecac were ordered in doses just sufficient to induce nausea, but not vomiting.
Dec. 31st. — During the past twenty-four hours has, been affected with vomltiog ; pupils
greatly dilated, with dull pain in head, lethargy of intellect and imperfect vision. At times
one pupil is dilated and the other contracted.
January 3d.— Vomiting and dilatation of pupils continue.
January 10th. — Patient feels much better than he did a week ago, has ceased to vomit, and
the pupils are not dilated.
. Januarv 13th. — Condition appears to be improved, the cedema has almost entirely disap-
peared ; |he lungs also are much less dull upon percussion. The same treatment haa been
continued up to the present time.
January 24th. — Patient has not been doing so well during the past five days. The Cream of
Tartar mixture has disagreed with his stomach, and it has been necessary to iotarmit the
diuretic. Pupils dilated. (Edema of extremities increasing. The cessation of the diuretic
medicine has been attended with a marked diminution of urine, only twenty-nine fluldooaces,
of low sp. gr. (1010) were excreted during the past twenty-four hours. The amonnt of alba*
men in the urine has also increased, and it now reaches one-fourth of the volume in tha test-
tube, when heat is applied. The bowels were opened by ten grains of the Extract of Rhabarfo,
and on the following morning the patient appeared to be less lethargic and more chetrfut,
and the pupils were not so widely dilated.
January 26th.— Patient rested badly during the night ; complains of pain In the lower part
of the abdomen ; pupils of eyes greatly dilated ; nervous and restless ; oppression in breath*
log ; stomach very irritable, qbstinate vomiting whenever the Cream of Tartar mixture is
administered. Four grains of Iodide Potassium were substituted, three times a day.
January 28th.— Patient rested badly and was disturbed by frightful dreams. Pnpils still
more dilated ; stomach irritable. (Edema increasing.
January 29th.«^Re8t imperfect and trouble^ ; pnpils dilated ; patient feels very weak aal
dfpressed.
February 1st.— rCough and oppression of breathipg increasing; patient weak, and depressed,
and nervous ; can retaio but little upon his stomach) from the nausea and vomiting. It li
impossible to administer sufficient medicine to act upon the kldpeys which secrete not one*
half the former amount of urine. The urine ip not only diminished in amount, bnt it is of
low sp. gr„ (lOlQ), and loaded with albumen and casts. It is evident that the constitneats of
tho urine are bnt partially eliminated. The warm bath and the hot air bath fulfil the oflca
of the diuretic mixture but imperfectly.
^ February 8th. — The coqdition of the patient has continued steadily to grow worse, ths
nervous symptoms incraaaing, and the anasarca in like manner angmeatlng . Patient rtrj
veak, unable to get out of bed, and passes his urine in small quantities and InToluatarily,
The patient lies in a dull, lethargic state, with pupils widely dilated, as if under the inflo-
euce of some powerful narcotic poiso^n. Urine scant, and loaded with albumen and nriosrj
casts.
February 9th. — Continues to grow worse, and more feeble ; is notable to move In bed with*
out suffering great pain ; has been vomiting almost incessantly during the past tweoty-foar
hours ; the fluid ejected reseijobles mills. Urinary excretion suppressed, bowels constipated,
constant hiccough.
February lOtb. — ^Vomitiog cootinuea, but the matters ejected have changed color, belni:
green instead of white. Pupils greatly dilated, muscles of extremitiea trembling, Intellect
dull and lethargic ; wH^p aroused, appears to h.e under the inf\uence of somepowerfiilpoitoa.
Dropsy arising from Lesions of the Kidneys. 643
The BlightCBt tOQch upon the sarface causes paio. The patient continued in tliis state, with
Tomittng, and hiccough, and suppression of urine, and died FebriHiry 11th.
The following table (page 644) presents the changes of the pulse, respiration, and temper-
atare, and the amounts of urine.
A nainber of other cases of Brighfs Disease have beeo uader observation daring our
medical service in the Charity Hospital, and careful post-mortem examinations were
made in the pretence of the Medical Class ; and it was observed that the degeneration
of the kidneys was frequently associated with fatty degeneration of the liver, heart and
arteries. These diseases occmr most commonly in the ill-fed and ill-conditioned laboreri
and drunkards, who consume the alcoholic stimulants undiluted, and to a great extent
substitute them for more substantial food. Fatty degeneration, cirrhosis of the liver,
and Bright's Disease of the kidney, oppear therefore to depend in a measure upon
similar causes.
It is also worthy of note that the temperature in this class of diseases, does not rise
to the height that it does in phthisis and idiopathic fevers ; but still the temperature
of the trunk is elevated above that of health, and is also subject to morbid perturba-
tions.
■
The truth of this observation might be illustrated by numerous observations upon
variouR diseases, recorded under our direction, but these must be deferred for the
present.
We will conclude these observations on the different causes of dropsy, with some gen-
eral observations on the .
TBSATHENt OF DROPSY ARISING FROM BRIQHT's DISEASE OF THE KIDNEYS.
There are so many minute yet important modifications, depending upon constitutional
peculiarities, habits of life, and special conditions of age, climate, and inherited or ac-
qtiired constitutions, that it is difficult to describe in detail, the treatment of any dis-
ease ; and the attempt is especially difficult in diseases of the kidney. We shall there-
fore attempt nothing more than the indication of those general principles of treatment
which should be kept at all times clearly in view. The student should ever remember
that DO description, however minute, will relieve him of the duty of studying each case
carefully by the bed-side, and of adapting his remedial agents and measures to the
causes of the disease, and the symptoms and the natural or acquired constitution of each
patient.
In chronic disease of the kidneys, it is almost always necessary to continue the plan
of treatment persistently for a length of time ; and without general principles, only
disq)pointment will result from the frequent change of remedies. In this class of
dtaeases, it is especially necessary that we should not only remove the secondary
eflfecta of the diseased action, but also correct, as far as possible, the morbid action
of distant organs, and relieve the kidneys by the supplementary function imposed
upon them. The supplementary actions of the skin and gastro-intestinal mem-
brane, are of the most important character, and the ph vsician should be careful lest con-
vulsions and coma, and even death may follow the sudden and injudicious arrest of the
vomiting and diarrhoea, by which the constituents of the urine are eliminated and
cast out of the system. It should be borne in mind also that the effusions in di'^eases of
the kidneys are not simple in their character as in cardiac and hepatic dropsy, but they
contain urea and other constituents of the urine ; and the very act of effusion may be a
process of purification of the blood. Hence even bandages to the lower extremities
should be applied with caution or wholly abandoned, as tendint; to throw the effusion
upon important internal organs; and for the same reason, th3 recumbent position
nhould not be retained too long, and the patient should take moderate exercise, as by
this means the internal organs, and especially the kidneys, are relieved, t^ a certain
extent, from the dropsical effusion.
Am the skin and even the lungs may act ss supplementary organs to the kidneys,
644
Droffn aritiMQ from Lesions qf the Kieht^s.
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Dropsji wrUingfrom Leriom ^f ITm Kidney$. 645
special attendon ahonld be paid to the clothing and to the sarrounding temperature and
hygrometric condition ol the atmoBphere,
The amount and character of the urinary aecretion may also be greatly influenced by
diet. It is well eatabliahed that an ezclusire diet of meat greatly increases the nitrogen-
iaed dements, (urea and uric acid, etc.) of the urine, whilst an exclusive farinaceous
diet greatly diminishes these constituents of the urinaiy excretion. The importance of
attention to the diet is placed in a dear light, when the relations of the retained uxea
to the nerrous phenomena and convulsions characteristic of Bright's Disease are con-
sidered.
Alcoholic stimulants, and sdmulating diuretics not only induce the disease, but when
persisted in, they aggravate the symptoms and accelerate its progress. Alcoholic stim*
ulants should be wiwdrawn at the earliest possible moment.
In the acute form of Bright 's Disease dependent upon the action of cold or the poison
of scarlet fever, the bowels should be kept freely open by saline purgatives, and the
congestion of Uie kidneys relieved as far as possible, by cut cups and leeches over the
region of the kidnevs, and the function of the akin should be fredy excited by the
warm bath, hot bath, vapor bath, and warm clothing. As purgatives, the compound
jalap powder, or cpeom salts, or a combination of carbonate of magnesia and epsom salts
(magnes. carb. gr. vi ; masnes. sulph. one drachm to one and a half drachms ;. aqu» month,
pip. one and a half fluidounces; mix; administer every four or six hours), may be
employed. As a general rule, mercurials should be avoided in both acute and chronic
Bnght's Disease.
nie diet shonld be of the severest antiphlogistic character, composed chiefly of fari-
naceous substances ; for in the acute form, the blood is not sufficiently detenorated to
demand rich nitrogeniaed food, and but littJe diet is wanted.
Stimulating diuretics are contra-indicated, and in order to excite the action of the kid*
neys, and to promote also the absorption of the dropsical eflfnsion, such diuretics as the
Acetate of Ammonia, and Bitartratc and Tartrate of Potassa, and the Seltserand Vichy
waters may be employed.
When convulsions and coma supervene in consequence of the retention of the urea in
the blood, local depletion by leeches and cupping to the temples, and in some cases geu"
eral blood-letting, and blisters to the shaven scalp, are in conjunction with the hot bath
and brisk purgation with elaterium and brisk bydragogue cathartics the main measures
to be instituted.
In the treatment of the chronic form of Bright*s Disease, the patient should be
required to dress warm, with flannd next the skin, he should occupy a dry and warm
dwelling, and avoid all changes of the temperature, and all exposure to the night air, or
to cold, damp weather. When the circumstances will permit of it, the patient should
remove to a warm, moist climate, for by this change, not only in the function of the skin
excited to increased activity, but the changes of the body are less, and the amount of
work performed by the kidneys necessarily diminished.
Owing to the constant loss of albumen from the blood, as well as to the poisonous
action of the constituents of the urine, it is necessary that the diet should be more
nutritious than in the acute form.
The German phyaidans have claimed important results in the treatment of chronic
Bright*8 Disease, by confining the patients to an exclusive diet of milk, without any
medicine whatever. In this plan of treatment, from five to six pints of ^ood undiluted
cow*8 milk were adminbcered dailv ; and some of the patients, who prior to the treat-
ment, had been in the most wretched condition, got rid of tiieir dropsy, recovered an
appearance of health, and regained so much of their strength, as to oe able to resume
their business and even to perform hard labor.
Prom the active measures should be exduded blood-letting; and mercurials; and
reliaoce, for the rdief of dronsy especially, and the dimination of the ddeterious
materials flrom the blood, shoula be placed on the judidous establishment of diaphoresis,
diuresis and purgation.
M6 Dr(^sy anting from Leiioiu of th« Kidnej/t.
One of the most efficieat modes of establishiDp; active diapboreeU u preTionsI; indi-
cated, is by tbe daily use of the hot batb, folloired by sveatiog for one or two honiB ia
voollen blankete. '
Stimalatjnf; diaretica should be avoided on acconDt of their irritating action on tbe
kidneys; snch diuretics as the Tartrate and Bitaitrate of Potossa, may be employed
persistentiy for a great len^h of time, and as far aa my experience extends, if aaminit-
tered in a manner previon^y recommended, their action is always sttended with benelt
and relief of the dropsical symptoms.
Of coarse, in those cases where the stomach is so irritable that neither the Cream of
Tartar nor any other diuretic ia home, there u little or no chance of recoTeiy.
Tbe dropsy may also be controlled, and to a certain extent, relieved, by the jndicjons
employment of aueh purgatives as Elaterium, Colocynth, Componnd Powder of Jalap,
Cream of Tartar and Sulphur, Epsom Salts and Olanber Soils.
It sbonld be borne in mind that the duratiou and reaulta of Brighi's Diaeaae, dqtend
upon the extent to which tbe kidneys have been altered ; the moat frequent tertDination
being death, cansed either directly by the affection of the kidney, or by interaurent
inflammation ; complete recovery may take place, but it is very rare ; some eaaea run
their entire conlse in a period of from six weeks to three months, and in others the
malady continues for years. Although in most cases, a cure may not be efleeted, the
phvsioian may accomplish much good by relieving the symptoms and prolonging life.
It is important therefore in a disease of snob a chronic nature, that the eonticnal
tendency to the deterioration of tbe blood, should be counteracted by the nse of Iron
and Quinine, and nutritious diet.
OBSERVATIONS
ON
DISEASES OF THE RESPIRATORY SYSTEM.
INVESTIGATIONS
ON THE PREVALENCE AND FATALITY
ov
PNEUMONIA
IN THE CONFEDERATE ARMY, DURING THE AMERICAN CIVIL
WAR-1861-1865:
WRH PBAOnOAL OBBEBVATIOIB 01 THE
BELATIYE TALVE OF THE YABIOUS MODES OF TREATING
PNEUMONU.
INVESTIGATIONS ON THE PREVALENCE AND FATALITY OF PNEU
MONIA IN THE CONFEDERATE ARMY DURING THE AMERI-
CAN CIVIL WAR OF 1861-1865: WITH PRACTICAL OB-
SERVATIONS ON THE RELATIVE VALUE OF
THE DIFFERENT MODES OF TREATING
PNEUMONIA,
CH APTKR XVI.
ON TUB PUKVALEMCK AND FATALITY OFPNKrjIUNIA AND OKTYIMIOIU KKYKU IX THK CUM'KP.
KRATK ARMY DrRINCJ THE WAB OF IHOl-lMVi.
Importance of Pneumonia in view of its Prevalence and Fatality. Table giving Mean Strengtli,
the Total of Sick and Wounded, the Cases of Pneumonia, and the Percentage of Pneumonia
in Mean Strength, etc., in the Confederate Army during Nineteen Months, 1 862-1 8G3.
Analyiii of tbii Table. Cases most Numerous in the Winter and Spring Months. Table
illustrating the Prevalence of Pneumonia in the Armies serving in Different Sections of the
(Confederate States. Cases in Virj^inia ; in the Army of the West, etc. Cases of, and
Deaths from. Pneumonia, Typhoid Fever, and other Diseases in the General Hospitals of the
Army of the Potomac, Northern Virginia and other Hospitals, during Fifteen Months, in
1862-1863. Common Continued and Typhoid Fever identical. Percentage of Deaths from
Pneumonia. Fatality from Pneumonia and Typhoid Fever. Fatality from other Diseases.
Cases of, and Deaths from, Typhoid Fever. Pneumonia, and some other Diseases in the
General Hospitals in and around Richmond, during Seven Months, in 1802-63. Cases of,
and Deaths from. Pneumonia, Typhoid Fever and several other D'seases, in the General
Hospitals in Virginia. Cases of, and Deaths from, Pneumonia and some other Diseases, in
the General Hospital at Charlottesville, Va., during Twenty*8ix Months, from July, 1861 to
Angnst, 1863. Fatality in Hospitals at Savannah, of Pneumonia and Typhoid Fever. Table
showing the Numerical Relations of, (*ases of, and Deaths from. Typhoid Fever and Pneu*
monia, In the General Hospitals in Virginia and Georgia. Progressive Diminution of the
Prevalence of Typhoid Fever during the War. Table illiistrating the Numerical Relations
of Pnenmonia and Typhoid Fever in the Confederate Armies during Nineteen Months, 1862-
63, Cases and Deaths from all Causes, and Cases of, and Deaths from. Pneumonia and
Typhoid Fever in the General Hospital* of Charlottesville and Staunton, Va.
The prevalence of Piieuniouia in the (*onfc'<lenite Army, and the high nite of mor-
tality amongat the casett treated in the field and in the general hoBpitaln, invested thit*
diaeue witli peculiar interest and importanee ; and the writer urged upon the Surgeon-
iieneral the importance of a thorough examination of the relative value of the different
modes of treatment employed by the (Confederate Surgeons. The following pQge«
contain facts relating to Pneumonia, which were contained in a ro|)ort to the Surgeot\*
(iencral during the progrew* of the recent civil war :
G50
Pneumonia in Confederate Army.
Tabu giving the dfean Strength, Officers and Men, the Total Sick and Wounded, and the Total Guet o
Pneumonia, and the Percentage of Pneumonia in Mean Strength, and in Sick and Wounded «» <*'
Confederate Army during Nineteen Months, January, 1862, to July, 1863, ConsoUdaUd from Field
and Hospital Reports, hy Joseph Jones, M. D., Surgeon Provisional Army C. S. A.
FIELD REPORTS.
HOSPITAL REPORTS.
a
■
biontk am>
Year.
If
E
§§
e ,
^ M
1|
1
-2
•
n
— b
S
3
X
H
' f
« a
1802.
JaDuary
February... .
March
April
May
June
July
August ,
September .
October
Xorember. .
December...
1863.
Janoary
February...
March
April
May
June
July
r'S
§
i
a
9 ,
H
a
£6
232,138
219,069
165,047
58,304
58,690
136.362
79,999
113,407
125,408
156,734
270,480
172,800
192,776
215,458
313,848
190,518
163,711
107,153j
72,396
ToUl I 160,231
90,757
71,672,
50,385
23,243
25^985
78,583!
41,700'
50,9871
42,450'
48,605
71,328
67,461
76,620
60,135^
92,788'
60,407
49,589'
33,805,
20,849;
115,416;
96,463;
63,387
27,559
30,491
94,487
55,9971
64,436
51,432:
59,841 1
90,472
85,769!
96,053i
80,889!
117,1711
74,806!
63,211'
43,l!4
24,807
3,960
2,041 '
1,849'
891
360
881
826
430i
179
3841
2,282
2,985;
1.70
0.93
1.12
0.06
0.61
0.65
1.03
0.379
0.142
0.245
0.84
1.72
1,057,349
2,676 1.38
1,997. 0.92
2,816' 0.89
1,779 0.93
1,593 0.97
26710.249,0.79
77' 0.106 0.37
a
a. V H
= S
S B 0
p.
4.35
2.84
3.67
3.83
1.38
1.12
1.98
0.84
0.421
0.79
3.20
4.42
3.49
3.32
3.03
2.94
3.20
9
h
e a
a
m
i
i
e
s
3
* 2
- ««
5-?
ill
til
\\
3,292
2,472j
2,341'
2,543;
9.7001
16,605;
18,918
21,546
46,733'
39,170!
44,890
29,032,
5,727
4,798
3,999
6,784
14,067
26,120
28,437
31,662
55,726'
53,970
50,164
44,282
337 1<» -^
365 10-2
4081 1"-^'"
540;21.2:i
6561
812
491
303
473
465
2,587
1,811
28,273
12,542 27,784 1,117
13,378' 28,652 963
12,809,24,812 1,086
14,884| 26,628 1,252
41,889 57,822 1,130
27,389' 46,702 483'
37,073 55,708 263
6.'*i
4.M*
2.y*
1.4u
l.Ul
l.U
7.1:^
8.41
l.Tt.
397,406
155421
From this table it appears that in the Confederate Army, with a mean monthly
strength of 160,231 officers and men, 1,057,349 cases of disease and wounds wort*
entered upon the field reports daring a period of nineteen months, (January, 1862 t<j
July, 1863, inclusive); and of this numoer Pneumonia constituted 28,273.
seventeen and six tenths per cent, of the mean strength of the army, on an averairc
suffered with Pneumonia during a period of nineteen months ; and this disease cousti*
tuted two and seven tenths per cent, of all cases of disease and wounds entered upw
the field reports.
During this period of nineteen months, 397,406 cases of disease and wouud^i wen-
entered upon the Hospital Jleports, and of this number 15,542 were recorded as Poeu
monia; and this disease, therefore, constituted 3.15 per cent, of all the cases of disa^
and wounds entered upon the Hospital Reports.
The cases of Pneuu^opia entered upon the Field and Hospital Keport^i wore relativtly
most numerous as compared to the mean strength and the total sick and wounded durioi:
the months of Uooember, January, February, March and April ; whilst the smallest
number of cases were recorded upon the field reports and transferred to the genenl
hospitals during the months of August, September and October. As a general niir
"the cascH of Pneumonia diminished, as the temperature became more elevated, and tfce
vicissitudes of the seatipn less marked. The month of July, 1862, is an appareu
exception, but it will bo observed that the number transferred to the general hoaptuU
was very small, only 491, or 2,59 per cent, of all diseases and w:ou]ids ; and dorinjr thr
Pneumonia in Confederate Army,
651
same month, in 1863, the number of cases of Pneumonia is smaller relatively than in
any other month, being only 0.106 per cent, of the mean strength, and 0.98 per cent,
of the sick and wounded transferred to the general hospital.
The disease, therefore, would appear to depend in large measure upon seasons ; or, in
other words, upon the effects of exposure to cold and wet, and to marked vicissitudes of
heat and moisture. The following tables present data for the investigation of the effects
of elevation, geographical position and temperature upon the prevalence of Pneumonia :
Tahiti iUusiraiing the Prevalence of Pueumonia in the Armiet serving in Differrnt Sections of the
Confederate States^ giving Mean Strength^ Cases of Wounds and Diseases entered during each Months
and Cases and Deaths of Pneumonia j [the Deaths given only wheti the records are complete)^ Con-
nohdatedfrom Field and Hospital Records on File in the Surgeon -General's Office^ ai Richmond^ hg
Joseph JoneSy M. />., Surgeon P. A. C. S.
CONFEDBRATK FORCKS SERVING IN VIRGINIA 19(0 NORTH CAROLINA.
Field Rei*orts.
I!
HosriTAL Rkports.
Month and Year.
Moan Strength,
OtflcorM nnd Men.
1862.
Januar/
February
March
April
May
Jane
Jnly
Angast
.September..
October
Norember
December
1863.
Janaary
February
March
April
May
June
July
Total
187,951
181.309
136,970
26,807
27,422
60,642
32,298
50,390
82,406
107,519
148,864
33,568
44,258
59,293
150,362
62,089
45,196
41,756
,39,432
Total Sick tntl
j Wounded en-
I tered during
Month.
73,740
60,413
42,027
10,419
11,393
29,011
12,863
17,349
25,037
29,286
32,141
7,503
13,144
10,937
29,710
10, 264
8,903
9,672
9,355
ToUl Cases
' Pneumonia.
3,247
1,617
1,516
470
205
246
203
94
. 95
227
788
185
307
337
1,094
264
130
68
36
79,396
443,167
11,025
Total Mick and
Wounded en-
tered during
Blouth.
1,690
1,508
1,302
6,048
8,811
9,446
17,318
33,476
29,702
30,724
26,522
11,142
11,969
11,05)
12,893
33,964
24,318
32,052
303 886
Total Outes
Pneumonia.
367
220
187
376
310
177
231
165
256
1,422
1,649
990
880
940
1,079
856
418
220
10,743
()52
Pneumonia in Confederate Army.
Confederate Forres Servhif/ in South (Wolinft, Geonjia mul Florida.
MONTH AND )RAR.
1862.
January
February*
March....
April
May
June :....
July
August
September
October
November
December
1863
January ^.
February
March
April
May
June
July
ToUl
FiRT.i) Kkpoktu
c y •
« V s
iM ^ »i4
19,148
25,262
25,730
28,980
26,313
28,020
22,008
23,784
24,200
25,007
24,710
20,570
19,70!»
31,880
38,901
33,303
20,307
23,109
19,478
25,670
}IO0PITAL REPOBTI.
8,027
6,740
7,305
11,109
11,148
10,487
9,495
10,091
9,807
9,404
7,202
5,7 J2
4,455
7,oo:»
10,157
9,402
7, on
0,372
5,748
157,313
1.)
320 1
82
272
78
281 1
78
407
55
116
104
50
70
57
52
52
57
27
14
19
22
28
29
31
23
28
924
24
23
24
47
75
85
118
151
92
40
§ ^
4
*<' I
10
27
25
14
2
10
1
• • «
1
3
•»
%*
r»
I
8
0
5
3
1
1
£
•
*
32
^5
1
i*
a
"3
i
^ s
2J20 !l27
1 ,002
905
1,039
1,726
2,108
3,643
4,492 I
2,970 I
2,355 !
2,131 .
1,045
1,350 I
1,400
1,309 I
1,758 ;
2,041
1,932 ,
1,634
3,598 I
39,750 '
83
85
20
142
212
232
87
104
5u
30
18
47
28
79
07
77
73
1,584
e
o
70
145
221
287
164
111
61
18
23
lo
37
5*<
127
83
146
173
79
28
16
1,H62
2 4
f.o
4;
59
4'>
I*.
I
4
r.
I*
4 •
(}tn/rifrrate Forces nercinff in (tnd arouuti Moftilc^ on Guif of Mexico,
Fir. LP ANI> HOHrtTAL KlCPORTlt.
Month ani> Ykau.
Mean Stn'iigth Uffi
1862.
January < 8.178
February \ 3,431
March^ '
April ! 2,511
May 4,955
June 7,025
July 3,625
August 9,208
^September 9,425
October 9,126
NoTember 9,571
December 8,923
1863.
January 9,213
February ' 9,231
March 9,417
April 5,121
.May 4,366
June 4,683
July 3,539
ToUl 6,752
Total Sick iuul Total
during Month.
I>ontl
in.
PiicuinonU
Urwik*.
2,918
1J048
1,715
3,444
4,971
3,140
5,296
4,929
4,536
3,899
3.610
3,708
2,845
3,233
1,815
2,063
2,006
3,291
68,453
90
28
• • •
27
140
135
127
158
72
55
67
74
39
41
36
40
58
42
59
1,201
37
1
14
39
23
38
31
11
40
121
114
89
94
84
43
40
H
•*
I
1,163
4
• • •
3
I
3
•
21
•
«t
4
1^
4
15
Pneumonia in Confederate Army,
653
Army of the Wett and &f Tennestet Bervimj in Tentietief^ Kenfuckt/^ Alahanuij and MiuUaifpi.
IfoXTB A5D VRAK.
1862.
Janaarjr
Febmarj
March ,
April
May
June
July
Aagost
September
October
NoTember.......
December
1863.
January %.
February
March
April
May
June
July
ToUl.....
e •> .
S5 O^t
FlKLI) KEPOfcTd.
40,67:>
10,658
30,025
9.311
15,082
33,791
48,058
50,604
63,494
61,226
64,441
55,121
•3
mm
«
'J'S'O
pa c
« s
"S o
34,114
11,197
18,251
2,677
5,379
9,720
19,747
27,066
20,800
27,728
28,169
21,873
t
i
1,435
799
455
29
127
145
1,190
434
520
600
648
■181
a
a
9
S «
0,5
I
*
*5
S o
40,273 j 226,711
6,963 ,6,974 1,090
Hospital KiPOBTd
...
■ • •
462
158 '
469
87 1
267
49
53
6
96
*•
i
498
51
518
123
917
108
1,001
150
1,056
144
977
141
660
67
« • •
•3
S
«
li
_ a
« s
■
a
1
si
A
^ 3
i
31
E?
d£
5,993
1,437
1,423
•■
t
2,010
116
1,484
121
4,151
219
4,980
252
1,258
65
10,902
586
7,347
276
12*527
859
1,160
136
253
116
326
241
42
280
202
,124
114
0
O .
C *
24
14
13
10
• • •
62
37
285
44
• • • ■•
209
• « • ••
195
55
37
31
27
2,916
2,957
44
7
2
542
Army of thr Valley of Virymia, General T. J. Jafkifon.
FiRLD AND Hospital Brports.
MO!CTH JlKD YkaK.
1862.
January
February
March
April ,
May
June
July
August
September
October
Norember
Uecember
1863.
January
February
March
April
May
June
July
Total
Mumi StrpDgtb Offl-
cen and Men.
9,278
8,193
7,418
9,654
16,731
18,099
15,589
15,643
21,123
34,200
Tutal Sick and Total iK-alhii
Wounded enterodl
during Month.
4,956
2,594
1,389
2,014
4,856
8,741
7,613
6,423
5,049
8,663
63
22
75
6
100
216
119
237
298
31
Pneumonia
Oasen.
284
241
38
37
81
83
155
31
10
84
Pneumonia
Deaths.
26
9
3
• • •
o
4.
(;
4
15,582
53,198
1,167
1,034
50
654 Pneumonia in Cor^federate Army.
In the Confederate forces serving in Virginia (chiefly in this State) and North Caro-
lina, with a monthly mean strength of 79,396, during a period of nineteen months,
443,167 cases of disease and wounds were entered upon the field reports, and of thi.<
number pneumonia constituted 11,025; that is on an average during this period.
13.88 per cent, of the mean strength was affected with pneumonia, and this disease
constituted 2,48 per cent, of all cases entered upon the field reports. During the same
period 303,886 sick and wounded were entered upon the hospital reports, and of this
number, 10,743 or 3.53 per cent, were recorded as pneumonia.
In the army of the West, afterwards called the army of Tennessee, which operated
chiefly in the elevated regions of Tennessee, Kentucky, Alabama, and Mississippi, with
a monthly mean strength of 40,273 during a period of twelve months, 226,721 cascj^
of disease and wounds were entered upon the field reports (some of the hospital report.<«
appear to have been lost,) and of this number, pneumonia constituted 6974 ; that is, cm
an average during this period, extending from the first of June 1862, to the 31st of
May, 1863, 17.31 per cent, of the mean strength were attacked by pneumonia, and
this disease constituted 3.07 per cent, of all cases entered npon the field reports ; daring
the period of twelve months (April Ist to October 31st; May 1st to July 3l8t,) in the
hospitals of the West, located in Tennessee, Upper Georgia, and Alabama. 54,672 sick
and wounded were entered upon the reports, and of this number 2957, or 5.43 per
cent., were recorded as pneumonia.
The proportion of cases of pneumonia appears, therefore, to have been greater in the
elevated regions of the West, than in Virginia. It is probable that the modifying
effects of the ocean upon the climate of Virginia, was the chief cause of this difference.
On the other hand, in an army of 25,670 men (average monthly strength,) servtn::
along the low hot coast of South Carolina, Georgia, and Florida, daring a period of
nineteen months, ^ only 8.25 per cent, of the entire command (mean strength) were
attacked by pneumonia; and this disease constituted only 1.35 per cent, of the total
number of diseases and wounds entered upon the field reports.
The percentage of the mean strength attacked npon the Gulf coast, was somewhat
higher even than in the army of Tennessee ; the ratio of the cases of pneumonia bein;;
17.22 per cent, of the monthly mean strength. It is to be observed however, that the
force serving in and around Mobile, on the Gulf coast, was comparatively small, beiDS
only 6752 ofiicers and men, and the statistics embrace both the field and ho^ital
reports. This confusion, therefore, of the field and general hospital reports renden it
impossible to institute a just comparison with the armies of Virginia, Tennessee, an<i
South Carolina, and Georgia. It appears also that the troops of the Golf coait
Were subjected to a more moist and malarious climate than the mass of the troop<9
serving in South Carolina, Georgia and Florida. A large portion of the troops serrio;;
along the Atlantic coast, in the latter department, were encamped in dry, sandy, pin^
barren, healthy locations, which, although elevated but a few feet above the level tvf
the ocean, are, nevertheless, remarkably free from diseases of the pulmonary or^pans of a
serious character.
It appears, therefore, from these statistics, that pneumonia prevailed to the greats
extent in the more elevated and northern regions of the Southern Confederacy, and in
the armies which were subjected to the severest labors, privations, and exposares.
Pneumonia not only prevailed to a considerable extent amongst the Confedenti-
troops, but it was also one of the most fatal of diseases.
Thus in a command with a monthly mean strength of 25,670 men, serving in thv
department of South Carolina, Georgia and Florida, during a period of ninenvn
months (January, 1862, July 1863,) 2220 cases of pneumonia, with 127 deaths, wm
entered upon the field reports, and 1786 cases, with 370 deaths upon the hospiu'
reports. As the cases were in most instances, first entered upon the field reports, ss<i
then transferred to the general hospitals, we will approximate more neariy to the trath
by assuming that the 2220 cases of pneumonia entered upon the field reports, indai'
those also transferred to the general hospitals, and the mortality of the cases tivated in
Pneumonia in Cor^ederate Army. 655
general hospitak, should be added to the mortality of the cases treated in the field ;
thns giving a mortality of 497 in 2220 cases of pneumonia. According to this calcu-
lation, 22.3 per cent, of the cases of pneumonia terminated fatally, or one death
occurred in 4.4 cases.
In the Confederate army serving on the Gulf of Mexico, in and around Mobile, with
a mean monthly strength of 6752, the cases of pneumonia numbered 1161, and the
deaths from this disease 151, during a period of eighteen months ; or one death in 7.6
cases of pneumonia.
In the army of Tennessee, during a period of fourteen months 8272 cases of pneumo-
nia were recorded, with 1291 deaths; the ratio of deaths, from this disease, being
15.5 per cent., or one death in 6.4 cases. The hospital reports gave a still higher mor-
tality, namely 18.2 per cent., or one death in 5.4 cases.
Upon the field reports of General T. J. (Stonewall) Jackson's army, serving in the
Valley of Virginia, during a period of ten months, with an average monthly mean
strength of 15,562 officers and men, 1034 cases of pneumonia were reported. During
this i^ort period 6?6 per cent, of the mean strength were affected with this disease.
The number of deaths entered upon the field reports of Qeneral " Stonewall '* Jackson's
army, was only 50, or 4.8 per cent, of the cases. The returns of deaths were incom-
plete ; it was also true that the cases of pneumonia in this active and fighting army,
were in most cases transferred to the general hospitals, and chiefly to the large geneiul
hospital at Staunton. The statistics of the Staunton general hospital furnish the most
correct data for an estimate of the mortality of pneumonia amongst the forces serving
in the Valley of Virginia, throughout the war, under Generals Jackson and Early.
During a period of fortj-four months. July, 1861 to February, 1865, in the General
Hospital at Staunton, Virginia, 833 oases of pneumonia were treated, with 191 deaths.
In this laige and well-conducted ho8pital22.9 per cent., (or one death in 4.3 cases,) of
the cases of pneumonia terminated fatally. A portion of this mortality, as well as of
the mortality in typhoid fever and gunshot wounds, was attributable to the previous
exposures and fatigue of the sick in transportation from a distance, during the active
operations of the Confederate forces.
The statistics of the general hospitals of Virginia, exclusive of the hospitals in and
around Richmond, possess great interest, as furnishing the most reliable data for the
determination of the rate of mortality in pneumonia. During a period of fourteen
months 4864 cases of pneumonia were entered upon these hospital reports, with a mor-
tality of 1261 ; the ratio of deaths amongst this largo number of cases of pneumonia,
treated in some of the largest and best conducted hospitals in the Southern Confederacy
was 25.9 per cent., or one death in 3.8 cases.
The following statistics will serve to illustrate the relative mortality from pneumonia,
and several of the more important diseases in Confederate hospitals.
Pneumonia in Confederate Army.
.§ I ■I '2 1
fl
llllll 777-^
Sfl
Pneumonia in Confederate Army 657
From the preceding table we gather that duriug this period of fifteen months, onu
hundred and thirteen thousand nine hundred and fourteen (113,914) cases of various
diseases and gunshot wounds were treated in the hospitals of Virginia, exclusive of the
hospitals in and around Bichmond ; out of thU number of cases, five thousand five
hundred and sixteen (5516) proved fatal.
The ratio of deaths fVom all causes to the entire number of eases treated, was 4.85
per cent, or one death in every 20.65 cases.
The deaths from common continued fever are here included under the head of typhoid
fever. After a careful examination of many eases registered os common continued
fever, and after conferences upon this subject with numerous surgeons in Virginia, I
have been convinced that the great majority of the cases reported as common continued
fever are nothing more than cases of typhoid fever. As the cases recorded as common
continued fever amount to near one-third the number of typhoid fever, and as the vast
majority of the former should have been classed as the latter, the most accurate calcu*
lation is that which combines the two classes together. The ratio of deaths to the
cases of typhoid fever and common continued fever was 25.92 per cent., or one death
from typhoid and continued fever in .3.85 cases. The ratio of deaths from typhoid and
common continued fever, to the entii*e nutnber of deaths from all causes, is 29.35 per
cent., or one death from these diseases in 3.4 deaths iVom all causes. Whilst on the
other band the ratio of cases of typhoid and common continued fever to the entire
number of oases treated is 5.48 per cent., or one case of these dlsea.ses in 18.25 cases of
all diaeases.
A fraction more than one fourth the cases of pneumonia terminated fatally, or more
exactly 22.86 per oent., or one death in 3.78 cases of pneumonia. The ratio of the
deaths fVom pneumonia, to the deaths from all causes, was 22.86 per cent., or one death
from pneumonia in every 4.37 deaths from all causes ; whilst on the other hand the
eajiea of pneumonia amounted to only 4.16 per cent, of the entire number of cases.
Tvphoid fever, common continued fever, and pneumonia together, caused two thou-
sand eight hundred and eighty deaths, out of five thousand five hundred and sixteen
deaths from all diseases ; that is, a little more than one half the deaths from all causes
were due to typhoid fever and pneumonia, or more exactly 52.39 per cent.
12.7 per cent, of the cases were classed under the head of chronic and acute diar-
rheea and dysentery, whilst the mortality from these diseases was 4.05 per cent, of the
cases of diarrhoea and dysentery, and 10.51 per cent, of the entire number of deaths
from all causes.
Only one case out of 11.6 of all diseases wuk due directly to the casualties of war ;
that is, the cases of gunshot wounds were only 8.59 per cent, of the entire number of
cases. The mortality from gunshot wounds was a little less than one tenth of the
entire number of deaths from all causes, or more exactly 9.35 per cent,, or one death
from gunshot wounds in every 10.69 deaths.
The ratio of deaths from all causes to the entire number of cases treated iu the hos-
pitali in and around Richmond, Va., during a period of seven months, September,
1862, to March, 1863, was 4.11 per cent., or one death in 24.37 oases.
The record of the deaths, during several months, was incomplete. In this table, as
in the preceding and succeeding tables, I determined the number of deaths from various
diseases from the long rolls in which the name of the deceased soldier, together with the
disease causing death, was recorded, without any classification as to the disease. In
several of the monthly reports, large portions of these rolls were absent from the con-
solidated medical director's reports. The labor necessary to the classification of the
diseases causing several thousand deaths was very great. In this table as in the pre-
vious one, the deaths from common continued fever are included under the head of
typhoid fever. During six months, September. October, November, 1862, January^
February, and March, 1863, two thousand seven hundred snd forty-eight (2748) cases
were recorded of typhoid and common continued fever, and during the same period
seven hundred and twenty-throe deaths from these diseasejj. Therefore more than one>
(i58
Pneumonia in Confederate Army.
C 4.
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Pneumonia in Confederate Army. 659
fourth, or 26.31 per cent, of the cases of typhoid fever, terminated fatally ; that is, one
ease of common continued fever proved fatal in 3.8 cases. During this period of six
months the deaths from these diseases constituted 24.94 per cent, of the deaths from all
causes ; that is, one-eighth of the entire deaths were caused hy typhoid and common
continued fever (one death from typhoid and common continued fever in eight deaths
from all causes.)
During four months, September 1862, January, February and March 1863, one
thousand five hundred and twenty-seven cases of pneumonia were entered, with four
hundred and five deaths.
During this period the ratio of deaths from pneumonia to the entire number of deaths
from all causes was 19.22 per cent., or one death from pneumonia in 5.42 deaths from
all causes ; whilst on the other hand, the cases of pneumonia during thess four months
were only 3.54 per cent, of the entire number of cases treated during this period. *
During four months, September, 1862, January, February, and March, 1863, typhoid
fever, common continued fever, and pneumonia, caused 41.67 percent, of all the deaths
from all causes.
It is important to note that the hospitals in and around Richmond were, to a con-
siderable extent, supplied with convalescent patients.
During four months, April, May, June, and July, 1863. one hundred and eight thou-
sand one hundred and sixty -five (108,165) cases were treated in the general hospitals in
Virginia, including those in and around Richmond ; and the number of deaths during
this period was two thousand seven hundred and five (2705.) The ratio of deaths
from all causes, to the entire number of cases treated, was 2.5 per cent.; that Is one
death in 39.98 cases.
The ratio of deaths from typhoid fever and common continued fever to the entire
number of cases of these diseases, was 17.77 per cent., or one death from these diseases
in 5.62 cases. The deaths from typhoid and common continued fever constituted 18.82
per cent of the entire number of deaths from all causes ; whilst the cases of typhoid
and common continued fever formed only 2.64 per cent, of the entire number of cases
of all diseases.
24.14 per cent of the cases of pneumonia terminated fatally, or one death in 4.05
cases of pneumonia.
21.29 per cent, of the deaths from all causes were due to pneumonia ; whilst on the
other hand, this disease formed only 2.16 per cent, of the entire number of cases of all
diseases.
Pneumonia and typhoid fever, and common continued fever, together, caused 40.11
per cent, of the entire number of deaths from all causes, these diseases included ; or
one death from these diseases occurred in 2.49 deaths from all causes ; whilst, on the
other hand, the cases of pneumonia, typhoid, and common continued fever, constituted
only 4.81 per cent of the entire number of cases treated.
If the statistics of individual hospitals be examined, similar results will be obtained.
We have selected the records of the Oencral Hospital at Charlottesville, because they
date from an early period of the war, and have been accumulated under the able admin-
Mtration of intelligent surgeons, and this hospital has drawn its patients directly from
the largest army in the Confederacy.
In the (reneral Hospital of Charlottesville, Ya., a small fraction less than one-fourth
the cases of Typhoid Fever, or one in 4.15 cases (24.05 per cent.,) terminated fatally.
The ratio of the cases of Typhoid Fever, to the entire number of cases from all cause.s,
was 8.66 per cent, or one case of Typhoid Fever in 11.54 cases of all diseases ; whilst
the deaths from Typhoid Fever were more than one- third of the entire number from
all causes, or, more exactly, one death from Typhoid Fever in 2.78 deaths, thus givini^
a ratio of 35.94 per cent, of deaths from Typhoid Fever. On the other hand, the ratio
of deaths from all causes to the entire number of cases treated, 5.79 per cent., or one
dcfttb in 27.24 cases of all diseases treated.
Nearly one-third, or, more exactly. 31.9 per o^nt. of th«» ca«»s of Pneumonia tormi-
660
Pneumonia in Confederate Army.
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Pneumonia in Confederate Army, 661
nated fatally, that is, one death occurred ia every 3.12 cases of Pneumonia. The ratio
of deaths from Pneumonia, to the entire number of deaths from all causes, was 23.84
per cent., or one death from Pneumonia in 4.17 deaths from all causes, Pneumonia
included. On the other hand, the cases of Pneumonia were less than one twenty-third
of the entire number of cases (4.32 per cetit.,) or, more plainly, one case of Pneumonia
in 23.13 cases of all diseases. Pneumonia included.
Typhoid Fever and Pneumonia, together, caused 51 U deaths out of 868 deaths from
all causes, these diseases included. That is, Typhoid Fever and Pneumonia caused
more than one-half, or 50.9 per cent, of the deaths from all causes, gunshot wounds
included ; or, one death from Pneumonia and Typhoid Fever occurred in every 1.67
deaths. On the other hand, the cases of Pneumonia and Typhoid Fever, were only
12.98 per cent, of the entire cases. And the ratio of deaths from all causes, to the
entire number of cases, was 5.70 i)or cent., or one death in 17.24 cases of all diseases
treated.
The largest number of caKcs of Typhoid Fever occurred in July, August, September
and October, 1861, and during the. first thirteen months (July, 1861 to July, 1863,
inclusive), 1004 cases of Typhoid Fever entered the hospital, whilst during the last
thirteen months (August, 1862 to August, 1863, inclusive), only about one-fiflh the
number of cases of Typhoid Fever entered, or more exactly, 203 cases. During the
first thirteen months, 253 deaths from typhoid fever occurred ; whilst during the last
thirteen months only 60 deaths, or not quite one-fourth the number of the first thirteen
months. During the first thirteen months, 1040 cases of measles were entered ; whilst
during the last thirteen months, only 20 cases of measles were recorded. This disease,
therefore, like typhoid fever, decreased as the war advanced. As a general rule, man-
kind are afflicted with these diseases but once during a lifetime, and during this war,
both diseases appear to have been intimately connected in their origin and spread with
the crowding together of the soldiers ; whilst they arc, without doubt, due to distinct
and wholly different poisons, still they have in this war been associated, to a certain
extent, in the time and circumstances of their origin and diffusion. We observe no such
law governing pneumonia. This disease was most abundant during the cold, wet, and
changeable weather of winter and spring, and there was no marked diminution of the
disease as the war progressed, beyond th^t incident to the hardening and strengthening
of the troops under exposure and fatigue.
The cases of gunshot wounds were 18,00 per cent, of the entire number of cases:
and the deaths from gunshot wounds were 17.62 per cent, of the entire number of
deaths, or, 5.44 per cent, of the entire number of cases of gunshot wounds treated.
In instituting comparisons between the statistics of the General Hospital of Char-
lotteBville, and those of other portions of the Confederate States, it should be borne in
mind, that the General Hospital of Charlottesville, was one of the nearest hospitals to
the largest and most active army in the Southern Confederacy. The severest cases of
disease were, as a general rule, left at this and other hospitals nearest to the scene of
active service ; whilst the mildest cases were forwarded to the more distant hospitals. It
results from these facti<, that all things being equal, as to treatment, nourishment, and
hygiene, the mortality in a hospital thus situatea and supplied with patients must neces-
sarily be heavier than iu hospitals connected with armies much smaller and compara-
tively at rest, where large numbers of the severe cases were treated in the field hospitals.
As high as the preceding rates of mortality in pneumonia and typhoid fever may
appear, they are not as high as in some others of the Confederate hospitals. Thus in
the two general hospitals of Savannah, Ga., Nos. 1 and 2, the ratio of mortality in
these diseases was extraordinarily high. And wo are at a loss to account for this high
death-rate, from the fiict that these hospitals were connected with a comparatively small
and inactive army. As the troops serving in and around Savannah were greatly exposed
to the influence of malaria, this depressing agent may have influenced, to a certain
extent, the death-rate.
In General Hospital No. 1» Savannah, Ga.. during a period of twenty -five months.
662
Pneumonia in Confederate Army.
Death!.
*» t- M CO
"* OO « CO
^ c«
CO ^
--»ca^«*co«o»oco^cs'^
C9 ^(0MC4C0C«^C0tO
^ d <* ^ ^« r^
1
' Total D
and W<
Entored
Mon
Caect.
Deaths.
00 A iM CO
o M ^ m
;0 CO ^ iO
lo r^ «o :
CO CI :
... , 448
... 1 329
<DooAa)'4<t«ci(oecoco
C40^COC9iOCOODaO'«^0>
C4coc4io^r«co«ooocoeao>
— C*0O'*C*l*- — «
0^edC91:*^C«^
coco»-^^iO-*ao^
«o
GUNSHOT
W0UND8.
: : : : :e»*-«-*oocoe«oo
. . . . i rH CI F-t
«-co^^ — ^^-^
eo
Gases.
o ;o o» i»
© ^
to
•
C4^e«cow<0i-i0'^cocoao
^(O«4«aocoia'<<«to
C« CO *- •-•
eq^^■<4•CD^•^co
■
<
'A
e
a
&
M
as
< >
9 OS
a Q S
s >« £
3 ^ «
5 >•
Deaths.
OO O C9 CI r- CO
»o : ""t lO CO C4 CO : ; -^ lO *-
^ . e« CO 1^ II I— c»
.-^ C- CO 00 c« c« : -^
Omm.
Deaths.
00 CO cq ^
;o CO : !
■<^-4^0iooae<i«->i-^aoao
c«cic4aococi ro*^
•-H : :e«co : :c» :r^e«co
OCOiO»^COCOQC
^ N — F- -^
«
«
Cases.
» CO CO ^ «-> A
l>- fH -^ CO CO ►-
aOCOCOi->l^tOCOiOO>C>S'*4>iO
•-^COiOCOCOOiC^'^ ^la^
00
H
OB
<
M
a
00 -^i : : C9 :
CO CO ■^ i-i CI I-.
O ^^ O tS C4
CO i«i fH
: — ^ 00 o '"t : :
I 't ci ^ r .
r.< .^ 00 «
-- CI
— c«
I
H
; = »< K
, S M ►
Deaths.
• • • • •
• • a • •
• a •
a • a
• • • •
^WWCo»
CO :i>-^CiC5 OC!ICOC«CaCOCO» :^co»
ooc-^^oo^coeo
J.
g - "
Deaths.
-
.
Oases.
^ : ^ : : ^
:::::::::;::
• : : X : : : t
1
1 H
Deaths.
I :
1 ■
BBMITT
PBYE
C«s«s:
»o t^ 00 — ^ 00
CO •-" c« ^
eococo-^ — coO"*c«roc««o
CO M : : ^ — ao o
HII
• * • • mi* •••... ,.4 . ^M ca ».< m* • n
I..
Deaths.
O M
•ft CO ^ t« kA :o
1- ^ Cl C* i-i
-* 11
*^C0OC0<-iOCIC0
CI ^i« ^N (M
^•aocoiOK— o
•!• •^ O »rt O CO
00 ^« tA O) O CO
CI »-i r^ ^-1
O^^ocicococa»-io^^ coc»;cco»a
coeor.<cococ««o*^ c«c< —..* —
Pneumonia in Coitfederate Army. 663
(December, 1861 to December, 1863, inclusive,) 178 cases of typhoid ferer were
recorded, with 91 deaths. In this hospital, therefore, more than one-half proved fatal.
The percentage of deaths in the cases of typhoid fever was 51.12 ; that is, one death
occurred in 1.95 ca&es. Between one-third and one-fourth of the entire deaths from all
causes were from typhoid fever, or, more exactly, one death from typhoid fever occurred
in every 3.65 deaths ; the deaths from typhoid fever were 27 per cent, of the entire
deaths from all causes. On the other hand, the cases of typhoid fever were a little less
than two and a half per cent, of the entire number of cases of all diseases ; or, more
exactly, 2.48 per cent of the entire number ; or, the ratio of cases of typhoid fever was
as 1 to 40.
In the cases of pneumonia, a little over one-third, or one in 3.18, or 31.35 per cent,
proved fatal. More than one-third of the entire deaths, from all diseases, were caused
by pneumonia ; or, one death from pneumonia occurred in every 2.87 deaths, giving
34.83 per cent, of deaths from pneumonia. On the other hand, only a little over five
per cent. 5.17 per cent, of the cases entered upon the sick reports were recorded as
pneumonia, giving a ratio of one case of pneumonia to 19.32 cases.
Pneumonia and typhoid fever, together, caused 207 deaths out of 333, the entire
number ; that is, these two diseases alone occasioned nearly two-thirds of the entire
number of deaths from all causes ; or, more exactly, one death in every 1.6 deaths, or
62 per cent of deaths. Whilst on the other hand, these diseases constituted only 7.65
per cent, of the entire number of cases.
Fewer cases of typhoid fever were received in 1863 than in 1862 ; thus in the
former year, 74 were entered, whilst in the latter, the sum was about one-third greater,
or 100.
In General Hospital No. 2, Savannah, Oa., during the nineteen months, (June,
1862 to December, 1863,) a small fraction over one-fourth of the cases of typhoid fever
proved fatal ; that is, one death occurred in every 3.918 cases, giving 25.5 as the per-
centage of deaths in the cases of typhoid fever. Of the total number of deaths,
between one-third and one-fourth were from typhoid fever, or, more exactly, one death
from typhoid fever in 3.378 deaths from all causes ; thus yielding a ratio of deaths from
typhoid fever, io the deaths ft-om all causes, of 29.6 per cent. On the other hand, the
ratio of cases of typhoid fever to the entire number of cases treated of all diseases was
only 4.26 per cent., or between one twenty-third and one twenty-fourth of the entire
number of cases (one case of typhoid fever occurred in every 23.4 cases of all diseases ;)
and the ratio of deaths from all causes, to the entire number of cases, was 3.67 per cent.
A little less than one-fourth the cases of pneumonia (or one in 4.32 cases, 23.14 per
cent.) terminated fatally. One-fifth of the deaths from all causes, were due to pneu-
monia, whilst the ratio of cases of pneumonia to the entire number from all diseases,
was only 3.174 per cent
Pneumonia and typhoid fever together, caused 62 deaths out of 125, or very nearly
one-half the entire number of deaths from all causes ; whilst the ratio of cases of pneu-
monia and typhoid fever to the entire number of cases of all diseases was only 4.49
per cent
Twenty-nine deaths, or nearly one-fourth of the entire number of deaths, were attri-
buted to remittent and congestive fever, in Hospital No. 2, Savannah, Oa. From June,
1862, to December, 1862 (six months,) 13 deaths from remittent fever were recorded,
out of only 141 cases treated ; that is, nearly one-tenth of the cases of remittent fever
during this period proved fiitaL In view of the present enlightened and successful
mode of treatment in this disease, this is certainly a remarkable ratio of mortality.
The statistics mi^ht be greatly extended, but they are sufficient for comparative pur-
poses. The following tables will furnish the necessary data for comparison with th^
records of other hospitals ;
664
Pneumonia in Confederate Army.
Tablet thowing the Numerical Retatiom of the duet and Death* by Typhoid and Common OonUnufd
Fever and Pneumonia^ in the General Hospitals in Virginia^ and in several Hospitals in Georgia,
during a portion of the war of 1861-1865. Consolidated and Calculated from the official records
on file in the office of Surgeon^ General S. P. Moore, by Joseph Jones, M. />., Surgeon, P. A. C S.
CASES AND DEATHS FROM ALL DISEASES AND CAUSES.
Name of
Hospital-.
dates a.nd length
OF TIME
OF STATISTICS.
General Hospitals in Vir-
ginia, ont of Richmond
General Hospitals in Vir-
ginia, in Richmond
General Hospitals in Vir-
ginia.,
General Hospital of
Charlottesville, Va
General Hospital No. 1,
Savannah, Ga
General Hospital No. 2,
Savannah, Ga
Guyton Hospital, near
Savannah, Ga
Jan. 1862— Feb. 18G3, 1
(15 months) i
Sept. 1862— Apr. 1863, j
(7 months) /
Apr. 1863— Aug. 1863,]^
(4 months) /
July 1861— Sept. 1863, \
(26 months) j
Dec. 1861— Jan. 1864,1^
(25 months) j
June, 1862— Jan. 1864, >
(18 months) /
May, 1862— Jan. 1864,1
(20 months) j
Hi
-a*
.J
is
3
^?
2 -<»
113,914
5,516
4.H4
20.H5
»3,852
3,849
' 1
4.11
24.37
108,165
2,705
2.5
.19.98
14,966
868
17.19
7,149
333
4 65
21.4*i
3,4U2
125
3.07
27.21
2,695
46
1.70
5H.58
CASES AND DEATHS FROM TYPHOID FKVEK AND COMMON CONTINUED FEVER.
Name of
Hospital.
DATKS AND LCNdTU
OF TIME
OF STATISTICS.
General Hospitals
in Virginia, ont
of Richmond...
General Hospitals
in Virginia, in
Richmond
General Hospitals
in Virginia
General Hospital
of Charlottes-
ville, Va
General Hospital
No. 1, Savan-
nah, Ga
(leneral Hospital
No. 2, Savan-
nah, Ga
Guyton Hospital
near Savannah,
Ga
January, 1862 — ]
February, 1803, >
(15 months) j
Septe'ber, 1862—
April, 1863, (7
months)
April, lRr,3— Au-
gust, 1863, (4
months)
July, 1861— Sep-
tember, 1863,
(26 months
December, 1861—
January, 1864,
(25 months)
June, 1862— Jan-
uary, 1864, (18
months)
May, 1862— Janu-
ary, 1H64, (20
months)
6,245 1,619 25.!)2 3.85 5.48 18.2."» 29.35 3 4
26.31 , 3.8 3.50 27.27 24.94 •».
2,8G:{
1,312
204
239
105
509 , 17.77 5.62 2.64 37.9 ltJ.82
I.
313 23.8 4.19 18.77 11.4 36.05 < 2 77
1»3 45.5« 2.19 2.85 3:..o 27.'j2 3::
42 17.57 5.66 7.02 14.23 33 6 2. •:
II 10.47 9.54 3.89 25.66 23 09 4 •
i : _
PMumoma in Cor^fderati Army.
ti^
CASES AND DBATH8 rBOM PKRUMONIA.
.-r-
Naxi or
Hospital.
! DATSS AMD LBXQTB
I OF TIME
OF STATISTICS. I
(General Hospitals
in Virginia, oat
of Richmond...
General Hospitals
in Virginia, in
Btcfamond
General Hospitals
in Virginia
General Hospital
of Charlottes-
▼ille, Va
General Hospital
No. 1, Savan-
nabf Qa
(General Hospital
No. 2, Savan-
nah, Ga
Go/ton Hospital
near Savannah,
Ga
January, 1862—
Feb'rj, 1863,
(15 months)
Sept'ber,1862—
April, 1863,
(7 months)...
April, 1863—
August, 1863
(4 months)...
Julj, ISGUSep-
tember, 1863,
(26 months)..
December, '61 —
January 1864
(25 months)..
June, 1862-Jan-
uary, 1864,
(18 months) ..
Maj, 1862- Jan-
uary, 18G4,
(20 months)..
•0
s
o
a
B
9
4,774
s
e
^7
n
1,261
2,344
647
578
20'
26.41
26.56
24.14
o
nt
§ 1 "^
?
B
r
i?
• a o
3.78
3.76
4.05
4.16
3.54
2.16
31.D 3.12 14.32
370 116 131.35
108
3.18
5.17
If
23.86
28.29
45.9
23.13
19.32
22.86
19.22
21.29
23.84
34.83
25 123.04 1 4.32 ' 3.174 131.5 120.00
7«
7 ' 8.y8 ! 11.14
2.88 34.08
I
c
lit
BS-5
§ I B
I?
a*
?B
4.37
5.42
4.71
4.17
2.87
5.00
15.21 I 6.57
Id the large number of cattes) (344,003) treated in these ho8pital8, 13,542 deiths are
recorded and of this number typhoid fever and pneumonia oaused very nearly one-half.
The last observation which we shall sustain by statistics, is that typhoid fever pro-
gressively diminished during the progress of the war, and disappeared almost entirely
from the veteran armies ; whilst, on the other hand, pneumonia continued to prevail,
and appeared to be chiefly dependent upon the vicissitudes of the climate.
This statement is clearly sustained by the preceding statistics of the Oaneral Ho.4pi-
lids in Virginia.
The statistics which we consolidated from all the returns on file in the Surgeou-
General^s Office, do not extend over nineteen months, but even during this comparatively
short period we observe a verification of the preceding observation, aa will be shown by
the following table ;
CiiC
Pneumonia in Coj^federaU Army.
Table iUuttrating the Numerical Relatioru of Pneumonia and Typhoid Fever^ m the Cbn/ederaU Armim
during Nineteen Montht, from January , 1862 to July, 1863. Calculated from Official Seports,
by Joteph Jonta^ JT. D., Surgeon P, A, C. S.
MOKTR AND YEIR.
FIELD REPORTS.
Pneumonia.
Per cent, of
ofPnea-
monla In
IfMtn
Strength.
1862.
Jmnaary
Februer/
March
April
May
June
July
August-.
September
October
November........
December
1863.
January ,
February
March
April
May
June
July ,
1.70
0.93
1.12
1.06
0.61
0.65
1.03
0 379
0.142
0.245
0.84
1.72
1.38
0.92
0.89
0.93
0.97
0.249
0.106
Per eent. of
caaes of Pneu-
monia In total
Sick and
Wounded.
4.35
2.84
3.67
3.83
1.38
1.12
1.98
0.84
0.421
0.79
3.20
4.42
3.49
3.32
3.03
2.94
3.20
0.79
0.37
Typhoid Fever.
Per cent, of
Caeee of Ty-
phoid Ferer
in Mean
Strength.
1.38
1.17
1.16
1.44
1.37
3.02
2.78
1.83
0.85
0.82
0.64
1.07
0.89
0.61
0.81
1.10
0.90
0.64
0.99
Per cent, of
Caeet of Ty-
phoid Ferer
in Total Sick
and
Woanded.
Per eent. of
CaaeeofPneo*
monia in total
Sick and
Wounded.
4.36
3.69
3.79
3.63
3.09
5.25
5.30
4.07
2.50
2.65
2.46
2.74
2.27
2..19
2.75
3.47
3.06
2.04
3.46
HOSPITAL BBPORTS.
Pneomonia.
Ferar.
Pm- oeftt. of
OMeaoT Ty-
I»lioMF^T«>r
la Total
10.24
10.72
17.00
21.23
6.76
4.89
2.59
1.46
I.Ol
1.18
5.76
6.23
8.90
7.19
8.48
8.41
2.69
1.76
0.98
9.6
10.8
8.1
14.5
7.1
6.6
lO.J
6.1
5.5
4.8
3.9
2.9
4.7
4.9
5.7
4.9
2.6
4.4
2.8
The following tables illustrate, still more clearly, the progressive d^cro^^ of typbokl
ff^ver. and the connection of pneumonia with the seasons :
Pneuntonia in Confederate Army.
667
Oatet and DuUhsfrom all CauseSf and Gates and Dealht from Pneumonia and T)fphoid Fever in the
General Hotpitals of CharloUeeville and Slaunionf Ftryinta, from Official Eeportt, by Joteph
Jones f M, D.f Surgeon Provisional Army C. S.
•
GX5BBAL HoaPITAL. GHABLOTTia*
TILLS, ViBOINIA.
Gbmbbal Hospital. Stacktox,
ViBOINIA.
MoifTB andTkav.
o.» o
ill
i 2i ■
si
i
»
ri
'r
o
S
ft
: H
• 1
H
e D &
!
: 8.5
: Z
! a !
9
e
•
i 9
(
a
si
•
Januarr. 1861
• • ■
2,608 ]
329
611
666
448
329
1
••• ' ■■•
••• *••
•■• •■•
•■• * •••
••• «••
••• •••
147 i 48
87 6
32 ! 12
33 1 14
31 41
12 22
• ••
...
76
46
24
27
16
6
•*•
• ••
« ••
« ••
« •■
1 1,430
938
615
734
1
•*•
*** 1
••«
•••
••• 1
•••
30
t
19
11
69
• « «
•••
•••
...
...
...
37
• ■•
•••
• ••
...
• ••
•••
3
...
22
151
255
2H9
193
TffbnMn
• »•
March ~
April
•%• •••
••• * •••
••• 1 •••
•«« ••■
' 18 284
10 74
■ «•
A
Jan«
Jal»
• ••
• ••
."**••• •••••• •••••
Angoat.
20
A«pt«mbar. .^
October
2
2
7
3
150
195
100
63
6
Norembar
Decamber ~
i
14
Totalt, 1861
4,781 S
226
300
290
639
429
754
337
682
886
340
916
993
(42 143
21 24
6 21
9 i 21
44 , 80
67 1 35
63 20
26 1 9
35 ' 2 1
23 1 1 1
11 1
32 38
42 ' 866
193
4
6
1
8
20
13
11
10
2
3
7
7
2,417
126
254
614
706
2,272
1,229
892
Ha'i
1,435
4,549
3,923
361
119 1
1
17
6
10
27
83
36
42
78
29
95
151 1
69
76
4
12
78
65
53
2:s
• ••
3
■ ■•
27
180
19
25
8
2
2
7
28
5
6
3
\
24
12
868
30
64
66
45
48
.34
56
l(Ki
20
222
96
6
47
JanoaiT. 1862 ..■•.
16
• ••
4
25
36
12
30
34
14
00
32
23
1
Fabmainr ~
Mmrch
1
a
April
7
June...
26
8
JalT
3 33
19
... i 7
25
Augilft...
39
H^otaknbar ^
6
Ortobar. «
NoTaaaber
1
16
27
6
21
21
42
<i6
Deoembar
64
118
15
Totala. 1842
6,692 £
11,473 1 -i
t
601
312
198
124
672
417
821
449
271
397 ,
301
469
181 370
r23 ' 51.1
41 = 49 '
28 23
17 15
14 6
11 14
8 13
7 6 1
11 8
10 , 2
7 9
10 1 16
27 29
189 ! 190
1
35 ao
138
180
11
7
6
8
2
2
• ••
1
1
2
6
299
1,165
16
12
6
3
16
14
11
66
20
18
5
16
91
284
4
6
2
3
6
3
1
6
7
2
3
3
17.165
19.582
102
96
483
165
639
1,642
642 1 4
761 :
15
8
13
37 ,
16
14
164
>30
1
6
75
14
Z\
16
26
12
\
3
6
lOl
,«.
ft
4
4
20
8
4
1
1
...
1
2
1
779
1,647
6
6
32
6
24
48
123
66
21
23
10
6
2:t9
Totela. 1861-1862
286
JftnaarT. 1863
1
February
1
March ^
iSS':::::z.:===:-
2
5
3
6
julr
8.428 25 !
1.209 37 I
11
J8
«*■•"•■*•*•••••• •••.••
fl««it^iabar • *
406
308
127
228
16 '
12 .
12
1
3
3
Ik Av^mhftr. «...•.. ••«»••.
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II
4.932 ! ]
401
145 ;
249
481
1,162
1,344
• •• 1
... ■
490
321
267
46
8
3
2
3
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2
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10
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43
13
1
1
2
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6
• •a
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13.723
226
108
177
138
1.475
826
l/>98
1,693
1A»
611
1 606
906 1
3
\
4
29 !
19 1
21
13
30
26
14
67
10
16
9
7
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30
61
1
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190
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T^mtm 1088-1864
, 4,850 i
9.782 i
21.266 1,
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120
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74
264
71
161
1,426
1 30
73
867
10,091
23,814
'109 < 1
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369
X^VBM*! »^» *«'•'■*•••••••••••
-
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—
668 Pneumonia in Confederate Army.
la the pnoediDg tables we observe a progressive and marked diininatioo of the
of typhoid fever, whilst the yearly flactaations of pnenmonia are not refenble to any
such law.
Thus, in the Oeueral Hospital of Charlottesville, daring the year 1861, the esses of
disease and wounds nambered 4781 , with 342 deaths : of this number, pneomonia
constitnted 143 cases and 42 deaths, and typhoid fever 866 cases and 193 deaths. Dnrio'j:
the year 1862, the total oases entered upon the hospital records, nambered 6692, with
381 deaths ; of these, there were of pnenmonia, 370 cases and 138 deaths ; typhoid
fever, 299 cases and 91 deaths. Daring 1863, total cases, 4932, and deaths, 1S9 ;
pneumonia, 190 cases, 46 deaths; typhoid fever, 190 cases, 43 deaths. Daring 18(>4,
total cases, 4850, deaths 208; pnenmonia, 143 cases, 28 deaths; typhoid fever, 71
casea and 30 deaths.
In the General Hospital of Charlottesville, during the first twenty-^ix months, the
largest number of cases of typhoid fever occurred in July, August, September and
October. 1861 ; and during the first thirteen months, (July, 1861 to July, 1862, both
months inclusive,) 1094 cases of typhoid fever entered the hospital ; whilst during the
iast thirteen months, (August, 1862 to August, 1863 inclusive,) only about one-fifth
the number of cases of typhoid fever entered, or, more exactly, 203 ca^es. During the
first period of thirteen months, 253 deaths from typhoid fever occurred ; whilst durin«r
the last thirteen months there wore only 60 deaths, or not qnite one-fifth the namb**r
of the first thirteen months.
In the General Hospital of Staunton the cases of typhoid fever decreased in the fol-
lowing manner : in 1861, 868 cases and 47 deaths ; in 1862, 779 cases and 239 deaths ;
in 1863, 365 oases and 58 deaths; in 1864, 192 cases and 29 deaths. The sum total
of cases of typhoid fever during both the years 1863 and 1864, was far less than durin^r
either 1861 and 1862, notwithstanding that the total cases of diseases registered was
greater in 1 863 and 1 864.
CHAPTKR XVII.
EXAMINATION li¥ THE mFFERE^T MclIlES (IF TREATlSd TSEl MOSIA.
Object! aad Importance of Ihe Inveatigntio
Diaease to run ill course, nninflnencod h;
Dietl kod Balfour.
Hatioaal Treatment designed to further tlie natural progress of Pnt
Method of Trenlmcnt ndiocntcd t>j I>r. John lluglies Bennelt. "
Todd.
Antiphlogistic System of Trcalmenl. The Uncet abandoned bf SoQthern phjaicians in tlie
ircatnient of Pneumonia. The statistics to prove the wisdom of iliis step, milling. Ei-
nmination of the data b; whicb the rclatire merits of the Antiphlogistic Sjslem of the treat-
ment of Pneumonia may be determined with some approach to accuracy. InTSlligations
of Louis OD Blood letting. Method and results of the TrealmcDt of Pneumonia by Louis,
Dr. James Jackson, Hughes Bennett, Rasori, Laennec and others.
RelaUons of Pneumonia to Malnria. Kelotions of PnenmonU to Clima'e. Statistics of the
(reatiDFnt of Pncumonin by dilTertnt melhods.
F.XA1IIN.ATIII.S OV THK niVFKRKST MDDF.B OF THKATINO PNKliMONIA.
After a carctul examination of the offioial reports, on filo in the Surgeon Uenenra
Office at Richtnond, Virginia, I established the important fact, that np to the time of
my examiaatinn, and contiolidatioQ of the sick reports and mortuary records (September,
1863), Pneumonia and Typhoid fever, had caused one half the deaths from all causes,
f^o-shot wounds included, in the field and general hoepitals. I wus led to draw up
extended reports, presctiting the reanlta of my investigations on the catises and treat-
ment of the most fatal diseascB. The manuscript volumes thns prepared, were captured
or burned ot the time of the evacuation of Richmond.
In the ofRcinl report on Pneumonia, I urged, that each Medical Officer of the Con-
federate Army, should, as far as possible, test the value of the different modes of treat-
ment before the profession. If such a plan could have been carried out by the Medical
Officers, in this gigantic struggle, it was believed that valuable contributions would
have been mode to the science of modicinc. The plan of investigating the phenomena
of Typhoid fever (Camp /ever), addressed to the Surgeon Oeneral and the Medical
Officers of the Confederate Army, waa also applied to Pneumonia.
It remained that an effort should he made to point out the line of inquiry to be pur-
sued in the investigation of the relative valae of the different modes ot treating Pneu-
monia, that results capable of comparison might be obtained. It was urged that there
exists no want of theories, or of positive assertions, or oi unbounded conGdenoe, in
special remedies in the treatment of Pneumonia : but unfortunately however, the m
called ezjH'rtence, avails bnt little in the accurate determination of queations involving
the lives of a large proportion of those afflicted. It is customary to dignify with the
title of exteiuive experience, the use of ona or more remediei, for a series of years,
amongst a number of patients, regardless of the intelligence which selected those reme-
dies, and regardless of the fact whether those remedies were selected as the result of
education, or of accident or prejudice, or as the result of careful and conscientious inves-
tigUioD and comparison of the relative effects and value of the different modes of treat-
ment It waa urged, that under all circumitances, of peacs or of war, and especially in
a oonteat in which the entire community was emptied of its male population, from boy-
OTO Diiftetie Syttem tf Treating Pneumonia.
hood to old age, and from the etateeman to the day-lafoorer, such iDvestigatioDs ahoald
be ooDsidered as of the greatest moment, and should be conducted with the most serapn-
Ions accuracy and honesty ; and the belief was expressed that with oonoert of action,
amongst conscientious and competent observers, results of great value would be achieved.
In the report referred to, the various modes of treating Pneumoniai were ehuned
under the following heads :
1st. Dietetic System ; 2nd. Rational Treatment designed to further the natural pro-
gress of Pneumonia towards reooveiy ; 3rd. Antiphlogistic System of Treatment ; 4th.
Antiperiodic, or Abortive Treatment of Pneumonia.
I. DIETETIC SYSTEM OF TREATING PNEUMONIA.
It is now established that Pneumonic inflammation is dependent upon definite con-
ditions, and will without any assistance from the physician, run a definite course through
successive stages, to recovery or death. The rate of mortality in cases left entirely to
the operations of nature, will depend mainly on the amount of the lungs involved,
whether one or both, and whether the whole lung, or only a small portion, and upon
the pre-existing state of the system.
In the following case of Pneumonia, which I treated during the recent war, the
remedies employed were of the mildest character.
OoMe 702. drcumeeribed Pneumonia^ attended tnth high fever, arreeted or retolved m ettimd
Andrew jRckson Sharpe, GoDfederate soldier ; Private ; age, 35 ; height, 5 feet, teTen
inches; weight, 150 lbs.; black hair, dark ejes.
Had measles ia the month of June 1862, in this hospital, and regained his osaal health.
General Oonfederate Hospital, Augusta, Georgia, July I7th, 1862. Patient siesed with
rigor, followed by pain in right side, high fever and troublesome cough.
July 18th. Pain in side severe, cough painful and troublesome; skin hot and dry ; pulse
and respiration accelerated ; dullness upon percussion over right lung. I ordered nothing
but the internal use of cold water, in such quantities as the thirst of the patient might dic-
tate. Evening, skin hot and dry; pulse 112; cough painful and troublesome; patient very
restless.
July 19th, 12 M. Pulse 100; respiration 24 ; temperature of hand 41<'C (105^ 8 F) : of
axilla 41^. 83 C. ( 107®. 4 F). Right lung dull on percussion ; auscultation revealed mioote
crackling crepitation, with some increase of vocal fremitus. The natural resonance of the
lung was more diminished, and the sense of resistance increased, more especially ov^r the
lower lobe of the right lung. At first the expectoration consisted only of glairy mucus, bet
it now presents the rusty color, and viscid tenacious characters of the characteristic poeuma-
nic sputa. Patient restless and depressed, and the hot "6urnii^" fever causes him to toss
incessantly from side to side in the bed. Breathing oppressed, and painful and borried.
Tongue dry and red. Severe pain in head.
- B. Tinct. Opii, two fluiddrachms; Pulv. Ipecac, ten grains; Sodas, Proto Carb., Iwo
drachms; Flaxseed tea, ten fluidounces. Wineglassful every two hours, or at shorter ieier-
vals, if the cough is troublesome. Apply flannel, saturated with oil of turpentine, over the
region of the lower and middle lobes of the right lung. Gold water as a drink, ad libttam,
ExtminatUfn of ^rfn«:-— Amount of Urine passed during the preceding twenty-fonr ho«r*«
July 18th, 12 M. to July 19th, 12 M., Grains 15,996.56. Specific Gravity 1016.3. Goldea-rel-
low color. Reaction acid.
Ko. 87. Anah/M of Urine Patted during iwenty^four hourt :
Urine PMMd I*riiM
DiiriiiffTw«ity-ft>ur £3i
lIoncB.
Gniu: Cmlai:
Amount of Trine 15,996.56 666.52
Urea.-* 432.32 18.00
Uric Acid 6.00 O.JO
Free Acid » 69.48 2.89
Phosphoric Acid 60.56 2.52
Sulphuric Acid ., 37.73 1.5T
Chlorine 13.11 O.M
Equivalent Chloride of Sodium 31.68 0.89
Phosphates of Lime and Kagnesia ., IT.OO o.Ta
Dietetic System qf Treating Pneumonin, 671
Evtninff, The mature caaied the patient to Yomit (Veely, and " much bile wai thrown off,"
The Ipecac and Soda mixture also excited free perspiration. The patient is now ( 9 P. M.)
in a gentle sleep, and the skin is bathed in perspiration. R. Continue Ipecac and Soda
mixture.
JqIj 20tb| 12 M. Pulse 70. After the relief of the stomach by the emetic, the scfere head-
ache disappeared, and has not returned, and the patient appears to be better. Skin moist, and
the temperature is not so eletated. Respiration more regular and lees painful. Sxpectora-
tion still rusty-colored, tenacious and gelatinous.
Continue ;turpentine stupes to the chest, and also the Ipecac and Soda mixture.
July 3l8t, 2 P. M. Patient continues to improve ; temperature of hand, 36®. I (97.® F);.
of axilla 38®. G. (100®. 4 F) ; pulse 62 ; respiration 20 ; skin feels cool and moist— in a pro-
fuse perspiration : pulmonary symptoms improTcd ; the rusty colored sputa has disappeared
and been superceded by clear, Tiscid sputa. The right lung is less dull on percussion,
although the crepitant rales continue.
EzammMUan of Urine: Amount of Urine passed during forty-eight hours, July 19tb, 12 M.,
to July 21st, 12 M. Grains, 28,980.48; Specific Gravity, 1022.6; orange colored. Upon
standing, the urine emits a putrid smell, and throws down a heavy^ deposit of urates and
phosphates.
JVb. 88. — AnahfiU of Uritupaued during forty^eight Kount
Urine, Forty- Urine, Twenty- Urine Inch
eif ht Honn. four Houra. Hour.
(iraint: Gnlnf: Ondn»;
Amount of Urine • 28,980.48 14,490.24 603.76
Urea 1,181.16 590.58 24.61
Uric Acid 34.00 17.00 0.70
Free Acid 166.75 83.37 3.47
Phosphoric Aeid 109.01 54.50 3.26
Salphurie Acid 58.32 29.16 1.21
Chlorine 6.22 3.11 0.12
Equivalent Chloride of Sodium 10.26 5.13 0.21
Phosphates 14.45 7.22 0.30
Phosphates and Sulphates and Carbonates of Soda,
Potassa 134.27 67.13 2.79
July 22d, 9 P. M. The left long appears to be involved to a certain extent. The cough is
more troublesome tban'yesterday, and the rusty colored pneumonic sputa has returned. In
addition to the crepitant and sub-crepitant rales, mucous rales are heard distinctly in lower
aud middle tubes of right lung. The pulse is regular and compressible, and the skin is moist.
Tongue clean.
Notwithstanding some apparent increase in the pneumonic symptons, the patient says that
he feels milch better: The patient was placed upon a mixture composed of Camphorated
Tincture of Opium, one fluidounce; Syrup of Ipecac, three fluidounces; Honey, four flui<l<
ounces. Teaspoonful every two hours.
July 23d. Continues to improve.
July 24th. 12 M. Pulse 76; respiration 16; Temperature of band 38®. 4 C ( 101®. IF);
of axilla 38®. 5 C ( 101®. 3 F ); tongue clear; patient much better.
Exammction of (Trine .-—Amount of Urine passed during the last seventy-two hours. Grains
45,004.07 ; Specific Gravity, 1023. Upon standing, the urine changed rapidly to the alkaline
eoodilion and emitted a putrid odor.
A</. 89. AnalgM of Urine pas^td during eeventy^iwo Kourt — July 21«/, 12 if., to July 24(A, 12 if.
Trine, Betenty- Urine, Twenty- Urine, Knch
two Houm. four Hour*. Hgur.
Gninii: Ortine: Gimins:
Amount , 45,004.07 15,001.36 625.05
Trea 2,134.52 711.60 29.64
Phosphoric Acid 105.02 35.00 1.45
Solpbario Acid 180.80 60.28 2.51
Chlorine 54.90 18.30 0.76
E<iaiTalent Chloride of Sodium 93-32 31.10 1.21
The patient continued to improve rapidly, and, in fact, on this day (July 24th), was dreued
^nd walking about the ward, although the temperature was about three and a half degrees
»bova the normal stand^rd^
Id the picccdiDg Case, 702, iltliQUgh but Uttl^ mcdicioe wan employed, acd that qf
672 Dietetic Syutem ^ Treating Pneumonia.
the mildoBt oharacter, the pneumonio inflammation resolved spoutaneously, and did not
paw into the stage of hepatization and suppuration. There was no subsequent pnni-
lent expectoration, and the recovery of the patient was rapid and complete^ The fiivor-
able result in this case could scarcely have been predicted or hoped for, of the 19th of
July, third day of disease, when the temperature of the axilla was IW^A F., and of
the palm of the hand, grasping the thermometer, 105^.8 F. The temperature of the
internal organs was, without doubt, at least from two to three degrees higher, and pro*
baUv reached 110'' F.
Vbat high degrees of febrile heat ore not necessarily fatal in Pneumonia, will be
elearly shown by an examination of the outlines of the histories of the two fotlowiDg
oases, 703 and 704, which I treated successfully in the Charity Hospital of New
Orleans :
f/ASK 'i 03 ; Double Pneumonia ; Oreat JSlevaiion of Temperature ; Recuverg.
John Venwick, age 23 ; laborer ; stout, muscular, well built man. Admitted into ChAritj
Hoipital, ward IS, bed 195, December 9tb, 1873, in the erening. I saw this patient for the
first time, December 10th, 8 a. m. Skin hot; cheeks flushed ; pulse 104; respiration 20;
tongue furred, and red at tip and edges ; temperature in axilla 104° F.; no appetite ; pain in
leftside; bowels constipated ; restless; considerable thirst; dullness over loirer lobe of left
lung, which is most marked posteriorly.
Breathing weak in the lower lobe and lower portion of the middle lobe of right long, bat
exaggerated in the superior portions. Vocal fremitus increased ; bronchial breatbiof and
bronchophony, with feeble crepitation heard orer those portions of the right Inog which
wera especially dull upon percussion. Expectoration scanty ; the sputa consisting of thick,
gelatinous, rusty colored, fibroid exudation. Urine devoid of chlorides; no aibumea: urea
and nric acid. Phosphoric and Sulphuric acids increased ; coloring matter of bile and bile
acids present. I ordered the following : R. Emplastri Cantbaridis, 6 by 8 inches, over lower
portions of right chest. R. Quinias Sulph., half drachm ; Pulv. Doveri, half drachm; saki*
divide into 10 powders ; one powder every three hours. K* Liq : Ammonias Acetatis, (Spts.
Mindereri), half a fluidounce every two or three hours. Diet, Milk Punch and Beef Tea.
Eight o'clock p. M. — Patient suflering much pain, with great oppression of respiration
Skin hot and dry. Temperature of axilla, 106°.2 F. Continue treatment. The blister has
not had the usual effect.
December lltb, 8 a. v.— The patient was delirious during the night. This morniD^ iht
skin is hot, but bathed in perspiration. Features haggard and pinched. Cheeks much flashed.
Pulse 116, full and bounding. Respiration 54, panting, oppressed and painful. Temperator*
of axilla 104^.8 F. Pneumonic inflummation progressing in lower and middle lobes of right
lung, and it has also invaded the lower lobe of the left lung, which is dull upon percnssion
and emits crepitant rales. Expectoration has ceased.
B« Tinct. Veratri Viridi, 5 drops every three hours. Continue ^Solution of Acetate «»f
Ammonia, and Quinine and Dover's powders. Dress blister with Simple Cerate. Milk I*«Bct
and Beef Tea in small quantities, at regular intervals of two hours.
Eight o'clock p. v.-^Respiration rapid and panting, about 60 per minute; pulse tull and rapid
With the invasion of the left lung by the pneumonic inflammation, there has been a progresairt
rise of temperature, and the thermometer in the axilla indicates 109^ F. It is probable that
the temperature of the blood in the internal organs is between inland 113^ F. No trace of
chlorides in the urine, which is of a brownish red color, and entirely free from albumen. >\
expectoration from lungs.
December 12tb, 8 a. ii.---Pu1se 1U» ; respiration 'iO. The fever subsided gradually dunu^
the progress of the night, and the patient breathed easier and obtained some refreshing rest
The temperature has fallen 5^5 F., and the thermometer now indicates in the axilla, 103^.5 F
Careful examination of both lungs, by auscultation and percussion, reveals the fact that
there has been uo fresh portion of lung invaded, and that crepitation is now heard Ui por>
tions of the lungs which were devoid of all respiratory sounds, except bronchial hreathisi:
The expectoration has reappeared, and the sputa presents the appearance of thick, tea >
transparent jelly, which adheres fiiroly to the bottom of the vessels in which it is feceire^
Chlorides still absent from urine. No altbumen in urine. I regarded the arrest of the pae^-
roonic inflammation in both lungs, and the reappearance of the expectoration, and th«
marked diminution of the temperature, and the absence of delirium, as most favorable ttgiu .i
this apparently hopeless case.
Eight o'clock p. M. — Patient continues in much the bume state, although, as was to haw
been expected, nnder any circumi^tances, there has been a slight rise of temperalare, ti«
thermometer indicating 104** in the axilla. There has been no iocrcase of the |i«e««<^^
Dietetic System of Treating Pneumonia, i>73
inflammation during this day, and there is just grounds for a favorable prognosis. I attrib-
uted the arrest of the pneumonic inflammation to the combined effects of the Veratria, Quinine
and Dover's Powders. The blister also, as well as the administration of nourishment and
alcoholic stimulants at regular intervals, may*also have contributed to the favorable result.
With the arrest of the progress of the pneumonic inflammation, that is, as far as the invasion
of fresh portions of the lungs is concerned, there has been a progressive decrease in the fre-
qaencj of the pulse and respiration.
December 13th, 8 o'clock ▲. u. — Continues to improve ; expectoration more abundant ; air
penetrating gradually the solidified portions of lungs, crepitant and sub-crepitant rales being
beard in the solidified portions of both lungs. Chlorides have reappeared in small quantities
ID Urine. Pulse 100; respiration 24 ; Temperature of axilla 104^.4 F.
Eight o'clock p. M . — The patient has continued to improve, and the temperature to descend,
and now stands at 102** F., having fallen during the past 12 hours, 2^.4 F., and the past three
days, 7<> F.
December i4th, 8 o'clock a. m. — Continues to improve. Pulse 84; respiration 28 ; tempera^
ture of axilla lOl^A F. 8 o'clock p. m.— Temperature of axilla 99°.8 F.
On the following day, the temperature rose to 101°.5 F., and for several days oscillated
between 99^.5 F. and 101^ F. The recovery of this patient was complete, without any abscess
of lung, or purulent expectoration, and he was discharged from my service in good health.
Cask 704 : Double Pm'umonm ; Temperature of Axilla reached 10»® /'.; Abtceu of Luftf/ ; TedU
oiu Oonvaletcenee ; Recovery.
August llaville ; native of Italy, age 21. Black hair and eyes, florid Complexion. Entered
Charity Hospital, ward 25, bed 377, November 19th, 1873. Says that he was taken sick two
days before entering the hospital, and that he had suffered with chills and fever occasionally
daring the autumnal months.
Complained of pain in right lung, difficulty in breathing, loss of appetite, thirst, and pain
in the bead, back and lower extremities. Five grains of Quinine and twenty drops of Tinc-
ture of Opium (Laudanum), were administered, and sinapisms applied to the chest. Novem-
ber 20th, the pain continues to increase upon the right side, the cheeks are flashed, and aus-
cultation and percussion reveal the presence of pneumonic inflammation in the middle and
lower lobes of the right lung. Pulse 100; respiration 52.
November 21st, 8 a. m. — ^Pulse 116; respiration 50; temperature of axilla 104® F. Great
dyapnosa, rapid respiration. Cheeks of a purplish red color. Sputa consists of blood, mixed
with tenacious. Jelly-like matter. Cough troublesome and painful. Pain in the right side,
greatest about three inches below the nipple, and extends towards the back. Patient was
restless and delirious during the preceding night. Tongue rough and covered with a yellow,
ish fur in the centre. Pulse rapid, full, strong and compressible. Upon percussion, right
lung dull over region of middle and lower lobe.
Auscaltation reveals crepitation, in inspiration, with bronchial respiration and increased
vocal fremitus over the lower and middle lobes of right lung. R. Quinise Sulph., Pulv.
Doveri (Ipecac et Opii), of each, one scruple; mix; divide into four powders. Sig: One
powder ^^ttj four hours. Apply Turpentine stupes over right side. Milk Punch and Beef
Tea at regular intervals. 8 o'clock p. m : Temperature of axilla, 105^ F.
November 22d, 8 a. m. — The patient passed a disturbed, restless night, but appeared to be
more comfortable this morning, the 'pulse being 106 and the respiration 24. Auscultation
and percussion revealed no increase in the pulmonary disease. The treatment and diet were
continoed. The temperature, also, of the axilla, has fallen one and a half degrees, and is
103*. 5 F.
Shortly after this observation, the patient expressed a desire to receive "extreme unction*'
from the Catholic Priest. He was accordingly, (without my knowledge or consent), taken
out of bed and placed in a chair, with his feet resting upon the bare floor. This exposure
brought on severe pain in the left lung also, with a rapid rise of the temperature, and at 8 p.
M., the thermometer in the axilla stood at 109® F. The temperature of the blood in the inter,
nal organs was most probably as high as 112® or 113® F.
November 23. — Patient delirious during the night, it being necessary to confine him to the
bed. The burning fever appeared to abate towards morning.
Eight o'clock a. m. — Restless, anxious, and at times delirious. Cheeks flushed, and of a
purplish blue color ; Hps and hands congested. Respiration rapid and panting. Expectora-
tion almost entirely suppressed. Respiration rapid, embarrassed and painful. Lower lobe of
left lung dull upon percussion, with crepitant rales and tubular breathing. Pneumonic symp.
toms of right lung aggravated.
Palie 130; respiration 50 ; temperature of axilla 102®.5. The exposure of yesterday has
eTideotly excited fresh inflammatory actions in the Inngs, both of which are now involved
(i74 Dietetic System of Treating Pneumonia,
(\ud the remarkable rise of temperature to 109® F., daring the OTeniDg, waa eridentlj doe to
the sudden spread of the pneuoionic inflammation.
I ordered the Quinine, and Dover's Powders, and Turpentine Stupes, and Beef Tea, and
Milk Punch to be continued as before, and ordered, in addition, the following : R. Liq;
Ammonie Acetatis, half a fluidounce every two hours. R. Tinct. Jelseminum SemperTirens
(Yellow Jassamine), ten drops every four hours.
Under these measures, the fever slowly declined ; a large portion of the right lung, how-
ever, passed into the stage of solidification and gray hepatization. A large cavity formed ia
the middle lobe of the right lung.
Id this case, daring the changes of the pulmoDary textures resulting from the pneu-
luoDic inflammation, the temperature for one hundred days oscillated between 100° and
104° F., the mean ranging between 101° and 102° F., as in some cases of Phthisis Pul-
monalis. Under the continuous employment of Quinine, Iron, bitter tonics, gentle
expectorants and Cod Liver Oil and nutritious diet, I had the satis&ction of seeiDg
this patient restored to health after an illness extending over four months. Daily
observations were taken of the pulse, respiration and temperature, with observations
upon the physical changes of the lungs and the characters of the urine, but it would
extend this report to too great a length to present the details.
The Confederate soldier, Andrew Jackson Sharpe, whose case has been detailed, No.
702, had in the month of August following, an attack of Intermittent Fever, and I
was thus enabled to institute a comparison between the phenomena of this disease and
those of pneumonia, oocurring in the same individual.
Cask 705 : InlermiiUnt Fever foUowinff Pneumonia in the Same Individual,
Andrew Jackson Sharpe, Confederate soldier ; had an attack of Pneumonia, which we har^
recorded (Case 702).
August 21st. — Had a chill this morning, about 8 o'clock, and at the present time, 11 o'clock
A. M , has fever. Pulse 94, respiration 28, temperature of hand 4P.4 C, 106^6 F., tempera*
ture of axilla, 41^.6 C, 106<>.9 F. Face flushed. Urine light colored. Urine passed after the
chill, during the onset and height of the fever, normal in color, limpid, without deposit, 9vtn
lifter standing several days ; reaction strongly acid ; specific gravity 1011. Amoant of arior
pnssed during 10 hours of the commencement and height of the fever, 7794 grains.
*Vo, 90. Analytie of Urinf parsed dmnff Ten ffoure of the commencement and htight of a p9roxy»w%
of Paludal fever.
doiinc 10
Amount of Trine , ,.»,,...,, ,.,..,.,., 7794.81
Phosphoric Acid ,.,...., Mt.M..tt..« , 2.9«
Sulphuric Acid.,.., , ^ 10.08
Chlorine., , ,..,., 42.16
Fixed Saline 1 Equivalent Chloride of Sodium 70.5«l
Conatituents, yPboiphatei of Lime and Magnesia ^ 0.23
74.22, j Phosphates, Sulphates and Carbonates of Soda, and Potassa.. 3.34
The saline constituents consisted almost entirely of Chloride of Sodium, whilst the Potassa
Falts appeared to be, in a great measure, absent. The presence of Chloride of Sodium, and
the absence of the Phosphates and Potassa salts in the urine during the active sUges of na-
larial fever, correspond with the pathological changes which we have demonstrated by th«
analysis of the blood and urine, and organs, in a large number of cases. During the chill of
Paludal fever, the spleen and liver, and, in fact, all the central organs, but more esp^ciallT
the spleen and liver, are congested with blood. The changes of the blood in the liver aa4
spleen, are of a peculiar nature : there is not a mere congestion and stagnation of the blood :
importoot changes take place in the blood of these engorged organs. I have determiaeil br
numerous microscopical observations, as well as by chemical analysis, that the mmd of tbV
enlarged and softened malarial spleen consists almost entirely of dead and altered colore
blood corpuscles. So also the Uver contains vast numbers of pigmentary fragments deposited
chiefly in the periphery of the lobnli, and which have resulted from the destnictioa aad
alteration of the colored blood corpuscles. The denial of the existence and the pathological
significance of the pigment particles of the liver and spleen in malarial fever, can be referred
only to absolute ignorance of the natural history and pathology of this diieue, and to
incompetency an tbe nafi of the microscope. '^
Dietetic System of Treating Pneumonia. 675
It is impossible that the pigmeot particles of the lirer aod the spleen of malarial fever,
which consist chiefljr of altered hematin, should escape the attention of any competent
microscopist.
AAer the active congestion of the Urer and spleen during the cold stage, the blood corpas-
cles which have been withdrawn from the circulatorj fluid, undergo profound alterations.
Therefore, after the chill, an impoverished blood circulates and undergoes chemical change.
This blood is characterized by a deficiency of colored corpuscles, and a preponderance of the
liquor sanguinis ; and, hence, it appears that the urine excreted during the first stages of tlie
paludal paroxysm presents corresponding characters: — as Chloride of Sodium is the salt
which more especially characterizes the liquor sanguinis, it will appear in the greatest abun-
dance in the urine ; and as the colored blood corpuscles have been withdrawn in a great
measure from the general circulation, we have during such withdrawal a clear, limpid, color-
less urine. As a large portion of the colored blood corpuscles have been temporarily with-
drawn from the general mass of the circulation, the salts peculiar to them, and resulting
from the chemical changes of their component elements, viz : the phosphates of potassa, lime,
magnesia and iron, will in a great measure disappear from the urine.
August 22d, 11 A. M.— Pulse 66 ; respiration 22 ; temperature of hand 38**. C. (100®. 4 F.);
of axilla 38^ 3 C. (101^ F.) Patient in a good perspiration; fever appears to be declining,
which change commenced about 7 a. m., when sweating commenced.
Examination of Urine: — The urine passed during the gradual subsidence of the fever, was
much more deeply colored than the urine of fever, and presented a reddish color. Amount
of urine passed during fourteen hours after the decline of the fever, from August 2lst, 10 p. m.
to August 22d, 12 M. : Grains 9601.20; specific gravity 1016. The phosphoric acid appeared
to be combined chiefly with the alkalies, for ammonia failed to precipitate but a very small
quantity of phosphates of lime and magnesia, and, in fact, so smaU a quantity, that it was
found impracticable to filter them from ihe urine. The crystals also appeared to be unusually
small, and to pass readily through the filter. The saline constituents consisted in considera-
ble measure of common salt, but not to so large an extent as during the fever.
No. 91 : — Anafyn't of Urine patted during fourUen hourt — Augutt 21, 10 P. Jf. /o Augutt 22, 12 if;
Trine Paaied During
TourtMn Bonn.
Grains:
Amount of Trine 9601.20
Phosphoric Acid 29.07
Sulphuric Acid 19.20
Chlorine 36.30
Fixed Saline ) Equivalent Chloride \ ra 04
Constituents V " of Sodium i
76.50 j Phosphates and Sulphates of Lime, Soda and Potassa 16.06
We observe a decided increase of phosphoric acid and phosphates. Some of the character-
istic changes of the urine in malarial fever are shown in the two preceding analyses.
These changes correspond with the phenomena. As paroxytmt characterize the phenomena
of malarial fever, so do marked changes, at difllerent periods of the disease, characterize the
urine
August 23d, 12 M.— Pulse 80; respiration 24; temperature of axilla 38^ 5 C. (101<>. 3 F.)
Examination of Urine: — Heavy crystalline deposit in urine, uf phosphates of lime, magnesia
and ammonia, and of urates and uric acid. Amount of urine passed during the last twenty-
four hours: Grains 12,927.60 ; specific gravity 1026.
No, 02: — Analgtit of Urine patted during twentg^four hourt , Augutt 22rf, 12 if., to Augutt 23</,12 Jf.
Tri»e Pwncd Dnrirg
Twentj'four Uoar».
Grains:
Amount of Trine 12,027.60
Phosphoric Acid 52.93
Sulphuric Acid 43.54
Chlorine.. 64.90
Entire Saline^ Equivalent Chloride of Sodium 106.99
Constituents [-Phosphates of Lime and Magnesia 15.81
146.43 J Phosphates and Sulphates ot Potassa and Soda 23.63
By a comparison of the various analyses of the urine in this ease, we observe a progrcs-
676 Dietetic System of Treating Pneumonia.
Bire increue in the tftUne constituents, And espvciallj of the phospbatei of lime aod
magnesia.
AbsolutelT' no medication was employed in the preceding case, so that it famishes daU
for tht comparison of the phenomena of Pneumonia and Paroxysmal fever, occurring at dif-
ferent times in the same inditidual.
That cases of fever should arise ia a hospital, or id camp at any time, iodependentJj
of the effects of exposure or fatigue, or the supervention of any recognisable inflamma-
tory lesion, may be accounted for in a measure by the fact, that tents and hospitals are
uflen loaded with deleterious exhalations, which may be capable of inducing febrile
excitement in the animal economy. Sudden check of perspiration, may also induce
general febrile excitement, not so much as Dr. Hall and others would have us believe,
from an impression upon the sensitive nerves of the surface transmitted through the
central spinal ganglia, and reflected upon the sympathetic and vaso-motor nerves, as
from the sudden suppression and perversion of the functions of the extensive glandular
system of the skin, and the consequent retention of deleterious matters in the blood,
which are capable of affecting the nervous system and inducing febrile action. In the
problem of the action of the emunctories of the skin, and of the amount and chemical
composition of the matters eliminated, cold or temperature enters as a material element,
tt is possible that the phenomena may be explained without resort to the theory of the
transmission of nervous influence to internal organs. Disturbances in the electric phe<
nomena of the nerves and muscles, and of the secretions, should also be considered in
the discussion of the origin of Irritative fever and inflammations. I select the
following case of Irritative fever, arising spontaneously in my hospital practice daring
the civil war, as affording materials for comparison with the case of Pneumonia ( 7<^2
previously recorded, in that it was treated strictly upon the so called esrj^ctant plan.
without drugs.
('A9R 70G : Fever oriyinating in Military HotpUal^ without any auiynabU cause^ and vithcMi antf •/*••
rprnibU local injfamnwtion ; treated upon the Kxpertant plan^ without drttys.
Powers, Confederate soldier; age 18 ; height 5 feet 7 inches; weight 115 pounds; I z'-'
hair, fair complexion. Has been in the General Hospital, C S. A., Augusta, Georgia, for «
weeks. Entered with bronchitis, and in an ana;mic condition. Native of Marion DUtrict
Sooth Carolina. Says that he had chills and fever last year ; and has bad pneumonia thret
times in his life. During his stay iu this hospital, hns been treated with Quinine, Iron, an<I
bitter tonics, and supplied with nutritious diet. Tnder this treatment the patient has im-
proved rapidly, gaining both in flesh and strength, and presenting a clear, healthy complexioe
The patient was in apparent good health, and fit for active service in the field, when on it**
night of July 18th, 1862, he was seized with severe pain in his head, followed by high fcvf
the pulse beating 130 per minute and the temperature of the axilla reaching 106^ F.
July 19th, 12 M., pulse 120; skin hot and dry; tongue moist, bnt red. Ordered his una*
saved from this moment. I prescribed nothing, but directed tbat the patient should be top-
plied with cold water, ad libitum.
July 20th, 11 A. M. Much better; skin cooler; pulse 112: skin warm but moist; ton^^if
red but moist. Bowels have been moved four times and are inclined to diarrhoea. I*nr«
orange colored. Nothing ordered beyond cold water and simple nutritious diet.
July 21st, 2 o'clock p. if. Pulse 92 : respiration 22; temperature of band 36* C., (9?* F
of aiilla 38°.4 C, (lOlM F.)
Examination of Urine. Amount of urine passed during the last 46 hours ; grains, 31,9M "'
specific gravity, 1012. 4. Urine rapidly underwent putrefaction, and emitted an offens-^t
i<mell, as in tbat of the case of Pneumonia, 702 ; while on the other hand the urine excreu '
during the active stages of malarial fever, as in case 705, did not undergo a similar charfv
and emit an offensive odor, until the febrile excitement had subsided.
Dietetic System of treating Pneumonia. 677
2io, 93. Anaiiftii of Urine patted during forty^eight houn.
Forty-light Tw«nty-foar Xtch bour.
honn. hoan.
Graiof. Oraina. Gralu.
Amonnt of Trine 31,890.60 16,945.30 664.38
UreA 741.12 370.56 16.44
Uric Add 22.68 11.34 0.47
Free Acid 46.32 23.16 0.96
Phosphoric Acid 06.90 48.45 2.01
Salphoric Acid 47.53 23.76 0.99
Chlorint 15.82 7.91 0.32
EqaiTalent Chloride of Sodiam 26.05 13.02 3.13
Phoupbates and Sulphates of Lime, Magnesifti and of
PoUssA and Soda 150.35 7ri.l7 0.54
Jnlj 22d p. X. Free of fever, pulse 84 ; skin cool.
Jul/ 2.3d, 2} p. X. Pnlse 96; respiration 22; temperature of hand 36<».8 C, (98^2 F.;) of
axilla, 38'' C, (100<'.4 F.;) skin moist ; tongue red.
EtammaUon of Urine, — Amount of urine passed during the last fortj-eight hours ; grains
19,857.12; specific gravity, 1009; normal color, slight deposit.
No. 94. Analtftis of Urine pasted during forttf'eigkt kourt,
Forty-Kiglit Twenty-four Each honr.
hours. houn.
OnUnii. Graina. Graiot.
Aokount of Urine 19,857.12 9,928.56 413.69
Urea ^ 636.90 318.45 13.26
Phosphoric Acid 22.71 11.33 0.47
Sulphuric Acid 44.10 22.50 0.93
Chlorine 3.57 1.78 0.07
BqoiTalent Chloride of Sodium 5.48 2.94 0.12
p. X. Free of fever; pulse 80; surface of hody feels cool and natural.
Jul/ 24th, 1 p. M. Pulse 96 ; respiration 16 ; temperature of hand, 36^.4 (97^5 F.;) of axilla
38®.2 C, (100<».7 F.)
Szamination of 6>iiie.-— Amount of urine passed during twentj-four hours; grains 9,515.52 ;
specific gravity, 1008; straw colored; heavy deposit of phosphates and urates. Alkaline re-
action and putrid odor.
AV). 96. Anahftitof Urine poMted during twentp^fovr kourt,
T*rine Twenty- Crin« rach
four houn. hour.
Graioa. Gralni.
AmoQQtof Urine 9,615.52 396.48
Urea „ 236.23 9.84
Phosphoric Acid T.62 0.30
Snlphnric Acid 11.31 0.47
Chlorine 1.48 0.06
Eqaivalent Chloride of Sodium 2.43 O.IO
During this day, all traces of the fever subsided, and the only perceptible effects, were those
of debility — the complexion being rendered paler, the skin more relaxed, and the patient more
languid and feeble than in health. As far as could be determined by physical exploration and
chemical research, no organ was implicated in this fever. With the exception of several dis-
charges from the bowels, on the 20th no derangement of any of the viscera were manifested,
and this slight disturbance of the alimentary canal, might have been produced by the copious
draughts of cold water.
The oonsideration of tho spootaneous resoltttion of such oases of fever, which in
their onset, forbode serioos conseqaenoes, is important in the warning which it giveH
against the unconditional acceptance of the statements of those who assert, that certain
fevers, and especially Typhoid fever, can be aborted or strangled in the earliest stages by
certain remedies and measures. If in this case (706,) Quinine or Opium, or any oth er
iremedy, had been used, the phystcian^ight have attributed the gradual subsidence of
^T^ Eietetie System of Treating Pneumonia,
the fever, to the so-called abortive effecU of his drugs ; whilst in reality, nature needed
no assistance ; — either the poison producing the fever being so limited in amount, as to
be readily destroyed during the changes of fever,— or else, the disturbances in the
nervous system and blood, and orzans, were so slight, as to be readily re-adjusted, by
the working of the natural and fixed laws of the economy. It would also be a subject
of inquiry to determine how far the free use of cold water internally, may have pro*
moted the favorable result ; as well as the probable effects of the withdiawal of this
agent, and free supplies of fresh air upon the progress and results of such a case of
fever.
An examination of the changes of the urine in the preceding case, reveals the f«ct
that the chlorine was diminished to a marked degree. The diminution of this element
is characteristic not alone of pneumonia, but all those diseases, as Typhoid fever, Small
Pox, and Bemittent fever, which continue for a considerable length of time^ and in which
little or no nutriment is taken. We have shown that the chlorides may be diminished
to a marked extent even in Traumatic Tetanus. It would expand the present volume
to too great an extent to detail the observations which we have made upon the urine in
Pneumonia and various other diseases in order to illustrate the chemistry, patholof^.
and treatment ; and I will content myself with an expression of such general conclu-
sions as will illustrate certain questions relating moro especially to the method of treat-
ment.
1st. During the active stages of Pneumonia, the Urea, Uric Acid, Free Acid, Phos-
phoric Acid and Sulphuric Acid, are present in increased quantities in the urine ; and
such increase is evidently due to the metamorphosis of tissue during the increaned
chemical changes of the forces.
2d. During the active progress of the Pneumonic Inflammation, the chlorine rapidly
diminishes in amount and may entirely disappear ; and its re-appearance in the nrioo
and progressive increase indicates an arrest of the farther progress of the pneumonic
inflammation. The reappearance of the chlorides in the urine may indicate the com-
mencement of convalescence, before auscultation and percussion afford any information
as to the progress or arrest of the pneumonic inflammation in the sound portions «>f
the lungs.
A similar observation is also true with reference to the indications afforded by tho
thermometer. The retention of the chlorides is connected with the morphologicaJ
changes of the pneumonic exudation, and their excretion is increased, during the absorp-
tion and disappearance of the exudation.
3d. In malarial fever, on the other hand, during tho chill and early sta^ of the
febrile excitement, Chloride of Sodium appears in increased amounts, whilst there is a
marked diminution of Uric Acid and Phosphoric Acid.
During the cold stage, the colored blood corpuscles are accumulated and altered in
the liver and spleen ; and during the hot stage an impoverished blood circulates and
undergoes chemical change ; as this blood is characterized by a preponderance of ih**
liouor sanguinis ; and as the chloride of sodium is the most abundant and charadeiisti-
salt of the Liquor Sanguinb, it will appear most abundantly in the urine. As a larcv-
portion of the colored blood corpuscles have been temporarily withdrawn froin ih'^
general mass of the circulation, the salts peculiar to them and their chemical duuijre«.
viz : the Phosphates of Iron, Lime and Potassa, will in a great measure disappear frt^m
the urine. Owing to the congestion of the liver, the bile also is altered in its propettk^
and appears to be excreted in larger quantities than in health.
4th. During the continuance of die fever however, the urine becomes of a ^^V*^
color, the Phosphoric Acids and Potash Salts, and Uric Acid gradually increase. Tht
increase of those constituents, in the urine during the progress of the fever, is readi'v
explained, by the fact that the altered blood corpuscles during the active changes of th<
fever, are themselves drawn into the round of chemical change, undergo deoomnoaitias
and yield up the coloring matters and salts to the eliminating action of the kidneyv.
6th. The remarkable changes of temperature, as well as the internal rotifsatMs
Dietetic System qf Treating Pneumonia. 679
characterbtic of the chill, are probably due to the action of the malarial poiaoo, or of
the blood altered by the paludal poison, upon the internal ganglionic centres. Thb
appears to be indicated by the remarkable fact, that during the chill, there is an actual
elevation of the temperature of the trunk sometimes as high af 107^ F., whilst there
may be a reduction of the temperature of the extremities as low as 87^ F., or ten
degrees below the standard of health, and 20 degrees below the temperature of the
trunk. This phenomena resembles in some respects that of the division of the sympa-
thetic in the neck. There is then during the chill a paralysis of the sympathetic sys-
tem, a dilatation of the largest blood-vessels, and especially of the veins and sinuses and
capillaries of the brain, spinal cord, liver and Spleen, and an accumulation of blood in
the central organs ; and attending this stagnation of the blood in the central organs, and
contraction of the capillaries of the periphery of the body, there is an actual rise in the
temperature of the mass of blood, as if by some agent or ferment, rapid chemical
change was excited in the vital fluid. It is a question whether the paralysis of the ves-
sels of the surface, be due to direct action of the vaso-motor nerves, or to the accumu-
lation of the blood in the largo central organs, consequent upon the paralysis of the
ganglia of the sympathetic Cerebro-Spinal system, whicn preside over circulation and
animal heat. When^the chills recur frequently, these phenomena will be frequently
repeated, becoming less distinct as they approach each other ; and in the remittent form
of fever, they are less marked, and the changes of the urine present greater uniformity.
6th. The disappearance of the Phosphoric Acid from the urine in the early stages
of the paroxysm, also indicate, perversion or arr&sc of the normal and nutritive and
chemical actions of the nervous system.
7tJi. In Typhoid, (Enteric, Continued, Camp) fever, uniformity characterizes the
phenomena; whilst paroxysmal changes characterize those of malarial fever. In
Typhoid fever the colored blood corpuscles are not specially altered, either in character
or amount ; neither are the spleen and liver specially affected.
8th. Typhoid fever is characterized by an elevated temperature with slight morning
and evening variations ; great mental, nervous and muscular depression ; rapid chemical
change of the elements of the nerves, muscles and blood ; great and continuous increase
in the amounts of Urea, Phosphoric and Sulphuric Acid excreted in the urine.
Dth. Pneumonia is characterized by structural alterations of certain defined ana-
tomical elements of the lungs ] malarial fever is characterized by certain definite lesions
of the blood, liver and spleen ; yellow fever, by certain lesions of the blood, heart,
liver and kidneys; typhoid fever^ by certain lesions of the intestinal canal: in each
case, the important question arises, what is the exact connection between the local lesions
or manifestations of diseased action, and the general pyrexiae.
If in Pneumonia, the exudation into the lungs coincides with the end of the pyrexiae,
it would appear that the exudation into the air cells, relieved or cured the fever ; and
the conclusion might be justified, that the lung disease is not a primary but secondary
affection, and that by purifying the blood, it brings to an end, a condition of general
pyrexias, arising from preceding blood disease. On the other hand, it maybe held that
the local inflammation of the lung is the primary lesion, and the fever is the result of
the disturbances in the blood circulation and nervous system caused by the inflammation
of certain anatomical elements of the pulmonary tissue. I do not propose to enter into
an exhaustive discussion of these theories, which would demand even greater space than
that devoted to the consideration of Traumatic Tetanus ; and will dismiss the subject
with the practical observation, that as a general rule, the fever is coincident with the
aapenrention of the local inflammation, and presents characters in accordanoe with its
extent and severity, and continues as long as active inflammation is present, and is
renewed in intensity whenever fresh portions of the pulmonary tissue are involved.
Acoordiog to this view the fever of Pneumonia resembles the traumatic or so-called
surgical fever attending wounds.
In the Dietetic System, which consists in allowing the disease to run its natural course
uQiofluenced by drugs ; during the active sta^, tbe diet is light, with cold water for
680 Dietetic System of Treating Pneumonia.
drink ; aud subsequeDtly when the fever and active symptoms aecline, a more generous
diet is allowed, with alcoholic stimulants if the forces are depressed.
Pr. Bietl treated 380 cases of primary pneumonia, in the Charity Hospital of Vienna,
by Venesection, by large doses of Tartar Emetic, and by diet alone, with the foUowiag
results :
In 85 cases of Pneumonia treated by Venesection, 17 died, giving 20 per cent, of
deaths, or one death in Jive cases.
In 106 cases treated by large doses of Tartar Emetic, 22 died, giving 20 per cent, of
deaths ; or one death in 4.818 cases.
On the other hand, in 189 cases treated by diet alone, only 14 died, giving 7.40 per
cent, of deaths, or 1 death in 13.5 cases.
In the experiments of Dr. Dictl, the superiority of the treatment by diet, was ren-
dered still more obvious, by the fact, that of 85 oases treated by diet, not one of the
deaths was uncomplicated.
According to Dr. George Balfour, who examined the statistics of the Homo^pathic
Hospital of Vienna, many severe cases of Pneumonia recovered under a form of treat-
ment which consisted in little else than to allow the disease to run its natural course,
under oertain regulations of diet.
In the expectant plan of treatment, adopted by Skoda, in the Charity Hospital of
Vienna, in which remedies were given to meet occasional symptoms, venesection being
practiced early if there was much dyspnoea, opium administered if there was much pain,
and emetics given if the expectoration was difficult and the mucus tough, during a
period of three years and five months, commencing 1843, 393 patients were treated, of
whom 54 (13.77 per cent.) died, or one death in 7.25 cases.
The comparison of these results would seem to indicate that the mortality was io a
great measure proportional to the interference with the operations of nature by vene-
section and drugs.
It is important, however, tbajb these experiments should be greatly extended, and
careful records kept of the phenomena manifest during the various stages of the disease.
The points of chief interest to be noted by the investigator are :
1st. The precise time and symptoms of the oommenoement of the disease.
2d. Hourly and daily variations of the pulse, respiration and temperature.
3d. Chemical constitution and pathological changes of the blood.
4th. Chemical constitution, and pathological changes, and daily variations of the
urine.
5th. Microscopical aud chemical composition and variations of the sputa.
6th. Careful observations on the various stages of the disease, which mark tb«
progress to recovery or to death. All critical discharges from the skin, lungs, kidneys
and bowels should bo carefully noted, as well as the attendant variations of tompenturr,
and of the circulatory and respiratory acts.
7th. In fatal cases, careful miroscpical and chemical examinations should be made
of the diseased structures.'*'
II. RATIONAL TBEATMENT D£SIGN£D TO FURTHKH THK NATURAL PROURSSS Of
PNEUMONIA TOWARDS RECOVERY.
This mode of treatment should evidently embrace the Dietetic System, and, altlKmgh
resembling in some respects the Expectant plan, differs from it, in that it is an atlCBpt
to treat disease by fixed principles, rather than according to casual sjmpUmBy the
design of the remedies being to excite and aid those natural proccsBcs by which the.
disease terminates favorably. However imperfect this system oiay now be, in
* Dr. Parkes, Emeritus Professor of Clini<fal Medicine in Uoiversit/ Collcga, has gireo a
valuable record of an uncomplicated case of Pneumonia, nnnodi&^d by any other ditcMe
or by treatment. Med. Times and Gasette, Feb 95tb,
Rational Treatment of Pneumonia. H81
to its possible improvement, still it is not too much to affirm that the principle which
underlies it, viz : the adaptation and conformation of treatment to the processes which
nature herself employs in the cure of disease, rests upon a firm foundation.
The principles of this system of treatment date as far back as Hippocrates ; many of
the subsequent writers on Medicine, however, have lost sight of the powers of nature in
the cure of disease, and it is only within comparatively modern times that the necessity
of conforming the treatment of disease to the processes of nature in the cure of disease,
has been recognized by at least a respectable portion of the medical profession.
It would perhaps be of some interest to introduce here, for purposes of comparison,
the views of those authors who have endeavored to establish the treatment of pneu-
monia upon fixed principles ; but as a large proportion of the systematic writers who
have exerted a decided influence upon the practice of medicine, have not only enter-
tained notions upon the nature and relations of the phenomena of inflammation, neces*
sarily imperfect, from the state of physical diagnosis, as well as of pathology, at the
time of the composition of their works, but have also failed to give any data by which a
comparison might be instituted as to the relative merits of their modes of treatment, we
will, under this division of our subject, confine our examination to the views and testi-
mony of only two modern writers, who may be taken as fair exponents of the Bational
System of treatment, and who have furnished data by which the merits of the system
may be tested, with some approach to accuracy.
The treatment which Dr. John Hughes Bennett pursues in Pneumonia, is founded on
the pathological principles, never to attempt cutting the disease short, nor to weaken the
pulse and vital powers, but, on the contrary, to further the necei*sary changes which
the exudation must undergo, in order to be fully excreted from the economy. To this
end, during the period of febrile excitement, Dr. Bennett contents himself with giving
salines in small doseSj with a view of diminishing the viscosity of the blood. As soon
as the puke becomes sofl, beef tea and nourishment are ordered ; and if there be weak-
ness, from four to eight ounces of wine daily. As the period of crisis approaches, a
diuretic is given, generally consisting of half a drachm of Nitric ^Sther, sometimes com-
bined with ten minims of Colchicum Wine, three times daily, to favor the excretion
of urates. But if crisis occnrs by sweat or stool, care is taken not to check it in any
way.
Dr, Bennett gives as the results uf this practice during eight years, in the clinical
wards of the royal Infirmary :
Total number of cases treated, 7H ; average age 30 J ; of these, 75 were dismissed
cured, and 3 died ; that is, one death in twenty-six cases. Of the 75 cases cured, 65
were uncomplicated, and 10 complicated. Average duration of single, uncomplicated
Pneumonia, 14 i days. Average duration of double uncomplicated Pneumonia, 20 days.
The fatal oases were all complicatod. The first with uncontrollable diarrhoea, and on
dissection conjoined with Pneumonia, there was found extensive fbllicular disease of the
ni aeons membrane of the duodenum, jejunum, but chiefly of the ileum. The second
case was complicated with persistent albuminuria and anasarca. No post-mortem exam*
inatioD could be obtained. The third case, that of a drunkard, was complicated with
delirium tremens, and lately violent convulsions. On dissection, in addition to the
Pneumonia, there was found universal cerebral meningitis, with exudation at the base,
as well as over both hemispheres of the brain.
From the results of his treatment, both with and without blood-letting, and fVom a
comparison of the results obtained by other practitioners, Dr, Bennett concludes ; ^* That
uncomplicated Pneumonia, especially in young and vigorous constitutions, almost always
gets well, if, instead of being lowered, the vital powers are supported, and the excretion
of eflTcte products assisted. It is exactly in these cases, however, that^we are formally
enjoined to bleed most copiously, and that our systematic works even now direct us to
draw blood largely and repeatedly, in consequence of the supposed imminent danger of
suppuration destroying the texture of the lung. Such danger is altogether illusory, and
the destruction of the tissue, so far from being prevented, is ftr more likely to be pro^
082 Rational Treatment 0/ Pneumonia.
duced by the practice. In fact, the only cases ia which it occurs, arc id aged or
enfeebled constitutionH, in which nutrients, and not antiphlogistics, are the remedies
indicated. We can, however, readily understand how blood-letting, practiced early, and
in young and vigorous constitutions, does less harm, or, to use a common expression, ^ is
borne better,' than when the disease is advanced, or the patient is weak, and th»
because then the vital powers arc less affected by it. Hence the diminished mortality
in the second sericH of Louis' cases, and probably in the army and navy cases. But
that it cures the greater number of persons attacked, or shortens the duration of the
disease, is disproved by every fact with which we are acquainted." (Clinical I^ectoros
on the Principles and Practice of Medicine, by John Hughes Bennett, M. D., F. K. S.
E., Professor of the Institutes of Medicine, and Senior Professor of Clinical Medicine in
the University of Edinburg. Third Edition ; Edinbui^, 1859 ; pp. 292-295).
Doctor Robert Bently Todd, in a Clinical Lecture delivered in July, 1857, thus pre-
sents his views of the Treatment of Pneumonia :
** A principal, and very important part of the treatment, to which, as most of you knoir, 1
pay very especial attention, is that which I may call the dietetic portion. The object of this
is to support the vital powers of the patient, and to promote general nutrition dnring the time
when those changes are taking place, which tend to check or alter the morbid process, and to
convert it into a healing process. When a patient suffers from Pneumonia, the tendeacy it
for the lung to become solid, then for pus to be generated, and at last, for the pus-infiltrated
lung-structure to be broken down and dissolved. Such are the changes when matters ukc
an unfavorable course. On the other hand, recovery takes place, either through the noo-
completion of the solidifying process, or by the rapid removal, either through absorption, or
a process of solution and discharge of the new material which had made the lung solid.
** It will scarcely be affirmed, even by the most ardent believer in the powers of therapeatic
art, that any of the measures which are ordinarily within our reach, such as the administra-
tion of certain drugs, or the abstraction of blood, or the application of blisters, exercise %dirtrt
influence m effecting these changes. Save in the case of antidotes, which directly antagonise
the proximate cause of the morbid state, medicines promote the cure of acute diaease, br
assisting and quickening some natural curative process. And he is the wisest practitioDer.
and will be the most successful therapeutist, who watches carefully the natural processes o(
cure — in other words, who studies the phenomena, both anatomical and physiological, which
accompany them, and of which, indeed, they consist.^'
You will perceive, then, that my argument may be thus summed up : Internal Inflam-
mations are cured, not by the ingesta administered, nor by the egesta promoted by the dmf:i
of the physician, but by a natural process, as distinct and definite as that process itself of
abnormal nutrition, to which we give^ the name of inflammation. What we may do by oar
interference, may either aid, promote, and even accelerate this natural tendency to get well,
or it may very seriously impair and retard, and even altogether stop that salutary proceas.
If then, this view of the nature of the means by which inflammation is resolved in IntcraAl
organs be correct, it is not unreasonable to assume, that a very depressed state of riul
power, is unfavorable to the healing process. Indeed, if you watch these cases in which
nothing at all has been done, or in which nothing has been done to lower the vital pover^,
you will find that the more inflammatory process itself, especially in an organ so importaoi
as the lung, depresses the strength of the patient more and more.
You will perceive, then, that according to these views, there are strong a priori reasons in
favor of the policy of upholding our patients, even in the earliest stages of acnte dtaeaae, bv
such food as may be best suited to the digestive organs, such as is most readily aastBiUitc4
and oalls for the least effort, the smallest expenditure of vital force, for its primary dtfeatioo.
Xntritive matter in a state of solution — broths, soups, farinaceous matte rs«-answera the
purpose the best ; and, also, alcohol, which is directly absorbed, without any previous
change, and tends to feed the Calorifacient process, and to diminish the waste of tissues
which would necessarily follow in order to maintain it.
Inflammation is a deranged nutrition. Like the normal nutrition, it involves to ppW ^r. I
waste, and as the latter is considerable, the former will be proportionally so. The teodcoc?.
in inflammation, is to the more or less rapid formation of abnormal products such as lym; I.
and pus; and the supplies for these formations must be drawn from the blood, or from thr
tissues, in both cases, with the effect of more or less exhaustion of vital force; in the latter
with more less extensive organic disintegration. The active chemical procsss which accom-
panies all these changes engenders the great heat of the inflamed part.
The more this process of inflammation draws upon the blood, the greater will be tbe e\-
haustion of the yital force, ai^d the more the whole f^amo will suffer; the more it fre-i« on
Rational Treatment of Pneumonia. 683
the tissues, the greater will be the difficalty of the repurative process. Is it not, then, im-
portant that adequate supplies should be conveyed to this process, abnormal though it be ?
And is it not likely that the most appropriate supplies may be conveyed to it through the
blood, so that the waste of tissue may be stopped, and the tendency -to abnormal formations
be checked, at least, from that direction ?
And this, in truth, seems to me, to be but the plain and simple fact; — you must feed
inflammations as you would other active vital processes. You must, that is feed
them to prevent them from extending to, and preying upon, healthy organic structures and
committing great destruction. Bear in mind, too, that you cannot stop an inflammation, so
long as the exciting cause of irritation is inherent in the inflamed part; you cannot cure an
inflamed eye so long as the irritating particle of dust remains adherent to it. It is wise
then, to try and gain time, until, by antidotal means, or by elimination, you can get rid of the
local irritation, whatever that may be.
This is a fact which I have so often verified, that I am able to enunciate it dogmatically,
that alcohol carefully administered from an early period, in small and often repeated doses, is
the best preventive of, and antidote to, delirium in acute disease. This fact, as regards the
influence of alcohol in the prevention of delirium, is one of the most important which the
clinical observation of cases treated by stimulants brings out. It is quite inexplicable by
those who refuse to study the action and mode of digestion of alcohol, and who, adhering to
old prejudices, rest content with a practice under which, to say the least, great mortality
occurs, rather than be at the trouble of carefully investigating the powers of an important
remedial agent. ♦ • «
Rapidity of convalescence is not the least inportant feature of the cases.treated by the up-
holding plan. Once the acute mischief is subdued, it is surprising with what rapidity the
patient emerges from the invalid condition.*
In his " Clinical Lectures on Acute Diseases," published a little more than two years
after the lecture from which we have just quoted, Dr. Todd advocates the same general
plan of treatment in Pneumonia. In the lectures devoted to the consideration of Pneu-
monia, Dr. Todd recommends the plan of treatment which consists, not in the use of
remedies directly antiphlogistic so-called, that is, of remedies intended directly to knock
down inflammation by withdrawing blood, the supposed fuel of all inflammation, and
reducing vital power, but in the employment of means which will promote the free
exercise of certain excretory functions, by which the blood may be purified, and certain
matters removed from the system, which, remaining in it tend to keep up a state favor-
able to inflammatory affections. The remedies used, tend to promote the free action of
the skin and kidneys, and in a less degree, that of the intestinal mucous membrane,
whilst at the same time, a free stimulation is maintained of that part of the skin which
is near the seat of the pulmonary inflammation ; and an essential part of the treatment
i.<i, that while the remedies are being used, no attempt is made to reduce the general
powers of the system, but they are, on th3 other hand, upheld by frequent and duly
apportioned supplies of easily assimilated nourishment, to supply the waste, which,
during the inflammatory process, must necessarily take place in the most important tis-
Hucs of the body, especially the muscular and nervous. The general treatment consists
in free counter-irritation, by the application to the back, and side, and over the region
of dullness, of flannels soaked in warm Spirits of Turpentine, kept on for about half an
hour, and generally applied at three periods of the day, for three or four days. A dia-
phoretic medicine is administered, consisting chiefly of the Litjuor Ammoniae Citratis,
of which as much as six drachms may be given every three or four hours ; an occasional
dose of a mild aperient medicine may be given, and for food, the patient is allowed at
least a pint of beef tea daily, with milk and bread. If the pain is severe, opium may
l>e given in moderate quantities, but usually it is not advisable to employ opium in large
dfiscs in the simple forms of Pneumonia, because it has some tendency to produce fur-
ther congestion of the lungs, and to depress the heart. Every influence of a depressing
nature, should be counteracted as far as possible: and although the exhibition of stimu-
lantu does not form a necrmtrt/ part of the plan of treatment, still they should be used
whenever necessary to uphold the patient's strength. When the vital powers are clearly
• Rcfiwrlu upon the Tn«tni4>nt of Acute Int«rnal InfUmmalionii fan «>xtnct fn>m a Clinical Lectur* dellTir*^ In
Jiiljr, IH.%7>, by R. B. ToUU, M. P., F. K .8.» Phydclan to Kinjc'i fullr;*'. Anhiv.*of M^'.licini', «Ut.«J hv LImH-l
M heml^^ M. ll., No. 1, |it>. 2, 4. Nu. 'Z, |>l>. M, r»5, 67, TiM.
684 Antiphlogtstic System of treating Pneumonia.
depressed, with a pulse iDcreasing in quickness, or when the patient has been preTioosly
* accustomed to live well, or in the habit of indulgin*; in the use of alcoholic drinks, then
wine or brandy, or what.is really the proper way of express! y.g it, alcoholic food, must
be exhibited.
With reference to the comparative value of this mode of treatment, Dr. Todd affirms
that he has had ample experience, during thirty years, with the various modes of treat-
ing Pneumonia, and especially with the plan of treatment with Calomel and Opium,
bleeding and Tartar Emetic, recommended by some of the highest authorities, and is
compelled to confess that they have given him so little satisfaction, that he has aban-
doned them in his practice. Under the Calomel, and Opium, Tartar Emetic, and
Bleeding treatment, he has seen too many die, and when recovery did take place, the
convalescence was tedious. If Dr. Todd had contented himself with the simple expres-
sion of his opinion against the received modes of treatment, his authority would surely
be no more worthy of consideration than the statements of the honored writers who^e
practice he condemns ; but he has furnished data by which the relative merits of hU
system may in a measure be determined.
From 1840 to 1859, Dr. Todd treated 78 cases of Pneumonia at Kings Colltve
Hospital. These he arranges in two periods : the one from 1840 to 1847, the other
from 1847 to 1859. In the former of these, which may be termed tJie pcrloii of reduc-
ing treaimentj the patients were treated very much in the manner just destcribed. Th^'
total number of cases was 78, and of these, 10 were fatal. Of the seventy-eight ca^nr:)
twenty-five occurred in the first period, and four of these proved fatal, or about one in
every six. In the second, the number of cases was fi fly-three, and in the^3 there were
only six deaths, or about one in nine ; fairly leading. Dr. Tood thought, so far as cao
be judged from the relative mortality in these two periods, to the inference that the
supporting plan of treatment is more favorable (certainly not less favorable) in it*
results than the severer measures which arc frequently had recourse to in this di^^ea.^?.
(Clinical Lectures on Certain Acute Diseases, by Robert Bcntly Todd, M. D., F. R. S.,
etc.; Phila., 18G0. Lecture x. pp. 199, 212. Lecture xii, p. 261. L(*cture xiii. pp
265, 276, 277 ).
HI. ANTIPHMHUSTIC SYSTK.M OF TREATMENT.
Volumes have been written upon the value uf blood-letting in inflammation, aaJ
physicians have attested their belief in its value, by the rivers of blood which have bo^ii
drawn in their battles with inflammation. We do not, however, intend to follow the
plan of the vast majority of the works upon blood-letting, and the systematic treati^^^
on ^' Practice," and enter into any hypothetical discussion of the effects and value of
blood'letting in pneumonia ; we shall eudcuvor to confine ourselves to an examination
of the data by which the relative merits of this method of treating this disease may be
determined with some approach to accuracy.
As far as our knowledge extends the medical profession of the South has, in a gn^At
measure, abandoned the lancet in the treatment of Pneumonia. It is difficult to decide
with certainty upon what grounds the physicians of the South have been led to aban-
don, in a great measure, the lancet; whether from an acquired knowledge of the def^tdy
sing effocts of the climate, or from supposed changes in the characters of inflammatort
diseaaea, or of the human constitution, or from a more thorough knowledge of tb*
effects of blood-letting, or because the practice has passed "out of fashion,'' or from th
discovery of more energetic and valuable modes of treatment, or from two or moiv. -r
all these causes combined. Whatever the reasons for the abandonment of the ancitni
method of combatting inflammation may have been, one thing is certain, the st^ti^t: ^
to prove the wisdom of this step are wanting in the Southern States. They arv or
tainly not furnished by the medical statistics of the Confederate States Aimy. «h: *
may be justly taken as representing, with tolerable accuracy, allowing for the expti^or.«
and hardships to which the soldiers have been subjected, the success of (^oafrdtTi^
physicians in the treatment of Pneumonia.
Antiptdogistie System of Treating Pneumonia. 686
As Id the case of Quinine, so also in blood-letting, in Pneumonia we need a careful
examination of its effects and relative value, based upon carefully recorded observa-
tions.
Louis, who was the first to examine the value of blood-letting, with any approach to
Philosophical accuracy, concluded, from his carefully recorded observations ;
First. That blood letting has a happy effect on the progress of pneumonitis ; that
it shortens its duration ; that this effect, however, is much less than has been com-
monly believed ; but that patients bled during the four first days, recover, other things
being equal, four or five days sooner than those bled at a later period.
Second. That pneumonitis is never arrested at once by blood-letting, at least not
on the first days of the disease. If an opposite opinion is maintained, it is because this
disease has been confounded with another, or because in some rare cases, the general
symptoms rapidly diminish after the first blood-letting. But then the local symptoms,
crepitation, etc., for the most part, continue to be developed not the less for this evacu-
ation.
Third. That age exerts great influence on the rapidity and progress, and on the
favorable or unfavorable issue of pneumonitis.
Fourth. That when blood-letting proves ineffectual, consequently in severe cases.
Antimony in large doses acts favorably, and appears to diminish the mortality.
Fifth. Blood-letting, notwithstanding its influence is limited, should not be neg-
lected in inflammations which are severe, and are seated in an important organ, both on
account of its influence on the state of the diseased organ, and because in shortening
the duration of the disease it diminishes the chance of secondary lesions, which increase
its danger ; that, as it is not in our power to arrest inflammatory diseases at once, wc
must not endeavor to attain this imaginary end by multiplying bleedings ; for it must
be remembered that a certain share of strength is necessary to the resolution of inflam-
mation, since it is much more severe and hazardous in proportion to the feebleness of
the patient, because this feebleness favors the development of secondary affections ;
finally, that these observations seem to show that the use of the lancet is to be preferred
to that of leeches in the disease. — (Researches on the Effects of Blood-Letting, by P.
V. H. A. Louis ; Boston, 1836 ; pp. 23, 48-40).
The first series of cases of Pneumonitis investigated by Louis, at the Hospital of la
Charit^*, numbered 78, of which 28 proved fatal, or one death in 2.78 cases, or 35.85
per cent.
All these ca^cs were in a state of perfect health at the time when the first symptoms
were developed. The facts relative to these fatal cases, even according to the testimony
of Louis, seem still farther to limit the utility of blood-letting. Out of the twenty-eight
cases in question, eighteen were bled within the first four days of the disease, nine from
the fiAli to the ninth \ and if on the one hand, we take together all the patients who
were bled for the first time within the four first days of the pneumonitis, whatever
may have been its termination ; and on the other hand, all those who were bled at a
later period ; we have in the order indicated, on one side forty-one cases, of which
eighteen or about three^sevenths were fatal ; and on the other thirty-six, of whom nine
or only one-fourth were fatal. Louis attempts to explain this result, so manifestly at
variance with some of his general deductions upon the utility of blood-letting, by the
fact that the patients bled within the first four days of the disease, were older than
ihose who were not thus actively treated, until after this period, and although the
difference of the average ages is slight, amounting to only three years, still he considers
that this may have had much to do with the result. The greater fatality in those bled
at an early period of the disease should however, we think, be referred more logically to
the depressing effects of largo bleedings ; and this result appears to support the viewj
not only that blood-letting in pneumonia is injurious, but that it is especially injurious
when it exhausts the powers in the very commencement of the disease. It would how
ever be improper to draw general principles of treatment from so few facts, for Ix>uis
686 AntipUogistie System of Treating Pneumonia.
himself remarks, that the facts which he has collected, are neither so nnmeroos nor so
varied, that the result can be considered henceforth as established laws.
The second series of cases of Pneumonitis observed by Louis at the hospital la Piti^
numbered 29, of which 4 proved fatal, or one death in 7.25, or 13.79 per cent.
Louis states that the total number of cases of Pneumonitis which came under his
treatment during four years at this hospital, was one hundred and fifty, and that blood-
letting, although usually carried to a greater extent than was practicable in his first series
of observations at the la Charity, oilimes to the extent of 20 to 25 ounces and more,
or even to syncope had not been more decidedly successful, and in do case was inflam*
mation arrested by its use. He expressed his belief that practitioners have been misled
in believing it possible to arrest pneumonitis at its onset, by large bleedings, from bavin;;
observed that in some cases, rare indeed, the bleeding is followed by a considerable
amendment in the general, and in some of the local symptoms, pain and dyspnoDa. Bot
the other phenomena remain, and are even augmented in intensity and extent after the
first blood-letting; if this has been practiced soon after the commencement of the disease,
and if then the patient is not aoourately examined, the practitioner believes that the
disease is arrested, when in fact there is only a diminution of febrile action and some
other symptoms. Whilst stating thus decidedly his experience from memory, he con-
fines his analysis of the effects of blood-letting in the second series only to 29 case^.
As in the first series of cases, the patients were in excellent health when the first symp-
toms of pneumonitis appeared, and not a doubt was entertained as to the character of the
disease which affected them, all having expetorated rusty, viscid, semi-transparent sputa ;
and all having had to a greater or less extent, crepitous rale, bronchial respiration and
broncophony, with more or less dullness on percussion in the corresponding part.
In his effort to find some explanation of the differences in the degree of mortality, in
the two series of cases, Louis does not attribute it to age, for the difference in this res-
pect was in favor of the patients of the la Charity, whose mean age was forty and that
of the others forty-three ; nor were the cases in which early blood-letting was employed
more numerous in proportion, at la Piti^ than at la Charity, nor can the difference of
mortality be imputed to the difference of seasons at which the patients came under
observation. Louis accounts for the fact by differences in treatment, the patient at la
Piti£ being bled less frequently, but more copiously, and antimony was used more freely
with them. Antimony was administered in increasing doses, from 6 to 12 grains in
six ounces of the distilled water of the lime tree flowers, sweetened with half an ounce
of syrup of poppies ; and the patient took this in the course of the day, in six or eight
doses. Out of 20 patients in a hazardous condition, to whom antimony was given, only
three died. The treatment of the patients at la Charity was farther different from that
of la Piti6, in this respect, that vesication was employed at the former and not at tht?
latter hospital. At the Hospital of la Charity, blisters were not applied in all the ca>.'^
which terminated favorably but only where bleeding was so ineffectual that fears wcr^'
entertained for the result. Vesication was used, in one half of the cases, or in twentj-
five patients, whose first blood-letting was during the first four days of the di^ea.^, <t
later ; and the average length of the disease in these cases was twenty-two days tw««
hours ; while it was fifteen days and eight hours only, in the other cases. An en- •'--
mous difference, which would seem to show that the unfavorable conditions under which
blisters were used, have not been sensibly affected by their action ; and LoaU thiTcf«»iv
infers that the vesication waa valueless. Louis farther declares that he had not only
rejected vesication in the treatment of pneumonitis ; but had also ceased to employ it
in pleurisy and pericarditis ; and one hundred and forty cases of pleurisy treated during
5 years at la Piti6 without vesication in a single instance, all recovered. Tho rco^ir*
which led Iiouis to reject vesication from the treatment of acute thoracic intlammat»»p.
are worthy of careful examination by the profession. This accurate observer, infnrK'i
us in his second series of observations upon the effects of blood-letting, that an attfti
tivc study and rigorous analysis of the facts forced him to acknowledge that anit'
inflammatory affections, so far from preserving from inflammation, organs which aiv v- i
Antiphlogistic System qf Treating Pneumonia. 687
the primitive seat of disease, are in trath, an exciting cause of inflammation ; insomuch
that the more severe the primitive inflammatory affection, and the more considerable
the accompanying fever, the more are the secondary inflammations to be dreaded. And
how then, asks Louis can we believe that the effect of a blister, is to check an inflam-
mation when this blister is one inflammation superadded to another ? And whilst he
admits that this is reasoning only by analogy, and whilst he does not advocate the aban-
donment of blisters in every case, he affirms that one thing is assuredly beyond question
and we should never be weary of repeating it ; that the therapeutic value of blisters is
not known ; that it must be studied by the aid of numerous and carefully noted facts,
just as if nothing at all were known about it.
The total number of cases upon which Louis bases his researches upon blood-letting
is 107, and of these 32 died, or one death in 3.34 cases, or 29.94 per cent.
The results of the researches of Doctor James Jackson, the able American editor of
the works of Louis, upon 34 cases of Pneumonia in the Massachusetts Hospital, corres-
ponded as far as they extended, closely with the results just presented. In the Massa-
chusetts General Hospital, Dr. James Jackson, treated during a period of four years,
from December 3d, 1831, to December 3d, 1835, 51 cases of Pneumonia, with a mor-
uAiiy of 8 deaths, or one death in 6.37 cases, or 15.68 per cent. These cases were
treated strictly upon the antiphlogistic plan, with repeated blood-letting, cathartics, tartar
emetic, and opium, in many cases, mercurials and colchicum. The mercurials were used
in small doses, and generally in combination with opium, and their influence was never
pushed beyond a slight soreness of the gums. The Colchicum (C. Autumnale) some-
times the root, and sometimes the seed, was used in the manner and upon the principles
laid down by Mr. Haden, of London, in his treatise on this article of the Materia
Medica. It was given in aid, or as a substitute for blood-letting, in such doses as to
induce nausea at least, and usually vomiting and purging ; and then continued in such
doses, as could be borne by the patient without much inconvenience. The Tartanzed
jtntimony was used afler the manner recommended by Odier, in Geneva, in practical
medicine : — a solution of the Tartarized Antimony was made of such strength that every
fluiddrachm contained a quarter of a grain of the mineral ; at first half a drachm or a
drachm is administered, but each succeeding dose was increased by half a drachm or a
drachm, until nausea, vomiting or purging is induced. As soon as either of these
occurred in an inconvenient degree, the dose was reduced to such a quantity as the
patient could conveniently bear ; or the medicine was suspended, till the operative effects
had ceased, and then recommenced in a smaller dose. Tne sensible effects of this medi-
cine and the colchicum wero very similar, as well as the appearance of temporary relief
which they induced.
Andral advocated bleeding strenuously, and enforced in his practice the principle laid
down by Galen, sixteen centuries before, that we should have recourse to bleeding,
whatever was the day of the disease, aye : even if it were the twentieth, every time it
was indicated. Andral records in his Clinique Medicale, 65 cases of Pneumonia treated
by blood-letting at all stages, even in the third stage, and by Tartar Emetic in doses of
from 6 to 32 grains in the twenty-four hours, continued for several successive days ; and
of this number of oases thus energetically treated, 36 or more than one-half, died.
According to Dr. Hughes Bennett, between the years 1812 and 1837, there were
treated in the Royal Infirmary of Edinburgh, 103 cases of Pneumonia, by the anti-
phlogistic plan of treatment, and of this number 41 died. When all incomplete and
doubtful cases were rejected from the list, and only those retained which were manifest
cases of Pneumonia, or acute inflammations of the chest closely allied to that disease,
the result was that in 50 cases, 19 died; or one death in 2.63 cases, or 38 per cent.
And according to the same author, in this Institution, from July 1st, 1839, to October
Ist, 1849, 648 cases of Pneumonia were admitted, and 222 proved fatal, or one death in
2.91 cases, or 34.26 per cent.
M. Griaolle, whose plan of treatment was similar to that of Jjouis, with this difference
that he advocated more moderate bleedings, reports 37 doaths in 232 cases occurring in
688 Antiphlogistic System of Treating Pneumonia.
his hospital practice, or one death in 6.27 cases, or 13.9 per cent. In like manDcr
with the cases reported by Louis, those bled the most exhibited the highest rate oj
mortality.
The method of treating Pneumonia, by large doses of Tartar Emetic, as advocated
and introduced into general practice by Rasori, about seventy years ago, (although many
other physicians, as Paracelsus, Huxharo, Pringle, Cullen, Mauyat and others, had
recommended Tartar Emetic in the treatment of fevers and other diseases, still there
appears to be no dissent from the view that it is to the Italian Physicians, and especially
to Rasori, that the practice of medicine is indebted for the revival of this practice, and
the introduction of this drug in large doses, as a cure for inflammatory diseases.)
although yielding results apparently from the statistics which have been published more
favorable than those by copious blood-letting, are still by no means uniform ; and in the
Southern States manv practitioners have abandoned the use of this remedy in Pneu-
monia, especially in the large doses recommended by the Italian physicians, on accoaot
of its depressing effects upon the forces, and its frequent injurious action upon the
bowels. As far as my knowledge extends, the Southern country aflfords no statistics by
which the relative value of this remedy may be determined. It is certainly a subject
of interesting and important investigation to determine* whether Tartar Emetic would
be more injurious in malarial, than in elevated, healthy, non-malarious districts.
Rasori employed this medicine, so as to obtain its full effects. After one or mon.*
bleedings, but sometimes without this measure, from 12 to 24 grains, or in severe ad-
vanced cases 20 to 30 grains were given during the day, and the same quantity repeated
in the night; and these doses were dailv increased until they amounted to a drachm,
or even several drachms in the twenty-four hours. Out of 832 cases of Pneumonia
treated by Rasori in this way, 173 died ; or one death in 4.8 cases, or 20.79 per cent.
The mortality differed somewhat in the military and civil hospitals ; thus it was fourteen
per cent, in the former and about twenty- two per cent, in the latter.
The success of Tom masini with this remedy, conjoined with bleeding, was mucbgrefttor:
thus he states, that out of 115 cases of Pneumonia, only 14 died ; or one death in ^.:f 1
cases, or 12.17 per cent.
The celebrated Laenncc employed Tartar Emetic with marked success in the treat-
ment of Pneumonia. The following is his method, together with his testimony to ita
therapeutic value in comparison with other modes of treatment.
*' As soon as I recognize the existence of the Pneumoniu, if the patient is in a st«te to b«&r
venesection, I direct from eight to sixteen ounces of blood to be taken from the arm. I verr
rarely repeat the bleeding, except in the case of patients affected with disease of the heart, <>r
threatened with apoplexy or some other internal congestion. More than once, I have tTcm
affected very rapid cures of intense peripncumonies without bleeding at all ; but in commoo.
I do not think it right to deprive myself of a means so powerful as venesection, except il
cachectic or debilitated subjects. In this respect Rasori docs the same. I regard blood^Ieitirc
ns a means of allaying for a time the violence of the inflammatory action, and giving time
for the tartar emetic to act. Immediately after bleeding, I give one grain of the tartar end c
dissolved in two ounces and a half of cold weak infusion of orange-leaf, sweetened with ha.f
an ounce of syrup of marsh-mullows or orange flower; and this I repeat every second hour,
for six times, after which I leave the patient quiet for seven or eight hours, if the symptoms
are not urgent, or if ho experiences any inclination to sleep. But if the Pnennonia btj
already made progress, or if the oppression is great, or the bead affected, or if both laofi tr
one whole lung is attacked, I continue the medicine uninterruptedly, in the same do«e. aaj
after the same intervals, until there is an amendment, not only in the symptoms, bat indicate 1
also in the stethoscopic signs. Sometimes even, particularly when most of the above mtz^
tioned unfavorable symptoms arc combined, I increase the dose of the Tartar Emetic, to a
grain and a half, two grains, or even two grains and a half, without increasing the qnaD:«t»-
of the vehicle. Many patients bear the medicine without being either vomited or purgti
Others, and indeed, the greater number vomit twice or thrice, and have five or six stloos the
first day ; on the following days they have only slight evacuations, and often tndee4 hate
none at all. When once tolnant'e of the medicine (to use the expression of Rasori i is esta-
blished, it even frequently happens, that the patients are so much constipated as to re^nlre
clysters to open the body. When the evacuants are continued to the second day, or wfce-*
AntipMogistie System of Treating Pneumoma. 689
there is reason to fear on the first, that the medicine will be borne with dlffiouUyi I add to the
six doses to be taken in the twenty-four hours, one or two ounces of the sjrup of poppies.
This combination is in opposition to the theoretical notions of Rasori and Tomasini, but has
been proved to me by experience to be very useful. In general, the effect of Tartar Emetic is
never more rapid or more efficient than when it gives rise to no eracuations; sometimes,
however, its salutary operation is accompanied by a general perspiration. Although copions
purging and frequent vomiting arc by no means desirable, on account of the debility and the
hurtful irritation of the intestinal canal which they may occasion, I have obtained remarkable
cnres in cases in which such evacuations have been very copious. I have met with rery few
cases of Pnenmoniat where the patient could not bear the Tartar Emetic ; and the few I have
met with occurred in my earliest trials, insomuch that this resnlt now appears to me to be
attributable rather to the inexperience and want of confidence of the physician than to the
practice.
I now frequently find, that a patient who bears only moderately six grains with the syrup
of poppies, will bear nine perfectly well on the following day. At the end of twenty-four or
forty-eight hours at most, frequently even after two or three hours, we perceive a marked
improvement in all the symptoms. And sometimes even, we find patients, who seem doomed
to certain death out of all danger after the lapse of a few hours only, without even having
experienced any crisis, any evacuation, or indeed any other obvious change, but the ra'pid and
progressive amelioration of all the symptoms. In such cases the stethoscope at once accounts
for the sudden improvement, by exhibiting to us all the signs of the resolution of inflammation.
These striking results may be obtained at any stage of the disease, even after a greater por«
tion of the lung has undergone the purulent infiltration. As soon as we have obtained some
amelioration, although but slight, we may be assured that the continoation of the remedy
will effect complete resolution of the disease without any fresh relapse ; and it is in regard tp
this point, more particularly, that the greatest practical difference between the tartar emetic
and blood-letting consists. By the latter measure, we almost always obtain a diminution of
the fever of the oppression and the bloody expectoration, so as to lead both the patient and
the attendants to believe that recovery is about to take place; after a few hours, however,
the unfavorable symptoms return with fresh vigour ; and the same scene is renewed, often five
or six times after as many successive venesections. On the other hand, I can state that I
have never witnessed these renewed attacks under the use of Tartar Emetic. In these cases
we observe only in the progress towards convalescence, occasional stoppages. And this is
more particularly the case, in respect to the stethoscopic signs; as we find that between the
period when the patient experiences a return of his appetite and strength, and fancies himself
quite cured, and the period at which the stethoscope ceases to give any indication of puK
monary engorgement, — more time frequently elapses than between the invasion of the disease
and the beginning of convalescence. It is necessary to observe, however, that this remark Is
still more frequently applicable to the disease, when treated by blood-letting ; and moreover,
that the patients subjected to the antimonial method, never experience the long and excessive
debility which too often accompanies the convalescence of those who had been treated by
repeated venesections.
The best way of appreciating any particular mode of treatment, is by its results. I am
#orrj to say that I only began last year to keep an exact account of the results of wine by
tartar emetic ; but I can affirm that I have no recollection of death from acute pneumonia in
any case when this medicine had been taken loug enough for its effects to be experienced. I
have only witnefsed a few fatal terminations, when the case was slight neripneumony, com*
plicated with severe pleurisy. I have, also, lost some patients, who, besides the pneumonia,
were afflicted with cancer, phthisis, disease of the heart, etc.; and these were the cases where
I bad no opportunity of observing the different degrees of resolution in this disease. Finally
I have lost some who were brought to the hospital, moribund, and who sunk before they had
taken more than two or three grains of the remedy. In the year 1824, at the Clinic of the
Faculty of Medicine, I treated by the tartar emetic, twenty-eight cases of pneumonia, either
■imple or complicated with slight pleuritic effusion. Most of these oases were very severe,
yet they were all cured, with the single exception of a cachectic old man of seventy, who. took
bat little of the medicine, because he bore it badly. During the present year (1825), I have
treated thirty-four cases in the same manner. Of these, five died : but, of this numb<fr, two
women — one aged fifty-nine, and the other, sixty-nine — were brought to the hospital mori-
bund, and sunk before they had taken more than two or three doses of the emetic tartar; a
third died of disease of the heart, when convalescent (torn the pneumonia ; and a fourth fell
M victim to chronic pleurisy, also in the period of resolution of a sub-acate pneumony. These
last two cases will be detailed hereaAer. The fifth case was that of a man seventy-two years
of age, who died of cerebral congestion, on the tenth day of the disease. Of these five cases,
then, the first two cannot be adduced in either way as instances of the effect of this remedy i
and the next two are proofs of its efficacy in pneumonia^ rather than the contrary.
The result, therefore, of the whole is, that of fifly-seven cases of pneumonia treated by tU^
S7
690 Antiphlogistic System of Treating Pneumonia,
tArUr emetic, onlj two individuals, both upwards of serentyi died of this disease, coojoioed
with cerebral coogestion, — that, is n little less than one in tweutjr-eigbt. In priTate practice,
during the last three or four years, I have not been called in consultation to cases of acote poen*
monia, or to cases uncomplicated with violent pleurisy, except such as appeared already
threatening a fatal termination ; and yet I do not remember a single case which proved fatal
under the use of the emetic tartar, except that of a plethoric subject aged seventy>two. * *
The above results of my practice are more favorable than those of Rasori's lately pub-
lished [Reveu Med., Mar. 1825]. This may be owing to two causes : first, because ausculta-
tion enables us to ascertain the existence of peripneumooy much quicker than we could do
from the ordinary symptoms; and, secondly, because, in all probability, many cases of sim-
ple pleurisy, or of pleuro-peripneumony with predominence of pleurisy, are comprehended by
Rasori, under the name of penpneumony^ — it being impossible to discriminate these different
affections from each other, without the aid of auscultation. I have already stated that we
must not expect equally favorable results in the treatment of pleurisy, as in the treatment of
pneumonia, by the tartar emetic.
My cousin, Dr. A. Laennec, physician of the Hotel Dieu, of Nantes, has treated with the
tartar emetic, during the last two years, forty cases of the pleuo-pneumonia. Of these, six
proved fatal, three in consequence of errors of regimen during convalescence. Substracting
these, then, the proportion of deaths will be one in thirteen.* Dr. Hellis, of Rouen, has lately
presented to the Royal Academy of Medicine, a Memoir on the Treatment of Pneumonia, after
the method of Riverius and Stoll, that is by repeated emetics.f Of forty -seven cases treated
by him, he only lost five, being a proportion of somewhat less than nine. This result,
although much less favorable than that which has followed the use of tartar emetic in larg»
doses, in my practice, is yet more so than that obtained from the employment of blood-letting
and diruetics, which I have stated to be one in six or eight." (A Treatise on the Diseases
of the Chest, and on Mediate Auscultation, by R. T. H. Laennec, M. D. Translated by John
Forbes, M. D. S., New York, 1830, pp. 255, 261.) '
M. Peschier and Dr. Gentile' of Naples, and many other Italian physicians, Dr. Bal-
four, of Edinburgh, Dr. Wolflf, of Warsaw, Drs. Wesener, Brughart, Foibos, Oraress,
Stokes, and many others, in France, Germany and England, have employed the Tartar
Emetic method, afler the method of Easori, iu the treatment of Pneumonia, with great
success. On the other hand, Wagner states, that out of 13 cases of Pneumonia treats
according to this method, seven, or more than one-half died — victims, according to his
belief, more to the practice than the disease. We have before given the testimoiiy of
Drs. Todd and Bennett against this remedy.
With reference to Calomel and Opium, in the treatment of Pneumonia, we are onac-
(|uainted with anv statistics by which the value of these remedies may be determined,
comparatively at least. The same remark applies to the Yeratrium, so popular as a
remedy in Pneumonia in certain portions of the South. Calomel and Opium have been
almost universally employed, in conjunotion with other more energetic remediea, as
bleeding and Tartar Emetic. They are, without doubt, agents of great power, which
have been used, in many cases, with as much detriment as good. Whilst, judicioiislj
used. Opium exerts a most salutary effect upon the progress of Pneumonia, not only in
casing pain and promoting sleep, often so essential to the comfort, and sometimea erea
to the life of the patient, but also in promoting free secretion from the skin ; it maj, ub
the other hand, when used in large and often-repeated doses, increase the congeatioci of
the lungs. Calomel may, in certain cases, especially in those in which the liver ha>
been rendered torpid by the action of malaria, prove a valuable purgative ; but> on the
other hand, when used in alterative doses, it mav produce mischief, by defibrinatinfrtlic
blood, and prolonging the convalescence. If the increase of fibrin in the blood be a
salutary process in inflammation, similar to what takes place in the blood of pregnant
women, and for a similar reason, of increased production and development of airacctin-.
then, whatever tends to break dowu the constitution of the blood, and especially tb<-
fibrinous element, weakens the reparative process.
It is well known that a change in the treatment of inflammation has been gndoally
progressing} with at least a portion of the profession. This change is said by its adro-
•Jour, de la Si'Ct. de H«d. d* U Soc. Aood. du dopart. d« U I^iro infer. l(i'2.'>,
t Thif Memoir haa dnce b<y*n publi«h(Hl )>t the Author. tin<l>>r th«* tit^o •* (11nlqn« M«'«1io»l^ <1» VHm*^ IHm R* -
Antiphlogistie System qf D'eating Pneumonia. 691
cates to be the result of iDcreased knowledge of the phenomena of inflammation, as well
as of a more thorough knowledge of the relative value of the different methods of treat-
ing inflammation. It is incumbent upon the advocates of these changes in the tn»it-
ment of inflammation, that they should not merely demonstrate the consistency of their
principles with the actual operations of nature, but should also illustrate their value and
truth by their results, in shortening the course of inflammations, iu modifying the inju-
rious effects, and in diminishing the mortality. By a course of careful and extensive
experiment, by careful, conscientious and competent observers, in various hospitals, and
upon, not hundreds, but upon thousands of cases, positive data will be furnished, by
which comparisons may be instituted, between the results of all the methods of treat-
ment We have, in the preceding pages, furnished many important facts bearing upon
the determination of the relative merits of the different modes of treatment, and have
endeavored to classify them, so as to facilitate future research, but it must be confessed,
that much remains to be accomplished, in subjecting the various remedies popular with
the |)^fession in ancient, as well as in modern times, to a rigorous numerical experi-
ment and analysis. The wisdom and practical experience of the older physicians
should not be lightly cast aside ; and in the present tendency to abandon blood-letting
and the more vigorous antiphlogistic treatment, so highly praised in former times, there
is danger that we may go too far in the opposite direction, and not only abandon reme-
dies which may be of great value under certain circumstances, but also forget the ser-
vices rendered by some of the older writers. Thus, the doctrine, that inflammation is
a reparative process of nature, and that it should be studied and treated as a modifica-
tion of the natural processes concerned in the preservation of the body, appears to be
but a revival of the doctrines taught by the celebrated John Hunter, who considered
inflammation as
*' Only a disturbed itate of parts, which require a Dew, but salutary mode of action to
restore them to that state wherein a natural mode of action alone is necessary." From such
a view of the subject, Hunter concluded that '* inflammation, in itself, is not to be considered
as A disease, but as a salutary operation, consquent either to some violence or some dis-
ease."
The division of inflammation into "healthy" and " unhealthy," by Hunter, and his
clear exposition of the dependence of the character and progress of the inflammation
upon the condition of the constitution and natural powers of the system, are still further
proofs of his recognition of the great principle which underlies all correct knowledge
and practice in this process.
The question also, whether there be an actual decrease or increase of power in the
Hystem during inflammation, which is now engaging the attention of eminent physicians,
and which i6 so intimately connected with the value of blood-letting and the antiphlo-
gistic remedies, recently discussed with so much ability by Drs. Bennett, Alison. Wal-
Ron, Bell, Christison, Easton, Kennedy, Markham, Balfour, and other English physi-
cians, evidently engaged the careful consideration of -Hunter.
In his " Treatise on the Blood, Inflammation, and Gun-shot Wounds," Hunter thus
states the question :
'* Whether the disposition for inflammation, and the change produced in the blood, arise
from a real increase of animal life, or whether it is only an increase of a disposition to act
with the full powers which the machine is already in possession of, is not easily determined ;
bat it appears to be certain that it is either the one or the other. There are some circum-
Rtanees, howefer, that would incline us to suspect it to be the latter, because there is often
inflammation when the powers of the machine are but weak, where it appears to be only an
eiertion of very weak powers, arising from some irritation produced.'' « • «
Again, in treating of the methods of resolution by constitutional means, Hunter thus
defines the principles which should govern blot)d-letting and the administration of
antiphlogistic remedies :
<>When I described inflammation,! obserred there was either an iocrtase of life, or an increased
692 Antiphlogistic System of Treating Pneumonia •
disposition to use with more violence the life which the machine or part was in possession of^
and also that there was an increased size of vessels and of course an increased circulation in
the part inflamed, and in the constitntion in general. If this theory of the mode of action of
the vessels in inflammation is just, then our practice is reducible to two principles, one con-
sisting in removing the cause of that action, the other in counteracting the effect. As to the
first, as we seldom know the cause, but only see the e fleet, except in some specific diseases,
for which we have a specific remedy, we do not know with any degree of certainty how to act;
but, as to the second, that is the effect, as it is more an object of our senses, we can apply
with more certainty our reasoning upon it, for reasoning from analogy will assist us in our
attempts. We find, from common observation, that many circumstances in life, as also many
applications to parts, will call forth the contraction of the vessels ; we are, therefore, fron
the above theory, to apply such means; and whatever will do this, without irritation, will so
far counteract the effect. I have already observed, that wherever there has been a violence
committed, or some violent action is going on, there is a greater influx of blood to that part.
Lessening, therefore, that influx becomes one mode of relief:' for, as the vessels dilate, they
should not be encouraged in that action. Although the increased influx is to be considered
chiefly as an effect, yet it is to be considered as a secondary cause; and from ovr igfoorance
of the immediate cause, it is probably only through such secondary causes that we can pro-
dace any eflfect; and upon these principles most likely rests, in some measure, the method of
resolution, for whatever will lessen the power and disposition will also lessen the effect, and
possibly then will likewise lessen the force of the circulation.
If the inflammation is attended with considerable action and power, as it were, increasiog
itself, then the modes of resolution are to be put in practice : the one by prodnciog a contrac-
tion of the vessels, the other by soothing or lessening the irritability or the action of dilatation.
The first, or contraction of the vessels, is produced in two ways: one by producing weak-
nets, for weakness excites the action of contraction of the vessels ; the other, by such appli-
cations as induce the vessels to contract.
1st. The means of producing absolute weakness are bleeding and purging; but the bleed-
ing also produces irritability for a time, and is often attended by a temporary weakness of
another kind, vis : sickness. The inconvenience, however, arising from this practice it, thai
the sound parti mutt nearly, in the same proportion, suffier with the infiamed, for bring-
ing the inflamed part upon a par with health, the sound parts must be brought much lower.
so as to be too low.
2d. The soothing may be produced by sedatives, relaxants, anti-stimulants, etc., sncb af
many soporifics, anodynes, etc.
The first method will have the greatest, the most permanent, and the most lasting effect,
because, if it has any effect at all, the diseased action cannot be soon renewed. The second
will act as an auxiliary, for so far as irritation is a cause this will also lessen it« and the t«3
shotild go hand in hand ; for whenever we lessen power, we should, at the same time, Ictsen
the disposition to action, or else we may increase the disposition ; but neither bleeding, porg*
ing nor sickness can possibly lessen the original inflammatory disposition, for none of then
will resolve a venereal inflammation when mercury will ; nor will they resolve the errsipe-
latons inflammation, although that inflammation has the very action for which we tbo«ld
bleed in the common inflamma'tion, viz : dilatation of vessels. However, these meftos nay, ib
some sense, be reckoned direct, for whatever will produce the action of contraction in the
vessels is counteracting the action ^of dilatation. Lessening the power of action beloocing lo
any disposition can only lessen or protract the efi*ects, which, however, will be of tiagnlar
service, as less mischief will be done, and it will often gire the disposition time to wear itself oc:.
Means employed on this principle should be such as give the feel of weakness to the eoDStita-
tion, which will affect the part, and will make the vessels contract ; but this practice then «:
not be carried to far as to produce the sense of too much weakness, for then the beftrt ac*«
with great force and the arteries dilate.
Bleeding, then, as a general principle, is to be put in practice, but this must be done wit*.
Judgment, for I conceive the eflisctsof bleeding to be very extensive. Betideti the lost of an>
quantity of blood being universally felt in proportion to the quantity lost, a nnivcrtal alam
is experienced, and a greater contraction of the vessels ensues than simply in proportioa « •
thit quantity, in consequence, as it would appear, of a sympathetic affection with the i^r
bleeding.
Too much blood, in an inflammation, is a load upon the actions of the circaUitioa. T«**
little produces debility and irritability, because there is loss of powers, with mn iacreas«
action to keep up which is now not supported. It would seem that violent actions of •.
strong arterial system required less blood than even the natnral actions, and evoa less «• :
than a weak or irritable system ; from whence we must tee, that bleeding can either rvi»r%
inflammatory action or increase it, and, therefore, is not to be used at random. * * *
However, bleeding should, in all cases, be performed with great caution, more partictiU- *
at first, and no more taken than appears to be really necessary. It thould only be (l«*rr
Antiphlogistic System of Treating Pneumonia. 093
eAse the conatitation or the part, and rather lower it when the constitution is alreadj bled or
brought below a certain point, or gives the signs of it from the situation of the disease, then
an irritable habit takes place, which is an increased disposition to act without the power to
act with. This, of itself, becomes a cause of the continuance of the original disposition, and
therefore will adroit neither of resolution nor suppuration, but continue in a state of inflam-
mation, which is a much worse disease than the former.
Purges were generally given in case of inflammation (probably, at flrst, from the idea of
humours to bo discharged), and such practice will answer best, when bleeding succeeds,
because it will lower the body to a more natural standard, and, of course, the inflamed part,
as a part of that constitution ; but here the same cautions are necessary that were given upon
bleeding, because nothing debilitates so much as purging when carried beyond a certain point.
One purging stool, shall even kill, when the constitution is very much reduced, as in many
dropsies; therefore, keeping the body simply open, is all that should be done. However,
although purging lowers considerably, yet its effect is not so permanent as bleeding. It
rather lowers action, without diminishing strength ; for if a person was to feel the loss of
blood equal to a purge, that sensation would be more lasting. # * *
In irritable habits, when the inflammation becomes more diffused greater caution is neces*
aary with regard to purging as well as bleeding ; for I observed on the subject of bleeding,
that in such constitutions, no more blood should be taken than would relieve the constitution,
as it were mechanically, not such a quantity as to have a tendency towards lowering or weaken-
ing the constitution, for in such cases the action is greater than the strength ; and whenever the
disposition between these two is of this kind, we cannot expect anything salutary from this mode
of treatment, and therefore should not increase it. In such cases, the very reverse of the
former method should often be practiced : whatever has a tendency to raise the constitution
above irritability should be given — such as barks, etc. The object of this last practice, con-
sists in bringing the strength of the constitution and part, as near upon a par with the action
as possible, by which means, a kindly resolution or suppuration may take place, according as
the parts inflamed are capable of acting.
Medicines which have the power of producing sickness lessen the action, and even the
general powers of life, for a time, in consequence of every part of the body sympathising with
the stomach ; and their effects are pretty quick. Sickness lowers the pulse, makes the smaller
vessels contract, and rather disposes the skin for perspiration, but not of the active or warm
kind ; but I believe it should proceed no further than sickness, for the act of vomiting is rather
a counteraction to that effect, and produces its effects from another cause, and of course of
another kind, which I believe rather rouse. It is probably an action arising from the feel of
weakness, and intended to relieve the person from that weakness. It is similar to the hot fit
of an ague, a counteraction to the cold one. There are few so weak ,* but they will bear
vomiting, but they cannot bear sickness long. If we had medicines, which when given
internally, could be taken into the constitution, and were endowed with the power of making
the vessels contract, such I apprehend would be proper medicines. Bark has certainly this
property, and is of singular service I believe in every inflammation attended with weakness,
and therefore, I conceive, should be oftener given than is commonly done ; but it is supposed
to give strength, which would not accord with inflammations attended with too much
strength, and considerable irritation.
Preparations of lead given in very small doses, might be given with success In cases attended
with great strength. * * The property of lead appears to be that of lessening the powers,
and not the action ; it therefore should never be used but when the powers are too strong, and
are acting with too much violence. However, lead certainly has the power of producing the
contraction of the vessels ; and therefore when there is great strength, lead is certainly a
powerful application." (The Works of John Hunter, F. R. S. with notes edited by James Ft
Palmer, London, 1837, vol. i, p. 303 ; vol. iii, pp. 2D«, 297, 300, 357, 372, 375, 381, 382, 385.)
It u evident that Huuter recognijed the faot, since demonstrated by Louis, that blood^
letting cannot arrest inflammation ; and it is still farther evident from the confirmation
which modem diaooveries, and especially the recent experiments upon the sympathetic
nervons system, are giving to his theory of inflammation, and from the philosophical
manner in which he n^lated his principles of practice in accordance with the opera-
tions of nature, as manifested in the character and changes of the blood, and the modi*
fications of the inflai^matory process in different constitutions and under different
circumstances of life, that the modems have made but little advance on his principles of
practice. Unfortunately wo have no means of determining numerically the success of
Hunter 8 practice in different inflammations. From his immense experience, and from
his still greater observation and judgment, and from the great caution, and from the
ijt>4 Antiphlogistic System of Treating Pneumoma.
inductive method which be employed in detemiiDiDg the action of remedies, and in
applying tbem to the relief of disease, and from his high poeition aa a Buccessful pnc-
tilioner in the estimation of the public, aa well as of the profeuion, we are led to
believe that the most eminent anccess attended his practioe.
The observations of Conheim and others have rendered it probable that the fint and
moat important changes, not only of inflammation, but also of Phthisis and Caneer are
to be found in the blood. The discovery of the transmigration of the colorless corpusclea
in inflammation, and the investigation of the changes which they sobseqnently nndergo.
have not only revolationised the theories of inflammation, but have tended t« K-ta-
tabliah upon a new basis the long neglected humoral pathology.
CHAPTER XVIII.
ANTIPEKlUDlC UK AUOKTIVK METHOD OF TREATING PNEU3I0NIA.
MALARIA.
RELATIONS OF PNEUMONIA TO
Vse of Quinine in the treatment of Pneumonia, bj Southern Physicians. Observations of
Jean Senac, Oaleatius, George Cleghorn, Morton, Lautter, Alibert, Laennec, Ramizini, Lan-
cisct, Sydenham, Huibam, Sauvages and Broussais, upon the relations of Malaria and
Pneumonia. Investigations of the author on the relations of climate to Pneumonia. Mor-
tuary statistics of Savannah, Georgia ; Augusta, Georgia ; Charleston, South Carolina ; New
Orleans, Louisiana; New York and Philadelphia. Cases illustrating the relations of Ante-
cedent Malarial Paroxysmal Fever to succeeding Pneumonia. Effects of the malarial poison
upon the blood. Modifications of the phenomena of Pneumonia, induced by the action of
the malarial poison on the blood, liver and spleen. Illustrative cases. Practical conclu-
sions deduced from these investigations.
IV. ANTIPEBIODIC OB ABORTIVE METHOD OF TBEATINO PNEUMONIA.
OF PNEUMONIA TO MALARIA.
RELATIONS
These terms are used, not so much to iodioate the true nature of this plan of treat-
ment, as to express the views which have led to its employment by various practitioners
in the Southern States.
Southern physicians have, for a number of years, used Quinine in the treatment of
Pneumonia ; and previous to the recent civil war, a number of articles have, from time
to Ume, appeared in the various medical journals, extolling the virtues of Quinine in
the treatment of this disease, and more especially in malarious regions. By many of
the advocates of the power of Quinine to greatly modify and even arrest the progress of
Pneumonia, the doctrine is held, that the disease arises from the same causes, is inti«
mately associated with Malarial Fever, and, in fact, is nothing more than one of the
forms of periodic fever. The rcmaric is not unfrequently heard, that Pneumonia should
be treated as a malignant remittent. Those who adopt the view oi the identity of par*
uxysmal fever and Pneumonia, believe that Quinine in full doses, is capable of arresting
the latter, in the same manner that it arrests or aborts the former.
We might bring forth numerous quotations from the old writers, to prove that the
belief in the identity of the causes and ultimate nature of Pneumonia and paroxysmal
fever, as well as the treatment by bark and Quinine, founded upon this view, are by no
means so novel as some of the modern writers, and especially American medical writers,
would have us believe. Our limited^space, however, will permit only brief references to
some of the most trustworthy authorities.
Jean Senac,* in bis celebrated and unsurpassed treatise on the ^^ Hidden Nature and
Treatment of Intermitting and Remitting Fevers," discourses in several chapters upon
the conversion of intermittent fever into Pleurisy and Pneumonia ; and, in his observa-
tions upon the method of detecting or distinguishing intermittents, when disguised
under the mask of other diseases, relates a case ot Intermittent Pleurisy, cured by feb-
rifuge remedies. Galeatius, near seventy years ago, in a work on Peruvian bark,
pointed out the efficacy of this remedy in the cure of Pneumonia, occurring in Inter-
* De Recondita Febrium Intermittenlium, turn RemilUntium Naturae t de carurn Cura^
tione: Variis expcriroentis et obserratioDibuD illustrata. 1700.
6U6 Antiperiodie Method qf Treating Pneumonia,
mittent Fever, and which he considered as one of the manifefitatioDg of paroxjamal
Fever.
Jean Senac* advances the theory that Intermitting fevers are due to certain noxioiu
and morhific matter, generated within the hody, or introduced from without, which is
capable of being diffused throughout the whole system. This matter is particulaiij
hurtful to the Liver ; it is accumulated in and exerts its action on that viscus. After
the matter has attained a certain state of accumulation and acquired a certain degree
of power, it irritates the texture and nerves of the liver, like a foreign stimulus, retards
the progress of the blood, and renders that fluid acrimonious and vitiated in its qoal*
ities. This matter, by its powerful action on the nerves, throws the whole system into
commotion, and is at length, by the fever that ensues, expelled and dissipated as it were,
both from the place primarily affected, and from every other part of the system. A
fomes, however, may still remain behind, which, gaining strength, by degrees, may pro
duce a recurrence of the same commotions. Sometimes the U)mes or active causes of
an intermitting fever may be hidden, or may be accumulated in a certain part, so that
that part may appear to be the only sufferer ; at other times it may give rise to pecu-
liar symptoms, in which the whole force of the disease appears to be centred, and it
may even counterfeit other diseases, which pursue a course peculiarly their own» exhib-
iting no resemblance, and possessing no affinity, whatever, to intermitting fevers. Senac
illustrates these views by numerous examples : Sometimes, without anv perceptible
change in the pulse, the most acute pains take place and return at stated periods : he
had frequently observed an excruciating affection of this kind situated above the eye, an-
accompanied by any other symptom, the commencement of the pain being, sometimes,
attended with a sort of palpitation around the affected part. This author also described
a kind of periodical opnthalmia, which uniformly made its attack at stated hours ;
although an inflammation of this kind does not usually disappear in a short space of
time, yet in the affection under consideration, the eye was soon restored to its natnrai
state. Senac met occasionally with cases of excruciating hemicrania, which he cooBid-
ered as the oflspring of intermitting fever, or rather which were intermitting fevers
converted into hemicrania. The whole head was at times attacked by a pain arisin«r
from the same source. In one case, the patient was so dreadfully tormented by a pain
of this kind as to be rendered almost insane ; at first view, the nature of this affect ion
was not discovered, but on a close examination, it was completely unveiled, for it
sdways made its attack towards noon, raged for a few hours, with great violence, and th^n
remitted. The febrile cause fixes itself not only in the orbit and in the eyes thensdvcv,
but also upon the external surface of the head ; indeed, it is capable of attacking erery
part of the system separately. So true is this, that in some patients certain p«rt»
seem to suffer from fever, while all the others are exempt from it; some of these psrti^
are periodically affected by a sense of coldness or heat, others by convulsive or treiift-
ulous motions, so various arc the forms under which the disease appears. But what is
not less surprising, pains arising from a febrile cause, yet unaccompanied by any exter-
nal signs of fever, oftentimes attack the internal parts of the body. This is illnslnted
by a case in which a very acute pain in the stomach, marked by periodical occuirettcc,
was, at length, cured entirely by febrifuge remedies. This pain was accompanied by &*>
change in the state of the'pulse, and no preternatural heat, and during its conlinnance tbe
functions of all the other parts of the system were unimpaired.
It would consume too much time, and, at the same time, would be only an amplifica-
tion of the ideas and facts already presented, to follow Senac through his description? of
the manifold effects of the febrile poison, upon other organs, as the brain, bowels, apfarn
and liver, and we will close our examination of his remarkable work, with his view^
upon the relations of Periodic fever and inflammation of the lungs.
The febrile poison, continues Senac, fulls not only on the brain, but aUo apon the
*De Recondita Febrium Intermittentiam, turn Remitteotium Natara et de camm
variis experimentis et obsevationibus illustrata, 1 700. Also Translation with notes by Cbariei
Caldwell.— Pbilad, 1805.
#
Antiperiodie Method qf Treating Pneumonia, 697
organg of respiration. It lens frequeDtly, however^ attacks these latter parts, nor,
indeed, is the reason of this suffioientlj understood. When it does attack them, its
mode of action is not always the same. It most frequently excites spasms in the- respi-
ratory organs, whicK are, at the same time, communicated to other parts of the system,
From these spasms, or from the irritating and almost corrosive action of the poison,
arise various pains. These sometimes attack the diaphragm, and affect the respiration
in a most severe and dangerous manner. At other times the pains become fixed in
the sides, and occasion such torture to the patients as to render them unable to change
their positions. From these causes, respiration becomes confined and difficult, attended
with cough, panting and shortness of breath. At times the disease assumes something
of the form of a suffocative catarrh, or asthma, from congestion and oppression
of the lungs, by means of thick mucus. But it occasionally appears in another shape,
no less formidable, namely, that of a severe pleurisy or peripneumony. The patient
is then affected with a spitting of blood, a fervid and lacerating pain in the thorax,
and a depressed pulse. Senac still farther alludes to the conversion of intermittent
fever into pleurisy and pneumonia in several chapters, and in his observations upon
the method of detecting or distinguishing intermittents when disguised under the mask
of other diseases, he relates a case of intermittent pleurisy cured by febriflige remedies.
George Cleghom, in his '' Observations on the Epidemical Diseases of Minorca, from
the year 1744 to 1749," describes a fatal form of pneumonia and pleurisy, with distinct
remissions. ^^ When those pleurisies," says Cleghorn,
''First became epidemical, their quick progress and uncommon mortality surprised me
greatly. I attempted to cure them by bleeding, once or twice a day, if the complaints were
violent, as I had always used to do in inflammatory fevers ; but the remissions in the morning
sometimes induced me to omit the operation : and the cessation of the symptoms, which
generally happened about the third day, made me imagine that the danger was over; so that
before the patients were blooded above two or three times, the exacerbation came on upon
the fourth or fifth day, and defeated all attempts by bleeding, blistering, or otherwise to
relieve them.
"Those unforeseen events startled me greatly, and led me to review the whole progress of
the disease, its symptoms and issue. I had observed that some escaped by means of expect0'>
ration and purulent urine, without much assistance from phlebotomy ; and considering the
periodical revolutions of the fever, the quick transition of the stitches from one part to another
together with the prevailing color of the blood, as well as that of the spitting, and other
excretions, I was apprehensive that those were what authors call bilious pleurisies, which
they allege are exasperated by large evacuations :* particularly Duretus,t who exclaims with
great vehemence against those physicians who trust principally to bleeding in the care of
those diseases, without waiting for the natural evacuations.'* Loc cit. pp. 164-5.
Morton appears to have frequently detected the malignant intermittent opncealed
under the mask of pneumonia and pleurisy. This physician relates, among others, the
case of a man who was seized in the mornins; with a violent shivering, and a pain in
the thorax of so severe a character as to render respiration scarcely practicable. The
pulae of the patient was small and rapid, his weakness was extreme, and universal oold-
ntm overspr^ all the limbs. Notwithstanding these symptoms, blood*letting from the
arm was employed as the neeessary and proper remedy for this spasmodio state of the
respiration. When, however, from the nature and return of the paroxysms, Morton
detected a fever of a malignant character, masked under the appearance of a peripneu-
mony, he made the bark the principal foundation of his treatment, and succeeded in
arresting the disease.
Lautter, as quoted by Alibert, in his treatise on malignant intermittently, has
recorded two similar cases in his Hist. Medic, bienn. morb. rural, etc.; Casus v. and ix.
Cabe 707 : A laborer of Luxembourg, thirty years of age, of a dry temperament,
being engaged in threshing corn, was seized, first with a trembling, and then with a vio-
•Ballon. E|4d. SpAnlm. Bianch. HUt. Hep. p, ill. } tIU. etc. Bftgl. Prix. HeU. 1, t. c. Ix. Lancia £pU. Bom. r. vt.
iO bomlae* rppnbUcv caUmltoaot aUiae f&nestiM! ipMUi pleurltldem, quae sua sponte iiullinii operl» lndlf«n« cum
tali iputo qiiitwceret, ex ev«Dtar redduot niortlferam. I)nr»»t (n Piaenot. Coac,
696 Antiperiodie Method of Treating Pneumonia.
lent coldness^ to which succeeded a short hot fit, and great thirst. The principal aymp-
torn was an excessive pain in ihe lefl side, which considerably impeaed respiraUon.
Being obliged to qait his work, he took to his bed ; the fever continaed nearly eighteen
hours in the same state, and then underwent a perceptible remission. On the morning
of the day following, the patient was still better. Although he was rather feeble, ihe
stitch in his side continued, and he was certainly in some degree feverish, yet he went
to work again, but all the symptoms returning toward evening, he again took to his
bed. Lautter was called in ; he found his patient laboring under a high fever, his
pulse was hard, his respiration laborious, painful, and almost suppressed ; the pain in
the side was extremely acute ; there was no cough. From the history of the disease,
the physician discovered immediately that it was a malignant intermittent, masked by
the predominant symptom of pleurisy ; not being able to strike immediately at the root
of the disease, because the exacerbation was then at its height, he employed himself to
moderating the violence of the symptoms. He drew from the arm of the affected side
ten ounce^ of blood, which was covered with an inflammatory cmst, and ordered an
emollient cataplasm to be applied to the part where the pain Uy, and to be frequently
renewed. Internally he administered barley-water with oxymel and nitre *, the patient
experienced relief, his respiration became easier, and the pain in his side abated ; yet he
passed a sleepless night with heat and great thirst. On the day following, his pul:w
was indeed less frequent, and was not hard, yet he had a high fever ; the pain in the
side continued, the urine, which was very high colored, deposited a lateritious sediment ;
the symptoms were now much milder, but as they had not altogether disappeared, the
foregoing remedies were continued. In the evening, the disease resumed completdy its
first state and appearance. On the morning of the following day, there was no remark-
able change, except that the acute pain in the right side disappeared for a short time,
but soon returned again ; the urine had undeigone no change since the day before, the
akin was constantly cold, etc. Lautter discovered immediately the malignant oharaiCK^r
of the fever. He took advantage of the remission to administer an ounce of the bark
in the space of twonty«four hours ; the next paroxysm was a very moderate one ; and
by oontinuing the use of the same remedy, the disease was radically cured.
Cass 708 : A woman, sixty years of age, having her system greatly heated by exer-
oiso, exposed herself imprudently to the coolness of the evening. She was attaked by
a Qold fit, which was followed bv a ibver of great intensity. A severe pain occurred in
the right side, extending round to the spine ; a dry and frequent cough added to it^
Aontenesa ; the respiration was short and laborious, and the succeeding night was passed
without sleep, Lautter was oalled in ; be found the pulse greatly agitated, fall and
bard, the tongue white and dry. Taking the disease for a pleurisy, he drew blood from
the arm of the side affected, and laid an emollient cataplasm on the part where the pun
was situated ; the blood was covered with an inflammatory crusL The ijmpioms
became milder.
On the same day, at one o'dock in the afternoon, the shivering returned with a s%bt
d^ree of coldness ; the febrile heat, the cough, the pain, etc., were all aogmaoted ; tht
paUe was as fUll and as h^rd as at first; blood was consequently drawn a seoond tim^,
aqd exhibited again mj\ inflammatoxy crust. There was now a remissioo of the fthriW
symptoms. On the evening of the day following, the cold fit returned ; the pain, the
heat]^ the cough, etc., inoreased oonsiderably, in oonsaquenoe of which the patient paged
a very bad night,
Next day there was a remission ; afVernooui another exacerbation, ushered in by •
cold fit. The physician contented himself with repeating the application of catA>
tksms, and administering cooling drinks. He had no fUrther recourse to blood-lectin *
ecause the patient's strength was greatly exhausted, and from the progress of the dis-
ease and the copious sedim,ent of the urine, it was easy to discover a doable tcitiaa
remittent larking under ^he mask of pleurisy. Lautter gave an ounoe of a mixtarp < i
bark to be t^ken previously to the return of the paroxysm which was veij near at hand
Daring the succeeding night, the patient experienced oaly a great heat, but the oiujh
Antiperiodic Method of Treating Pneumonia. 699
and the pain in the side did not increase. On the following day, the same medicine
was continued, and there was scarcely even the shadow of an exacerbation. By the
continued use of the bark, the patient was very soon resfeored. (A treatise on Malig-
nant Intermittents, by J. L. Alibert, translated by Charles Caldwell, M. D. ; Phila.,
1807 : pp. 46, 50.) Alibert, in the same connection, recounts a similar case of inter-
mittent pneumonia, occurring in a student of medicine in Paris, which was success-
fully treated by wine and bark.
Case 709 : Laennec observed the existence of intermittent malarial pneumonia (per-
nicious pneumonic fever) in a muscular, robust man, who had entered the hospital with
a recent syphilis. On the sixth day of his admission, the patient suffered with a
paroxysm of intermittent fever of considerable violence, and he stated tbat he had had
a paroxysm two days before. A third paroxysm ooeurred on the third day after, but it
was entirely different from the preceding paroxysm ; it commenced with a more con-
siderable chill, was accompanied with a violent headache, extreme dyspnoea, and hemop-
tysis. Upon exploring the chest during the middle of the paroxysm, the respiratory
murmur was found unaltered except at the root of the lungs, where it was masked by a
rale crepitant well characterized, principally on the ri^ht side. Laennec, without hesita-
tion, declared the disease a double pneumonia in its initial stage ; tartar emetic, six
grains ; sulphate of quinine, eighteen grains, to be taken in three doses. The patient
vomited a little and had but one stool ; the next day he thought himself cured. But as
the rale crepitant had not entirely disappeared with the cessation of the febrile paroxysm,
the two prescriptions were continued. The following paroxysm was very short ; the
rale crepitant was slightly developed, and the hemoptysis reappeared ; but the fever had
scarcely ceased, when all the symptoms disappeared (that is to say, as soon as the disease
ceased, it no longer existed.) The tartar emetic was discontinued on the fiRh day, the
respiration having become pure and natural ; the sulphate of quinine was continued for
some days. The patient was now cured of the fever, and the anti-syphilitic treatment,
which had been suspended, was resumed. Three weeks afler, the intermittent fever
reappeared , it was now simple and benign, and a few doses of the sulphate of quinia
entirely arrested it ; the patient remained six weeks longer in the hospital, and left in
good health. In like manner M. Fleury records a remarkable case of tertian pneumonia,
which was attended with almost complete disappearance of the distressing pneumonic
symptoms during the intermission of the fever, and which was arrested by quinine and
biark. (See Physiological Pyretology ; or a Trciitise on Fevers, etc., by F. 6. Boisseau,
trans, by J. R. Knox, M. D.; Philadelphia, 1832; pp. 44.3-4H6.)
We might present the testimony of many other writers, as Ramazini, Lancisi, Syden-
ham, Huxham, Sauvages, and Broussais, to show that the notion of the production of
pneumonia, by the same causes which generate the variuus forms of malarial fever, has
been not only long, but widely held by the medical profession ; but the authors already
cited arc believed to be sufficient for the establishment of this proposition.
Without attempting at this time to settle the question as to whom belongs the honor
cif first giving bark and quinine in pneumonia and inflammations generally, we have
shown conclusively that the former remedy has been freely used in the treatment of all
fevers and inflammations for at least a century ; and as the principles which led to its
administration did not differ materially from those which now lead to the use of quinine,
and as the bark necessarily included this constituent, if any credit is due to this method
of treating inflammations, it rests with the older writers.
We will endeavor in the next place to determine the relations of malarial fever to
pneumonia, by the application of those facts and principles which huvc been developed
by our own investigations.
We shall content ourselves with the expression of only those general results of our
investigations which bear upon the treatment of pneumonia.
RELATIONS OF PNEUMONIA TO MALARIA.
We will in the first place, institute a comparison between the mortality occasioned by
700 Relations of Pneumonia to Malaria,
pneumonia in malarious and non-malarious locations. The collection of the following
statistics, has necessarily involved much time and labor, in the inspection of the topo-
graphy, and in the classification and consolidation of the mortuary records of various
cities. •
Upon examination of the mortuary records of various cities, it was found that the
deaths from Pneumonia, were fVequently entered under the heads of Pleurisy, Inflam-
mation of the Lungs, and Congestion of the Lungs. I have grouped together the
deaths from these causes, as well as those from Hydrotborax. Hydrothorax as a general
rule results from Pleuritis, a disease referable to the same general causes as pneumonia,
and often associated with it. This grouping was absolutely necessitated by the various
modes of recording diseases adopted by different cities. Thus in Savannah, and in the
southern portion of Georgia, Pnenmonia was oflen called Pleurisy, and was evidently
entered under this name upon the bills of mortality, or rather upon the mortuary record^
of the various cemeteries^
MORTUARY STATISTICS OF SAVANNAH, OEORQIA.
No more important field presented itself than Savannah, Georgia, for the investiga-
tion of the relations of 3Ialaria to Pneumonia, and I consolidated from the mortuarv
records of thts city various tables, presenting at one view the deaths caused annually and
monthly, by fevers, and inflammations, and all other causes during a period of 50 yeaiv.
1804 to to 1854, inclusive.
These statistics related exclusively to the whites, as the record of diseases of tht*
blacks were so imperfect, as not to permit of any general or specific classification. Th:^
relations of the mortality to the population, were calculated from the following data :
Population of Savannah, 1800; whites, 2G18 ; blacks and colored, including nei:rv.»
slaves, 2548; total 5166 : 1810, whites, 2400, blacks and colored, 2725 ; total, 5215
1820, total population, 7523: 1830, total population, 7776: 1840, whites, 577S:
blacks and colored, 5436; total, 11,214: 1850, whites, 8395; blacks and colored.
6917 ; total, 15,312 : 1860, whites, 13,875 ; blacks and colored, 8417 ; total 22.292
1870, whites, 15,166 ; blacks and colored, 13,068 ; total, 28,235.
Savannah is situated on the Savannah River, eighteen miles from its mouth, on a
sandy plain, elevated forty-two feet above half tide. On the north, this plain is ter-
minated abruptly by the Savannah Biver, a turbid stream pursuing its sluggish oourso
through the low grounds and rice fields of South Carolina and Georgia. On the ea«t
and west, the city is flanked by extensive tide swamps, formerly under wet (rice) cultniv
at the present time, and for the past fifly years, or more, under dry culture. The dry
culture system of the extensive paludal districts above and below Savannah, and of the
islands and lands immediately across the river in front of the city, was instituted in
1818. The sandy plain extends for several miles beyond the city. Savannah therdbre.
is surrounded on all sides, except the south, by malarious districts. In tact, up to 181^.
she mieht justly have been regarded, cs a city situated in the midst of a vast manh. or
rice field, reclaimed by a system of dams and canaJH, from its original condition of a
rich alluvial swamp.
With the establishment and perfection of the diy-culture system, and with the drain-
ing and cultivation of the surrounding low lands, the health of Savannah has steadiSv
improved. Thus in the ten years, from 1810 to 1819 inclusive, during the wet (rice
culture system, the deaths amongst the whites, average as 1 in 14 of the avenge popa>
lation of those years; in the ten ^ears, from 1820 to 1829, inclusive, as 1 in 17 ; in
the ten years from 1830 to 1839, inclusive, as 1 in 24 ; in the eight years, from 1<4(*
to 1847, inclusive, as 1 in 33.
The heavy mortality occasioned by fevers, chiefly referable to the action of heat and
malaria, in Savannah, is shown by the following tables, giving the total deaths from f?vcrs
and other diseases, and by all diseases ; and the monthly deaths from fevers in Savaonah.
during a period of 50 years, 1804 to 1853, inclusive*
Relatione of Pneumonia to Malaria.
701
Thiol Annual and MwMy Jkatht of the WkiU InhabitantM of Savannah from Dever, and Total
Deaths from other Diteasee and from all caueetf in Saveamahy Georgia^ during a period of 60
yearty 1804-1864.
1
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3
I
...
25
6
2
14
6
11
11
10
19
11
13
3
10
6
14
1
8
10
4
3
38
9
686
39
21
11
27
22
20
15
31
30
13
55
58
56
46
14
66
214
36
16
24
10
5
8
26
6
6
8
6
3
'I
10
3
11
32
38
23
19
15
28
10
13
9
11
4
13
20
23
41
21
1363
17
67
24
29
21
12
20
10
50
21
46
27
56
104
21
147
197
62
35
20
9
6
13
26
3
6
6
5
13
6
10
7
9
26
41
64
19
30
11
33
6
20
15
7
18
25
26
29
61
9
1633
9
10
'I
2
4
6
it
12
10
47
• a a
40
63
27
18
9
I 2
2
15
6
1
6
2
;
3
5
1
1
30
14
27
29
6
10
23
1
6
8
2
9
10
8
5
42
9
669
1
1805
2
1806
1807
80
77
150
142
1808
3
1809
63f 120'
2
1810..
1811
46
87
120
64
166
117
125
106
150
134
3
2
1812
5
1813
5
1814
1815
130 103
146, 126
313! 148
76 135
323 187
649; 168
183 202
133' 158
109 159
42 94
23 103
62 173
96 225
23 123
32' 177
28 139
17 130
57 159
36, 166
34 163
57- 171
38 211
100. 258
108, 163
154 213
124 256
83' 222
62 210
01 165
61 196
67. 172
1816
1817-
4
13
1818
1819..
...
9
1820
10
1821
17
1822
1823
1824..
1
3
1825
1826..
1
3
1837
1828
3
1
1829«
1
1830
1831..
147 ...
216 ...
• ••
I
1832-
I
1833-
202... 1
197 ... 1
1834-
1
1835
228 ...
249 ...
• ••
2
1836
3
1837-
358 ... 1
331|
367 ... 2
38o;... 4
305^..! 1
6
1838-
1
1839-
6
1840-
6
1841-
3
1842-
272'...
256,...
247...
229...
240 ...
210...
295...
1
1
a « »
1
1
• ••
«•«
1
• ■ .
• *•
. .•
46
...
1843
2
1844
3
1845-
1
1846-
60
28
180
\fi1
3
1847-
1
1848-
50 248
71* 286
63! 321
75 339
202 440
76 394
aaa
1849-
357
384
• • •
• • «
2
1850-
1
1851-
414...
642...
470 ...
3
3
1853-
3
1 _
1
, ■ • •
ToUl
4888
19444
14,332
139
702
Belationa tf Pneumonia to Malaria.
Total mofUhltf Deathi/rom all causae Feven exehtdedf and /htm all eametf indading FsverM, m 5s«a»-
nahf Oa, during a ptriod of Fifty Sfears, 1804-1853, tiie^'ve. — WkUet.
Deaths from all Caoses, FeTert excladed, each
Month during Fifty years.— Whites
Deaths fm. all Causes, Fevers incloded ,
each Month durinjc 50 years. — Whites.
TOTAL DEATHS FROM OTBIR D1SIA8I8.
Total Dkathi raoM Firns akd oribb Dim*i.
TEAR.
0
S
•
•
•
or
B
P
:
X
o
>
■
•
•
•
•
■
•3
p
c
I
>
a
e
at
•
•
a
•
03
5
O
o
o
o-
a
.
o
s
a*
<•
O
n
o
s
A
t
m
•
p
a
B
p
•
•
cr
6
P
•5
p
"t
o
tr
I
9
9
•
>
Be
•
•
•
•
B
a
9
m
B
:
•
s
G
CO
s
:
s
a*
-1
O
A
O
t
t
i
• 3
1804
10
13
9
9
16
5
10
10
12
8
16
8
19
14
17
9
14
18
13
15
8
8
8
22
7
8
10
8
11 8
10 9
9, 6
1612
10 10
8
1
6,11
14
5
7
16
5
10
11
9
4
7
5
3
5
7
14
10
14
8
9
12
8
10
10
18
12
12
15
19
21
16
19
16
12
16
19
12
10
6
23
17
28
31
17
24
13
11
13
16
21
12
17
17
20
13
24
25
13
15
17
11
10
20
24
12
10
18
17
15
10
12
11
12
• • •
22
13
16
15
11
10
8!
7
9
15
13
8
"1
9
10
14
17
18
5
17
10
13
9
9
17
6
10
10
15
12
17
9
19
18
21
9
18
18
13
16
9
8
10
24
8
8
11
8
18
7
14
15
20
21
17
11
11
8
9
8
6
7 14
11 11
2 5
9,12
12 11
20
8
9
17
14
15
11
18
15
7
20
13
10
20 49
22i 39
15 23
20 37
18 34
21 31
12 20
29 45
17 44
32 30
40. 67
23' 67
19 70
46, 58
17 29
41 92
117 232
35i 52
31 30
28 37
18 21
11' 20
20 23
34 52
14 14
19 17
12 21
8 15
38 21
26! 30
14' 34
32 27
21 17
34 28
30 48
23' 64
40i 45
33 43
31 30
17' 45
27 37
16 28
33 26
19i 27
31 26
27 50
30 55
24 49
69 101
47 66
1
1
29. 19 12
1805
6|11
10 2
10
6
' 72' 24 12
1806
9
611
. 43' 19 8
1807
9* 9
12
9
10
17
10
7
12
11
6
15
13
10
9
21
20
11
11
27
19
13
8
8
14
15
5
13
10
7
13
8
8
21
20
22
17
13 9
10* 9
' 50 30 7
1808
9,12 11
8*12
911
' 37' 35 12
1809.
7 6
11' 9
6
8
12
8
12
6 12
9
6
7
8
31. 21 17
1810
12 14
6. 5
7
5
6
20
15
6
14
9
8
13
7
17
15
7
5
14
14
17
12
9
14
12
15
26
18
16
14
13
14 6
15 10
36 12 16
1811
10
6
12
13
10
9
16
16
11
7
24
16
13
7
15
9
6
8
6
14
8
13
16
7
16
10
19
9
7
5
6 14
6 12
8 13
16 18
22 22 10
1812
11
4
9 11
6 16
56| 22 13
1813
15 8
40 19 l*i
1814
9 15
10
9
6
14
10
9
8
16
12
58< 24 it
1815
6113
8
8
8
4
18
15
II
11
14
11
14
12
12
37 24 10
1816
11
12
11
8
9
12
8
10
62l 31 lo
1817
16152
127' 59.28
1818
17
16
13 8!l8
10.22134
38 . 14
1819
17
8
17
14
11
11
175 62 IC
1820
11 13
22 32
12 10
lO'll
16 29
53
21
21
24
10
228t 66 2K
1821
23 33
15
79' 43 J. •
1822....'.
12
li:30
13l24
59' 33 I r*
1823
16
8
20
9
11
25
28
13
It
12
8
22
12
33 29 1 :
1824
5
5
12
12
6
19
8
5
11
11
9
4
3
7
14
7
4 5
4 12
15 13
20 19
14 17
10
11
11
12
12
15
17
6
5
13
12
6
4
3
7
20 1 1 1 1
1825
6
10
8
11
6il3
18 13 S«
1826
13 10
13
15
8 16 21
39 40 1 ;•
1827
15
4
12
9
7
15
16
10
12
13
12
6
11
12
25
16
14
16
23
19
ll'26
11 9
13 11
8,13
17
8
29 28
1521
47 33 ::»
1828
15 1« 1*
1829
15 28 12
6 16'11
23
10
10
19
16 28.16
7 17 14
7 9 18
8 8l22
13 13 16
13:12 10
121832
33 29 1 1
1830
6
10
15
28
18
8
15
16
16
10
10
2o:
13
14
12
8
5
12
23 8 1 :>
1831
7
8
13
12
8 18
8,14
11 10
8
13
21
12
18
15
23
19
13
21
10
18
20
25
17
14
17
25 14 it
1832
18
13
26 21 IT
1833
6
13
!5
20
20
6
8
20
19
21
6:i2
12 n
30 31 l«>
1834
11
9
35 33 U
1835
7|12
12 15
13 18
15 17
15 17
1421
14
15
12
25
16
14
16
8
20 9 11
1836
18*12
18!28
r3,15,19;25
14 19;32 40
15 2022 25
15 171114
24 19 31
1837
29
30
17,31
23
14
42 €1 l:*
1838
17
18
20
22
16
281
25
69' 39 \:^
1839
I2;i9
2ri6
24 19
24;25
12,17
12 12
9;l0
19ill
2637
22*36
15
24
14
25
25
25
20
19
19
101 42 3')
1840
35 17
15 9
22,17
19 10
24;16 24.28|18
21 23il8 25 14
55 64 IZ
1841
18 18<2ril
22 24 21
51 21 12
1842
20
16 16
9 5
1815 22
26
2011619 10 13
•S«# d * • «
1843
17
18
8 8
911
5 14 14,17*24
13
17|17i 8; 8j 516
57 41 :
1844
13 17
17 27,26
16
19
12 12 18 9'12 1^ 32
17 17*13 10.16.14 12
32' 17 :i
1845
16'l7
713
13 10 16
11 5
10 15I26.14
19
21
19
24
46 20 .: .
1846
13
14 15
8 19 19,17 23,11
7
23
14
12
13 14 15 12 25
19 16 12 15 10
18 22;26(18 16
21 1813111631
29 18 17,22 25
38 IS^.4
1847
22 12
19
16 10
15: 7
18,16 I6!l2
23 14 :
1848
14 19 18
19.26il5 n
232233
28
14
19
51 37 :4
1849
29 13
23,27
30 26
32 34
44 45
20
18
26 15,28 17,37 51
17 22 23116 35 29
30
26
29
14
76 4t> .'*
1850
29 17
20,31
39.34
24
27
55 47 -
1851
26 29 2021 26 27!43'40'
30|28
21 31 28,31 25
56 4^ 4 .
1852
25l22!24!26'30:31 60 58'59.39i
3235
44 47
26 22 24 35 37
119 loi 4:
1853
21 22
18 21 22138 45 42
37
39
23122
i
22 2931
51 46 «:
• ••
« • •
• « •
• • «
_l_
...
•«.
•••
•^■■^^^ ^^^^B^ ^P^^
ToUls
• • •
• • «
• • •
• • •
■ • •
• • •
• ..
• •.
• •.
• •••
•»•
1
• ^^^m « •*
Relations qf Pneumonia to Malaria.
703
It b evideDt, from the preceding tables, that the various forms of fever, ioclttding
Yellow fever, Bemittent, lutermittent and Congestive paroxysmal fevers, occasioned
more than one-third of the mortality in Savannah, Oeorgia, daring a period of fifty years,
1804-1853, inclusive: or, more exactly, four thousand eight hundred and eighty-eight
deaths from the various forms of fever, in a grand total of fourteen thousand three hun-
dred and thirty-two deaths from all causes ; or one death from the various forms of the
so-called malarial fevers in 2.9 deaths from all causes. The heaviest mortality from
fevers occurred in the months of July, August, September, October and November ;
and, in two months, viz : September and October, two thousand seven hundred and
eighty-five deaths were caused by fevers alone, during fifty years, out of a grand total
of four thousand eight hundred and eighty-eight deaths ; more than one-half the deaths
from the various forms of fever, therefore occurred in the autumn, during only two months.
During the entire period of fifty years, only eighty-three deaths were recorded as due
to the various forms of continued fever, entered in the mortuary record, as typhoid,
typhus, nervous, spotted and continued fevers.
If, on the other hand, the fevers be excluded from the consolidated mortuary record,
we observe a remarkable uiiiformity in the monthly deaths.
The great increase in the death-rate during the months of July, August, September,
October and November, was, therefore, clearly referable to the action of the causes, as
heat, moisture and mahuial exhalations, inducing the various forms of fevers, and, especi-
ally, paroxysmal fevers.
A careful examination of the mortuary records of the colored population, revealed
the facts that whilst they were by no means exempt from the so-called malarial or pa-
ludal fevers, they suflFered to a far less extent than the whites, and their bill of mor-
tally presented a more uniform character throughout the entire year. This statement
will be sustained by the following consolidated record of the monthly deaths amongst
the colored inhabitants of Savannah, Geoi^a, during a period of twelve years — 1840-
1851, inclusive:
Mamthiy Deathi amongti Blacks and Colored (Negro) j JnhabitanU of Savannah^ Ga.^ during a period
of 7Ve/p< ^forf, 1840-1851, ine^utive.
T I A a
Jannary .....
Pebraary....
Sfarefa
April
M»f
Jnoe
July
Aogutt
September .
October.....
N^OTenber..,
December...
1840
1841
1842
1843
1844
1845
1846
1847
1848
1849
1850
16
13
21
17
10
15
7
11
19
34
28
7
18
15
7
8
19
6
11
20
21
19
11
12
24
16
11
24
10
13
15
24
24
18
8
18
10
12
11
13
12
15
16
31
21
12
24
15
13
26
19
10
23
28
23
19
11
15
18
19
11
17
11
30
25
25
13
18
15
29
19
12
11
17
25
21
16
20
20
14
15
20
8
18
13
13
32
15
30
13
19
11 23
18
14
17
21
25
21
26
19
18
23 16
15
18
19
31
19
28
18
22
13
13
17
19
20
21
18
29 1 29
16
18
11
6
15
21
15
20
19
15
22
1851
20
8
13
17
18
29
18
16
16
23
13
12
An examinaton of the " Colored" mortuary record revealed the fact that whilst the
monthly mortality was more uniform, at the same time, the deaths from pneumonia,
pleuritis and tetanus were relatively greater than amongst the white inhabitants of
Sftvaunah,
704
Relations qf Pneumonia to Malaria.
Deaths Oaiued by Fneumoniaf PUwrity and Hydrethorax^ and by all Dueaset and Aeeidenti, in tke
WkiU Population of Savannah^ Oeoryia^ during a Perhd of Fifty Yean, 1804-1853, inebmcf,
with the ratio of deaths from Pneumonia^ Pleurisy and Hydrotkorax^ to the total deaths from alt
causes^ and to the White Population, and the ratio of deaths from all causes to the population.
lEJOL,
I?
KB
r
E
t
i
f
a
t
i
s
hip
I- a
HI?
Es??
lali f
9 P>
1804
1805
1806
1807
1808
1609
1810
1811
1812
1813
1814
1815
1816
1817
1818
1819
1820
1821.,...
1822
1823
1824.....
1825....,
1826.....
1827.....
1828.....
9
207
13
238
7
159
6
230
5
219
6
183
10
163
3
212
8
226
8
214
11
300
5
233
3
272
4
461
10
211
3
510
3
817
7
385
8
291
6
268
3
136
7
126
8
235
15
321
3
146
23,
18.3
22.8
38.3
43.8
30.5
16.3
70.6
28.5
27.0
27 2
46.6
90.6
115.2
21.1
170.0
272.2
55.0
36.3
44.6
45.3
18.0
29.3
21.4
48.6
290
201
375
436
523
436
249
1,003
376
376
282
640
1,100
850
350
1,200
1,233
542
487
666
1,033
600
525
293
1,500
Total dwthffkom Pnauioofila, PleorUy Aod Hydrathormx, i9T.
Total deatbf fion all eaaiM, 14.332.
Batlo or dwtbi from P&«omoala, Pl«aiisy and Hydrothomi fa total daathi twm all oaoMa, oaa daath U <«.«w
Of foar hundred and niDetj-seveo deaths caused by Fneumotiia, Plenrity and Hjdio-
tboras, amongBt the white inbabitanta of Savannah, (Georgia, daring a period of fifH
years, 1664-1853, inclusive, sizty^pve occurred in January; sixty«8even in Bebruary
fifty-six in March; twenty *five in April; twenty*seveo in May; nine in June; thirteen
i|i July ; twelve in August , nioeteon in September ; nineteen in October ; thirty-niiM
in Novenber, aqd forty-siz in December.
Thus, during the season of Spring (March, April and May), one hundred and eisrht
deaths were caused by Pneumonia, Pleurisy and Hydrothorax, during a period of fiAj
years ; during Summer rJune, July and August), thirty-four deaths ; during Winter
(December, January and February), one hundred and seventy-eight deaths.
It is evident, therefore, that Pneumonia, Pleurisy and Hydrothorax were in Saran-
nah, Georgia, during a period embracing half a century, related to cold and ticbH'
tudes of temperature, rather than to the action of Malaria, which caused the greater
number of deaths, at the period in which the smallest number from Pneumonia, Pleu-
risy and Hydrothrax occuned.
Out of a grand total of fourteen thousand three hundred and thirty*two deaths fri/i^
Relations of Pneumonia to Malaria. 705
all causes, daring a period of fifty years in Savannah, only four hundred and ninety-
seven deaths are due to Pneumonia, Pleurisy and Hydrothorax, or one death in 28.8
from all causes.
With reference to the relation of the deaths from these diseases to the population,
the highest rate occurred in 1805, viz: one death in two hundred and one inhabitants,
and the lowest rate occurred in 1828, viz : one death in fifteen hundred inhabitants.
The ratio of deaths from these diseases, to the population, was greater during several
years of the Wet Culture System, but the difference was very slight, and in the
majority of the years of this period, it was less than under the Dry Culture,.
MORTUARV STATISTICS OK AUGUSTA, GKORaiA.
Augusta is situated on the southwest bank of the Savannah river, one hundred and
twenty miles N. N. W. of Savannah, and one hundred and thirty-six N.W. of Charles-
ton, in latitude 33°, 33', longitude 5°, 18'. The city is generally well built, and is
handsomely laid out, with wide streets crossing each other at right angles. The beau-
tiful alluvial plain upon which the city Is located, is elevated about one hundred and
fifty feet above the Fca, and abont thirty-two feet above low-water mark in the Savan-
nah river. Opposite Centre street, the river is three hundred and fifty yards wide, and
below Mill street, it is one hundred and ninety-one yards wide. On the 28th of
May, 1840, the river rose thirty-seven feet above the low-water mark, and inundated a
large portion of the City and occasioned much injury to property. In March, 1841,
the river rose thirty-three feet. The soil of the plain upon which Augusta stands,
unlike the sandy, porous soil of Savannah, consists of a rich deposit or silt from the
river, which is composed chiefly of a light brownish-yellow clay. The falls in the Sa-
vannah river, about eight miles above the city, are situated on the line of the junction
of the granitic and tertiaty regions.
Population of Augusta, 1840, whites and blacks, 6403 ; 1845, whites, 3948 ; free
persons of color, 440 ; slaves, 3114; total, 7502. 1850, whites, 5256 ; blacks and
colored, 4,961 ; total, 10,217. 1860, whites, 8444; blacks and colored, 4049; total,
12,493. 1870, whites, 8957 ; blacks and colored, 6431 ; total, 15,389.
^
Relations of Pneumonia to Malaria.
If the preceding table be compared with the correspondiDf; tabic relatiog to th<>
ttioiitbly mortality in Savannah, it will be bccd that the deaths are mocb mon-
uoirorinly distributed during the whole period of the year, in Augusta, GeorgU, Th;-
difference appears to be due, in a great measure, to the f^catcr exemption of the laiKr
city from the vanoua forms of Malarial or Parosj'smal fevers.
It will be seen from the following table, that the deaths from the variooM fonv ' ''
Malarial fever, were relatively, about eight fold more nameroos in Savaniub.
Geoi^a. ■
Relations of Pneumonia to Malaria.
707
Deathifrom TSfphoid Fever ^ Yellow Fever ^ and the varioiu forms of Malarial Fever j in Augutta^ Ga.
during a period of Eighteen yeart^ 1848-1865, incluaive.
WHITES
1.
1
1
BLACKS AND COLORED.
\
J
1
YEAR.
3 o-
S -»
IB C
t »
>
S
^
s
9
c
>
c
C
QD
QQ
5
cr
O
o
«.♦
o
cr
as
o
<
n
3
a-
n
•
O
o
a
3
cr
TOTAL DEATHS
PROM FRTBRS
a
a
1 5
•
•
•
•»3
V
c
<
o
>
X
^
e
>
00
CO
o
3
cr
C
o
o
<
3
3
a-
TOTAL DEATHS
FROM FEVERS
1848
1 ...
1
2
. . .
2
1
3
2
4
2
2
47
4
1
4
2
4
4
6
2
11
7
11
117
« • >
4
3
3
5
12
57
1
• • •
5
5
8
4
8
8
7
9
11
1 50
2
• • •
1
1
6
3
12
1
1
• • •
• • «
• • ■
3
6
9
11
4
2
62
. • .
• • .
...
1
3
1
• • •
• • •
• ■ •
• • •
1
1
1
1
1
1
4
2
18
4
11
6
17
32
25
128
24
9
25
19
28
17
32
91
59
44
68
1
1
1
1
4
1
2
1849
1
3
1
2
3
1
2
2
7
• • •
1
2
3
2
8
1
• • •
1
2
• • •
3
• • •
■ • «
« • •
• ■ •
■ • •
1
1
• ■ •
5
1850
2
• • •
• ft ■
■ • •
1
1
• • •
• • •
• • •
1
■ • «
9
1851
1 ...
1 ...
.. 1
1
• ■ «
• • •
1
■ • •
1
3
2
3
4
• • •
1
2
2
2
1
19
9
1
12
55
0
7
3
5
9
9
6
2
3
• • •
5
16
3
G
10
81
3
4
1
3
1
k • •
6
5
3
1
3
12
12
7
6
69
10
1852
1
• • •
1
1
12
1853
6
1854
1
3
2
1
2
2
2
1
12
•)
. • .
5
33
1
19
1855
1
4 • • .
.. 1
• • •
• • •
• • •
1
I
■ • •
9
1
« • •
1
1
2
1856
3
1
■ ■ •
3
1
2
• • •
1
5
1857 „
.. 1
3
2
12
1858
• • *
• • •
1
1
2
1
• • •
• « •
• • «
• • •
2
« • •
• • •
1
• • •
1
1
1
1
■ • •
2
1
1
2
1
2
12
3
1869
2 1
1
• • •
1
4
2
■ ■ •
3
17
2
1
• ■ •
2
2
1
6
2,'>
1
2
2
3
3
1
20
48
• • •
2
2
2
4
• • •
56
84
1
1
3
4
■ • •
2
48
• • ■
• • •
2
1
1
2
18
•
• ■ •
• « •
2
1
• • •
• • •
• • •
9
7
1860
11
1861
1 ..
15
1862
2...
4 2
2 3
3 1
BIO
1
2
* • •
1
7
9
2
1
5
'?A
19
1863
2
1
1
6
• • ■
• • •
17
1864
8
1865
9
7
• • •
3
1
5
154
Total 2)
639
76
32
317
1
t
In 1854, Yellow fever caused amongst the whites, forty-five deaths in September;
fifty -two in October, and twelve in November ; amongst the blacks and colored, four
in September, seven in Octuber, and two in November. Both in the white and in the
negro race, the heaviest mortality was caused by fevers in the months of August, Sep-
tember and October ; but the relation of the deaths to the population and total mortal-
ity, was greater in the former than in the latter.
It is also still farther worthy of note that whilst in Savannah, during a period of 50
years, Typhoid fever scarcely appears upon the records of deaths, and increased their
number to an almo.st inappreciable extent ; in Augusta on the other hand, it caused
during a much shorter period of eighteen years, a considerable proportion of the deaths
by fever. Thus amongst the whites Typhoid fever caused, 1848, 3 deaths; amongst
the blacks, 3 deaths; 1841), whites (i, blacks 4; 1850. whites 4, blacks 1; 1851,
whites 16, blacks G; 1852, whites 9, blacks 7; 1853, whites 16, blacks 4; 1854,
whites 18, blacks 4; 1855, whites 17, blacks 2; 1856, whites 2, blacks 3; 1857,
whites 18, blacks 7; 1858, whites 8, blacks 3; 1851), whites 15, blacks 5; 1860,
whites 11, blacks 6; 1861, whites 26, blacks 12; 1862, whites 58, blacks 11 ; 186.3,
whites 23, blacks D ; 1864, whites 24, blacks 3 ; 1865, whites 28, blacks 65. Total
deaths* from Typhoid fever, whites 302 ; blacks 155 ; total in both races, 457.
A considerable proportion of the mortality of 1862, 1863, 1864 and 1865, was due
to the soldiers in the military ho.spitals, and to the influx of strangers, both black and
white. It appears that the deaths and di.'^Gase.H of the soldiers were entered upon tho
records of the City Cemetery.
After the close of the war, in 1865, there was a great influx of negroes into Augusta,
and the small pox which had appeared in January, destroyed 74 negroes and 8 whites.
The returns for 1866, extend only up to the Ist of July ; but during the first five
months of this year (1866,) Small Pox destroyed 260 blacks and 37 whites. Total
deaths all cau.<9es during this period, whites 373, blacks 468.
708
Relations of Pneumonia to Malaria.
5 «
•2-2
1^
8"^
I-?
III
^ «9 «
^ O Si
••^ a a
s ^ "•
•5 ^Qo
*•« Si
5 s S
S ,^
i.l 2
5 2 5
Proportion of doatht, oil canwt, la
total popaUUoa, Whites ond Btocko.
1 death la
rtloB of deaths, all eaasos la
Blaek aod Colored p^ttlatlon. 1
death la
Proportloa of deaths, all eauaes, la
white popolatlea. 1 death la
P« op lo >^ >^ (^ (^ QC 1-^94 9* 3fi;£'StSzi&^!5'
«<9to^«s>c<59Q94MMr9e3e<n»nS*eii<-ii-i
«§^5SS25S??S?5?59§SSS5;;S*
— ^o
SSS9^§^*^s^^S^$^^^liSS;::s
Proportloa of deaths from Poeanoaia fiS9A'^^S2^S%SSS2l6^SS?^99
ud Pleurisy la Blacks aud Whites. gS$:S §§?5?^ ;9l ^^ cS S^^ ^ S £:^2S
10 total popalatloo. 1 death la
< ProportioB of deaths from Pneamoala
aad Ploarisjr. amoagst Blarks, la
Blaek popolatloa. 1 death la
, Proportion or deaths from Pacamooia ' SSM t S SSS 2 S S S§ 5? i c * 2 5 g 2
1 aad PlcnrlsT, la Whiles, to White, ^SUS SJs » SSH R*S5 8 S m ^ oSr^^
I popolatloa, 1 death la
Proportloa of deaths frvm Paeomooia
aad PlearisT, amoacKt Blacks
Whites, la deaths from all cause
1 death la ,
Ki Blarks aad ' '^ o.^^r-l®. » '^«. ^^.^^ ^^-^ ^^^^SS
>m ail cause*. t^ n r^ f^ rm ^ t^ r* r^ t^ r^ r* *'
ToUl deaths from all can.es. Blacks > ^ S S g^cS S 21 ^ Si^;i H§Sr; g «g
aad Whites. I ^r5^4is>«r3rt*rt«5rtJO*rtrt«<*»«SeC;
Total deaths frosa Pneamoala aad eiisr?a"CS?;t9o«c»>^r*^<c<-*9S*29SS'^S
Pleurisy, Blacks aad Whites. S^NSSSHs'5«Srtco3rt«'*r53*;;^5
Proportloa of deaths ftwm Paeu- ' q . 't «. -: «% «=; 9 »•* '*'. =. *". **. *'. •^. **. ®. '®. ^ *~ "S
mooia aad Plearisy la deaths ' i-g«e4f-®»S*£2*'*'**"*'S"*^2
I i 1 from all causes.
Total deaths fhmi all causes
I g ■ Totol deaths frvm Paeumoaiaaad i-i r- .-. c •- 'Ci.- *»■ 5 o e* r- •S 35 x «2 » ft 3 S S
S Pleurisy. ,-^^,-^,H9*^p^^*ir-^^ **.^ci
5
)
c
<
«
<
December
November
October.
September
Au^^uat
June
I •«•••••••
May
••«•«•••■ I
«%pn ■•••»•••««•
Man*h.
•^ * " "i u^fci jr» ••*■■«••*■■■••••••■••■
^I'l ?:~i?r5i« :-^ .■^•>i : — ^rtO^S
: • • •
^^ »^ • * ■ . • •
■M : M
•M t- ^ ^ : •-«
: : : : rt
»- 01 *i :?»»-' : ^" t- o
• ■ rt • • • • * •■t »£
'»« ■?! r: rt ^ ^ >* ■>• :•-■•»'?« : "J* ^ < « ^ ^-
p- I-: e^TT'ji'F^ M ?: M «r — : rr rnrs'^'M^i-
' Proportion of dealhs from Pacti- ! •' *! '1 • "^ '* -T •* «. ^^I '." »^ "^i r ». «. t -^ »! ** ^
I I nimla and Pleurisy in deaths ® ?| ' 3i * 3J ^i;:^ ^2 ;; '■Si^ S SH ;:2.^
I from mXX cnnme*. !
X
I Tots! doalhs from all caii*r«.
Tnial deaths fk^tra PueumonU aad
Plruri>3 .
December
^ i- ,- ?l 5^1 SI r" il M ?« i^J >i M 5* «▼ "T c: ?*
— ■* X r. * •* X ?• r. ^. « '"t r- 1- ?? x o 5 « x ^
fc I NoTember.
i*|-
October..
September.
August
July
June.
May ....
"April"
A^&BIVU ■•••■••«•>•«
February.
! January..
ii
rt
p- M r? :
•- ?i t»
-« ^
: M i-i ^ ?• M •■: rt I- ?• n
^ • Vk ^ A| ^m IWl a^ ^^ '^ m^
' • '•'' '■ ' y —
■M : — ; p- M ^ P* ^ :
•A .^ «i
M »^
r: ■"^ i-i — ' ^"^ ^ i- ^ M r: IT^TS ;r- ^ M ;*e*
;:sTii^~^'5Tr: m.s?: Mrtp*rt'^n«sr-r-«
*l 1^ tf 1--
2'
. *
iCttr-xeiO»-'Nn^tfs»i-|
iiiill
■U
S
RelatioTis of Pneumonia to Malaria. 709
In the preceding table I have endeavored to unfold the relations of Pneumonia and
Pleurisy, to the seasons, to the white and black races, to other diseases, and to the
general death rates of the white and negro races.
From this table it is evident, that in Augusta, Georgia, during a period of Vi years,
1845 to 1865, inclusive, 6240 deaths from all causes occurred amongst the whites ; 435
of which were caused by Pneumonia and Pleuritis ; the number recorded as due to the
latter disease, being very small. Amongst the whites one death from Pneumonia was
caused in 14.3 deaths from all causes. The highest relative mortality was caused
amongst the whites in 1845, when one death from pneumonia occurred in 6.5 deaths
from all causes, but the highest absolute mortality as related to the white population,
occurred in 1864, when one in 180 of the white population died from Pneumonia and
Pleurisy. The least relative mortality amongst the whites was in 1865, viz : 1 death
in 53.7 deaths, but the least absolute mortality occurred in 1846, when only one in 1124
of the inhabitants died from Pneumonia and Pleurisy.
During the same period amongst the blacks and colored (negroes and mulattoes)
out of a grand total of 3324 deaths from all causes, Pneumonia occasioned 457, or one
death in 7.2. This disease therefore was relatively to the whole number of deaths,
nearly twice as fatal amongst the negro race : this statement also is to a certain extent
true of the absolute mortality occasioned in the negro race by Pneumonia and Pleurisy.
The highest relative mortality amongst the negroes, occurred in 1864, and amounted to
one death from Pneumonia and Pleurisy, in 3.7 deaths from all causes, and the lowest
relative mortality in 1845 and 1846, in the former year being 1 in 67, and the latter 1
in 96 ; the highest absolute mortality occurred in 1864, when one in 69 of the negroes
died from Pneumonia and Pleurisy.
During the period embraced in the table, the grand total of deaths in Augusta,
Georgia, was 9564, and of this number Pneumonia caused 893, or one death in 10.7 from
all causes in the white and black races.
Both in the white race and in the negro race, the disease was most fatal in the months
of lowest temperature, and of greatest vicissitudes of weather ; and it was least fatal in
the hottest months, and those characterized by the heaviest mortality, from malarial
paroxysmal diseases.
Both in the white and black races, the smallest mortality was occasioned in the months
of June, July, August and September, only 141 deaths occurrtrig in these three months,
out of a total of 893 deaths. The heaviest mortality occurred in the months of Decem-
ber, January, February, March, April and May, 627 deaths being caused in these six
months during a period of 21 years, and only 266 during June, July, August, Sep-
tember, October and November, the months of the his^hest temperature, and of the
greatest malarial influence.
In Savannah, Georgia, on the other hand, out of a grand total of 14,332 deaths from
all causes, amongst the white inhabitants, during a period of 50 years, only 497 deaths
were due to Pneumonia, Pleurisy and Hydrothorax, or one death in 28.8.
A careful comparison of the mortuary statistics of Savannah and Augusta, which we
have consolidated, classified, calculated and presented in the preceding tables will show
that Pleurisy and Pneumonia caused both relatively and absolutely about twice as great
mortality in Augusta. The statistics farther show that this difference is due not to any
so-called malarial or paludal poison or cause, but rather to the greater severity, and more
frequent changes of the climate of Augusta.
The preceding investigations clearly and unequivocally establish the absolute indc-
pendence, in its origin or cause, of Pneumonia, from the cause or causes which produce
the various forms of Paroxysmal Malarial Fevers.
This conclusion will be still farther sustained by a comparbon of the following mor-
toaiy statistics.
Relations qf
PTUinrtloD of tk^lbii fi
Pneumoma to Malaria.
BeUUions of Pneumowa to Malaria,
711
Dfitihtfrom Pneumonia^ Pleuriiia and Hydrotkorax^ and from all CauteSy in New OrUanSj La., during
a period of 9 years, embracing 1849, 1850, 1853, 1867, 1809, 1870, 1871, 1872, 1873.
Papulation of New OrUant, U.S, C.,1850, WhiieMj 89,459; i?/flr*«anrf Cb/orerf 26,916; <ote/,116,375
" 144,596; *• <« 27,074; " 168,670
u
K
1860,
1870,
((
It
140,923;
((
n
50,456;
«
191,418
YIS.VR.
a
a
p
e
SB
1849
17
15
12
1850
12
18:>3
25
96
1«67
47 31
17 35
49 31
1869
1870
1871
1872
41
40
62
313
36
85
1873
55
Totals
323
p
"1
•1 ! *-<
23
23
31
36
43
39:
541
46'
42
24
12
32
24
60
321
23
27
31
13
17
16
14
56
26
20
33
37
337 265,232
e
D
>
a
c
QD
5
cr
O
o
o
cr
»
25
o
<
5
cr
*1
a
3
or
* 22,
• 5""
A*:3
3 = "■
-S3
Sal
•
o -
■ 1 5<
E. -^ P"
2 3
a I
6
8
12
19
19
20
7
25
16
132
5
10
5
10
19
7
10
10
7
6
18 16
9
15
24
115
7
101
12
85
3
8
8
30
15
34
17
3
18
136
11
t
10
31
17
20
7
17
25
16
11
2l|
20
16
21
19
20
6
9
13|
29
44'
30'
39,
37!
19
''I
I
o a
6.9
143 68.8 9862
144 61.6; 7836
1941^80.5 15,033'
299' 33.4 10,096'
351
331
281
348
361
17.0:
22.3i
21.51
17.5;
20.71
6001
739i
6059
6122
7505
145 149 226 2452 31. Ij 76,505
R?
29
S3
B 3-?
.5 •
E5i
a 9 «
111
c ■ •*
813
11.8
808
14.9
794
9.8
618
16.8
569
31.6
578
24.5
711
33.0
573
32.6
554
26.6
In 1860, Pneumonia, Pleurisy and Hydrotborax, caused 169 deaths out of a grand total of
7341 deaths from all causes, or 1 death to 998 inhabitants ; 1863, 301 in 7172 deaths from all
causes, or 1 death in 698 inhabitants ; 1864, 440 in 8498 deaths, or 1 death in 395 inhabitants;
1865, 309 in 7016 deaths, or 1 death in 582 inhabitants; 1868, 235 in 5293 deaths, or 1 death
in 808 inhabitants. The proportion of deaths from all causes, in the years just given, was,
1860, 1 death in 22.9 inhabitants; 1863, I in 23.7; 1869, 1 in 20.5; 1865, 1 in 25.6; 1868, I
in 35.7 iahabitants.
Belatiom of Pneunumia to Malaria.
Dealht front Tafiammation and Oongtilion of tit Lungi, { Pntumonia), PUarUj/ and Bgdndtarax, in
yew York, mlh Uu rtlatioiu to total diathi fnm all eaiua, aad tlu PopuUtiMi of tkt CiH,
during Fifty Year; 1801-1B63, melutiBe. Population of New York, IBOO, 60,469; IBfli.
T5,T70; 18I0,96,3T3t 1BI5. 100,619 ; 1820,123,706; 182S. 166,086 ; 1830, I0!,5e9; 1S3J,
270,089; 1840,312,710; 1845,371,223; 1850,515,394; 1855,629,619; 1860,605,358.
I %%3 ■
'til
.iff
■'■51,
i\ '-in
si MfS
'n I'm
Jfllr
'llrt
ii I
HI
f r ffif
I 2014
I 2108
2187 '
I 2!iZ4
25S3
I 2283
1974 ■
I 2507
5U5 I 3176 37.3
3542
37.2
43.3
42.9
4W1
36.1
5018
33.9
4073
34.6
5181
34.3
5181
36.2
H45..... 647
7,082. 39.1
8,O0!'| 34.9
8,732 3n.I
8,053 37.2 ■
7.93.1 38.4
8,471 3G.8
9,17G 3ii.G
ibIois
20.8
20.4
16,976
30J
23,024
23.9
21,631
14.9
12,703
34.4
Relations of Pneumonia to Malaria.
^u^/' Deathi froitt all CUf<«e«, amonjA Whites ami BfarkSj an J Dtaiht from PneumoMa^ Pleurisy and
UydroiKorax^ in Philadrlphia, Pfntisylvania^ during a period q/* 10 years^ 1831-1840 inclusive.
v.
; ?Li.
^l^
2 *^
rsiB,
l'^7.
YEAR.
n
if
II
i l?l
i o n
• 2 rj
" •• -
5-3? =
i i ^
1-2
Ml
fp
=1-
292
flMi
r§
: ?
: 2 =»•
: ? 5
i.r??
1831
174,541
4623
:j7.89
39.6
33.6
597
15.9
1832
179,694
6425
' 28.21
28.83
22.65
325
583
19.1
1833
185,000
412H
45.36
47.32
35.28 •
243
761
17.2
1834
190,461
4765
40.09
41.46
33.27
247
771
19.4
1835
196,084
5358
37.39
38.32
31.21
334
:.87
16.0
1836
301,976
5022
41.25
43.80
24.47
296
706
17.0
1837
207,834
4881
43,89
45.16
30.75
321
647
15.3
1838
213,970
5118
43.27
45.00
29.23
328
656
15.6
1839
220,387
4765
48.08
49.48
31.30
322
683
14.4
1840
226,693
4593
49.57
52.28
38.68
297
760
15.3
! 48.678
i 41.15
43.12
31.05 ,
3005
1
10.1
Out of a graud total of forty-eight thousand six hundred and Heventv-eight deaths
occurring in Philadelphia, during a period of ten yeani, 1831-1840, three thousand
and five, were caused by Pneumonia, Pleurisy and ITydrothorax, which gives the pro-
portion of 1 death in 16.1 deaths from all causes.
From a careful comparison of the preceding statistics, the fullowing conclusions may
be established:
First The death-rate from Pneumonia, is, both relatively to the total mortality,
and absolutely in proportion to the population, less in such cities as Charleston, Savan-
nah and New Orleans, in which the various forms of Malarial Fever are most prevalent
niid fatal, than in cities situated in the interior, and in the more northern latitudes, and
in localities comparatively free from malarial influence, as Augusta (reorgia, New York
and Philadelphia.
Second, In Charleston. Savannah , Augusta and New Orleans, Pneumonia and Pleurisy*
prevail most in the coldest and most variable months, when Malarial fevers are compara-
tively rare.
Third. The preceding stutlMtijs, which cover a sufficient period of time and relate to
localities widely separated, on the North American Continent, establish, conclusively,
that there is no connection between the origin and cau.sation of Pneumonia and
the action of that cause, or those causes, which induce or produce the various forms of
Malarial fever.
It is, however, true that the action of malaria induces a state of the Human System
which modifies the progress of inflammations, and which is characterized by profound
changes of the Blood and of the Liver and Spleen, and by periodic congestions of the
internal organs, and periodic disturbances of secretions, excretions, circulation, tempera-
ture, and nervous and muscular forces. We will proceed, therefore, to present the gen-
eral results of our investigations on the relations of the action of Malaria on the Humau
System, to the Symptoms and Progress of Pneumonia.
GENERAL BK8ULT8 OF INVEsTIOATIONg ON THE RELATIONS OP THE ACTION OF
MALARIA IN THE Hl'MAN SV8TEM, TO THE KYMPTOMS AND FROtiRBHH OP
PNEUMONIA.
First. Tfiere is ho ntcewary connection between Fneumonia and Mularlal Ftvei\
In healthy, elevated, non malarious regions, pneumonia is almost nevei^ complicatedt
with malarial fever.
90
714 Relations of Pneumonia to Malaria.
In malarious regions, on the other hand, pneumonia is frequently complicated vith
malarial fever. The local inflammation frequently appears in those who are laboring
under the action of the malarial poison, and the disease partakes of the paroxysmal
character.
If the system of healthy individuals be reduced in malarious regions, by any depres-
sing agent or disease, as by the amputation of a limb, or by the inflammation of some
organ, as of the lung in pneumonia, the malarial poison is most likely to exert its cflcct^f.
In such cases, the paroxysmal character of the inflammatory disease is due not to the
pre-existing action of the malarial poison, but to the fact that the system has been :«o
depressed as to be unable to resist the action of the malarial poison.
Second. The Malarial Poison induces profound alterations in the constituents of (he
Blood.
Under its action, the colored-blood corpuscles are more rapidly, and to a greater
extent, destroyed than in any other disease. The fibrin is diminished and altered io
quality. The albumen is in like manner diminbhed. The extractive and colorini;
matters of the blood are frequently increased. The unhealthy hue of the complexion
in malarial fevers, appears to be due to both the destruction of the colored blood corpa<-
cies and the presence of coloring matters in the blood.
Third. Ihirinp the active stages of Malarial Fever ^ phosphorus^ and the compound*
of phosphorus in the nervous structures and in the colored blood corpuscles^ as vcell as
sulphur and the compounds of sulphur in the muscular structures^ vndergo more rapid
changes than in the normal state, and phosphoric acid and the phosphates, and sulphuric
acid and the sulphates appear ift increased quantities in the urine.
The waste of phosphorus and its compounds in the blood corpuscles and nervoo^
structures during the active stages of the fever, is far greater than the supply of thest*
elements through the food.
The nervous disturbances and debility characteristic of malarial fever are, in a meas-
ure, if not entirely, due to these rapid changes in the phosphorescent materials of the
nervous structures, and especially of the central ganglionic cells.
Fourth. During the slow action of tlie MalaHal Poison, as well as during the
active stages of the paroxysm, important changes take place in the Liver and Splren.
In both organs, the colored-blood corpuscles are destroyed in large numbers, and the
coloring matter, resulting from the disintegration of the red corpuscles, accumnlates in
them, and in conjunction with other changes in the nutritive processes of these organs
produce those characteristic alterations of the normal color. In fatal cases, oellalo$ie b
found in both the liver and spleen, whilst grape sugar is absent from tho liver. The
bile is altered both in chemical constitution and physical properties.
Fifth, That the chemistry of the hody is still farther deranged in Malarial F^vtr. .1
evidenced hy the changes in the excretions.
During the chill, and at the very commencement of the hot stage, phosphoric acid
disappears almost entirely from the urine ; as the hot stage progresses, and the febr^T
action and the heat commence to decline, there is an augmentation of phosphoric acid.
But what is still more important in its bearings upon pneumonia, the uric acid b
increased, or remains at the normal standard, during the chill; disappears alm^t
entirely during the fever ; and then increases rapidly, and rises to a high figure, aft^r
the subsidence of the febrile excitement, and often continues for days^ two, three, ^oi
even six times more abundant than in the normal state.
If it be true that the presence of a morbific material in the blood, as uric acid. Id
gout and rheumatism, will often prove an excitant to inflammatory action, this tendenrj
in malarial fever to the generation of large quantities of uric acid during the ioterml^
sions, and even during the period of convalesence, is important in its bearings, not onk
upon pneumonia, but also upon neuralgic affections.
I have in my own case observed changes in the urine, and especially in the uric add,
during severe headaches of malarial origin, similar to tlxose observed in well defir«rJ
cases of paroxysmal fever.
Relations of Pneumonia to Malaria. 715
Sixth. One of the most marked and important of the phenomena of Malarial Fever ^
in iU connection with inflammations of internal organs, is the congestion of important
organs at stated intervals.
It would even appear that, a£]ie from the general depressing effects of the malarial
poison upon the heart and circulatory system at stated periods, and the consequent stag-
nation of the hlood in the central portions of the circulatory system, the altered hlood
corpuscles, and the products of their death and disintegration, as the coloring matter,
may under certain conditions obstruct the smaller vessels, and give rise to local and cir-
cumscribed congestions and even effusions.
It results from these effects of the malarial poison :
(a.) When inflammation is excited from any cause, in a system subjected to the in-
fluence of the malarial poison, the natural tendency is for the inflammation to assume a
low form, from the altered condition of the constituents of the blood and structures,
and from the derangement in the processes of nutrition, and of those physical and
chemical acts by which the nervous and muscular forces are developed.
It is well known that the causes which are most influential in the production of inflam*
mation are such as enfeeble the heart, impair the tone of the arteries, reduce the activ>
ity of the secreting organs, and debilitate the muscular and nervous forces.
Imperfect nourishment abo, either in consequence of the defect in the quantity or
quality of the food, or of incapacity of the digestive powers, impairs the powers of the
system to resist the effects of deleterious and depressing agents, as cold ; and produces
a liability to low forms of inflammation and fever, and to various epidemic and conta-
gious disorders.
In malarial fever, even when the digestion is unimpaired, the action of the poison, by
impairing the constitution of the blood, and by deranging the nutritive processes of the
different organs and tissues, and by deranging and depressing the chemical actions con-
cerned in the development of the physical and nervous forces, produces similar results
to those witnessed in ill-fed and ill-conditioned beings.
The process of inflammation, whilst including both congestion and determination of
blood, is essentially more complex than either or both of these conditions, and includes
changes of the blood within the vessels, and changes of the relations of the capillaries
to the blood, and of the blood to the surrounding tissues.
The character of these changes, as well as the extent and progress of the inflamma'^
tioD, will depend upon the constitution of the blood, the forces moving that blood, and
the condition of the forces active in the nutrition of all the organs, as well as of the
forces especially active in the inflamed tissue. Thus, when the character of the blood
has been altered and the forces depressed, the solid products of inflammation are less
capable of organization, the lymph effused possesses inferior plasticity, and the effects of
the local inflammation upon the general system, in causing inflammatory fever, are more
depressing and dangerous. Ah therefore the tendency of the malarial poison is to
derange the conditions upon which the maintenance of healthy nutrition depends, viz :
the regular supply of healthy blood possessing a definite composition and relation of its
elements, and of a certain supply of physical and nervous force, and the healthy consti-
tution of the organs and tissues, it is evident, not only that inflammation engrafted upon
the system laboring under the effects, or under the direct action of the poison, must be
correspondingly altered from its progress in the healthy constitution, but also that the
state of the system induced by the action of the malarial poison is conducive to the ori-
gin of inflammation.
(b.) From the destruction of the fibrin and red blood corpuscles, consequent upon
the action of the malarial poison, the tendency of inflammations excited in systems
under the influence of the malarial poison is to diffusion.
The increase of fibrin in the blood, and in the inflamed structures, appears to be de»»
tined, in the economy of nature, to limit and circumscribe the inflammatory action, by
the fibrinous matter thrown out within and around the inflamed part.
The colored blood corpuscles, which crowd the inflamed part, appear to contribute by
71 G Relations of Pneumonia to Malaria.
the chemical changes which thej excite, and especially by the increased oxidization of
the protean elements, to the formation of fibrin, which in this view may be considered
as one of the controlling and limiting elements of inflammation. Whatever therefore
tends to diminish the red corpuscles and fibrin, tends to interfere with the natural pro-
cesses employed by nature in the limitation of inflammation, and directly promotes the
diffusion of the inflammation over a greater extent of tis^ue, and in a corresponding
degree renders it more severe and dangerous.
We have in these facts an explanation of the sudden and fatal character of many ca^es
of pneumonia occurring in those who have been for some time under the influence of
the malarial poison.
We have had under treatment, and recorded at length elsewhere, cases which were
suddenly seized with pneumonia during the period of convalescence from malarial ferer.
These patients were destroyed, or rather drowned, by the rapid pouring out of sertms
fluid into the air cells and bronchial tubes of the lungs. In such eases the capillaries of
the blood, being in an enfeebled state, the fibrin of the blood being diminished in quan-
tity and altered in physical and chemical properties, the colored blood corpuscles beins
diminished in number and physically and chemically altered, the solid matters of the
blood having been diminished, and the physical and chemical relations between the indi-
vidual constituents of the blood and capillaries having been disturbed by the action of
the malarial poison, healthy limited inflammation was impossible.
Diffused inflammation of all the structures of tho lung resulted; the sjrous portion of
the blood poured into the air cells, bronchial tubes and trachea ; the supplies of oxj^s^'d
were in a great measure cut off*; the chemical changes of the solids and fluids were in j
corresponding degree checked ; and the physical forces, heat, and electricity, and the
nervous force, developed by those change?, wore, as a necessary consequeace, correspontl-
ingly diminished.
Broussais in his history of chronic phlejruiasije. has recorded several analogous cas^-^
of fatal pleuritic and pulmonic affections attacking those suffering with malarial fever:
and Andral, in his " Olinique Medicale,'' hi\s given at length a fatal case of pneumonLi.
with pulmonary oedema and double pleuritic effusion following and supervening up-n
intermittent fever.
The following cases, 710 and 711 treated by me (1857,) in the Savannah Marine
Hospital and Poor House, will illustrate the influence of the Malarial Poison on the
progress of inflammation in special structures.
Cask TIO: Irisbman, nge 2(: ; height, r> feet 11 iiiclips : ueight, 17o pounds: black b^ir
black eyes; lull, dark brown beard and tnousttiche. Limbs full and round, rliest broad aou
well developed. Has been in America, (New York) nine years, and in Savannah three moaib*
During this time he has followed the occupation of a baker.
September 11, 12 m., 1857. Has just entered the Savnnnah Hospital with Remittent fever
Pulse accelerated but feeble, and his complexion shows the effects of malarial ferer Sa,is
that he has been sick for one week, and has been living near the depot of the Albany ft")'
Gulf Rail Road, in a low malarious situation. I'ndcr the action of Sulphate of Qoiaia ani
stimulants, 'the febrile excitemcut disappeared iu the course of four days; the patient how-
ever, was left in a very feeble condition ; complilucd of great weakness, his pulse was feeble
the action of the intellect sluggish, and he had a peculiarly disagreeable smell, which vasoot
permanently removed, cither by water, or by change of clothing. Under the action of looii?
lie recovered sufficiently to walk about the yard ; but continued however, weak, low spiritei
and indisposed to action.
September 27th. Complained of tx)rpor of the bowels. A mild Cathartic was administerx ^
September 28th. Has a cough. The wind has been from the North East for some tiAf
and the weather has been cold and dnmp, and epidemic catarrh is prevailing. Aboot tv'--
thirds of the hundred patients now in the hospital are suffering with the influenza.
This patient was up and about the wards, assisting and nursing the patients all day. V'
was up and about, wlien I went the rounds of the wards at 9 o'clock p. u. Short]/ afirr i' *
he complained of greiit oppression of the lungs, difficulty of breathing, und loss of masci
power.
29th, 9 o'clock a. m. During the night took a sudden and remarkable change for the wo-v
Rc^piration spasmodic, and sounds as if the air cells, bronchial tubes and trachea contAir*
Belattons of Pneumonia to Malaria. 717
larfre quantities of flaid, and is attended with a load rattling sound, in the tborax. The
churning, rattling, gargling, crackling sounds of the lungs and trachea are rery loud, and can
be distinctly heard over the upper wards of the hospital. Muscular power completely
exhausted ; lies upon his back, and is unable to turn upon either side. Surface of extremities
cold; surface of trunk cool, several degrees below the normal standard. The temperature of
the extremities does not differ essentially from that of the snrrounding medium. The expres-
sion of bis eyes and countenance, and his efforts to converse, show that he is intelligent ; he
is however entirely unable to articulate and expectorate.
Sinapisms were applied to the extremities, epigastric region and chest, and stimulants were
administered freely. These did not present any beneficial effects — did not arouse the clrcula-
tion, and did not increase the animal temperature, because the supply of oxygen necessary
for the chemical changes which generated the physical, rouBcular and nervous forces were
cut off. The mustard scarcely reddened the skin, even after the application for several
honrs.
The patient continued in this state, with a gradual diminution of power, until 1 o'clock, a.
M. the next morning, when the painful respiratory sounds were hushed in death.
Autopsy eight hours after death. Exterior: — Body in good condition, not emaciated ; limbs
foil and round; muscles of trunk and extremities covered by a thick layer of fat; face and
hands sallow and sunburnt: surface of the skin, which had been covered by the clothes,
fair.
Uead: — Dura-mater presented the usual appearance. Arachnoid membrane transparent and
healthy ; blood-vessels of pia-matcr filled with blood. When the dura-mater was removed, an
nicer in the substance of the brain was discovered, occupying a position near the centre of
the superior surface of the left hemisphere of the cerebrum. This ulcer was three-fourths of
an inch in length, half an inch in breadth, and one-eighth of an inch in depth. The walls were
thickened and much harder than the surrounding brain. The blood-vessels of the surrounding
pia-mater and brain were congested with blood, and a small quantity of bloody serum was effused
between the arachnoid and pia-mater in the immediate neighborhood of the ulcer, but nowhere
else. The appearance of the ulcer, and the congestion of the blood-vessels around by no means
acconnted for the death of the patient. The thickened walls, the absence of pus, and the sound
state of the structures of the brain around, show not only that the ulcer was of long standing,
but also that it was rapidly healing. The existence of this ulcer will account, in part, for the
dull, lethargic state of the intellectual faculties, but not for the death of the patient. The
ventricles of the brain contained a small quantity of clear serum. The structures of the brain
were of the usual consistence and appearance.
Chest: — Ueart normal in size; the right ventricle contained a large, yellow fibrinous clot,
attached to the chordae tendinete and carnie coluronsp, and extended through the auriculo-
venticular opening into the auricle.
This clot was firm in texture, and weighed one ounce. The left ventricle contained a small
light-yellow clot ; the aorta also contained a small, flattened, ribbon-like, light-yellow clot.
These clots were evidently formed previous to death, when the circulation was exceedingly
feeble.
Lungs : — The lungs were greatly distended and did not collapse in the slightest perceptible de-
gree, when air was admitted in the pleura. They were congested with blood, and resembled
liver; and when handled, they were remarkably heavy, and felt more like liver than lungs.
When cat, the air celts, and large and small bronchial tubes, were found filled with serous
fluid, and numerous fine bubbles of air. When the lungs were squeezed, pints of this serous
fluid flowed out. In many portions of the lungs the serous Huid was clear ; in others it was
reddish. The fluid resembled serum in all respects, and was not mucus. Here, then, \vc
have the cause of the death of this patient. He was drowned.
Abdominal Cavity: — Stomach pale, and perfectly healthy in appearance ; intestinal canal,
from the stomach to the anus, pale and healthy in appearance.
lAver: — The normal reddish-brown color of the liver, was changed in most parts, to a mix-
tore of light bronze and light olive, and, in several places, resembled the normal color. In
two circular spots, aboat three inches in diameter, the liver was of a dark, bluish-slate color,
like that of a recent case of malarial fever.
The cut surface of the liver approached more nearly to the normal color than the exterior.
The blood of the liver, after exposure to the atmosphere, assumed a red arterial color. It i^
evident, from this examination, that the structures of the liver were recovering from the effects
of the malaria] fever, and that the organ was regaining its normal color.
Spleen : — Slate colored, enlarged and softened. The pulp of the spleen presented a dark
purplish -brown color, which did not change to the red arterial color as rapidly as the pulp of
healthy spleens ; the change of color, however, was much greater than that of the pulp of the
spleen in recent cases of malarial fever. This organ, like the liver, appeared to be recovering
from the effects of malarial fever.
Kidneys : — Healthy.
71^ Relations of Pneumonia to Malaria.
We believe that we have now all the facts necessary for a rational explanation of the phe-
nomena presented by this case.
The malarious poison, and its effects, had produced profound olterations in the blood
and capillaries, liver and spleen, and primarily by its action, or secondarily by tb«*
action of the altered products in the blood, affected the sympathetic and oerebro-spinai
nervous systems. The patient, although weak and lethargic on account of these patho-
logical alterations and the ulcer upon the brain, was, nevertheless, in a fair way of recov-
ery ; the alimentary canal had resumed its healthy actions, and the liver and spleen were
fast recovering, and he was gaining strength daily. We can, in view of these facL«.
safely assert that if no other disease had occurred, the lesion of the lefl hemisphere ^}\
the brain, and the effects of the malarial poison, would not have proved fatal.
In this state of slow convalesence, the patient was suddenly seised with the prevailioL'
influenza. The mucous membrane of the bronchial tubes and air cells was irritated.
The irritation of the mucous membrane was followed by congestion of the blood- vesM-U
and capillaries of the lungs. The capillaries were in an enfeebled state ; the fibrin of
the blood was diminished in quantity, and altered in physical and chemical propati«ii( ;
the colored blood corpuscles were diminished in number, and physically and chemicallv
altered ; the solid matters of the blood were diminished ; and the physical and chemical
relations between the individual constituents of the blood and capillaries were distarbed.
Healthy, limited inflammation was impossible. Diffused inflammation of all the struct-
ures of the lungs resulted ; the serous portion of the blood poured into the air-oel!''.
bronchial tubes and trachea ; the supply of oxygen was in a great measure cut off; the
chemical changes of the solids and fluids io a corresponding degree checked ; the phjv
ical forces, heat and electricity, and the nervous force, developed by the chemical
changes were, as a necessary consequence, correspondingly diminished. The immediate
cause of the death of this patient, was a deprivation of oxygen and the retention of car-
bonic acid gas. We may say, with truth, that he was drowned.
Cask 711: Irishman, laborer and boatman; age 30; height 6 feet; weight 150 ponn.!>
tnll, spare frame, light hair, blae eyes; pale, sallow complexion. Has been ranning on rt«t
boats and rafts, up and down the Savannah River, between Savannah and AugQsts, for x^-
last twelve months. Habits irregular; addicted to the use of ardent spirits. Says that b «
constitution has suflered much from the exposure to the hot sun and night air on the rir-r
and also from an intemperate use of ardent spirits.
September 20th, 1857. A flat, laden with wood, which be was bringing to the city vi«
sunk in shoal water. He was all day in the water up to his waist, fishing out the wood ; ac
at night had a chill, followed by fever. The fever went off before morning, and oa the n.t.
dfty he was employed Again in the water. The chill returned at night, and was followcti : '
high fever. Has been sick from that day to the present time, September 27th, witboat •* ^
medical attendance. Pulse 106; respiration accelerated, labored; skin hot and dry: c.<.'-
tenancc distres<>ed; has a haggard, anxious look; complains of great thirst, of paiat in •
back and bones, and of great exhaustion. His pulse although rapid is feeble, aad bis fo'^*'*
appear to be completely exhausted. His fever remitted slightly on the next day, bat retort* .
on the 29th inst. Under the action of large doses of Sulphate of Qoinia, and Sioaf '«x*
Stimulants, (snake root tea, milk punch, wine, whisky and brandy,) the febrilo excttes-
subsided, the urine regained its normal hue, and on the 4th inst., of the following noatt •
pulse was TO aud respiration 18; temperature normal and function of skin aorBA* •'
although apparently very weak, the patient was able to be up and about the ward. V .' z
the attack the saliva was acid, and the urine copious; from 20,000 to 35,000 pmias «t-
excreted daily. The specific gravity was correspondingly low, from 1013 to loI4. The »* - -
daot discharge of urine was due to the large quantities of water which bis thirst led ^ z
take, and also to the diuretic action of the infusion of snake root. Thronghoat tbe % •• *
his pulse was feeble, and his forces greatly exhausted, and he required close attvatioe i
the free administration of Stimulants.
October 5th. This morning, escaped clandestinely from the hospital.
Hth. Has returned. Pulse 120 ; skin hot and dry ; respiration accelerated, labored --*
plains of great pain in the back of his head and neck; these parts are twollea aad pa -
upon pressure, (('old water dressing to back of head and neck).
^Kh. His head has been shaved, and the tissues above the occipital bone, and abe*^ "•
left temporal and parietal bones are swollen, and the skin looks black, and is ttlcerai*: -
several places. The swelling extends down along the neck, and reaches the taperior ^ -
Relations (ff Pneumonia to Malaria, 719
of the left shoulder. To the finger the swollen parts feel as if there was a collection of fluid
beneath the skin. Sajs that he is suffering intense pain; countenance distressed and haggard ;
pulse 128 ; skin hot and dry ; respiration thoracic, labored, accelerated. :r
loth. Pulse 160, feeble ; skin hot; respiration spasmodic and labored. In addition to the
intense pain in the back of his neck and left side of the head, he complains of Intense pain in
his chest. The pain in the chest cuts short the respiration, and renders it spasmodic. His
countenance Is expressiye of great agonj and terror.
lltb. Pulse 140, rapid and verj feeble ; respiration 24, labored, thoracic, spasmodic. The
pain in his chest is intense; he groans and cries out at every breath, and the expression of
his countenance is indicative of great agony, terror and horror. Was restless and delirious
during the night, and during bis delirious visions spoke and acted as if he was engaged in
mortal combat. Has no hope of himself, and refuses all medicine. The back of his neck and
side of head is much swollen, and when pressed with the hand there is distinct fluctuation.
Hoping that discharge of the pus or fluid, would aff'ord relief, a free crucial incision was made
at the most prominent part of the swelling. Nothing but blood issued. The hesmorrhage
was so great, that it was necessary to check it by the application to the wound of a compress,
saturated with Tincture of Muriate of Iron.
12th. Dnring the night was delirious; would rip out the most terrible oaths, and cry out
that the devils were after him ; had beaten him severely, and were endeavoring to throw him
out of the windows. At other times he would speak and act as if he had been in mortal
combat, and was wreaking vengeance upon an imaginary antagonist. These actions excited
the suspicion that the injury on the back and side of the head was received from a blow.
The patient died at one o'clock a. m.
Autopty nifu hourt after death. Exterior. ^^-Mo^y much emaciated; back and side of neck
much swollen. The inferior surface of the trunk and neck presented a mottled appearance
from the settling of the bluod by gravitation during the last hours, when the circulation was
feeble. On the right leg there were the marks of an extensive ulcer upon the skin covering
the tibia]; the cicatrix presented a purplish, angry color. When incisions were made into the
swollen 'parts of his neck, and back and side of head, the spaces between the muscles, the
meshes of the fibrous tissue surrounding and connecting together the muscles and the fibrous
tissue of the skin, was found to be completely filled and distended with golden colored
coram.
//ra^.— Dura-mater healthy. Arachnoid membrane transparent throughout its entire extent
over the hemispheres of the brain. At the base of the brain, it was slightly opalescent.
Blood-vessels of pia-mater, not more filled with blood than usual. The cortical and medul-
lary substances of the cerebrum and cerebellum, and the structures of the pons varolii, the
medulla oblongata and superior portion of the spinal marrow, appeared natural in CQUsistence
and color. Ventricles of brain contained 10 fluiddrachms of golden colored serum. The supe«
rior longitudinal sinus of the dura-mater contained a golden yellow, elongated clot, the dia*
meter of which was about one-half that of the longitudinal sinus.
( 'heMt.'—H^ fivi somewhat enlarged. Pericardium contained one fluidounce of golden scrum.
All the cavities of the heart contained golden colored clots. The right auricle had a large
golden colored clot, which was attached to the carnae columnar and chords tendiueas of the
Auriculo-ventricular valves. The aorta and carotids, and pulmonary arteries contained
elongated golden colored clots, having diameters nearly equal to these of the arteries. AH
those clots were firm and elastic.
Zmn^«.— The lungs did not collapse when the cavity of the chest was opened. Exterior sur*
face of the pleura covering the lungs, and lining the wiiUs of the thorax, was covered with
eoft coagulable lymph of a golden yellow color. Adhesions were numerous, but as yet, not
strong, on account of the soft, fresh condition of the coagulable lymph, which was evidently
tiut recently effused, probably within the last seventy hours. This inflammation of the pleura
occasioned the severe pain in the chest during life. The lungs were much congested with
Iflood, and when cut, they resembled lirer. The bronchial tubes and air cells, contained much
serum. This serum poured in large quantities from the cut surface. The anterior surface of
the middle lobule of the right lung had a dark blackish, red spot, about one inch in diameter,
which resembled at first sight a wound from a sharp instrument. An examination of the
exterior of the chest, and interior surface of the ribs, showed neither wound nor fracture of
the ribs. When closely examined, this portion of the lung were found to be more congested
and solidified than the surrounding portions.
Abdominal Cavity. — Alimentary Canal. The stomach although enormously distended with
gas, was pale and healthy in appearance. Small intestines also pale and healthy to the naked
eye. Liver of a light, bronze color. The color is lighter than that of the liver in the active
stages of malarial fever, but resembles the color of a liver which was recovering from the
eflfActs of malarial fever. Cat surface of a light, bron/.o color, and not of such a deep and
decided bronze as the liver in the active stages of malarial fever. The right lobe of the liver
bad npoQ its under surface a slate colored spot, three inches in diameter, which resembled in
720 Relaticns of Pneumonia to Malaria.
ftU respects the lifer of a recent case. When an incUioa was Mad« across tbis spoi, the cut
surface presented for one sixth of an inch, the trne malarial hne ; belovr tbis, it approacbei
more nearly the normal hue. The structures of the liver did not appear to be softened.
SpUm, — Much enlarged, of a dark, slate color, and although much softer than a norma!
•pleen, it was much harder than a spleen of a recent case of malarial fever. Weight, 3*.
ounces. Tbis organ, like the liirer, appeared to be just recovering from the effects of malaria;
fever. Kidneys appeared to be somewhat enlarged : the caltces infundibula and pelvis of thf
kidnej contained a small quantitj of a thick yellow fluid.
The folloiviog appears to be the cause and history of the la^t attack :
The patient left the hospital when he was in an exceedingly feeble ooDditiuo, after a
Hevere attack of Kemittent fever. It is probable that he indulged his taste for ardent
spirits ; for the day on which he left the hospital was *' Election Day.'*
The wind was from the northea.st, and the weather damp and coot, with occaaioiial
^euds of rain and mist. Exposure to this cool, damp wind, fVesh from the oceaD, and
the low-grounds end swamps of Georgia and South Carolina, not only daring the da} .
but probably during the night aleo, in a state of intoxication, induced a aevere attack of
pleuro-pneumonia.
The swelling on the back of his head was due either to a blow, or to inflamniatioo in
the cellular tissue and muscles, analogous to the inflammation of the lungs, and probably
arising from the same cause.
The large amount of scrum effused into the bronchial tubes ; the l^rge anaooot of
golden colored serum effused into the cellular tissue of the neok and head, and the lann?
golden fibrous clots in the heart and arteries ; the settling of the blood in the moHt
dependent parts of the body ; the appearance of the cicatrix, and the inflamed spot in
the lungs, all indicate disturbances in the constitution of the fibrin, and of the rehrtioito
between this element and the other elements of the blood to each other, and to the
blood-vessels and capillaries.
Andral, in his ^^Clinique Medieale," gives the following interesting case of Poeumo-
uia, with pulmonary cedcma, and double pleuritic effusion, following Intermittent ferer.
Cask 712. — A man about fifiy-eight years of age, of a strong make, was seized the 8th o^
August, 1822, at 8 o'clock in the morning, with a violent shivering, which, at the end of so
hour, was followed by heat, then by a profuse sweat. On the 9tb, there was apyrexia. The
12th, the patient entered La Chariti'. We saw him at the beginning of the third accession
he felt icy cold in the trunk and extremities; however, the skin was burning hot; pvl$^
hard and frequent. At nine o'clock, the sensation of cold was succeeded by a seusation o;
burning heat, and sweating soon set in. Twelve grains of Sulphate of Quinine were prescribed
for the next day, the 13th, to be taken in three doses, at noon, at 4 o'clock, and at 8 o'clock
at night. On the morning of the 14ih, the patient no longet felt any shivering, bat merely a
little beat, with some frequency of pulse. On the 15th, apyrexia. On the lt>th, Uia day of
the fever, at 10 in the morning, the patient felt a slight shivering, then hA was seized with a
burning beat over all the right side of the thorax, from the last ribs to the axilla. The pan
which was augmented by the slightest motion, did not cease till 10 o'clock at nigbu la the
night a profuse sweat took place.
In the morning there whs great dyspnoea; speech short and panting; decnbitas on tbv
back. The pain of the preceding day had not reappeared, but the patient expectorated thrr*
or fuur viscid, transparent sputa, of a greenish yellow color. A well marked, crepitoos r».v
WAS heard on the right, anteriorly and laterali3\ Posteriorly, on both sides, the respiratiot
was very loud, sufficiently clear, mixed in some points only, and at intervals, with a crepitoci
rale ; ii was the same on the left anteriorly. Pulse frequent and bard ; skin hot and dry
tongue whitish; dinrrha>a. (He was bled to eight ounces). The blood presented a large crai-
saracnium, without a coat. On the 18th, a loud, crepitous rale was heard over all the parts
of the chest; percussion elicited everywhere a clear sound, except low down on both aides.
from the sixth or seventh rib. The pneumonic characters of the expectoration still coatiaatd
Pulse, llu; forty-three respirations in a minute; the tongue was dry and pale. (Aaother
bleeding to eight ounces; sinapisms to the legs ) A thick, greenish coat on the surface cf
the crassamentuni. On the 1 9th his state was the same. He died the next mornlog.
Post-mortem. — On cutting into the tissue of the two lungs, an enormous qaaatitj of frothy
colorles.s serum was seen to gush out from every part. "The pulmonary par«ncby«* vat
everywhere of a groyish white color, and crepitated perfectly, except near the right lna|:. U
this latter part there was observed in separate patches a tissue o( a livid, r^d color, which dd
Relations of Pneumonia to Malaria. 721
«
not crepitate, Bud was very taaily torn. Tbcse different inflamed portions combined, would
■curcely have equalled tbe size of an orange. On the left, from the level of the seventh or
eighth rib to tbe diaphragm, the lung was separated from the thoracic parietes by a liquid of
a deep red color, the quantity of which scarcely equalled half a pint. Superiorly, false mem-
branes, of recent formation, limited this effusion, and united tbe lung to the ribs. On the
right, there existed another effusion similar to the preceding, with respect to its being cir-
cumscribed, and also with respect to the quantity of the liquid, but which differed from it
with respect to ihe quantities of the latter. It was a turbid serum, in the midst of which a
considerable number of albuminous, (locculi floated. A black, coagulated blood filled the
tour cavities of the heart, and distended the right auricle in particular.
When this patient entered La Charity, he was afflicted with an intermittent fever, exempt
from all serious complication. The fonrtb fit was prevented by Sulphate of Quinine. To-
wards the time when the fifth should have returned, tbe shivering and pain of side marked
the invasion of the pleuritis on the right side; the respiration soon became embarrassed;
some crepitons r^Xt was heard at first in some parts, then over almost all the thorax ; finally,
pneumonic sputa appeared. The general existence of the crepitous rule seemed to announce a
general inflammatory engorgement of the two lungs ; there was no such thing, however, and
tbe autopsy proved that this r&Ie was due to serous effusion.
(c.) The liability of persons who have suffered with malarial fever in the summer
and fall, to be seized witlx Pneumonia in the winter and spring, and the danger of these
inflammatory attacks, following or engrailed upon paroxysmal fever, have long been
known to the public, as well as to the profession.
In many caseSi these inflammations, engrafted upon malarial fever, or following its
eflfects, are clearly dependent for their excitation upon the vicissitudes of the weather,
sod especially vpon the agency ot oold.
In healthy beings exposed to cold, there is at first, through the stimulating effects of
the cold air inspired, and of the change of temperature upon the exterior, an increase in
the circulatory and respiratory actions ; more oxygen is introduced and distributed, the
chemical changes of the system become more rapid, and the temperature of the body,
notwithstanding the increased radiation and loss of heat, is maintained at the normal
standard by the increased ohemical actions. As long as the fixed normal temperature
of health is maintained in the trunk and important organs of animal and vegetable life,
no evil results follow. If, however, through the prolonged action of the cold, the mate-
rials capable of keeping up the temperature be exhausted, or if the nervous and muscu-
lar Agrees be so depressed that the respiratory and circulatory actions are so impaired
thai the materials are not distributed with sufficient volume and oeiority to maintain the
necessary chemical changes to preserve a fixed temperature, the heat of the body gradu-
ally descends, not only by progressive conduction and radiation from the exterior to the
centre, as in an inanimate cooling body, but the chilled blood circulating in the vessels
of the exterior, and in the capillaries of the lungs, mingles with the mass of blood in
the interior, and still farther and more rapidly reduces the temperature of the great
central organs. At the same time, the contraction of the vessels distributed through
the superficial structures, under the prolonged action of cold, forces the blood inward
toward the largest venous receptacles, and thus induces a state of congestion in the cen*
tnU organs.
It is B well established fact, that a fixed temperature is absolutely necessary to the
maintenance of the healthy nutrition of the tissues, to the proper performance of the
functions of secretion and excretion, and to the regular and active development of the
Dervoua and muscular forces. Not only by the congestion of the internal organs, but
also by the disturbances induced in the chemical and physical processes concerned in
secretion and excretion, by the loss of that amount of heat or physical force which is
one of the essential conditions to those actions, do tho.se changes in the mutual rela-
tions and constitution of the blood, and capillaries, and organs ensue, which frequently
result in the establbhment of inflammation. And it is not unreasonable to suppose
that daring such disturbances, chemical products may be formed of a totally different
character from those of the healthy organbm ; just as in the laboratory, with the sauo
organic materials, different products are formed under difforrnt decrees of heat ; ai;i(\
91
7:^ Relations of Pneumonia to Malaria.
aliKi, thai tbe excremeDtitious matters neoessarilj resultiog from tbe Dutntaoa of t^
organs and dereloptDent of the forces may be retained in the blood and stmctiireB, tram
the congestion of the kidneys, and the impairment, if not total oessatioD of the laiictiAii
of the skin, consequent npon the constriction of its pores and vessels and dimiontioci «*f
its nerTous sapplies, following the redaction of temperature ; and still farther, that
these altered products and excrcmentitious matters may irritate certain organa and
excite in them inflammation.
As therefore, the malarial poison destroys those constituents of the blood and Denroa»
system most intimately associated with, and necessary to, the generation of heat, and
of all the nerrous atd physical forces , and as it farther depresses the nervous and
muscular forces, and the action of the heart, and the tonicity of the arteriea, and tend*
of itself to induce congestions of the internal organs, it is evident that it reodcn it»
victims, when exposed to the vicissitudes of weather, and especially to the prolos^
action of cold, exceedingly liable to inflammations.
(</.) The action of the ^malarial poison is attended, not only with derangement in
various nutritive processes, but also with the generation of increased quantities of the
In like manner, in inflammations existing in healthy organizations,*when resolutioD
takes place, there is an increasedjexcretion of the urates.
If, therefore, the existence in the blood, and non-elimination of these excremeotitioos
bodies in certain diseases, as gout and rheumatism, tend to excite local inflammations,
it is but reasonable to suppose that their non-elimination from any cause, as firom the
effects of cold, previously described, may, in like manner tend to excite local inflamma-
tions in those suffering from the effiects of the malarial poison.
(«.) After the excitation of Pneumonic Inflammation from any cause, the periodic
changes, and especially the periodic congestions of the internal organs, induced hy th^
action of the malarial poison, tend to aggravate and increase the inflammation.
During the cold stage, the blood stagnates, and accumulates in the capilUries ^f
important organs, because the blood has been altered by the malarial poison and the
changes which it induces : because the relations between the blood and its oontainin^
vessels, especially the capillaries, have been disturbed ; because tbe r^al»r nonnai
chemical changes necessary for the development of the forces which work the madijpery
are not generated with sufficient energy, or if generated, with even increased eneif^.
they are not generated in the right position and in the proper quantities, and the cor-
relation of tbe physicali cbemicali nervous and vital forces is ^thus deimngod ; beoaoM
the action of the sympathetic nervous system which accompanies the blood-TeBsek, and
regulates the circulation, and respiration, and secretion, and nutrition, and excrecioo.
and relates them to each other, and to the cerebrO'Spinal system, has been disturbed by
the direct and indirect action of the poison, by the airect action of the poison npoo th^
flympathetic and oerebro-spinal nervous systems, or by the relations of the ^emical
tb$ngeB indnoed, or the products generated in the constituents of the blood bj the
malarial poison, to the sympathetic and cerebro-spinal nervous systems.
From these facts and considerations, we arrive at the following practical ooodiisioBs
Fint Whilst the malarial poison cannot be said directly to produce poeUDODia.
still it is capable of inducing such changes in the blood, and in the nutritive and esot •
tory processes, as to predispose the system to thyt and other inflammations. And tlMR-
fore,
Secondly. The physician should never in the treatment of pneumonia, in tboee wbo
have been exposed to the action of malaria, lose sight of its effects in comptkatim:
inflammation of the lungs, and of the consequent necessity of arresting* at cncv, if
possible, tbe farther action of the malarial poison.
As no remedy can ccmparo with quinine for the accompHsbmcnt of this n^uh. i*«
iii?e would in the present state of our knowhdgc appear to be imperatively dcmandtd
in the treatment of ineva'onia arising in malaricus regions, and prcfenting veil markid
and recurrent paroxysms.
Relations of Pneumonia to Malaria. 723^
Tbb remedy may be indicated even when the patient has exhibited none of the
symptoms of malarial fever, before the appearance of inflammation, for it is well estab-
lished that the malarial poison may be present in the system without manifesting any
eflTecta sufficient to excite the attention of the physician or patient. Thus, mechanical
injuries in those who have been exposed to the action of malaria are frequently attended
with the appearance of paroxysmal fever. Whilst the strength was unimpaired, th^
system resisted the morbid influences of the poison ; but when the forces were reduced,
by the injury and the consequent inflammation, then the effects of the poison were
manifest. In like manner the depressing effects of the pneumonic inflammation may
'80 weaken the forces as to bring the system under the dominion of a poison, which it
had before resisted.
Thirdly, In the treatment of pneumonia in malarious districts, the physician should
never forget the similarity, in some important respects, between the effects of the
malaria] poison and general blood-letting.
The malarial poison, whatever it be, destroys rapidly the colored blood corpuscles.
Whatever, therefore, diminishes the colored blood corpuscles, acts in concert with the
malarial poison.
Creneral blood-letting more rapidly diminishes these important constituents of the
blood, so essential to healthy nutrition, to the maintenance of the nervous and muscu-
lar forces, and to the successful progress and resolution of inflammation ; because the
colored blood corpuscles rush along chiefly in the centre of the vessels, and are evacu-
ated more abundantly than the other constituents of the blood.
The malarial poison also reduces rapidly the forces.
General blood-letting reduces rapidly the forces.
The two, in this particular, again act in concert.
We would not, however, deny that circumstances may arise where blood-letting, and
especially local blood-letting, would be beneficial in malarial fever, and in pneumonia
complicating this disease. Whenever blood-letting is used it should be borne in mind that
it does not, and cannot, cure malarious disease ; its beneficial action is only temporary,
and BO far from curing the disease, the relief which it has temporarily afforded will
vanish, if other remedies, especially the sulphate of quinia, be not used ; and as a
geoenil rule, without these remedies, the patient will be in a much worse condition than
if the blood-letting had not been employed.
In considering the use of general blood-letting in malarial fever, we should ever re-
member that the cerebral symptoms, the delirium and the torpor of the intellectual fac-
ulties, and the congestion of the internal organs, are not inflammatory ; they are not due
to an exaltation of the functions, or to an irritation of the congested organs, but rather
to a loss of power in the circulatory apparatus, heart, arteries, capillaries, and veins, and
to disturbances in the physical, chemical and nervous forces. Hence, therefore, in pneu-
monia, complicated with malarial fever, we will best guard against those dangerous peri-
odic changes and congestions, not by depleting, but by stimulating and anti-periodic
remedies.
Fourthly. It results from all this, that stimulants and nutritious diet are especially
indicated in pneumonia, complicated with paroxysmal fever.
The nutritious diet supplies the elements of the blood Which have b}cn destroyed ;
and the stimulants not only arouse the depressed nervous system, and through the sym-
pathetic and O'jrebro-spin.il gaiigi'a, excite the circulatory system to a full and salutary
action for the introduction and distribution of the elements of nutrition and secretion
80 necessary to the favorable progress and termination of all inflammations, but they
also preserve the elements of the blood and tissues from too rapid chemical change and
destruction, by taking their places, and themselves undergoing the chemical changes
which are for the development of the physical forces which work the machinery.
FifVhly. Quinine may arrest inflammations, or promote their resolution by other
modes than its anti-periodic powers, as by its sedative and excretory powers, or by its
nflaeoee on the nervous system and capillary and general circulations.
724 Relations of Pneumonia to Malaria.
If the value of this agent in the treatment of inflammation d^iends upon some rach
power other than its anti-periodic efiects, then the important result is reached^ that this
remedy is valuable in non-malarious, as well as in malarious regions.
Upon this question, however, we need definite experiments and investigations.
We hope, at some future time, to present the results of experiments upon the effects
of quinine, both upon the healthy and diseased organism, designed to elucidate those im-
portant questions concerning its mode of action.
Finally. We need, above all things, careful records uf the results of the treatment
of pneumonia with quinine in full doses.
As far as my knowledge extends, no well established data exists by which we may
determine the relative merits of this agent in the treatment of pneumonia. I have
heard experienced and intelligent physicians affirm that, in private practice, when this
drug was used energetically in the early stages of the disease, not more than one case in
fifty would prove fatal. This is surely an extraordinary result, and far different from the
results of the treatmsnt of pneumonia in the Confederate hospitals, which, it must be
confessed, as shown by the hospital records themselves, are bad enough ; and in fact.
no better, and even worse, than the heavy mortality characteristic of the rigid anti-
phlogistic method with bleeding, blistering, calomel, and opium and tartar emetic. The
Confederate Surgeons did not use blood-letting to any extent in the treatment of pneu-
monia, and in many cases of this disease employed quinine, stimulants, and natritious
diet.
In our own practice, civil and military, we have used quinine freely in the treatment
of pneumonia, and especially in those cases which were complicated with malarial fever,
and apparently with marked benefit and highly favorable results, but we are indined tn
the opinion that a large share of this success was due to two facts, viz : quinine, a com-
paratively innoxious, and at the same time a tonic medicine, was substituted for the
heroic and poisonous drugs so extensively employed in the treatment of pneumonia, and
our patients were supplied with nutritious diet, and the strength was supported ; in oth^
words, depressing agents were withheld, the strength was supported, and nature was
allowed to have her perfect work.
The Confederate statistics demonstrate that but little confidence can be placed in the
dogmatic assertions of practitioners, apart from a careful record of cases and the preser-
vation of the actual statistics.
The carefiil determination of the value of quinine in the treatment of poeamooia.
as well as the best mode and period of its administration, as well as the relatire adioo
of this agent in malarious and non-malarious regions, should engage the careful attri-
tion of Southern physicians.
In the institution of any investigations into the relative value of quinine in the
treatment of pneumonia, the following well-established fiicts are worthy of oonstuit
consideration.
Uncomplicated pneumonia, especially in young and vigorous constitutions, aliDOM
always gets well, if instead ot being lowered, the vital powers are supported, and ilie
excretion of effete products assisted.
From the accounts which have been published concerning the natural program of
pneumonia, it would appear that very slight cases of limited inflammation may be
valescent on the seventh day ; that the majority of cases of medium intensity
between the seventh and fourteenth days, and very severe ones between the foarteeDth
twenty-first days.
In the report of the cases, the extent and character of the inflammatioo,
with the symptoms, progress, complications, and termination of the diseuC) as well m thr
exact period of its commencemeut and the establishment of convalesoence, shonM be
noted with scrupulous accuracy.
Without the carefitl record of these points, the value of such investigations will Kr
greatly impaired.
Relations qf Pneumonia to Malaria, 72&
Oaided by the preceding priaciples, the general plan which I hare pursued in the
treatment of Pneumonia, has been as follows :
Absolute rest and quiet in a well ventilated room of mild but equable temperature.
When in the commencement of the disease, the bowels are constipated, they should be
thoroughly evacuated. In an adult eight grains, of Calomel, or ten grains of Blue
Mass, followed if necessary with Castor Oil, or a Saline purgative in from four to six
hours, will generally be found sufficient to unload the bowels. During the progress of
the disease, it will generally be sufficient to procure one or more actions from the bowels
every second or third day according to the constitution and habit of the patient. The
bowels m:\y bo kept open by gentle saline purgatives or enemas. When diarrhoea
accompanies pneumonia, it should not be suddenly checked, but should be controlled by
such remedies as Opium, Bismuth and Ipecac.
The local applications consist chiefly of Oil of Turpentine and Blisters. In ordinary
cases unattended with severe pleuritic pain, Turpentine stupes applied over the region
of the affected lung will be sufficient ; when, however^ the pain is severe and the oppres-
sion of breathing great, benefit will oflen result from the application of a blister, over
the seat of the greatest pain. Sulphate of Quinia, Opium, Ipecac, Aconite, Yeratrum
Viride and Yellow Jessamine, (Gelseminum Sempervirens,) have been employed during
the active stages of the disease, i'rom their supposed or known effects upon the progress
of inflammation.
«
In the treatment of adulu, I have derived benefit from a combination of equal parts
of Sulphate of Quinia and Dover's Powder, (Pulv. Ipecac et Opii); of this mixture
from four to six grains have been administered every two, three, four or six hours.
This combination should be continued during the active stages of the disease. The
Yellow Jessamine has been administered in doses, varying from 10 to 20 drops, every
two, three, four or six hours. Alcoholic stimulantii appear to be demanded in some
cases of Pneumonia. I have generally combined the whiskey or brandy with milk, and
administered the milk punch in moderate quantities at regular intervals. As far as
my experience extends, alcohol administered in sufficient doses and at regular intervals,
in Pneumonia, reduces the temperature, prevents or controls delirium, and diminishes
the waste of the solids and fluids during the febrile state, by undergoing chemical change
in the blood.
Nutritious and easily digested aliment is of the greatest importance, in a disease in
which large demands are made upon the blood for the products of inflammation and
the evolution of new structures.
I have employed Quinine in the treatment in Pneumonia, as an anti-periodic, and
for its effects on the nervous system, and for its power of diminishing the temperature
and equalising the circulation. Quinine preserves the integrity of the blood, regulates
and promotes excretion, canalizes the circulation and fortifies the system not only against
the action of the malarial poison, but also against the action of the morbid products
absorbed from the inflamed lung. According to Binz, Quinine has the power of
arresting putrefaction and fermentation, and is an active poison for all low organisms,
animal and vegetable ; and Dr. G-race Calvert has confirmed the observations of Binz,
and announced the power of Quinine 'to prevent the development of Fungi. These
facts have been applied to the explanation of the effects of quinine upon the process of
inflammation. Thus, according to Conheim's views, pus being mainly a collection of
white blood globules, which have passed through the walls of the vessels — Quinine
having the power of arresting the motions of the white corpuscles, hence, preventing
their exit from the vessels — the alkaloid arrests, or at all events diminishes the forma-
tion of pus during the course of inflammation. The well-established effect of Quinine
in producing a decrement of tenipercUure tn/ever, has been referred to its power of
destroying the ozonizing power of certain substances ; and as the red corpuscles have
this power, quinine in the blood is supposed to diminish the oxidation of tissue, and
thos to lessen the production of heat. Thus Ranke and Keener, found that the tissue
changes were diminished under the action of large do^es of Quinine. Zuntz has recorded
'26 Belations of Pnenmonia to Malarta.
the observation that Qainine in ten grain doses, lessens the daily excretion of urea by
one<third or more ; and Uarah has found the same to occur when Quinine is adminis-
tered in fevers. Harley added Quinine to blood, and found that it took up leas oxygen,
and gave off less Carbonic Acid, than blood which had not thus been treated. Zuntx
and Schute have employed tha changes in the alkalinity of the blood for the determi-
nation of the same fact. Thus, if fresh blood be drawn, a development of acid begins
in it ; and as this acidification depends on oxidation, the diminished alkalinity of the
blood thereby produced, furnishes a test of the rapidity with which oxidation proceeds;
and it has bsen determined by the experiments of Zuntz, Scharsenbroich ana Schute,
that quinine, bebeerine, cinchonine and picrate of sodium, lessen in different degrees,
the production of acid and consequently prevent the oxidation of the blood.
The experiments of Binz ftre especially important in their bearing on the question
of the direct action of quinine on the chemical changes of the blood, or of its indirect
action through the nervous system, which show that when putrefying liquids are iojeoled
into the circulation, the temperature of the body rises ; but if the fluids be previously
mixed with quinine, whereby the putrefactive processes are arrested or destroyed, the
rise in temperature is either entirely arrested or considerably diminished. Such expe-
riments, not only throw light upon the therapeutic action of such alkaloids as oninine,
but they also illustrate, as it were, the very nature of the processes of those qiaeases.
the effects of which they modify or counteract by the peculiar chain of chemical actiona
which they induce in the blood.
I have employed Dover's Powder in the treatment of Pneumonia, for the sedative
effects of the Opium, the expectorant effects of the Ipecac, and the diuretic properties
of the Sulphate of Potassa.
While local blood-letting, by means of cut-cups, applied over the region of the dis-
eased pulmonary structures may be used, general blood*letting should be employed
with caution in malarious regions, on account of its depressing effects on the heart and
nervous system ; there are cases, however, of a sthenic character, in which general
blood-letting may prove of decided benefit.
As far as my experience extends, the Tincture of Yellow Jassamine (Qelseminnm
Sempervirens), diminishes the frequency and force of the heart's action, diminiahca the
frequency of respiration, promotes free diuresis, and directly reduces the animal tem-
perature, and acts as a sedative to the nervous system.
Whatever treatment may be adopted in pneumonia, attention to diet is of prime im-
portance. The strength of the patient should be maintained, and the materiab for the
proper constitution and regeneration of the blood, and development and changes of the
products of inflammation, should be supplied in sufficient quantities at short and rsfca-
far intervals. Milk, and concentrated beef and chicken tea, should hold the highest
place amongst the aliments employed during the active stages of pneumonia.
In private practice, the proportion of deaths under the preceding plan of treatment
has not exceeded three per cent.
It is my experience, that in hospital practice, the rate of mortality in pneumooia, is
greatly increased by the following causes :
First. The severest cases, as a general rule, are sent to the hospital ; and the pro-
portion of Double Pneumonia is greater than in civil practice.
Second. The cases are often sent in the active stages of the disease, and the aymp-
toms are aggravated by the exposure and fatigue incident to the transfer.
Third. In many cases, the re.<)ult has been decided before it is in the power of iht
physician to accomplish any good treatment.
Fourth. Many hospital patients have been debilitated and depressed by poverty,
intemperance, severe labor and exposure.
Fifth. A larger proportion of cases supervening upon, or engrailed on fatal forma of
disease, as Phthisis Pulmonalis and Bright's Disease of the Kidneys, occur ia ho^tal
practice.
Relations of Pn$umonia to Malaria, T21
Sixth. The types of pneumoaia manifeBted in different BeaBone^ and in different
periods are more marked in hospital patients.
The preceding propositions will be illustrated to a certain extent by the following
statistics and oases :
Daring a period of forty-five months, out of a p-and total of two thousand three
hundred and eighty cases treated by me, in the Charity Hospital of New Orleans, with
a mortality of two hundred and thirty*five (9.83 per cent, or 1 death in 10.12 cases)
of this number, diseases of the Respiratory System, including Phthisis Pulmonalis,
numbered two hundred and ninety-nine, with sixty-thrce deaths (one death in 4.7 cases,
or 27.5 per cent.^ ; Phthisis Pulmonalis numbered one hundred and fifty cases, with*
forty-six deaths (one death in 3.2 cases) ; all other diseases of the Respiratory System,
including Pneumonia, Pleuro*pneumonia, Pneumothorax, Hydro-pneumothorax, Bron-
chitis, acute and chronic. Asthma, Pleuritis and Emphysema numbered one hundred and
for^-nine cases, with seventeen deaths (one death in 8.7 cases, or 11. per cent.).
Tha fatality accompanying pneumonia, as well as the type of the disease varied within
wide limits during different periods: thus, during twenty -seven months (January,
1869 to April, 1870 ; October, 1870, to April, 1871 ; October, 1871, to April, 1872 ;
out of a total of one thousand one hundred* and eleven cases, with one hun-
dred and six deaths, only nine cases of pneumonia were treated, all of which
recovered and were discharged; during six months, October, 1872, to April,
1873, total cases of all diseases, two hundred and thirteen : deaths, thirty-
nine from all causes ; Pneumonia, twenty-two cases, nine deaths (and of this number
thirteen were cases of pneumonia uncomplicated and confined to one lung, all of which
recovered ; two cases of pleuro-pneumonia supervening upon malarial fever, both of
which terminated fatally, seven cases of double pneumonia, involving the greater por-
tion of both lungs, all of which terminated fatally) ; during six months, October,
1873, to April, 1874, total cases, five hundred and thirteen ; total deaths from all causes
fifty-two ; pneumonia, twenty cases ; deaths, two (and of this number, eighteen casetf
were uncomplicated, all of which recovered, and two cases were complicated with
phthisis, both of which terminated fatally) ; during six months, October, 1874, to April,
1875, total eases, four hnndred and thirty-nine, total deaths thirty-seven ; pneumonia,
twenty-eight cases ; five deaths (of this number, eighteen cases were uncomplicated, all
of which recovered, five cases of pleuro-pneumonia, with one death, five case of double
pneumonia, with four deaths).
It will be observed that even in Hospital practice in New Orleans, under the plan of
treatment which I have pursued, recovery was the almost universal result in uncom-
plicated pneumonia, whilst in all the cases including those complicated with Phthisis
and Malaria, (oases 79, deaths 16), the mortality was one death in 4.9 cases, or 20
per cent.
These results are placed in a still more favorable light, by the fact that in 801 cases
uf Pneumonia treated in the same Hospital at large, 1856-1860, 300 terminated
fatally, one death in 2.6 cases, or 37.3 per cent; 1866-1870, 409 cases, 184 deaths,
one death in 2.3 oases, or 43.9 per cent.; 1871, 109 cases, 44 deaths, one death in 2.5
cases, or 40.3 per cent.; 1872, 135 cases, 59 deaths, one death in 2.3 coses, or 43.7
per eeat; 1873, 161 cases, 61 deaths, one death in 2.6 cases, or 37.9 per cent.; 1874,
130 cases, 43 deaths, one death in 3. cases or 33. per cent.
The following brief notes upon a portion of the casas treated in my wards, will
illustrate the general results :
Cask 713: J. C, age 50; native of Ireland; laborer; entered WnriJ Hi, December 15tb,
1874. Pnenmonm of rigbt lang: tubalar breathing; crepitant and fubcrepitant ralei; dull-
ness opon percuition ; increase of vocal fremitus ; broncbopbony ; rapid puNc and respiration ;
elevated temperatare ; fluabed cheeks; tongue coated witb brown fur; rusty colored gputa.
The boweli were opened by a mercurial, and four grains of a mixture of equal parti of
Qoioine and DoTer't Powder were administered every three hours ; and ten drops of the
TiDCtare of Yellow ^esfamioe Gelseminam, every six hoars. Turpentine stupes were applied
728 Relations of Pneumonia to Malaria.
orer the region of the inflamed lung. Milk Panch and Beef Tea were administered at regu*
lar intervals. In the course of nine days, the chlorides reappeared in the nrine and the
febrile excitement subsided, and convalescence was established. The patient was discharged,
capable of performing his usual manual labors, on the 15th of January, one month after bis
entrance. As many of the patients entering the Charity Hospital of New Orleans, are with-
out homes or means of support, beyond their daily labors, it has been my custom to retain
the patients in the wards, until capable of performing such labors as are necessary to their
daily support. The length of time, therefore, which the patients remained in the hospital, U
not a just criterion by which to judge, of the rapidity of convalescence in disease.
Case 714 : P. McD., age 35 ; native of Ireland ; sailor ; Pneumonia of right lung. Ed*
tered Ward 29, December 26th, 1874. Treatment as in preceding case ; recovery rapid and
complete ; discharged January 5th, 1875.
Case 715: E. M., age 31 ; native of France; clerk; entered Ward 30, December 28tb, 1874.
Pneumonia of left lung. Treatment as in case 718; recovered; discharged January 23d,
1875.
Case 716: D. F., age 24; native of New Orleans ; gardener; entered Ward 2^^ January
3d, 1875. Pneumonia supervening upon, and complicated with Malarial, fever. Entered on
the 4th day of the Pneumonic inflammation. Quinine and Dover's Powders were freely iiaed,
and both the Pneumonic inflammation and Malarial fever were arrested, and the patient was
discharged January 15th, 1875.
Case 717 : W. C, age 38 ; native of Ireland; laborer; entered Ward 29, January 5th, 1873.
Pneumonia of right lung complicated with Intermittent fever. Treatment as in preceding
case ; recovered ; discharged January 18tb.
Case 718: B. B., native of France; age 44; baker; entered Ward 29, January 8th, 1875.
Pneumonia of right lung; recovered ; discharged January 16th.
Case 719 : H. R., native of China ; age 23 ; laborer ; entered Ward 30, January Ilth, 1815.
Pneumonia and Intermittent fever. Treatment as in case 713 ; recovered; discharged Jana-
ary 18th.
Case 720: J. K., age 19; native of New Orleans; laborer; entered Ward 13, January I7th,
1875. Pneumonia, lower lobes, both lungs; recovered; discharged February 10th, 1875.
Case 721 : 0. A., age 20 ; native of Austria ; laborer ; walked all the way on foot from New
York. Entered Ward 29, January 19th, 1875. Pneumonia of left lung, accompanied with
intense jaundice. High temperature, ranging from 103° to 105° F. Sputa of a golden color;
sweat of a golden color; saliva in mouth golden colored; urine high colored and loaded
with bile. Bowels were kept open by mercurials ; Turpentine stupes were applied over
region of diseased lung, and Quinine freely administered. Recovered; discharged ianaary
27th, 1875.
Case 722: J. O'B., age 39-; native of Ireland; brakesman; height, six feet, six iuohts ;
entered Ward 29, January 20th, 1875, on 4th day of disease. Pneumonia of both langs,
complicated with Pleuritis. Treatment as in case 713. Pneumonic inflammation arrested .
progress satisfactory ; recovery; discharged February 5th, 1875.
Case 723; J. B., age 48; native of Ireland ; laborer; entered Ward 30, January 25lh, l87i.
Pneumonia; recovered; discharged March I2th, 1875.
Case 724: M. McM., age 40; Ireland; carpenter. Ward 29, January aotb. PDcnmoBia
and Intermittent Fever; recovered; discharged February 8th.
Case 725: H. R., age 40; native of Ireland, laborer. Ward 29, February 4th. PneuMo*
nia. Treatment ns in case 713. Recovered; discharged March 3d, 1875.
Case 726: J. C, age 20; native of Ireland; laborer; entered Ward 29, February 25lh.
Pneumonia; recovered; discharged March 18th, 1875.
CiSE 727; H. B., age 23; native of Germany; baker; Ward 30, February 2Tth, 18T1
Pneumonia supervening upon and complicated with Remittent Malarial fever. Patt«ai ^*d
high fever, and delirium, and great prostration for five days. Treatment consisting chiefly of
Quinine and Dover's Powder, and Tincture Yellow Jessamine. Recovered ; discharged M^rch
18T5.
Case 728: J. H., age 57 ; native of Ohio ; laborer; Ward 30, March Ist, 1675. Pneumoaia.
Recovered; discharged March 13th.
Case 729: J. F. C, age 48; native of France; painter; Ward 30, October t3th, 1874
Double Pleuro-Pncumonia. Had been sick six days, before entering the hospital. DttUoes*
upon percussion over both lungs, especially over lower lobes, where there was tabula*
breathing, and absence of respiratory murmur; Pleuritic effusion upon right side. latcfts^
pain upon right side. Rapid pulse and respiration ; great prostration ; cheeks Much coa*
jzested; lips purple; tongue dry and coated with brown fur, and red at tip and edgw.
delirium. Prognosis unfavorable. Died October 16th, three days after entering the ho^ta:.
Case 730: J. D., age 39; native of Ireland; laborer; Ward 29, December 23d. Doutic
Pneumonia with bloody expectoration. Dullness upon percussion, absence of respiratork
murmur, and tubulsr breathing, over lower lobes of both lungs; sputa coorifU of alvofl
Relations of Pneumonia to Malaria. 72*J
pure blood. lligU fever, tiushed face, rapid respiration ; congested lips and extremities ;
delirium. Prognosis unfavorable. Expectoration ceased entirely on the 24th ; patient died
December 25th, 1873, on third day after entering the hospital.
Case 731 : P. H. K., age 33 ; native of New York ; laborer; Ward 30, January 5th, 1875.
Had been sick four days. Double Pneumonia and Pleuritis. High temperature, rapid pulse
and respiration ; furred tongue ; wild delirium. Lips and cheeks congested and presenting a
]mrple appearance. Intense pain over inflamed portions of both lungs. Chlorides absent
from urine. Little or no expectoration. Died January loth.
Case 732 : (i. A., nge 38; native of Maryland; sailor; Ward 13, January 17th, 1875.
Had been sick four days before entering. Double Pleuro-Pneumonia. High temperature ;
rapid respiration ; great prostration; congested purple lips and cheek.^ ; delirium. Under
the use of Quinine, Dover's Powder, and Tincture of Vellow Jessamine, and together with
nutritious diet and alcoholic stiumlantii, thi^ apparently hopeless case recovered, and was
discharged February I8th.
Case 733 : J. S., age 40 ; native of England : Failor; Ward 20, January 24th, 187.'). Patient
had been aick tlx days before entrance into hospital. High fever ; great prostration ; severe paiu
in right side ; profuse expectoration of scro-purent matter. Auscultation and percussion,
revealed, in addition to pneumonic solidification of lungs, the exi<;tenceof an abscess in right
lung, resulting from the destruction of the pulmonary tissue by the pneumonic inflammation.
Died February 13th, 1875.
Posi'mortem Kxantination. — Inferior lobes and posterior portions of both lungs in a state of
rrrey hepatization. Left pleuritic cavity contained fluid, and coagulable lymph with adhe-
sions. Abscess of right lung. Liver enlarged and cirrhosed. Kidneys normal. Urine con«
taioed 00 albumen.
Case 734: R. W., age 27; native of Oerniany; clerk; Ward 30, February 11th, 1875. High
fever, rapid pulse; pneumonic sputa; dullness upon percussion and bronchial breathing,
over lower lobes of both lungs. Under the action of Quinine and Dover's Powder, and
Tiocture of Yellow Jessamine, together with alcoholic stimulants and nutritious diet, pneu-
monic inflammation arrested. This patient was suffering with secondary syphilis. Recovered,
Diicbarged February 24th.
Case 735: P. H. C, age 45 ; native of Ireland: laborer; W. 13, February 22d. Had been
•tick six days. Dullness upon percussion with bronchial breathing over upper lobes of both
luDgi. Double Pneumonia. Little or no expectoration. High fever; rapid pulse, rapid
respiration ; great congestion of capillaries of lips, cheeks and extremities. Delirium. Feb.
24th, temperature of axilla, evening, 105^ F.; 2r>th, morning, temperature, 104^.5; evening,
106°; 2Gtb, morning, temperature, 107°; violent delirium. Face and extremities present a dusky
purplish appearance. Died February 26th. Post-mortem. — Upper portions of both lungs
solidified, and passing into stage of gray hepatization.
Case 736: P. C, age 30; native of Ireland; hack driver; W. 13, February 27th. 187:j.
Had been sick 8 day.s.
Dullness upon percussion, with bronchial breathing over large tracts uf both lungs. High
fever, rapid pulse, rapid respiration, little or no expectoration ; chlorideii absent from urine.
So albumen in urine. Blue lips, and dusky, congested countenance and extremities. Feb.
28tb, temperature of axilla, morning, 103°. 5; evening, 104°. March 1st, morning 102°.5 ;
evening, 104°. Wild delirium, passing into coma. Died March 2d, 1875.
Pott-mortem. — Portions of both lungs in stage of gray hepatization. Both patients (Cases
735 and 736), entered in the last stages, and treatment appeared to exert no appreciable effectt
upon the progress of the disease.
Case 737: H. K., age 23; native of England; sailor. Entered ward 13, Feb. 10th, 187C
Plenro-Pneumonla of both lungs, and Pericarditis engrafted on Phthisis Pulmonalis. Enterea
with elevated temperature, rapid pulse, rapid respiration ; oppressed respiration, blue lips
and bands. Dullness and absence of respiratory sounds, with exception of tubular breathing
over left long) and over npper lobe of right lung: friction sound oyer region of heart; no
expectoration ; chlorides absent from urine.
Sounds of heart indistinct. The sufferings of this patient were great on account of the
pleuritic pain, oppression of breathing, and oppressed action of the heart. February I2th,
evening, temperature, 10.~>; 13th, morning, loi^'; evening, 105<); 14th, morning, 103°; even-
ing, 104°.8; 15tb, morning, 101°.4; evening, 104°; morning, pulse, 112; respiration, 31 ;
Hth, morning, pulse 122 ; respiration 35 ; temperature, 10.3°.3 : evening, 104°: 17th, morn-
injf, pulse, 120; respiration, 42; temperature, 104°; evening. 105°; IHth, morning, pulse.
110; respiration, 42 ; temperature, lo3.
Died February 18th, 1873.
Post-mortem examination revealed tubercular deposits in both lung:* : solidifiention, and
f oftening, and gray hepatization of entire left lung, and of upper lobe ol right lung: golden
colored, coagnlable lymph over surface of pleura and pericardium HrDncliial tubeo filleit
with «ero-purulent matter. Tavity in right lung.
ti
73(> Relations of Pneumonia to Malaria.
•
Ca8b 738: A. G., native of Cuba; age 23 ; Bailor. Ward 13, Feb. 4th, 1873. Pleoro-
Pneamonia of both laogs, engrafted on Phthisis Palmonalis. Entered with high feTer, rapid
paUe, rapid respiration, greai prostration, deliriam, dullness over both longs, with crepitant,
sub-crepitant, mucous, sibilant and sonorous rales. Expectoration quite profttse, and alio
purulent, and partially gelatinous, a^d rusij colored. Flatness upon percussion, most aiarked
in inferior clavicular region of both lungs. Died Feb. 16th, 1873.
Pott-mortem Examination. — Miliary tubercles scattered through both lungs. Portions of both
lungs were in a state of pneumonic inflammation and hepatization. Coagulable lymph apon
pleura.
Large cavity in superior lobe of left lung. Pneumonic inflammation conflncd chiefly toleU
long.
In this case, (738), the patient had, eight months before his death, suffered with a sodden
and profuse haemorrhage from the lungs. At this time entered the Charity Hospital, and
after remaining three weeks, was discharged in an apparently improved condition.
In the early part of January, the patient was much exposed to wet and cold, on board a
small vessel running between New Orleans and Havana. Was suddenly attacked with severe
pain in left side, difficulty of breathing, increase of cough and high fever. When the patient
entered the Charity Hospital, on the 4th of February, he was very restless, cried oat: com-
plained of intense pain in both sides; distressed, haggard expression ; high fever, rapid pnlse.
rapid respiration ; cavernous respiration in superior mammary region of left lung ; frictiua
sounds of pleoritis ; crepitant, sub-crepitant, mucous, sibilant and sonorous rales. Right Inn g
dull upon percussion, with crepitant, sub-crepitant, sibilant, sonorous and mucous rales.
The temperature exhibited marked diurnal oscillations, as manifested by the following record :
July 5th, morning, temperature, 103°; pulse, 90; respiration, 3G ; evening, 1U5^. 6tb.
morning, temperature, 101^.8; pulse, 88; respiration, 34; evening, temperature, 105°. ^.
7th, morning, temperature, 100°.6: pulse, 80; respiration, 34 ; evening, 105°.8. 8tb, morn-
ing, temperature, 101°. 4; pulse, 90 ; respiration, 35 ; evening, 105°.4. 9th, morning, tem-
perature, 102°; poise, 88; respiration, 33; evening, temperature, 106°. 10th, momiog, tern-
peratore, 101°; pulse, 88; respiration, 33 ; evening, temperature, 106.°7. lltb, morn inf, tem-
perature, 106°; pulse, 104; respiration, 42; evening, temperature, 106°.9; pulse, 140; res-
piration, 50. 12lh, morning, temperature, 104°; pulse, 130; respiration, 44; evening, tem-
perature, 105°.l ; pulse, 136 ; respiration, 50. 13th, tnorning, temperature, 10I°.3 ; pulse, 140 .
respiration, 50 ; evening, temperature, 105°.6 ; pulse, 160; respiration, 50. 14tb, morning,
temperature, 102°; pulse, 130; respiration, 44; evening, temperature, 103°; pulse, 140; res-
piration. 50. 15th, morning, temperature, 102°; pulse, 144; respiration, 42; evening, t«B*
perature, 104° ; pulse, 150 ; respiration, 44. 16th, morning, temperature, 10l°.8 ; pulse, IIJ
respiration, 42. Died Ju'y 16th, at 2 p. m. Marked decline of temperature before death.
On the night of the 10th inst, the patient was suffering such intense pain from the plenntic
inflammation, that he called for a knife, with the avowed intention of committing suicide.
This case illustrates, in a clear manner, the marked elevation of temperatnro which tLf
supervention of pneumonia and pleuritic inflammation is capable of inducing in patientj snfo
fering with phthisis pulmonalis.
As a general rule, the temperature is elevated above the normal standard in phthisic, tut
this elevation is less than that characteristic of pneumonia.
Casi 739 : P. H., age, 38; native of New Orleans : ward 13, November 23d, 1872 ; plearo-
pneumonia of both lungs, engrafted on malarial fever. Both lungs involved ; right lung entirrif
solidified; flatness on percussion, and absence of respiratory murmur over right long, a a li
superior portion of left lung ; violent delirium ; rapid, feeble pulse ; congestion of capillanei
lips and extremities purple ; no trace of chlorides in urine ; no albumen ; urine higb-coIorYd
and loaded with urea and aric acid ; sputa very small in amount and almost entirely absent
I was compelled to use opiuoi with great caution in this case, on account of the great
embarrassment of respiration and the pain caused by the pleuritic inflammatioo. Complete
solidification of the iaflaised portions of the lungs had occurred before the patient •oterri
the Charity Hospital.
Pbti^moriem JSzamnatioH .*<-*Pleara of both lungs inflamed and coated with fibrtoont effiasics
Gray hepatization of right Inng and of superior portion of left lung.
Casi 740 : J. P— , age 42 ; native of Ireland; ward 29, February, 1873 ; double poeo-
monia. Disease caused by exposure to cold, damp and wet on banks of the Mississippi. Er-
tered with great oppression and capillary congestion : lips blue ; dullness on percossioa ovrr
right lung ; tubular breathing, and absence of vesicular murmur in lower lobe of left lasr
Temperature of axilla, at time of entrance, February 14th, m., 103°. 2 F. lt>th, poise, u:
respiration, 28; temperature, morning, lu3°. 17th, pulse, 130; respiration, 22; temperature
103°. 5. 18ih, morning, pulse, 132; respiration, 22; temperature, 104° F. Died July IStb
t^ASK 741: A. McC , age 54; Scotland; laborer; entered Charity Hospital, March r^ti
1873. Plenro-pneumonia of both lungs supervening on malarial fever. Disease caused tt
exposure to wet and damp in swnuips of Mississippi river, and abus^ of alcoholic st'imalac «.
Itelations qf Pneumonia to Malaria. 731
Entered my ward in extremis: rapid, feeble polie; labored, embarrassed respiration; un-
healthy malarial hue ; cons^estion of capillaries of face and extremities; lips and eitremities
congested, and of a mottled, purple appearance; dullness and flatness upon percussion over
greater portion of both lungs; great pain during respiration, cries out with every breath;
died March 31st, fifty hours after entering the Charity Hospital.
Post-mortem examination, confirmed the diagnos s, viz: pleuro-pneumonia of both lungs.
The liver and spleen presented the characteristic alterations ot malarial fever.
Case 742:— D. M , age 40. Native of Ireland. Entered Charity Hospital, January
28tb. Pleuro-pneumonia of both lungs, caused by exposure to cold and wet in swamps of
Mississippi river. This patient entered in extremis ; complete flatness upon percussion over
entire right Inng; entire absence of respiratory murmur, and presence of tubular breathing
over position of large bronchial tubes. Lower lobe of left lung flat on percussion. Qreat
difficulty of respiration ; high fever ; rapid pulse ; capillary congestion ; surface of extremities
mottled; lips blue; veins distended with black blood.
January 28th. — Evening, temperature, 104^.6 ; pulse, 112 ; respiration, 64. 29tb, morning
temperature, 104^.5; pulse, 112; respiration, 52 ; evening, temperature, 104^8; pulse, 112;
respiration, 60. 30th, moruing, temperature, 104^.2; pulse, 120; respiration, 48 ; evening,
temperature, 105°; pulse, 120; respiration, 60. 31st, morning, temperature, 104^.5; pulse,
116; respiration, 60; evening, temperature, 104°; pulse, 128; respiration, 56. Died Febru-
ary 1st, morning.
Died seventy hours after entering the hospital, February 1st, 1873.
Pott'tnortem examination — DiagnoniM eonfirm-d: — Gray hepatization of entire right lung, with
eflTusion of yellow, golden colored lymph on pleura. Hepatization of lower lobe of left lung,
with effusion of coagulable lymph upon pleura. Liver, slate color on exterior, with pigment
granules.- Spleen enlarged and softened.
Casb 743 : C. P , age 25 ; native of England. Entered Charity Hospital, February
10tb« 1873. Pleuro-pneumonia engrafted on malarial fever and chronic dysentery. Disease
referred to exposure in swamps of Louisiana, and to cold, wet and bad diet. Patient had suffered
with malarial fever and chronic dysentery tor some time, before entering the hospital. Flat-
ness over entire left lung, with absence of respirHtory murmur, and presence of tubular
breathing over region of large bronchial tubes. No expectoration. Frequent action of
bowels, of a dysenteric nature, and attended with great pain and straining.
Post-mortem examination revealed gray hepatization of entire left lung; congestion of right
lung; slate colored liver, with pigment deposit; enlarged spleen, and congestion and ulcera-
tion of large intestines.
Casb 744: S. M. C , age 21, native of Virginia; entered Charily Hospital, February 19th,
1873. Complained of severe pain in left lung, with oppression of breathing. Auscultation
and percussion, revealed dullness upon percussion with hurried breathing over left lung, tubu-
lar breathing, and absence of respiratory murmur. Dullness and flatness most marked over
left lung. Violent delirium. It was npcessary to confine the patient in bed. Quinine, Dover's
Powders, Alcoholic Stimulants and blisters to side, produced no visible beneficial effects.
19tb, temperature of axilla, morning, 100°. 5. 20th morning, 102°.5 ; evening, 103°.5. 21st,
morning, 103°; evening, 103°. 22d morning, 102°; evening, 104°; intellect wanders. 23d
morning, 102°. 5 ; evening, 102. 24th morning, 103.5; evening, 103°.; pain in both sides, flat*
ness upon percussiun over lower lobes of both lungs. 25th morning, 103°.; evening, 103°.5.
26th morning, 104°.; evening, 105°. 5; auscultation and percussion reveals that the pneumonic
inflammation is extendingi in both lungs. 27th, morning, pulse, 128 ; respiration, 24 ; tempera-
ture, 103°.5; evening. 104°.5. 28th, moniing, temperature 105°.; pulse, 120; respiration, 24 ;
crening. pulse 140; respiration, 38 ; temperature, 104°.5. March 1st, pulse, 140 ; respiration,
ATi ; temperature, 104°.5. Died March IsC, 1873.
Pott-mnrtem, — Right lung solidified, with the exception of about one-fourth of the upper
lobe. Left lung solidified, with the exception of a small portion of the border of the upper
lobe. Portions of both lungs in a state of gray hepatization ; soft, readily broken down by
the finger, and filled with purulent matter. Liver enlarged.
In this case, the violent delirium appeared to be due to the imperfect oxidation and purifica-
tioo of the blood by the respiratory process. Throughout the active stages of the disease and
up to the fatal termination, the chlorides were absent from the urine, as well as also albumen.
This excretion whs of a deep red color, and load<id with urea, uric acid, biliary acids and the
coloring matters of the bile.
Casb 745: J. K., age 43 ; native of Ireland ; laborer. Entered Charity HospilAl, March 8th,
1973 ; high fever; delirium ; lips and hamls purple and congested ; great oppression of respi-
ration; flatness upon percussion, over entire left lung ; absence of vesicular murmur; tubular
respiration over region of large bronchial tubes ; little or no play in the lungs during respi-
ration. Dullness over lower lobe of right lung. Hreat congestion of the capillaries of the
extremities, and the veins appear to be filled with black blood. No expectoration. Bled at
Bose. Died within twenty-four hours after entering my ward, (March 9th.)
732 Relations of Pneuimnia to Malaria.
Pott'/noriem Exatainaiion revealed gray hepatization of entire left lung, effusion of coagulable
lymph on surface of pleura, solidification of lower lobe of right lung. The solidificatioo of
the left lung, and of the lower lobe of the right lung was complete.
The absence of expectoration in this and other cases of pneumonia, which occurred daring
the winter and spring of 1873, appear to be referable to the severity of the type of the disease
and to the rapidity with which large practs of the pulmonary tissue was solidified.
Casi 746: P. H., age 38. Native of New Orleans. Entered C. H., Nov. 23d, 1872. Hai
been exposed to malaria, wet and cold, whilst working in swamps of Mississippi River, and
has suffered with Malarial Fever. Both lungs involved in the pneumonic inflammation. Right
lung solidified. Flatness upon percussion and absence of respiratory murmur, over right
lung and superior portion of left lung. Violent delirium; rapid, feeble pulse; congestion of
capillaries of face and extremities which present a purple, mottled appearance. Great pain
and difficulty in respiration. Diagnosis: pleuro-pneuuionia of both lungs, engrafted on Mala-
rial Fever. No trace of chlorine or albumen in urine. Urine scant, high colored and con-
centrated ; loaded with urea, uric acid and bile.
When Nitric Acid is added to the urine, a heavy deposit of uric acid falls, but heat dissolves
this deposit and renders the urine clear. November 23d, morning, pulse 102 ; temperature
104^.4 F.; evening, pulse 144; temperature 104^.4; 24th, morning, pulse 120; temperature
103°; evening, temperature 105®. 3; 25lh, morning, temperature 103°; evening, 105°.6; 26th,
morning, pulse 110; temperature 104°; evening, pulse 128; temperature 105°.3; 27th. morn>
ing, pulse 126; respiration 18: temperature 104°. 5; evening, pulse 12C ; respiration 24
temperature 103°.5; 28th, morning, pulse 114; respiration 24 ; temperature 103°; evening,
pulse 108; respiration 30; temperature 104*^.3; 21Ub, morning, pulse 114; respiration (» > :
temperature 102°.5; evening, pulse 132; respiration Od ; temperature 101°. Died November
30th, 1872 ; sputa very scant, almost entirely absent.
Post-mortem, — Pleura of both lungs coated with yellow plastic lymph. (> ray hepatization
of right lung and superior portioa of left lung. Liver and spleen presented evidences of ttie
preceding action of the malarial poison.
Gabs 747 : T. S., age 20, native of Boston, Mass.; entered C. II. 13th February, with Pneu-
monia and Dysentery. Dullness upon percussion of left lung ; discharges from bowels mucun
and blood. Tnder Quinine, Dover's Powder and Sub. Nit. of Bismuth, the patient reco^erc J
The temperature during the active stages of the Pneumonia, ranged from 102° to 101°. 8 F.
Case 748: Augustus J., age 34, native of Sweden. Admitted January 20th, 1^73. Wi-
seized with pain in side and difficulty of breatliiuij^^ and fever, two days before entrance int.t
hospital. Had suffered with Malarial Fever. The following observations were made opoo
the pulse and temperature: January 2 2d, morning, pulse 108; temperature 104°.6; eveoin.:.
pulse 104; temperature 103°.9 ; 23d, morning, pul.>«e 81: temperature 100°. 5; evening, po.».
108; temperature 104°. 2; 24th, morning, pulse 100; temperature 09°; evening, poise 1*>4 -
temperature 104°; 25th, morning, pulse 80 ; temperature 1)0° ; evening, pulse I04 ; tempera*
ture 104° ; 26th, morning, pulse 08 ; temperature 101 : evening, pulse 100; temperatnre 1«>2' .
27th, morning, pulse 08; temperature 102°; evening, pulse 82; temperature 101°; 2Mh.
morning, pulse 80; temperature 10l°.6; evening, pulse 88; temperature 10:i°; 2ath,momiB^.
pulse 72 ; temperature 101°; evening, pulse HO; temperature 102°; 30th. morning, pulse T(>
temperature 90°. 3 ; evening, pulse 76 ; temperatnre 101°. 8. Daily record^ of the temperatnre
were made in this case, up to the date of his discharge, March 3(1, I>^72. Uecovery atlnbot**-]
chiefly to Quinine, Dover's Powder and nutritious diet.
Cask 749: J. H., age 45, native of Canada. Entered ward 13, Jauuary 9th, 1873. Hai
been suffering with symptoms of Phthisis Pulnionalis, vi^ : cough, expectoration and fe^er
for some time before the present attack. After exposure to wet and cold on the Miasi»>tp;ki
River, was seized with pain in the side, oppression of breathing and high fever. Patient
determined to come South to New Orleans, on account of his health (cough, fever and ntj^h:
sweats). Whilst passing on steamboat, from Cairo to Memphis, was exposed to cold and vet.
and on the 26th of December, 1872, was seized with pain in right side, attended with iocesvAst
cough, profuse, purulent and pneumonic expectoration, great oppression of breathing, rap: ;
pulse and elevated temperature.
January 13th, 1873. Mucous, sonorous, crepitant and sub-crepitant rules heard over bv:t
lungs. Expectoration profuse and purulent. Morning, temperature 100°; evening, lOC*^'.
January 14th. Dullness upon percussion over upper portioa of right lung; greatest Abo««
fifth rib, in which position the dullness is more correctly termed absolute flatoesi. Left !■:•;
more resonant, and mucous and sonorous rules heard loudest in infra- clavicular region N>'
albumen in urine, chlorides also absent.
Trmperattire. — .Morning Oi»°, evening 103; I'lth, morning 101, evening 105 ; ICth, momtr-
99, evening 106; 17th, morning 100. evening 105.5 ; 18th, morning 99, evening lOt^ : I*^*
morning 100, evening 105.8 ; 20th, morning 99.4, evening 106.1 ; 2Ut, morniog 99, even • .•
103 ; 22d, morning 99.4, evening 105 ; 23d, morning 102, evening 107.8 ; 24th, moreiBg^ !«•* 4
evening 105; 25th, morning loi). evening 105; 26lh, morning 0^.85 evening 10T.3 : ?*:•
Reiations of Pneumonia to Malaria, 733
morning 97.5, e?emog 107.2; 28tb, morning 100, ereniog 107.3; 2Utb, morning 99.5 F.
Swelling of feet observed January 21st. January 2Gtb, bad severe cbill in the afternoon,
lasting three hours, attended with great elevation of temperature in the stage of reaction, and
with profuse sweating. Another chill, afternoon of 27th. Large dose of Quinine, in all about
40 grains, were administered each day, on the 27tb and 28tb. No beneficial effects whatever
were observed, and the temperature reached 107, in the evening of both days. Died January
29th, 6 p. M. Temperature fell before death.
This case, 749, furnishes another striking illustration of the marked elev.ition of tempera-
ture induced by the supervention of Pneumonia in Phthisis Pulmonalis.
Thus, the axillary temperature reached, in the evening of the 23d of January, nearly 108°
F., or, more exactly, 107°. 8 F. It is probable that the temperature of the central organs was
at least 110° F. I have already recorded two cases of Pneumonia, uncomplicated by Phthisis,
iu which the high degree of 109° F. was manifested in the axilla. Both these cases recov-
ered, thus furnishing evidence that such high degrees of temperature are not necessarily fatal
in Pneumonia.
The chills and profuse sweats which characterized the case (749), appeared to be due to the
absorption of the products of inflammation.
Sudden elevations of temperature in Phthisis may also be excited by intiammation of the
brain and its meninges, as in the following case.
Case 750. — J. M., age 15, native of Austria. Entered ward 15, Charity Hospital, Dec. 21,
1872. Pale, anxmic, emaciated ; feeble, irritable pulse ; flatness in infra-clavicular region of
both lungs. Cavity with cavernous respiration in right lung. Marked daily oscillations of
temperature. January 3d, pulse feeble, copious discharges from bowels. It was necessary
to control the bowels by astringents and opiates. On the 21st and 22d of January this patient
suffered with violent pain iu the head and delirium. During the delirium, although the
patient is able to speak only a few words of " broken " English, he repeats accurately my
prescriptions and directions to the nurse, and remarks to the patients and medical students.
On the 20th, the day preceding the'cercbral disturbance, the maximum temperature was
I02°4. F., whilst on the 21st, during the delirium, the thermometer in the aiilla indicated
I0(>°.2 F., or an abrupt rise of 3°.8. Under the free use of alcoholic stimulants, in combina-
tion with milk and nutritions diet, the violent delirium subsided, and on the 25th the maxi-
uium axillary temperature was 103°.2.
On the 2d of February the patient again complained of paiu in the head, the pulse became
fuller and stronger, the patient became delirious, and the increase of temperature was marked,
and the thermometer in the axilla reached 105°. 4. With the subsidence and disappearance
uf the delirium, the temperature again declined.
The pain in the head and delirium returned at intervals, Feb. 7lh, 8th, 9th, 10th, 14th,
I5tb, 16:h, 22d, 2:)d, and March 8th, and at such times the evening temperature ran high.
The following observations will illustrate the sudden oscillations of temperature in this
case :
January 1 1th. Tanprraturf, — Morning 102, evening 103 ; 12th, morning 101.5, evening 103.2 ;
L'Jth, morning 102, evening lO.'i.G; 14th, morning 101.8, evening 103; 15tb, morning 101.8,
evening 103.5; 10th, morning 101.5, evening 104 ; 17th, morning 101.5, evening 103 ; I8th,
morning 102, evening 103; 19th, morning 100.2, evening 102; 20th, morning 100.2, evening
102.5; 2Ist, morning 100.3, evening 106.2; 22d, morning 99, evening 104.2; 23d, morning
101, evening 104; 24th, morning I OO.C, evening 103.8; 25th, morning 100.8, evening 103.1 ;
2(Ub, morning 101. evening 103,1; 27th, morning 101, evening 103.5; 28tb, morning 102,
evening 102.G; 29th, morning 100, evening 103.0; 30th, morning 99.8, evening 103; 31st,
morning 100.2, evening 103. February Ist, morning 105.5, evening 102; 2d, morning 100,
crening 105.4: 3d, morning 99.2, evening 103; 4th, morning 99.1, evening 104; 5th, morning
100, evening 103 ; Cth, morning 101.2, evening 102.5; 7th, morning 101, evening 104; 8th,
morning 101, evening 104. C ; 9lh, morning 101.5, evening 102; 10th, morning 101, evening
104.6; 11th, morning 101.2, evening 103.8; 12lh, morning 100, evening 103.6 ; 14th, morning
loo, evening 104.5; 10th, morning 102.2, evening, 105; 16th, morning 101.2, evening 104.8;
17th, morning 100, evening 103 ; 2l8t, morning 101.6, evening 102 ; 22d, morning 101, evening
lo5; 23d, morning 101, exening 104.6; 24th, morning 101, evening 103.8; 25th, morning
103, evening; 104.8; 26th, morning 100, evening 103.8. March 2d, morning 102.5, evening
103.8; 3d. morning 102.5, evening 103.7; 4th, morning 102.5, evening 104.6; 5th, morning
102.8, evening 104.8 ; 6th, morning 102.2, evening 103.5 ; 7th, morning 101, evening 104 ; 8th,
morning 90, evening 105 ; 9th, morning 102, evening 102.8 ; 10th, morning 101, evening 103.4
1 1 tb, morning 101, evening 103.8.
Notwithstanding the gravity of the symptoms in this case, and the elevated temperature,
the strength gradually improved and the weight increased, under the continuous administra-
tion of the Hypophosphites of Lime, Iron, Soda and Potasjia, Cod-Liver Oil^ Alcoholic
Stimulants and nutritious diet.
Ca«r T.M. — N. W., age34; native of Denmark; sailor, clerk. Admitted iato the Charity
734 Relations of Pneumonia to Malaria.
Hospital JftDuary 13th, 1873. ISuffered with coagh attended with (trtTf December, 1871. At
this time suffered with hemoptysis, which induced great prostration. Has had no recurrence
of the haemoptysis, bat has been under the care of physicians, and has pnrsaed his ordinary
avocations up to the time of his entrance into the Charity Hospital, February 1st. Patient
emaciated, cheeks flush ; eyes bright; skin hot; pulse rapid ; suffers with harsh, distressing
cough. Voice greatly altered from its natural tone ; harsh and sepulchral. Patient sajt that
he has never suffered with syphilis. Marked depression in super-clavicular, and also ia iqfra-
clavicular regions, over apices of both lungs. Dullness not amounting to flatness, over apices
of both lungs ; more marked over the left ; puerile respiration over middle and lower portions
of both lungs. Rude broncho-vesicular respiration over portion of upper lobe of right long.
Sub-crepitant rales over inferior border of left scapula. Decubitus preferable on left side.
This then is a case of Phthisis Pulmonalis, with circumscribed, interstitial Pneamonia. This
patient was attacked at various times with severe and incessant cough, high fever, attended
with increase in the purulent mucus. At such times the sputa became much more teoAcioai.
These exacerbations, were always attended with increased temperature. The following obser-
vations will illustrate the daily oscillations of temperature :
January 18th, morning 102, evening 104.4; 19th, morning 103, evening 105 ; 20tb, morDlog
102, evening 105; 21st, morning 103.2, evening 102; 22d, morning 101, evening 102 ; 23d
morning 102, evening 104; 24th, morning 101.5, evening 105; 25th, morning 102.2, evening
105; 2Gth, morning 101.2, evening 103 6; 27th, morning 102, evening 103.6; 28th, morning
102, evening 104; 29th, morning 101.4, evening 104.4; 30th, morning 100, erening 103.
The observations on the temperature of this patient were continued for near 100 days, and
during this time the maximum morning temperature was 102, the minimum 98.5; the maxi-
mum evening temperature 105 F., and the minimum 101.5 F.
I attributed the sudden elevations of temperature in this case to pneumonic inflammatloo
of circumscribed portions of the lungs.
Under the continuous use of Cod-liver Oil, Hypophosphites, Alcoholic Stimulants aad oiitri-
tious diet, the improvement of this patient was slow, but marked, and upon the 1st of March,
he was stronger and in fuller flesh than upon his entrance.
Case 752 : J. A., age 26, native of New Orleans ; barber. Admitted, Charity Hospiul,
December I9th, 1872. Tubercular deposits and cavity in right lung; Phthisis; iaereascd
respiration ; cavernous respiration ; bronchophony ; crepitant and mucous rales.
The temperature was recorded daily during a period of 30 days. The maxima m morning
temperature 102.6, minimum 100 ; maximum evening temperature 104.5, minimum 99. As a
general rule, the temperature in this case of Phthisis did not rise above 102.6, during the 24
hours. This patient improved under the treatment with Cod-Liver Oil and hypophotpbites.
and bitter tonics, and with the increase of flesh there was also a diminution of temperatare,
and the variations between the morning and evening temperatures were less marked.
Case 753 : A. K., age 32 ; native of Sweden. Entered Charity Hospital, September 21st,
1872. Says that his father died with Syphilis. Had suffered with cough and fever several
months before entering the hospital. Dullness on percussion, and tabular respiration, and
mucous rales, in sub-scapular region of both lungs. Profuse purulent expectoration.
In this case during a period of 120 days in which observations were made apon the temper-
ature, the maximum morning axillary temperature, was 101, minimum 100; maximam evening
temperature 102.8, minimum 101. The mean evening temperature was 102.2, and the mean
morning temperature 100.5.
The pulse in the morning ranged from 72 to 82 ; in the evening from 81 to 92 ; respiration,
morning 30 to 36, evening 36 to 40.
Under the continuous use of Cod-Liver Oil, Syrup of Hypophosphites, and Tincture of
Cinchona, with nutritious diet, this patient slowly improved, and was discharged at his own
request, February 3d, 1873, a favorable opportunity having offered for his retnrn to his native
country.
Case 754: J. W., age 32; native of Ireland. Entered Charity Hospital, September tJ.
1872. Dullness on percussion, with tubular breathing, bronchophony and mncoas ralc«, la
infra-cIavicular region of both lungs. The existence of Phthisis also manifested by the per-
sistent elevation of temperature. The morning axillary temperature ranged between 99 aai
100.2; and the evening temperature between 101.5 and 103, during a period of 20 days.
Improved under treatment.
Case 755: N. B., age 33; native of Ireland ; car driver. Entered ward 13, December lit,
1873. Has led a life of exposure, and had htemorrhage twice from his lungs. Donn^ the
past three months has suffered with cough and fever, and has lost considerable flesh. :^ri
that both his parents lived to old age, and died of acute diseases. Apex beat of heart la
normal position, but the first sound is accompanied by a murmur, propagated along the co«rse
of the aorta. The pulsations of the arch of the aortu are distinctly visible in the supra-stcraa:
region, which is much fuller than normal. When the hand is placed on the tumor la the
notch of the sternum, the enlarged dilated arch of the aorta can he distinctly lelt, and astroBg
Relations of Pneumonia to Malaria, 735
impalte if commanicaied to the fiogerSi synchronous with the contraction of the ventricles.
Patient suffers with night sweats, and expectorates purulent matter. Infra-claricular regions
of both lungs, flat and dull upon percussion, with tubular breathing and mucous rales. Diag«
nosis ; dilatation of arch of aorta and phthisis pulmonalis.
During a period of 90 dajrs in which observations were made on the temperature, the
morning axillary temperature ranged between 99.5 and .101 ; and the evening temperature
between 101 and 103 F. This patient continued under treatment 18 months, with slight
changes. There was no apparent increase in the size of the aortic dilatation or aneurism ;
which result appeared to be due mainly to the state of almost absolute rest.
God-liver Oil, Hypophosphates, Tincture of Cinchona, gentle expectorants and sedatives,
with nutritious diet, appeared to moderate the rapidity of the march of the disease, but the
patient was gradually reduced in flesh and strength ; an exhausting, purulent expectoration,
and night sweats, with harrassing cough, continued throughout the disease. Uncontrollable
diarrhoea appeared during the last forty days of existence, and hastened the final issue.
Case 7&6 : T. C, age 37 ; native of Indiana. Entered ward 13, December 2d, 1873. Dis-
ease, Phthisis, complicated with Hydro-Pneumo-Thoraz of left lung. The Pneumo-Thorax
appeared to have been the result of the softening and ulceration of a tuberculous mass upon
the surface of the lungs^ As far as could be estimated, by careful auscultation, percussion
and succussion, about two quarts of liquid had been effused into the left pleural cavity. The
heart was displaced and pushed over to the right of the central line of the sternum. Suc-
cussion gave a metalic, splashing sound. The fluid extended up to the lower border of the
«ixth rib, when the patient was in the standing or sitting position. Below the border of the
sixth rib there was entire absence of all respiratory and vocal rounds ; above the sixth rib
there was marked amphoric ^respiration and metallic tinkling. There was tympanitic reso-
nance, on percussion, from the summit of the affected side to the level of the fluid, and flat-
ness below, the relation of the flatness and tympanitic resonance changing with the change in
the position of the patient.
In this interesting case daring 14 days in which records of the temperature were kept, the
morning temperature ranged from 98.5 to 100^.8 ; evening temperature from 101 to 102^.5.
Before death there was a marked decline of temperature.
Case 757 : Wm. G., age 22 ; W. 13, Dec. 29th, 1872. Phthisis Pulmonalis. In this case,
the morning temperature ranged from 98 to 101^.5, and the evening temperature from 98.5 to
103° P., during a period of thirty days.
Case 758 : J. E. D., native of New York ; gardener; age 25 ; ward 27. Has been suffering
with cough, fever and night sweats for four months. Has had haemorrhage from the lungs.
Disease, Phthisis Pulmonalis. Entered Charity Hospital, October 6th, 1872. This patient has
led a wild, reckless life, and has also suffered with syphilis. In this case, the temperature
varied within wide limits, and such variations appeared to be connected with inflammatory
action in circumscribed portions of the lungs.
I abstract the following observations from the record which I kept of the changes of the
pnlse, respiration and temperature, up to the date of the discharge of this patient, who felt
himself sufficiently improved to attempt a journey to his relatives in Xew York. From let-
ters received from this patient, I learned that he bad reached home in safety, and continued
to improve.
October 12th, morning, pulse 110, respiration 26, temperature 101.^5; evening, pulse 118,
respiration 28, temperature 102^. 13th, morning, pulse 120, respiration 28, temperature
100.^6; evening, pulse 126, respiration 28, temperature lOl.e?. 14th, morning, pulse 112.
respiration 30. temperature 100.^5 ; evening, pulse 102, respiration 30, temperature 100.^8.
15th, morning, pulse 106, respiration 37, temperature 95.^7; evening^ pulse 130, respiration
.14, temperature 102.^6. lOtb, morning, pulse 118, respiration 40, temperature 101.^5; even-
ing, pulse 114, respiration 44, temperature 103®. 17tb, morning, pulse 120, respiration 36,
temperature 101.^2 ; evening, pulse 120, respiration 40, temperature 105.^3. 18th, pulse 120,
respiratioo 38, temperature 102.o2. 20th, evening, pulse 136, respiration 38. temperature
105'*1. 33d, morning, pulse 120, respiration 4i, temper itnre 100.^1; evening, temperature
103.<>8.
Cabs Y50 r A. Q. Age 19. Entered ward 13, January. 1873. From the history, it was
evident that this patient had suffered with phthisis pulmonalis for atveral months before en-
tering the Charity Hospital, and that from exposure to wet and cold the right lung had been
affected with interstitial pneumonia. The pneumonic symptoni:$ continued from the 21st to
the 29th of January, and the maximum axillary temperature was I04o.8 F. On the 19th of
February, symptoms of circumscribed interstitial pneumonia again appcarcMl, nod the maxi-
mum temperature was reached on the 22d, when the thermometer in the axilla reached 103^.8.
The following extracts from the record, extending over sixty days, will illustnite these
changes in the temperature of phthisis as influenced by the pnemonic intlammation :
January 22d; morning, temperature — decreet, 104.8, evening KjO.D: 23d, morning 100.5, even-
ing 104.2; 24th, moroing 99, evening 104 : 2.^th, morning 99, evening 104 : 20th, morning 101
73C Relations of Pneumonia to Malaria,
•vtDtuglOd; 2Tlb, moroing 102, ereniog 105: 28th, mornijig 101.3, erening lu3.i*; :vtli
morning 101, evening 102 : 30th, morning 99.7, erening 101.8 ; 31st, morning 100.2, eTeuns
lOl; Febntarj Ist, morning loo, evening 101 ; 2d, morning 99.5, evening 100: 3d, moninz
99.8, evening 102.3 ; 4tb, morning 100.2, evening 101.8; 5th, morning 99, evening lol.e
Oth, morning 99.9, evening 101.8 ; 7th, morning 99, evening 100.5 ; 8th, morning 99.^, evening
102; 9tb, morning 99.7, evening 100.5 : lOth, morning 99.9, evening loo.3 ; IJth, mornin;
98.5, evening 100.3; 14th, morning 99.4, evening 100.4; 15tb, morning 99.2, evening l«>l.j
ItUb, morning 99.5, evening 100 ; lith, morning 99.5, evening 101.7 ; 18th morning 9i«.8, err.
ning 101.5; 19th, morning 100, evening 102.8; 20th, morning 101.2, evening 103; 21tt, more.
ing 101.2, evening 103; 22d, morning 101, evening 103.8 ; 23d, morning ]0».5, evening 102.5
The temperature remained for a number of dajs oscillating between 99° and 102^. There
frns no retnm of the pneumonic inflammation, and the patient improved under the a«ua.
treatment with cod-liver oil and tonicg, and was finally discharged at bis own request.
Casi 760: J. C. K . .\ge 24. Entered ward 13, Febroarj- 4th, 1873, with pneamooia.
of lower lobe of right lung. The temperature ranged ft-om 104.8 to 105.4, until the Mb.
when there was a decided improvement in all the symptoms. The temperature oscillate-i
between 98.8 and 103. until the 19tb, when there was evidence of a fresh accession of pneo-
roonic inflammation involving the middle lobe. The temperature reached the highest potci
on the 22d, 105.8, and tt^en descended rapidlj and continued oscillating between loo and Wi,
uutil convalesence was folly established. The following observations extracted from the
record of thirty days, will illustrate the effects upon the temperature of the pneumonic
inflammation :
February 4th, evening; temperature — decreet, 104.9; 5th, morning 103, evening 105; 7iL.
morning 102, evening 104.9; 8tb, morning 101, evening 101.5; 9th, morning lol, evcoinjr
101.5 ; lOth, morning 101, evening 103.2; lltb, morning 100.8, evening 102.6; 12th, momio;
100, evening 101.2 ; 13th, morning 100, evening 102; 14th, morning 100.4, evening 10i.<»
15th, evening 100.8; 16th, evening 100.4 ; 17th, evening 101.5; 18th, evening 9^.8 ; IStli.
morning 99.5, evening 103 ; 20th, morning 99.5, evening 104.3 ; 21st, morning lo5, evenloi:
104.3; 22d, evening 105.8; 23d, morning 102, evening 102.1; 24th, morning 101, erening lol.3
25th, morning 99.8. evening 102.9; 2Gth, morning 99, evening 101.5; 27th. moroing IC «
evening 99.1 ; 28tb, morning 99.5.
The temperature maintained the normal standard after the 28th, and there was no return
of the pneumonic inflammation, and the patient was discharged as soon as his strength wai
sufficient for active worlc.
Gasb 761 : J. J., age 21. During convalescence from yellow fever, this patient was attackei
with pleuritis of the right lung, November 4th, 1873. The highest point of temperature was
reached on the 6th and 7th, when the thermometer stood at 103.5. After the subsidence of
the active inflammation, and after some efl'usion had taken place, the temperature for a perloc
of seven days oscillated between 98.5 and 101.5.
Casi 762; A. W., age 21. Entered Chanty Hospital, November 1st, 1873. Pleuro-Pneb-
monia of left lung. The highest point reached by the temperature in this case was 1<V|, an:
for a period of sixteen days, the temperature oscillated between 99.8 and 104 ; the pulse rangr--:
from 96 to 130, and the respiration from 28 to 58.
On the 13th day, there was a marked depression of temperature, and chlorine re>appcare:
in the urine. Recovery in this case was complete, and without any accumulation of liquid *z
the diseased pleuritic cavity.
Case 763: J. \V., age 35; native of Ireland. Entered Charily Hospital, December Ir.
1872. Has been exposed to cold and wet ; was seized with cough, chill, pain in left side, acj
high fever. December Isi, left lung dull upou percussion; crepitant and sub-orepitaDt ra*'ft
beard over left lung. Respiratory murmur diminished, and tubular breathing increase.
Expectorates rusty colored sputa ; chlorides entirely absent from the urine. The bowels were
opened with 10 grains of Calomel, combined with 5 grains of Quinine. The action of ib.«
purgative, was followed by the mixture of Quinine and Dover's Powders, Turpentine StQp«-«
were applied ever left lung. The strength of the patient was sustained with nntritioga d:e*
Tnder this treatment recovery was speedy and complete. The following observationi w
illustrate the changes of temperature.
December Ist, morning, pulse 92. respiration :>0, temperature 100.5; evening, pulse 1.4
respiration 30, temperature 105.2. 2d, morning, pulse 108, respiration 24, temperature l<^\
evening, pulse 150, respiration 30 tcmperjiture 105.3. 3d, morning, pulse 120, respiratioo Z*
temperature 104; evening, pulse 120, respiration 24, temperature 104.5. 4th, morning, poU*
110, respiration 24, temperature l<*:r2: evening, pulse 112, respiration 24, temperatorc I >•»
5th, morning, pulse 104, rcspirntion IH, temperature 101 ; evening, pulse 116, respiraiioa **
temperature 102.8. Gth, mornin;^', pulse SI), respiration 18, temperature 99.8; evening, pu's*
92, respiration 18, temperature 100.2. 7th, morning, pulse 80, respiration 18, temperatcr
97 ; evening, pulse 84, respiration 18, temperature 97.5. 8th, morning, pulse 38. respirmi.er
12, temperature 97.5 ; evening, pulso Tf^, respiration 1«, temperature 97 2. 9ih. m*»ra'T j
Relations of Pneumonia to Malaria. 737
pulse 80, respiration 18, temperature OY.5 ; eTcning, pulse TO, rc8piration 18, temperature
1>7.5.
Cask 764 : C. P., age 25 ; native of England. Entered February lOtb, died February 15th,
1873. Disease, Pleuro-Pneumonia, engrafted on malarial fever, and chronic dysentery. Dis-
ease appears to have been caused by exposure in swamps of Louisiana, cold, wet, bad diet
and impure water. The patient had suffered with malarial fever and chronic dysentery for
some time before entering the hospital. Flatness over entire left lung, with absence of respi-
ratory murmur, with tubular breathing over region of large bronchial tubes. Xo expectora-
tion. Bowels *' running off; " discharges dysenteric, and attended with great pain. The
temperature remained elevated, with but slight oscillations during the entire progress of the
disease, ranging from 104.8 to 10G.2 degrees.
The following observations were recorded : February 1 2th, morning, pulse 108, respiration
44, temperature 105.5; evening, pulse 120, respiration 46, temperature 106.2. 13th, morn-
in?t pulse 110, respiration 44, temperature 105.6; evening, pulse 120, respiration 46, tempera-
ture 105.5. 14th, morning, pulse 110, respiration 44, temperature 105.5 ; evening, pulse 120,
respiration 46, temperature 106. 15th, morning, pulse 120, respiration 44, temperature 104.7;
'evening, pulse 110, respiration 48, temperature 105.
At the time of death, on the evening of the 15th, the temperature indicated active chemical
change, and reached 105 degrees F.
Death occurred on the 7th day after the supervention of the Pneumonia.
Bowels moved continuously throughout the disease. Pulse rapid; cheeks greatly con-
gested. As the disease progressed, the lips became blue.
Autopwy 16Aour« after death. — >Heart normal. Lower lobe of loft lung completely solidified,
and in a state of gray hepatization. During life there had been dullness and absence of res-
piratory murmur over this portion of the lung, bronchophony and tubular breathing. Upper
lobe somewhat congested, but collapsed. Exudation of coagulable lymph on pleuritic sur-
face of lower lobe of left lung. Right lung congested, and apparently in the first stage of
pneumonic inflammation. Liver cirrhosed, enlarged, slate colored on surface and bronze
color within ; lobnli distinct. Spleen enlarged to about four times the normal size, and soft-
ened. Ileum, colon and rectum, (mucous membrane) congested, Some ulcers of mucous
membrane in colon. Peyers glands distinct, but without any special deposit.
Cask 765 : T. McD., age 28 ; native of Ireland. Entered Charity Hospital, November 12th,
1872. Pleuro-Pneumonia of right lung Intense pain in right side; rusty colored sputa.
lias been sick for several days before entering the hospital. November 13tb, morning, pulse
110, respiration 45, temperature 103; evening, pulse 130, respiration 36, temperatue 104.6.
I4tb, morning, pulse 106, respiration 30, temperature 103 ; evening, pulse 120, respiration 27,
temperature 105. l.'>th, morning, pul.se lou, respiration 30, temperature 101.8 ; evening, pulse
100, respiration 23, temperature lOO. IGth, morning, pulse 90, respiration 21, temperature
08.4; evening, pulse 83, respiration 22, temperature DD.
This patient continued to improve, and was discharged. At my first visit. I placed this
patient upon 6j grains of the mixture of equal parts of Quinine and Dover's Powders, every
four hours, and also gave Tincture of (/inchona and alcoholic stimulants. I'ndcr this treat-
ment the temperature rapidly fell, and the respiration became slower.
Case 766: H. 0*R., age 4i) ; native of Ireland. Admitted into Charity Hospital, February
Mh, 1875. Was seized on the 28th of January, with some pain in the left side. In the three
following days the pain extended to both side.s of the thorax. February 5th, hurried respi-
ration, rapid pulse, elevated temperature. Lower lobes of both lungs solidified, crepitant
rales, and respiration over lower portions of middle lobes exaggerated ; vesicnlar murmur over
upper lobes of both luugs. The patient is of great size, being 6.} feet in height, and with
broad chest, and large limbs. Ttter prostration of strength ; rusty colored sputa.
February 5th, morning, pulse 124, respiration 40, temperature 10L6: evening, pulse 128,
respiration 48, temperature 105.4. 6th, morning, pulse 122, respiration 44, temperature 103.4.
7tb, noroing, pulse 124, respiration 16, temperature 103.6. 8th, morning, pulse 120, respira-
tion 44, temperature 102.2; evening. piiLse llo, respiration 36, temperature 102. 9th, pulse
too, respiration 36, temperature 98.5. 10th, morning, pulse :»6, respiration 30, temperature
'jO ; evening, pulse 88, respiration 38, temperature loo. Ilth, pulse 84, respiration 32, tem-
perature 99.5; evening, pulse 88, respiration 36, temperature 99. 12th, pulse 88, respiration
28, temperature 99.5 ; evening, pulse h2, respiration 28, temperature 98.5.
This patient was treated with ijuinine, Dover's Powder and Tincture ftf Vellow Jessamine.
The pneumonic inflammation was arrested in both lungs. The temperature doseonded, and
the patient was discharged at his own request, at the eud of two weeks.
The prcccdinu observations not only illustrate the inethoi of* trviutui Mit and the gen-
eral characters of the ca.ses of Pneumonia in my wardH in the Charity Hospital, but
ihoy alw) show thut the olcvatcd tomperatur*^ CffJYer) charactcrihti<- oC the a.ctivc 8la»|re
Relations of Pneumonia to Kalaria,
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Helations of Pneumonia to Malaria.
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740 Relations of Pnenmonia to Malaria.
of Poeumonia, is coincident with and accompanies the progress of the local inflamma-
tion, and subsides when this is arrested. The length of the febrile excitement will
depend upon, not merely the extent of the pneumonic inflammation, but also upon the
character of the changes through which the altered lung tissue passes. In those cases
in which the cfl'used fibrinous efl'usion in and around the air cells is absorbed and
developed into dense tissue, the fall of temperature is rapid and comparatively perma-
nent. In those cases, however, in which the inflamed tissues undergo degeneration or
disintegration, and abscesses of the lungs, with profuse expectoration of purulent mat-
ter occur, the temperature may remain at an elevated degree for indefinite periods of
time.
When Pneumonia supervenes upon Phthisis, the elevation of temperature is rapid
and fully as marked as that which occurs in uncomplicated cases ; it appears, however
as far as my observations extend, that in such cases, the daily oscillations are greater,
the morning temperatures being as a general rule, lower than in uncomplicated cases.
When the pneumonic inflammation subsides, the temperature assumes the course char-
acteristic of Phthisis.
I have drawn up the preceding table, with the design of determining, as far as possi-
ble, the relative value of the dificrent modes which have been employed in the treat-
ment of Pneumonia.
The important fact illustrated by this table is, that the mortality from Pueuiuonia, in
a large number of Confederate hospitals (those entered upon the table were selected
without any reference to the character of the statistics), was far greater than the mor-
tality in this disease under diflferent modes of treatment in European hospitals.
The mortality in these Confederate hospitals has been twice as great as that
under Tartar Emetic in large doses, and about four times as great as under tht*
Dietetic System, in which the powers of nature are simply supported, and drugs aban-
doned. These facts are surely sufficient to excite an earnest and diligent inquiry into
the relative merits of the different modes of treating Pneumonia, now in use by Southern
physicians.
It will be observed, that Dr. S. Ames, of Montgomery, Alabama, treated 68 cases of
Pneumonia during a period of five years, 1849-183i-J, inclusive, with only two deaths,
or a mortality of 2.7 per cent., or one death in thirtj'-four cases.
It remains that we should examine the method of treatment employed by this accu-
rate and learned physician, which yielded such favorable results, in a highly malarious
region.
The paper of Dr. Ames was published in the New Orleans Medical and Surgical
Journal, January, 1854, pp. 417-441. For many years certain dcfocta in the treatment
of Pneumonia, by means chiefly of mercury, emetic tartar and blood-letting, had attracted
the attention of Dr. Ames ; and the dissections which he then made, showed that some
of his patients dying between the sixth and tenth days, had a smaller aggrogate of
disease of the lungs than others who recovered had manifested, at any time in the attack,
by physical signs. In connection with this fact, two things were noticed by Dr. Ames :
First, that the fatal cases, having less disease of the lungs, were attended with oertain
complications and a new set of symptoms, w^hich seomed very materially to inflnenoe
the progress and result of the attack ; and second^ that these complications had a certain
relation to the treatment. The complications were an ileo-oolitis, with its attendant
symptoms j a dry and red tongue, tympanitic abdomen, and diarrhoeic or dysenteric
stools ; sometimes succeeded shortly after its advent, sometimes accompanied from the
beginning by an affection of the liver and brain, giving rise to jaundice, delirium and
coma. The relation of these conditions of disease to the treatment, was evinced bv
several circumstances. It was observed that those cases in which the treatment wx«
begun early resulted less favorably, as a general rule, other things being nearij eqnal.
than those in which the treatment was begun later, and consequently was less proCiacCed ;
that in the former the complications were more common, and when not fata], the attack
was more obstinate, and followed by a slower convalescence ; and lastly, it was obsenrr*]
Relations of Pneumonia to Malaria. 741
that serious affections of the gastro-intestiDal macous membrane never occurred in the
beginning of an attack, nor indeed at any time in the progress of it, before any treat-
ment was begun.
Thus, the facts seemed very obviously to lead to the inference that these complications
were produced by the deleterious agency of the remedies, or some one of them employed
in the treatment. At the same time the nature of these new conditions of disease, in
connection with the well-known toxicological properties of the medicines, while it served
to confirm the former inference, pointed to the mercury and antimony as the only agents
concerned in producing them. While either mercury or antimony are capable of super-
inducing these forms of disease when administered in Pneumonia, the accidents arising
from the one are less frequent, and somewhat different from those arising from the other ;
the latter, however, being equally formidable when they do occur. An ileitis or gastro-
enteritis is most common, and is the usual result of poisoning by tartar emetic. Mer-
cury on the other hand, may induce an inflammatory state of the intestinal mucous
membrane, less frequently, if ever, involving that of the stomach, and more frequently
that of the larger bowels, and occassionally, it may about the same time, the liver
and brain. When the two medicines are given together, the resulting complications are
apt to involve all the structures mentioned, and it may be added, are more likely to
occur. These complications were of the most formidable nature, always aggravating the
pulmonary disease, and rendering it less amenable to treatment, they not unfrcqucntly
led to a fatal termination when death most probably would not have occurred from the
pulmonary disease alone. The experience of Dr. Wm. M. Boling, of Montgomery,
Alabama, was similar to that of Dr. Ames. Thus he affirms, that : '' Among the cases
of Pneumonia which wc have treated with tartar emetic principally, wc do nut hesitate
to say, that half as many deaths have occurred in consequence of gastro-entcritis —
induced seemingly by the remedy, — ^supervening during the progress of the disease, or
at the moment of apparent convalescence, as from the primary disease itself '**
W^ith reference to btood-Uttlng^ the objections which Dr. Ames noticed in the courso
of hb experience, to its employment to any great extent in Pneumonia, were presented
in two aspects. In the first, a considerable mitigation of the symptoms has been
obtained, which lasting but a few hours, has been followed by a reaction in which the
disease has passed beyond the point of severity it had previously attained ; that is to
Hay, the pulse became in the reaction more full, frequent, and sometimes harder ; the
respiration increased in frequency, while the restlessness and general feeling of malaise
were aggravated. Along with these untoward signs, there was commonly a more or less
evident extension of the limits of the diseased parts. In this manner, the effect of one
blooding was to render the indications for another more urgent, and if repeated it was
again followed by temporary relief and an ultimate aggravation ; results which he has
known to follow repeated diurnal or semi-diurnal bleedings, until the near approach of a
fatal issue arrested the treatment. The observations of many years, satisfied Dr. Ames,
that sudden and violent changes for the worse, of the kind here spoken of, do not occur
in the progress of Pneumonia, unless bleeding constitutes an essential part of the treat-
ment ; or more accurately they did occur in one hundred and thirty-two cases not bled.
lABnuec had previously made a similar observation, that in Pneumonia, by bleeding we
almost always obtain a diminution of the fever, of the oppression, and of the blood
expectoration, so as to lead the patients and the attendants to believe that recovery is
about to take place ; after a few hours, however, the unfavorable symptoms return with
fresh vigor ; and the same scene is renewed often five or six times, aAer as many venc
sections.
The treatment of Pneumonia, which Dr. Ames finally adopted, consisted in discarding
the three principal remedies in common use, and substituting others in their stead, after
the following manner :
On vbiting, for the first time, a person of adult age having Pneumonia in the firnt
* New Orleans Medical and Surgical Journal, vol. v. 1648, p. 21M.
742 Relations of Pneumoma to Malaria.
or second stage, plearo-pneumonia or pneumo-bronchitis, the following prescripdons are
made:
R. Tincture Aconitum Napellus (saturated,) gtt, zii; Quiniae Sulph. Vel. Ferro-
Cyan., grains, xxxvi ; Morphia Sulph., grain, i ; m. ft. pil. xii.
K. Solution of Phosphorus, gtt, xvi; water, 4 fluidounces,
Of the first, two pills are directed to be taken every third or fourth boar, usually
every fourth, each dose being preceded one or two hours, by a teaspoonful of the phot»*
phorus mixture. If an anodyne be required in addition to that contained in the pills,
a quarter of a grain of Morphine is given at bedtime. If the disease is in the first
stage, the beginning of the second, or after the second stage is fully developed, if there
be much pain, not yielding permanently to anodynes, a large blister is directed to be
applied over the seat of the disease.
The preparation of Aconite used, is a saturated alcoholic tincture, made by percola-
tion through a pound of the bruised root alcohol enough to make a pint of tincture.
This obtains, if the root be of the right species, is unmixed, and not too dry or too long
gathered, a stronger tincture than that of Dr. Fleming, of London, whose paper on the
therapeutic and toxicological effects of this drug, first suggested to Dr. Araes its em-
ployment as a substitute for bleeding and antimony.
The dose advised, two drops, may be considered a medium dose, when made up into-
pills, according to the prescription, or a full dose if given in water.
The curative influence of this medicine, though by no means dependent on doses suf-
ficient to produce any poisonous effects, is, nevertheless, more promptly exerted, in pro-
portion, as the latter are developed within certain limits. It is desirable, therefore, to
give enough, or repeat the dose oflen enough to induce some nausea, orsli<:^ht vomitinj:.
particularly in the first stages of pnetimonia. It b not needful to go farther, as a <;u'q-
eral rule, in order to get the best effects of the remsdy, without, at th3 sam 2 tim?, h ir-
rassiug the patient with its sickening influence,
On some occasions, however, when the attack wears an unusually threatening aspnc,
a more decisive impression may be required ; and in such a case, it is better to repeat
the dose more frequently, rather than enlarge it much. Under ordinary circumstances,
the development of the toxicological action of the remedy, to any great extent, is nut
de^irable ; for if the dose be too large or be too often repeated, its effects may becom.*
exceedingly distressing to the patient, and alarming also to him and his friends. In
such instances there occurs, more or less suddenly, a feeling of great prostration of
strength and sinking ; coldness, palor, and profuse sweating of the skin ; pretty constant
though not painful nausea ; frequent attempts to vomit ; purging ; a slow, feeble, and
thready pulse, and sighing respiration ; to these symptoms there are added a drync^5,
or rather a feeling of dryness, and constriction of the throat ; burning, tingling aod
numbness in the mouth, and numbness in the skin of the hands and feet, and frequently
over other parts of the surface.
Children bear somewhat larger doses, in proportion to age, than adults. A child 5i\
or eight months old, can generally take one-fourth of a drop without inconvenience, an I
one twelve or eighteen months will frequently bear a third or a half a drop. The dov-
for adults and children, should be repeated, except in coses of unusual violence, At in
tervals of not less than three hours ; in no circumstances ought the intervals be K^^
than two hours*
The best effect of this remedy in pneumonia, like bleeding, is exerted in the firs*
stage, or that of capillary repletion. After the second stage is completed, throa^h<M2t
the greater part of the inflamed structure, though not at all doubtful as a remedy, o^r.
indeed, any the less efficient or certain in its curative action than before, the lattor i-
usually less promptly exhibited as regards both the rational and the physical signs. A-
a substitute for bleeding, it seems to possess several other advantages. While it rvdu<
ces the force and frequency of the pulse with greater certainty, though somewhat li^*
speedily, its action in this respect may be kept up for any length of time required « with-
out fear of present or subsequent injury from it of any kind ; if suspended, there U tr*
Relations qf Pneumonia to Malaria. 743
tendency to any violent reaotion in the circulation, nor, indeed, to any speedy febrile
reaction at all, the pulse coming up to the natural standard, after having been brought
below it very slowly. Hence, if it be thought desirable for any reason to suspend its
administration during the night, no fears need be entertained of finding the pulse mate-
rially accelerated the following morning. Convalesence is never retarded through the
influence of this remedy, and, unlike bleeding, it is safe, as well as efficient, in all cir-
cumstances of the acute disease, if used with but ordinary caution.
Dr. Ames was indebted to the representations of the value of phosphorus by his
friend, Dr. James Berney, of Montgomery, for his employment of this remedy in
diseases of the lungs. The solution of phosphorus, referred to in the prescription, is a
saturated solution in Anhydrous Alcohol, diluted by nine additional parts of Alcohol.
If the medical qualities of Aconite adapt it more especially to the first stage of pneu-
monia, 80 it may be said, those of phosphorus recommend it more particularly in the
second and third stages. Given alone in the first stage, it is occasionally effectual in
arresting the further progress of the attack, but cannot be depended on for this purpose
with nearly the same confidence as Aconite alone. More frequently it does not prevent
the second stage from forming, and. decided signs of amendment are commonly deferred
to the fifth or sixth day. While either Phosphorus or Aconite, within the experience
of Dr. Ames is more efficient in either the first or second stage than any other single
remedy, it is- nevertheless desirable to obtain their combined action, as being more effi-
cient than either, separately.
According to Dr. Ames, Phosphorus certainly acts as an expectorant, with great
promptness and efficiency in pneumonia and bronchitis, in some forms of asthma, and in
the bronchitis of asthmatic subjects. It is also an effective remedy in irritation about
the neck of the bladder ; in chronic or sub-acute inflammation of the inner membrane
of the urethra and bladder ; and also as a diuretic in dropsy. Its action on the lungs
seems from its effects, to be directed especially to the minute bronchial tubes, and the
air cells ; and in inflammation, more especially to the capillary vessels than to the heart.
J)r, Ames places Phosphorus in that class of medicines, which combine the properties
of a sedative to the heart's action, and of a stimulant to the contractile force of the
capillaries. These properties make them, as they have proved to be in practice, espe-
cially applicable to, and efficient in, acute inflammation and fevers ; though applicable in
all cases, whether chronic or acute, in which the vital power, and the force of the heart's
action are equal to, or above the standard of health. In this class may be placed in the
order of their relative value in acute inflammatory affections generally : first. Aconite ;
secondly, Antimony ; thirdly. Phosphorus ; fourthly. Quinine. Dr. Ames puts Phocf-
phorus jn this class, solely because of his own experience, and that of a few others, of
its immediate sedative, or contra-stimulant influence on the general circulation, when
•riven in a dose large enough Co produce any sensible influence of any kind on the action
of the heart, but still not large enough to excite inflammation or a high state of irrita-
tion of the stomach and bowels. Its sedative or contra-stimulant, is its medicinal or
therapeutic effect. Its poisonous effects is the reverse of this, namely, highly stimulant
by reason of the local inflammation it excites. There is a point at which it ceases to be
iiicdicioal or sedative, and becomes poisonous or stimulant. Thus it is not possible to
produce by it the extreme depression which follows large doses of Aconite ; for when
the dose is enlarged for this purpose beyond a certain point, a new and opposite action
U immediately set up, by which the power is lost or merged in the local inflammation,
and its concomitant influence on the nervous system and the general circulation.
In the estimation of Dr. Amos, Quinine was a very important agent in the treatment
of pneumonia, in the Southern States. If it be sometimes inefficient, it is also at times
todispensable. When a malarious taint is an obvious complication, or when the pul-
iDonic disease, seems at it were engrafted on an intermittent fever, no other remedy can
be so confidently depended on. But this taint may exist, while the signs of it are so
masked as to be detected with groat difficulty. The excess of fibrin in the blood, the
violence of the local inflamn\ation^ and the exalted state of the innervation, may overcome
744 Relations of Pneumonia to Malaria.
the tendency of the cause of periodical fever to manifest itself in the osnal way. H«noe,
it becomes a safe rule to begin the treatment of pneumonia in malarious districts (ao-
called^) by making quinine a component part of it.
The custom of Dr. Ames was to give it in the manner specified, unUl its peculiar
effects on the head became very well marked, and if the signs of amendment are not
then satisfactory, or such as may be properly attributed to the quinine, to discontinue it.
and give the Aconite in water.
Dr. Ames regarded blisters as important adjuncts in the treatment of pneumonia.
He found them to be most beneficial when applied in the first stage of pneumonia. So
applied, they never seemed to produce any general irritation, were prompt in relieving
pain, and appeared to assist in resolving the local inflammation.
Morphine, (or Opium), besides its occasional use as an anodyne merely, was intro-
duced into the plan 'of treatment, in order to effect two special objects. One of these
was to prevent any irritation of the bowels, or to remove it if present. The tendeoc}
of the disease is to take on this kind of complication, which, when it occurs, always
aggravates the danger of an attack, as well by its unfavorable reaction on the primary
affection, as by the presence of disease in the two vital organs instead of one. The pre-
disposition to an enteric complication is sometimes so strong as to be developed into
active disease from very slight causes ; even Quinine, slightly irritative as it is, may
produce this effect. Hence the advantage of combining the opiate with it, and of so
timing the doses of the opiate as that its quieting effect on the bowels may be conttno-
uous. The rule with Dr. Ames was to keep the bowels quiet, cathartic or even aperi-
ent medicines forming no part of the treatment.
The other object was to prevent inflammation of the pleura, which Dr. AnQie«>
endeavored to accomplish by the judicious use of opiates, and occasionally by the aid of
blisters.
In his opinion, the fears so often expressed by systematic writers, in regard to the
use of opiates before the acute febrile excitement is subdued, and the apprehension of
their aggravating the inflammation by checking expectoration, was altogether onfoanded.
In noting the cases, Dr. Ames followed the rule of excluding all cases of disease of
the lungs in which the diagnosis of Pneumonia could not clearly be made out, as well
:is those in which the pulmonic inflammation was not the primary and predominant di5>
case. Of the 68 cases recorded upon the table of Dr. Ames, 19 were whites and 4t>
blacks. Both of the deaths occurred amongst the blacks. In nine oases both lansrs
were affected, and in forty cases the inflammation was confined to the led or rit»hi
liinjr.
We have thus eiideiivurcd to give a thorough and impartial analysis of tho paper of
Dr. Ames, as it appears to be the most important contribution to the therapeutics of
Pneumonia which has ever emanated from Southern physicians.
In 1866, I submitted the tabular statement of results of the treatment of Pneaniooi4
in various Confederate and European hospitals, together with an outline of my inveeU-
irations on the relations of malaria to Pneumonia, to four medical gentlemen in who9<>
ability and judgment I had confidence, and these practical observations on the tre«t*
nicnt of Pneumonia, will be ccncludcd with extracts from their replies.
ChABLQTTBSVILLB, UKITSaSITY or VlKQIVIA, I
itfoy 1ft, 1867. i
Dit. JosRPii Jones :
jVy Dear Doctor:
'• • # ♦ ♦ •
I do not remember to Iiavc seen ftn3'ivhere else, as just and as philosophical a view of iht
subject, or as clear a statement of the way in Tvhich the presence of the maUrial poUoo m^j
prediBpose to inflammation of the lungs.
Vour tabic of the mortality of Pneumonia, under different modes of treatment, has fur-
nished me food for much reflection. The death rate at our Ho8pital| exceeded any tliat
occurred in the Confederate service, except at Atlanta, Aad as the treatment consisted (m»
Relations of Pneumonia to Malaria. 745
far as I controlled it,) in carefully supporting the paiient by nutritious food — gentle revulsion
by turpentine stupes or light blisters, the use of saline diaphoretics, and the timely adminis-
tration of stimulants, I feel reluctant to accept the obvious inference that the enormous mor-
tality was due to the plan we pursued. And my difficulty is increased by the recollection
that our quarters were comfortable, and the corps of nurses both ample and excellent.
Will the fact that our Hospital was next to Lee's Army, and consequently arrested the worst
cases, both of sick and wounded, (many of such cases arriving in a moribund condition,)
furnish the desired explanation ?
Or is it possible that the diagnosis was more rigorous at some points than at others.?
I find the results of the treatment which I have indicated, so satisfactory in Civil Practice,
that you will excuse me for doubting whether it deserves the credit of the Confederate Mor-
thlity at Charlottesville. * * •
Believe me, my dear Doctor, very sincerely and kindly, your friend,
J. S. DAVIS.
Philauklphia, December 8th, 1866.
Dr. Joseph Jones :
My Dear Doctor: — I should sooner have replied to your letter of the 12th ult., but from
two causes ; 1st, in consequence of absence in the country I did not receive it in due time,
and 2d, when it reached me I was very unwell, and have continued so till near the present
time.
I find from your letter that, at the time you wrote, you had not received a copy of the just
completed 6th edition of my Practice, which I requested my publishers to send you in my name ,
and which I presume was on its way to you, at the moment of your writing. By consulting
my observations on Miasmatic or Bilious Pneumonia, (vol. 2d, pp. 18 and 31,) you will find
that I fully recognize with yourself the frequent connection of pneumonia and marsh miasm,
and the importance of the use of quinia in the complicated affection. My owu experience
long since abundantly convinced me that quinine is not only capable of curing this form of
Pneumonia, but is often essential to a cure.
I looked over your article, and was gratified by the amount of observation you had collected;
but I hope to be able to do it more justice hereafter. * *
Vou will have noticed that I write with difficulty. My nerve centres have been so much
debilitated by age, etc., that it is even painful for me to use the pen ; otherwise I should have
written probably much more fully on your paper ; as Pneumonia is a subject in which I have
been much interested. * *
Very truly, your friend,
GEO. B. WOOD.
Philadelphia, Nov. 22, 1 806.
/V**/". Joseph Jonetf M. D. :
Mt Dear Dr. Jon'ks — Your favor of the I2lh inst., has reached me, and demands my
acknowledgment and thanks. I have read your paper on Pneumonia, with much pleasure. I
agree with you fully in your views of its relations with malaria, and have always considered
it an error to confound it — an incidental disease, arising from non-specific modes of causation,
with the maladies produced by a morbid agent, a specific poison, limited in its source.
Your tables are of high value. Our worst mortality in the Confederate Hospitals (Atlanta
Kg. I), is very little — a mere fraction above that in Paris and Edinburgh, under Louis and
Bennett — and our average quite as favorable as that of the United States, as given in circular
.Vo. 6, one in four and a fraction, and that of the English in the Crimea, one in four. When
we consider that the United States had all the world to draw upon in providing necessaries
and comforts — setting aside medicine altogether — and that we were absolutely destitute in
many places, and comparatively so everywhere, the result is consoling though not
pleasant.
Nothing seems stranger than the contrast of statements which are presented in good faith
by the compilers of statistical records. In every Bill of Mortality that we take up, we find
Pneumonia occupying a prominent place, perhops, frenerally the second, Consumption being
first. In Ramsey's table, for thirteen years, of New York mortality, Consumption yields
37,038 ; Convulsions 23,003 ; Marasmus 1H,6U6; Cholera Infantum 16,331 ; Pneumonia 15,138 --
Inflammation of ("best 168 * (.'ongestion of Lungs 3,230 . 18,.')36. But ConvuKsions, Ma-
rasmus and Cholera Infantum, are vague words ; and Inflammation of Lungs stands fairly
second on the list. From Philadelphia tables, just at hand, for six years inclusive, 1858-1863,
I take the number of deaths ascribed to Pneumonia (Inflammation of Lungs) 37X1.
Now, when I find Bennett affirming, in his late pamphlet, that all his patients get well, and
others making similar statements, with a little modtfication, 1 am amazed and humiliated. If
all cases "tend to recovery," liow have so many thousand!^ bceu hindered from this natural
746 Relations of Pneumonia to Malaria.
ti'rniination, and " dune to death ? *' If by the interference of our Profession, the sooner we
disbnnd the better.
I have seen very few cades die of Pneumonia, complicated or uncomplicated ; but I hare been
unfortunate enoufrh to lose one occasionally in my large and long practice. Yet I never au
ti'ud one without flattering myself that I had been of some use to him — either palliating his suf-
ferings, or, if I could not save, prolonging his life.
Hi.spital cases, my dear Doctor, do not offer fair tests, as thus : if a wretched pauper be
hi ought from a niiscrnble and filthy hovel into a comfortable ward, cleansed, warmed, clothed,
fi>d — j)c undergoes a change of condition far more impressive than all the appliances of the
.Materia Medica could effect — a change for the better, hygienic, curative, in every whv
restorative.
But select cases, in g6od houses, in a city, and change nothing of their surroandiogs ; let
one hundred be poulticed and dieted, or left to quiet rest in bed, and treat another hundred
with Qutnin, a few with the lancet pro re-nata, above all with Opium or with Calomel — all in
prudent moderation ; obtain statements from the intelligent among them as to the alleviation
of suffering, note the duration of the cases, the proportional mortality, and the bodily vigor
and restoration of organic integrity of the convalescents. These would be instrocti%e
records, and when extensive and varied enough, would be conclusive. At present, we must
continue doubtful and anxious — such is the destiny of the reflective physician, certainty
seems unattainable, but ''Probability is the Rule of Life," and I think it probable that «e
do rather more good than evil.
Vive et vale Dear Doctor, and use Time to add to our useful knowledge.
Yours, with great esteem and regard,
«.\M L HENRY DICK.^ON.
PlItLAnKLlMlIA. Dccrmhtr \itk, IStJU.
Doctor Joseph jonks :
J/v Most KutecmeU Frirnd, ^" » » •
I l^ave read with much interest your paper on Pneumonia and Malaria. I endorse every
word of it except protien^', (there is no such organic body — albumen or albuminoid expresses
the truth.) I go further, healthy inflammation not merely limits disease, it cures and eitin.
guishes it, and it disappears. When perfect hepatization — the second sta^e of PoeumoniA
has taken place, the primary affection which preceded and induced inflammation is strangQ*
lated by the coagulation of healthy fibrin; all vital action, circulation, inervation, nutritive
action, all are terminated, the tissue is reduced in structure and vitality, to cartilaginou*
tissue or even below it.
December 8th, I had proceeded thus far, when 1 was interrupted, and soon after was seixe«l
with a most furious attack of Neuralgia, which continued all yesterday ; and to day my bea<l
has been a *' muddle,'' from the opiates with which I was compelled to stupefy my nervous
sensibility.
Now to resume our subject, John Hunter was the first who recognized that intlamnation
WHS a salutary process, a therapeutic agent of nature. Inflammation of that type or natorr
he called healthy inflammation ; but there was another type or kind of inflammation, «bu !i
not only failed to arrest or to influence a diseased state favorably, but actually to agpravat<^
it; that he named unhealthy inflammation. He could not account for the difference. Tb^
rapital/act of inflammation had not then been ascertained ; we are indebted for it to Aodral
and Gavarret. It is that inflammation develops tibrin in the blood. It is the blood that
determines the type of inflammation. When the crasis of the blood is normal, the fibrin
possesses its plastic properties in a perfect state; it coagulates firmly, glues tissues together,
and consolidates loose spongy tissues, and redures them to the loweM type of structure — a';
vital action, normal or pathological, is arrested. This is healthy inflaromaiton. But il the
rrasis of the blood be deteriorated, or contaminated, inflammation does not convert aihumeo
into fibrin, or produces an imperfect uncoaj^ulahlc fibrin, and this is unheali!iy inflammaiioB
It fails to arrest the disease. In Pneumonia there is no second st.^gc — nles in the lung* an 1
bloody sputa coutinuc to the end — always fatal.
For a ^eriad of forty years Pneumonia presented its uoira il typu*. runnin;; thr jU;rU it* fir#t
second, and third stages. Except in double pneumonia, the death rate wa< small. Aboat
1857 or 1858, a change took pla^e ; many cases remained in the first stage — the second sta^v
aborted; no perfect l^^patiaation occurred ; and all such were fatal. A nu'nbcr of our res-
pectable citizens were victims; as Dr. Hare, Dr. J. K. .Mitchell, Judge Kane, and Atber«.
Cases are now less frequent, and I am not informed as to iis present type, t'lues of Pnra*
monia have be^n diminishing for the last five years, and I have not been able to a«rcrt»
whether it has. i;esnmed its normal type of three successive stages.
'•>
Relations of Pneumonia to Malaria. 747
aria is perreclly correct, Tbcre cna l>« do donbt Ibsl it freqaenlly
, and is elicited into Kctiriij cDiacideaUl!]- irith tb« d«Te!oproeal of
another diaeasc. 1 have not met with il in Popumonia; but in a ptriod from 1B20 to 26, when
we bad all forms of malarial diieasM in the gummer, caica occurring in tbe winter frequentl}'
assumed tbe intermiltent tvpe.
if J dear Doctor, I have made an effort to write though with difficult;, 1 fear you n-Ill Rod it
difficult to read what I have written— my fingers are bo stiff, and my hand unsteady, that
writing in long tellers is almost illegible.
Adieu my last, best friend, but most esl
o B SE n V A. T I o isrs
ON DISEASES OF THE
Osseous System.
MOLLITIES OSSTU]Sr
(MALAKOSTEON, OSTEO-MALAOIA, OSTEO .NARCOSIS, KNOCHENERWEICIirNO,
UACHITISMl'S ADULTORrM. RICKETS, OK SOFTENIXG OF
BONES IN THE ADULT.)
OBSERVATICNS ON DISEASES OF THE OSSEOUS SYSTEM— MOLLI
TIES OSSIUM.
CHAPTER XIX.
nisTonicAL notej? on mollities ossum.
No mention of this disease in the irorks of Hippocrates, Paulus .Egincta, Arctaeus nud oilier
ancient writers. Observations of Sachsius, Pctra i\ Castro, Avicenna, Morgagni, Fernelius,
Ruellius, HildanuSi Gabrielli, Courtialis, Bauda, Saviard, Valsalva, Petit, Boerhaavc and
others. Reference to the literature of Mollities Ossium.
The peculiar condition of the bone:3, known as Mollities Ossium, is so rarely met with
in the United States, that many experienced and a^ed practitioners have never seen a
C';ise ; but one case was recorded in the largest American medical journal, during a
[KTiod of thirty years from its commencement, and a careful examination of several of
the largest American medical journals has added nothing to the li&t of cases ; and even
in the annals of European medicine, we can scarcely find twenty-five well marked exam-
ples.
It ifl doubtful whether the ancients wore acquainted with this disease ; we have been
unable to discover in the works of Hippocrates, Paulus .Kgineta, Aretaeus, and other
ancient writers, any observations which could be referred to Mollities Ossium.
If the statements of Sachsius and Petra a Castro are to be received as applying tu
this disease, it was known to the Arabs, under the name of Alachad and Alzemena,
and wan cured by Avicenna ; some of the interpreters of Avicenna, however, regard the
di?4eaiie which he is said to have cured, as a paralysis of the limbs, rather than a sofl-
iM^sw of the bones.
Abbon, the monk, who lived in the ninth century, relates an cxtraonlinary instance
where a very large man was reduced by it to the diminutive size of a child. Abulssdda
riKserte that the body of the prophet Gatteb was without bones, so that his limbs could be
f* tided up like a garment. Hollerius is thought to be the first medical writer who made
mention of Mollities Ossium ; he recorded the observation that there was a woman in
Paris, whose whole body was soil and flexible, and without solid bones. ( De Morbis
luternis. Kara Qua^dam, No. 7, 4to. Paris, 16u9).
John Baptist Morgagni, in his ^' Seats and Cuuhch of Disease," mentions several
atithon, as Fernelius (1500-1558), Kuellius Jacobus Uollerius, Gulielmus Fabricius
Hildaous (1560-1634), Peter Borellus (1620-167H), Thomas Bartholin (1616^1680),
and Daniel Protenius, who had recorded observations apparently referring to this din-
ease, but it is difficult tor decide the nature of the softening, whcthor the roniilt of
syphilis, cancer or rickets.
The fint unequivocal observation which Morgagni (|Uotefl, \a that of (fabrieli, who,
to 1688, in dissecting the bones of a matron, fhund them universally !«oAened and flexi-
ble, the long bones being converted into a soft, reddish flesh, apparently without
VeoaciouB fibres. Morgagni also quotes a similar observation of C^ourtialis, on another
752 Mollities Ossium,
woman J whose boucs could be bcut, and resembled fungous and sofl flesh, impregnated
with a bloody serum.
One of the earliest and most distinct accounts of the disease was given bj Baada, in
1665, who, in 1650, observed for ten years the progress of the disease in the case of a
citizen of Sedan.
Saviard, in 1691, and Lambert, in 1700, published cases.
Morgagni describes briefly a case observed and related to him by Valsalva, aboat the
latter part of the seventeenth century, although it was not published until 1760. Thu
case of Valsalva, was that of a woman who had completed her fiftieth year, and waa
attacked with a pain in the lower jaw, attended sometimes with so large a flux of blood,
that it was intended to have restrained the discharge by the application of the aotual
cautery, if it had not ceased spontaneously. In a little time after, the woman b^:aii to
be troubled with pain in her bones ; with which, having long been afilicted, she began,
as often as ever she was moved,'to complain that all her bones were broken ; and, indeed,
those who stood by her, are said to have heard a cracking in her joints at that tiino.
To this symptom another was afterwards added, that the bones of the lower limbs began
to be bent, as if they were made of wax, and to be in pain, even on the slightest modoo.
At length, in examining her body after death, the ossa innominata, the ossa femoris and
tibia, and those bones that make up the arch of the cranium, were found to be fiexiblo,
just as if they were made up of pretty thick paper ; on their surface they were spongy.
and at the meditullium, in some places, carious. Morgagni afterwards saw these booe».
f jr Valsalva had preserved them, and describes the oblong ones as curved into the form
of an arch, and those that composed the vault of the cranium depressed into the figure
of a plane.
Morgagni further records the ititerestiog observation that all of them were of a very
bid color and small, because they could not be cleaned internally, giving an noctaosity
t) the fingers in handling them.
This observation, indicating that the bones had undergone fatty degeneratioo. ha^
been confirmed, as we shall see hereafter, by more recent and extensive observatioQ^.
This change was similar to that described by John Hunter, in the case of MoUiti«s>
Oisium reported by Mr. Goodwin. (' The component parts of the bone were totally
altered, the structure being very different from other bones, and wholly oompoaed of a
new substance, resembling a specias of fatty tumor, and giving the appeanmee of a
spongy bone deprived of its earth, and soaked in fats.*' )
Petit, Manchart, Platoer^ Haller and others, have recorded observations which might
be referred to this disease ; and Boerhaave mentions an instance in which a man wh«»
lived with his bones in a state of softness, and not without the most severe paina, had
his bones after death similar t^^ a pultacoous substance, like that which is prepared from
bones in Papin's digester.
The disease appears to bo sometimes confined to a single bono. Thus, in a cac^e
reported to Mr. Solly by Mr. Hodgson, of Birmingham, the patient was about thirty
years of age^ the leg much bent, the integuments much thickened and alcerated, caiasio;r
so much annoyance and injury to the general health, that it was thought right toam|w-
tate the limb ; no other bones were affected. The tibia and fibula appeared to be formed of
a very loose, cancellated structure, being extremely thin and friable. The canoellased
structure was filled with a isoft, red material, resembling that which is found in fvtal
bones. Mr. Solly refers to unother cuso, in which it was supposed that the sune dis-
ease existed in the femur, and not in any other bone, of a man about fifty years of acv
It had been in this state for niuny years, and after it became so, it had once been fnw^
tared with very little violence. The bone was very much thickened and bent; it did
not appear to ho a caso of necrosis ; an instrumsnt was constructed for this patienl., It
which the weight of that side was transferred to the leg from the pelviA, so as to pn.-
te ;t the femur from pressure, and with this contrivance, the man wa^ able to walk and
fo'low his employment. Med. Chir. Trans., vol. ix, p. 453.
MoHitici4 Ossium is not confined to the human species. I have aeeu a well
Mollities Ossium. 753
case iu a inoukey iu New Orleaus ; all the extremities were affected, the bones beiug
softened, fractured and distorted iq various directions. Mr. Spooner, Professor of
Anatomy in the Vetinary College, informed Mr. Solly that he had observed the dis-
ease iu some hounds belonging to Lord Middlcton. 'the bones of the skeleton were
softened ; the disease attacks one bone after another. Medicines appeared to exert no
effect in arresting the disease. A post-mortem examination revealed the same forbid
appearances as those described by Mr. Solly in the human subject,, viz : deposit of red
matter, and great vascularity of the cancellated and luminated structure of the bone.
The case published by Sylvanus Bevan, in the " Transactions ot the Royal Philo-
Hophical Society," in 1743 ; the case of Anne Elizabeth Queriot, of Paris, called also
Madame Supiot, the details of whose history were given in England by Ambrose Hosty,
by M. Morand, in England, and by Mr. Bloomfield ; that of Mary Hays, reported by
Pringle and Gooch, and several others, will be found recorded in the following pages.*
*Tbe SeaU and Causes of Diseases Investigated by Anatomy ; in five Books, &c., by John
Baptist Morgagni, Ciiief Professor and President of the University of Padua. Translated by
BeDJamin Alexander, M. D., vol. iii, pp. 344-347.
Trait6 des Maladies des Os. Par M. Du Verncz. Paris, 1751. Torae 1. Preface V., p.
13«.
Sachsius, In Schol. and Obn. 37. A. 1, Dec. 1 Epb., X. C.
Avicenna, Vid. c. 2; Fen. 2, 1, 3. Can. Avlcen.
Fernelias, De Addit. rer. Cans., 1, 2, c. 0.
Jacobns Hollerins, In adjectis, 1, 1, de Morb. Int. Ilaris quibusd, n. 7.
Hildannt, Cent. 1, Obs. Chir. 4.'>, and Cent. 6, Obs. 74.
BorelluB In fine Epilog, additi, ad. Cent. 4, Hist, and Obs. Med. Pbys.
Bartholin, Cent. 6, Hist. Anat., 40.
Protteniat, In Act. Med. Hasn., vol. 3, Obs. 24.
Gabrielli, Eph. N. C, Dec. 3. A. 2. Obs. 3.
Gagliardi, Anat. Off. c. 2, Obs. 3.
Courtialts, Hist, de TAcad. R. des Sc. Ann. iToo, Obs. 2.
Kariard, Noaveau Recueil, kc. Obs. 02, p. 274, 1702.
Valsalva — Morgagni. Epist., Iviii, 4.
8. Bevan, Phil. Tr., fol. xlii, p. 48S.
Petit, Mem. de la menie Acad., A. 1722.
Maachart, Eph. N. C, Cent. !). Obs. 30.
Nebelins, Act. N. C, Tom. 1, Obs. l.*>, and Turn. 5, Ob<. 1 1 1
('amerariut, Tom. Cod. 1, Obs. 53.
lioerhaare, Proelect. ad. Inst., ^ 4ul.
Bromfield, Htstoire de la Maladie SinguTut*. par M. Muriiud. Filis, 17.%2.
Mem. de PAcad., 1753. Ambrose Hosty.
Phil. Trans., 1753, vol. xlviii, p. 20.
John Pringle. Phil. Trans., 1853, vol. xlviii, p. 21)7.
Perciral Pott, Phil. Trans., 1740, vol. xli. No. 459, p. tiltJ.
Bromfield, Chirnrgical Observations and (^a:»es, vol. ii.
Lndwig Haller, Diss. Med. Pract., Tom. vi, p. 327. lAp». 1757.
II. Thompson, Med. Obs. and Inquiries, vol. v. p. 251).
Acrel, Dissertatio, kc. Tpsale, 1785.
Renard, RamoUissement Remarkable, kc. Mayence, 18U4.
Howtbip, Med. Chirurg. Trans. Edinb., vol. ii, p. 136.
Fries, Dissert, de EmolUtioni, Ossium. Argento, 1775.
Boyear, Traits dei Maladies Chir., t. 3, p. 007, &c. Paris, 1814.
Ricberand, Nosoge. Chir., t. 3, p. 142.
Goocb's Chirurgical Works, vol. ii, pp. 3!i3'3mt. Ed., 17U2.
James Wilson, Lectures on the Structure and Physiology of the Parts comprising the 2Sk«-
letoa, and on the Diseases of the Bones and Joints, p. 252, kc. London, 1820.
M. Roberts, Archives Gen{*rale8 do Mi'decine, 183(, p. 435.
Medico-Chirurgical Review, 1830, p. 254.
Gentleman's Magazine, August, 1748.
M. Saillant, Histoire do la Socit-te Royal de &Udecin«. Annee 1T8U, p. Ii8.
Thomas Blizard Curling, Medico-Chirurgical Tran^iactions, vol. xx, 1836, pp. 33G-373.
^<amuel Solly, Medico-Chirurgical Transactions, vol. ix, 2d Series. 1844, pp. 435-4G1.
J. W. Tenney, American Journal of the Medical Science«v vol. xxvi, 1H30. pp. 500-500,
94
764 MoUities Ossiu'm.
TLomas K. Clmuibcrd, Lundoo ■.■o»t, Mfttch 2j, IH54. Itnuking'i Abilrai-l, \nbi, tdI. i, p
114.
Cbarlci Bell, London UnccI, Marcb lA, 1834, p. S18.
Hrnrj Bence Jonn, Fbiloiopliiral Tram., I84S, p, 55.
William Macintjre, Mrd. Cbir. Trim., vol. Kx>iii.
DHlrjni[il«, Dublin Qiinrltrly Journal, 1846, p. 85 ; Path. Soc. Tr«n!., IS4U-T.
Simon's Animal Chimlslry, Am. Ed., p. all ; p. GOI.
Mnnibiind. Simon's Animal Chcmitlr.c. p. 511,
Bottovk, PruiLli, Il0KD«r, L«hni*nn, Voa Blbra, Marcbaud, Rene, Solly, It boil, am, Har-
iiirl, lluipron, on ihc Chemical Com poiii ion of tha Bonet in Uollltitt Uaiium. (iimon's Animal
Cbrmialry, p. 601 ; Bccquerel and Rodier'i Palhological Cliemiilry, p. 507 ; Rokiianikj'a
PuiboloKK'al Anatomy, lol. iii. p. 144 ; L«bmn.nn's Pbytiologiol CbemUtr; ; Mcdico-Cbirur-
fciralTrani., vol. ^1 ; tiny'iHoipilslRtportB, No. tIii; April, 1830, No. »; Uedico-CbiTDrfical
Itvvitw. July 1, 1830, pp. 246-247, Am. Ed.; Uedico-Chirurglcal Trang., vol. ixTii, p. 433 :
Tbe New York Medical Record, March 15, 1869, vol. Ir, No. 74, p. ii.
CHAPTER XX.
TASKS ILLVSTRATINO THE NATURE, PROGRESS, TERMINATION. AND ANATOMICAL LESIONS OF
MOLLITIES OSSIl'M.
Caae of Miss Bozel, observed by the aathor. The origin of the disease referred to constitu-
tional derangements rather than to a strictlj local disease of the bones. Cases reported
by Sjlranus Bevan, Ambrose Hosty, John Pringle, J. W. Tenney, Thomas R. Chambers,
Samuel Solly, and others.
Mr attention was directed to this singular disease bj the following case : Miss Raney
Drucilla Bozel — ^and after comparing this case with others, we thought that it would
not prove an unprofitable task to bring forward such a collection of cases as would
illustrate more fully than has jet been done, the main features of the disease. Such
an inductive investigation of this rare disease appeared to be more especially appropriate,
as the records of its history are scattered in fragments in journals and systematic trea*
tises.
Case 767 : Miss Raney Drucilla Bozel, Nashville. Tennessee, October 1, 1868 ; was
called by Mrs. Bozel to attend her daughter, Miss Raney Drucilla Bozel, age 18, of
humble parent^, who had always lived in great poverty. At the present time the
patient. Miss Bozel, together with her father, mother, and younger sister, occupy a
small room about ten feet square in a wooden building, erected by the U. S. Govern-
ment during the war, at the foot of Fort Naglie ; the entire family is supported chiefly
by alms, the mother's attention being taken up principally with the care of her sick
daughter, and the father being aged, feeble, and afflicted with an eruption upon the
skin, and an indolent ulcer upon the back.
The father, mother, and Miss Drucilla, all present pale, cadaverous faces, resembling
those who have long been subjected to the action of malaria.
Miss Drucilla was born in Bedford County, Tennessee, three miles from Shelby ville,
in a healthy locality, and her mother states that she was a healthy child up to the age
of five years, when they moved to Southern Dlinois, and settled on an island in the
river, opposite Paducah, Kentucky.
The island lay in Madison County, Illinois, between the Tennessee and Ohio Rivers,
was low, and subject to overflow. The island was overflowed the year afler the removal
of the family, and at this time the lower part of the house was under water, and the
house occupied by the family, as well as the surrounding ground?, continued damp
during a considerable portion of the spring and summer ; the freshet occurred in the
month of May. Shortly afler her removal to this low, malarious situation. Miss Dru-
cilla, who up to this time was an active, healthy child, was seized with the aye, and
suflTerred with it for eighteen months.
The softening of the bones commenced just after the freshet, and whilst she was suf*
fering severely with malarial fever, and whilst the house and surrounding lands were
damp, and covered with the river deposit. The bones of the leg first became painful ;
poultices appeared to relieve the suffering temporarily. Then the jaws were attacked,
became painful, and both the upper and lower jaw upon the left side became carious,
and have continued occasionally to discharge pus and small fragments of bone up to the
present time. The diseased surface sometimes heals up, but breaks out again.
About three years ago the left ann began to lose its bone, and has Apparently lost all
756 mollities Ossium.
the earthy matter of the humerus for the space of some five inches. The mother
states that this loss of the substance of the bone was attended with great pain.
At the present time the middle portions of the humerus of the left arm have appa-
rently disappeared, or been converted into a flexible cartilaginous mass, only about two
inches of hard bone remaining at the upper humeral and lower ulnar articulations. The
arm can be bent at right angles to the natural course of the humerus, and it can be
twisted around its centre ; and it feels In this portion like a mass of flesh. The fore-
arm and hand of the lefl side present a natural appearance. The right humerus of
right arm feels rough and enlarged, and is painful to the touch. Ulna of right ami
apparently of natural length, but anterior portion projecting outwards, and tha hand
thrown inwards. Radius apparently destroyed, or converted into sofl flexible material,
throughout a considerable portion of its extent.
Right thigh and leg much less afl^ected than the left. Knee-joint of right leg much
swollen, with distinct veins ; ankle-joint much deformed the fibula projecting bevond
the ankle, and the lower portion of the tibia converted into soft, flexible material,
shortened and diminished in size. The mnrks of several ulcers are visible upon the
right leg.
Left leg — tibia aud fibula divided or absorbed in the region of the upper third, an«l
large masses of a hard nature — like the callus of the fractured bones in healthy indi-
viduals— have been thrown out around the extremities of the bones. Her mother
states that this bone was fractured at night, whilst the patient was lying in the bed, and
that the fracture was attended with an audible snap. If the statement was correct, the
fracture was occasioned by the action of the muscles of the thigh, afler the weakenini:
and absorption of a large portion of the shaft of the bone. The correctness of the state-
ment is sustained by the existence of callus around the extremities of the boners.
J -eH foot and ankle in place and of good shape.
Patient suffiers with continued pain in left side of the lu^d ; night in lefl eye much
impaired, and eyeballs very prominent. a.s if the orbits had been thickened and the »oU
parts pushed forward. At times the pain in the head i.< said to be quite intense.
Complexion sallow, with leaden, jaundiced hue, and anasmic , the complexion of thU
patient iiesemblos in all respects that r)f one who has been long subjected to the action
of the malarial poison, and whose blood, liver, and spK^en have been thoroughly affect^l
by its action.
The eflbct of the mollities ossium has been to arrest the growth of the patient, f**r
although eighteen yeai*s of age, she is only tliroe feet nine inches in length, and wei^>
not more than a child of four years of age. In exhibiting the ease before the medicj!
class, I took Miss Drucilla out of the carriage and carried her upstuin.^ into the amphi
theatre in my arms, with as much ease as if she had been a small child.
Intellect clear, and spirits good and cheerful ; talks most intelligently and chcerfiilU
and although confined entirely to the bed, and unable to do anything for heredf, is .^
great comfort to her mother, and a general favorite with all ; and her mother told m«r
that in their groat poverty and distrc.«»s. and in the numerous .*«traits which befell them.
she was her main stay for advice.
The softening of the bones docs not appear to have had any connection wiih sypht^t^.
as the patient was perfectly healthy up to the time of the appearance of the malariai
fever, at the age of five, and her younger sister, born afler the family lefl the aabeal-
thy island on the Ohio river, is a fine healthy girl of ton years of age, with* full w»*"
formed limbs, and rosy, healthy countenance.
The ill-health of the father appears to be due to bad diet and the irregular habits jin i
exposure incident to great poverty.
The menstrual function has never been performed by this patient.
I conceived the indications in this case to be :
1st. The enrichment of the blood with those salts which were wanting, and whi< ^
would more especially supply the elements for the bones.
2d. The improvement of the general condition by nutritious diet and thf action . f
alteratives.
Mollities Ossium. 757
3d. The regulation of the bowels, which haJ been habitually constipated or
costive.
4th. The restoration, or rather the establishment of the function of menstruation.
We sought to accomplish these results by the administration of fifteen grains of a
mixture of equal parts of the phosphates of iron and lime in a cup ot rich, fresh milk, '
three times a day ; by an alterative plan of treatment, consisting of iodide of iron and
iodide of potassium (B. Syrup of iodide of iron, one fluidounce; iodide of potassium,
two drachms; syrup or ginger, eight fluidounces — mix. Teaspoonful in wineglass-
ful of water three times a day) ; and by the regulation of the bowels and uterus by the
pilb of aloes, rhubarb, and myrrh of the United States Pharmacopoeia, and the admin-
istration in liberal quantities of digestible and nutritious diet.
Under this treatment, the menstrual function was established, (in the language of her
mother, "she became a womin"). the general health improved, and the head symptom.s
were alleviated.
lu the latter part of December, my residence was destroyed by fire, and having to trans-
fer my family to Georgia, and amid a pressure of cares and labors, I lost sight of this
case ; previous to this, the mother was in the habit of calling at my office every
day for advice and assistance, and my visits also were at regular intervals.
I was subsequently informed by her mother, that Miss Drucilla died ailer a brief
illoeas, on the 1st of February, 1861). I could gather nothing more than that the ill-
ness was brief, and that both the stomach and head were deranged about the time that
the menses should have appeared.
The connection of this case in its origin, with a severe and prolonged attack of mala-
rial fever, during exposure for months to a damp, unhealthy, malarious atmosphere, is
interesting and important.
I have elsewhere shown that the malarial poison not only de.<5troys the blood corpus-
cles more rapidly than any other febrile poison, but ahoditninufwa the phosphates of the
hlood. (Observations on somr. of the Phi/sica!, Physiologisah and Patliological Phv-
tiomcna of Malarial Fever^ Transactions of the American Medical Association. 18oif].
Rapid destruction of the bones, as well as of the integuments and muscles, has been
sometimes witnessed as one of the results of the action of malaria upon the human ^sys-
tem, and I have elsewhere recorded such cases (Iransactions American Medical Asso-
ciation^ 1850)'. and, in March, 1869, I had in my wards in the Charity Hospital, a
case of chronic malarial poisoning, in which one leg had been destroyed by extensive
ulceration, and the other leg was threatened by large ulcers. A careful examination
of the histories of these cases demonstrated that the destruction of the tissues could be
referred neither to the action of mercury nor the effects of acquired or hereditary syphilid.
It is possible that in certain stages of malarial fever, and in certain states of the
human system, acids, as the phosphoric and lactic, capable of acting upon the inorganic
constituents (or mineral elements of the bones, phosphate and carbonate of lime, and
phosphate of magnesia, ) may accumulate in the blood and structures, and cause a solu-
tion and absorption of the earthly matters. By numerous analyses of the urine in
malarial fever, I have shown that during the chill, and at the very commencement of
the hot stage, phosphoric acid disappears almost entirely from the urine, whilst the
organic acids and sulphuric acid are increased ; as the hot stage progresses, and the
febrile action and the heat commence to decline, there is an augmentation of the phos-
phoric acid ; the uric acid is cither increased or remaids at the normal standard during
the chill, disappears almost entirely during the fever, and then increases rapidly and
rises to a high figure after the subsidence of the febrile excitement, and often continues
for days, two, three, and even six times more abundant than in the normal state. The
salts of lime contained in the urine also undergo marked variations in quantity during
the different stages of malarial feVer, diminishing during the chill and first stages of the
fever, and increasing as the febrile excitement declines. In the first stages of the
paroxysm the phosphoric acid appears to be, to a considerable extent, free, and uncom-
bined either with the alkalie.^. soda and potassa, or lime : after the oontiunance of thoie
7^^ Mollities Ossium.
changes, which result in the increased formation of phosphoric acid in the nerrooa and
moscalar stmctures, the insoluble phosphates of the structores appear to be disolred*
and hence the accumulation of the salts of lime in the urine. On the other haod, the
chloride of sodium, a highly soluble salt, increases in the earlier stages, and diminbhes
in the urine during the intermission or remission.
The pale, sallow, aaemic hue of this patient, together with the rapid, feeble pulae, an J
psriodic febrile excitement, indicated profound alterations in the composition of the
blood, and derangement of the nutrition of the organs and tissues.
It is not unreasonable to refer the origin of the disease in this case to the denng^
ment of the blood and nutritive acts bj the presence and continued action of a specific
poison, especially as this disease is known to originate most frequently amongst the ill-
conditioned and ill-fed inhabitants of large manufiicturing towns, and in females whoae
menstrual function had been deranged for long periods, and whose forces had been de-
pressed by the demands made upon the nutritive elements by repeated pregnancies.
In a word, we are disposed to refer the origin of the disease in this case to coostita-
tional deran<]^ments. rather than to a strictly local disease of the bones.
This conclusion is further sustained by the fact that a large proportion, if not all the
cases of mollities ossium heretofore reported, exhibited marks of constitutional deruige-
ment, fever, wasting, and abnormal condition of the urinary secretion preceding and
accompanying the local disease in the bones.
We cannot regard the osseous tissue solely from a chemical point of view ; neither is
it correct to regard it as a simple, uncomplicated texture. In addition to the phonbate*
and carbonates of lime and magnesia, which might be regarded as comparatively devoid
of vitality, bone presents a complicated structure into which the most highly vitalix-Hl
and most complex tissues, as vessels and nerves, enter. The numerous cavitie» and
canals which penetrate the fresh bones are not empty, but contain a true nutritive
plasma, complex in its constitution, derived primarily from the blood circulating through
the osseous tissue, and obtaining its physical and chemical elements directly from that
fluid, and in common with all the other fluids of the body, subject to physical laws of
endosmosis and absorption, and to chemical changes. The investigations of Virehow.
Djnders, and Hope, have even rendered it probable that the bone-corpuscles aod their
prolongations are lined by a membrane, and cannot, therefore, be viewed as simple
excavations in the compact structures.
It is not unreasonable therefore, to refer certain structural alterations of the bones to
derangements of the blood, from which the nutritive fluids and plasma of the cell alar
spaces are derived. While an excess of earthy salts in the blood, conjoined with an
increased alkalinity, may tend to the deposition of phosphates, on the other hand an
increase of acid in the blood, whether received from the alimentary canal by ab«orptioo.
or from the mal-assimilation of the elements of the nutritive fluids, or from some arrvst
or perversion in the process of secretion, would tend to the solution of the mioera'
constituents of the osseous system.
In the following case, reported by Sylvanus Bevan,* thesoflening of the bones wjs
preceded and accompanied with a frequent and copious discharge of urine, gridoal wast
ing of the body, hectic fever, quick, feeble pulse, thirst, pains in the should srs ani.
limbs, and loss of appetite. After the continuance of these symptoms during the period
of two years, accompanied with ^eat emaciation, the patient was attacked with an iotc-r
niittent, which appeared to alter the character and quantity of the urinary disdiinr^
and, after the relief of the intermittent fever, the appetite returned, the broathios:
became freer, and the hectic fever was much lessened \ but the pains in the limbs coo-
tinued, and, afler being confined to her bed for several months on account of the wcmk-
ness and pains in her limbs, the bones of the legs became soft and pliable.
Cabs 768: The wife of one B. S., id the year 1738, was Uken with a diabetea, witk tht
usual sjmptoms, viz : a frequent copious discUarge of urine, a gradual wasting of the bod« ,
• An vxtmonllnary 'csm of th« Bodm of t iromf n IwoomliiR aoft and S^xiMf. By Mr. 8ylv«a«s ■•«*•, T ft.
Phlloff. TranP.. vol. xlii, 174:{. No. 470. p. 4hA.
Mollities Ossium. 759
a hectic feveri with a quick, low pulse, thirst, great pains in her shoulders, hack and limhs,
and loss of appetite. She continued thus two years, much emaciated, though using the com-
mon medicines; at which time she was attacked with an intermittent, which soon left her;
nfter which the diabetes gradually decreased, so that in a few months she was free from that
disease, bnt the pains in her limbs still continued. She recovered her appetite, breathed
freelj, and her hectic much lessened, though she had some appearance of it at times.
About eighteen months since, she had such a weakness and pains in her limbs, that it con-
fined her to bed altogether ; and in a few months the bones in her legs and arms felt somewhat
soft to the touch, and were so pliable that they were bent into a curve ; but for several months
before her death they were as limber as a rag, and would bend any way with less difficulty
than the muscular parts of a healthy person's leg without the interposition of the boned.
April 12, 1742, after a tedious illness, she died, near the age of forty, and, with the consent
of her friends, a post-mortem examination was made. On raising the cutis, the membrana
adiposa was found much thicker than was to be expected in a person so much emaciated ; the
sternum and ribs, with their cartilages, were very soft; and all the cartilaginous parts of the
ribs, at their articulations^ from the clavicle downwards, were doubled over each other, on
the left side, about an incli. On raising the sternum, he found that the lungs adhered close to
the ribs for four or five inches on each side, but were more loose and flaccid than usual, and much
less in size ; her heart was of the common she. Upon viewing the liver, it was found to be
at least a third part larger than common; the spleen was about half an inch in the longest
part, and a quarter of an inch thick; the intestines were very much inflated. She had ap-
pearances of several anchyloses formed in the small joints, viz : carpal and metacarpal bones ;
but, on laying them open. Dr. Bevan found them only like a thin shell. The cartilaginous
epiphyses of the bones were entirely dissolved, and no parts of the heads of the bones
remaining but an outside not thicker than an egg-shell.
On making incisions in her legs and arms, five or six inches long, Dr. Bevan found the outer
Uminio of the bones soft, and become membranous, about the thickness of the peritoneum,
contaioing, instead of a bony substance, a fluid of tlie consistence of honey, when it is thick,
of a reddish color, not at all disagreeable to the smell. There was no appearance of any
bones in her leg and arms, except near the joints, which were in part dissolved, and what
remained were very soft and full of holes, like a honey-comb ; also the bones of the head
would easily give way to the pressure of the fingers. It is remarkable that those parts of the
bones that are most compact and hard were first dissolved, while their heads, which are more
spongy and soft, had not so entirely lost their substance.
When she was in health she was five feet high, but after her death she was but three feet
seven inches in length, though all her linbs were stretched out straight, which is seventeen
inches shorter than she was in health.
In the following case of Anne Elizabeth Queriot, of Paris, reported by Ambrose
Hostj, the disease oecurred after pregnancy, and was attended with great pain and
weakness in the limbs, with an abundant white chalky sediment in the urine, which
fermented strongly with acids ; dead, (edematous state of the flesh ; rough, scaly skin ;
increased heat, cough, laborious respiration and spitting of blood, and black sputa which
stained the napkins, and also with a peculiar sweat, which stained all the linen that
Couched her skin. The attendant physician supposed that the phosphate of lime was
discharged both by the skin and kidneys, and in the sputa.
Casi T69:* Anne Elisabeth Queriot, aged 35, native of Paris, was married in the year 1746,
was brought to bed in 1747, and for the first time complained of great weakness in the small
of her back, loins, and thighs, and could scarcely walk. A second lying-in, a year after,
removed her complaint for about six weeks, after which it returned. In the year 1749, being
two months and a half with child, she was seized with a loss of blood, and miscarried. Two
months nfter, she foil on her left side, which gav<3 her great pain in her leg, thigh, and hip of
that tide, and made them swell ; but there was neither fracture nor dislocation. Her pains,
after soma time, abated ; but the weakness of her limbs continued.
She was a third time with child, which revived her former pains, and caused her pains all
•ver her body, with a swelling as before. This confined her to her bed, yet her pregnancy
terminated favorably, after which the swelling went off; but her limbs wen* so weak that she
v'ould not stand upon her feet.
In about six months after her last lying-in hei* pains returned worse ilian belore ; and about
^he vmi^e time an abundance of white chalky sediment appeared in her urine, and the fore-
inger of her right ht^nd was observed to be distorted towards the little finger, which was
the first appearance of t\»e dissolution that ensued, ^^oon nftcr, the lower extremities began
• Th« Gm» of Anne Kllx*betlt Queriot, of Purit, whuM lloneii dUtorted and suaciitHl. Hy AmliivM HuNty, M. D. ,
S»f Parts. Philosophical TfMDMctiontt, l7iVl, vol. xlvlll, p. W ; Al»rid|tmi»nt of Hiil. Tnm«. vol. x, i»j» :Ji:ullr..
7G0 Mollities Ossium.
to turn upwards gradually, aud almost in n parallel line with the body, and coutinaing till, in
nine months, her lower limbs were turned upwards. All the bones were affected, especially
the thorax, which bad lost its natural form and capacity, and she was altogether miserably
distorted.
This miserable state was attended with exquisite pains, and according to the seat of them
the patient used to say, " Now, such a part works." Sometimes they abated, and then sb^
felt so sore as not to bear being touched ; and during this ease from her pains, a quantity of
the aforesaid sediment passed by urine, though little or none passed during her sufferiogt. It
was quite cretaceous, and, reduced into a Due powder, fermented gently with acids. She
could bear no corering but a few napkins, both from inward heat, and to avoid loading her
breast. Notwithstanding her preternatural posture, the evacuations by stool and urine were
regularly and easily performed. Iler flesh seemed dead and a'dematous, the skin rough and
gcaly, BO that a modification was often apprehended. She had a cough, a laborious respira-
tion, and sometimes a spitting of blood, Trom the coarctation of her breast, all its bones ply*
ing inwardly. She was capable of no other motion than turning her head on both tides,
stirring her left arm in the shoulder-joiut only, and separating her fingers, but not bending
them. She had her menses regularly till about three months before her death. She gene-
rally had a low fever, inward heat, sweats, and restlessness. Her fever ran very high in
August, attended with delirious headache, raving, and subsultus tendinuro. A little before
her death, came on a deafness, a dimness of sight, a scalding of her eyes, and a constant
dropping: violent pains in her head — in short, a great weakness in all the organs, which
showed how much the head was affected.
The distortion of her limbs went so fast In August and September, that almost everb' day
something new was observed ; especially the left foot, during that time, came down gr&dn-
ally near eighteen inches from under her ear, where it lay before. It was also observed, in
August, that her neck grew visibly smaller, the thorax much narrower. And then the nap-
kins in which she spit grew black in washing, and stained as from the mercurial ointoient ,
though this caase was not suspected,, as it could not be learned that she had ever used any
mercury. In a month after he observed the same thing on all the linen that touched her
skin. He got a napkin rubbed with soap, then dried, and afterwards washed. This method
had almost taken off the stains, as it docs those from the mercurial ointment. Her linen
stained all the washing, like linen impregnated with it. These spots appeared on the linen a
mixture of a cretaceous matter and grease. Since this remark was made, more of the white
sediment was seen. This and the apparent nature of the stains, made him believe that it
was then discharged by the spittle and the pores of the skin, and mixed with oily particles of
her fluids, which had acquired a quality analogous to that of mercury, of staining all Uaen.
Dr. Hosty was also led to think that this sediment was the earthy matter that givea the booca
their solidity and hardness, which had been dissolved by the same vitiated quality of the
fluids, and evacuated by the emnnctories already mentioned.
After great sufferings she died the 9th of November. Her body was opened in the preaenct
of some of the most celebrated anatomists and academicians of Paris. The operation was
begun on the left tibia, cutting on the fore-part of it from below the knee to its bftsia. It
was wonderfully altered ; more or less soft in all its length ; in some points entirely dissolved,
and its sides not thicker than the gristle of the ear. The spongy substance of its extremities
supple, yielding to the least pressure. The reticular matter was quite destroyed. The peron«
was entirely dissolved in the middle, and only slight marks of its extremities remained.
Instead of marrow, they found in all the bones a red, thick matter, like coagulated blood.
mixed with grease. The rotula was entire, but very soft and spongy; the condyles of the
femur the same. All the cartilages were found in their natural state. The head of the
humerus was much diminished and flattened, its middle part very small, pliable, softened in
all points, yet in some friable.
The cubit and radins suffered the same allerntions with the humerus. By stretchlag all
he» limbs, they laid them straight ; but they soon after returned to their former curve. The
phalanges of the fingers were not so much softened, but were easily cut and bent like whale*
bone. The femur was rather a fleshy body than a bone ; its cavity was filled with a reddish
suet, instead of marrow, which accumulated in different points, and bulged ont the fleshy
sides. The capacity of the pelvis was much diminished; the bones that compoMd it mm
softened, thickened, and contracted. The spine kept its natural form ; the vertebrae soft aad
supple. The sternum and all the cellular bones seemed solid, but could bend, and were easily
cut. The ribs, though softened, were still friable. Some of them, toward the sternum, wrere
doubled over each other. The cUvicles seemed almost cartilaginous. The shoulder-bUdes
were much thicker than natural, less broad, and entirely disfigured. The two protuberaoce*
called acromion and coracoides, almost joined. The skull bones were easily cut in slices, and
were twice as thick as in their natural state. Both plates were joined in one, and no trace
at all of a diploe. Their substance abounded with an extremely diluted serum, easily sqnecaed
out by a gentle prcs?uro of the fingers. The sutures almost obliterated ; the bones of the
Mollities Ossium. 701
hasU and the face ehareU in the calamity. The teeth hard as usual. The dura mater was
incorporated with the bones. The brain not softer than ordinary : its right hemisphere was,
by one-third, larger than the left, and, hence, perhaps, the weakness of her left side, often
manifested by pains, aches, defluxions, heaviness, falls on that side, and every illness which
she had from her infancy, beginning in some part of it. When yonng, she fell on her head,
down two pairs of stairs. The membranes that separate the two hemispheres of the brain
were much thicker than common. In fine, all her bones were so soft, that the scalpel, with
very little force, ran through the hardest of them, even the rocky apophysis of the ear bone,
so called from its excessive hardness.
Nothing extraordinary was found in the vl^cera : but their si^c diminished by the compres-
sion, and a universal cachexy.
There coukl be no cauMC asj*i^ned of this woimin's disorder, an nhe gave no sign^
plain enough to prove either a scurvy, pox, or king s-evil, either hereditary or acquired ;
her parents having lived healthy, the one to the age of eighty, and her mother being
then living, aged sixty, and in good health. She had three children, who died of di.^-
orders common to their age ; one four years old, died of the mea.<4les.
In the following cose of Mary Hays, reported by John Pringle, the patient suffered
first with chlorosis (green sickness) and suppression of the monse^^, and was seixed with
pain universally attended with feverish symptoms.
Case *ilO: Mary Hays,* of Stoke-Holy-Crosg, near Norwich, gave the following account,
June 2l8t, 17&2 : That she was born January 11th, 1718, and never married, nor was addicted
to any kind of intemperance ; that her father was unhealthy a great part of his life, but she
knew not what disease he was subject to ; that her mother died when she was a child, but she
did not remember having ever heard of her being unhealthy ; that she, herself, was always con-
sidered as a healthy, strong girl, till about fifteen years of age; then fell into the green sickness,
and took various medicines to no purpose; that this disease, as far as she could recollect,
was all she had to complain of, doing the ordinary work in a farmer's house till October, 1784.
She then was seized with pain universally, attended with feverish symptoms. Thus she con-
tinued seven weeks, after which the pain was chietly confined to her thighs and legs, but not
increased by external pressure.
In September, 1740, she broke her lu^^ as she was walking from the bed to her chair, without
falling down, and heard the bones snap. The fracture was properly treated, and regard had
to her disposition; but the callus was generated, the bones growing flexible from the knee to
the anj(le in a few months, as did those of her other leg. Soon after, those of her thighs
were visibly affected in like manner. Both legs and thighs became oedematous, and subject
to excoriate, discharging a thin, yellow Ichor. The winter after breaking her leg, she had
symptoms of the scnrvy, and bled much at the gums.
"^ Many emnient physicians, who were of opinion thai this disease of the bones might arise
from acidity abounding in the blood, prescribed for her, but without effect, unless the regu-
larity of her menstruation for the Inst eighteen months may be attributed to a chalybeate
medicine, though roediciues of that nature had no effect formerly, when she was in a condition
to take exercise and regularly persisted in the use of them.
For some considerable time past i<he had found little alteration in her complaints in general,
though her appetite and digestion were rather better, but that the difSculty of breathing,
which she bad long labored under, gradually increased, and the thorax appeared %o much
straitened as necessarily impeded the expansion of the lungs.
Her spine became much distorted, any motion of the vertebrae of her loins gave extrenitv
pain, and her thighs and legs were become entirely useless, which wholly confined her to bed
la a sitting poftore : and the bones she rested on, having lost their solidity, were much
f pread. Also the ends of her finger and thumbs, by frequent endeavors to lift herself up for
ease, became very broad and flat. Then she measured but 4 feet, though before this disease
came on her the was about 5] feet high, and well shaped.
This if the best Information that could be obtained from her own mouth, and. what was
observed in the case before and at the first mentioned time, when she readily consented td tlfe
examination of her body, etc., after death.
From that time to her death, which happened July <ith, 1753, the chief thing she' complained
of, and what the people about her observed, was a gradual increase of difficulty of breathing,
a wasting of flesh, a cessation of her menstruation for the last fonr months, a tendency in her
legs to mortify, which had lout/ been anutfircotu^ and excoriated almost nil over ; she retaining
her senses perfectly to the last moment of her life, and dying without ^hQwing the least signs
of the agoniefi of death.
• A Bemarkabio Ca»<' of Kragnily, FIt'&ibility, and I>i«H>Iution of tli« Uun«-4. Mv Jcba I'riuglc, M. 0 .
Fhlloa. Tninr, IT.vl, xo\. »WHl, p. V^*"; Al>ri«Jgfn<'nt "f FhH«w Jna* , '"I- %, |M». M»»i-i<iH,
V. K. «<.
Vt
7G2 Mollities Ossium,
«
Two (lavs alter death, ber limbs being first well stretcbed out, she was cxacilj- measure*!.
Hnd found wanting of ber natural stature more than 2 feet and 2 inches. Then the thorax
iind abdomen were opened, the sternum being entirely removed, with part of the ribs, io order
lo gain at once a full view^ of these cavities, and discover how the viscera there contained had
obstructed each other in their respective functions. The heart and lungs were sound bni
flncfid, and much confiutrd in their motion, to which the enormous size of the liver con-
tributed in some measure, extending quite across the abdomen, and bearing hard agniost ih«»
diaphragm. The lungs did not adhere to the pleura, nor was the liver scirrhous, but lanltv
only in bulk. The mesentery was sound, except only one large scirrhous gland on it. The
pleura extremely small. Nothing else was found observable in these cavities.
The skull was not opened to examine the brain, as intended through want of time, the
minister waiting at the church for interment, and the relatives becoming impatient, but the
operators had no reason to suspect any defect there, from any previous complaint.
All her bones were more or less affected, and scarcely any would resist the knife. Those of
ihe head, thorax, spine, and pelvis nearly to the same degree of softness. Those of the lower
extremities much more dissolved than those of the upper, or of any other part. They were
cut quite through their whole length without turning the edge of the knife, and mucb Um
resistance was found than firm muscular flesh would have made, being changed into a kind oi
parenchymatous substance, like the soft, dark colored liver, only meeting here and there with
bony laminic, thin as an egg-shell.
Those bones were most dissolved which in their natural state were most compact and'
contained most marrow in their cavities, and the heads of them were last dissolved.
This perhaps is the more worthy of observation, as it held good throughout, and
looks as if the wonderful change they had undergone might be caused bv the marrow
having acquired a dissolving quality, for it was evident that the dissolution began within
Hide, from the bony Uminas remaining here and there on the outside, and Dowheie else.
and the pain not being increased at first by external pressiirc.
The periosteum was thicker than ordinary — ^the cartilages rather thinner — but
nowhere in a state of dissolution like the bones. The day after this examination s(»mf
of the whole substance of the leg and thigh bones, that was entirely dissolved into a
kind of pulp, was sent to an ingenious chemist, and by the experiments which he made
he said he could discover neither acid nor alkali prevailing in it.
The disease in the following case, reported by Dr. J. \V. Tenney, was preceded and
accompanied by general weakness, emaciation, and copious discharges of urine, depositin;:
an abundant light colored sediment, and by suppression of the menses. The patient
referred the origin of the disorder to exposure to a cold atmosphere and standing io
snow in thin shoes afler fatigue and profuse perspiration.
Case 771 : .Mrs. D. W., »t. 43, was the mother of five children. Her health had been \ui
indifferent for tbc last fifteen months. She complained of general weakness, and especia..*
m her lower limbs, emaciation, very copious discharges of urine depositing an abundant ligKi
colored sediment. She had experienced some colic pains, and in walking her gait was roUicg
bringing the centre of the gravity at each step directly over the limb on which the weight •.;
the body was thrown.
Her menstrual periods had ceased for about eighteen months. The origin of ber di$ordf-
she had always snpposed to have been exposure to a cold atmospbere and standing io snow .:.
thii^ shoes after fatigue and profuse perspiration. After that period hitting the foot, ia waA-
i(>Pf against the slightest impediment, was sufficient to throw ber down.
In November last, being troubled with neuralgic pains about the face and jaw, and sar*
posing they might proceed from a decayed tooth in the under jaw, she requtstcd that it ni^dt
be extracted, but on attempting to raise the tooth with the forceps it was found Decessary to
desist and use rollers, as the bone seemed to bend though but slight force was used. Afrv
days after it was found so diflicult to extract the last tooth on the right side from the want o'
firmness in the bone and tension in the muscles that it was left in the socket. From this i:n.f
the muscular strength of tb^ patient failed fast, though ber .ippetite remained tolerably good,
and ber stomach generally retained and digested her food, though it occasionally rejected all
nourisUment fur a day or two. She became at length unable to support bv.r weight or raUe
herself from the bed to ^kicb she was soon confined.
In the latter part of ^arch ber thigh-bone was found tlcsed at about a Hgbi augle near lU
centre. Thp patient was not sensible of it till it was accidentally discovered and »Q|»po»c«l
to be broken ; but, u^pn bringine it into its natural position, no crepitation was |>erreiTrt
MoUities Ossium. 763
and the extreme emaciation of the limb enabled us to saiitfy ourselves that instead of being
broken the limb was bent.
The outer limbs on examination, also, were found in the same condition, especially the lonf;
booea, which hal so far lost their firmness as to be perfectly flexed from their position, which
thej would receire again by their elasticity.
The disease still continued its progress, the firmness of the bones diminishing till June 9th,
when she expired. During this time the mental faculties remained bright, and with an
unusually rapid flow of ideas ; vojce strong, pain not severe.
Autopsy 26 hourt afttr death. — Corpse perfectly flexible ; emaciation extreme; ceJema of the
lower limbs, and right arm, which had supervened during the last two or three days; fulness
and hardness of the abdomen ; thighs evidently shortened.
On cutting down upon the left femur, where the alteration of structure had first showed
itself, no fracture was found, but the bone had doubled over on itself in such a manner that
without altering the general direction of the limb it had shortened it about two inches.
About two inches below the lesser trochanter, the bone formed a right angle by bending
inward, producing a prominence which might have been mistaken for the greater trochanter,
while the limb was covered by the integumeuts. The neck of the bone was also bent, approxi-
mating the head of the boue to the greater trochanter. The bone was so soft in every part as
to be easily pierced by a scalpel. The cartilage covering the articulating surface was in its
natural state, but much harder than the bone. On laying 0|ien the medullary cavity, the
medulla was found disorganized, very much resembling coagulated blood. This cavity was
much larger than common, and the osseous substance much diminished. It was so thin and
devoid of earthy matter ns to be easily compressed by the fingers, so as almost to obliterate
the internal cavity.
The external surface of the bone was less diseased, the osseous matter remaining bciug
principally upon the outside. This bone was entirely detached and preserved.
The bones in the other parts of the body were examined, and found more or less in the
fame condition. The right humerus and femur seemed equally flexible, and had not retained
their shape; the bones of the legs and forearms, though retaining their shape, could evidently
be bent considerably and recover their position, though, if the strain was carried beyond a
certain point, the texture was broken, and it would not recover its position, though a perfect
fracture would not take place.
The phalanges of the fingers, the tarsal bones, the bones of the pelvis, the cranium, could
all be pierced by a scalpel. The bones of the spine were so soft that the vertebrss could be
cut into or their processes cut off with more facility than if they bad been cartilage. The
ribs of the right side had doubled over upon themselves, in a manner similar to the femur, so
as to shorten them about an inch and a half, and materially diminish the capacity of that side
of the thorax.
The muscular texture of the body was materially altered. It was pale, flabby, and so des-
titute of fibrin that it could be easily torn ; even the tendinous portions of the nnscles
possessed liitle more strength than the loose cellular tissues of the body.
This appearance, in a greater or less degree, existed through the whole muscular tissue.
The heart, for instance, was flabby, and could be e isily cut with the finger nails, especially
the right side. The uteru*) was in the same state, though not to the same degree.
The nerves retained their natural form, har&ness and strength. The brain was not exam-
ined, as no symptoms during life indicated any disease of that organ. The lungs were healthy,
though the common observation, that they were softer than natural, might be applied to all
the internal organs. The omentum had a dirty appearance, and rough, gritty feel. Coats of
the stomach healthy. Kidneys healthy.*
It Is worthy of note, that in the preceding case the muscles were altered as well u
the bones; and in thi.5 softcnin*;, and perhaps /'i//y degenercttion of the muscles, wo
find additional and eonclujtivc proof that the origin of the disease cannot be referred
alone to the local changes in the bones.
If the disea.sc was dependent upon an inflammation and alteration of the porio;teum,
wc would not find this membrane so uniformly heilthy and unaltered.
That the blood and blood-vessels arc active in the changes of the bones, without any
true inflammatory action, appears to be clearly shown by the fact that the wasting pro-
ceeds from within outwards, from the most vascular to the less vascular.
The following case of Mollities Ossium, reported by Thomas K. Chambers, M. D.,
is interesting, as aflfording a portrait, at an early stage of the disease, when it has rarely
• raM of MolliUr* OMhim. B% J. \\ . Trnncv. M. !>.. of nvuit-r, M««. Anerican JvuhmI of th« MmUcaI Sci-
•o€m. vol. ««»i, l»af», pp. 'iO<M%00.
764 Mollities Ossium,
been a subject for observation, and as indicating that the defeneration of the bones was
preceded by that of the muscles, and that the degeneration of the two tissues was
dependent upon the same crasis.
It is also worthy of note, that the degeneration was least advanced in the external
circumference of the bone, and perfect fat-vesicles were found in both bone and muscle.
Casb 772 : * The case was that of a young woman, twenty-six years of age, admitted into
St. Mary's Hospital, in March, 1853. She had nerer been able to follow any calling, on
account of weak health. The principal features of the cnse, in the early stage, cooststedin
defective muscular power, the flesh of the body feeling exceedingly soft and flabby, the calf
hanging down flaccid and baggy. During her residence at St. Mary's Hospital the bones of
the back and limbs were examined several times, without any deviation from the natural state
being discovered.
Spontaneous fracture, first of one femur and afterwards of the other, occurred at St. Oeorge't
Hospital, and subsequently very marked changes in the osseous structures took place. Tbof.
In April, 1853, the right arm became painful to the touch, and paralytic ; in May, the samf
misfortune happened to the left upper extremity ; in June, the pelvic arch gave way ; in Jolr.
the ribs on the right side fell in, and she began to suffer much from dyspnoea and cough ; in
August, the bones of both arms were quite soft ; towards the end of October, the distortioo
of the lower parts of the trunk was so great that the Avces could not be expelled. She died
in November.
The bones throughout the whole system were found soft and unresisting, and a sharp
instrument could be readily passed through them. A section of the tibia was of tbe color of
muscle, and presented to the knife scarcely more resistance than brain, its shape beioi
retained by the aid of the tough periosteum.
The microscope exhibited the bone as consisting of large, fiit vesicles, some containioi^ a
white, others a reddish oil. The parts next the periosteum, which felt gritty, presentev!.
when examined under a quarter-inch glass, some islands of opaque bone, the bone co^pn•rlf^
being indistinct, and the canaliculi not to be discovered.
The addition of hydrochloric acid caused a slight disengagemeut of gas.
The muscular fibre presented everywhere the characteristic degeneration.
In the preceding case, the mupcular syatoni. a.s well an the o»»eou.s, ha«l underpon**
fatty degeneration.
Mr. Samuel Solly has described two interesting cases of MoHitL's O-isiuni. which
fipjree in their general Rymptonw with those previously rcoord.Ml.t
Cask 773 : The first case described by Mr. Solly, was that of a ^'ouug woman, aged twenty-
nine, who, having enjoyed good health in early life, began to decline at nineteen, after ao
attack of scarlet fever. She suffered pains in the back, and passed urine with a whitish sedi-
ment, and her spine began to yield. The clavicle, which was fractured from a slight caa«<
. never united agaiu. The spine began to yield about the age of twenty-four or twenty-fi«?
the patient began to stoop; and could not support iier:»c!f in the upright position for a&«
length of time. At this time she had paralysis ol the ri<;hi hand, winch took place sadden!;!
and lasted about fourteen days.
A visit to Gravesend was proposed by her fricn<ls. but in crossing King William Street. «br
fell down and struck her knee against tbe curbstone. For this accident she was admitted a«
an out patient at the Western Dispensary, and continued so about six months. She denv^-i
benefit from bathing the knee with salt water, and the limb was restored sufficiently to caa^ *
her to walk. After this she kepi a day school, but became nervous and despoodiof. H^'
friends remarked great difference in her manner, her disposition seemed chao|red from tr
open and amiable temper, to one of restlessness and suspicion. They became fearfal that s^hf
was going out of her mind. She still, howrvcr, continued to conduct her school with 1'^'
usual attention and care.
In May, 1839, being exposed to damp, she had an attack of acute rheumatism, whea ^^*
was placed under the care of Mr. Dutton, of Vork Street, Bryanstone Square.
She was confined to her bed for six weeks, but during the course of her disease she ccn >
plained very much of pain over the head, but particularly at the posterior pari. She wc«
occasionally violently delirious. At the approach of convalescence, mania set in, and d«nf«
its existence she attempted to commit suicide.
* t«iincet, Marrh i-i, 1KJ»4. n.iiiktng'tf Abstract, 18.>l. vol. I, p. 114.
f Medico-Chirurgical Transactions, vol. xxvii ; 2d series, vol. ix, 1844, pp. I41>45.V !IIe<i '»•
Chirurgical Review, April, 184ri, Am. ed., pp. 418-450.
MoUities Ossiiim, 765
In Aagttsti 1839, she was remoted to St. Lake's Hospital. At this period her general
health was better than it had been for some time, and her appetite was good, but the cata-
menia had ceased for about three months. She was much deformed about the hips and
shoulders, but not in her extremities.
Her mother reports that she was able to walk about six months after her admission into
the hospital. Though suffering a good deal of pain, her mind was improving, and hopes were
entertained of her speedy and total recovery, when she slipped down and suffered much at
ihe time, but there was no fracture, and the injury was considered of so slight a nature that
the surgeon of the institution was not consulted about it. -But from this time the mother
states she was not able to stand alone ; she was carried, or pushed herself from place to
place on her haunches, and, though she frequently screamed violently as in pain, she had no
fit, nor did she lose her senses. She was not unruly, nor at all maniacal, but worked with
her needle in her usual quiet manner. The progress of the disease affecting the condition of
the lower extremities was evidently the sole cause of her inability to walk. The head was
now first observed by her mother to be enlarged, and the eyes to project, caused no doubt by
the thickening of the walls of the orbits. After remaining at St. Luke's thirteen months she
was discharged incurable, but not paralytic ; on this point, I took care to assure myself par-
ticularly. From this hospital she went to the Marylebone Infirmary, where she remained
five weeks, from thence she was removed to the Islington Infirmary, where she remained two
months, Init Dr. Solly was not able to gain any particulars of importance regarding her con-
dition in those institutions. She was then sent to the Lunatic Asylum atHoxton for six week^,
was again received into the Islington Infirmarv. from whence she was sent to Hanweli on the
lllh of April, 1842.
At the time she was received into this asylum, she was much emaciated and enfeebled, with
loss of power in her lower extremities, and two or three months before her death the bones
of the extremities were observed to lose their natural direction and become curved. Sub-
sequently fractures took place from the slightest causes. She suffered excruciating pain
during the whole time she was in the asylum, which she referred to her bones ; she did not
suffer from spasm of the muscles, as many of these cases do, and the urine, during the whole
time she was at Hanwell, was clear and natural. Her appetite was good, and all the function.*
duly performed, with the exception of the catamcnia. Large doses of morphia and other
sedatives were administered, to procure sleep and relieve pain. Her mental aberration was
extremely slight. Her sufferings were terminated by death, on the 20th of October, 1842.
Poit-morffm fxttminttlion of ihr body^ Hanwell, October 29th. Height, measnred after death,
four feet two inches, great emaciation. Head large in proportion to the size of the body ;
chest very much deformed, pinched up, and projecting anteriorly, very narrow from side to
side ; the ribs appeared widened, the pelvis extremely narrow, spine curved forward almost
at a right angle in the upper dorsal and cervical regions. Both clavicles broken and bent at
an acute angle ; head of one humerns swollen, shaft of the left broken and bent ; radius and
ulna slightly swollen, the right radius broken ; the lower extremities enlarged at the epiphy-
ses ; ossa femora on both sides broken, that on the right side in one place, that on the left
in two; the fractured portions were held together by the periosteum, but there was no attempt
at union, nor appearance of callus ; tibia and fibula on both limbs bent; all the bones of the
extremities could be fractured with the slighest force ; by merely pressing them between
the finger and thumb they gave way and cracked like a thin-shelled walnut. A longitudinal
and transverse section of the long bones showed that the osseous structure of the bone was
nearly absorbed, a mere shell being left. The interior was filled with a dark grumous matter,
rarying in color from that of dark blood to a reddish-light liver color. I could not detect
any pus globules in it under the microscope. The bones of the vertebral column and ribs
were similarly affected ; cranium very much thickened and at least half an inch in diameter,
so very soft as to be easily cut with a knife, and very vascular : the two tables were con-
founded, and the diploc obliterated. Thin slices of the cranium, under microscope, showed
that a considerable alteration had taken place in its ultimate structure. The laminated
structure of the outer and inner tables was extensively absorbed. The Haversian canals
enormously dilated, and the osseous corpuscles diminished in quantity. Joints all healthy ;
cartilages perfectly natural. Weight of brain 2!bs. 5) ozs.; arachnoid membrane milky and
slightly thickened. The brain as well as the viscera of the chest and abdomen were perfectly
healthy.
Chemical analvsis of the bone bv Dr. Lecson : —
• MeduUit,
An!mal matter 24.78
Phosphate and carbonate of lime 1.83
Water 73.30
100.00
766 Mollities Ossium.
Bone.
ADimal matter '. 18.75
Phosphate and carbooate of lime 29.17
Water 52.0U
100.0(1
In the preceding case the parents were healthy, both of whom were living at the
time of the report ; the mother aged 61, and the father 66. She lost one sister at the
age of 21, of apoplexy, and a brother at the age of 38, of diseased liver, and som^
affection of the head. She enjoyed a good state of health up to the age of 16 ; was
well developed and inclined to be corpulent ; her mental faculties were remarkably
acute, and at the early age of 16 she held her situation of governess in the family of a
colonel in the army. It is worthy of note that the disease supervened after ao attack
of scarlet fever (soon af^er the age of 19), and that whilst in the earliest and most
active stages, the urine contained a whitish sediment, in thelatt3r staq:3?, this excretion
was clear.
In the second case reported by Mr. Solly, the urine was found on examinatioo to
contain a large quantity of phosphate of lime, between three and four times the quaatity
of healthy urine. The examination of the bones alter death showed an excess of £ittT
matter, deficiency of the phosphates, and disproportion of the medullary cells to the
substance of the bone. The lefl kidney contained a calculus, consisting solely of the
phosphate of lime.
The following is the report of this case by Mr. Solly :
Case 774: The patient was a female, Sarah Newbury. I found her sitting up in bed ; her
countenance very cheerful, and excepting its extreme emaciation, not unhealthy. Her mind
WAS very active, and all her answers to my questions clear and intelligent. She is thirty-nioe
years of age, and has been married nine years and a half to a strong, healthy man in the police
force; has never had any children. Her height, nt the time of her marriage, was about fire
feet five inches and a half; her general figure slight. She was born in Dorsetshire, bat va«
in service for fourteen years in London, as a housemaid, previous to her marriage. She wa«
always able to do her work with ease. Her general health has been good, though, she savf,
she never was particularly strong or robust, and has been subject to sick headaches. She
has been always regular at her monthly periods, but has suffered both before and after marriai^e
Troni the white discharge. She considers that her health has been failing her for aboat three
years, but more than that time. In May, 1840 — that is, about three years and a half ago—
she was seized with a violent pain in her back when she was stooping; and after that she bad a
strange sensation down her right leg, as if a pea was rolling down. She does not remember
liny other circumstance relating to her general health, until June, 1841, when she bad rheu-
matic pains in her limbs, but never any true rheumatic fever, nor any swelling of the joint*
Prom this time she constantly suff'ered from what she considered rheumatic pains, and was »o
feeble on her feet that in February, 1842, she had a fall — which, in fact, she says aba had been
expecting every day — when her left thigh was much bruised ; but she did not feel anything
give way; but in consequence of the bruises she was confined to her room. After this, the
occasionally suffered a great deal of pain in her limbs, which, she says, seemed to be tn her
bones; and she was not able to walk unless on her left leg, and with assistance, draggtog the
right after her. In the April following — that is, about two months after the accident — when
her husband was lifting her from the fireplace to carry her to bed, she says she saddeoly fell
the most excruciating pain, just as if her thigh were being broken in a thousand pieces : aa«i
licr husband told me that he felt her thighs give away, and that they were suddenly drawn
up ; and from this time she has been entirely confined to her bed. She says that the muscle*
of her arms were now painful and swollen, but by rubbing them with oils she relieved them
Her present condition, October 2, 1843 : I do not perceive anything abnormal in the appear-
ance of the bones of the head or face. The countenance is emaciated. There is a l*terAl
curvature of the spine; in the dorsal region the convexity is to the right, the concavity to the
left. In the centre of the lumbar region the spine curves forwards: the inferior vertebrae.
with the upper portion of the sacrum, projecting* backwards ; the lower portion, with the
coccyx, turns suddenly forwards, forming almost an acute angle. On the left side the rih*
project backwards to their anatomical angles ; from that point they are bent directly forwards
forming an acute angle, which projects posteriorly, looking at first sight like the sptttoai prv>
cesses of the vertebrae in a very thin person : the side of the thorax from the angles betac
flattened or itlightly concave, and the lateral itSameter of the chest much dimioished io coof»-
Mollities Ossium, 707
quence. This latter deformity has evidently been produced by her lying altogether on the left
side, either on a pillow or on her arm. The claTicIes have both been fractured and reunited,
and are bent at a right angle in the centre. The bones of the arm and hand are all natural.
I could not examine very accurately the ilia, but I perceived that they were evidently folded
inwards. Both thigh bones are broken. The lower portion of the left is twisted around, so
that the patella faces inwards. The right thigh is bent completely at an acute angle in the
centre. The lower portion turned outwards. The tibia and fibula of both legs and the rest
of the bones, appear quite healthy.
I now made her an out-patient of St. Thomas's Hospital, for she refused to corae into the
house, and I prescribed for her a simple bitter infusion, as her appetite was failing. This,
however, she refused to take ; and I received a letter from her a few days afterwards forbidding
my visiting her any more. I mention this to account for my losing sight of the case until the
litb of April, 1844, when her husband called on me to request that I would admit her into
the hospital, which I did on the following Tuesday.
April 15, 1844. Present condition : the disease had been progressing, but not very rapidly.
The countenance is rather more emaciated, and both mazills appear narrowed from side to
side. The alveolar cavities of the superior incisor teeth are softened, allowing them to pro-
trude forwards, and she is not able to bite with them. The right humerus has given way in
the centre, and the arm lies perfectly useless in the bed. It cannot be moved without giving
her great pain. The radius and ulna are not apparently altered, but the metacarpal bones
and phalanges are quite soft. The whole hand is rather swollen and pu0y, and its natural
appearance changed.
The thorax is much narrower. On the left side there is a depression about the ctrcum-
fvrcnce of an orange, the centre of which is occupied by the fifth rib — about an inch and a
half from its Junction with its cartilage; in this depression the action of the heart can be
ili!}iinctly seen and felt. Its sounds are natural. I think that the spine is rather more curved
than when I saw it in October. I do not perceive any particular alteration in the lower
extremities, though it is most probable that \hg right thigh-bone has become more flexible,
ns previous to her removal to the hospital the foot was drawn completely over the head — the
«iime position as represented in the case of Madame Supiot. She complains of the heat, and
likes to have very little clothing, as much produces a sense of suffocation ; she perspires very
very freely. I inquired of the sister whether she ever shows any particular desire for salt,
Hi has occurred in similar cases, but I learn that she does not.
April 1 5th. On her admission she was allowed wine and arrow-root, a mutton chop, and a
pint of porter daily, and was also ordered the infusion of orange-peel, a rhubarb pill when
necessary, and an opiate at night if required.
20th. On this day she died suddenly, without any circumstance having occurred during
her slay in the hospital that I considered worthy of note, as illustrating the pathology of the
case. I procured some of her urine, which was found on examination to contain a large
quantity of phosphate of lime. Mr. Heisch, who examined it, says, "between three and four
timet the quantity of healthy urine."
She was too suspicious and irritable to let me venture to take any blood, even in the smallest
quantity, during her life. As, however, it was perfectly liquid afier death, I had no trouble
in procuring some for examination under the microscope, but it did not exhibit anything
uiinatural. Dr. Rees kindly analyzed a portion of it, but he informs me he detected nothing
iiltiiormal The immediate cause of her death appears to have been asphyxia. Mr. B. Travers
naw her in her last moments, and he says the laboring condition of the respiratory organs
uAs very painful to witness. She took a little wine about twenty minutes past six, when her
>i»ter noticed some difficulty ol breathing, and the patient stated she thought she was sinking;
>lie then became purple, and struggled some little time before she expired.
21 St. PctUmortem ezaminaiion Jifieen fiourt ajler death. — Thermometer Co® Fahr. 10 a. u.
(General appearance of the body : great emaciation ; integuments of the head and face and
upper part of the neck, livid. As regards the state of the limbs, in addition to what has beep
reported during life, it was found that the radius and ulna on the right side had gi\-cn way
aoove the middle, and that the metacarpal bones a:d phalanges of the same hand were all
flexible. On the left side all the bones of the upper extremity appeared in their natural con-
tlition inasmuch as their form was not altered; hut in testing ihoir strengih they yielded to a
\eTj slight force, and they might be bent in almost any direction, thf litminatcd thell break-
ing oft short. In the lower extremities the tibia and tihula of the left side yielded about two
inches from the knee-joint ; below this point they were firm. Those on the light side resisted
presanrc, and though they were not so heavy or hnnl n^ in a healthy Fuhject, the discnfe had
^riilenily made very UttU if any progress in them.
//«a</. — Calvarium very soft ; dura mater excessively adlierc-nt and, trhi-n toin off, innumer-
able vessels poured forth their blood in large quantity. The under surface of the calvarium
was more vascular than I scarcely ever remember to have ^ecn it. and all the ve«$(eN were fuU
Qf darl( blood.
768 Mollities Ossium.
Some serous efiusion within the cavity of the arachnoid.
The brain was healthy throughout; the hemispherical ganglion was natural in appearance,
neither pale nor dark-colored.
Thorax: — This cavity was so much dimiuished in its transverse lateral diameter that a
skewer passed from one side to the other, through the intercostal space between the fifth and
sixth ribs, gave only four inches. On the right side there was a general depression of all the
ribs ; but on the left, the fourth, fifth, and sixth ribs were, especially, bent inwards, immedi-
ntely over the heart. It was in this hollow that the heart could be seen pulsating during
life. The serous membranes of the heart and lungs were all healthy.
The right lung was compressed to about oue-fourth of its natural size, presenting the ap*
pearance which it does when bydrothorax is present, for it was excessively congested, and
almost impervious to air; very much consolidated, but not from inflammatory effatioo. The
left lung WHS also diminished in size, but to not more than half the extent of the right; it wa^
likewise much congested. The heart was natural and full of blood.
Abdomen: — Intestines tympanitic, venous congestion of the liver; spleen small, and rather
sanguine; pancreas healthy.
The lacteals were distended with chyle, which presented the ordiunry granulnr appearance
of this fluid.
The thoracic duct was almost empty ; the fluid which it contained consisted of i^anular
matter similar to that of the lacteals, and also some chyle-globules, which were of the usual
character. Different parts of the sympathetic nerve were examined, but they presented
nothing unusual in their appearance.
The left kidney contained a calculus of considerable si^e, which, on examination, was fonnd
to consist solely of phosphate of lime.
Female organs healthy.
Seeiion of tfte bones: — The bones of the skull were not thickened; they were very vascular
and soft, though by no means so much so as in the first case ; they contained, in small quan-
tity, the same kind of red substance which was observed in the former case. Their section*
exhibited a similar open reticulated texture as that in the skull in the first patient.
A section of the radius exhibited very beautifully the progress of this disease ; at both
extremities there was merely an unnatural degree of vascularity, though the vessels formin;:
it were not very red. The bead of the bone was more injected than the lower end of it; at
the lower part of the upper third, the cancellated structure had been partially absorbed, and
its place occupied by the red grumous matter. So little of the earthy matter had beet*
removed, that the bone retained nearly all its natural firmness.
Sectiona : The Sternum. — Externally this bone did not seem much altered in firmness ; it was no:
nt all altered in form. But internally the disease had advanced rapidly, absorbtioa of xht
earthy matter having taken place in patches, and the red substance occupied its place. The
appearance it exhibited has been very beautifully represented by Mr. Kearny.
Rib», — It was evident, from the external form of these bones, that they were exteasivelr
diseased. Only one was divided, which was interesting, from its showing the disease in vari-
ous stages of development.
Spine, — The same appearance in these Lones as in the rest.
Thigh'bontt. — The right one alone was divided, and in this the disease had made such pro-
gress, in the centre of it, that the whole of the osseous matter had been lemoved, and nothio;;
but periosteum and membranous matter left ; while at the upper part of the lower third vr
ihc bone, the red matter wns abundant, exhibiting various hues, from a deep Modena red, to
a bright scarlet crimson, the osseous laminated shell remaining, but almost as this ss a
wafer ; then towards the condyles a portion of the bone was nearly of its natural color, obIt
yellower and softer, from an abundance of fatty deposit. The extremity of the boDe, to tb«
extent of about one-third of an inch, was of a bright red color, contrasting beautifnllj with
the clear, healthy color of the cartiingc. This redness was evidently the effect of iDflammatoijr
injection of the vessels.
A section of the head, neck, and upper third exhibited, to a certain extent, the same ap-
pearance as a corresponding section in the case of Caroline Slephens. There was, however.
H difference of considerable interest, in n pntbplogical point of view, in illustration of tbt
course of the disease.
The cells which contaii.td the red matter -were distinct throughout the section, but ia soaie
of them this matter had become entirely obsorbed ; a transparent serum occupied its plsi^
The head of the bone was completely hollow, and filled with serum ; there were two other
smaller cavities nt the lower portion of this part of the bone, filled in the sane nanaer.
The red matter I examined carefully under the microscope, with my friend, Mr. Birktttt. *f
Guy's, who has drawn up the following report of his observation :
• From the cellular spaces of the cranial bones, a soft, reddish, gelatinous solid coald t«
removed. It mingled readily with water, rendering the fluid turbid. In it I could soe cells
with nuclei of two kind<). The fir?! round, ond clearly exhibiting a nucleus and aucleolos
Mollities Ossium. 769
they were, bowever, few in number, and certainly could not be said to compote the mass of
the solid, which apparently contained a delicate fibre of fatty matter. The second kind were
very clear, their edge being remarkably distinct, and the clear oval outline inclosing one
bright central nucleus, rarefy twOj never more. There was a tendency to elongate into the cau«
date cells, but this appearance was very rare. Many other cells of irregular fignre and shape,
some with, others without central nuclei, existed.
*' Large cavities existed in the body of the vertebree, filled with a dull, oily, reddish matter,
and which contained a great number of cells having an irregular outline, and some a very
distinct nucleus, rendered more distinct by dilute acetic acid. I could find no distinctly cau-
date cell, as in the cranial bones, and the identity of these cells with pus-globules, (for they
appeared larger than pus-globules commonly are), or the commonly called nucleated cells of
raalignftDt disease, was difficult to determine; in the femur I saw nothing but fat cells and
blood-disks."
"The red colored matter in the bones," says Mr. G. Rainey, of St. Thomas' Hospital, who
also examined it, '< consists of a multitude of roundish bodies, almost the sise of the blood cor-
puscles, each of the bodies being filled with a minutely granular substance. Besides these
bodies, it contained also fat globules, but no regular fat vesicles, and it appeared to be wholly
destitute of any fibrous or cellular structure."
Mr. Simon, of Ring's College, examined portions of the bones, and thus expressed himself
in a note to me on this subject : " My examination was not at all satisfactory as to the ulti-
mate nature of the disease. There was great excess of the natural fatty matter, and dispro*
portion of the medullary cells to the substance of the bone ; in parts there was apparently
extravasation of blood, which may have arisen from violence. I was unable to discover any
new cell formation, at least any mature one ; cytoblasts were exceedingly plentiful, so as to
suggest the probability that some such formation was in progress, but nothing further, with
the exception of some two or three apparently detached young fat cells. Decidedly there
was no show of growing cartilage."
After a careftil coDsidenition of all the facts, and especially by compariDg the appear-
anoea after death with the Bymptoms during life, of this awful disease, Mr. Roily
was led to believe that it is of an inflammatory character ; that it commences with a
morbid action of the blood-vessels, which give rise to that severe pain in the limbs
invariably attendant on this disease, but more especially in its commencement, and
exhibita itself after death, by an arterial redness of the parts. The absorbent vessels
are at the same time unnaturally excited, and the earthy matter of the bone is absorbed
and thrown out by the kidneys in the urine, which excretion is sometimes so abundant,
aa we have seen in the last case, that it clogs up the calices and pelvis of the kidney and
forms there a solid calculus.
The place of the phosphate of lime in the bones, is supplied by that morbid secretion
of red, grnmous matter, which has been so universally found in this disease, and which
was ao abundant in both the cases just related. The microscopical examination of this
matter confirmed Mr. Solly's impression, that it is an adventitious, morbid product, and
not simply the fatty matter of the bone, altered by the effusion of blood into it.
Mr Solly ooncludod that the enormous hypertrophy of the bones of the skull, in his
first ease, aa also in that of Madam Supiot, demonstrated that it is an active disease,
and not a mere atrophy. Indeed, he supposed that the inordinate vascularity of the
bones of the skull, though unaccompanied by increase of thickness, in his second case,
proves nearly as much ; and he had no doubt but that if this patient had not died so
auddeoly, bat had survived another twelvemonth, a similar thickening of the skull
would have taken place. It is interesting, in relation to the pathology of the brain, to
observe the eflfect of this disease on its solid covering in the case of Stephens, where the
intellect was deranged. Whereas, in the latter instance recorded by Solly, the mind
remained perfect to the last« where the skull was not altered in it dimensions.
Dr. Thomas Blisard Curling has recorded the following case of Mollities Ossium,
under the head of Eccentric Atrophy of Bone :
Ca8b775:* Catharine Burne, aged 72, was brought to ibe I^ondun Hospital, from the
workhouse at Poplar, February 18tfa, 1833, in consequence of a fracture of the right femur.
* Obaerffttionii on tioine of th« Forms of Atrnplijr <*f Iloni*. By Th' tuus Blir«rd rarUia • Mrdico-Cblnirf k«l
TrUMK- Uoni, 1K36, vol. xx.pp. S-'^S-a?*}.
f7
770 Mollities Ossium,
She bad been an inmate there since the 18th of September, 1827, and bad been bed-ridden
for nearly four years, on account of paralysis of the lower extremities. The hip and knef-
joints had been in a state of flexion so long that it was impossible to straighten them, and for
some years she had experienced great pains in tbe knees and thighs. She bad been subject
to hysteric fits, also to a slight cough, and ever since her last confinement had been troubled
with incontinence of urine, in which secretion, nothing peculiar h:id at any time been
remarked. Her appetite had always been good. On being turned in bed by a nurse, on the
morning of the day that she was sent to the hospital, her right thigh was suddenly fractured.
About a fortnight after her admission, whilst being moved in bed, her right humerus was
nlso broken. The arm was placed in splints, but from this time she gradually sank, and died on
the 1 9th of March. .On examining the body, the lungs, abdominal viscera, and mesenteric
glands were found healthy, but the heart was rather flabby. There was considerable calca-
reous deposit in the lumbar and iliac glands, and a fistulous communication between the
vagina and bladder. Between three and four ounces of serum escaped from the cavity of the
arachnoid ; and between the layers of that part and the dura-mater covering the upper sur-
face of the brain, some tubercles were found. All the articulations were in a healthy state.
The periosteum was everywhere normal, except over the trochanters, where it was entirely
detached, owing, most probably, to inflammation induced by the pressure to which they bad
been so long subjected. The bones of the skull and pelvis might be cut with a strong knife,
but the. ribs and vertebras were only slightly affected, being scarcely less firm than usual.
The femur consisted of a thin shell of bone filled with medulla, its cellular structure being
entirely obliterated, except in the head of the bone and at the trochanters, where there was a
slight appearance of cancelli greatly enlarged. Some dark spots were observed at different
parts of the interior, which were found to be produced by extravasated blood. The fractured
extremities of the right thigh bone had a slight ligamentous connection. The tibia also con-
sisted of a mere shell of bone, elastic, and yielding under the finger like a thin piece of ivorj.
the cancelli being removed, and the interior likewise filled with medulla. Although only a
thin lamina of bone remained at their extremities for the attachment of the articulating carti-
lage, that structure was not in the slightest degree affected. The tarsal and metatarsal bones'
and the bones of the phalanges of the toes were much less firm than in the natural state, and
their cellular texture enlarged. The humerus was firmer than the thighbone; it did not
yield to pressure, and in order to make a section of it, the use of a saw was necessary .
whereas, all the bones of the lower extremities could be readily cut with a-knife. The walls.
however, of the bones of the superior extremities were preternaturally thin, and their medul-
lary cavities evidenty enlarged. Upon making section of the different bones, patches o( h
light red color were remarked at different parts, and these, upon inspection with a magnifier.
were found to arise from the minute vessels of the medullary membrane being highly injected
with red blood. The oily substance with which the bones were filled, closely resembled the
mednlla of an old subject, and several of the bones having been placed for some months in
water to masoerate, it was converted into adipocire, a beautiful specimen of which wv
afforded by a section of the humerus
It is to be regretted that it was impossible to obtain a fuller account of her state of
health, and of the difTordut secretions at an earlier peHod of the disease.
From a review of all the circumstances connected with this and other forms of atr>>
phj of bone, Mr. Curling concludes that the wasting of the osseous tissue is here th^
result of defective nutrition, and not of increased activity in absorption, and resembles
the decay which occurs in advancing years ; in both, the lesion is more remarkable io
females than in males, and in both, the atrophy is chiefly eccentric, and the interior of
the bones is filled with an increase in the medulla.
If it were owing to the latter action, continues Mr. Curling, we should expect that
the wasting process would go on most rapidly in the cancellous and vascular parts i'f
bone, whereas wc firxd that the c^^nscr parts, and those of inferior vascularity are most
rapidly removed,
Again, the disease appears first in the bones of the lower extremities, for the sustr
reason, prohat^y, that all morbid changes consequent upon defective nutrition, or a feeble
circulation, commenoe oftei^er in the depending parts.
According to Mr. CurUng, the various apearances preaeuted by the medulla, whicli
is sometimes described an yitiatedx or as being of a reddish color, and resembling flesb.
liver or tallow, is owing to alight modifications in the secretion, together with soot
degree of inoreaaed ya^ularity in the medullary membrane, or to tho medulla lunttz
mixed up with blood accidentally efiused^ as would readily happen, if th^re va? mU'h
Mollities Ossium. 771
•
distortion. Mr. Curling was »itLsfied, from his examination of the bones in this dis-
ease, that the matter with which the bone8 arc filled is nothing else than an increase of
the true medulla, somewhat altered in appearance, but very slightly in its cssentinl
characters.
M. Saillant, in a case which he brought before the Faculty of Physic in Paris, in
1792, calls the disease medullary gout. Indeed, rheumatism has frequently been con-
sidered as giving rise to it. All the cases have been accompanied with severe pains in
the limbs, and many of them preceded by severe rheumatic attacks. M. Kiiian asserts
that the most common exciting cause is violent cold, produced by getting wet through,
especially during menstruation, or the presence of the lochia ; he also enumerates sud-
den fright, grief, misery and poverty. The most severe cases, according to this author,
occurred in women confined in damp prisons.
Mr. Howship remarks in reference to this disease, that it is the ^^ effect of a morbid
action in the capillary's arteries upon the medullary membranee within the bone ; and
most probably the progressive absorption of the bone itself was merely one of the oon-
seouences of the long continuance of the malady."*
if the view expressed by Mr. Solly be true, that Mollities Ossium is of an infiamm-i-
tory character, it is evident, however, that the altered state of the osseous tissue is essen-
tiallv different from that which commonly occurs in inflamed bones. Thus, in inflam-
mation of the bones, the periosteum is always more or less involved, and the appearance
of extravasation of blood in Mollities Ossium may arise, in part at least, from the frac-
tures and distortions of the bones.
It is well known that in bad cases of scurvy the bones occasionally become so brittle
that they are broken by the slightest causes, and do not unite again by callus, as long
aa the scorbutic state continues. And in some cases of scurvy the callus of old fractures
18 destroyed after it had been formed. Boyer, in his Lectures on the Di»ea$e8 of the
BoneSy states, that if the bones of a scorbutic person be boiled, the periosteum separates
very soon, lamellae scale off, and, in some cases, the bone dissolves entirely. They also
fall into powder if kept for some time, but particularly if exposed alternately to heat
and moisture.
It is also well established that in this peculiar state of the system induced by same-
neaa of diet, and salt food, the smallest injuries, and even vaccination, may be attended
with the most extensive and foul sloughing and gangrenous ulcers, involving in one
common destruction integuments, muscles, nerves, vessels and bones.
The origin of this state of the system is clearly referable primarily to changes induced
ID the blood, and secondarily to the perversion of nutrition and the degeneration of the
solids.
In like manner it would appear to be more philosophical to refer that peculiar state
called mollities ossium, to derangement of the blood and nutritive processes in its origin,
rather than to a peculiar disease of the bones, originating solely in the osseous system.
In many of the cases there would even appear to be some connection between this
disease and scurvy. The case related by Mr. Clooch and Dr. Pringle, to the Royal
Society in 1753, had symptoms of scurvy, and bled much at the gums. Madame
Sapiot, for two years before the disease commenced, had been in the habit of eating a
pound or a pound and a half of common salt in the course of a week, without any
vehicle. In this case the gums swelled much, and were separated from the teeth,
allowing them to fall out. In the case of Sarah Newbury, there was no bleeding of
the gum, bat the teeth became loose in consequence of the softening of the maxillae.
Again, the disease is frequently attended with symptoms of a remarkable kind, which
can only be referred to changes in the blood and vascular system. Thus, in the case of
Madame Supiot, it was noticed that, when the bones were softening, the urioe deposited
a white, chalky sediment, which came away after her pains, and ceased towards the
termination of this protracted case, when scarcely a bone remained for the disease to
•
* Sdiabarg Medico-Chirurgical Traoaactions, vol. ii.
772 Mollities Omum.
prey upon. Both the oriae and saliva stained the linen black. In the case of James
Stephenson, recorded by H. Thompson in his Medical Observationt and Inqairia (yoL
t), for the first two years of the disease, the urine deposited a whitish sediment, which,
upon evaporation, became like mortar, and the patient, a shoemaker, at Wapping, voided
three or four small jagged stones some time after a complaint in his loins.
In the case related by M. Saillant, the urine was high colored, turbid and fetid, and
the hands and feet were constantly covered with an unctuous humor, which, as it dried,
thickened into scabs. In the case reported by Mr. Howship, the perspiration was
abundant, and possessed an unusual fetid odor. In another case reported by M. Saillant
there were copious sweats, and an almost incessant salivation.
All these circumstances seem to indicate that the blood was loaded with somethiog
which was necessary to be eliminated by the skin, kidneys and salivary glands.
These symptoms sustain the view advocated by Meischer and others, that the earthy
parts of the none, after being absorbed, are excreted with the urine, in which they
deposit a white sediment, cretaceous and soluble in acids, and that this solution of the
earthy parts of the bones is dependent on an acid diathesis, as exhibited in acid eracta-
tions, vomiting and sweats.
CHAPTER XXI.
RELATIONS OF MOtiLITIES OiSTCM TO FRAOIUTAS OSSU'M.
Cue of Marshal Lewis, observed by the author — lUastration of the bereditarj brittleness or
bones, recorded bj Dr. Paull, of London — There is a state of the osseous system, correctly
indicated by the term Fragilitas Ossium, which cannot be referred to the syphilitic, scrofulous
or cancerous cachexia, and which exists with health.
Whilst it \a true that the bones become fragile in ecrtaia stages of mollities ossium ;
and whilst a certain degree of fragilitas ossium occurs in old age, and in some cases in
the latter stages of syphilis/ and in certain cases of cancer, where the whole mass of
fluids is infected, and the virus attacks the bones, destroys the vital parts, and renders
them brittle-r-at the same time there is a true fragilitas ossium, distinct from these
diseases and from mollities ossium.
I have enjoyed the rare opportunity of seeing these two diseases at the same time and
10 the same place, and of comparing the two diseased actions.
The following case of fragilitas ossium came under my observation at Nashville,
just at the time when I was treating the case of Miss Rancy Prucilla Bosel.
Casi 770 : Blarshall Lewis ; dark mulatto ; age 24 ; Nashvillf , Tennessee, 1868. liis father
and mother stated that, when about two years of aji^e, Marshall was attacked with typhoid
fever in the fall of the year, during an epidemic of this disease which prevailed in the neigh-
borhood. The case was somewhat protracted, and the attending physician administered
calomel daily in small doses. The child recovered entirely, and enjoyed good health. When
three years of age, Marshall accidentally fell out of the door (the house being built on the
ground and low,) and caught on his hands. His legs striking -the door-sill, were fractured
ahort off about the middle. The attending physician set the legs in pasteboard splints, and
directed that they should be wet with vinegar, which caused the splints to slip off, and the
bones of both legs united irregularly. Since this time he has had numerous fractures, num-
bering in all near >f//y. The slightest fall produces fractures of the leg or thigh-bones.
Several fractures have occurred during play.
At the present time Marshall enjoys excellent health ; has never been sick, with the excep-
tion of the attack of typhoid fever. Weight, 150 pounds; has weighed near 170 pounds, but
St that time was more active in his habits (followed his trade of boot-making) than at the
pretent time, when he leads a sedentary life, studying his books diligently and endeavoring to
acquire an education.
Chest large, full, and well developed, with powerful muscles. Height of Marshall, 4 feet 4}
inches. Breadth of shoulders, across from the outer border of one humerus to the outer
border of the other, 18 inches. Circumference of chest, 40 inches. The well-formed chest is
•applied with powerful pectoral muscles, and long, muscular, strong arms. Length of body
from crest of ileum to top of head, 26 inches ,* from crest of ileum to bottom of foot, 26}
inches. The latter measurement is not one-half what it should be, owing to the numerous
fractares and bending of the legs and thighs. Arms powerful and long ; length of arm from
•boulder to end of wrist, 32 inches. Hands large and powerful. Right forearm has been
broken near the wrist-joint, and in the elbow-joint, which is consideraby deformed. The left
fore-arm has been fractured twice.
The great size of the muscles of the arms and chest appears to be the result of the constant
ose of crutches in walking — cannot walk without crutches.
The thighs have been fractured so often, that they are bent like bows. The leg bones were
in early childhood broken about the middle, and the upper fragments projected anteriorly,
forming almost right angles with the lower fragments \ and the ends of the projecting bones
are covered with a hard, thick, shining, bom-like skin, although they do uot strike the ground
774 Mollities Ossium.
in walking. The length of the right thigh ia only 15 inches, and that of the right leg aboot
.16 inches. Feet quite small; the patient wears No. 2 shoes. Length of foot, 8 iochet;
breadth across sole of foot, 3\ inches. Thighs, although missltapen and bent like a bow,
with large masses of callus thrown out along the femur, are still large and muscular, whilst
the muscles of the legs are greatly wasted.
The parents were disposed to regard the brittleness of the bones as due to the typhoid ferer
and calomel, but nearly one entire year had been passed in good health before the appearance
of the fragilitas ossium ; and in addition to this, in reply to various inquiries relating to con-
stitutional and family diseases and tendencies, I was informed that the niece of Marshall's
father has had numerous fractures, being afBicted in a similar manner with Marshall, althoogh
she has borne children and is apparently stout and healthy.
Mother of Marshall, a powerful, hardy, black negro woman, age 52, has had twelve children,
all of whom were vigorous and strong. Those of her grown children whom I have seen are
large and healthy. Father of Marshall, a stout, light mulatto man, 52 years of age.
The points of interest presented by this case, as distinguishing it from moUiti«
ossium, were :
1st. The fractures were attended with little or no pain, and healed rapidly by the
formation of callus.
2d. The general health of Marshall Levtis appeared to be perfect, and there were no
marks of cachexia or of a scrofulous or syphilitic taint.
3d. The appearance of the same brittle state of the bones in a niece of his father*s
indicated a constitutional origin of the disease, or rather that the brittlenen of the
bones was hereditary.
Dr. Paull, of London, has recorded a striking illustration of the hereditary btittle-
ness of bones and their repeated fracture in members of the same family. All the
members of a family residing in the commune of Offenbach have had fractures ; three
of them have each had two fractures ; another three ; one has even had as many as five
fractures of one or the other extremity ; and to produce these injuries oo considerable
violence was in general requisite. The father and grandfather before them bad fric>
tures of the limbs. Dr. Paull, moreover, described this fkmily as a very healthy one,
without any scrofulous or other perceptible taint. It is remarkable that not ooe of
them suffered a fracture before the age of eight, so that one might suppose thai thb
peculiar fragility of the osseous matter was developed only towards the age of pubertj.
Dr. Paull conceived that the condition of this fragility consisted in some change of tb«
chemical constituents of the bones in their relations to each other.
It has been frequently observed that men addicted to the use of brandy ofVen exp.*-
Hence fractures (in consequence of a degree of brittleness induced in the bonea,) which
require a long course of treatment to insure their consolidation. Dr. Paull met with this
fragility of the bones in a subject of this kind, a man 54 years of age, who hung him-
self at Yorchlengen ; the ribs, particularly, snapped like glass, and a very moderate force
sufficed to fracture the long bones. But if fractures in these old drankanls an cored
only very slowly, precisely the contrary was the case in the family above meotioDed ; ivr
in every instance that occurred in it the fracture was very speedily consolidated, so that
generally the callus was perfectly firm at the end of three weeks. When the aame booe
has been broken a second time, it has never occurred at the seat of the callus.
We are justified by these cases in assuming the position that there is a state of tho
osseous system correctly indicated by the term fragilitas ossium, which cannot be referrfd
to the syphilitic, scrofulous, or cancerous cachexia, and which exists with perfect health,
and the repeated fractures are rapidly united by odlus.
Cabs 777 : A remarkable case of fragility of the bones, accompanied by caries and altera-
tion, with profuse suppuration, came under my notice in the female irards of the Charity Ho*-
pital, during the summer of 1869. The disease, which occurred in a Tirgio adult fcma'c
twenty-eight years of age, was referred to the action of inherited and constitutional sjph. «
This case was so remarkable, that, I obtained the body, after death, which apparently tta«
caused by the profuse suppuration from the numerous open ulcers, commnnicatang viih ibc
fractured extremities of the carious bones, and prepared the skeleton, which is preterred ic
the pathological collection of my Practical Laboratory of Pathological Chemistry and Tot.-
Mollities Ossium, 77
cologj. The iotellect was clear, and the appetite and digestion good up to the time of death.
The following is an outline of this singular case:
I observed this unfortunate woman in the Charity Hospital, only a- day or two before her
ueath. At the time of my observation, she appeared to be exceedingly feeble, and was a mass
of offensive, running sores. I obtained the body after death, and bad the skeleton carefully
prepared. The hymen was perfect, and the disease appeared te have been derived from in-
heritance, and to have manifested itself in early childhood. The feet are very small — not
much larger than those of a child four years old, and appear never to have been used in walk-
ing. All the long bones of the body were more or less carious, and in almost every case frac-
tured, or, rather, ulcerated through at one or more places. The pelvic bones were carious,
and the os-sacrum a mere shell. The vertebrae were all carious. The upper jaw contained
one small tooth, and the lower jaw three teeth. The alveolse was completely absorbed. The
outer and inner tables of the skull were perforated in several diff(erent places. The lower
JAW, on the right side, was eroded through. The position of these fractures or erosions, were
marked during life, by open running sores.
It is impossible, with the pen, to portray, adequately, the terrible condition of this unfor-
tunate female, whose bones literally rotted piece-meal by piece-meal during life. And the
best description which we can give of the skeleton is to say that the bones of the feet, ankle,
the OS calls, were carious ; the tibia and fibula, the femur, the pelvic bones, the os-sacrum,
the radius and ulna, the humerus, the scapulae and sternum, the lower jaw and the cranium
were all eroded through in various places.
The bones are diminished in specific gravity, and present a light, spongy appearance,
»8 if they had been acted upon by corrosive fluids, in and around the vascular canals.
The bones resemble more nearly those of cancerous growths, and of joints affected by
syphilitic and rheumatic inflammation. In a case of ankylosis of the knee-joint, the
effect of syphilitic and rheumatic inflammation, occuring in a prostitute, and in which
the patella is consolidated with the femur, the tibia and fibula consolidated with each
other, and the articulating surface of the tibia, with that of the femur, the bones are
light and spongy, as in the preceding case, and are of far less relative weight, density
and tenacity, than the bones of an ankylosis of the knee-joints from mechanical injury.
In the ankylosis resulting from mechanical injury, although the patella is firmly consoli-
dated with the femur, and the tibia and fibula firmly consolidated with each other and
the femur, the bones present the characters and density of healthy bone.
The bones from the woman supposed to have suffered from inherited syphilis were
carefully compared with necrosed bones, resulting from mechanical injuries ; and it
appeared that the former were lighter and more spongy than the latter. Thus the se-
questrum from the thigh of a confederate soldier was employed as a good object for an
intelligent comparison.
Case 778 : The following is an outline of this case :
Charles R. Barker, G. S. vols. Tth Reg. La. Vols. ; height, five feet, eight inches; weight,
in health, 154 lbs; brown hair and eyes; nervous, sanguine temperament. Wounded in right
leg at first battle of Manassas, 2l8t July, 1861.. Minie ball struck the lower portion of the
right femur, about two inches above the inferior termination, the knee-joint. The bone was
not fractured ; the ball simply buried itself in the femur. The force of the ball must havo
been greatly spent, otherwise it would have passed entirely through the bone. The wound
inflamed, and assumed an unhealthy appearance, and twenty days after the reception of the
wound, the ibigh was amputated near the middle, or about eight and a half inches from the
trochanter major, in the general hospital at Culpepper Court House, Va. After the operation,
the wound did not heal, and the stump assumed an unhealthy, suppurating state. The patient
was confined to his bed for more than four months, during which time, there was but little
progress in the healing of the wouud, the discharge continuing, although there was partial
union of the flaps. At the end of this period, the patient attempted to walk on crutches, and
on th« 30th of February, 1862, whilst the snow covered the ground, went out. This caused
the stump to inflame, an accumulation of pus took place around the bone, and the flaps were
opened. At this time, large quantities of ofTensive pus were discharged. The patient was
so much reduced by this condition of the stump, that he was compelled to remain in bed
until the first of June. After this date, the wound slowly improved and considerable portions
of the flaps united. In December, the patient was able to travel to Georgia, and enter the
general hospital at Augusta, January 10th, 1863, and at this lime came under my treatment.
Aft«r careful examination, the bone was found to be extensively diseased ; and the discharge
(CQCD several fistulous openings was profuse and fostid. At the tim^ that this patient enteretl
776
Hollities Ossium,
tbe general hoiplul, hs was in » moit wealc and feeble con4itioD, and Buffered Trom becUc
Tever coniequent upon tbe coadilion of tbe ilump. The palie WM rapid and reeble, aad tbe
compleiion duikj and aahealttij. The alougbing vent od rapidly, until tbe bone of Ibe
thigb was eipoied ftDd denuded. Tbe palient wai placed upon tbe Tarlraie of Iroa and
PolaiM, Sulpbate of QuiDis^geiieroui diet, and alimuianti and opialei. Under this treat me nt,
the patient gathered sufficient tlrengtb to reEume tbe use af his crutehei. After some im-
prudence, tbe patient wai again prostrated. Tbe bone, nbUh wai eiamined daily, Gnillj
protraded a little and gare unmiitakable eridence that it was detached. On the 24th of Uaj,
1 placed llie patient under the influence of chloroform, and abstracted Ihe hone, ieiea and a
half incbet in length, nod eitending to tbe Irochnnler. I lost sight of ibis patient, nntil I
found him in the Charity Boipital this winter, jast after I had eihibiled tbe dlieased bone to
the medical class. Tbe limh healed up entirely, and Ibe patient n-eara a itninp. Tbe periol-
team of the bone threnr out another bone, and tbe tbigli feeli as if it bad a large bone.
The bonea affected with syphilis, were io strikiag contrast to the dense, strong booe*
of a man who hsd suffered with rickets and caries of the vert^ne, and who was «id-
denl; killed.
Specimens illustrating these varioug points, are preserved in my Practical lAbntorj.
The following case Ulastrated the ravages caused by Scrofula, and the wonderful
resources of nature in the endurance of disease. I olMerred this case in NashTille,
Tennessee, and at my request, Br. John W. Morton, Jr., drew up a careful report, and
also caused the execution of photographs.
Cltl 779 : lUutlraling tt
'e Curia of the Virltbru anil Sibi, and Per/oralioii of tlu Lwtgt.
rs. From birth up Ii
was stout and healthy, and
1 inflammation of tbe Lyn-
phalic Glands of ibe neck. la 1803, Joined the Federal Army, but returned to bis bone in
Alexandria, Tennessee, in 18ii4, in feeble health, with eiteniive ulcerations on the neck and
chest. Came to Nashville, 1866. I saw him for the Grst lime, July IStb, 1B6T. The follow-
Ing was his condition: Blitck skin, woolly bead, wilh thick projecting tips ; large, swollen
abdomen; heads of iong hones en Urged ; knee and ankle-joiols swollen; bands and feet
very large; ill-formed. Appetite irrcgulnr, somelimes deficient, at olber timei raTenoaa.
Craves fruit and vegetables. Speaks with great difflcnlty ; voice feeble and irregnlar; air
issues from an nicer wbich penetrates through the 3d and 4th ribs of the left side, and oOH-
mnnicatrs with tbe lung. The patient breathes through this opening as well as tbrongh tbo
mouth. He is able to practice respiration through tbe opening when the mouth is closed.
The opening into tbe lung is about one inch in diameter, and is surrounded by extensive
marks of ulceration. Tbe last cervical, Isl, 2d, llth and 12th dorsal vertebra are carions,
and discharge pus. The spine has both a lateral and anterior curvature. Tbe bead is forced
down upon tbe chest. It is necessary for tbe palient to carry a pad upon the chin ia order
to facilitate respiration. Liiternl and anterior and posterior inotioas of ibe head alnoU
entirely lost. I'lcera eiist over Ihe neck end breast and sternum, which disoharge pni and
fragments of bone. Pus, with IraBm'n's of bone, issue from Ihe ear. A larga ulcer is aJ»o
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20
21
20
19
131
131,
ISI
130
51
TOi
10
61
7UJ
:i
71
71
"i
19
15!
'4
10)
16
16
IG
1*1
16
17
16J
1st. Healthy sultjecl
3d! "
4th. "
5th. " "
Mollities Ossium,
777
fuuud in the left axilln, which penetrates through the ribs into the lungs, and respiration \»
performed through this as well as through the one previously described. Several of tlie
bones of the feet and hands are In like manner carious. Pulse, in sitting posture, 102, stand-
ing, 120; respiration, sitting, 32, standing, 48; temperature of hand, 98.^5, under tongue,
09.^5. Very feeble, walks with great difldcnlty. The heart has been displaced and rests
beneath the upper portion of sternum. Left lung contracted, right lung much consolidated.
Died apparently from suffocation, December 20tb. The preceding measurements will illustrate
the effects of the caries of the vertebrae and ribs in altering the proportions of the form in
this case.
^* . '-> 3
C HA PTER XXII.
HELATIUNS OF MOLLITIKS OS.ll M TU RICKJ-rTS ^RACHITIS).
Di'ficieucy of phosphate of lime characteristic of both Rickets and Mollities Ostium; the
former confined to no sex; a disease of childhood, and capable of cure; the Utier most
commonly attacks adult females, and is almost universally fatal — Distinctions between the
ciianges of the bones iu these two diseases — Results of microscopical inTesti^atioos.
Upon a superficial view, rickets and uic^llities ossium appear to be closely connected ou
iiccount of the flexibility of the bones and the fractures upon slight cau;se8 which
characterize both diseases. Some authors, led by these general resemblancee, have
regarded the latter disease as rickets attacking the adult, A careful analysis and com.
parison of the phenomena of the two diseases, however, will show that the resemblanct-sj
of the two affections are far exceeded by their differences,
A deficiency, actual and relative, of phosphate of lime in the osseous system, charac-
terizes both mollities ossium and rickets ; in the former, however, the skeleton, origi-
nally normal in structure, loses its earthy matter, becoming fragile, soft and pliable ; in
the latter, the osseous structure is abnormal from the first, or from an early age. Irueria
found that of 346 cases of rickets, 201) were affected l)etweeu the first and third year,
these were congenital; 34 occurred between the ages of four and twelve; 148 wciv
males and 198 females. Cases of congonitnl racliitL^ have been mentiimed by llipj").
crates and other writers.
Mr. Tamplin* has described a skeleton affected with ricket^s in a seven mouths' fcvtu-.
Kickete has been observed in the young of wild animals (lions and tigers) born darin::
the captivity of their parents. The disease appears to be intimately connected with a
marked cachexy of the system, which seems to be identical with the scrofulous, and t.i
be induced by insufficient nourishment combined with bad hygiene, and damp, foul air.
The process of dentition also, by the disturbances which it cau.ses in the alimentary
canal, and by the drain which it establi.shes upon the mineral constituents of the iilo"»i
tends to develop and aggravate the disease.
On the other hand, mollities ossium attacks adult-*, and especially women after th»)
have commenced child-bearing.
Mr. Curling states : that " there is a .^kelotun in tlu- collection of the Collr^' "f
Surgeons in Edinburgh, where the spine, thorax and pelvis, are greatly distorted by tb»
disease, taken from a female, who had had seven children, each labor having been accom-
panied with increased difficulties, and the death of all the children, excf'pt the lastchil-l.
whose life was saved by the performance of the Civsarian ^►?ctinn, which o|vniti-j
however, proved fatal to the mother. Medico-Chir. Trans., vol. x. p. :]i\\.
In the sixteen cases collected by Mr. Curling.f thirteen occurred in females, and onli
three in males ; eleven were fatal between thirty and forty ; iu none did the di&ca«.*
show itself before puberty ; but two patients were above fii\y years of age, and xnera!
of them were delivered of children during the progress of the complaint.
The softening of the bones is slow and gradual in rickets, and unaccompanied hvfciln
* Lectures on the Nature and Treatmt^nt of Deformities. \m. ed.. pp. ir»<i-l.'»T,
f Medico-Cbirnrrf, Tran<?., vol. vt, p. XU'u
Mollitics Osaium. 77^
*
while in mollitles ossiuui it is sudden and rapid in its progress, aud accompanied often
with great pain.
The progress of this affection of the osseous system varies greatly, the bones becoming
atrophied in some instances in a few mouths ; more commonly, however, the disease is
extremely chronic, going on for many years before the death of the patient. In most
cases, it is noticed that the various functions were duly performed, unless interfered
with by the destruction consequent upon the yielding of the bones, and it is distinctly
stated that the internal organs were found in a healthy condition after death, showing
that the disease is not associated with any particular lesion of important viscera.
Sir Charles Bell,* in his Lectures, Illustrated by the Hunterian Preparations, quotes
from the '' Medical Observations and Inquiries," a remarkable case of Mollities Ossium,
where a man going up stairs struck his toes against a step, and broke his thigh bone.
The surgeon attended, with all proper appliances, to the thigh bone, but the usual
period expired without union being discovered at the fractured part. A consultation
being called, on raising the leg the thigh-bone broke again in the hands of the surgeons.
The disease proceeded to such an extent that the flexor muscles twisted the bones, so
that the heels were drawn back of the head, and the trunk itself before death, became
greatly flexed.
Mollities Ossium progresses, in almost all cases, to a fatal issue ; in rickets, after a
time, the abnormal condition is cured by treatment, or the progress of age ; earthy
matter is deposited in even more than its due proportion, the skeleton becomes solid and
strong, and the general health may be entirely restored.
If the patient outlive rickets and die afterwards, it will be found, upon dissection,
that the bones have assumed great weight and density, and, in some instances, the cavi>
ties of the cylindrical bones are said to have been filled up with earthy matters. And
it has been noticed, in some instances, that such persons, on recovery from the disease,
acquire a surprising degree of strength. Sir Charles Bell* mentions an individual by
ihc name of Farrel, known on the streets of London as *' Leather-coat Jack,*' who
would throw himself under a hackney-coach, and allow the wheel to go over him, for a
pot of porter. This short, deformed man, who had been afl^icted with rickets in his
youth, exhibited great feats of strength, bearing an anvil on his breast, and carrying the
tallest men by placing his arms under their thighs. Sir Charles Bell also cites the
extraordinary manifestations of strength by another dwarf, aud rickety subjt>ct, called
the *' Little Hercules."
The general health in Mollities Ossium is hopelessly impaired, the flesh and strength
diminish daily, and in some cases the muscles undergo fatty degeneration. The observa-
tions thus far recorded, have not been sufliciently numerous or accurate to decide the
((uestion whether the degeneration of the muscles is always present in this disease.
The fatty degeneration of the muslces in those cases in which it has been observed
can with great reason be referred to the action of the same causes which induced
the softening and degeneration of the bones.
The pale color of the muscles in some cases of rickets appears to be due to the
nnn?mic condition of the system, rather than to fatty degeneration of the muscles; and
we have just seen that after n^covery from this dis<»;ise, the mu^^cular strength, so far
from being impaired, is often wonderfully increa.«ed.
In Mollities Ossium, the loss of earthy matter in the osseous system is rapid, aud is
frequently attended with a ('o[)ious phosphatic deposit in the urine, and the bones do
not simply lose their earthy constituents and become re<luced to their cartilaginous flexi-
ble tissue, but there is an actual change in the living cellular elements of the bones, and
a progressive degeneration, so that in many castas, the bones consist tinall}' of an external
r^hell filled with oily or lardaceous matter held in membranous tissue.
AecorJing to Mr. Curling, the atrophy is eccentric, commencing invarlal)ly from the
interior of the bones; in the long bonrs, aflfecting first the internal part of the shaft|
• Loadon Lnacct, Mttrch l,^, lyni, p. l»18.
780 Mollities Ouium,
or moi-e deuse aud compact part of the osseous tissue, aud subsequently exteudiog to
the vascular cancellous extremities, until, if the patient survives, no part of the proper
osseous structure remains, its place being supplied by increased secretion of medulla.
In the flat bones, the diploe first becomes affected, and the atrophy goes on in like manner
from within outwards, until the two external tables are entirely destroyed, and nothing;
but the medullary tissue remains. In the majority of instances, the atrophy commences
first in the bones of the lower extremities, and extends afterwards to those of the upper
and of the trunk, so that eventually no parts of the bony system escapes. The teeth
have never been known to become affected in this disease, affording another argument
in favor of the view which regards them as independent of the laws that regulate the
osseous system. It is remarkable that even in the most extreme cases of this disease*,
no change is produced in the articulating cartilages, nor in the periosteum, with the
exception of a little thickening occasionally observed in the latter. In the case reported
by M. Saillant, the long confinement appeared to have led to atrophy of cartilage and
anchylosis of the patella, also of several of the vertebnc aud bones of the carpus. Mr.
Curling refers the presence of fractures, and the absence, in other cases as well marked,
to modifications in the wa.sting process — upon the more or less rapid decayof the earthy
parts, as compared with the animal constituents. Thus, when the earthy part^ waste
faster than the softer structures, there is distortion without fracture ; but. on the other
hand, when the animal parts waste more rapidly than the earthy materials, then there
is fragility without distortion, In some cases, however, there is fragility in the first
instance, and aflerwards, when the disease is farther advanced, distortion. The!«o physi-
cal properties being dependent solely upon the difference that exists in the n»lativc pro-
portions of the earthy and animal matters.
Though pathologists are still in doubt as to the exact nature of the change of thf
osseous system in this disease, the observations of Mr. Solly and of Mr. Dairy mplc have
shown the existence of a process of active change, as manifested in the afflux of bloo<l
to the parts affected, and the abundant cell growth. Mr. Dalrymplo has found, by
microscopical observation, that the bone corpuscles are considerably enlarged. Enlan^o-
ments of the Uaverscian cansils and of the lacunae is observed ; the cancelli aic loadoil
with large oil drops, oflen tinted red, and combined with thin, numerous cells, vanrin!r
in size from the y^^j^ ^ z\f5 of an inch in diameter, containing a rounded nucleus, also
varying much in size, and occasionally .<«howing various stages of division and of end«v
genous development. And whilst there is a diminution (»f the earthy constituents, then*
is at the same time some important change in the animal basis of the bone*, it no longtT
yields healthy gelatin, and is saturated with oil, which, to a great extent, is not contained
in cells, but lies as a free fluid in the cancelli and medullary canal, and readily drmios
out when the bone is placed in an inclined position. The color of the oil is also pecu
liar, presenting bright yellow, pink, and deep crimson hues. These changes ar« pi\>ba>
bly owing, as Bennett has said, to an exudation from the blooii-vessels, mingled with
more or less extravasation of the colored corpuscles, in which new cells arc develope<l.
combined with fatty transformation of the albuminous and fibrinous materials.
Virchow has traced fatty degeneration in inflamed bone as a part of the process of
softening which precedes its expansion or absorption. Very often small fatty molecult^
appear in the bone-corpuscles ; and Virchow has traced their enlargement, and the gra-
dual softening, disintegration and final liquefaction and separation of the proper buD<*
substance immediately surrounding and including each corpuscle. Analogous chang««
have been traced by Goodsir and Redfin in cartilage ; and Virchow has pointed ont
their relation to fatty degeneration as a part of the inflammatory process. And thes^
changes in inflamed bone are of special interest, inasmuch as they arc the results of th-
same process as that by which normally the medullary spaces and arolie of growiiu
bone are formed, and by which mollities ossium is supposed to be produced.
On the other hand, the softening of the bone in rachitis should be regarded as arrests 1
development of bone, with an increased growth of cartilage-oells. In this disease tli«-
whole bone is soft, easily cut with a knife, and preternaturally flexible ; cancnUou« xcx
Mollities Ossium, 781
ture of a brown or reddish hue predominates, and is at first filled with a sarous liquid,
which may be squeezed out, as if from wet leather ; after some time the serous or albu-
minoid liquid occupying the tube and caucelli is transformed into a gelatinous substance,
which is gradually organized into a cartilaginous state. The power to separate and
deposit bony or earthy matter appears to be entirely wanting; in the organic cells of the
osseous system in mollities ossium, whilst in rachitis this power is only temporarily
suspended or arrested, and is resumed with increased energy after the removal of the
diseased state.
Mr. Edward Stanley, as early as 181 G, in a valuable article, published in the Seventh
Volume of the Medico-Chirurgical Transactions, described the process of restoration of
the Bones in Rickets. Mr. Stanley endeavored to show in this paper, how the soft
rickety bone, which presents an almost uniform structure throughout, being without any
distinction into solid walls and medullary cavity, becomes changed into the condition in
which it will be found, when upon the restoration of healthy actions it has acquired
strength and power of resistance. Previous to the investigation by Mr. Stanley, very few
observations had been made respecting rickety bonos, during the continuance of their
soft state or state of disease, and none at all respecting the process by which they resume
their solid and healthy condition. LeveilM had given an acconnt of the structure of a
soft, rickety bone, with a representation of its curved figure. It is described as having
l>een exceedingly light, yielding with facility to the scalpel, and presenting throughout
a cellular and spongy texture. Memoires de Physiologic et dc Chirurgie pratique par
Sacrpa et Leveille.
Bichat remarked, concerning the condition of the bones in rickets : '* In this disease
the solid structure forming the walls of a long bone entirely disappears, the whole inte-
rior of the bone presents a homogeneous appearance, and cellular texture throughout ;
the periosteum Ls also thickened.*' (Anatomic Generale, Tom. iii.)
The several bones examined by Mr. Stanley, exhibited nearly the same structure as that
here described by Leveille and Bichat, excepting that the periosteum was not thickened
afi is mentioned by the latter ; the consistence of the bones was nearly that of common
cartilage, they presented throughout an areolated texture, and the cells were in some
parts large, and contained a brownish, gelatinous substance.
Such is the state of the soft ricketty bone, during the continuance of the diseased
action which constitutes rickets ; but to this there must necessarily succeed some process
of restoration, some new modelling of itA internal structure, in order to produce that
distinction between the external walls and internal cavity which it is afterwards found
to acquire. From an examination of a series of rickety bones, which had undei^one
difTerent degrees ot curvature, and where the process of restoration had been completed,
Mr. Stanley discovered that there invariably obtains an exact relation to the circum-
Btaoces of each case, with respect to the situation, extent an<l direction in which the
earthy matter b deposited ; thus it is obvious that in the curved bone, the part where
there \b the greatest need of strength, to prevent its further yielding, is in the middle
of itfl concavity, or in other words, in the line of its interior curve ; and it is just in
this situation that strength and compactness will be first imparted to the bone by the
deposition of phosphate of iime. Mr. Stanley farther found that the greatest resistance
being wanted at this part, the walls were accordingly rendered thicker here than else-
where, and the degree to which this excess in thickness was carried, bears an exact ratio
to the degree of curvature which the bone has undergone. Mr. Stanley introduced an
example drawn from a principle in mechanics ; thus if a weight be placed upon the top
of a hollow elastic cylinder curved to the degree of one, and the same weight is placed
upon the top of another cylinder curved to the degree of three, in the latter case, the
Auperincumbent weight will tend to increase the bending of the pillar with a greater
force than in the former ; if therefore it becomes necessary to apply in both cases a
power of resistance, this ought to be so much greater in that instance where the dis*
position to bend is greater. It is obvious what will be the application of this tirinciple
to the strengthening of a curved, rickety bone, as may be readily oxomplificHl }>y
7H2 Mollities Ossium,
examiuiDg boues that have suffered different degrees of curvature ; thud according t»
the extent in which a bone has yielded, and the weight it has to support, the thickne»
and solidity of the walls in the line of the interior curve, will be found greater than io
any other situation ; it will also be noticed that the bony fibres are arranged obliquely
across the axis of the bono, in a direction evidently calculated to augment its stren|:th
and power of resistance. Lastly, if such a bone as the tibia has become bent perbap
into an angle, or so as to form the greater part of a circle, and at the same time it ha5
to support a great superincumbent weight, the deposition of the bony matter may not U*
confined to the thickness of the walls in the concave side, but may extend across the
medullary cavity, rendering the bone here perfectly solid, and thereby greatly augniont-
ing its strength and power of resistance.
Mr. Stanley presented to the ScK-iety three drawings, the first represeQtin<; ih**
internal structure of a rickety bone in its softened and diseased state ; the two otlwi>
representing sections of bones differently curved, but which had by the restoration of
healthy action, ac<|uired compactness of structure. In one, the deposition of Iwnt
matter is confined to the thickening of the walls of the concave side; in the other bimi
a tibia which has become bent into an angle, the medullary cavity is filled by o6seou^
matter at the part which has yielded, and the bone consequently made solid in thv>
situation. (Medico-Chirurgical Transactions, London, 1816, vol. vii, pp. 404 to 410. <
I have confirmed the accuracy of Mr. Stanley's observations by making careful j^i*-
tions of rickety bones.
k
CHAPTKR XXIII.
RKLATIOXS OF MOLLITItS* OSSilM TO CANtEB.
The bhuleiiess of tht boues in cancer baa long been observed — Casei recorded of sofieuing aud
alterationi of the bones, by Lovisius, Perciral Pott, and Prof. R. \V. Smith.
MoLLlTiKS Ossium, in that, as far as is known, it is not amenable to remedies, but
pursues its career steadily, unaffected for good by medical treatment ; and in that there
is in this dii^ease an increased cell-generation in the affected structures ; and, still further,
in that, in recorded cases of cancer, some of the bones have been found in a state
closely resembling, if not identical with mollities — be^irs a stronger resemblance to cancer
than to any other disease.
The brittlcncFs of the bones* in canter has long been observed. Thus, the celebrated
lx>vi8iuf , more than a century ago, in dissecting the body of 'a woman sixty years of
:i'.rc, who had labored fur some time under a cancer of the breast, and who had broken
ih.* OS humeri, and, soon after, the os femoris also, by a slight effort found the bones
not carious, but dry and fragile, with the medulla, in like manner, dry, friable, and cjuite
hx>8e from the parieties of the bony cavitieij.
In a case which recently came under uiy observation in the Charity Hospital, of
cancer of the breast in an aged negro woman, several of the ribs on both sides were soft,
cartilaginous, and readily cut with a knife, (^anceroiis deposits were found also in the
liver and spleen.
In the following ca«c, recorded by the celebrat^id Percival Pott, it will be observed
that softening of the bones was attended with fever, great muscular debility and pain,
and the formation of steatomatous and scirrhous tumors.
Case 780'^ : In Norembcr, 17.'>7, a geutleman, aged 27, complained of a swetting in the inside
of bit right thigh. On examination, it appeared to be an encysted tumor of the steatomatoiis
kind, lying loose bet\reen the sartorius and vastus internns muscles. Mr. Pott took it out,
and tbe patient got well in six weeks. After this he continued well for near a year, except
that be complained at timc.« of a slight pain in the joint of that hip, which went off and
ruturned at different times. He then fell into such a disposition to sleep, that no company nor
diversion, nor his own endeavors to the contrary, could keep him awake after eight or nine
o'clock iu the evening, if he sat down. Tills continued on him for three or fonr weeks, and
then tbe pain in bis hip became worse. The cold hath, fle.sh-brush, horseback exercise, a
course of sethiops mineral, cinnabar, of antimony, gum guaiac, calomel, purgatives and
mineral waters, as well as travelling and chan(,'c of ciimitte, afforded no rflief. Pcriodicnl
heat and thirst returned every night, with a quick, bard pulse.
In September, 1739, the sight of hi* left eye became dim, and the dimness f^radualiy increased
until the sight was lost, and the ball of th*" rye was cMilarged and tliru^t forward out of the
orbit.
Tumors appeared in different parts, li>e or bi.\ on hi!> head, two or ihuM- in hi:< back and
one in tbe neck, all lying just under the $kiu.
December 2d, 1739, bis chief complaints at this limu was exct'S>ivu languor, inability to
move bis right hip, and when moved by another person, a very acute paiu iu it, an incnpacity
of sleeping when in bed, an intense thirst in the night, ^>ith a quick, hard puUe.
After subjecting himself to several courses of treatment, with cinn.'^bar, ul" aoiiaiony, mer-
* An Accuiint of Tuiuifin wliiUi ruKlcnd Ui« I!4iiiri> Nilt. 1( luiiiiiiiiialfil to (In- l»<>\n^ «i.4,iti\ hv Mr IVni^nl
I otf, 8iirgron, 174% Vol. xH, No. i.'>\ p. t;|0. Al>ri«lffinrnr. vol. mH, fip. 4<^-4«7.
784 Mollities Ossium.
curj, and other remedies, without any benefit, and being reduced extremely low, be abandootd
pbysic. The inguiDal glandi of the hip became much eolarged, the patient lost all power of
stirring or helping himself, and died 3[ay 2d, 1740.
For a considerable time before he died he was nourished by fluids only ; jet as soon as erer
they were received into the stomach, in however small a quantity, they gave him acate pain
at the bottom of his belly, just above the pubes. Upon dissection, Mr. Pott fuund the tumor
which he had taken out of his thigh two years before ossified in the inside.
On dissection, the first thing that oflercd was a large tumor on the sternum, which had been
{■erceived about three months before he died. It was as large as a turkey's egg, and to bard
and immovAble that Mr. Pott was in doubt whether it was upon or under the bone. On
removing the skin, it appeared covared by the expansion of the tendons of the intercotul
muscles and the peribsteum ; this coat being taken off, it was of a suety kind of substance
for about half an inch deep, and below this was a kind of cartilage intermixed with a great
many bony particles. Mr. Pott then shaved off all this diseased body even with the surface
of the rest of the sternum, but found no bone, it being quite dissolved and confounded with
the mass of matter that composed the tumor, which was equally protuberant within the thorax,
and composed of the same materials.
Parts of the fifth and seventh ribs were dissolved in the same manner, into a kind of snb-
gtance between bone and cartilage, with a thin coat of steatomatous matter.
Within the cavity of the thorax were thirty-seven of these diseased bodies, most of tbem
attached either to the vertebrx or the ribs ; and wherever they were attached the cortex of
the bone was destroyed, and its internal cellular parts filled with diseased matter.
Immediately above the diaphragm, was a large scirrhous body, lying across the apioe aad
the aorta, the latter of which lay in a sinus formed in its lower part; it bad no attacbments
to any other part, and weighed 13.] o^s.; and from its situation roust have taken its rise from
tiftw of the lymphatic glands lying about the thoracic duct.
From the origin of the aorta from the heart quite up to the basis of the cranium, all the
blood-vessels were surroun()ed with these scirrhous bodies, and the thyroid gland was diseased
in like manner, and bony within. On the left side was another of these bodies, made out of
the glandulae renalis, weighing 9j o/.s.
On the right the glandulae renalis wag iu a natural state, but the cellular membruDe vbicL
surrounds the kidneys was filled with a large cluster of these bodies of different sixes, some
of them entirely suety, intermixed with bony particles; three or four of them were aitacheJ
to the body of the kidneys, and there was a sort of cartilage beginning to ossify.
The pancreas was quite scirrhous and very large. One very large tumor sprang from the
spongy body of the third vertebra of the loins, the bony texture of which wa« so diaaoUed
and mixed with the matter of the tumor, that the knife passed through it with great ease.
The inner side of the os ilium^ all the ischium and pubis, were covered with these appearances.
and on removing them the bone was found in the same state as the sternnm and ribs. The
middle of the right os femoris was surrounded with a mass of the same matter, and the boot
underneath in the s^ame state.
In the bottom of the orbit, surrounded by the recti muscics, was a pretty large steatoma
which occupied the protrusion of the eye, and by pressure ou the optic nerve cagsed the
blindness.
In diflfiised cancer the whole hone luuy l>e Hoftened by the distcnsiun of its cells with
the luaterial of soft cancer, the cancelli luaj be partially or completely absorbed, naU
general disintegration of the bone induced. And it would appear that some eases des-
cribed as mollities ossiuui were really instances of diffcised canoer of the bones. Aod
in the close resemblance of the two affections must be found the grouDds upon which
some authors have ehtsscd niollitios with cancer. Thin confusion is not to be wondered
ut when the ob^icurity and difficulty which surround the history and investigation of
cuncer of the bones are considered.
Professor H. W. Smith, of the rniversity of Dublin, has recorded a remarkable c«ee
of cancer in the bones, a brief tmtlitie of which we ji^ive.
TaseTHI*: The patient was a to male, »Tt. G.I, of sallow complexion and very uubealthT
nppearance.
Four years brfori* licr lUatli. anil eight after the catamenia had ceased, she began to «affcr
from lancinating pains in the lett brenst, and a small, hard tumor formed near the nipple, a&d
very soon became adherent to the skin, was uneven upon the surface, and after some tint tbe
a\illnry glands beonnie enl.aiyed and indurated. The tumor underwent no further chaagr*
MMil.liu lln-j.ltal (uucti.-, Mj»i< h l.'> Ij-V. ; lUukiuu** A^^lmr!, N XXII, .July to l>ec»iii)fcr. IsV., |\ ]l ".
MolUties Ossium. 7H5
for iiro jeart and a half, when a scab furmed upon its surface, upon the separation of whish,
a verjr superficial ulcer not as large as a shilling remained ; this sore never increased either
in extent or depth, and yielded but little discharge. In fact, during the remainder of her
life, the diseased breast attracted no share of her attention, and the lancinating pains which
were first experienced latterly ceased altogether. Severely, however, and almost unceasingly,
did she suffer from pains, which she conceived to be of a rheumatic character, in all her
bones: she had cough and pain in the right side: her appetite failed, her sleep deserted her,
and her flesh wasted away ; she was for a long time before her death completely bedridden ;
she conld not endure that any one should touch her ; nnd her efforts to move herself in the
bed were, upon several occasions, followed by fracture.
She died exhausted by pain and suffering and in a state of complete emaciation.
The post-mortem examination, which Dr. Smith conducted with the greatest care, proved
most interesting, and revealed an immense extent of cancerous deposit limited to a single
syitem ; for, with the exception of a tubercle about the si/.e of a small nut in the liver, the
organs, in all the cavaties, were perfectly healthy ; while, upon the other hand, nearly the
entire skeleton from the head to the feet was pervaded with cancer.
The cranial bones in several places had been softened and absorbed ; the left clavicle was
fractured external to its centre, and the anterior of the bone was occupied by scirrhous mat-
ter, from its sternum to its acromial extremity ; the left humerus was broken in its centre, and
the cancerous deposit filled the medullary canal from the head of the bone down to its lower
extremity ; both the right and left thigh bones were fractured and in portions absorbed and
universally infiltrated with the cancerous structure — the medulla of the bones of the legs
preiented a most unhealthy appearance ; the ribs contained numerous deposits of scirrhus in
their interior, and several of them were fractnred ; the disease occupied the spinal column
from the lower part of the cervical region to the sacrum, the cancellated tissue of the bones
had diaappeared, and its place was occupied by a firm, elastic, scirrhous structure of uniform
coniiitance and of a roseate hue; and the bones of the pelvis were entirely converted into a
scirrhous structure.
The characters of this heterogeneous deposit were precisely the same in all the affiected
bones ; it was white, firm, tough, and dense in its texture, highly elastic, and cut like cartl«
lage ; it in no respect differed from true scirrhus as it Is seen in the human breast. The
osseoui tissue in contact with it bad suffered no alteration but such as resulted from
absorption.
It ii evident that nucU a caae ah the prcoediDg vraa iovolved in obicurity during the
life of the patienfc, and simulated closely niollities ofisium in many of its symptoms.
In a case of secondary cancer in the spine and other parts after removal of scirrhus
of the breast, reported by Mr. Cceear Hawkins, the centre of the neck appeared a little
Kunk forwards, as if the upper vertebra) had been depressed in that position. Upon
dissection, the body of the fifth cervical vertebra was very irregular on its surfuoe, and
was softened throughout, with much enlargement of the cells of the oanoelli, which
was filled with a sanguineous pulpy fluid ; the two adjoining vertebno showed a lesser
degree of the same morbid structure. Mr. F. Holmes hatt recorded a case of cancer
of the bones after scirrhus of the breast, in which some of the ribs were perfectly
flexible ; and in a ease of well-marked oanoer of the pelvis, he found a condition of the
innominate bone bearing an almost equally close resemblance to mollities.
In some cases of cancer, where the disease involves the soft parts as well as the'
osseous texture, it is sometimes difilicult to determine in which tissue the disease had
its origin ; it appears to be true, however, that whether the bone be primarily . or
seconduily afiected, its density is altered and it is rendered more fVagilo and spongy in
its texture.
It would appear that in this di»eas<', in like manner, with mollities ossium and
syphilitic inflammation and ulceration, the earthy constituents are acted upon and
dissolved by acid fluids. In the case of the cancerous growth, it may be that the din-
solved phosphate of lime may take some part in the gniwth of cancer cells ; it certainly
18 deposited in a peculiar manner in and amongst theno cells, which partake in the ease
of bone, of the character to a certain extent of rapidly jrrowing cartilage cells. The
following cases occurring in our practice in the Charity Ilo.'^pital, will lie of int^^est in
this connection.
We have preserved in our pathological laboratory, two feniitrs from two cases of cancet
786 Mollities Ossium,
of the thigh. Ihc fuHowiDg is the description of thc^c casce, with the prciervcd
specimens:
Oa8i782: Superior portiou of Femur of ad ulult male, afflicted with Cancer of the
thiflch.
The trochADter minor and the shaft of the femor for four inches below, preient a rough,
hypertrophied, cancellated appearance, with numerous spiculse of bone. The booe *is light
and porous, verj different from healthy bone. The following it an outline of the case :
John Morris, male, age, twenty-five ; height, five feet, six inches ; weight, one bandrvd
and sixty pounds: dark brown hair ; blue eyes ; ruddy complexion ; native of Norway : sea-
man ; has been subject to rheumatism, three or four years ; had syphilis one year ago.
Admitted to Charity Hospital, ward 18, bed 268, March 22d, 1869, with swelling of left thigh,
extending to Poupart's ligament, accompanied with pains ; says that his leg began to swell
two months ago. During a period of two months before the swelling commenced, the patient
had been standing in the water, whilst surveying on the coast. As the patient presented the
appearance of a cutaneous eruption which was supposed to be syphilitic, he was placed upon
Iodide of Potassium and Bin-Iodide of Mercury. The eruption disappeared, and the general
health improved under the use of these alteratives, and the skin affection disappeared; but
the swelling of the thigh, which presented a hard, nodulated feeling, like a collection of
lymphatic glands, continued to increase. The local application of Tincture of Iodine and
Iodine Ointment, neither relieved the pain nor arrested the progress of the tumor. The pain
was so intense that it was necessary to administer opiates freely at bed time. The folloving
are the changes of the pulse and temperature :
April 2d. Complains of sharp lancinating pains in right shoulder and left thigh, and knee.
Pulse 100 ; respiration 25.
April 6th. Complains of continuous pains during the night in left leg. The patient locates
the pain in the bone of the leg. Bowels loose. Pnlse 100, respiration 32.
April 15th. As the case did not yield to ordinary measures, I called a consultation, and
it was decided to plunge an exploring needle into the tumor. When this operation was
performed, nothing but bloody serum, to the extent of one or two pints, issued.
May 12th. Pulse 100; respiration 28 ; temperature of axilla 100^ F.
May 14th. Pulse 100 ; respiration 25 ; temperature hand 97.25° F ; temperature axilla 10(»^ :»
» 13th. ** 100; •' 25; '• *• 9G.:> " *' |oo«».TJ
** 16th. *' 100; '» 58; " " 10<»®.5
'* I7lh. " 100; " 27; ♦• •• lOO^•:'
'« 19th. « 100; temperature of axilla 90^75.
«' 29th. *( 100; respiration 26 ; temperature of axilla 10(*.
'* 31st. '' 102; temperature of axilla 102°.
June 4th. '' 130; respiration 35; temperature of axilla 101 °,5
*< 6tb. << 105 ; temperature of axilla 100°.
During an attack of illness with which I suffered in July, the wound was freely probed and
lanced. Suppuration of the structures of the thigh took place, the bowels became loose, the
patient became restless and feverish, and was bathed in profuse, clammy sweats, and finalli
died about the middle of July, in a greatly emaciated condition. Upon post-mortem examin-
ation a colloid cancer In a state of decomposition and gangrene surroundtd the upper third of
the femur.
The femur of adult female who died from cancer of the thigh. The trochanter mmur
and shaft of the bone for four and a half inches is hypertrophied and roughened, and has shut
out wing*like projections and elongated spiculse. These spiculse are most nomerons, forsDiog
a porous, cancellated structure, apon the posterior surface of the femur, and the roaghne?^
extends down, in a line, half an inch broad on the posterior aspect of the bone, within two
inches of the lower extremity of the femur. The bone is light, porous and un!ike the bocft
in health.
The following is an outline af this interestisg case :
Cass 783: Cordelia Hamilton, colored; age forty-seven years ; field hand and cook ; oat^t
of Kentucky; was admitted to ward 34, Charity Hospital, July, 1869. Patient sars that op tr
July, 1868, one year ago, her health had been good. At that time, she noticed a swelling .e
her right thigh, about the middle third ; but this did not give her much pain, or ioterferr
with her duties for several months. The swelling increased, with lancinating pains, ard
occasional loss of sleep at night. Patient was never married, never had any children, and
the mammat^ were not developed at all. Height, four feet, seven inches. On admixsion, the
patient was somewhat emaciated, apparently feeble, and was too weak to stand up long at a
time, and was unable to walk without crutoheg. The right thigh was verv much ealargetl
and felt warmer than the left and the leg below. The pnlse was about 95 per minnte. Soir-
disturbance in action of heart referred to pericardial effusion. Respiration normal
Ntlent mlTercd with a oongh which, somietir^osi, gaxe tronble a^t night. Temperati-f-
Hollities Ossium» ?^f
under axilla, 100^. Appetite poor, bowels torpid, skin moderately cool, except over
the affected thigh. The thigh felt nodulated and hardened, and the disease was pronounced
to be a malignant growth surrounding and involyiog the bone. Exploration with trochar
gave no evidence of pus. The right thigh continued to enlarge, and the knee and leg
became oedematous. On the 18th of August, the right thigh measured at knee, sixteen and a
half Inches in circumference; at middle, twenty-five inches; at junction with trunk, twenty-
two inches. The sound left thigh measured at knee, eleven inches ; at middle, twelve inches,
and at the junction with trunk twelve inches. The following are the observations on the
pulse, respiration and temperature upon the four days preceding death :
August 25, 9 A. M. Pulse 96; respiration 16; temperature of axilla 101^.2
•* 16; *' " 100<>.5
" 16; " *« 99®.5
•* 16; '• *» 101O.2
" 16; '« "* 100®.5
" 16; " " lOQo.ft
" 15; •* » 99^6
'» 15; " '« 100*>.0
Died August 1 2th. The forces gradually gave way without any marked symptoms. Before
death, the emaciation had been extreme.
The following are the results of the post-mortem examination :
ExUrior : — Great emaciation. No mammary development upon chest Right thigh greatly
enlarged ; left, a mere shadow ; the bone with the skin and thin layer of muscles.
Chest: — No adhesions. Luugs emphysematous. Pericardium contained considerable fluid.
Abdomen: — Peritoneum very thin ; sigmoid flexure greatly distended with gas; small intes-
tines greatly contracted and anaemic.
Liver friable, and on its convex surface a small circumscribed abscess. Kidneys lobnlated,
and contained cysts and small abscesses. Generative apparatus poorly developed. The
abdominal aorta, and its branches, presented appearances of calcareous degeneration. The
blood was remarkably thin.
The right thigh was carefully dissected. A large encephaloid cancer involved the muscular
structures of the thigh and surrounded the bone, and numerous osseous spiculse extended
from the femur into the cancerous mass. Under the microscope the tumor was found to
consist of cancer cells, fibrous tissue, oil globules and granular masses. At one portion near
the bead of the femur, the tumor was undergoing softening, and this portion was loaded with
granular matter.
" 6 p. M.
96;
August 26, 9 A. M.
" 6 p. M.
88;
86;
August 27, 9 A. M.
" 6 p. M.
88;
85;
August 28, 9 A. M.
" 6 p. M.
88;
86;
CHAPTER XXIV.
('<>\*>*TITUTloK OF THE BLOOD, CONDITION OF THE TEMPERATURE, PULSE, AND RESprRATloX, AXI»
THE CHARACTERS OF THE URINE, IN MOLLITII-S? OSSIUM.
ObserTatioDS of Dr. Bence Joofs and Marchand.
ConBiUution of the Blood in MoUities Ossium. — As far an our infoniiatioii extends,
no analysis has been made of the blood in this disease. The future investigator should
direct his attention not merely to the determination of the albumen, fibrin, and red
corpuscles, but should endeavor to determine whether any special acid or salt exists io
the blood in excessive quantity. A careful search should be instituted for lactic and
phosphoric acid, and for lactates and phosphates.
Temperature, Pulse, and Respiration in MoUities Ossium. — In like manner we have
no critical observations upon the state of the temperature, circulation, and respiration in
this disease, and we know but little beyond the general observation that the pathological
phenomena are attended by fever.
Progress and lermination of Mollities Ossium, — The various functions appear to
have been duly performed in most cases, unless interfered with by the distortion oociae-
quent upon the yielding of the bones ; and pathologists have distinctly stated that tho
internal organs were found in a healthy condition aHer death, thus showing that tht*
disease is not associated with any particular lesion of important viscera.
The progress of mollities ossium appears to vary greatly, the bones beeomiog soft in
some cases in a few mon/hs ; more commonly, however, the disea.se goes on for many
years before the death of the patient.
Condition of the Urine in Mollities Ossium. — The observations which we have
already recorded establish the fact that the phosphates are frequently in exoeos in th^
urine of this disease. We need an extended series of analyses of the urine, oollected
during definite periods of time (twenty-four hours) and at stated periods in the progress
of the disease.
The most complete and interesting examination of the urine in this disease was made
by Dr. Henry Bence Jones.'*' It is to be greatly regretted that, in his analjaM, I>r.
Jones selected an arbitrary quantity ( 1 0()0 grains, ) in<«tead of the whole amount exciHed
during twenty-four hours.
This case was reported both by Dr. William Maeirityref and by Mr. Dalrymple-X
The following is an outline of the report of this case by Dr. Macintyre :
Cask 784: A tradesman, aged 4.*), came under Dr. Macintyre's care on the 30lh of October.
1845. He had suflfcred for upwards ut' twelve months from excruciating pains in Ui€ chett
loins, and back. When first seen, he was much emaciated ; the pain had becom* fixed in the
left lumbar and iliac regions, and the patient, in consequence of the great agony prodaccd tv
moving the body on the thighs, was constantly in a semi-flexed position. There wm eaqoititV
tenderness on pressure at the brim of the pelvis in front. Nothing very satisfactorr eooM l*«
^On a New Substance occurring in the Trine of a Patient with Mollities Ossium. By Ueorv
Hence Jones, M. A., F. R. S., &c. Philos. Trans., 1848 p. 55.
fCase of Mollities Ossium and Fragilitas Ossium accompanied with Trine strongly cfaarr^^
with Animal Matter. .Med.-Chir. Trans., vol. xxxiii., 1850.
tOublin Quarterly Journal, 1846. p. r:». Path. Soc. Trans., 1846-7, p. 148.
MoUities Ossium, 7811
made out regarding the abdomioal and thoracic organs, except that the cardiac ioipuUe was
too strong, and the praecordial dullness too great, without cardiac murmur.
The patient attributed his illness to a strain, but it appears that for some time previously
he bad been subject to wandering pains about the breast and shoulders. The urine of this
patient was submitted to the examination of Dr. Bence Jones, with the following result. The
free acid was increased, the phosphates were in much larger amount than in health, and the
urine was loaded with a peculiar form of animal matter resembling albumen in its chemical
composition coagulable bj heat, but not bjr nitric acid.
The following table presents the general characters of the urine, as determined by Dr. Bence
Jones:
Daf*. rj»ii. phmtf In Krscll'in. PrectpfutM, *c.
Not. 1, 1845. 1034.2 Slightly acid. Sediment of phosphate of lime
oxalate of lime, and urinary
casts.
*' 3, *' 1043.2 5.68 Acid. Urate of ammonia, phosphate
of lime, and urinary casts.
" 7, <* 1039.C 5.65 Tlightly alkaline. Phosphates of lime and casts.
•* 8, *• • *' Heavy deposit of phosphates.
*' 9, « 1037.2 « Loaded with urates.
*' 18, " 1039.6 Acid. Trate of ammonia, phosphate
of lime, and oxalate of limt.
'• 27, •* 1031.3 8.05
*» 29, »' 1037.9 8.24
"30, " 1042.7 11.85 Slightly acid. Xo fibrinous cylinders.
The complete analysis of 1000 parts of urine, on the 18th of November, gave —
Water '. 890.72
New substance (resembling albumen) 66.97
Urea 29.90
Cricacid 0.96
Earthy phosphates 1.20
Chloride of sodium 3.83
Sulphate of potash '.MO
Alkaline phosphates.. 4.45
The following are the conclusions arrived at by Dr. Bence Jones, after a careful
examination of the peculiar albuminoid substance in the urine :
1st. This substance is an oxide of albumen, and from the ultimate annlysis, it is the
hydrated deutoxide of albumen.
2d. In this case of mollities ostium, 66.97 parts of this hydrated deutoxide of albu-
men were passing out of the body in every 1000 parts of the urine. Hence, therefore,
there was as much of this peculiar albuminous substance in the urine as there is ordi-
narily albumen in healthy blood. As far, then, as the albumen alone is concerned, each
ounce of urine passed was equivalent to an ounce of blood lost.
3d. The peculiar characterittic of this hydrated deutoxide of albumen was its solu-
bility in boiling water, and the precipitate with nitric acid being dissolved by heat, and
re-formed when cold. By this reaction a similar substance in small quantity may be
detected in pus and in the secretion from the vesicular seminales.
4th. This substance must again be looked for in acute cases of mollities oesium.
The reddening of the urine on the addition of nitric acid, might perhaps lead to the
re-discovery of it ; when found, the presence of chlorine in the urine, of which there
was a suspicion in the above case, should be a special subject of investigation, as it may
lead not only to the explanation of the formation of this substance, but to the compre-
hension of the nature of the disease which affects the bones.
This patient died on the 2d of January. On the following day, Dr. Jones saw that
the bony structure of the ribs was cut with the greatest ease, and that the bodies of the
vertebra) were capable of being sliced off with the knife.
According to Mr. Macintyre, the sternum, ribs, and cervical, dorsal and lumbar vcrte-
bne were found soft and brittle ; the cancellated structure loaded with a blood-red, sofY,
pi^latiniform substance, which, under the microscope, was found composed of j^rannlar
790 MolUties Oaaium.
f
matter, oil globules, nucleated cells, with a few caudate cells, and blood disks. The
thoracic and abdominal organs presented nothing unhealthy. The patient^s death took
plac« without any satisfactory opinion having been arrived at as to the nature of the
case.
We do not gather from the record of this post-mortem, whether the kidneys were
diseased ; the appearance of the modified albumen may have been due to the existence
of Bright's disease of the kidneys. Future inquiries should determine whether thi^
substance is characteristio of mollities, and whether the lactic acid, and lactates and sul-
phates, as well as the phosphates, are increased in the urine.
Case 785 : Marchand"*" analyzed the urine of a child with osteomalacia three dsy»
before its death.
The fluid was invariably acid, and contained in 1000 parts :
Water 938.2
Solid conBtituents .- 61.H
Urea 27.3
Trie acid ^.. o/j
Lactic acid and lactates i .-. 14.2
Piiosphittes of lime and magnesia VT
Other substances and loss 13.7
Not only were the earthy phosphates, in this instance, five or six times as abundant
as in health, as was the case in one of the instances of this disease recorded by Mr.
Solly, but what is especially interesting, in its bearings upon the nature of raollitiefi,
the LACTIC ACID and lactates toere gredtly incretued.
♦Simon's Animal Cbemistrv, Am. ed., p. 511.
CHAPTER XXV.
loMPAKlHUN 0>' THE I'UOIU'AL iXlMPl)t*ITION OF TUK VOUKii IS HOLLlTlfitt 1>C»1UM WITU THAT
OK HEALTH AXD VARIOUS DISEASED STATKHt-tJEXERAL COSCLUSlOX^.
Aimlycig of bealthy bonei by varioui chemists, and of the boaes in HoUities Ussium timl
various diseased states, by Bostock, PrOscb, Bogae, Ragsby, Lehmano, Von Bibra. Marchand,
Ucese, TuBon, Barruel, Buisson, Valentin, and others — General eonclasions as to the nature
of MoUities Ossium.
Xi)TWiTiit$TANDiNO the Comparative simplicity of the analysis of bone, much remains
to bo accomplished before the true nature of its alterations in various diseases are deter-
mined with accuracy. Unfortunately, many analyses of morbid bones are unaccompanied
by any minute or accurate history of the case. In such a disease as mollities ossium,
it would be of the greatest importance to determine whether, in the resorption of the
bone earth, the strongly basic phosphate of lime is replaced by a less basic salt.
The neglect to ascertain the quantity of the carbonate of lime in the fresh bone, or
ill the earthy constituents, by the direct determination of the carbonic acid, as well as
(he employment, in most analyses of bones, of the older method of Berzelius for tho
determination of the phosphate of lime, has left it doubtful whether it exists in bone as
8CaO, aPOj or 3CaO, PO5.
The following tables will present the most important results obtained by chemists,
and at the same time furnish data for the determination of the characteristic changes in
naoUities ossium.
Becquerel and Kodier give the mean composition of human bone, as deduced fVom
fifty-four analyses, made by different experimenten, as follows :
Phosphate of lime., , , 54.07
Phosphate of magnesia « « 1.20
Carbonate of lime , , 7.40
Fat.., 1.35
Soda and salts of soda 0.9.3
Cartilage 35.r5
Lehmaon represents the constitution of compact osseous tissue, as deduced from the
host analysis, as :
Phosphate of lime 6T
Carbonate of lime •
Fluoride of ealeiam 1
Fbotpbate of magnesia • 1
Mineral constituents 67
Cartilage , ,,, , 33
100
The comparison of the composition of the (k^uc^ itt tnolliti^ii o^SMMil with that of
health, reveals the following marked chan^ :
\^ Increase of fat.
792 Mollities Ossium,
2. Decrease of phosphate and carbonate of lime.
ii. Relative increase of organic or cartilaginous matter.
Whilst the fat in healthy bones may vary between one and two parts in the hundred,
ill mollities ossium, on the other hand, according to Prosch, the fat varies from 5.26 to
11.63 ; according to Lehmann from 29.18 to 34.15 parts ; according to Von Bibra, from
4.15 to 13.28 ; according to Marchand, from 6.12 to 9.34 ; according to (iarrod, 20.35.
In health the phosphate of lime may vary in different bones; in the adult, betweeu
54 and 60 parts in the hundred ; in mollities ossium, according to Bostock, it reached
only 13.6 per cent.; according to Prbscfa, it varied between 13.25 and 33.66; according
to Bogne, it varied betweeu 23.23 and 28.11 ; according to Kagsby, 17.48; aocordiog
to Lehmann, it varied from 17.56 to 21.02 ; according to Von Bibra, from 46.79 to 55.01
according to Marchand, from 12.56 to 21.35.
In heaJth the carbonate of lime may vary in different bones from 7 to 8 per cent.; iu
mollities ossium, according to Bostock, it reached only 1.13 per cent.; according to
IVosch, it varied between 5.95 and 4.60 , according to Bogne, between 0.94 and 1.07
:iccording to Ragsby, 6.32 ; according to Lehmann, between 3.04 and 4.08 ; aoeordiog'
to Von Bibra, between 4.94 and 7.49 ; according to Manchard, between 3 and 3.70 per
cent.
In healthy adult bones the cartilage may vary between 32 and 36 per cent.; in molli-
ties ossium, according to Bostock, it reached 70.75 per cent.; according to Proscb. it
varied between 49.77 and 74.64; according to Bogne, between 63.42 and 70.60;
according to Lehmann, between 41.54 and 50.48 ; according to Von Bibra, between
29.17 and 32.54 ; according to Marchand, between 61.20 and 75.22 ; according to Rees.
the animal matters varied between 67.50 and 73.87 ; according to Garrod. 58.37 per
cent; according to Buisson, 54.37 per cent.
It remains that a comparison should be instituted between the composition of th«
bones in health, in mollities ossium, and in various diseased states, in order that we may
determine whether these changes are characteristic of the disease under consideration.
The results of some of the most trustworthy analyses, by the best chemists, will be
found in the following tables :
Mollities Ossiunu
m
Tablk. — Coinpotilwn o/ iituUhy JiontM (^Jlumau) aecorJhtff to Ju/i HUrit^ litr:eiiHK^ 7%omton,
Marchandy Vnlrntin^ and Lehmaniu
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Femur
:.7.12
N.!K» 1
.70 (
[1.00
29Ji4
]J<2
...
< Tibia
.'.7.1H
M.y:! 1
.70 (
Ul
29-58
2.00
• »• » • •
HnmcniH
.'.«.«i
UM < 1.59 (
».59
29.Wi
1.09
• ■ • "••
Ulna
57.52
8.97 . 1
.71 (
[).«i7 '
29.14
1.9U
■
■ •• • ••
KadiuH
ri7Jtt
8.^»5 1.72 i (
[).63 '
29.43
Ijm
'
■ • • ■• •
Kills
W.J«1
8.GG . 1.40
r».(iO
3:1.00
2.S7
Clavicl<>«t
.VJ.3."i
M.8M l.»i» (
L59 1
30.66
1.8.3
'• •
■ •■ •••
Vertt-bne
44.2fi
8.00 1.44 (
[J.-VJ 1
43.44
2.31
• •• • ••
Fibula
.>7.39
H.92 1
.63
D.60
29.49
1.97
• ■• •■ •
Scapula
M.76
H.58 1
.53 «
0.51
32.90
1.73
a * *
a ■ * • ■ •
Metacarpui
:.7.77
M.92 1
M (
0.61
2iiJa
1.89
• •• • • •
Cranium i
.%-.««
■ H.75 1
.69 <
[).63
29.87
1.40
• • •
Man, V> yteKn
Femur
.VJ.83
7.33 1
.32
r).69
29.70
1.53
1 v
Tibia
M.ft.'S
7.<J» 1 1
J(»
1.70
:i0.42
1.55
Humf'ruH
.V.I.nTi
7.76 1
.09
0.72
•29.28
1.28
« • « ■ -•
11 na
mjMi
73* 1 1
Xi
9.73
29.96
1.29
• •• • • •
Ribs
50.66
' 6.64 1
.07
9.62
33.97
2.04
• • • ■• •
Cranium
:W.i:^
8.00 1
.40
9.90 '
21».92
1.35
• • *
... :►« y«ani
CompHsub.
of femur
:>8.23
8.35 1
.03
D.92
31.47
1.35
• ■♦
Spongy bone
of femur
42.82
19.37 1
1
.00
0.99
35.83
U^
Weaian, A2 yn.
Femur
61.17
1 4.46 1
1.29
0.90
28.03
2.15
1
• • «
76 yr*.
Femur
.^7.36
' 7.4» 1 1
.10
0.97
33.16
0.93
B«n«Hua,
Huoiaa bona
Bonen
^.04
1 11 JO . 1
1.16
■ ••
37.17
1
1 1.30
t
TboBUon.
Humftn
Femur
4«.07
14.0U ' t
).49
< ••
39.72
t.«
1 2.50
• «f
Femur
:»l.l2
9.77 (
).6a
**>
35.93
t •■»
, 0.50
1
MarcbMid,
Man, 30 yean
Femur
53.26
10.21 ]
L.05
...
32.25
1
1 1"
t
VfttontiB,
... ,]» years
TibU
52.93
7.66 1 (
).25
• • •
38.02
...
' I.IO
L*IUD*0.
... 4'> ye^rt
■ Humenu
5b.61
0.20 :
1.08
...
• •.
.t.
i 1.72
51.52
•■ ■ ••^^^^^■p •
... . * «
BadiuB
52.25
9.76 ]
1.06 '
.-.
, •
...
. 1.72
33.76
Ulna
vj.oe
9J1 1
1.07
■ »
• ••
. ..
' 1.38
■ 33.23
I Femur
5«i.'i3
' 9.28 , '
1.09
^
• • *
...
• 1.44
28.61
«••
' ,. . ...
FibuU
.W.liO
• 9.33 1
LOG
...
» ...
...
1 1.44
1 34.1:j
Com})o$itioii of Bonei in MolUtieH Omum (^Osteomalacia),
Vertebra.
(B<»lurk.)
Pboiphate of lime 13-^0
PboBpbata of magnesia 0-82
Carbonate of lime 113
Salpbate of lime and sulpbate of soda -^-T^*
Cartilage "^ ••'»
Fate
V»r etra.
(Prowb.)
13.25
iPretcb.)
33.66
"riios
0.00
74.64
ri.2«;
4.60
0.40
40.77
ILCa
100
794 Mollities Ossium^
An aDalysis, by Bogiic, of the bones of a man aged thirty-two yean who died from
Osteomalacia ; yielded the following results :
BeapoU. Radliu. r«a«r. PMelte.
Phosphate of lime 26.92 28.11 23.50 23.23
Carbonate of lime « 0.98 1.07 0.97 0.94
Phosphate of magnesia 5.40 6.35 5.07 5.03
Cartilage and vessels 65.85 63.43 69.77 70.60
Soda, iron and loss 0.86 1.05 0.69 0.64
Ragsby analyzed a rib in this disease, and found —
Phosphate of lime and magnesia 17.48
Carbonate of lime and salts ..~ 6.32
Cartilage, vessels, and fat ~- 76.2o
Specific gravity 0.721
After the removal of the fat, Lehmann found —
1. 2. 3.
Phosphate of lime 36.86 31.71 35.8T
Other salts 4.96 7.91 5.68
Cartilage 58.16 60.36 58.4
In two cases of Osteomalacia, occurring in persons aged about forty years, Lebmann
found—
0) w
rrmnr. r««U. Ftmwr. Chia.
Phosphate of lime 17.56 21.02 18.83 19.14
Carbonate of lime 3.04 3.27 3.83 4.08
Phosphate of magnesia 0.23 0.44 0.54 0.60
Rolnble salts 0.37 0.63 0.43 0.41
Cartilage 48.83 50.48 41.54 42.43
Fats 29.18 23.13 34.15 32. ^.'i
The three following analyses of bone in Mollities Ossium were made by Von Bibra .
Tl)»l« of a Fi-oinr «r • ttmmr wt »
75.T<«rt, iOT««n. •! trv^
Phosphate of lime with a little fiuorids of calcium 55.01 46.79 53. 2S
Carbonate of lime... , , , 4.04 6.37 7.49
Phosphate of magnesia « , ,.,....., 9.01 1.20 1.2i
Baits , 0.31 1.37 l.:ii
Cartilage , 29,17 30.S9 3-V:»4
Fat , 8,58 13.28 \\\
Marchand found the bones of the child, whose ease has been noticed under the Iieii4
of the changes of the urine in Mollities Ossium, composed in the fbllowing manner :
Phosphate of lime 12.56 15,11 14.78 21 55
Phosphate of magnesia « 0.92 0.78 o.so o.:.*
Carbonate of lime , , 3.20 3.15 3.<K) 3.7»
i"uis: o[ ioT.} »•" ••«" '••" ^ ^«
Fluoride of calciom \
Chloride of sodium \ 1.00 1.20 l.oo 2 <^1
Iron and loss j
Cartilage 75.22 71.26 72 00 ♦Jl.^o
Fat 6.12 7.50 7.20 ».34
In a paper published in the twenty-first volume of the Mtdioo-Ckirurfieal TrauM^
actions^ Dr. Reese demonstrated, by analysis, that the different bones of the adult hiimao
skeleton, in health, contained animal and earthy matter in different proportions. Subse-
quently Dr, Beose had an opportunity of examining some bones affected with Mollltiif5.
and the following is the result of careful analyses pf three specimens from the «aiii«
ndult Hubj^t : — they are compared with those obtaine<Ji from healthy bone^.
Molliiies Ossium. 795
HOLLITIKS. HSALTH.
r— * ' — — — ^ r — — *- \
v.*th. Animal e...k. AnlmiU
«•'«*•• auutr. *"*^- muter.
Fibula 32.50 «7.50 60.02 39.98
Ribs 30.00 70.00 f)7.49 42.51.
Vertebra 2G.13 73.87 57.42 42.38
Dr. Reese obseri'es: "On examining this table it will be observed tbat in the diseased, as
well as the healthy bone, the fibula contains more earthy matter than either the ribs or ver-
tebra; and the ribs more than the Vertebra; thus we have the same order preserved in
health."
It may be noticed that the vertebra and ribs in health approach very nearly in their
proportions of animal and earthy matter ; while in mollities a considerable difference
exists between them in this respect. This indicates that though the bones are all acted
upon by the absorbents in mollities, yet that the absorption does not go on equally in
the bones, some being acted on more than others. There, is however, an approach to an
e<)uality of action ; for, notwithstanding that the diseased bones have lost about half
their earthy matter, yet they keep the same order as regards proportional constitution
which we observe in health, viz : the fibula containing mt)ro earthy matter than the ribs,
and the ribs more than the vertebra.
Having ascertained, by previous experiment, that the earthy matter obtained from
the long bones of the extremities contains, as nearly as possible, 86 per cent, of phos-
phate of lime in health, and that the earthy matter from the trunlc bonen contained, on
an average, 83.03* per cent., T determined on mixing together the earths obtained from
the fibula, ribs and vertebra affected with mollities, and subjecting them to analysis.
This bone-earth, on examination, proved to contain only 78 per cent, of phosphate of
lime. There is evidence here that the absorption of earthy matter by disease is accom-
panied by a decrease in the proportion of phosphate of lime to carbonate. This would
seem to show that the absorbents carry away earthy matter containing a very large per-
centage of phosphate of lime, for were it otherwise, we should never find bone earth
containing so small a percentage as 78 of that earth ; the 8nmlli%st in health being 81.2
of phosphate, to 18.8 of carbonate of lime. That the carbonate is absorbed together
with the phosphate of lime in certain though small pi*oportion in these processes, is
proved by the fact that bones, even those most changed by the abwrption of their earthy
matter, are not very greatly removed from healthy bone earth in the general average
proportion of phosphates and carbonat^e of lime. {Gnt/^s Hospital Reports, No. 8,
April, 1839; No. 9, MedkO'ChinngUnl Rtvinr, July Isi, 1839, pp. 246-247. Am.
cd.)
The carbonate of lime in the bones analyzed by Dr. (J. 0, Reese may have been
derived from the burning of some organic acid, as the lactic, during the preparation of
the bonc-carth for analysis, and without the clear demonstration of the extsten.!e of the
carbonate of lime as such ip the bone ])revious to incineration, we cannot lay much
stress upon its apparent or relative increase when compared with the phosphate of lime.
Solly J has given the following analysis of the medullary membrane and osseous sub-
stance of an individual affected with osteomalacia. The analysis of the affected bone
was made by Dr. Tu.«on.
Animal matter 24. 7« 18.75
Talcareoas phosphates 1.6>'^ 29.17
Water 7:l31» 52.08
The chemical examination of a case (detailed by Dr. Ramsbotham, in the n ports of
the Pathological Society*) by Ih, Garrod, yielded :
♦ This average was drawn from results obtained from seven specimens ; the extremes were
81.2 and 85.0.
t Medteo-Chirorg^cal Transactions, vol. xxvii, p. 435.
* Reports, A(C., 1647-48.
79C Mollities Ossium.
Fatty matter « 20.35
Gelatin jielding matter 58.37
Carbonate and phosphate of lime and phosphate of magnesia 21.28
M. Bamiel, Jr., found 18 parts of earthy salts, and 82 of organic matter, in 100
parta of bone affected with osteomalacia. The bones of the forearm, which were less
softened, afforded 29 of salts and 71 of organized matter, per cent.
Dr. Buisson, in a thesis published in 1851, gives the following analysis of the inferior
extremity of the femur of a female suffering from osteomalacia. She was thirty-eight
years of age, and her bones had been fractured more than eight times.
Cartilage 54.37
Pboepbates 39.16
Carbonates 6.47
Th&ie analyses, says the author, prove that the same results are obtained, whether
the bones be softer or more fragile than in health. In all cases there is a considerable
decrease of the organic matter. (Simon's Animal Chenmtr^, p. 601. Becquerel and
Rodier, Pathological Chemistry, p. 507. Rokitansky's Pathological Anatomy, vol. iii,
p. 144.)
On the other hand, as the basij^ of comparison, wc have given the composition of
healthy bones.
Yon Bibra has made the most complete analyses of human bone, and the results of
his elaborate labors are especially valuable, as 8er\'ing the purpose of comparison with
diseased bones, as he has carefully separated and dotermined the proportion of fat ; whilst
the analyses of Borzclius, Thomson, ^larchand, ^'alentin and lichmann, do not fumisth
the proportions of this important constituent of healthy bones. The determination (»f
the propoition of fat in the healthy bone, as.sunics a position (»f transcendent importintv
as the Htjirting point for the determination of (he amount and character of the alteration
and degeneration of bone in various diseased states, and especially in those disea.<e9 of
the osseous system which, like mollities, is as.sociated with fatty degeneration. Thr
results of the analyses of \o\\ Hibra will Ik* found in the fiillowinjr table, together wiih
those of several other distinguished chemists.
In the following table it will be seen that, in rickets, according to the analyses of
MM. Pclouzc and Fremy, it appears that the. di'croase of calcareous matters was even
greater than in individuals suffering from mollities ossium ; and in the analysis by Nar-
chand, the calcareous salts, and es|)ecially the phosphate of lintc, are greatly diminished,
and the proportion l>etween the organic and inorganic nnitters is pnvisely the inverse
of what it is in health. The analysis of bones affected with nicliitis yields, tberefoiv.
results similar to those announced for mollities (»ssiuni, vix : decrease of phosphate oi*
lime, <uid increase of the cartilagiiums and fatty mattci-s. It will bo seen, however, that
the fatty matters are inciV4U^Ml much more uniformly, and to a tar greater extent than
in mollities (xssium.
In caries there is a marked decrease of the proportion of phos]»hsite of lime; in sune
cases a slight increase of the carbonate) o^ lime ; no appreciable change in the propor-
tion of the phosphate of magnesia and soluble salts : normal proportion of cartilage, and
a frequent and decided increase of adipose matt(*r.
The few analys««^ in necrosis indicate a slight diminution of the itartilagiDoas >v^>
stance, an increase of calcareous salts and the normal proportion (»f adipose matter.
In the tophaceous deposits of chronic arthritis there is decrease of the pho^hate of
lime, increase of the carbonate of lime, and great increase of the adipose matter.
Whilst, therefoi*e, this comparison est^iblishes analogous changes in the bones of oectaiii
diseases, as caries, neoriisis, and arthritu*, at the same time we have a demonstratioD that
mollities ossium i!« especially characUTized by the dengeneration of the oAseous straetore
into fatty matter. We cannot agree with those pathologbts who soo nothing lu tbr^
disease but a fatty degeneration of bone. In those diseases, as caries sod arthritis in
whi-jh wc have a similar change, but to a It^s degree, we have inflammatory action ; and
MoUUies Ossium.
Tablb. — ChftKicat Campotitioa of Dittatd Bonn m Bathilii, Cari44, Kitrotit, OtUojuuit, Scltrotid
Ezottoiu, Otttvid Tumor, ATihnlU, and Callvi. Bn Ldmmn, Rtg^, Ton Bibr; Fihuie
Kalntf.'n, l/attaignt, Marehand and Sinu/n.
—
1
AttTBD.
in
[
fi
!
i
jf
in
1?
S
s
Poloni* ud
DuMlTBrKbn
.';."
0*t
IJ? TS.Tfi
«.»'
...
... ,irt
r*nur
\f.
^■^
1 JJ^
Vim Blbm
::: ::;
HiUarpi
'»j«
s^w
O.M
sliil
i.UH
3.11
'■"
.-. KH
Tinai
l.U
UhiHnn
Anhrltli, III
csatHdtpi
j "i'xt ' wJw ■ ^
1JW 'iuis iii,«> ' i
798 Mollities Ossium.
the true and most important question with reference to mollities ossiam is the determi-
nation of the causes which led to such an alteration of the bones as led, not merely to
the absorption of the earthy salts, but also to the effusion of inflammatory products in
the bony structure, and their final conyersion into fatty matter, as in those disease:*
which are, in their inception, truly inflammatory.
The view that the earthy phosphates, in mollities ossium, were removed by s^me aclJ
generated in the living system, was suggested at an early day in the history of the
disease ; and, in fact, this idea appears to have been suggested by the effects of acid^
upon healthy bones in rendering them flexible like cartilage.
Dominic Gagliardi, who, discoursing upon the observation of Gabrielli upon mulliciesi
ossium, in 1689, supposed that the earthy matter of bony gypiuni^ as he called it, is^
softened in consequence of its being alkaline, by the acids which are thrown into th*
vessels of the bones ; and that from hence it is that persons subject to rheumatic and
arthritic pains, but peculiarly to pains from ^Mues venerea," are also subject to have
their bones become sofl. This statement led to the experiments of softening the botics
by means of acid liquors.
Morgagni adopted the same opinion, and conjectures that a humor is carried into (he
bones which is capable of softening them, and refers to the experiments of Ruy»ch,
who showed that acid liquids would remove the earthy particles, and render the bone^
so soft and elastic as to be bent into any shape.
Ruysch, in recording his expsrimsnts, mikes the following application in th * fonn of
a query : ^' Docs it from hence appe.'^^r in what manner that memorable disease wa.^
brought about wherein a virgin, in Franoe, biing affected, hid all hir bon^ softenod
down like paste?"
More recently Marchand has propounded a chemical theory of mollities ossium ani
rickets, which is a further elucidation of the old idea of the action of ao acid humor in
the blood. This theory of Marcband we have thrown int) thr^e propoMtiims as
follows :
1. The diseases which exert the gr«3atest influence over the condition of the bone*,
altering them from their normal state, are scrofulous affections, to which rickct'^ and
mollities ossium may be considered as belonging.
In these two diseases, the earthy matter of the bone becomes diminished, an J the
bone falls into a st^ite such as if it had been macerated in muriatic acid ; supple ; flexible
and ill-adapted to serve as a support to the other organs of the body. The cartilage
itself undergoes nn essential alteration, and is incapable of being converted by boiling
into gelatine.
2. Concurrently with these changes, phosphate of lime is eliminated in lar);e 4|aao-
tities with the urine. This salt, otherwise little soluble, and discharged gjncr.&]ly in
small ((uantity by the kidneys, is, according to Berzelius, readily soluble in lactic acid .
anything, therefore, which causes a superabundance of this acid in the system, i^
capable of depriving the organism of a large share of the earthy matter of th* bone«.
Sngar of milk, grape sugar, starch, and gum are readily converted into lactic acid
but they are so in the stomach only when digestion is ill-performed, in which cas? lactic
acid may be an abundant product in the system.
3. Rickets and mollities ossium, therefore, are not essentially diseav» of the b.mei,
but seem to be the result of imperfect digestion or nutrition ; to improve which i5 can*
scqucntly our first indication.
None of the substances readily converted into lactic acid should be taken as »agAr.
starch, gum, etc., nor even milk (rickets are often the consequence of children having
been too long suckled,) but animal food and such other as is freely digestible, sh*>uld
be chosen, in aid of which we ought to employ such medicines as may restore th«
general tone of the system
This chemical theory of Marchand is sustained by the discovery of increased quan-
tities of lactic acid and lactates in the urine of rickets and mollities ossium ; and by
the actual discovery of iaetic acid in the diseased bones of the latter diseaae.
MollUies Oasium. 71*9
C. Schmidt proved clenrly thai Tree lactic acid van present in tlio fluid of the cylin-
drical boDesin this disease ; and Lehmann states that the fluid occurring in these bones
exhibits very often, although not invariably, an acid reaction. Weber, who alone
appears to have inveHti{cated the composition of the phosphate of lime contained in
thi»e bones, found in addition to carbonate of lime t basic phosphate of lime, and
believes that phosphate of normal bone (3CaO,POi) is converted by means of the free
acid into this less bssic salt.
The singular and painful disesae of the jaw-bones, produced by the fumes of phos-
phorus and phosphoric acid,* renders it probable that in molljties oasium, most of the
pain and irritation of the bones may be caused by the liberation of phosphoric
acid in the phosphate of lime which has been subjected to the action of the free lactic
acid.
INDEX TO VOL. I., MEDICAL AND SURGICAL MEMOIRS.
A
ABSORPTION. Experiments illastratiDg the process of. 558-578
Experiments on Living Animals, showing that their membranes exert a Phy-
sical Influence capable of changing the molecular arrangement of Chemical
Substances in Solution, passing through them by Endosmose... 561
Experiments determining the action of the Sulphate of Magnesia, in solution,
on Living Animals 564
Experiments on the Reciprocal ActioA of Serum and Solutions of the Sulphate
of Magnesia through dead animal membranes 571
Derangements of the process of Absorption in the Human System 577
ABORTIVE SYSTEM OF TREATING PNEUMONIA 695
ACONITE. Value of as a remedy in Traumatic Tetanus 406
Value of nsa remedy in Pneumonia 742
•BGINETA, PAULUS. On the cure of Tetanus 337
ALBINUS. On Nervous System 7
ALCOHOL. In Treatment of Tetanus 397
ALLEN. CHARLES. On Tetanus 405
AMES, S. On Cerebro-Spinal Meningitis 470-549
On Pneumonia, its Treatment, etc 740-744
ANALYSES of Urine in Malarial Fever 488-677
Of Urine in Traumatic Tetanus 143-156
Of Blood in Cerebro-Spinal Meningitis 449-472
Of Hfalthy Blood 584
Of Blood in Malarial Fever 585
Of Blood in Marsh Cachexia 587
•Of Blood in Cardiac Dropsy 608
Of Blood in Chronic Bright's Disease 637
Of Urine in Pneumonia 670
Of Composition of Bone in Man 793
Of Composition of Bone in Mollities Ossium 794-799
ANATOMY of Nervous System 4, 5, 7, 23, 28, 46
Microscopical and Anatomical Investigations of the Brain and Spinal Cord
in Vertebrate Animals 48
Investigations of Valentin, Volkmann, Kolliker and others, on Minute Ana-
tomy of Nervous System 48, 49, 50
Investigations of J. Lovkhart Clarke, on Minute Anatomy of Spinal Cord 50
Investigations of Professor J. L. C. Schroeder Van der Kolk, on Minute
Anatomy of Cerebro-Spinal System 52
of Medulla Oblongata 54
Professor Owen on the Comparative Anatomy of the Cerebrum and Cere-
bellum in fish 62
of Foetal Brain, according to Tiedemann 64
of Cerebrum and Cerebellum, according to J. Luys 72
of Sympathetic System 87-90, 185
Minute, of Nerves 174, 175, 176
Pathological, of Traumatic Tetanus 199-224
Pathological, of Insanity 225
Pathological, of Dementia and Paralysis 230
Pathological, of Epilepsy 236
Pathological, of Paralysis 248
Pathological, of Cerebro-Spinal Meningitis 450-483
Pathological, of Malarial Fever 497-501
Pathological, of Yellow Fever 497-501
Pathologinil, of Dropsy arising from Alterations of Blood 589-603
Pathological, of Cardiac Dropsy 609-619
Pathological, of Hepatic Dropsy 621-63:*
Pathological, of Renal Dropsy and of Bright's Disease of Kidneys 636-645
802 INDEX.
ANATOMY, Pathological, of Pneumonia 717
Mollitiei Ossium 755-799
ANTIMONY. Injection of into blood, effects 366
Value of as a remedy in Traumatic Tetanus 346-401
Value of as a remedy in Pneumonia 688
ANTIPHLOGISTIC SYSTEM OF TREATING PNEUMONIA 684
ARET^US, the Cappadocian, on the Cure of Tetanus 336
ARISTOTLE. On Nervous System 2
ARNOLD JOHANN WILHELM. On Reflex Action 41
ATLANTA. Statistics of Confederate Hospitals in 738
AUGUSTA. Georgia, Mortuary Statistics of, in Tetanus and Convulsiont 266
Mortuary Statistics of, in Fevers, Pleuritis, Pneumonia and Hydrothorax 706-709
AURELIANUS. On the Cure of Tetanus 337
B
BALY, WM. Experiments on Reflex Action 4ft
BACON, LORD. On Medical Science 411
BALLANTYNE. On Treatment of TeUnus witti Chloral 353-378
BANKS, J. T. On Cerebro-Spinal Meningitis, amongst Confederate Troops at Fred-
ericksburg 429
BAKER, R. L. Treatment of Tetanus 369
BAILEY. Treatment of Tetanus 370
BASCOME. Treatment of Traumatic Tetanus 369
BARUCH. On Treatment of Tetanus 379
BARK. Employment of, in Treatment of Pneumonia 695
BENNETT, JOHN HUGHES. On Treaiment of Pneumonia 681-687
BELL, SIR CHARLES. Discovery of the sensitive functions of the posterior roots
and of the motor functions of the anterior roots 2o
Examination of, claims of 21
Respiratory System of Nerves 23
On the Nerves of the Orbit 25
On the Nervous Circle 25
On the functions of some parts of the brain, and on the relations between the
brain and nerves of motion and sensation 26
Analysis of Works 20-28
On Rickets and Mollities Ossium 77^
BECK, J. A. On Treatment of Traumatic Tetanus 354-37^
BELLADONNA. Effects in Tetanus 4o6
BBLLINGERI. On Structure and Functions of Spinal Curd 21
BELLINGSEA. On Treatment of Tetanus - 375
BERNARD, CLAUDE. On Section of Sympathetic 100, 111, 112, 113, 114
BERNARD SEIGFRIED, (ALBINUS). On Structure and Functions of Nerves 7
BERGSON AND ACKERMANN. On Circulation of Brain Km
BICHAT. Analysis ot Work on Life and Death, and statement of views on structore,
functions and relations of Cerebro-Spinai and Sympathetic Systems 14, 83, 31 »
BIDDER. Experiments on Brain and Spinal Cord, illustrating the relations of the
Nervous Forces to Secretion and Excretion lot
BILE. Condition ot, in Yellow Fever and Malarial Fever S«><*
BIRKELL. On Treatment of Tetanus -... 35a-3Tj*
BlSHt)P. On Treatment of Tetanus ^ 37:
BLANE, SIR GILBERT. On Instinctive Actions .-^^
On Treatment of Tetanus ^... 343-357
BLACK VOMIT OF YELLOW FEVER. Effects of Sub-cutaneous Injection of, on
Living Animals ~^« 521*
BOLTt)N, JAMES. On Treatment of Tetanus - 3Tj
BLOOD. Eiperiinents on Abstraction of 272-27;
("oinposition of in Cerebro-Spinal Meningitis 449-472
Characters of in Malarial Fever 4^5
Experiments on the Effects of Gases on the Blood of living animals 5o.-
Action of Carbonic Acid on, 509; Carbonic Oxide, 510 ; Bin-oxide and Per-
oxide of NitroKen, 512 ; Chlorine ^ il4
Experiments on the Action of Animal Poisons on the Blood, 519 ; of Copper-
head. 519; of Rattlesnake, 523; of Black Vomit ^.!••
rhangf s uf in various Diseases 53«^^i4
Composition of in health Sx^
« INDEX. 803
Paget'
BLOOD. CompositioD of in Malarial Ferer 585
CompositioD of ID Marah Cachexia 587
Composition of in Cardiac Dropsy 608
BLOOD-LETTING. In Tetanus, 344-401 ; io Cerebro-Spinal Meoingitis, 482-545 ;
In Pneumonia 684
BOERHAAVE, on the Structare and Functions of Kerres 6
BONES. Diseases and Composition of 751
BRAIN. Views of Aristotle, Pythagoras, Plato, Herophilos, Erasistratus, and Galen
on structure and functions 1-5
ObserTations on bj Rondeletius, in 1550 4
Observations of Varollins on its connection with Spinal Cord 5
Views of Willis, as to its structure and functions, 5 ; of Boerhaave. 6 ; of
Albinus, 7 ; Malpighi, 7 ; Unzer 8; Prochaska 12 ; Bichat 14 ; CuTier 17 ;
Le Gallots 17; Alexander Walker 19; Sir Charles Bell 20; Magendie 21 ;
Bellingeri 21; Muller 22 ; Bell 23-28; Hall 29; Muller 37 ; Arnold 41
Minute structure of, obserTations on by Valentin 48 ; Remak 48 ; Stilling
49; Volkmann49; Kdniker49; Clarke 50 ; Van der Kolk 52
Comparative Anatomy and Physiology of, according to Professor Owen 62
Thedmann on Anatomy of Fcetal Brain 64
Experiments on, by Flourens 66; Desmoulins 67 ; Rolando 67 ; Magendie 68;
Bouillaud .\ 69
Literature of. Diseases of 70
Doctrine of Gall 70
Minute structure of, according to J. Lays 72
Observations of Poufour du Petit and Marc Dax, on relations of loss of speech
to lesions of Brain 73
Experiments on yarious portions of the Brain, by Fritsch and Hitxig, 73 ; of
Ferrier 74; Hitzig 76; of Carville and Duret, 76; Dupuy 76; Bartholow
77; Fournie and Beaunis 77 ; of Nothnagel 77
Lesions of, in Insanity, 225 ; Dementia 230 ; Epilepsy 236 ; Paralysis 248 ;
Cerebro-Spinal Meningitis 421, 437, 450, 483; In Yellow Fever and Malarial
Fever 497
BOUILLAUD. Experiments on the Brain 68
BRACHET. On Section of Sympathetic 97-99, 107
BRIGHT'S MEDICAL REPORTS 360
BRITTON. On Treatment of Traumatic Tetanus 349
BROWN-SEQUARD. On Functions of Spinal Cord 61
Experiments on Sympathetic System 101
Experiments illustrating the relations of the nervous system to secretion and
excretion 107-111
BROMIDE OF POTASSIUM, IN TETANUS 378
BUDGE. Experiments on Elevation of Temperature consequent on Section of Sym-
pathetic 103
c
<\\LABAR BEAN. Extract of, in treatment of Traumatic Tetanus 404
TAMPBELL, HENRY F On Excito-Seireiory Syntem of Nerves 96
« A MERER. On Nervous System !....* 99
TARPRNTKR. WILLIAM B. On Structure of Nervous System in Invertebrate
Animals 44
TASES. Traumntic Tetanus. 142, 156. 157, 158. 161. 163, 166, 1H8. 170, 182, 199,
201, 209, 210, 213, 214, 216, 217, 218, 219, .342, 355, 35<;.3H3.
Trtiumatic Tetanus. Table showing the age, sex, nature of injury, results
and methods of treatment in 420 cases :5.'>-383
Insanity 225. 22G, 220
Dementia 230
Epilepsy 236
Paralysis 248
Pernicious Malarial Fever, reported by Hippocrates 416
Cerebro-Spinal Meningitis, reported by Hippocrates 417
Cerebro-Spinal Meningitis occurring in Confederate Army, 424, 425, 426, 427,
428, 429, 422, 434
Cerebro-Spinal Meningitis, 438, 440. 441, 442, 443, 444, 445, 446. 447, 454, 458.
459, 460, 461. 462, 463, 464, 465, 467, 473
Gangrene of both feet 470
804 INDEX.
GASES. Illastratiog the coiapositioD of the Urine in Malarial Fever 488, 489
lUastrating the Temperature, False and Respiration in Intermittent. Remit-
tent, and Pernicious Malarial Fever 490, 491, 492, 493, 494, 495« 4i»^
Softening of Brain 533
Tubercular Meningitis 533
Cerebro-Spinal Meningitis .*. ^ 543
Dropsy, arising from effects of cold 58o
Acute Dropsy 581
Marsh Cachexia 587
Illustrating Dropsy induced by the action of the Malarial Poison, 589, 590, 591,
592, 593, 594, 595, 596, 597, 598,600, 601, 602, 603
Illustrating Cardiac Dropsy, 606, 609, 610, 611, 612, 613, 614, 615, 616, 617, 618, 61!
Illustrating Hepatic Dropsy 624, 625, 627, 628, 629, 630
Illustrating Dropsy arising from Disease of Kidneys, 637, 638, 639, 640, 641, 642. 644
Illustrating Natural History and Treatment of Pneumonia, 670, 671, 672, 673,
674, 675, 676. 699, 716, 717, 718, 719, 720, 727
Phthisis Pulmonalis 729-737
Mollities Osslum 755-772
Fragilitas Ossium 773-777
Rickets ^ 778-782
Cancer of Bones 783-7x7
CARDIAC DROPSY 605-620
CELSUS, A. CORNELIUS. On Nature of Tetanus 155»
CEREBELLUM. Anatomy and Physiology of 62, 79, 169, 179
CEREBRUM. Anatomy and Physiology of. 62, 79, 169, 179
C-EREBRO-SPINAL NERVOUS SYSTEM. Anatomy and Physiology, History of.
progress of Doctrines relating to 1-137
Comparison of Lesions of, with' those of other Diseases, as Insanity, Epilepsy,
Paralysis, and Traumatic Tetanus 2o9-254
CEREBRO-SPINAL MENINIGITIS 411-553
History of « 4n-«3S
Cases observed by Hippocrates 417
Epidemics of, in various countries - —.....,... 419—43-
Statistics of, in Confederate Array 424, 425, 42t
Report on, by P. Gervais Robinson 427
Report on, by W. D. Mitchell -« 42^
Report on, by J. ;T. Banks 42i*
Report on, by R. J. Breckinridge - 432
Report on, by G. A.Moses 434
Natural History of 431^-450
Pathologica! Anatomy of .* ^ 45(^-483
Relations of to Malarial Fever 48:>-56T
Comparison between the Changes of the Blood in Cerebro-Spinal .Meningitis.
and those induced bv the action of ccrtnin Poisons ~ ...... « 507-^5*4
CEREBRO-SPINAL ME.VING'ITIS. Derangements of the Circulation, Respiration,
and Secretions in, referred to local inflammation, congestion and alteration
of the Meninges of the Brains and of the Nervous Structures. 534-51*
Historical Notes on the Treatment of *.. 542-5:»"
CHLORINE. Amount of, in Urine of Tetanus !J»*
Action of. on Animals 2i>^
CHLORAL HYDRATE, in treatment ot Traumatic Tetanus 352, 354-3:«:
in treatment of Cerebro-Spinal Meningitis 54-
CHLOROFORM, in the treatment of Traumatic TeUnus .~ 350, 39t^-3^<>
Experiment on Action of, on Living Animal *'*
In treatment of Cerebro-Spinal Meningitis 54*
CH.VRLKSTON. S. C. .Mortuary Statistics of, in Tetanus, Trismus Nascfouam.
and Convulsion? 261, 262. 2t"
Moiluitrv Statistics of. in Pneumonia 71*
C1IALMKU8. LIONEL on Natur. of Tetanus 15-
t'HESKLDKN. on Anatomv of Human Bodv - 3N
CH1R.\C. on Nervous System « T
(MIOSSAT. on Nervous System 7^-1'
TLARKE. J. r.OCKHART on Minute Structure of Spinal Cord -."-Sr
CLIFT. Experiments on Nervous System
t>n Pathology of Telitnu^
'•
*•
INDEX. 805
Pages
CLKGHORN, GEORGE on Remittent Pneumonia 697
COITER, on Nervous System b
COLD. BLOODED ANLMALS. Action of Heart in 283
Experiments on, with Poisons 280
COLD AFFUSION in Traumatic Tetanus 346
CONVULSIVE DISEASES. Experimental Illustrations of...... 270-334
COLERIDGE, on the effects of the Imagination in the Cure of Disease 234
COLUBER, GUTTATUS, Eic, Action of Hydrocyanic Acid on 281-290
COPPER HEAD. Action of Poison of, on Animals 519
COPLAND, on Symptoms and Nature of Traumatic Tetanus 162
on Patholog? of Tetanus 215-216
CONFEDERATE ARMY. Cases and Deaths In, from Diseases of the Nerrous Sys-
tem 424-425, 426-436
Statistics of Pneumonia and Typhoid Fever in 650-668
CORONELLA GETULA. Action of Hydrocyanic Acid on 290
COURTEEN, on Nervous System 79
CRAIGIE. on Pathology of Tetanus 215
CROCODILE, Brain of 63
CRI'IKSHANK, WILLIAM. Experiments on Parvagum and Intercostal Nerve 82
On Nervous System 79, 99, 107
rULLEN, WILLIAM, on Nature of Tetanus 159
Treatment of Tetanus 339
CrRLING, THOMAS BLIZARD, on Absence of Inflammation in Tetanus 163
Patholoey of Tetanus 209-216
Treatment of Tetanus 343
On Mollilies Ossium 778
(TRRIR, JAMES on Temperature in Tetanus 160-164
On Treatment of Tetanus 343
CUVIER, on Reflex Action 16
CYANIDE OF POTASSIUM. Poisonous effects of, on Animals 293-318
I>
PALTON, JOHN C. M. D., PROF. Experiments with Sulpho-Cyanidi* of Potassium
and Strychnine, illustrating the relations of the Muscular and Nervous Forces 124
DALRYMPLE, Observations on Mollities OsMum 754
DAVIS, JOHN S. M. I)., PROF., University of Virginia. Letter on Treatment of
Pneumonia in the ConfVderale Army 744
D.WY, JOHN on Animal Electricity '. 117
DAVY. HUMPHREY, SIR: Experiments wiih Nitrous Oxide Gas 234
DAZILLE. on Tetanus * 304
I)E la RIVE, Hypothesis of the Nature of the NtTvoua Forces 125-129
DE.MME. on Patbologici.l Anatomy of Tetanus 222
DK.^CARTES, on the Nature of the Nervous force 116
HESMOULINS, on the three distinct orders of nervous phenom na; those which
produce .Muscular Contraction ; that which produces Sensation ; and those
which produce thought 67, 68. 73
DEMENTIA, Case of ! 230
DICKSON, HENRY M. p., PROF. Letter on Treatment of Pneumonia 715
DIETETIC SYSTEM of Treating Pneumonia 670-680
DIETL. on the relative value of the different methods of treating Pneumonia 680
DIGITALIS, in the treatment of Pneumonia 690
DICKSON, on Pathology of Traumatic Tetanus 223
DOGS, Experitnenls on, with various poisons, as Hydrocyanic Acid, Cyanide of
Potassium, Strychnine, Bromine, and Animal poisons 304-306, 317-321, 325
513, 519-530.
DROPSY. Considered as a symptom of Various Diseases 5.'»7-646
Causes of 557
Arising from derangement of the nutrition of the tissues, leading either to an
increase of Secretion or diminution of Absorption 579-583
Arising from Derangements or .Vlieralions of the Blood 5H-I-604
Arising from the Action of .Malaria ri84-604
.Vrising from Derangements of the circulatory apparatus— <*ardiac Dropsy 605-620
Hepatic, arising from some obstruction to the circulaiioo of the blood through
the Liver 621-63*
Arising from Lesions of the Kidney — Ucnal Dropsy 635*646
806 INDEX.
DRELINCOURT on NerTous System 1 79
DUBOIS, REYMOND, on Electric Phenomena of Nerves and Mascles 117-119, 123
DUPUYTREN, on NerTous System 79
DUPUY, on Functions of Cerebrum and Cerebellum 76-107
DUVERNEY, on Nervous System a.... 79
DUNBAR, ROBERT, on Cercbro-Sptnal Meningitis 4S2
E
BDDOME. On treatment of Tetanus 372
EHRENBERG. Observatious on Minute Anatomy of Nervous System 4^
EPHESUS. On Nervous System 79
BLLIOTSON. On treatment of Tetanus ^ 366
ERASISTRATUS. On the Functions of the Brain 3
EVE, PAUL P., M. D., PROF. Treatment of Traumatic Tetanus 374-378
EXGITO MORTORY or true Spinal System of Marshall Hall » 33
EXCITO SECRETORY System of Nerves 96
EXPERIMENTS. Experimental Illustrations of Convulsive Diseases 271-336
Illustrating the Action of Physical Agents 272
Abstraction of Blood 272
Effects of Electricity on Living Animals «... 274
Mechanical Injuries of Cerebro-Spinal Nervous System 376
Division of Medulla Oblongata; Artificial Respiration 277
Action of Prussic Acid and Cyanide of Potassium on Living Vegetables.. 379
Action of Hydrocyanic Acid on Cold-BIooded Animals 2§o
Action of Prussic Acid on Siren Lactrtina, 280; on Coluber Quadrivittatas,
281 ; on Coluber Guttatus, 281 ; on Emys Serrata 292
Relations of the Action of the Heart in Cold-blooded Animals to the Cerebro-
spinal and Sympathetic System 282
Illustrating the direct action of Prussic Acid, Cyanide of Potassium, and
Strychnia, on the Heart of Cold-blooded Animals 390-«i^6
Illustrating stimulant effects of Chlorine ., „ 296
Effects of Biuoxide and Peroxide of Nitrogen...... „.... « ., 2dr
Illustrating the direct action of Hydrocyanic Acid on the Medulla Oblongata. 29!^
Illustrating the action of Hydrocyanic Acid and Cyanide of Potassium on
Warm-blooded Animals, Mammalia atU-SM*
Relations of the Action of the Heart in Warro-Blooded Animals to the Cerebro-
spinal and Sympathetic Nervous System 30^-31^
To determine whether Prussic Acid, Cyanide of Potassium and Strychnia.
. exert any direct and special action on the heart, independent altogether of
the action of these agents on the Cerebro-Spinal Nervous System 316-321
Comparative, on the Action of Poisons and the Division of the Medulla
Oblongata 3S4-i::
Illustrating the Action of Chloroform on Warm-Blooded Animals by Subcu-
taneous injection and inhalation S>
Illustrating effects of Sulphuric Ether by Inhalation i:*'
Effects of Gases on the Blood of Living Animals 509-M.*
Carbonic Acid Gas » :» »*
Carbonic Oxide Gas .^ jI •
Biuoxide and Peroxide of Nitrogen j :
Chlorine L.4
Injection of Atmospheric Air into Blood * .,.,. r**
Exclusion of Air ^ :» .*
Nitrogen Gas *:"
Action of Bromine on Living Animal, when inhaled li •
Action of the Poison of Certain American Ophidians, 519-528 ; Poison of Cop-
perhead, 519 ; Rattlesnake hy>
Action of Blood and Black Vomit of Yellow Fever on Living Animals 522^-^^
Osmosis and the Action of Purgatives 55lf-*i**
On Living Animals, Illustrating laws of Endosmose !•'•'
On Physical Influence exerted by dead Mucous Membranes, on Chemical ab-
stances in Solution passing through them ., ••:
On the Action of Sulphate of Magnesia in Solution, on Living Animals.. 5c «
On the Reciprocal Action of Serum, and Solutions of the Sulphate of Magnesia,
through dead Animal Membranes ..^ 'T.
On the Reciprocal Action through dead Animal Membranes, of water and
Saline Solutions „ « ^*4
INDEX. 807
FARADAY. On ADimal filectricitj IT,
FERNELIUS. On Nervoas System ^ ^ 115
FERRIER DAVID, PROF. Experiments on Bmln ^ 74-75
FERGUSON, A. On Treatment of TeUnua 377
FEVER. Malarial 47"
Malarial; Tabular View of the Changes of the Blood, Urine, Circulation, Tem-
perature, and Respiration ^ 485-496
Malarial. Pathological Anatomj of. : 497-501
Malarial, Relations of, to Cerebro-Spinal Meningitis 463-506
Differences between the Symptoms and Pathological Lesions of Cerebro-Spinal
Meningitis and Malignant Malarial Ferer 506
Intermittent 676-720
Remittent ', 716-718
Malarial, relations to Pneumonia 695-746
Malarial, changes of Blood in 584-587
Malarial, cases of illustrating changes of Liver and Spleen in, attended with
Dropsy 657-668
Malarial and Typhoid, Mortuary Statistics of, in Confederate Army 657-668
Malarial, Statistics of, in Charity Hospital 589
Mortuary Statistics of, in Savannah, Georgia 701-703
Mortuary Statistics of, in Augusta, Georgia........ 705-709
In Gangrene 479-480
In Meningitis, Cerebro-Spinal 440-449
In TeUnus 157-166
Typhoid 477
Typhoid and Malarial. Statistics of, in Confederate Army 657-668
In Pneumonia 670-737
Typhus 477
Changes of Blood in Various Fevers 507, 531-534
Typhus 477
Yellow 477
Yellow, Pathological Anatomy of. 497-501
PISH. Prof. Owen, on Functions of Cerebellum of. 62
Brain of 71
PLOURENS. Experiments of, on Functions of Cerebrum and Cerebellum 66, 69, 73, I6i»
On Circulation 286
FODERA. On Functions of Spinal Cord 37
FONTANA. On Nervous System 79, 81, 285
FOURNIR AND BAUNIS. Experiments on Brain 77, 78, 169
FOVILLE. On Functions of Cerebellum 77-78
FRASKR. On Treatment of Tetanus 405
FOSTER, M. On Treatment of Tetanus 377
FOULKE, 0. Ou Treatment of Tetanus 369
FRANQUE. On Amount of Urea excreted by Healthy Men 190
FREE ACID. In Urine of Tetanus 192
FRAGILITAS OSSIUM 773
FRANCOIS. On Tetanus 255
FrOATE, F. H. On Treatment of Tetanus 374
FRERICHS. Observation on Pathology of Liver and Pigment deposits 596-599, 600, 627
o
GALEN. On Nervous System 4, 5, 79, 115
On Tetanus 159
(;ALL. On Functions of Brain 67, 70, 71
GALL BLADDER, in Malarial Fever 500
in Yellow Fever 500
GALLOIS. JULIAN JOHN CJilSAR LE. Analysis of Worku and Experiments of, on
Nervous System 16, 17, 18, 19, 65, 79, 83, 286, 312
<; ALLUP, JOSEPH A. Obtervationri on Spotted Fever....469, 473, 421, 536, 537, 538, 547, 546
(;aLVANI. On Animal Electricity 117, IIH
GANGLKKVIC System of Nerves, relation of, to Cerebro-Spinal System and to Secre-
tion and Excretion 4. 10, 11. 13, 15, 16, 18, 36, 79, 115, 184-1H7, 282, 290, 309
<;ANGRENE. ('ase of, illustrating Pulse, Respiration and Temperature 479
i;KRHARD, W. W., M. D. of Philadelphia, Observations on Spotted Fever..472-474, 551, 552
d08 INDEX.
Pkgf*
6ILB. On Treatment of Traumatic Tetanas 36!^
UOOSBY, PRIVATE C. S. A. Case of, Illustrating Pathology of Cerebro-Spinal
Meningitis 450-454
GLISSON. On Muscular Irritability 6
GRAINGER. Observations on Functions of Spinal Cord 44
GRAHAM. On Treatment of Tetanus 372
GRAY SUBSTANCE OF CEREBRUM AND CEREBELLUM 72
GITHENS, DR. Of Philadelphia, on Cerebro-Spinal Meningitis 445, 475
GUTHRIE. On Tetanus 161, 366
GUTTMAN AND EULENBERG. On Injury of Sympathetic System 99
GUYOT. On Diseases of Brain 71
GRAVES. ROBERT JAMES, M. D., PROF. On Reflex Function of Nervous System 30
H
HALL, MARSHALL, M. D. Observations on Nervous System \b
On Reflex Function of Medulla Oblongata 29-36
On the Principles of the Movements in the Animal Economy 31
Divisions of Cerebro-Spinal and Sympathetic System, according to Functions 32
True Spinal or Motory System 33, 34
Analysis of Works and Discoveries of. 29>36
On Epilepsy 233
On Relations of Cerebro-Spinal System to Action of Heart and Circulation.... 286-2di*
HABERSHAM, S. E. On Treatment of Tetanus in C. S. A 382
HAMILTON WILLIAM, SIR. Translation of the Dicta of Albinus, on the Structure
and Functions of the Brain and Spinal Cord 6
HAMILTON, F. H., M. D.. PROF. On Treatment of Tetanus 37*J
HAMMOND, WILLIAM, M. D., PROF. On the Influence of Diet and Exercise on the
Urinarv Excretion 190-l!#«i
HARLEY. Experimfnts of, on Eflfects of Strychnia and Brucia on the power of the
Blood to absorb Oxygen 33C
HARNING, W. On Treatment of Tetanus 37T
HALLER. On Irritability .' 8o
On Nervous Force U»»
On Action of Heart .'?.:
On Velocity of Circulation 3J-
HAIGHTON. On Nervous System Tf
HARLESS. On Irritability of Muscular Tissue 123
HAYGARTH. On Effects of Mind over Disease 236
HARTLY. On the Etherial Medium and Fluid UT
HEPATIC DROPSY H2I-61M
HEART. Experiments of E. H. and E. Weber, on effects on Heart's Action of Gal-
vanizaiiou of Medulla Oblongata I7^
Observation of Valentin, on Action of ITj«
Observations of Brown-Sequard, on Action of I8(i, lb
Death Caused in Tetanus by Spasm of Hesri 19:
Observations of C. H. Parry, Travers, Currie, Howship, Curling and Liston,
on Condition of Heart after Death IHl-l**..
Relations of the action of the Heart in Cold-Blooded Animals to the Cere-
bro-Spinal and Sympathetic Systems - 282'.2:*
Observations of Redi, Marcot, Aristotle, Pliny. Haller, Wepfer, Stalpart,
Brinius. Morgagni, Haller Brodie, Spallanzani, Sylvestre, Humboldt, Hunter.
Vogel, Mangili, Prunelle De Saissy, Edwards, Goodwyn, Allen, Pepys.
Volkmann, and others, upon the action of the Heart » 2t^-2..*«»
Relations of the action of the Heart in Warm-Blooded Animals to the
Cerebro-Spinal and Sympathenic Systems « - 3«ii*-31».
Observations of Lametrie, Cattus, Coiterus, Peyron, Petit, Beningerus,
Morgagne, Haller, Hall, Hunter, Le Gallois, Cruikshank, Bichat, Brodie.
Phillip, Scarper, Winslow, Bell, Cheselden, Behrinds, Swann, Robert Lee.
and others, on the Ganglia and Action of the Heart — 309>3!»
HK.\T. Animal. Relations to Nervous System. Experiments on Sections of the
.Nerves, illustrating the relations of the Sympathetic and Cerebro-Spioal
System to Animal Temperature ~.. — 97-111
Effects of injuries of the Sympathetic and Cerebro-Spinal Systems oo
Animal Temperature 98-105, 107-II«»
III Tetanus 154-1 1 *•
INDEX. 809
HKAT. ObserTations of Wan^erlicb on, in Diieases 105, 164-165
Sudden rise of Temperature in Fatal Cases of Traumatic Tetanus 165
In Cerebro-Spinal Meningitis 440-449
In Gangrene 480
In Malarial Fever 486-49G
In Pneumonia 672-676, 727, 728, 737
IIRSTER, A., M. D. On Treatment of Tetanus 373
IIKNKLG, on Treatment of Tetanus « 371
IIELMHOLTZ, on Muscular Action 122
HRNXEN, JOHN. On Pathology and Treatment of Tetanus 219, 235, 342
HEROPHILUS. Classification of Nerves 3
HIPPOCRATES. Observations on TeUnus 158, 159, 209, 336
Cases of Pernicious Malarial Fever 416
Cases of Cerebro-Spinal Meningitis 417
HITZIQ. Experiments on Functions of Brain 73, 74, 169
HOPGOOD On Treatment of Tetanus 372
HIGGINS, C. C. On Treatment of Tetanus 367
HORATIANUS, OCTAVIUS. On Treatment of Tetanus 338
HOUSTON, M. H. On Treatment of Tetanus in C. S. A 379
HERING, On Velocity of Cir-culatlon 328
HOMER. On Muscles and Nerves 1
HUMBOLDT, ALEXANDER. Report on Work of Le Gallois 18
On Animal Electricity 117-129
HALE, E. On Spotted Fever 535, 550, 557
HEPATIC DROPSY 621-634
HUXHAM. On Blood in Scurvy and Putrid Fevers 531-532
HYDROCYANIC ACID. Experiments Illustrating action of, on living animals 280-333
HUNTER, JOHN. On Inflammation 691-693
On Traumatic Tetanus 340-355
I
INFLAMMATION. John Hunter on 691-693
Process of in Pneumonia ~ 714
INHIBITORY NERVES 110
INTERMITTENT FEVER 47r
Temperature in m .• 486-496
Urine in 486-496
Blood in 485-584
BlooJ in, Chemical Analyses 585
Pathological Anatomy of. 497-501
Statistics of, in Charity Hospital... 589
Cases of, Illustrating Lesions of Spleen and Kidneys and Dropsy supervening,
with Pigment Spleen and Liver ., 589-604. 674-677
INTERMITTENT ACTION OF HEART IN TETANUS 145. 178-183
J
JACUBOWITSCH. On Structure and Relations of the Sympathetic and Cerebro-
spinal Nervous Systems ^ 185-187
JACKSON, JAMES. On Cerebro-Spinal Meningitis 430-469
JACKSONt SAMUEL, M. D., PROF. On Relations of Sympathetic and Cerebro-
spinal SysUms ,.... ^. 90-92
Letter relating to Pneumonia ^ 746
JACKSON, J. D. Case of Traumatic Teunns 161
JEWELL, J. S., M. D., PROF. On Injury of Sympathetic „ 98
JEWELL, W. On Mortuary SUtistics of Philadelphia 539
JONES, HENRY BENCE. On Urine in Mollities Ossium 788
K
KAU8SMAUL k TENNER. ExperimenU on Section of Nerves 104
KEPLER. Observations on Crystalline Lens of Eye 19
XILPATRICK. On Treatment of Tetanns ., 375
KIDNEYS. Dropsy arising from Disease of. ^ 635-646
KOLK, SCHROEDER VAN DER. On Minnte Structure and Functions of Cerebro-
spinal System ...» 52-00
On Reflex Action of Cord^. «...««....,«, „.« « ,«« 57-60
810 INDEX*
On Epilepsy ~ 237-243
KOLLOCK, P. M. On Treatment of Tetanus 375
KNOX. Treatment of Tetanus 378
KRAUSE. On relations of Nerves to Muscles 176
KUHNE. On Function of Nerves 176
L
L-ENNEC. On the Treatment of Pneumonia with Tartar Emetic ^ 68H
On Intermittent Pneumonia « Hl>9
LARREY, BARON. On Function of Cirebeilum 70
Cases Illustrating Nature of Tetanus 168, l7o
On Treatment of Traumatic Tetanus 341, 355, .V»7
LATTTER. On Pneumonia 697
LEHMANN. On Influence of Diet and Exercise on amount and character of Urinary
Excretion 190-Ii»i
LE GALLOIS, JULIAN JOBN CESAR. Analysis of Experiments and Researches
on the Functions oi the Brain and Spinal Cord ^ ]6«)9
On Relations of Sympathetic and Cerebro-Spinal Systems S3-84
On Action of Heart 385
LEE. ROBERT. On Nerves and Ganglia of Heart ^„ 314-316
LEGROS AND ONIMUS. Experiments on Peristaltic Movements of the Mtcroscopi-
cal Arteries ....^•.... 203
LEBBY, R., M. D., of Charleston, S. C. On Treatment of Tetanus ^^ 371
LECANU. Analysis of Urine' 189
LEVICK, J. J. On Spotted Fever ^ 475, 507, 508
LONGET. On Nervous System and Functions of Cerebellum 68, 79, 1«>9
LEVY. On Condition of Pia-Mater in Cerebro-Spinal Meningitis 468
LOBSTEIN, JOHN FRED., PROF. Analysis of Work of, on Sympathetic Nervons
System ..^^ ^ 87-90
Relations of Sympathetic and Cerebro-Spinal Nervous Systems...- 87-90
LIVER. Pathology of, in Malarial Fever -.. *™^ 499
Pathology of, in Yellow Fever « 49ti
Cases of Malarial Fever, Illustrating Pathology of Liver, and Pigment
Deposits - 569-604
Dropsy arising from some Obstruction of the Circulation of the Blood through
the Liver. Hepatic Dropsy, Illustrated by Cases 622-634
Cirrhosis of Liver.. 629*631
Treatment of Hepatic Dropsy , 633
Observations of Frerichs on ., , 595
LUDWIG. Experiments on Sympathetic.,,..,. >,^ 1 10
On Vaso- Motor Centres ,...., 11^
LYNN. On Treatment of Tetanus 366
LUYS, J. On Minute Structure of Cerebrum and Cerebellum and Spinal Cord 72, 113
LOUIS, P. C. H. A. On the value of BIood-Lettiug and Blisters in Pneqinooia ^5-»^T
M
MAGENDIE. On Sensitive and Motor Nerves 2U22
On Functions of Brain 73
Experiments on Blood of Living Animals 531
MALARIA. Relations of to Pneumonia 699-74«
Tabular View of Changes of Blood, Urine, Pulse, Respiration and Tempera-
ture in , 483«49<
Pathological Anatomy (^. 597-501
Relations of Malarial Fever to Cerebro-Spinal Meningitis 501-5o7
MALPIGHI. On Function of Brain 7
MARTIN, S. On Treatment of TeUnus 37j
MALIGNANT PESTILENTIAL FEVERS 4U
MACNAMARA. On Treatment of Tetanus 3&3.354
MATTEUCCI. On Nervous Force and Animal Electricity ., in»ll«»
On Continuous Electric Current in Treatment of Tranmatic Tetanns 347-36T
MANN, JAMES. On Epidemic Perineumonia Notha, and its Relations to Spoifced
Fever « 547, S48-549
MACINTYRE. On MoUities Ossiuro ?•»
McARTHUR, DUNCAN. On Treatment of Tetanus %z:
McLEOD« On Therapeutic Effects ol Hydrate af Chlaral^.„,.^.,..v *.•,. 154
INDEX. Sll
Pagen.
McCartney. On Nervous System 79
Mcdowell, W. a. On Tetanus 372-373
McGRIGOR. On AmpulatioD in Tetanus 342
MEDULLA OBLONGATA. Experiments Illustrating tbe Direct Action of Prussic
Acid on 299-303
Structure and Functions of. 31-33, 54, 55
M.4LARIA. Dropsy produed by Malarial Fever 584-604
Blood, Chemical Constitution of, in Malarial Fever 584-586
Malarial Cachexia 581
Relations of to Cerebro-Spinal Meningitis 589
Cases of Malarial Fever 588-604
MERCURY. In Treatment of Tetanus 344
MEYER, J. R. Doctrine of the Unity of the so-called Imponderable Forces 120
MEUX, T. O. On Treatment of TeUnus , 374
MENINGITIS, CEREBRO-SPINAL 411-553
History of, 411-438; Natural History of, 439-449; Pathological Anatomy of, 450-483
Relations to Malarial Fever 484-502
Comparison between the changes of the Blood in, and those induced by the
Action of Certain Poisons.. 507-534
Petechia in, due to Derangement of the Circulation caused by the Local
Inflammation 534
Treatment of, 542-553 ; Duration of, 543; Mortality in, 544 ; Blood-Letting in, 545-549
Mercury in. Blisters in. Carbonate of Potassa in. Quinine in 549
Observations of Gallup, James Mann, Ames, Toudes, Broussais, Burns, Greene,
Hale, Miner, Gerhard, Geo. B. Wood and others, on the Treatment of Cere-
bro-Spinal Meningitis 544-553
MINOR, T. On Treatment of Cerebro-Spinal Meningitis 551
MITCHELL, S. WIBR. On Injuries of Nerves 99
On Wound of Right Sympathetic Nerve 09
Experiments of, on the Artificial production of Convulsive Affections of the
Nervous System 205-207
.MITCHELL, W. D. Report on Cerebro-Spinal Meningitis in the Confederate Army. 428
MITHIEL AND ORIG. On Centre in Cervical Portion of Cord, which Regulates
Animal Temperature « 105
MOLBNELLI. On Nervous System ; 79
.MORTON. On Relations of Malignant lutermittents, to Pneumonia 697
MOLLITIBS OSSIUM 751
Historical Notes on 751
Observations of Sachsius, Petra k Castro, Avicenna, Albusedda, HoUerius,
Morgagni, Fernelius, Ruelius, Ilildanus, Gabrielli, Bauda, Valsalva, Hunter,
Goodwin, Petit, Marehand, Plainer, Haller, Bevan, Hosty, Morand, Bloom-
fleld, Pringle, Gooch, Solly, Tenny and others, on Mollities Ossium 751
Cases Illustrating the Nature, Progress, Termination and Anatomical Lesions.. 755-772
C/aae of Miss Bozel, of Nashville 755
(>a8e Reported by Sylvanus Bevan 758
Case of Madam Qneriot, of Paris 759
Cose of Mary Ilayii, Reported by Pringle 761
Cose Reported by Dr. J. W. Tenney 762
Caae Reported by T. K. Chambers 763
Cases Reported by Samnel Solly 764
Case Reported by T. B. Curling 769
Relations of, to Fragilitas Osfiium 773-777
Case of Marshall Lewis 773
Case of Leather Coat Jack, Reported by Hell 779
Relations of, U) Cancer 78.1-7H7
Cases of Cancer of Bones, Reported by Pott and others 7H3-787
Condition of the Blood, condition of the Ti'mperature, PuUc and Respiration,
and tbe character of the Urine in 788-797
Comparison of the Chemical CumpoMition of the Hones in Mulliiies (Msium,
with that of Health and Various Diseased siutefl 791-797
General Conelusiona 79H
MORGAGNI, JOHN BAPTIST. On Functions of Brain and Action of Heart 309
On Traumatic Tetanns 3:i5
On Mollities Ossium 751
812 INDEX.
MULLKR, J. On Motor and SeDsUWe Nervei 21, 21
Od Reflex Actions of Gerebro-Spinal System 37-41
On Laws of Action of the Sjoipatbetic Nerve and the propagation of impres-
sions in it ~ 92
On the Actions of the Sympathetic Nerve in liToluntary Motions 92, 93
On the Sensitive Functions of the Sympathetic ^ 94
On the Organic Functions of the Sympathetic 94-96
N
NERVOUS SYSTEM. Introduction to the Study of Diseases of the Nervous System 1-137
Historical notes relating to the Anatomy and Physiology of the Nervous System 1
Views of Homer, Pythagoras, Plato, Aristotle, Heropbilus, Anazagoras, Era-
sistratus and other ancient writers, as to the Nature of Nervous Action..... 1-3
Views of Galen, Rondeletius and VaroUius ..^ 4, 5
Demonstration by VaroUius, that the Cord is made up of four columns, arising
from four Encephalic Roots 3
Observations of Goiter, Laurentius, Bauhinus and Monro, on the Roots of the
Spinal Nerves ^
Willis, in 1664. established the Classification of the Cranial Nerves 5
Doctrines of Willis 6
Views of Qlisson, on Muscular Irritability 6
Speculations, relating to the Nervous Spirit ^
Doctrines of Boerhaave, Van Sweeten and Haller ^
The Doctrine of the School of Leyden, as evolved by the younger Albinos..... 7
Views of Malpighi, Fracassatus and Batholin, concerning the Structure of the
Brain and Spinal Cord 7
The earlier Anatomists examined the Brain, only by slicing, so as to obtain
Sections, but VaroUius endeavored to unravel its parts, and in this impor-
tant method of investigation was followed by Willis, Vieussens and Gall... 9
Analysis of the Works and Investigations of John Augustus Unser, on the
Nervous System 8-12
George Procbaska, on Nervous System 12-14
Marie Fraoyois Xavier Bicliat, on Nervous System 14-16
Cuvier, on Reflex Action ~ 16
Investigations and Experiments of Julian John Caesar Le Gallois...... 16-19
Experiments of William Clift ^ 19
Views of Alexander Walker, on Sensitive and Motor Nerves ^ 19
Investigations of Sir Charles BeU, on the Nervous System 30-28
Magendie's Experiments on Sensitive and Motor Nerves 20, 21
BeUingeri, on Spinal Cord 31
George Newport, on Sensitive and Motor Nerves 2h
Dr. Marshall Hall, on Reflex Actions and on Functions of Cerebro-Spinal
Nervous System 29-36
J. MuUer, on Reflex Actions and on Functions of Brain and Spinal Cord « 37-42
John Wilhelm Arnold, on Reflex Action of MarshaU Hall 41-44
Mr. Granger, on Spinal Cord 44
Dr. Carpenter, on Reflex Actions 44
Investigations of Dr. Wm. Bayly and George Newport, on Spinal System 45-4s*
History of the Development of the Doctrine of Reflex Actions in the Cerebro-
spinal Nervous System 9-4 A
Results of the Microscopical and Anatomical Investigation of the Minute
Structure of the Brain and Spinal Cord » 44-6^
Ehrenberg, on Minute Anatomy of Nervous System - ^^
Valentin, Volkroann and KoUiker, on Minute Anatomy of Nervous System..... 48, 49
J. Lockhart Clarke, on Minute Structure of Nervous System 50-53
Schroeder Van Dcr Kolk, on Minute Structure of Nervous System 53-A6
Doctrine or Reflex Nervous Action, as developed and expounded by Schroeder
Van Der Kolk 56-KO
Views of E. Pfliiger and Brown-S6quard, on Reflex Action 61
Results of Investigations directed more especially to the determination of the
Functions of the Cerebrum and Cerebellum 62-79
Results of Anatomical and Physiological Investigations on the Strncturc asd
Functions of the Cerebrum and Cerebellum, by Prof. Richard Owen 62
Investigations of Tiedemann <4
Investigations of Sommerring «i4
INDEX. 813
Pikgei.
NERVOUS SYSTEM. Hjpolbesis of Dcs Cartes 65
Theory of Willis, on Fuactions of Cerebrum 66
Experiments of Flonrens, on Fanctions of Cerebrum and Cerebellum ^ 66
Experiments of Rolando 66
Experiments of Serres and Desmoulins 66,67
Experiments of Maj^endie and Fod6ra 67
Experiments of Bouillaud.. 68
Experiments of Longet 69
Yieirs of Dr. R. B. Todd, on Functions of Cerebrum and Cerebellum 69
Views of Fovilie, Gall and A. Flint 70
Barron Larrey, on Functions of Cerebellum 71
J. Luys, on Minute Structure of Brain 72
Investigations of Pourfour, du Petit and Marc Dax 73
Experiments on Brain by Fritsch, Hitzig and ScfaiflT. 73
Experiments of Professor David Ferper, on Brain 74-75
Experiments of M. Carvillo, M. Duret and M. Dupuy *. 76
Experiments on Human Brain, by Dr. Robert Bartholow 77
Experiments on functions of Cerebrum and Cerebellum, by Gudden, Founie,
Beaunis and Nothnagel 77-78
Relations of the Sympathetic and Cerebro-Spinal Systems 79-115
Obserratiohs and experiments of various observers on the Sympathetic Ner-
vous System 79
Opinion of Boerhaave, as to the cause of the action of the heart; experiments
of Haller, on Irritability ; views of Willis, on Sympathetic System ; obser-
vations of Dr. Robert Wliytt, as to the Nature of the Sympathy of the Nerves 79-81
Demonstration by Scarpa, that the Sympathetic System receives nerves from
all parts of the Cerebro-Spinal Systtrm ; division of the Sympathetic into
three orders, the Cercbru-Spinal and Vegetative by Wurtzell; views of
Prochaska, on the Relations of the Sympathetic and Cerebro-Spinal Systems 81-82
Experiments of Pofour du Petit, on the effects on Secretion and Nutrition of
Section of Nerves 82
Experiments of William Oruilcshanic, on Section of the Parvagum and Sym-
pathetic Nerves 82
Bichat, the originator of the doctrine of the Organic System of Nerves 83
Experiments and views of LeGallois, on Cerebro-Spinal and Sympathetic
Systems /. 83
Experiments of Mr. William Clift, on Nervous System 84
Analysis of the Experiments and Investigations on the functions of the Cere-
bro-Spinal and Sympathetic Systems, by Dr. A. P. Wilson Philip 84-87
Researches of Locbstein, on Sympathetic 87-90
Dr. Samuel Jackson, on functions of Sympathetic System 90-92
J. Miiller, on Laws of Action, and propagation of impressions in Sympa-
thetic System 92-96
Actions of Sympathetic System in Involuntary motions 92-94
Reflex functions of Sympathetic Nerves 94
Organic functions of Sympathetic... 94-96
Dr. Henry F. Campbell, on Excito-Secretory Nerves 96
Experiments on Section of Nerves, illustrating the relations of the Sympa-
thetic to Nutrition, Secretion, Circulation, Respiration and Animal Tem-
perature 97
Effects of Section of Par-Vagum as illustrated by the experiments of Petit,
John Reid and others 97-98
Cases of Section of Sympathetic, by J. S. Jewell and S. Weir Mitchell 98-110
Experiments of M. Claude Bernard, on Section of Sympathetic 101; changes of
Temperature induced by Section of Sympathetic 100-104
Relations of the Nervous System to Temperature 105-114
Experiments of various observers as Budge, Kaussmaul, Tenner, Naumyn,
Quinck, Wunderlick and others, on the relations of the Nervous System to
Animal Heat 103-110
Discussion of the Inhibitory Theory 110
Experiments of Brown-Scquard, Claude Bernard and others, illustrating the
relations of the Sympathetic to secretion and excretion 111-115
Hypothetic Discussions and Investigations, concerning the Nature of the Ner-
vous Force 115-120
814 INDKX.
NERVOUS SYSTEM. Views of Plato, Oalen, Bauhin, Dea-Cartes, Haller, Riolanaa,
Willis, Malpighi. Sylvius, Newtoa, GaWani, Aldini, Hamboldt, Philip, VaUi,
Xobili, Becquerel, Matteucci, and Dubois Reymond, as to the Nature of Ner-
vous Force , 115-130
Mutual Relations of the Muscular and Nervous Forces ^ 120-130
Views of Miiller, Mayer, Owen, Helmboltz, Dubois Reymond, Bernard, Althus,
Bowman, and others, as to the Nature of Muscular Force 120-130
Physical and Fntellectual Constitution and Relations of Man....^.....^......^.*^...- 130-137
Classification of Intellectual Powers.. 133
General observations on the relations of the Nervous System to disease, and
•n the general sources of disease - 134
Relations of Nervous System to temperature in disease 165-169
Portion of Nervous System involved in Tetanus IC6
Cerebellum in Tetanus ......m....^ - *• 169
Minute Anatomical Structure of Nerves 174
Relations of Medulla Oblongata, to action of the heart •• 179
Observations of M. Jacubowitsch, on the Minute Structure and relations of
the Cerebro-Spinal and Sympathetic Systems ^ 165
Effects of Cold on Cervical Spine 305
Relations of the Mind to Disease 230
Experiments on the Action of Poisons on the Nervous System ..271-234, 509-531
NEW ORLEANS; Mortuary Records of, in Traumatic Tetanus, Trismus Nase«n-
tium and Convulsions « 263-265
Mortuary Reeord of, in Pneumonia and Pleuritis ^ Til
NEWTON, SIR ISAAC, on the relations of the Physical and Vital Forces 117
NITROGEN. Experiments with the Bin-oxide and Per-oxide of. 296, 327, 513
NOTHNAGEL. Experiments on Brain 79
OBEAH. Worship of Obi, or Practice of Witchcraft and Sorcery amongst the negroes ;
Description of, by Mr. Long, and by Bryan Edwards, in his history of the
West Indies 230-233
OBLONGATA. Medulla, Structure aud Functions of, according to Prof. Scbroeder
Van Der Kolk 54-61
Action of Prussic Acid on 29S^303
ORD, J. L. On Treatment of Tetanus 371
OSORIO. DON DIEGO. Case of. 2:i3
OSMOSIS. Experiments and Observations on 557-57H
OWEN PROF. RICHARD. On Comparative Anatomy and Physiology of Cerebellnm
of Fish 62-63
On Nature of Nervous Force 121
P
PARRV. On Spasm of the Heart in Hydrophobia and TeUnus..... 161
On Pathology of Tetanus 216
On Treatment of Tetanus 361-365
PARACELSUS. On Treatment of Pneumonia with Antimony 6M
PKLOPS. On Treatment of TeUnus 159-337
PEET. On TeUnus in India 256
PETIT, POURFOUR du. Experiments of, on Section ot Sympathetic 82,99, 109
PARALYSIS. Cases illustrating Pathology of. ....w 246-251
PEACOCK. On Treatment of Tetanus 367
PESCAY. On Lesion of Muscles in TeUnus * 2«i:»
POLAND. On Pathology of TeUnus 210
On Suttstics of TeUnus in Guy's Hospiul 237
PFLUGER k LISTER. Experiments on Galvanization of the Spinal Cord, illustrat-
ing the Inhibitory Theory ., « II0
PINCKNEY. H. On Treatment of TeUnus — 376
PHILIP, A. P. WILSON. Experiments and Observations of, on Cerebro-Spinal
and sympathetic systems 64-97
Analysis of works of 84-67
On Nature of Nervous Force 117
KxperimenU of, on Action of Heart 3I2-31J
PLATO. On Faculties of the Mind 2
On Animal Spirits 115
PNEUMONIA. Sutistics of, in the Confederate Army, during the Civil War of '6I-*65. 649-6««
INDEX. 815
PNEUMONIA. Caseg of, entered in Field RcporU of the Confederate Army, Janu-
ary, 1862 to July. 1863 650
Cafes of, entered on Hospital Reports of the Confederate Army, January, 1862,
July, 1863 «5l
Cases and Deaths in the Confederate Forces, serving in Sonth Carolina, Georgia
and Florida 65i
Cases and Deaths in Confederate States Army, serving in and around Mobile,
Alabama, on Gulf of Mexico 652
Cases and Deaths, in Army of the West O.^a
Cases and Deaths, in Army of the Valley of Vijginia, General T. J. Jackson... 65.3
Cases and Deaths in General Hospitals, in the Army of the Potomac 656
Cases and Deaths in General Hospitals, in and around Bichroond, Virginia 658-660
Cases and Deaths in General Hospital at Charlottesville, Virginin 662-667
Cases and Deaths in various Confederate Hospitals 664-667
Rxamination of the Different Modes of Treatment 6<;9
Dietetic System of Treatment.. ti7o-r,m)
Rational Treatment 6H0.|)H4
Antiphlogistic System of Treatment tiH4-(t!)4
Antiperiodic or Abortive System of Treating PneumuniH .. (;s).'»-747
Table Illustrating the rate of Mortality in Pneurooniji uiiilvr D.ITerent .Minli*
of Treatment 738
CaMi Illustrating Symptoms and Results of Treatmvut of. 67o. (iT7. 716, 7'JO, 727. 730
Mortnary Sutistics ot, in Savannah, Georgia 701.704
Mortuary Statistics of, in Augusta, Georgia.... 7u5>709
Mortuary Statistics of, in Charleston, South Carolina 710
Mortuary Statistics of, in New Orleans, Louisiana 710-711
Mortuary Sutistics of, in New York 712
Mortuary Statistics of, in Philadelphia 713
Relations of, to Malaria 700-747
Results of Investigations on the Relations of the Action of Malaria in the
Human System to the Symptoms and Progress of Pneumonia 713-747
Method of Treatment by Dr. Dietl, 680 ; Dr. Hughes Bennett, 681 ; Dr. Robert
Bently Todd, 682 ; by P. C. H. A. Louis, of Paris, 685 ; Dr. James Jackson^*
of Boston, 687 ; by Andral, 687 ; by Grissole, 687 ; by Rasori, 688 ; Tom-
raasini, 688; by Laennec, 688; John Hunter, 691; by Jean Senac, 695;
George Cleghorn, 697 ; Lautter, 697 ; Broussais, 699 ; Dr. S. Ame*, of Mont-
gomery Alabama, 740 ; Dr.- J. S. Davis. 744 ; Dr, George B. Wood, 745 ;
by Dr. Samuel Henry Dickson, 745^ by Dr. Samuel Jacksoni 746
POTTER, H. 6. On Treatment of Tetanus 368
PLUTARCH. Oa the Plague 414
POLLOCK, D. On Treatment of Tetanus 369
PROCHASKA, GEORGE. Analysis of Work of, on Nervous System 12-14
On Reflex Nervous Actions 13
On disttnctiot) between Voluntary and Involuntary Actions 13
On Influence of Nerves over Circulation and Secretion 13-14
PRESHAW, W. S. On Treatment of Tetanus 369
PREVOST. On Treatment of TeUnus 163
POTASSIUM, SULPBO, CYANIDE. Eff^ects of, on Nerves and Muscles 124
Cyanide, experiments on eflects of, on Plants and Animals 270-330
PRUSSIC ACID. Experiments Illustrating effects of. on PlanU and Animals 376-330
PULSE. Changes of, in TeUnus, 178; in Cerebro- Spinal Meningitis 4Hft
Changes of, in Ma!arlal Ytrtr 486
Q
QUININE. In the Treatment of Pneumonia 724-74*i
QUINCKE AND NAUNYN. Experiments of, llluiitrating the Relations of ihr Ner-
TOO s System to the Divelopment of Heat 104
QUICK, L. J. Treatment of Tetanus 377
R
RASORI AND TOMMASINI. On the Treatment of Pneumonia with Turtar Ewttic. C88
RANKIN. W. H. On Treatment of Tetanus »...., , 309
RATTLESNAKE. Action of Poison on Living Aninmls. ,, ^ 524-528
RBID, DR. JOHN. Expenments of, on Section of Nerves ,^... $)
REFLEX ACTION of Nervous System, Cerebro*Spinal Nervous System. Ohserva^
tiont on, by Un«er^ 0-U; Prochask*^ 13-14; C^Tlec, 16; Le Gallois^ 17 ;
816 INDEX.
PhgM
REFLEX ACTION. Sir Charles Bell. 25 ; Geor^re Newport, 28, 45, 6C ; MnrsbAll
Hall, 29; Blane, 36; Mayo, 36; Fodera, 37; J. Muller, 37; Joban Wilheim
Arnold, 41; .W. B. Carpenter, 44; Schrceder Van der Kolk yz
Of Sympathetic Nerrous System. ObserTations of Philip, 84 ; Legallois,
83 ; Lobfltein, 87 ; Samuel Jackson, 90; J. Milller, 92; H. J. Campbell, 96;
Marshall Hall y6
REYMOND, DU BOIS. Researches on the Electricity proper, of the Nerves and
Muscles. Analysis of labors 119, 120, 123, 1**7
RHAZES. On Medical Authors - ^ . 4i:»
RIVE, DE LA. On the Nature of the Nervous Force and Relations to Electricity... 126-129
REMITTENT FEVER. Symptoms and Pathology of. 485-501
Statistics of, in Charity Hospital 589
RIOLAN. On Nervous System « iJ»
ROLANDO." On Functions of Brain CC-T:5
RENDELETIUS. On the Origin and Distribution of Nerves 4
RIOLANUS. On Functions of Ventricles of Brain 116
ROOSA, St. JOHN. On Treatment of Tetanus 377
RODIER AND BECQUEREL. On Composition of Blood in Acute Dropsy 580-582
On Composition of Blood in Health ^ 584
On Composition of Blood in Marsh Cachexia 586-587
RENAL DROPSY „.. 636-64tS
S
SAMUEL, on Nutritive Nerves 105-109
SANDWITH, HUMPHREY, on Pathology of TeUnus 221
On Treatment of Tetanus \ 368
S.WANNAH, GEORGIA, Mortuary Sutistics of, in Tetanus and Convulsions 259-260
Mortuary Statistics of, in Pneumonia 700-705
Mortuary Statistics of, in Fevers 700, 701, 702
SCARPA, on Structure and Distribution of Sympathetic Nerve 82
SCHMIDT, H. D. PROF., on Minute Structure of Nerves 1^4
SENAC, JEAN, on Relation of Pneumonia to Malarial Fever 695-697
SEQUARD-BROWN, Analysis of Investigations and Experiments of, on Nervous
System 61, 101-110, HI, 180, S38-246
On Structure of Spinal Cord 61
On Effects of Section of Sympathetic 101, 111, 18<i
On Epilepsy ". 238-24«;
SHAUGHNESSY, on Treatment of Tetanus ! 367
SYMPATHETIC SYSTEM: Observations on, of Unzer, 12; Prochaska, 13; Bichat,
15,83; Le Gallois, 17, 83; Philip. 84,286; Cuvier, 16; Lobstein, 87;
Samuel Jackson, 90; MOIIer, 92 ; Brown-Sequard, 101-111 ; Claude Ber-
nard, 100; Jacnbowitsch, 185; Wbytt, 81, 288.
Experiments on Section of the Nerves, illustrating the relations of the Sym-
pathetic to Nutrition, Secretion, Circulation, Respiration an'd- Animal Tem-
perature 97
Effects of Gun-shot wounds of Sympathetic on Animal Temperature 9^9:*
Relations of to Cerebro-Spinal System ; 75^9<
SMITH, G. A. On the Treatment of Tetanus 361
Sympathy of the Nerves, Robert Whytt, on 81, 285
SMITH, C. H. On Treatmont of Tetanus...*. ^ .• 569
SYPHILIS. Effects of, on Brain • 229
SOLLY. On Treatment of Tetanus 36; on Mollities Ossium 7do
SOMMERRING. On Nervous System ^ P
STILLWELL. C. On Treatment of TeUnus 375
SPALLANZANI. On Nervous System « f
SELKIRK. On Treatment of Tetanus 3«»»
SPASMS. Statistics of, in Savannah, Charleston and Ktvr Orleans » ..., 259-266
STILLING. On Spinal Cord 2e^9
SLOMAN. On Treatment of Tetanus 372
SWANN. On Ganglia of Sympntlietic and Nerves of Heart 82
STANLEY, EDWARD. On Mollities Ossium 781
STRYCHNIA. Effects of, on Living Animals 293, 295, 319-32«
STRYCHNINE. Tabular view of the symptoms of TeUnus and Hydrophobia, and of
the Poisonous Effects of Strychnine, Woorara and Hydrocyanic Acid 332-333
STAPLETON. On Treatment of Tetanus.... „ S««
SWEAT. On Treatment of Tetanus » ^ 5T5
INDEX.. 817
T
TABLES. Pulse, Respiration aud Temperature in Traumatic Tetanus 157
Amount of Urea excreted in 24 hours 189
Deaths from Tetanus during a period of 50 years, in Savannah, Ga 25!)
Deaths from Spasms and Convulsions during 50 years in Savannah, Ga 2C0
Deaths from Traumatic Tetanus in Charleston, S. 0., during 14 years 261
Deaths from Trismus Xascentiiim in Charleston, S. C., during 14 years 261
Deaths from Convulsions in Charleston, S. C 262
Deaths from Tetanus, Trismus Xascentium and Convulsions in New Orleans.. 262-265
Mortuary Statistics of Augusta, Ga. and Nashville, Tenn 266
Deaths from Traumatic Tetanus in various cities 267
Tabular view of the Symptoms of Tetanus, Hydrophobia, and of the poison-
ous effects of Strychnia, Woorara and Hydrocyanic Acid 332
Showing the Age, Sex, Nature of Injury, Results and Methods of Treatment
in four hundred and twenty cases of Tetanus .355-383
Diseases of Brain and Nervous System in Confederate Army 424-426
Pulse, Respiration and Temperature in Gangrene 480
Tabular view of the changes of the Blood and Urine, and Circulation, Respi-
ration and Temperature in Malarial Fever 485-496
Tabular view of the Pathological Anatomy of Yellow Fever and Malarial Fever 497
Illustrating the Duration of Cerebro-Spinal Meningitis 543
Of Mortality, in (?erebro-Spinal Meningitis 544
Osmosis and the Absorption and Action of Purgatives 575
Chemistry of Blood in Malarial Fever 585
Chemistry of Blood in Marsh Cachexia 587
Pulse, Respiration and Temperature in Disease of the Heart 611
Pulse, Respiration and Temperature in Bright's Disease of Kidneys 640, 641, 644
Statistics of Pneumonia and Typhoid Fever in Oonftderate Army 650-667
Monthly Deaths from Pneumonia, in Savannah, Ga., 1804-1853 701-702-704
Monthly Deaths of Colored Inhabitants of Savannah, Ga 704
Statistics of Pneumonia, in Charleston, New Orleans, Augusta, Philadelphia
and New York ^ 700-713
Illustrating relative mortality under different modes of Treating Pneumonia 738
Illustrating the Chemistry of the Osseous System in Health and Disease 793-797
TRAUMATIC TRTANTS. Investigations on the Nature, Causes, Relations and
Treatment of Traumatic Tetanus, Illustrated by Observations on various
Diseases of the Nervous System, and by Experiments on Living Animals
with certain poisons 142-407
Observations on the Natural History of Traumatic Tetanus; Changes of the
Pulse, Respiration and Temperature ; Character and Changes of the Urinary
excretion 142-198
Cases illustrating the Natural History of TeUnus 142, 158, 161, 163, 166, 168
' The Essential Phenomena of Fever and Inflammation absent in Tetanus 154
Temperature in Traumatic Tetanus 154-166
Observations of Hippocrates, Aretseus Galen, Horatianus Rhases, Celsus
Brown, Cnllen, Chalmers, Rush, Lind, Currie, Travers, Byrne, Jackson,
Pringle, Blane, Trotter, Hennen, Abernethy, Guthrie, Larrey, Baudens,
Macleod, Le Monnier, Prevost, Copland, Curling, Holmes and others, on the
temperature of Traumatic Tetanus 154-166
Portion of the Nervous System involved in Traumatic Tetanus 166
Case of Tetanic Spasms, caused by fracture and depression of the Cranium,
reported by Professor E. Geddings, of Charleston, S. C 166
Case of Tetanus recorded by Baron Larrey, supervening on Lance wound of
right side of head 168
Relations of the Cerebrum and Cerebellum to the phenomena of Tetanus 169
Case of wound of the Cerebellum, followed by Tetanus 170
The phenomena of Traumatic Tetanus, dependent upon the exalted functional
activity of the gray matter of the Medulla Oblongata and Spinal Cord 171
Partial or localized Tetanus 172
Thft Phenomena of Tetanus, elucidated by the aid of the more recent discov-
eries of I'bysiological Science ^ 171-178
Observations of Valentin, Kolliker, Kuhne, Formann, Beale, Grandey, Mitchell.
Schmidt and others, on the Minute Structure and mode of distribution of
Nerves , 174-17^
818 INDEX.
TRAUMATIC TETANUS. Theory of the propajraiiou of the irritation, from the
circumference to the centre of the Nervous JSystem n»»
Condition of the Circuifttion and Respiration in Traumatic Tetanus 178-l«:s
Kxperinients of E. H. k E. Weber, on the ctfects upon the action of the Heart,
of the excitation of the Par-Vagum and Medulla Oblongata, by a powerful
Magneto-Electric Current 1"'^
Experiments of Dr. Brown-Sequard, illustrating the effects of Section of the
Pneuraogagtric Nerves on blood-vessels of heart 1H'>
Observations of Parry, Travers, Currie, Ilowship. Copland and Curling, on the
production of Death in Tetiinurs, by Spsisni of the Ileart 181 -IH:;
Observations on the Functions of the Skin, and condition of the Aliinenljiry
Canal in Tetanus '. IW-IHT
llelations of the Sympathetic System to the Piienomeim of Tetanus 184-U*7
Views of M. Jacubowitsch, on the Structure and Relations of the Syrapalhitic
and Cerebro-Spinal Systems iJ^^
The Motor Ganglionic Cells, of tiic Spinal Axis and Sympathetic, chiefly in-
volved in Tetanus 1^"
Changes of the Urine during the Various Stages of Tetanus 18S-li*^
The Urea increased during the Active Stages 188-1I»2
(Mianges of the Free Acid, Uric Acid, I*hosphoric and Sulphuric Acids ll>2-IT'r»
Changes of the Chlorides 1^3
Observations of various authors, as Bccquerel, Bird. Lchmann, Draper, Parkcs
and Hammond, on the Urine in Health and Disease 181«-li>«>
Theoretical Observations, on the Physical Phenomena of the Nerves and Mus-
cles, during their Violent Manifestations in Tetanus 12*7
Observations on the Pathological Anatomy of Tetanus ll>I»-'i-4
Cases Illustrating the Structural Alterations of the Cord iu Tetanus IJ>9-2J4
Discussion of the Causes of the Dilatation of the Blood-Vessels of the Spinal
Cord and Medulla Oblongata, and their Relations to the Spasms 203, 2<'.^
Researches of Messrs. Legros and Onimus, on the Peristaltic Movement of the
Microscopic Arteries 2":*
Experiments of Dr. S. Weir Mitchell, on the Effects of Cold on Cervical Spine 2oj
Observations of Curling, Morgagni, Dncros, Rokitansky, Larrey, Dupuytren,
Hennen, Pelletier, Murray, Liston, Craige, Copland, Parry, Wallace, Reid,
Valk, McDowell, Sandwith, William Aitken, Lockhart Clarke and Dickson,
on the Pathological Alterations of the Spinal Cord in Traumatic Tetanus.... 209-221
Comparison of the Lesions of the Cerebro-Spinal System in Traumatic Tetanus,
with those observed in Various Diseases of the Nervoos System, as Epi-
lepsy, Syphilitic Neuroses, Insanity and Paralysis 224-2r. ;
Relations of Traumatic Tetanus to Climate 254-27ii
Mortuary Statistics of Tetanus in India , , 2.*»«i
Mortuary Statistics of Tetanus in London, Ireland, New York and Bombay.... 2'»7
Mortuary Statistics of Tetanus in Savannah, Georgia -:»:»
Mortuary Statistics of Spasms and Convulsions in Savannah 'Z*^*j
Mortuary Statistics amongst Whites and Blacks in Charleston, S. C, from
Tetanus, Trismus Nascentium and Convulsions 261, 2t«*
Mortuary Statistics of Tetanus, Trismus Nascentium and Convulsion.«, in New
Orleans, Louisiana ^ „ 263-2fr-'»
Mortuary Statistics of Nashville, Tennessee, and Augusta, Georgia 2»>>
Relative Mortnliiy from Tetanus, in various American, European and Asiatic
Cities ::',.7
Experimental Investigations on the Action of Physical Agents, and of certain
Poisons, upon Living Animals, instituted with the Design of throwing light
on the Mode of Action of Fever Poisons, and of the Phenomena of Convul-
sive Diseases 271-3-;4
Experimental Illustrations of Convulsive Diseases 271
Experiments Illustrating the Action of Physical Agents 272-27:*
Experiments on the Action of Prussic Acid and Cyanide of Potassium on Plants 27^
Action of Hydrocyanic Acid on Cold-Blooded Animals 2*<«»
Relations of the Action of the Heart in Cold-Blooded Animals, to the Cerebro-
spinal and Sympathetic Systems 2j*2
Experiments upon the Relations of the Sympathetic and Cercbro-Spinal Sys-
tems to the Action of the Heart, by Redi, Morgagni, Haller, Spallanzani,
Bichat, Humboldt, Provincal, Home, Edwards, Fontana, Whytt, Le Gallois,
Philip, Clift, Flourcns, Hall, Bidder, Volkmann and others....' , 283-2V »
INDEX. 819
TRATMATIC TETUNDS. Kxpcrimenls Illustrftling the direct Action of Prnssic
Acid, Cyanide of Potas-Bium and Strychnine on the Heart 290-206
Experiments on the Effects of Chlorine on the Circulation 296, 297
Kxperioients with Bin-oxide of Nitrogen, Per-oxide of Nitrogen amLStrj'chnia 298
Kxperiments Illustrating the direct Action of Prussic Acid on the Medulla 299
Experiments Illustrating the Action of Prussic Acid, Cyanide of Potassium,
Strychnine, Chlorine and other Poisons, on Warm-Blooded Animals 303-327
Relations of the Action of the Heart in Warm-Blooded Animals to the Cerebro-
spinal and Sympathetic Systems 309-316
General (/onclusions, as to the Natnre of the Effects of certain Poisons 327-334
Tabular View of the Symptoms of Tetanus and Hydrophobia, and ot the
Poisonous Effects of Strychnine, Woorura and Hydrocyanic Ac-id 332
Treatment of Traumatic Tetanus .' 334-i07
Historical Notes on the Treatment of Tetanus, Practice of Hippocrates,
Aretsus, Pelops, Aurelianus, Paulus .4vgineta, Celsns, Cullen, Brown, Hun-
ter, Larrc}*, llennen, MacGregor, Dickson, Blane, Currie, Tracers, Curling,
O'Brien, Hall. Matteucci, Poland, Bretton, Todd, MacLeod and others 33G-3r)-t
Table showing the Age, Sex, Nature of Injury, Results, Methods of Treatment
in Pour Hundred and Twenty (^ases of Tetanus, consolidated by the Author 355-383
Analysis of the Results of Treatment in Four Hundred and Twenty Cases of.
Tetanus 384-4U7
u
TRINE, Composition of. in Traumatic Tetanus 142, l.')!, 188, 198
UREA. Amount Excreied in Health 189
Amount Excreted in Traumatic Tetanus 188«192
Amount Excreted in Malarial Fever 487-489
Amount Excreted in Typhoid Fevir 191
Amount Excreted in Pneumonia 191,670
CRIC AClD. Amount Excreied m Health 192
Amount Excreted in Traumatic Tetanus 192
Amount Excreted in Malarial Fever 488
Amount Excreted in Pneumonia 670
TRINE. Composition of, in Malarial Fever 487, 489 679
Composition of, in Pueumonia 670
Composition of, in Mollitles Ossium 788
TN/ER, JOHN ATGTSTTS. Analysis of Work on Structure and Functions of tho
Nervous System 8-14
On Relation of the Spinal Cord tu Voluntary aud Involuntary Motions 11-12
On Reflex Actions 11-12
V
VALK, W. W. t)n Pathology of Tetanus 219
On Treatment of Tetanus 369
VALSALVA. On Nervous System 8
V.'\LLL On Relations of Nervous and .Muscular Force and Electrical Force 117
VALENTIN. On Nervoas System 177-2H9
VAROLLITS. On the Relations o! the Spinal Cord to the Brain .'i
VANUERPOOL. On the Treatment of Tetanus 3T&
VAN SWEITTEN. On Nervous System U
VASO MOTOR SYSTEM OF NERVES 97-1 r,
VIETSSENS. On Relations of the Sympathetic to Circulation M«)
VOLKMANN. Cn Structure of Spinal Cord 49
Experiments of, on Vaso Motor System of Nerves 97-289
VOGEL, JULITS. On Osmosis 560
VOLTA. On Muscular Contractility* and un .Vnimal Electricity 118
VINCENT. On Treatmenr of Tetanus 36G
VIRCHOW. (in Mollities Ossium 780
w
WAGNER, on Diseases of Brain 70
WATSON, THOMAS, on Dropsy ,.... 37»
WALKER, ALEXANDER, on Sensitive and Motor Nerves 20^
WALLACE, on Treatment of Tetanus ,, 366^
WINTREL, on Ganglia of Sympathetic H'3
WELLS, SPENCER, on Treatment of Tetanus 3U
WALSHR. WALTRK IIAYLH;, on tlie Nulor* of Droptjr of Cardiac Urigin «»-«■•*
WALDEYBR, oa Structure of Ner»e( IT'i
WEBKR, on the loBurDce of Lhi Kervci in SecrciioD iiud In (lamination \"i
WBBBR, E. H. B. Experimcati on effecti of Glcclricilf on Mednlla Oblongata and
Action of th* Heurt i;»
WILUS. THOMAS, on Structure and Function* of Brain :., s
On Function* of different pact* of Brain „ 6i!. 7r>
Nature if NtrToni Force UK
WINSLOW, on rilaliooi of S^mpathBtie and Cerebro-Spinal Sjltemi- ;!>. Km
WITCHCRAFT aiDOngst Negroes iM-irJ
WOOD, J. R., on Treatment ot TetBDua - 3'iJ
WOODWORTH, L, on Treatment of Telanu* V.i
WOOD, GEORGE B. M. D., PROP. Treatment of Ceteb to -Spinal Haningili* ^:>J
Letter of, relating to Malaria and Pneumonia _ i4S
WU.NDERLICH, on Change! of Tcmptralure in Disease I04.1i;i
Y
YEIXOW FKVEK. Patbologicnl Analore; of *yT-j.il
Slatillic) of, at Angusta, Ga , 7i>7
Cerebro-Spinal Sjstem in V.
Fatty Oegenaralion of Heart in 4T.-.
Puibological AllerBtlons of Liier in _ *'■•'.'
Gall bladder, Bile, Kidneji and Spleen in Fawl Caiei of. _ _- 5CKi-iiii
Riperimenls on Living Animala, with aubuntaneout injecliena of the Blood,
and Black Vomit of. , .v^H
YELLOW JESSAMINE, in Treatment of Pneumonia Tsr.
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