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EDicAL >ND Surgical Memoirs:
COKTAINING
INVESTIGATIONS ON THE GEOGRAPHICAL DISTRIBUTION, CAUSES,
NATURE, RELATIONS AND TREATMENT
OF
VARIOUS DISEASES,
1855-XS70.
By J08EI*H[ JONES, M. D.,
I*r0f<ess0r of Chemistry and Clinical Medicine, Medical Department UniversUy of Louisiana : VisHing Physician
of Charity HospiUU: Honorary Member of the Medical Society ^ Virginia : Formerly
Surgeon in the Provisional Army of the Confederate States.
VOLUME I.
IHTBODDOTION TO THB pTUDY OF DI8BA8BS OF THE NEBV0U8 SYSTEM. INVESTIGATIONS ON TBAU-
Af ATIC TETANUS, EPILEPSY, PARALYSIS, AND CBBBBBO-SPINAL MENINGITIS. CLINICAL
OB8EBVATI0NS ON DISEASES OF THE LYMPHATIC AND CIBCULATORY SYSTEMS, AND
OF THE LIVER AND KIDNEYS. INVESTIGATIONS AND RESEARCHES ON PNEU-
MONIA. OBSERVATIONS ON DISEASES OF THB OSSEOUS SYSTEM. ILLUS-
TRATED RY 800 CASES OF DISEASE, 400 PHYSIOLOGICAL EXPER-
IMENTS, 95 ANALYSES OF THE BLOOD AND URINE, AND
60 TABLES, ILLUSTRATING THE SYMPTOMS AND
MORTALITY OF DISEASES UNDER DIFFER-
ENT MODES OF TREATMENT AND IN
DIFFERENT CLIMATES.
Vinoe ^VdCaluxn. Sono,
NEW ORLEANS:
PBTNTED FOR THE AUTHOR, BY CLARK & HOFBUNB, 112 GRAVIER STREET.
1876.
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BOSTON MEDICAL LIBRARY
IN THE
FRANCIS A. COUNTWAY
LIBRARY Of MCnCINE
Kntebei) according to Act of Conorus, ik the year 1875, bt
Ik the ovricr. or the Librarian or Conoress at Washinoton, D. <".
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^ *^'
IPO IPlBLjm BffSI3M[OXl.ir
OF
MY MOTHER,
MARY JONES,
AND OP
MY FATHER,
Rev. CHARLES C. JONES, D. D.
THIS VOLUME
IS
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PREFACE.
The object of tbe Medical and Surgical Memoirs, is to place in aD accessible form
lor the use of Students aud Practitioners of Medicioe, the results of inyestigatioDS and
researches, which the autbor bas conducted during tbe past twenty years, and wbicb
embrace tbe eyentfnl period of tbe American Civil War, 1861-1865.
Situated at a distance from public libraries^ and deprived of personal intercourse witb
learned men and original investigators, of congenial pursuits, wbose counsel migbt have
removed doubts, and directed and stimulated exertion, tbe author bas labored under
disadvantages, wbicb necessitated the purchase of original works and monographs
relating to tbe subjects under investigation. The effort, therefore, has been made to
present such an analysis of tbe' labors of otbers, in connection with tbe subjects exam-
ined, as migbt prove of value to Students and Practitioners of Medicine, more especially
in the Soutbern States.
The autbor bas bad no tbeories to maintain or destroy, and it bas been his constant
aim to purify from error the observations which he has recorded.
The inductive method has been followed ; diseases bave been carefully watched, and
traced through tbeir different stages during life, and tbe vestiges left bebind 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, bave
been observed ; and tbe facts thus gathered, bave been interrogated, analyzed, separated
and classified ; and thus tbe effort bas been made to eliminate or deduce fixed princi-
ples in patbology and therapeutics. Wbilst facts are true and unalterable, in tbat they
exist, on the other hand, the deductions, or estimate of tbe value and relations of tbe
facts may be true or false, in accordance witb tbe mode of action of tbe mind which
interprets them ; tbe more tborougbly tbe mind lays bold of and determines tbe numer-
ous relations of facts, the nearer does it approach to tbe demonstration of fixed relations*
or kws.
The cases reported bave been drawn, to a large extent, from hospital and military
service, not because tbe experience gatbered in private practice bas been eitber less in
amount or value, but because in tbe Camp, and in tbe Civil and Military Hospital, it
has been possible to keep tbe patients more tborougbly under observation and control,
and in fatal cases, to command tbe necessary post-mortem examinations.
In tbe hot and almost tropical climate of tbe Soutbern States, it bas been necessary^
in tbe prosecution of investigations designed to illustrate tbe nature, causes, relations
and treatment of endemic and epidenxic diseases, to encounter tbe hostile malaria of
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VI PEBFACB.
swamps, marshes, crowded Hospitals and Military Prisons, and to endure the attacks of
disease.
The pursuit of these labors has necessitated the almost entire renunciation of that
repose which is so grateful after laborious occupations ; and the time devoted to their
record and publication, has been snatched, as occasion offered, during the daily dis-
charge 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 Study of Diseases of the Nervous System, 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 facts 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 Pyasmia, 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 the various observations and statistics relating to the Medical and Surgical
history of the Confederate Army.
OBKERAL HOSPITAL, AUGUSTA, GEOKGIA,^^
February 9th, 1863. )
S. P. Moore,
Surgeon General C. S. A.^ Richmond, Va :
SiE : — Accompanying this, I have the honor to forward to the Surgeon General a small
manuscript volume containing observations on Traumatic Tetanus. I have endeavored care-
luUy to investigate the phenomena presented by a case of Tetanus, 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
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PRBFACE. Vll
i etrefiil and full record wag kept of the pulse, respiration, temperature, nerYous and mnscu-
Itrpheoomeoa, and physical and chemical changes of the urine throughout the course of the
disease.
I hope that results worthy of the Consideration of the Surgeon General have been estab-
lished bj this laborious inyestigation. It appears to be not unphilosophic to draw general
cooclnsions from a single carefully considered case, of a characteristic and well defined dis-
ease, for we must admit that if there be anything that can be called science in medicine, it
mast 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 hare attempted to establish from the results of the inyes-
tigation of this case.
The essential phenomena of inflammation were absent. The phenomena were exaggerated
maiiifestations of nervous and muscular action, rather than results of structural alterations.
The increased actions in the nerTous 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 eyeu 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-
ditions and relations 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 investigations 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
and 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
maeealar 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
Mttteucci, Humboldt, Nobili, 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 Teta-
nos. 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
ii 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, )
Surgeon Genkral's Oitiob, j
Richmond, Va., February 17th, 1863.
SUBOION JOSIPH JONEB,
Augusta, Oeo,
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 benefit to 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,
Surgeon <?«N«ral, C. S. A.
Augusta. Georgia, June 28th. 1863.
S. P. MooRi,
Swgeon Cfmeral, O. 8. A.j Richmond , Va,
Sib: Accompanying this, I send the Surgeon General, by express, the first manuscript
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VUl PREFACS
volume of ni7 labors, conducted in accordaace irith the order issued fhiin the Surgeon
Oeaeral's office, Ricbmood, Virgiaia, Pebruarj 17th, 1863.
Since the reception of this order, I have devoted all the time not absolutely demanded for
the discharge of my duties as Surgeon, to the investigation of the class of diseases indicated ;
and this volume contains a portion of the results of my labors. In the prosecution of th^e
investigations, the Inductive Method has been followed ; the phenomena and individual factt
havp been observed and recorded, and general principles established bj the analysis, compAr-
isun, classification, and combination of the facts and phenomena.
If the Surgeon General will furnish an order suflSciently definite and liberal, the present report
will be preliminary to a more extended investigation of disease in the different divisions of
the Army of the Confederate States of America, by which we hope to establish facts and prin-
ciples of universal application, and permanent value. By such an extended study of the
diseases of armies under all the variations of climate and soil, and under all the varied circom-
stances of toil, exposure 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 investigation, 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 examinati3ns 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 Fever, 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 pf 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 recognized 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
diseases indicated in the order of the Surgeon General, are necessarily circumscribed within
narrow limits, and dependent upon peculiar circumstances &nd 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 strnggle 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 Confederacy ; an 1 after entering the medical
service as a Surgeon, I have been engaged up to the present time in the investigation of the
class 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.
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PREFACE. IX
In conclnsion, allow tnc lo express my high a{)preciation of the honor conferrodf apd to tes-
tify my urgent desire to fulfil the high and responsible trust, by every means in my power.
Very respectfully, your obedient servant,
JOSEPH JONES,
Surgeon P. A, C. S,
'CONFEDERATE STATES OP AMERICA.)
Wau Depabtment, Sxjbgeok Gkneeal^s Office, V
Richmond, Virginia, July I5th, 1863.)
SuftGEOM Joseph Jones,
Sir: 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
enough are discovered, to justify the belief that much very valuable acquisition to the science
and art of medicine is contained therein.
For the zeal, 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
is believed they oflFer, 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,
SURGEON GENERAL'S OFFICE,)
August 12tb, 1863. /
The Surgeons in charge of the General Hospitals in Virginia, will give every facility to
Surgeon Jones, to carry out the within instructions.
S. P. MOORE, Surgeon General.
RICHMOND, VIRGINIA, \
AngWit 6th, 1864. /
S. P. MOORB,
Surgeon General C, S. A.y War Department ^ Richmond y Va.:
Sir:— I have the honor to deliver to the Surgeon General, tho 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 HI communication with Richmond has been seriously threatened, and even interrupted by
the Federal Forces, I deemed \t 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.
During 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 percent, 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 (f 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
sick and wounded, then the deaths in the General Hospitals connected with all the Confede^
rate Forces, would equal 25,588. According to this calculation the total deaths from all
causes, in the Confederate Armies, during 19 months, Jan'y 1862 to July, 1863, were 68,838,
If we consider the Hospital Records as imperfect as the Field Records, then the total num-
ber of deaths would reach 85,897.
After careful 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
19 months, in the Confederate Forces, between 17,209 and 21,474 deaths.
It woold be fair to assume, that Pneumonia and Typhoid Fever, together, have caused near
50 per cent.; ©r between 34,419 and 42,948 deaths, in the Confederate Armies during 19 months,
January, 1862 to July, 1863.
The great mortality of Typhoid Fever and Pneumonia, amongst the Confederate Forces^
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X PREFACE,
invests these diseases with peculiar interest and importance, and should lead to a lAoroM^A
examination of the differeiH modes of treatment now before the Profession. Each medical officer
r'hould, AS fur as possible, test the value of the different modes of treatment, and carefully
record the results. The Surgeon General will find in the present volume, 3d Chapter, pp.
^57-514, a careful comparison of the results of the different modes of treating Pneumonia, in
European and Confederate Hospitals. The mortality from this disease, in a large number of
the Confederate Hospitals has been far greater, than what has occurred in this disease, under
different modes of treatment in European Hospitals.
^n many of the Confederate Hospitals, the mortality from Pneumonia has been twice as greut
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, Py»mia
and Spurions 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 Manigault, 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,
Surgeon P. A. C. S.
CONFEDERATE STATES O^ AMERICA,)
SruuKON Gekkbal's OrrioK, War Depabtmkkt, >
Richmond, Virginia, Augnst 6tb, 1871)
Surgeon Joseph Jones is directed to iustitute 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 tbii
order. Medical Directors of the Field and Hospital, and Chief Surgeons of Corps, Divisions,
Districts and Brigades, and Surgeons and Assistant Surgeons of Regiments and General Hos*
pitals, will afiord 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 he may deem necessary for the illustration of
the various subjects of inquiry indicated in this order.
Officers of the Engineer Department are respectfully requested to furnish Surgeon Jones
with the necessary facilities for the examination and copying of such Maps, as illustrate the
Topography of important Posts and Districts occupied by 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 Office, for th«
use of the Medical Department of the Confederate Army.
S. P. MOORE, Surgeon General CS- A,
Th« surrender to the United States Forces April 27th, 1865, by General Joseph E.
Johnston, of the Confederate Forces under his command, and of the country east of the
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 dose of the war, the author has endeavored as time and occasion offered, tu
Reproduce those portions af his labors, which appeared to be of chief interest to the
iV|edioal Profession of Awjerica, and some portions of these labors which have been
brought to such a stage of completion as might admit of general conclusions, will be
^und in the present series of the ^^Gdical apd Surgical ^(emoirs.
JOSEPH JONKS, M. P,
Jf{o. 49SSi. Ckarlts StrtetA
* <;omer<ffSt. Andrnv. J
K»^ Oi^^KA«8, La., Derembery 18TJ\,
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COISJ^TEN^TS.
OBSERVATIONS OX DISEASES OF THE NERVOUS SYSTEM 1-553
CHAPTER I.
lolroduction lo the study of the diseases of the Nervous System. Historical notes
reUtiog to the anatomy 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
nature of nervous 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 Bell, that the Spinal nerves were 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,
and runs isolated from its origin to its termination. Views of Galen^ Rondeletius
and VarolUus. 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, but VarolUus endeavored to unravel its parts, and in this impor-
tant method of investigation, he was followed by Willis, and, more recently, by
Vieussens and Gall. Hypothesis advanced by Thomas Willis. Doctrines of the
successors of Willis, and, more especially, of the school of Leyden (the school of
Boerhaave and his disciples). Doctrines of the younger Albinus. Analysis of
the works and labors of Unzer Prochaska, Bichat, Cuvier, LeGallois, Wilson Philip,
Alexander Walker, Sir Charles Bell, J. Muller, 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 in vertebrate animals.
Analysis of the labors of Remak, Stilling, Volkmann, Kolliker, J. Lockhart Clarke,
Schroeder Van der Kolk, and others. Theory of the Re^ex action, as expounded
by Schroeder 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 Desmouliu, Rolando, Fiourens, Magendie, and other
physiologists, upon the functions of the Cerebrum and Cerebellum. Recent experi-
ments of Fritsch, Hitiiig, 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
du 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,
natrition 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 inhibitory nerves. Relations of Chemical Changes and Animal Temperature.
Ancient and modern theories of animal heat. Examination of the progress of
P:ig«ti.
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modern discovery, with reference to the physics and chemistry of animated beings.
Nature of muscular force. Views of the Ancients and Moderns as to the nature of
the mechanical forces of animals. Relations of the muscular force, to the che-
mical changes of the food and blood. Mutual relations of the muscular and ner-
vous forces. Relations of the Nervous force to Electricity. Relations of the
Intellectual and Physical Forces. General Conclusions 1-137
INVESTIGATIONS ON THE NATURE, CAUSES, RELATIONS AND TREATMENT
OF TRAUMATIC TETANUS, ILLUSTRATED BY OBSERVATIONS ON VA-
RIOUS DISEASES OF THE NERVOUS SYSTEM, AND BY EXPERIMENTS
ON LIVING ANIMALS WITH CERTAIN POISONS 141-407
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 structural alteration ; an irritation in a distinct nervous branch is
propagated to the spinal cord, and the disease after its establishment, 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 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, Aretseus,
Paulus .£gineta. CelsuB, 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 fatal issue, referred to several
causes, as 1st, the eflfects 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; 4th.
The translation or extension of the irritation of the gray matter into true inflam-
mation ; 5th, The 'extension of the irritation from those portions of the spinal
cord especially connected with the reflex functions to those gaujjrlionic centres
within the brain and spinal cord, which regulate the production of animal heat;
Cih. The extension of the irritation to the sympathetic or vaso-motor system of
nerves ; 7th. Chemical «nd physical alterations of the blood. Portion of the ner-
vous system involved in<Traumatic Tetanus, intellect unaffected. Cases. Tetanus
essentialy 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 force, than
is necessary for the maintenance of the normal relations between the nerre 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 disease.
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 141-198
CHAPTER III.
Observations on the Pathological Anatomy of Traumatic Tetanus. Comparison of
Pathological changes in this disease, with those of Insanity, Epilepsy, and Paraly-
sis. General conclusions as to the nature of Tetanus, and its relations to Climate
and changes of Temperature. Cases illustrating the Pathological Anatomy of
Tetanus. Blood-vessels of gray matter of spinal cord congested and dilated.
Discussion of the cause of the congestion and dilation. Analysis of the invcsti-
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{rations of various EDatomists and physiologists, upon the eflfects of congestion of
the blood-vessels of the spinal axis ; more especially of S. Weir Mitchell and
Beojanain Ward Richardson. Analysis of the labors of various pathologists,
with reference to the lesions of Traumatic Tetanus, as Morgagni, Rokitansky,
Larrej, Dupuytren, Pellitier, Hennen, Craigie, Curling, Copland, Parry, Travers,
Sandwith, 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.
Kxperimcntal 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
Tetanus 271-334
CHAPTER V.
Treatment of Traumatic Tetanus. Historical Notes on the Treatment, illustrating
lUe methods advocated by Hippocrates, Aretaius, Galen, Celsus, Pelops, Paulus,
-figineta, and many ancient and modern writers. Tabulated cases illustrating the
results of treatment with various remedies. Discussion of the relative value of
the difiTerent 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. Relativt 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
the 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 DURLNG THE CIVIL WAR OF 1861-1865 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
Southern Confederacy during the war of 1861-1865. 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
^giment, 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
Snrgeon Rhodes' Brigade, Army of Northern Virginia." " Report of J. T. Banks,
M. p.. Surgeon Thirteenth Regiment Georgia Volunteers, Army of Northern Vir-
ginia." "Report on the preceding papers, by Surgeon R. J. Breckenridge, M. D.,
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 1-438
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CHAPTER VII.
Natural Historj of Cerebro-Spinal Meningitis. Changes of temperature, pulse and
respiration. Pathological Anatomy of Cerebro-Spinal Meningitis 439-48.T
CHAPTER VIII.
Observations on the relations of Cerebro-Spinal Meningitis to Malarial Fever. Cases
of Cerebro-Spinal Meningitis, which occurred at Savannah, Georgia, February and
March, 18G3. Effects of derangements of the blood, arisingfrom 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 at of the
nervous functions in Cerebro-Spinal Meningitis, may all be referred to the local
inflammation, congestion and alteration of the meninges (especially the pia-mater)
and structures of the brain and spinal cord. Cerebro-Spinal Meningitis resembles,
in its origin and progress, inflammatory diseases, and has frequently prevailed at
the 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 483-541
CHAPTER IX.
Historical notes on the treatment of Cerebro-Spinal Meningitis. Table illustrating
ilie natural history and duration of Cerebro-Spinal Meningitis. Ratio of mortality.
Uelativu 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 542-55.*)
CLINICAL OBSERVATIONS ON CERTAIN DISEASES OF THE LYMPHATIC
AND CIRCULATORY SYSTEMS, AND OF THE LIVER AND KIDNEYS,
ILLUSTRATING THE RELATIONS OF DROPSY TO VARIOUS DISEASES... 558-6.34
CHAPTER X.
Observations on Oiimosis. Preliminary remarks eonoerniug the objects of the inves-
tigation. Definition of the term Dropsy. Osmosis, endosmosis, exosmosis, imbi-
bition, capillary attraction, absorption, diffusion, experiments on living animals,
illustrating the phenomena of osmosis and the absorption and action of saline
purgatives 538-578
CHAPTER XI.
Dropsy arising from derangements in the nutrition of the tissues, lending either to
an increase of secretion, or diminution of absorption. Sudden accumulation of
fluid in the peritoneum. Researches ot Andral, Becquerel and Rodier, on the
causes of Acute Dropsy. Constitution of the blood in Acute Dropsy. Treatment
of Acute Dropsy r»79-583
CHAPTER XII.
Dropsy arising from derangements or alterations of the blood, leading to derange-
ment of the nutrition of the tissues, with an increase of secretron or a diminution
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of absorption. Effects of the prolooged action of the malarial poison in deranging
the coDttitntion of the blood, and in inducing Dropsy. Constitution of the blood
in malarial ferer. Constitution of the blood in marsh cachexia. Treatment of
Dropsj arising from the action of malarial poison ,.... 584-604
CHAPTER XIII.
Dropsj arising from derangements of the circulatory apparatus, attended with venous
obstmctions and congestions, increased serous effusion from the distended blood-
vessels and diminished absorption. Cardiac Dropsy resulting from structural alter-
ations of the heart and large blood-yessels. Cardiac Dropsy ; dilatation of heart ;
<leath. Cardiac Dropsy ; dilatation of heart ; general anasarca ; death. Dilata-
tion 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
ascending 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 the 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 TllK PREVALENCE AND FATALITY OF PNEUMONIA
IN THE CONFEDERATE ARMY DURING THE AMERICAN CIVIL WAR OF
1861-1865: WITH PRACTICAL OBSERVATIONS ON THE RELATIVE
VALUR OF THE DIFFERENT MODES OF TREATING PNEUMONIA
61!)
CHAPTER XVI.
ON THE PRKVALENCE AND FATALITY OF PNELMONIA AND OF TYPHOID FEVKH IN TUF* CONFED-
ERATE AKMY DURING THE WAR OF 1861-1865,
Importance of Pneumonia in view of its prevalence and fatality. Table giving mean
strength, the total of sick and wounded, the cases of Pneumonia, and tiie Percent-
«ge of Pneumonia in mean strength, etc., in the Confederate Army during nineteen
months, 1862-1863. Analysis of this table. Cases most numerous in the winter
Mud spring months. Table illustrating the prevalence of Pneumonia in the Armies
serving in the different S3Ctions of the Confederate Stiitci^. Cases in Virginia ; if\
the Army of the West, etc. Cases of, aud deaths from, Pneumonia, Tjrphoid Fever
and other diseases, in the General Hospitals of the Army of the Potunvu*, Northern,
Virginia, and other Hospitals, during fifteen months, in 18G2-18G:i. Common conn
tinned and Typhoid Fever identical. Percentage of denths from Pneumonia. Fa-,
tality from Pneumonia and Typhoid Fever. Fatality from other diseases. Cases.
of, and deaths from, Typhoid Fever, Pneumonia, and some other diseases, in tho.
General Hospitals in and around Richmond, during seven months, in 18G2-18G3.
Cases of, and deaths from. Pneumonia, Typhoid Fever, and several other diseases
in the general hospitals in Virginia. Cases of, and deaths from. Pneumonia, and
lome either disei^es, in the General Ho8pit(^l a^ Cha^rlottesv^Ue, Ya., during twenty-
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six months, from July, 1861, to August, 1863. Fatality in Hospitals at Savannah,
of Pneumonia 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. Progressive diminution of the prevalence of Typhoid
Fever during the war. Table illustrating the numerical relations of Pneumonia
and Typhoid Fever in the Confederate Armies during nineteen months, 1862-18G3.
Cases and death? from all causes, and cases of, and deaths from. Pneumonia and
Typhoid Fever in the General Hospitals of Charlottesville and Staunton, Ya G49-668
CHAPTER XVII.
EXAMINATION OF THE DIFFERENT MODES OF TREATING PNEVMONIA,
Objects and Importance of the Investigation, Dietetic System, which consists in
allowing the Disease to run its course, uninfluenced by drugs. Hlustrative 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 physicians 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 Antiphlo-
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 670-694
CHAPTER XVIII.
ANTIPEKIODIC OR ABORTIVE METHOD OF TRTIATING PNEUMONIA: RELATIONS OF PNEUMONIA TO
MALARIA.
Use of Quinine in the treatment of Pneumonia, by Southern Physicians. Observa-
tions of Jean Senac, Galeatius, George Clcghorn, Morton, Lautter, Alibert, Laennec,
Ramizini, Lancisci, Sydenham, Huxham, Sauvages and Broussais, upon the rela-
tions of Malaria and Pneumonia. Investigations of the author on the relations of
climate to Pneumonia. Mortuary statistics of Savannah, Georgia; Augusta,
(leorgia; Charleston, South Carolina; New Orleans, Louisiana; New York and
Philadelphia. Cases illustrating the relations of Antecedent 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 mala-
rial poison on the blood, liver and spleen. Illustrative cases. Practical conclu-
sions deduced from these investigations 695-747
MOLLITIES OSSITM— (MALAKOSTEOX, OSTEO-MALACIA, OSTEO-SARCORIS,
KNOCHENERWEICHUNG, RACHITFSMUS ADULTORUM. RICKETS OR
SOFTENING OF THE BONKS IN THE ADULT) 751-793
CHAPTER XIX,
HISTORICAL NOTES ON MOLLITIES OSSIUM.
No mention of this disease in the works of Hippocrates, Paulus jEgineta, Aretaeus,
nnd other nncient writers. Ohservfttions of Sachsius. Petra a Castro, Avicenna,
Morgngni, Perneliiis, Ruellius. llildunus, Gabrielli, Courtialis, Bauda, Saviard,
Valsalva. Petit, Boerhanve, and others. Reference to the literature of Mollities
Ossinm 751-754
CHAPTER XX.
CASES ILLUSTRATING THE NATURKl, PROaRESS, TERMINATION, AND ANATOMICAL LESIONS OF MOL-
LITIES OSSIUM.
Case of Miss Bozel, observed by the author. The origin of the disease referred to
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^'onstitutional derangements, rather than to a strictly local disease of the bones.
Cases reported by SyWanus Bevan, Ambrose Ilosty, John Pringle, J. W. Tenney,
Thomas R. Chambers, Samuel Solly, and others 755-772
CHAPTER XXI.
KfiLATIONS OF MOLLTTIES OSSIUM TO FilACJlLlTAS OSSIUM.
Case of Marshall Lewis, observed by the author. Illustration of the hereditary brittie-
ness of bones, recorded by Dr. PauU, 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. 77.3-777
CHAPTER XXII.
RELATIONS OF MOLLITIES OSdlL M TO IIIOKETS (UAGUITIS.)
Deficiency of phosphate of lime characteristic of both Rickets and Mollitics Ossium ;
the former confined to no sex ; a disease of ciiildhood, 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 tiiese two diseases. Results of
microscopical investigations 778-782
CHAPTER XXIII.
' RELATIONS OF MULLITIES OSS 1 CM TO t'ANCER.
The briitleness of the bones in cancer has long been observed — Cases recorded of
softening and alterations of the bones, by Lovisius, Percival Pott, and Prof. R. W.
Smith 783-787
CHAPTER XXIV.
CV»N?«TITrTlON OF THE BLOOD, CONDITION OF THE TEMPEKATIUE, PULSE, AND RF^'^PIRATION, AND
THE CHARACTERS OF THE URINE, IN MOLLITIE.S OSSIUM.
^Observations of Dr. Hence Jones and Marchand. 788-790
CHAPTER XXV.
COMPARISON OF THE CHEMICAL ( OMPOSITION OF THE BONES IN MOLLITIES OSSIUM WITH THAT
OF HF^VLTH AND VARIOUS DISEASED STATES— (JENERAL CONCLUSIONS.
Analysis of healthy bones by various chemists, and of the bones in MoUities Ossium
and various diseased states, by IJostock, Prosch, Rogne, Ragsby, Lehmann, Von
Bibra, Marchand, Reese, Tuson, Harruel, Buisson, Valentin, and others — Cleneral
conclusions as to the nature of Mollities Ossium 701*799
INDEX 801-81G
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INTRODUCTION' TO THE STUDY
Piseases^lj^enTdns ^g^ttm.
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MEDICAL MEMOIRS.
OBSERVATIONS ON DISEASES OF THE NERVOUS SYSTEM.
CHAPTER I.
INTRODUCTION TO THE STUDY OF DISEASES OF THE NERVOUS SYSTEM.
HmoKicAL noteSf relating to the anatomy and physiology of the Nervous System. Relations of the sympathetic and
Cerebro^nal Nerroos system. Views of Homer, Pythj^ras, Plato, Aristotle, Herophilus, Erasistmtus and other
SQoeDt writers, as to the natnre of nervous action. As eariy as the days of Erasistratus, there was apparently, the
oommencemeot of that long series of observations, which ended in the important discovery of Sir Charles Bell, that
tbe Spinal nerves were the organs of motion through their anterior roots, and of sensation through their posterior ;
and tiie recognition by physiok>gist8, that each ultimate nervous filament is distinct, and runs isolated from its origin
to ite tenniuation. Views of Galen, Rondeletius, and Varollius. Results of the labora of the Anatomists of the six-
tMQth oeatory . Willis, in 1664, established the classification of the Cranial nerves, at present received. The earlier
UMtomists examineil the brain, only by slicing, so as to obtain sections, but Varollius, endeavored to unravel its parts,
aod in this important method of investigation, he was followed by Willis, and more recently by Vieussens and Qall.
Hypotbeoes advanced by Thomas Willis. Doctrines of the successors of Willis, and more especially of the school of
L^den (the school of Boerliaave and his disciples). Doctrines of the younger Albinus. Analysis of the works and
Iborsof Unter Prochaska^ Bichat, Cuvier, Legallois, Wilson Philip, Alexander Walker, Sir Charles Bell, J. MUllei,
Maceodie, Mayo, Bellingeri, George Newport, and Marshall Hall. History of the development of the Doctrine of
Befliax action. Exaoiination of the results of the Microscopical and anatomical investigation of the minute stricture
"f the Spinal Cord, and brain in vertebrate animals. Analysis of the labors of Remak, Stilling, Volkemann, KUliker,
J. Lockbart Clarke, Schfooder Van der Kolk, and others. Theory of Reflex action, as expounded by Schroeder Van
*]erKoIk. Historical account of investigations, directed more especially to the determination of the functions of the
Orebmm and Cerebellum. Progressive development of the Neural axis in the animal kingdom. Analysis of the
i&bon and investigations of Desmoulins, Rolando, Flunrens, Magendie, and other physiologists, upon the functions of
the Cerebmm ami Cerebellum. Recent experiments of Fritsch, Hitzig, Ferrier, Nothiiagel and others upon the fiinc>
tiom of circumscribed portions of the Cerebrum and Cerebellum. Analysis of the works and labors of various
t'twmen, as Haller, Willis, Vieussens, Prochaska, Polour de Petit, Bichat, Le. Gallois, William Clift, Wilson Philip,
Lobftein, Samnel Jackson, J. MUller, and others. The laws of the action of the sympathetic and of its reflex actions
sod relations to the Cerebro-Spinal nervous system and to secretion, nutrition and muscular motion as expounded by
tbf eminent physlOogist J. MUller. Analysis of the experiments, on section of the Sympathetic, Pneumogastric,
ud other nerves, by (Jruickshank, Petit, Amemann, Brachet, John Reid, Mayo, Longet, Claude Bernard, Brown-
Seqnard and others. Relations of the Cerebro-Spinal and sympathetic nervous systems, to nutrition, secretion, and
Mimal temperature. Examination of the theories advanced as to the existence of vaso-motor trophic and inhibitory
nerree. Relations of X/'hemical (^langes and Animal Temperature. Ancient and modem theories of animal heat.
Examination of the progress of modem discovery, with reference to the physics and chemistry of animated beings,
nistonr of the application of the thermometer, to the investigation of physiological and pathological phenomena.
Nature of muiKular force. Views of the Ancients and Moderns as to the nature of the mechanical forces of animals.
R^latiuDfi of tbo muscular force, to the chemical changes of the Food and Blood. Mutual relations of the muscular
aad nenruus forces. Relatiuns of the Nervous force to Electricity. Relations of the Intellectual and Physical Forces.
|icQ«ni Conclusions.
HISTORICAL NOTES RELATING TO THE ANATOMY AND PHYSIOLOGY OP THE NERVOUS
SYSTEM.
It would be ft matter of much imerest to trace the mode in which the human mind, in the
^•uliest 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
of the Ancient Egyptians who were amongst the first and most successful cultivators of
Medicine, and the first great teachers of the theory and practice, was lost at an early date,
such 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
even Hippocrates, is held to have had no correct conception of the difference between the
nervous and muscular systems. For muscle, Hippocrates employs the word flesh, and he uses
iodiscriminately the same terms, for nerves, sinews and ligaments, and he assorted that the
nerves contract the limbs. Hippocrates, in his book, "rfc Insania^ observes, that man is sane.
*ho8e bniin is undisturbed, although in another work, referred however, by commentators to
the spurious works, he places the mind of man in the left ventricle of the heart.
Pythagoras, considered the Universe as a unit, animated by Divine intelligences, each
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2 Introduction to the Study of Diseases of the Nervous System.
according to its perfections, occopjing its proper sphere : absolute nnitj 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 incalalable chain of intermediate
beings was conceived, whose perfections or attributes 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 macrocosm^ included three secondary worlds ; and Man the little world, or microcotm^ was
composed of a body, soul and spirit, manifested by three distinct faculties, viz : sensibility,
thought, and intelligence. Man is the point pf union between divinity and matter, con'
necting heaven and earth ; the light of wisdom and intelligence that beams in his thooghts,
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 sub.tle 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, U 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 recognized three distinct faculties of the mind, having
three distinct seats, viz , 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 Galeo,
Yesalius, Fernelius, 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 Phiedon :
" l8 anything more rational than to think by the thonghts alone, disengaged from all foreign or sensfble agency; to
apply at once the pure essence of thought in Itself, to the reeearch of the pure eesenoe of each thing in itsrif, wMiont
the ministry of the eyes and ears, without, in short, any intervention of the body^ whoee lightest influence only
pren
hei
of things, must it not be in this manner.*'
Plato held with Anaxagoras, that mind or intelligence is the first cause ef 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 Supreme Intelligence charged the secondaiy goda with the formation of mortal animala. These gods hav-
ing received fh>m the hands of the celestial Father the immaterial prhiciple of the human soul, fiftshioned a body for
It, with the most regular and polished of the primitive trianglee. This luminous and incorruptible l»ody, which
enrelopee the immaterial soul, was placed in the brain of man. The gods also endowed, the visible and gross body
of the animal with another, modal soul, the seat of the violent and fetal -passions. This occupied the length of the
spinal marrow, leaving between it and the divine soul, the interval of the neck for fear that the two subetance«, of
a nature so different, being too closely connected, the least pure, might tarnish or embarrass the other by its contact
" Therefore the gods placed the mortal soul in the chest and trunk ; and as this soul contains a good and h bad
principle^ they divided the cavity of the trunk into two departments, just as is done with the apartments of males and
femals, by means of the diaphragm, placed in the middle as a iiartition. Nearer th« head between the diaphragm and
the neck, they placed the manly and courageous, or bellicose principle of the soul ; so that being submitted to, and
in concert with the reason, it may restrain the revolts of the passioin and desires, when these are unwilling to be
controlled by the influences which reason sends down fh>m its citadel.
** That portion of the soul which requires food and drink, and all that the nature of our body renders necessary,
is located between the diaphragm and the umbilicus. The gods have extended it over this entire region, like a rack,
where the body may find its food. They have confined it there, like a ferocious beast, which it is necessary, never*
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 and logician
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 org^n tui gentrit,
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 vapours arise from the waters and earth, and when they reach the cold middle region of the air, are
condensed into water, which &lling upon the earth cools it ; so also the hot spirits carried finom the heart to the
brain, vrith the blood, and there being cooled, are condensed into water, which again descends to the heart for the
purpose 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 was
not ignorant.) to arise in the heart.
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Introduetion to the Study of Diseases of the Nervous System. 3
The anatomical and physiological views of Aristotle may be gathered from the following
quotations :
"That which ia first found in opening the head, is the brain, and it Is placed In the anterior part. All Anjmftlff pos-
ses ing a brain, that la to say. all those which have blood, as well as those of the order MoUosca, have it generally
]daced In the same position ; but ^e brain of man is much more considerable than that of other animals proportion-
aUy to the siae of his body, and is also the most humid. The brain is enveloped in two membranes ; that nearest to
the cxanium is the strongest—the other, which rests immediately upon it, is weaker. The brain is always composed
ct two lobesjindependently of the cerebellum, which lies beneath, and whose form |ind structure differ from that of
the brain. There la usually a little cavity in the middle of the mass of the brain ; Its substance is naturally cold to
the touch, and neither veins nor blood are ever found in its interior; but the membrane which envelopes it is full of
** Let us qpeak now of the nerves, they proceed also fh>m the heart, that viscus containing nerves in its structure —
fai its largest cavitira ; and what is termed the Aorta is a nervous vein, whose extremities are nothing else than
nerves. At the points where those extreiheties terminate around the joints of bones, they are not hollow, and are
ras»plible of the same tension as the active nerves. But the difference between the nerves and the veins is, that the
nerves do only proceed without iuterruption flrom one unique substance to all parts of the body, like the veins. The
nerves on the contrary, are distributed on all sides, and to the articulation of the bones. If they proceed Axtm the
mat trunk, their continuity would be apparent in emaciated animals.
The principle nerves are those of the brain, on which depend the power of leaping, then another double nerve-
called ttie tendon ; then the extensor and the nerve of the shoulder, which contribute to the ^strengfth of the body.
"So particular name is given to the nerves, which belong to the articulations, because all articulations of the bones,
axe brand together by the nerves. In general, the nerves are found In great abundance around the bones, except
the bones of the head which are united by sutures."
It is evident from the preceding quotations, 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.
Herophilus of the Alexandrian School, who lived in Egypt, in the time of the first
Ptolemy, 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 medullary matter of the brain ; and that the animal spirit
was from the head, and the vital from the heart.
It appears according to the most certain traditions, that Erasistratus and Herophilus were the
first, after the nervous system had been recognized as the ultimate organ of the animal and
vital functions, and the brain ascertained to belts centre, who appropriated to different, parts of
that organism, the functions of sensation and voluntary motion. Rufus, the Ephesian, who lived
uDder Trajan, says that Herophilus distinguished three sorts of nerves ; the first which serve
for sensation and voluntary movements, proceed from the brain and spinal marrow as
ranncles ; the second and third are destined to unite the bones and muscles. Although Hero-
philus had not entirely shalcen off the prejudice which confounded tendons, ligaments and
membranes with the nerves, nevertheless his doctrine was a decided advance upon that of
Hippocrates, Aristotle and the Asclepiadase.
Erasistratus placed the source of sensation in the meninges or membranes, and of voluntary
motion in the substance of the brain, the nerves being mediately, or immediately the pro-
longations of these mismbranes. 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, ErHsistratus 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
organi:»m, was again advanced by Fernelius. in 1550, by Rosetti, in 1722, and by LeCat, in 1740,
and by each of these authors the hypothesis was regarded as original.
As early, therefore, as the days of Erasistratus, 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 are 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 Erasistratus 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 number of the cerebral coovolations; 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, must, 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 functions 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 nervous action have
been divided, and, as we have seen from the preceding examination of the views of Erasistra-
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4 Introduetion to the Study of Diseases of the Nervous System.
tus, the coDclasion that sensation and motion are the functions of different portions of the
nervous system, was the first, as it has been the last to be adopted.
Galen expressed in his writings many clear and sound yiews 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 ; he demonstrated, by actual experiments, the action of various muscles, and bis
views as to the action of the muscles, were not only anatomically and mechanically correct,
but l)is discoveries 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 musular motion upon the nerves, which, according to bis
view, all originated in the brain. Galen says tliat-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 mast
be ; and this, he adds, is in the brain, and not in the heart ; although he is not always con-
sistent in the shares which he assigns to the heart and to the brain, in the elaboration of the
animal spirits, 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 composed
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 the vault
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 lungs, to draw in the air, and contracted to expel it ; the atmos-
pheric fluid penetrates the cavitji 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 fourth 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 had done before him, the contrast of the two phenomena
of sensibility and motion, and actually designated distinct nerves of sensation and motion,
he was ignorant of the fact, that each nerve by its double origin on the anterior and posteiior
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, to
the enveloped substance of the cerebrum, cerebellum, spinal coid and luTves; 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^se spirits, is in
its own nature uniform and indifferently competent to either function, it therefore depended,
according to this theory, upon two accidental circumstances, 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 some 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, his
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. Laurentius, of Montpellier, a celebrated professor in
the same university with Rondeletius, some thirty years later (1595), advanced the same doc-
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Introduction to the Study of Diseases of the Nervous System. 5
trine; as a new and hitherto unheard of observation. This anatomist and physiologist first
attempted a sensible demonstration of the fact, by resolving under water, the spinal chord
iDtOk its 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 cervical medulla, the motion of
the thigh may be lost, while the motions of the arms and thorax shall remain entire. Lau-
rentins, 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 Yarollius in 1572, when he showed that Galen was mistaken, in holding that the
spinal chord is a continuation of the cerebellum alone. Yarollius 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 fact, 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 Jt>y Goiter, and Bauhi-
nus (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 anatomists of the sixteenth century, described with more exactness than Galen, the
various 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, '
that of 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 prt:sent rf^cognized. Willis described
the olfactory nerves as the first pair, which previous to him were not recognized as a pair, and
he added the sixtti and ninth pairs, which former anatomists had not recorded, and he was the
first to describe in a distinct manner the '• Nervous Centre,^^ the pyramidal eminences which con-
nect the brain with the spinal marrow. The earlier anatomists examined the i/raiu only by
slicing, so as to obtain sections, but Varolius endeavored to unravel its parts, and in this
important method of invesiij^ation, 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 infundibulum 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-
bellom 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
are 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-
tmuously into the nerves which regulate involuntary movements; but those of the cerebjum
tnmultuously and irregularly according as the animal actions are vehemently performed or
quiescent. To excite sensation, the spirits flow along the nerves to the brain. Willis dis-
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6 Introduction to the Study qf Diseases of the Nervous System.
tinguished between a thick Dervons fluid, suitable to nutrition, and the extremely volatile
animal spirits, subserrient to sensation and movement. He explained the unity of the nervoas
actions, by the communications or anastomosis of the nerves ; and he also held that the unioo
of the cerebrum and cerebellum is attained by 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 emotiods of the nund,
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
of the brain, which absorbs lymph and carries it off again, through another vessel, and keeps
the plexus choroides expanded.
Glisson, 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, Glisson assumed the existence of cer-
tain mild, sweet fluids or vital spirits, which resided in the nerves ; the existence of a peon-
liar nervous spirit like air, had been previously maintained by Erasistratus, Aseleplades,
Galen and others, and this theory found its most phiosophical expression in the doctrine of
an etl^er 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 capillamenta 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 ? " 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, m it was contained in vessels and confined by
boundaries.
The successors of Willis, especially of the school of Leyden (the school of Boerhaave and
his 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 from the cerebellum, as the fifth pair of cerebral nerves, is wholly derived from
the medulla of the cerebellum, the pons varolii.
Boerhaave held, with Willis, that the cerebrum is the organ of animality, a distinct part
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 cerebellum are prolonged, the former into the anterior, and the latter into the posterior
columns of the spinal chord. Boerhaave held that all nerves are composite, being nmde 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 its 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 sensorium 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 encephalic 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 sensorium 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 sane nerve may contam within its
sheath, both memory and sensitive tubules, distinct in their origin, transit and distribntion,
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 (Bernard Seigfried) Albinus ; not in any of his published works, but
in the prelections he delivered for many years in that university, on physiology. From a copy
in the possession 6f Sir William Hamilton, of the dicta of Albinus in this course, very 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
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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© narTM hare a triple destiDatioii, li they minister, (1) to Toluntary motioQ, (2) to sensation, (3) to the vital
wiergieB, secretion digestioD, etc Albinos seems to acquiesce in the doctrine that the brain proper is the ultimate
onan of the flntand second function, the Ailer-Brain of the third.
Nenres. again, are of t^o kinds. They are either such, in ^thich the ftinction of each ultimate fibril remains iso-
lated in ranction from centre to periphery (the cerebrospinal nervesX or such in which they are mutually confiuent
(the ganglionic nerves).
To tfpaik oniT of the cerebro-splnal nerves, and of these only in relation to the ftinctions of motion and sensation ;
diey are to be distinguished into three cisssee, according as destined : (1) to sense, (2) to motion, (3) to both motion
and sensation. Examples of the first class are the olfittctory, the optic, the auditory, of which last he considers the
portio mollis and Uie portio^ura to be, in propriety, distinct nerves ; of the second class, are the large portion of
those passing to musoles, as the fourth and seventh pairs ; of the third class are the three lingual nerves especially, the
ninth pair, fibrils of which he had frequently traced, partly to the muscles, partly to the gustalory papillaa of the
toogue, and the subcutaneous nerves, which are seen to give off branches, first to the muscles, and thereafter to th^
tscttle papillse of the skin. The nervous fibres which minister to motion, are distinct in origln,4n transit, in termina*
tion, from those which minister to sensation. This is manifest in the case of those nerves which run from their origin
in separate sheaths, either to an organ of sense (ns the oUiEictory and ppticX or to an organ of motion (as the fourth
and sixth pairs, which go to the muscles of the eye) ; but it is equally, though not so obtrusively true in the case
where a nerve gives olf branches, partly to muscles, partly to the cutaneous papilUe. In this latter case, the nervous
fibrils or fistulse are, from their origin in the medulla oblongata, to their final termination in the skin, perfectly
distinct. The medulU oblongata is a continuation of the encephaloe, made up of two columns, from the After-Brain.
Immediately or mediately it is 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 aflbrds an origin to the sensitive fibrils ; whilst another, the organ of motion, does the
samerty the motoiy. In their progress, indeed, after passing out, the several fibrils, whether homogeneous or not,
are so conJolDed by the investing membranes, as to exhibit the appearance of a single nerve ; but when they approach
tiieir destination they separate, those for motion ramifying through the muscles, those for sensation going to the
cutaneous papiUse or other organs of sense. Examples of this are afforded in the ninth pair, the fibres of which
(against more modem anatomists), he holds to arise, by a double origin in the medulla, and whidi, after running in
the same fheaths, separate according to their different ftinctions and destinations ; and in the seventh pairs, the hard
and soft portions of which are respectively for motion and for sensation, though these portions, he elsewhere maintains,
omtht Yather to be considered as two distinct nerves, than as the two-fold constituents of one.
The proof ot this is of various kinds. In the first place, it is a theory forced upon us by the phenomena ; for only on
tfaissuppositloncan we account for the following &cts: (1). That we have distinct sensations transmitted to the
biain from different parts of the same sensitive organ (as Uie tongue) through which the same total nerve is difftised.
(2). That we can send out from the brain a motive infinence to one,— nay, sometimes to a part of one muscle out of
a idarallty among which the same total nerve (e. g. the Ischlatic) 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
itamnbiUty.
In the ttcond place, we can demonstrate the doctrine, proceeding fh>m centre tP periphery, and tnm periphery to
centre. Though ultimately dividing into filaments beyond our means of observation, we ran still go fkr, In following
out a nerve, both In Its general ramifications, and in the special distribution of its filaments, fbr motion, to the mus-
des, and for sensation to the skin, etc.; and how far-so-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
which they werv constituent. And Main, In following )>ack the filaments of motion from the muscles, the filaments
of sensation from the skin, we find them ever collected into larger and smaller bundles, within the same sheath,
but never losing their individuality, never fbsed together to fi>rm the substance of » laive chord. The nerves are
thus not analogous to arteries, which rise fh>m a common trunk, convey a common fiuld, divide Into branches all
similar in action to each other, and to the primary trunk. For every larger nerve Is only a complement of smaller
nerves, and every smallest Ufrve is only a faslculous of nervous fibrils; and these, not only numerically different, but
often differing flrom each other in the character of their functions.
** In the fMrd place, that in the nerves for both motion and sensation, are enveloped distinct nerves or fibrils for
their several functions— this is an Inference, supported by the analogy of those nerves which are motive or sensitive
exelnsively. And in regard to these latter, it becomes Impossible, in some casei, to conceive why a plurality of nerves
should have been found necessary, as In the case of the two portions of the seventh pair. In reality distinct nerves, if
we Admit the supposition that each nerve, each nervous fibril is competent to the double office.
** In the fotaik |rface, the two species of nerve are distinguished by a difference of structure. For he maintains the
old Galenic doctrine, that the nerves of motion are as compared witn those of sensation, of a harder and more fibrous
tutnre; — a diversity which he does not confine to the homogeneous nerves, but extends to thi* counter filaments of
the heten^eneous. This opinion, in modem times, by the m^ority surrendered rather than reftited, has been also
subsequently maintained by a small number of the nioet accurate anatomists, as Malacarae and Reil ; and to
this result the recent observations of Ehrenberg and others seem to tend. (See Memoirs of the Berlin Academy
f^>r 183r., p. ti06.8q.; Mueller's Phys., p. 698).
*" Finally, to the ol^ectlon — Why has nature not. In all cases, as In some, enclosed the motive and sensitive fibrils
In distinct sheaths ? As answer, snd /I/U argument, he shows, with gpreat Ingenuity, that nature does precisely what
in the circumstances, always afTords the greatest security to both, more especially to the softer fibrils ; and he might
bare added as a sixth reason and second answer, with the smallest expenditure uf means.
The subtllty of the nervous fibres is mucli greater than Is commonly saspectcd ; and there is prol>ably no point
of the body to which they are not distributed. What is the nature of their peripheral terminations It Is, however, diffi-
calt to demonstrate, and the doctrines of Ruysch and Malplghi in this respect are, he shows, unsatUfactory. (The
Woiks of Thomas Beid, D. D.; Notes and Supplementary Dissertations by Sir William Hamilton, Edinburg, 1858, pp.
86M75.")
tfarcellns Malpighi^ held the ancient opinion of Plato, that the Brain is an appendajre to
the Spinal Chord, in which medullary fibres collected together radiate towards the brain,
until they end in the cortical portion, just as the fibres in the stem of a cauliflower, radiate
into the leaves. Fracassatus, also adopted this opinion, and Thomas Batholin, affirmed, 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?
veil known however, that Plato, had already staled that the spinal chord is first formed and
the brain is an appendix. Malpighi maintained- that the cortical portion, secretes by means
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8 Introduction to the Study of Diseases of the Nervous System.
of a glandular structure, which he pretends it contains, a coagalable 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 Albinus clearly showed that the cortex of the brain was not
altogether vascular.
The doctrine of the Leyden school and especially of Boerhaave and Albinus, in regard to
the nervous system, and in particular touching the distinction and Isolation of the altimate
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 vetiera-
lile age of 79. It was howviver, 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 cognizance
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 is 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 chisses, altliough
independent of xeason, 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
which had occupied and baffled the greatest intellects, from Plato downwards, and a satisfac-
tory solution had never been been given to the world.
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, Santorini,
Morgagni, and Spalianzani flourished in Italy^ Winslow and Vicq d'Azyr, in France, — Albinus,
in Holland, — Lieberkiihn, Haller and Sommerring, in Germany, — and Cowper Cheselden and
the Monros in England ; whilst Kriiger, 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. Sommerrinpr, and of a great number of other
physiologists, had put this fact beyond question. They had demonstrated that 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 reflex
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 mu(;h that he advanced,
remains to be duly appreciated.
Unzer endeavored to distinguish the physical forces, from the vital, nervous and intellect-
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Introduction to the Study of Diseases of the Nervous System, 9
aal forces of animals, and if his analysis was defective in some respects, it was necessarily
so from the imperfect state of those fandamental branches of knowledge npon which the
more restricted and complicated phenomena of living beings, depend for their proper eluci-
<Iadon and development.
The following is a brief outline of the work :
The primary 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-
mnnic&ted to the mechanical machines.
Animal nature, is the aggregate of the proper animal forces, and the science of these
uncomplicated, is the ^AynoZo^ o/amma/ na^re. 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 forces^ independently of the mind; out of these a third division arises,
which describes the animal nature as an independent whole^ compounded of these two animal
forces.
The First Part, is devoted exclusively to the animal sentient forces of the animal machines,
which are considered with reference to their action, in two ways ; namely, partly per m, as
they themselves act in the animal machines — the brain and nerves — and partly in reference to
their influence on the mechanical machines, with which the nerves are incorporated. In the con-
cluding chapter, the connection of the concepUve force, and the animal moving forces, or in
other words, of mind and body is set forth.
In 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
kinds of forces of the nerves which act in the body, as animal motive forces, namely, the
iense-iike impressions, which are divided into internal and external. These two kinds of
impressions are considered in the second and third chapters respect! v^ely ; and in the fourth,
their relations to the mental forces are elucidkted. Modern physiologists, Haller, Zimmermann,
Whytt, and Oeder, had rendered much service to this department of physiology, by contri-
buting materials thereto, Haller, indeed, began to trace out the plan of this new department,
which certainly did not exist before him, but there he stopped : Dnzer ventured to extend this
outline, 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
kinds of impressions, and the entirely different law by which they move the body without
having recourse to the hypothesis of vital 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
designation of irritability, but denied it to be a property of the nerves ; and finally, he demon-
strated in advance of Le Oallois, 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 Unzer affirmed, that many phenomena of the animal economy, hitherto inexplicable
can be understood, and he showed how the vis^nervosa is sufficient of itself to develop these
movements in bodies, which were formerly attributed to the influence of the mind or soul,
and vice vers&. Unzer details many facts to show that the spinal cord constitutes a separate
centre of nervous 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
by nearly a century the doctrine of the so-called Excito-Secretory functions of the nervous
system, the discovery of which has been claimed by physiologists of the present day.
In the Third Part, Unzer describes the economy of animal forces io 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 origfin of life, maturity of the animal forces,
decline and death of animal nature.
The following quotations, which I have selected from various portions of his work, will illus-
trate the views of Unzer, with reference to some of the more important questions and doctrines
of neuro-physiology and pathology :
"The proper aalaud mftchines in anfmal orgaQianu are the brain and nerves, in which the vital spirits (the nerrons
fluid), are prodaced and distributed, with the object of constituting the medium uf the functions of these organs.
" Tkt bredm w the teat of ths mnU. We feel that we thlnlc in the head ; nowhere else are we conscious of our exist-
ence ; in no other organ is there a thought, or an Idna or consciousness. Now, since the sentient faculty of animals
Is their sool, the soul can have its seat nowhere else than in the brain, and it would be absurd to maintain that it is
(tiffnsed throughout the body. It is sufficient to a physician to know, that the thinking faculty can have no other
<«eat than the medullary matter of the brain.
" The brain m Ou labonUorf of the vital apiriU, It appears certain that there is such a fluid eesenoe secreted fh>m
the T«»els of the gray matter of the brai i into the hollow tubes of the medullary matter, which is carried into the
tabes of the nerves to their termination, and supplies the principle whereby the nerves are rendered capable of being
the orsans of the senses and of movements. (Haller^s Physiology, Sec 383). As the gray or cortical sulMtanoe of the
brain is the seereting organ of the vital spirits, the medullary substance must be the seat of the animal sentient
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1() Introduction to the Study of Diseases cf the Nervous System.
**Tbe braiQ abo gires origin to all th« neires, which are continuations of the cortical sabetanoe, giren off partly
from it directiy in small bandies, termed the cranial nerres, and partiy firom a thick cord of it termed the sfrfaal
marrow, whi. h passes through the spine, whence the nerves are distribnted to all parts of the body.
** The nerves geneially are enclosed in an investing membrane, and, like the blood-vessels, divide and sub-divtde
in the greater part of the body, which they either penetrate or form loops in ; or, having lost their investing ouan-
brane,are so incorporated with th' soft parts, that they can be no longer traced. Their essential element Is the
medullary matter of the brain, or the son substance enclosed within the cortical substance of the brain ; wherea»
their investing membrane seems to have no share in the proper animal functions allotted to them. Every nerve I0 a
bundle of much siuHller fibrils, each of which runs an independent course to and ftom the brain. Eveiy oerve has
its special point of origin in the brain, and every fibril must have its special origin fh>m that point, from whence ii
takes an entirely independent and separste course through the medulla oblongata and the spinal cord, to iti»
minutest termination. According to all pn>babtlity, 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, as the eyes, eaia, etc^
without exciting sucli machines to motion, if they be appropriated to certain movements, or at lea»t without ci>-(^>er-
ating therein. The first are termed, in relation to their function, itwtor nene» ; the other are wemithe nervm. Tuey
are, however, identical in structure and only differ in their local relation. Each nerve may be either the one or tbr
other, according to its distribution, and each motor nerve is at the same time endowed with tiie properties of the
sensitive. The motor nerves have ganglia, composed partly of their own fibiils, and partiy of other nwvous twigs
and nerves which accompany them, whereby the direct course of the fibrils and nerves is interrupted. The nerve»
of the senses, which have no motive influence on the mechanical machines of the orsfans, have no ganglia.
''AH the phenomena of motion and sensation manifested through the nerves, render probablM the existence of a
remarkably subtle fluid essence, which is present invisibly in the medulla of the brain and nerves, and is the mean«
whereby all the functions of both are performed. It is termed the vital apiritt or neriH>H$ fluids but It is not known
how and when it contributes to the animal actions. It is not that fluid matter which b seen in the mednUa of the
brain and nerves, but a much more snbtie spirit, imperceptible to the senses. It is inferred fh>m the phenomena
which betray its existence, tUat this nervous fluid is a remarkably mobile fluid, a s]rfrituons vapour, which can be
neither aqueous, not glutinous, nor elastic, nor ethereal, nor electirical, pp. 17-18. • * *
" The seat of the soul is in the brain. Whenever the brain is destroyed, or its natural fhnctions interruptad, the
sentie.it force ceases to act. So soon as it Is restored to its natural functions, conceptions return. The whole brain i»
not Inunediately necessary to thought, since large portions of it may be lost or be defective, or be compressed, or oasi-
fled, or its ftinctions otherwise Interrupted, without any perceptible influence on the mental powere, which, as to th«*
cortical substance at least, is not remarkable, because it Is not the seat of mind : but it cannot be deduced ftxym any
observation whatever, that the whole brain may be wanting, (as, for example, when the head is removed, or the toaio
entirely destroyed, or the fhnctions of all its parts generally interrupted), and the slightest trice of mental opera-
tions ever be perceived. Fnrtiier, when a thought arises in the mind, a change must necessarily occur concnrrently
therewith in tiie brain, and particulariy in the medullary substance, without which the sentient foree cannot act ;
and when this change occurs in the brain, the sentient force is necessarily excited into action.
Whatever may be reasoned on the matter, a change in the brain must consist in a movement, and the modvUaiy
matter must also be endowed with a motive force, which a^ts in harmony with the sentient force. So that eadi dis-
tinct class of perceptions is always connected with certain animal movements, and with the movements of a certain
class of perceptions ; for it is ascertained from numerous observations, that, after certain injuries of the mednllacy
portion of the brain, especially of that part fh>m which the nerves of sensation arise, certain kinds of peroeptiona, as
for example, certain sensations, are prevented or disappear, and together with them all the ideas, desires and InstiDCtB
dependent thereon, as well as other ilaealties of the mind. (Haller.) This motive power of the brain, which Is con-
nected with the sentient force (mind), is an animal-sentient force, and hence arises tke ,fiMdamtMtal gmenU primoipi$ <■
the doctrine of the oomtectioit b^ween ftody and mwtd, that the meduMary nuMer of As brain pomemte an animal-eemtimi foroe^
by meant of whieh^ at every act of mindy urhethm' U be a aenaoMon, imoorfooiion, dstfrs, r^fieetUm or ooaobMion, Osrs it pro-
duced in it a certain ammal movement, neoeteary thereto^ wiOunU wMek the act of thought cam neither arte nor ettntinme, amd
with which Ui^faUihtyairiHe and oviMmmt p. i/^ * *
" External impressions may be made on many nerves at the same time, and the mind can distinguish all and emeh
of the external sensations thence arising, although the impressions come from the most distinct nervte into a com-
mon trunk (as, for examfde, the sfrfnal cord), before they reach the brain, and there form tike material ideas of aa
external sensation. In the same nerve, and at the same time, different impressions may be made, yet the. mind aoca-
mtely distinguishes them ; so that every external impression on each part of a nerve takes also an nnlntermpted conne
to the brain, and can there form the material sensation peculiar to itself, and distinct fh>m all others, without being
Gonfiinnded or mingled, either on its way with other impressions ascending at the>ame time, 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 fibrils
which receive the impressions, run a distinct course to their origin, and remain quite separate, however they may be
united with other fibrils to form an entire nerve, or however the latter may be united to form larger trunks, as the
spinal cord. Further, at the plaoe of origin of the nerve In the brain, there is a distinct point* where the material
ideas most be developed ft»m the external impressions which it brings to the brain.** Ch^. 11, pp. 36-37.
" It is incontrovertible that many nerves, althongh sensitive, are mainly appropriated to certain special move-
ments ; and that the external impressions necessary thereto, are sudom or never transmitted to the brain, or only
those of a certain kind ; but tiiat, for the most part, it is their normal condition to remain in the nerve. The nerves
of the stomach, intestines, and heart illnstrate this point.
** What prevents the propagation of all these impressions to the brain ? There is nothing to be found in the nerves
adapted to this end, except certain formations found scattered on the motor nerves, termed ganglia, and the point of
insertion of the smaller fibrils in the larger trunks, where also a sort of ganglion is formed. At those points the
direct course of the fibrils Is interrupted, and here the external impression traversing the a can be deflected, and iti
transmission to the brain prevented ; the more especially, as the outer thick coat of the ganglion acts In some degree
as a muscle, and by a slight compression, can hinder the transmission (Monro). But is it not projable that an exter-
nal impression on motor nerves of this kind, is expressly intended, when it reaches the ganglion, to be deflected to
the trunk or branch of another nerve, or to another fibril of thi* same nerve interwoven In the ganglion T For there-
by it would cause a reflected or retrogressive action in the fibril, as if an impression were excited in it, and sent ttom
above downwards, or as if sent fkom the brain ; when thus deflected, it puts certain parts into movement. Just as an
impression really transmitted along the nerves fh>m above downwards, and so imitates the latter by this reflected
ooune. If, however, this coi^ecturo be groundless, still the fact remains, that external impressions on certain nervea.
not received directly, excite movements without reaching the brain, and without being felt.** Chapter 11, pp. 41
and 42. • *
Thus, it is intelligible, bow a nerve may retain its sensibility and yet have lost motor power ; being sensitive and yet
paralysed, as it Is often observed. If on the other band, the obstruction involves those flbres only at the oerebral
origin of the nerve which transmit the external impression to the brain, the latter will develop no material idea in
the brain and no sensation in the mind ; bnt a spontaneous conception can excite a material idea (an internal impres-
sion) at the origin of the nerve, and this may be transmitted along the flbres, and produce actions in the body, such as
a voluntary movement for examfde. In other words, the same nerve may be insensible, and still the channel of the
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Introduction to the Study of Diseases of the Nervous System. H
«III. How ooaM it be poerible to explain theee two claaiee of phenomena, if the extitence of this difference in the
itvile of the Mune nerve be not admitted ? It Is manifest to eveiy one, that the nerrocw fibrils are distinct, and sepa^
fated fkoB each other at their origin. From these and oUier considerations, which will be stated subsequently, this
doctrine of two diBtin<A classes of nerve^fibrils exlstina: in the same nerre, and which are ^propriated to the two
kinds of the internal and external impressions respecQTely, acquires an air of truUifulness which rende're it worthy
of acceptance, p. 68. * *
** The nerres may hare an influence over the blood vessel, on the secretions, and on the whole circulation, in various
mtju. In tibe ftrst fdaee, through the hsart, a compound hollow muscle, throughout which nerves from various sources
an distribnted ae in other muscles. These nerves, like all others, can receive external impressions, since an animal
ftds when the heart is pricked or Irritated. They consequently transmit external impreanons in such cases to the
teain, and pioduce therein at their origin external sensations, or cerebral impressions. When there is no impedi-
oMUt, these are (nopagnted downwards along the same nerve, and, oonsequenly, may not only have an influence on
the movement of Ute heart, but may excite sentient actions. In the same way, the sensational conceptions, desires,
and aversions, sometimes excite cardiac movements, which are sentient actions produced through the nerves by
itaifoos material external sensations; examples of this kind are numerous, as when ideas, foreseetngs, and emotions
ohaue the movements, p. 90. * *
** nif nerves have another Influence ; namely, on the vascular qrstem generally, since they are incorporated with
the coats of ttk9 arteries, and thereby probably supply animal force to the muscular fibres which they surround. > * *
** A thiid kind of influence poeseseed l>y the nerves, is on the vessels distributed to the muscles. It almost neces-
ttrily follows, that the numerous blood vessels distributed in them are affected by the contractions excited by the
■ervea, consequently the latter indirectly favor the circulation of the blood in the veins, and agitate and mix that in
the arteries, thereby fiivoring its course towards the lungs. They regulate the secretions of the liver mesentery, etc.,
«Bd ^1lminf«% or retard them, they urge on the bJood,and the large muscles of the abdomen impel the blood contained
in that cavity towards the heart. (Haller's Physiology, 1416). Many of these acts are sentient, nay, are even volition-
al ; and if to all these actions of the nerves on the blood vessels and the circulation, the direct action of the brain on iti
orattitadinoas capillariea be added, it is clear that this apparently simple mechanical motion of the heart Is much
under the important influence of the mind, and the still more important influence of the nerves, p. 92. * *
** The glands are a tissue of vessels and nerves, and their function is to separate the secretions fh>m the Mood. The
nerves exercise the same influence on th^se as on other vessels, and, consequentiy, secretion, which ordinarily
iippsars to be rimply physical, Is not only animal, but is also sometimes a sentient action. The nerves have the most
taaniftst influence on those glands which are surrounded by muscular tissue, or so placed between muscles that the
latter by their action, express the fluid from the glands when secreted; so that it is poured out. Examples of this
kind are the prais (€^en), the urinary bladder, the bowels, the stomach : also the parotid glands which are emptied
fay the action of the muscles of mastication. (Haller^s Physiology, { 233). Many glands pour out their secretions
tnm external sensation, (titillatlon— pain); many from Imaginations, sensational anticipations, desires, etc., as, for
example, the salivary glands fh>m the r*'Collection or anticipation of an agreeable taste, or In hunger; many fh>m
pasriona, as the lachrymal and soxuar glands; many even from acts of will, ae when tiie saliva Is stimulated to flow
by volQBtaiy mssticalion, or weeping Is feigned.
**The action of the nerves In the viscera is very complex, varying with the number of nerves distributed, or with
the vmrioas impressions of which the latter are susceptible ; or they are influenced by the muscles, muscular tissues,
j^laods etc which surround, or are in relation to them ; or as the nerves act directiy or by sympathy, p. 94. * *
" Keverthfleas external impressions on nerves cm proceed to the brain without exciting a visible movement in the
point touched,— can be felt, — and can be reflected by means of the internal impressions of the senMtion along the
prindp^ nerve and Its branches, and if there be no hindrances, can excite movements in tiie mechanical machines to
which the nerves are distributed, and, consequentiy, develop sentient actions in other parts by means of the external
«eiMatSon thus excited on such snrfiice. Thus titiUation of the mucous membrane of the nostrils excites eneexing,
and a convulsive movement of the diaphragm and respiratory muscles, the nerves of which are in natural connection
with thoae of tiie nasal mucous membrane ; thus, also, many an external sensation of tiie cutaneous surface excites
by means of the nerves, a tremor of the muscles in relation to it, which is termed a afnuUhr. Thus, also, a titiUs
tion of the nasal mucous membrane excites effusion of mucous, which Is a sentient action of titillation In tiie capIN
laries or terminating tubuli of the minute glands. Thus, also, the cutaneous surfiice becomes inflamed, and swells
fnm tihe stimulus of an acrid irritant. Thus, also, cold contracts the respiratory pores by a sentient action on the
minute terminations of the arteries, and interrupts perspiration." Chapter III, pp. 108-109.
**KxteroiU sensations excite the functions of the gl(md$^ namely the exer«tion o/fluid» ; and when they are enclosed
in muscnlar tinues, the evacuation takes place according to their mode of action on muscular tissues; but when
there is no muscular tissue, they excite an afllux of fluid, in virtue of thoir action on the teniilnating mouths of the
mbali. Thus a strong flavour excites the stnn'eHon and discharfFO of the saliva; irritation or pain in the eye.
oxdtee the flow of tears; thus, also, titillation causes parts to be lubricated, by Irritating the nerves of the glands,
and favoring a secretion Hud discharge of their fluids; and, also, irritation and pain of the bronchi cause a mucous
discharge from the irritated glands— all being manifestly sentient actions in the glands, from external sensations."
Chapter 111, p. 110.
**The extermal imprtmUm on tike nerMs etmprodmoe Ike tame movemeHttt in the bodg <u if it were/dt, aUfMmgk U it no^/ett, nor
mmmilUdto the btxriH.
"If the nerve of a limb be irratated witii a needle, movements take place exactly similar to those produced in th**
natural condition by the volitional conceptions; thus, the diaphragm renews its motions, as in respiration, if the
tnink ci its nerve be Irritated ; the body of a dog, or of an ox, (nay, even of a man, as is seen in executions by
decapitation), will be thrown Into the most violent volitional movements when the spinal cord is cut through ; if
ianich an one the cord be irritated inferiorly, the movements Involve the feet only; if superiorly, panting, respira*
tion, palpitation, deglutition and vomiting result. When an irritation of the spinal cord produces spasmodic convul-
sion of the whole body, but a particular nerve has been previously divided, the limb to which that nerve is distributed
is unaffected by spasmodic action, because the irritation cannot be transmitted to it ; thus, also, a decapitated frog
rbes op and springs forward, and if thrown into water, begins to swim so soon as its spinal cord Is irritated with a
needle in the cervical region. Just as if it knew what it had to do. Bilguer relates a somewhat similar case, in which,
if a certain part of the neck, where suppumtion had taken place, was irritated, the patient was obliged to stand
upright in spite of himself, etc. A great variety of well autiienticated facts of this kind may be found in Haller's
Phydnlogy.
" The moffementB of the Umba display the influence of the rw HerpoM strikingly, because its action is greatest on the
nnaealar portion of the organism. These, as a thousand experiments prove, may arise, as nerve actions, although
they usually occur as sentient actions Irom external sensations and sensational conceptions, instincts and passions, as
well as volitionally. Thus a decapitated animal will stand, move forward, raise itself up, leap, fly, or flutter its
wings, seek food, clean, defend or conceal itself, copulate, etc. A decapitated roan, immediately after decapitation .
fltn^rgles to free his hands, attempts to stand upright and to stamp with his feet ; if the bead of a pigeon lie cut off
whilst It is running, it continues to run on for some distance, until it knocks against something; a frog leaps for-
ward without its head, so, also, a headless fly flies, a snake, a fish, a worm, writhes and twists aboutif touched,
although wholly deprived of sensation ; a fly makes the movement of brushing its eyes, by a natural instinct,
although its head be cut off; a headless snail seeks its food by its usual plan of feeling about ; a decapitated tortoise
does the same thing, and will live for half a year after decapitation, and raiseitself up. or endeavor to do ho, if placed on
Its back ; an ear-wig nips with the nippers of its abdomen at its own separated head, when the head bites the abdu-
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12 IfUroduetion to the Study of Diseases of the Nervous System.
men ; the abdomen of a wup will sttog ; animals that fight with their hind feet, use them rigoTotuly when decapi-
tated at ovenr irritation applied to the nenree; butterflies, catterpUlars and silk worms copnlate after decapltatkm,
and they and flies deposit their ova ; in short, all the instinctiTe actions of animals are sometimes seen to oocnr ■«»
nerre actions ; and it naturally follows that they occur at first in newly bom animals as sudi, and that it is only
after the perception of external sensations, that they become sentient actions.** p. 213.
'* The following irrefkagable truth follows fh>m these two leading principles: WhiU the amimal maekimm of t
bg nabtre vrith the ptopm-tif of eondactimg extemai imprtmiomM to ike bnim^ to Viat tktp mag (here exeile uttUerial ideme. ^Mmg
riee to mmoMoim, amd of receMmg imtemal impreeeiom eamaed by oonospfiofM, they oUo poeteee amother tmd entirely a(feremi
properly ^ amd are intended by natm-e to effect, bw meam of the eaOemal imprtuione thqf receive, whether the latter reoA the
brain and arefM or iio(, the mme mopementt whieh are footed when they do reach the brain, and arefdi; amd to ^eet, by
ineamof an imtermaiimpret$ion,which they receive firom a to¥eh or irrUanl eaueed by mo conotptSom whatever, the eamemtoW'
mente at are ^eeted by meant of the cerebral foreet, when the eame internal impreeeiom ie prodmoed by a conception, p. 192.
** In animals with a sentient brain, every external Impression which is felt passes directly to it, and exdtea tiierein
a material idea, and in the mind a conception. Having reached the brain, it is turned back or reflected, as it were,
and goes back as an internal impression of a conception, into those nerve fibrils that move the limb, which the
external impigession is enabled to control by means of a sentient action of its sensation. * * When a polype recairee
external Impressions, they pass onwards to the nearest ^ganglion whence they are reflected as'if fh>m a brain, «ither
entirely, or in such a way, that they only partly reach other ganglia, and thus they can be reflected many times. It
is sufficient that at these points the extendi impressions are transferred into internal, and pass again ttom the
ganglia along the nerves to the mechanical machines, which they put in motion, no act of thought taking frfaor
during the transformation, because there is no brain, (for in that only is the seat of the conceptive force), nor arr
the internal impressionB adopted to excite a sentient action.** pp. 197-198.
*^ An external impression is changed into or develops an internal impression, whenever its course, whidi ft*
naturally towards the brain flrom the terminating fibrils, is so reflected or turned back, that it returns in the direc-
tion from the brain downwards to the branches and terminations of the nerves. * * In the nerves there Is do
place in which it can occur, except the ganglia of the motor nerves, and at their separation into branches and fibrils.
According to all probability, these ganglia and points of division of the nerves, perform in the motor nerves the
office of ue brain, in relation to the external impressions, since they deflect these ftom their course upwards, and
communicate an internal impression, either to other nerves and their branches, or to diff'erent fibrils in the same
nerve, conducting in the direction of the brain dovmwards, whereby these twigs and fibrils are suitably stimulated,
and such muscular movements excited, as would have been caused if the external impression had reached the bfain
and been turned back or reflected from thence by the intervention of an external sensation, p. 216. * *
** This explains what takes place in similar drcumstanoes, when an impression is made on the spinal cord, and
spasms and convulsive movements are excited in all parts below the point of irritation, except those, the nerves of
Ddiich are cut through. The reflected external impression passes as an internal impression to, and only excites
movements in those muscles to which it can be transmitted Anom the point of reflection, p. 224.
**Example6of this class of nerve-actions are to bo met with daily, which sometimes are mistaken fbrsentleBt
actions (which they often aooompanv), sometimes for special operations of unfelt external impressions acting through
the brain, sometimes for inexplicable sympathies.** n. 224.
(The Principles of Physiology, by John Augustus Unaer; Translated and Edited by Thomas Layoook, M . D.,
Sydenham Society, July, 1851).
George Prochaska, born at Lospitz, in Moravia, April 10th, 1749 (Professor of Anatomy and
Diseases of the Eye, at Prague, 1778, Professor of Anatomy, Physiology and Diseases of the
Eye, at Vienna 1791), published his work, ^*De Functionibus Systematis Nervosi," in 1784.
Prochaska adopted the principle of a general seusorinm commune, but subdirided it
in accordance with the yiews 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 9otd sensorium ; the seat of the
body sensorium is the brain and spinal cord, and, as all obseryation 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 nnd 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
its impressions in its ganglia and plexuses, without the consciousness of the soul.
In accordance with this consensus of the nerves, as well in the brain as in the spina! 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 uterus, often causes nausea, vomiting, headache,
toothache, etc.
Prochaska used the term, '* vis nervosa,^* to designate that agent, by which the nervous sys-
tem is 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 :
** For instance, the irritation or impression of too strong a light, goes to the optic nerve, from whence it can onl)
eet at the cillMy nerves through the brain, and induce contraction of the pufrfl, so as to exclude the too vivid light
from the eye, and obviate its unpleasant impression.**
He gives the following examples of reflex actions :
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Introduction to the Study of Diseases qf the Nervous System. IH
* * ** Vei7 many lostancM which might be ftddacad, undoubtedly prore this general Uw of the reflections of
the Mneoriom commune, of which it may be sufficient to mention a few. Irritation being made on the Internal mem-
bnne of the nostrils excites sneeiing, because the iminresBion made on the olftM^tory nerres by the irritation Is oon-
dacted along them to the sensorium rommune, there by a definite law is reflected upon motor nerves going to mos-
des employed in respiration, and through these produces a strong expiration through the nostrils, whereby the air
pawing with fbrea, the cause of the irritation is removed and ^ected. In like manner it hsf^ns that when irrita-
tioB is cauaed In the trachea by the descent of a partiple of food, or a drop of fluid, the irritation excited is oon-
dactad to the sensorium commune, and there reflected on the nerves devoted to the movement of respiration, so that
a violent ooo^ is excited, a most suitable means for expelling the cause of irritation, which do^ not cease until
die inttaat be ejected. If a Mend brings his finger near our eye, although we may be persuaded that no ii^uiy U
iterat to be done ua, nevertheless, the impression carried along the optic nerve to the sensorium commune, is there so
^oted to "
I Qpon the nerves devoted to the motion of the eyelids, that the eyelids are Involuntarily clored, and prevent
the offensive contact of the finger with the eye. These, and innumerable other examples which might be brought
forward, manifestly show how much the reflection of sensorial impressions into motorial, effected through the senso-
rium commune, has reference to maintaining the conservation of the body.
** SInee the principal function of the sensorium commune thus consists in the reflection of sensorial impressionri
into motor, it is to be noted that this reflection may take place, either with consciousness, or without dbnsciousnese.
The moTements of the heart, stomach and intestines, are certainly in nowise dependent on the consciousness of tho
•oul, for whilst no muscular movement can be excited, unless a stimulus applied to the sensorial nerves passes, by u
peculiar reflection, to the motor nerves, and excites contractions of the muHcIe, it is at the same time certain that
the reflection of the impressions suitable for exciting those movements. If it take place in the sensorium oonunune, h
efliected without consciousness. But it Is a question whether these Impressions, In order that they may be reflected,
io really travel so &r as the sensorium commune, or, widiout taking this long circuit, are reflected nearer in the
gaaglia^ fkYHn whence these parts derive many nerves ? But that reflection of sensational impressions into motor an*
effected In the sensorium commune ilsell^ while the mind is alt<M;ether unconscious, is shown In certain acts remain-
ing in apoplectics deprived entirely of consciousness; >for they nave a strong pulse, breathe strongly, and also raise
the hand, and very often unconsdooslv applv it to the affected part. The sensorium commune also acts Independ-
ently of oonsdousoess In producing ttie convulsive movements of epileptics, and also those which are sometimes
observed In persons buried In profound sleep, namely, the retractions of lynched or irritated limbs, to say nothing
uf the motion of the heart, and of tLe resplratoiy acts. To this category also belong all those motions which remain
for KHoe time in the body of a deca|ritated man, or other animal, and are excited when the trunk, and particularly
the medulla spinalis, are Irritated, which motions certainly take plffce without consciousness, and are regulated by
the remaining portion of the sensorium commune existing in the medulla spinalis. All these actions flow ttom the
ofganiam, and by physical laws pecnlinr to the sensorium commune ; and are therefore spontaneous and automatic.
The actions taking place in the animal body, with accompanying consciousness, are either such as are independent of
voUtion,or such as the mind can restndn and prohibit at pleasure ; the former being governed by the sensorium com-
Bune alone independently of the mind, are as much automatic as those of which the soul is unconsdons. Of ^ie
chancier are sneedng, fh>m an irritant applied to the nostrils,cough, ftom an Irritant follen Into the trachea, vomit-
ing, from a titillation of the fiiuces, or after taking an emetic, the tremors and convulsions in St. Titus* danc^, and In
a paroxysm of> intermittent fever.
''FnrUMr, it may be asked, whether the external impressions made on the terminations of the nerves and passed
onwards to the ganglia are extinguished in the ganglia themselves, or whether, being reflected by a flxed law, they
return again along the nerves to the parts to be moved ? The celebrated Unzer, and the eminent WInterl taught,
that external Impressions are reflected In the ganglia, as they are reflected in the §«m$orimn commiMM, and that the
gaagHfc are special sensoria, — a doctrine which does not appear altogether destitute of probability. For If we con-
rider that the minute and invisible nerves disseminated over the Internal membrane of the heart and auricles, per-
esive the vtlmulus of the Inflowing venous blood, and although they cannot transmit the impression of that stimulug
to the mmmfrimm oomwmwe through the ganglia of the intercostal (great sympathetic) nerve, yet communicate it to
the motor nerves distributed through the substance of the heart (ventricles) and auricles. It follows that there is
aeceasarily a consensus between the sensory nerves distributed on the inner membrane of the heart and the motor
nerves diaeminated through the substance of the heart (ventricles) and auricles, which must take place either in
ganglia of the intercostal nerve, or below them, in the communicating branches or plexuses of nerves. It seems
probable, therefore, that besides the aemorktm conmmme^ which we coi^ecture to be in the meduUa obtongataf meduUa
mtmaH$y pons voroUi and emra of the eerebmm and e«r«Mhim^ there are special teiuoria in the ganglia and plexuses of
the nerves in which external impressions ascending along the nerves are reflected, that need not ascend all the way
u> tiie amtmrimm oomwaas, to be reflected thence.^*
Prochaska also tbns notices the important distinction between the two great classes of
iDTolnntarj and voluntary acts :
** Heverthelees, this need for rest seems only to be a characteristic of the nerves which are subordinate to
the win and not to the involuntary, which have to provide for the motion of the heart, resplrstlon and digestion ;
and whose via-nervosa is active, without Interaiisdon, during the whole of life, although It may be weaker or
trtronger ; though It cannot be doubted, that both kinds of vis have a similar origin, and are of the same nature,
«tUl <^)servation shows that the one belongs to the will, the other is involuntary ; that the former is exhausted by
■ensation and motion, and requires rest and repose ; with the latter the contrary takes place : and finally, that the
two kinds of vis are Independent of each other. This distinctness and Independence of the volnntary and involun-
teiy via-oervosa is shovm, not only In sleep, but also In apoplexy, when the voluntary vis-nervosa is quite arrested,but
the involuntary performs Its duty. So, also, in cases of fever, the voluntary vls-nervoea is quite weakened, but the
involuntary Is so much the more active.**
Prochaska records, in bis careful and comprehensive description of the different parts of
tbe nervous system, the fact that the fifth pair of nerves, and all the spinal nerves, are
enlarged near their origin by ganglions. In like manner, with Unzer, he dwells upon the fact,
that nature proceeds gradually from tbe most perfect and highly complex brain, to the sim-
pler and simplest ; and that, at last, animals exist altogether devoid of brain.
Prochaska also noticed the influence of the nervous system over the blood vessels, and
especially the capillaries ; and refers 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 also to a reflex action. Thus, he says :
B phenomena take place If the nerves be stimulated locally ; but the same thing happens when the nerves
are exdted, not directly, but Indirectly through the brain. We know that thus tbe face is suffused with tb<'
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14 Introduction to the Study of Diseases of the Nervous System*
blush of modeflty ; grief causes a oopions flow of tean, congestion of the ressels of the conjunctiva aud spelling of tb«
whole face. The sight of agreeable food provokes the saliva; it is not unusual for some persons to vomit or be
pnxffed by only seeing a medicine ; a lascivious idea erects the penis, etc.
'* The face of a man struck with sudden terror is pale, and some men become pale when in a paroxysm of rage,
which paleness is without doubt owing to a repulsion of the blood from the cutaneous biood vessels, to those In me
interior of the body, Inasmuch as the nervous system is affected in terror or rage, the question ariiiea, whethw^ the
cutaneous nerves then affected completely repel the blood ft^m the cutaneous vessels, by contracting them to tbe
inner vMsels of the body?
" Other phenomena occurring in the natural state, besides those mentioned in the preceding paragraphs, are Intel-
ligible by this congestion arising in the irritated part. And in diseases there are frequently opportunttiea for ob-
nerving the operaoon of that nervous influence on the vessels, in virtue of which fluids flow more copioiMly and
Immediately to the irritated parts. Inflammation itself is noUiing else than a powerful attraction and deTiation of
blood from a stimulus, by which the vessels become filled, swell, are rendered tense, red, painful, etc. If this stlmn-
lus be sufficiently powerful, It draws the nerves of the heart into sympathetic action, and by increasing the mov«^
men is of the latter, produces fever, the concommitant of inflammation."
Prochaska also discassed the question. *' Have the nerves any wfiuenee on teereUon f "
Boerbaave, in considering the causes which operate in producing such varied secretions
from the blood, did not attribute any definite share to th*i nerves ; Haller conjectured that the
nerves operate in the secretion of the fluids, since they surround the vessels of the viscera
like sphincters, and thus either delay or promote secretion ; Tissot also devoted an entire sec-
tion of his work on the functions and diseases of the nerves, 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 truth, since it has been shown how great Is the influence of the nerves on the vessels, in virtue of whidi
Mtimnli can excite a m»re copious flow of fluids to a part, we Infer that the same thing occurs in the secretiiig vis-
cera, which consist almost entirely of vessels. So soon, therefore, as, by nervous action, the fluids are more ooni.
uusly attracted to secreting viscera, the secretions are necessarily increased. Moreover, since the nerves have tlie
property of causing spesms, or contraction of the c^illaries. It is maoifeet that the secretions may be diminished, or
entirely interrupted by the influence of the nerves, the secreting vessels being entirely closed by constriction.**
Proohaska adduces various examples, as the putrid and dissolved state of the blood in
fevers, the eflfecis of section of the eighth pair of nerves in altering the character of the secre-
tions of the stomach ; the vomiting of foetid, bilious matter, excited by disease of the brain
and by irritation of calculi passing along the ureters, diarrhoea, 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
secreted, that it can modify or alter them, or entirely change their nature.*
Marie Francois Xavier Bichat, born November llth, at Thoirette, in the 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 ihe encephalon and spinal marrow and their annexes, subserving the operations of the
understanding 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 Unzer and Prochaska.
According to Bichat, the functions of the animal are of two very difflerent 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 rejects 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 mores according to its influence, and frequently is
enabled to communicate by its voice, its desires, and its fears, its pleasures and its pains.
The aggregate of the functions of the first order, Bichat named the organic life^ 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 functions of the second class.
* "Dissertation on the Functions of the Nervous System, by George Prochaska, M. D.*' Translated and Edited by
Thomas Laycock, M. P., etc, Sydenham Society. 1861. pp. 369-460.
t " Physiological Researches on Life and Death, by Xavier Bichat** Translated firom the French, by B. F. Gold.
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Introduction to the Study of Diseases of the Nervous System, 15
because it is exclasively the property of the aoinial, he denominated the animal life. .He
regarded the sanguiferous system as a middle system, the centre of the organic life, as the
brain is the centre of the animal life. In this system, the particles, which are about to be
assimilated, 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 parts ;
the one the pabulum of all parts of the body, and derived from the aliment, the other exore-
mentitions, composed of the wrecks and residue of the organs, and constituting the source of
the exterior secretions and exhalations.
As defined by Bichat, the animal and organic life, are each of them composed of two orders
of functions, which succeed each other, and are related and manifested in an inverse direc-
tion. Thus, in the animal life the first order is established from the exterior of the body
towards the brain ; the second from the brain towards the organs of locomotion and the
roice. The impression of objects successively aflfect the senses, the nerves and the brain ; the
first 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
faoctions, is almost passive ; in the second, he becomes active. This second order is the
result 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-
motive organs and voice, which are the agents of volition. External bodies act on the
animal by tpeans of the first order of functions, the animal re-acts upon them by means of the
.second. 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 animaj
which feels the most, also moves the most.
A doable 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
at one time, it ceases to be at another. Its organization remains unaltered, but its elements
vary every moment. The molecules of its nutrition, by turns absorbed and rejected from
the animal, pass to the plant, from the plant to inorganic matter, Teturn to the animal and so
proceed in an endless revolution.
Bichat endeavored to establish the following general differences between the two lives :
The organs of the animal life are symmetrical, those of the organic life are irregular in their
cooformatfon and position ; the animal life is, as it were, double, its phenomena performed,
as they are, at the same time on the two sides of the body, compose a system in each of
them independent of the opposite system \ on the contrary, the organic life is a single system
io which everything is concatenated and concentrated where the functions on one side cannot
be interrupted, and those on the other side subsist. Harmony is the character of the
animal, discord that of the organic functions; the functions of the animal life intermit, the
functions 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
habit; whatever relates to the understanding belongs to the animal life, whatever relates to
the passions belongps to the organic life ; the organic life is the term in which the passions end,
and the centre from whence they originate ; the vital properties are only those of perception
and motion, but in the two lives they possess a very diflferent 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
an animal contractility which has its principle in the brain, and is essentially subject to the
influence of the will, and receives from the brain the irradiations which put in motion, and
ceases 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 oi volition, and gives rise to
the phenomena of digestion, circulation, secretion, absorption and nutrition.
Nothwithstanding the strong lines in which Bichat drew the apparent distinctions between
the animal and organic lives, he admitted that though at the first glance, the two sensibilities
present a remarkable difference, their nature nevertheless was essentially the same — the one
being only the maximum of the other. Thus he says :
"It is evident that the diatinction above established, with respect to Mosibilitj consists in the different modiflca-
doos of which this power i» susceptible, and not in its nature, which is erery where the same. This Ikculty is com-
mon to all the organs and forms their true and vital character; but as it is more or less abundantly distributed to each,
it gives to each a different mode of existence. No two parts e^joy it in the same proportion. In these varieties there
isa defcree above which the brain is the term of it, beneath which the organ alone is sensible of the impression. If
to render my ideaa on this head. Intelligible, I am to use a vulgar expression, I should say that distributed in such a
•lose to an organ, sensibility is animal ; in such another dose organic. Now that which varies the dose of sensibility,
bsoraettmes the order of nature (in which way the skin and the nerves are more sensible than the tendons and cartl-
lagas): at other times disease ; thus in doiibllng the dose of sensibility to the cartilages, inflammation renders them
«)Dal in this respect, and even superior to the former, and as a thousand causes, may at every moment exalt or dimi-
Qish this power in any part of the l>ody, it may be changing from the animal to the organic type."
Bichat labored strenuously to establish the entire independence of the cerebru-»|Mual und
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16 Introduction to the Study of Diseases of the Nervous System,
sympathetic systems ; and the fnodameatal proposition of his book, apon which the whole
chain of reasoning rests, as to the diflference 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 nervous system
of the brain. He affirmed 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, is
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 faots, 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 sympathies. Thus he held, that:
" The most namerous eympathies exist between the internal viscera and the brain, or its different parlB. Brei?
8tep which we make in practice, preeents as with affections of the brain originating sympathetically, (torn thoee of
the liver, stomach and intestines. Now, as the effect of every kind of passion is to produce a change of power in the
one or the other of these viscera, such change will sympathetically excite either the whole of the brain or some of
its parts whose re-action upon the muscles, which receive from thence their nerves, will produce the motioiis wfaitdi
are then observed. In the production of ^eee motions the cerebral organ accordingly must be paarive, it is active
only when the will presides over its effects. The effects indeed of the passions, are similar to those dlMsaes of Vbt
internal organs which by sympathy are the causes of atony, palsy and spasm. * *
** A man is informed by letter and in presence of company, o( a bad piece of news, which it is his interest to oonoeal ;
ifuddenly his brows contract, he grows pale, and his features, are moulded according to the nature of the passkM
which has been excited. These are sympathetic phenomena produced by the abdominal viscera, which have been
affected by the pMslons, and which, in consequence, belong to the organic life. But in a short time, the nun is capa-
ble of putting a restraint upon himself, his countenance dears up, his color returns. Meanwhile the interior sanli-
ment continues 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 hM resumed the empire.**
Cuvier 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.
Ouvier regarded the gangUa^ when considerable, as each a kind of secondary braio, 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 foculty of sensation, Is the medullary substance. In all the ^»«"m1«
in which we can distinguish it, that substance is divided into filaments, which, arising fh>m certain centres, distribute
themselves over most parts of the body, where they appear to serve other properties foeddee that of procuiinc seBsa>
tions. The centres (h>m 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 substance which forms the essence of this system, is divided into filaments that approach eadi
other, and unite in bundles, which contain more filaments in proportion as they are tnu»d nearer to the common
fiisdculn of all the nerves, called the spinal marrow, the anterior extremity of which is Joined to the bndn, that te to
wy, to a medullary mass of more or less magnitude, and differently formed according to the various kinds of stnimals.
(Yom the action of extemiU bodies on our own, we perceive that the nerves affected by that action communicate with
the common fasciculus, 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 different nerves,
whether that communication be produced by cords passing fh>m one to the other, or through the medium of the
biuin. These phenomena are called tgrnpaJOde* ; they consist of involuntary motions, or rather of sensations, experi-
enced in places different fh>m those that are affected. These sensations do not seem to depend upon the inflneoce of
the will, or the imagination, and frequently exist while we are ignorant of the place really affected, or the motioo thai
lias occurred.
" The sneezing which succeeds to irritations of the nostril, affords an example of the sympathy produced by the
union of nerves; the nerves of the nostrils, which come trom the opthalmic branch of the fifth pair, are connected
by the sy mpatheticus mi^jor, with the nerves of the diaphragm, and by this means the excitement is communicated. The
sneesing which takes place upon looking at a bright light, is to bo ascribed to the union of the ciliary nerve with
the fifth pair ; the irritation is communicated to the nose, and thence to the diaphragm.
" Another example of the same kind conslstd in the great changes wlUch the eyes present in different internal
diseases of the body. These changes so important to the physician, are almost all produced by the union of die
Hvmpatheticns mi^Jor 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 «
nerve which may communicate irritation.
** Thns tears are excited by a strong smell. This is occasioned by the opthalmic nerve sending at the
I)ranche8 to the nostrils and the la«-hrymal gland.
"The vomiting produced by pushing a finger into the throat, Is owing to the distribution of the eighth pair of
nerves, which go both to the pharynx and to the stomach.
'' The eighth pair, or nervus vagus, and the great intercostal or trisplanchnius, are the nerves which produce the
greatest number of this kind of phenomena, because they are distributed to a great number of parts, and form nniow
with a great many other nerves ; they have therefore been named KympathMcw major, and i^fmpathetiru* mecUm."
li<M:tnres on Comparative Anatomy, etc., translated by James Macartney, 1802, vol. II, pp. 120-121.
The important experiments of Julian John Caesar Le Gallois, illustrating the action of the
spinal cord, as an independent centre of influences, as well as the philosophical researches
of Lobstein which anticipated by more than a quarter of a century, many so-called discoveries
in the physiology and pathology of the nervous system, will be more fulfy considered when we
examine the relations of the cerebro-spinal and 'sympathetic nervous systems.
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Introduction to the Study of Diseases of the Nervous System. 17
The first researches of M. Le Gallois, were made on the foetus Id 1806 ; two years after-
wards Id 1808, he communicated his first obserrations to the professors of the faculty of
niediciue of Paris, and illustrated the effects of decapitation and the functions of the
medulla spinalis ; on the 2d and 16tb of March, 1809, at the request of M. Thouret, dean of
the faculty of medicine of Paris, be demonstrated publicly before the same Society of
Professors, that the principle of the trunk resides in the medulla spinalis; and the same
experiments were afterwards repeated on tbe 16tb of April, before Messrs. Cbrtussier and
Dum^ril. whom ihe society had chosen a committee to examine tbem, and who made their
report on the 27th of the same month. The subject was far from being exhausted, and M.
Le Oallois soon after beg^un bis researches upon the motions of the heart. M. Magendie
proved soon after by experiments, that it is by acting upon the medulla spinalis that the
poison of ttie Indians, known under the name of upas tieuU^ kills animals ; and about the
same time Mr. Brodie, of the ^oyal Society of London, instituted experiments to determine
the changes of temperature and the state of the secretions in animals kept alive after decapi-
tation. .Mr. Brodie asserted, that the decapitated animals, which are kept alire, cool as
rapidly, 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
tbe life is preserved by artificial respiration after decapitation, and he pointed out that the
inflation of the lungs was ovSb of thi principle causes of tbe refrigeration, together with
derangements of tbe 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
a connected form in his work entitled " Experiments on tbe Principle of L'>ft^ and particularly on
the Principle of ihe Motions of the Heart and on the Seat of this Principle ;'* a translation of which
by Drs. N. C. and J. G. Nancrede, appeared in this country in 1813.
ft was not the original object of M. Le Gallois, to explore tbe cause of the motions of the
heart, as he had adopted the theory of Haller on the subject ; experiments undertaken with
other Tiews led him to the conclusion, that it was impossible for him to understand his own
experiments* without determining, whether the nervous power influences tbe motions of the
hea£t; and if so. in what way it has this effect. A peculiar case of labor excited in him the
desire to know how long a full grown foetus can live without 'breathing, after all communi-
catioQ between it and the mother has ceased. In order to solve this question by direct expe-
riment, be placed the foetus of animals in various situations, similar to those in which the
hnman foetus is occasionally placed, when it ceases to communicate with the mother. When
the foetus suffers decollation from artificial delivery by tbe feet, he found that tbe 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
off" tbe head, 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
4>y inflating the lungs, to supply the place of the natural respiration. M. Le Gallois con-
cluded from these facts, that decollation, proves fatal by destroying the motions of inspiration,
and that consequently, the power on which these motions depend is in the brain ; but that
that on which tbe life of tbe trunk depends, is in the trunk itself Endeavoring by destruction
of successive portions of the spinal marrow, to ascertain tbe precise seat of each of these
powers, he found that, that on which the motions of inspiration depend, resides in that part
of the medulla oblongata, from which the eighth pair of nerves^ take their rise ; and that on
which the life of the trunk depends, in the spinal marrow. By successive destruction of
varioas portions of the cerebro-spinal system, he sought to demonstrate, that it is not by all
tbe spinal marrow, 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 tbe spinal marrow,
we only destroy life in those parts of the body which correspond to that part. His experi-
ments also illustrated tbe important fact, that if we interrupt tbe circulation, in any particular
part of tbe spinal marrow, life is weakened and soon extinguished in all the parts which
receive nerves from it. There are therefore two ways of destroying life, in any part of an
animal ; the one by destroying that part of the spinal marrow from which it receives its
nerves, tbe other by interrupting the circulation in that part of the spinal marrow. He
hence concluded that two conditions are necessary to preserve tbe life of any part of tbe body ;
vii: the integrity of the corresponding part of the spinal marrow, and the circulation of the
blood, 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
anterior parts, after that of the posterior purts is destroyed, by destroying the corresponding
portions of the spinal marrow, or ok^. nerm. By numerous vivisections and by carefully des-
troying different portions of the cerebro-spinalaxis, M. Le Gallois arrived at the conclusion,
that the power on which tbe motion of tbe 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-
tion : and that each portion of the spinnl marrow influences life in two different ways ; by
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18 Introduction to the Study of Diseases of the Nervous System.
the one it is essential to the existence of life in the parts which receive nerres 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 Gallois, 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.
4tb. 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. Prochaska placed the sensorium commune, in the brain and spinal marrow conjointly.
(Opera Minora, tom. ii, p. 51). Before him, however, Marherr, Hartley, and others bad 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, tnken
alone, the cause of its life and 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 differeot
parts of the body. (loc. cit. p. 152).
On the contrary, M. Le Gallois demonstrated that the spinal marrow is uot merely a means
of communication, between the different parts, but that from it, the cause of the life and ikr
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 bundle of nerves, crcutus funis 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 tt large nerve arising from the brain, in the
same manner, as all those which pass through the foramina ot 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 syir^tem and organs, and capa-^
ble of receiving and exciting motor and sensitive and reflex acts.
Thus, with reference lo the relations of the brain to the spinal cord, .M. Le Gallois observes :
** When I move mv arm, the principle of this motion emanates (h>m the medulla spinalis, and not from the brain,
but it is the brain which determinee and ilirects it, in the mode appropriated to the purposes for which I make it.
Cold-blooded animals furnish an evident proof of this assertion. If a salamander be decapitated, at the flivt Yertabim.
it may continue to live for several days; but although it movee its body and limbs with as ranch force, as woald be
to trant^rt it from one place to another, it remains in the same place, and it may be left npun a plate, without fear
of its escaping. If we examine all its motions, we perceive that they are all irregular and without design. It moT«s
its paws in of^KMite directions, so that it cannot advance, or if it tikes one step forward, it soon takes another bai^-
wards. The same thing is observed in decapitated fh>g8; thpy no longer know how to leap, or if they do leap^ it i»
only when their bind legs meet with a particular support. If they are laid on their backa, they sometimes agitate
themselves, seemingly to change their situation, but they remain in the same position, becanse they no lungerkDow
how to make the motions neoesnary to place themselves on their l>elly. But generally speaking, all these animala
perform few motions, unless they are touched, and we conceive that it ought to be so ^nce of all the sensea, that of
touch alone can transmit impressions to them. * *
** Reptiles, as the tortoise and salamander, preserve life lor whole months after decapitation. The tortoise from which
Redi removed the brain, by opening the cranium, survived the operation for several months. It is a well eatablished
(act that birds continue alive and even walk and run after their heads have been cut off. The fttct has fk«qaently
been quoted of the Emperor Commodus, who, whilst ostriches were running in the circus, amused himaelf
by cutting off their heads with arrows, in the form of a crescent. These animals were not prevented from runnlni:
as before, and only stopped at the end of the course. Several physiologists have obtained a like result, by decapitating
turkeys. (Lam^trie GSuvres, Philosopb, 1751, p. 56). C!ocks (Kaanw Boeiiiaave, impet. faciens. Mo. 331, p. 262, Urb.
Tosetti, Mem. sur les part, sensi, et irritab. tom. ii, p. MH); ducks, (M.Cuvier, Leouns Oraloi), pigeons (Woodward, cite
par Haller). * * Desault relates in his Journal a case where the spinal marrow had been cut completely acroas by a
gunshot, in which the palsy of the inferior extremities did not take place. A like case is found in the Seieeta Medica
PrtMeotmriiatia. Authors assort, that a calf continued to walk a great ways after decapitation, (Riis quoted by Hal-
ler); that a woman walked a few steps, (Rzadskinski, Hist. Nat. Polon p. 3(>3); that a man was able to hold hi!*
»word and brandish it at three different times; that another man struck his breast with both his hands. (Struve.
Anthrop, Sublimior, 1754, p :J81 . ♦ •
^Decapitation itMclf is not necessary to produce thes<< pbenomeuH, they are likewioe obtained, and in a manner
*Kxperitt:(*« mii le principe de la vie notamment sur celui dt^ mouvemens du otpur el sur le siege de ce prindpr.
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Introduction to the Study of Diseases o^ the Nervous System. 19
stin more cfariona, after the simple section of the medulla spinalis, perfonned at the occiput. In this case the head
is allTe, as well as the rest of body, as is evinced by the motions of the month and of the eyee. And noTerthelees. the
animal Is exactly in the same state, as if it had been decapitated, riz : no longer able to govern its motions. A situa-
tioo, truly extraordinary, in which both the head aud the body, possess life separately, without being able to exercise
any action over eadi other ; the head lives, as if it were without a body, and the body as if it were without a head."
M. Le Gallois, by making successive pections 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 '' immediaU principle" Le Gallois held, that
"■ The brain spears to act upon the medulla spinalis, as the latter acts upon the parts which it animates. It is
through the nerves that the medulla spinalis transmits its action, and the nerves appear to be formed of the same
SBbstanee with the white and medullary part of the brain, and medulla spinalis. I conceive, therefore, that the
white part of the medulla spinalis, is composed of nervous fllament&, having their origin or termination at one end
in the brain and at the other in every part of the medulla, and that it is in the cinerftious part of the medulla that
both the spinal nerves, and the principle that animates them arise.**
In this last supposition, that the spinal nerves were connected with the grey matter of the
cord, and that 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-sj>inal system, which has more recently been demonstrated to
be tnie by the careful anatomical and physiological investigations of Shroeder, Van der
Rolk, Lockhart Clarke and others.
Similar experiments to those of Le Gallois were performed by A. P. Wilson Philip,* and
Mr. William Glift,t the results of which differed chiefly in showing that the action of the
heart, although capable of being influenced through the brain and spinal cord, depended
rather upon its own ganglionic system, and that of the great sympathetic.
It would 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
of seose. Thus, Empedocles appears to have been the first who attempted to explain the
nature of sensitive impressions, by the supposition that an elementary affinity existed between
exterior objects and the organs of sense. He conceived that there exists in each of the
organs 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
vaporous, the tongue a humid, and the organ of touch an earthy constitution. Aristotle,
Qalen and iheir successors did not make any special modifications in the theory of Empedo-
cles, except to add the hypothesis of spirits, of which they made as m&ny species as there
are different senses. 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
spirits connected themselves with the organ of sight, where they put themselves in communi-
cation with the luminous particles ot bodies, and the auditive spirits were communicated to
the ear^ where they were associated with sonorous particles.
The celebrated mathematician, Kepler, announced in the beginningof the seventeenth century,
that the crystalline lens was not. as had been supposed till that time, the seat of vision, but
that its function is to refract the rays of 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 submitted the membranes and humors of the eye to careful dissection and exam-
ination, and this Complicated organ became to be one of the best understood in the organism.
8ir Isaac Newton, also, by his researches on light and colors, contributed to the perfection of
the theory of the visual function. In like manner, the organ of hearing was studied by Cas-
serins, Duverney and other anatomists ; the osselets of the small muscles of the internal ear,
and the semi-circular canals were described, the acoustic perve was followed in its windings
and ramifications : and R. Vieussens established the seat of audition in the membrane which
lines 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 filaments 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
the authority of Cullen and the Monroes, continued to prevail, notwithstanding the teachings
of Boerhaave, Albwins, Fnzer and Prochaska on the Continent.
* Experiments, made with a view to ascertain the principle on which the action of thp heart depends, and the rela-
tion whldi subsists between that organ and the nervous system, by K. P. Wilson Phtllm physician in Worcester. Phi-
kiaopfaical Transactions, 1815, p. 65.
t Experiments to ascertain Uie actiun of the spinal marrow, on the action of the heart in fisheis by Mr. William
ailt. Phllooophical Transactions, 1815. pp. 91 .9G.
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20 Introduction to the Study of Diseases of the Nervous System,
Mr. Walker obseryes, in the " Archives of Universal Science," for July, 1809, published in
Edinburgh, p. 172 :
^Medullan' actioD commences in the organs of sense, passes to the- spinal manvw by the anterior fasdcnll, of tbr
spinal nerves, which are, therefore the nerres of sensation— ascends through the anterior columns of the spinal mar-
row,'^ etc., and " it descends through the posterior columns of the spinal marrow, which are therefore its deaoending
columns, and expands through pMterlor fasciculi of all the nerves, which arc therefore nerves of volition/* * *
As in some cases, sensation exists without volition, and as almost all nerves arise by distinct filaments, I am of opin-
ion that whenever a part having both sensation and volition, is supplied from one nervous tmnk, that tanak envel-
opes, both a nerve of sensation and one of volition.**
It is evident that the preceding statements involve 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 «en<a^on to the anterior^ and motion to the potierior roots; and
this hypothesis appeared to be supported by general analogy, and to be in conformity 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, as Willis, Boerhaave and Albinus, had referred the
automatic, and Pouteau the automatic and voluntary motions to the cerebellum ; and the
experiments of Plourens and other physiologists, performed after the enunciation of the
theory ol 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 paralUlism
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 nervont fila-
ments of motion in the posterior to the cerebellum, Mr. Wallfer proposed the hypothesis
wl^ich, independently of precise experiment, had the greatest weight of probability in its
favor.
Sir Charles Bell, in 1811, in a treatise entitled ".4n Idea of a New Amtomy of the Brain,
Submitted for the ObMrvation of the Author^t Friends" 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 expre89ly instituted on the roots
themselves of the spinal nerves, to establish that to the filaments ascending by the posterior
roots belong exclusively the function of sensation * and afterwards, bnt 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 roots are the sole vehicles
of voluntary motion.
The same theory was advanced by .\f. Magendie eleven years later, and J. Muller has
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 essay, in 1811, recorded the following
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 convulsing 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 convulsed."
Sir Charles Bell supposed at first that the anterior roots contained nervous fibres for sensa-
tion as 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 philosophic^ an^ 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 pathologioftl lesions upon
them. Sir Charles Bell was led to the more correct inference, that the single rooted nerves
were connected with the anterior columns of the spinal cord and corresponding parts of the
brain, and the anteribr roots of the double rooted nerves were exclusively 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 }i, Magendie, Fodera,
Bellibgeri or any other physiologist had 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 of which we will give, and also upon the statements
contained in Mr. John Shaw's Manual of Anatomy, published September, 1821, and in several
papers by Mr. Shaw, (a pupil of Mr. BelTs) which appeared in the Quarterly Journal of Sci-
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Introduction to the Study of Diseases of the Nervous System. 21
ence, December, 1821, and March, 1822, and in the Medico-Ohirurgical Transactions, April,
1822.
Majoand Mag^endie both published memoirs in August, 1822, upon the sensitive and motor
nerves, 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 by Sir William Hamilton, and by a
number 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. LXII., p. 532. and by EUiotson, (Human Physiology, 1840. p. 465), have been
recently ably supported by Bernard, (Rapport sur le Progr^s et la Marcbe de la Physiologic
Generate en France, Paris, 1867, pp. 12 and 154), and by Professor Austin Flint, Jr., (Histori-
cal Considerations Concerning the Properties of the Roots of the Spinal Nerves ; Quarterly
Journal of Psychological Medicine, New York, Vol. II., p. 625 et seq ; Journal de V Anato-
mie, Paris, 1868, Tome V., p. 520 et seq., and p. 576 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 flur les Fonctions des Racines des Nerfs Rachidiens ; Journal de Physiologic, Paris, Tome
II, p. 276 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-
ally connected with motion."
In a subsequent 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 he was undeceived by a letter from Mr. Shaw, who stated
that Charles Bell had divided the roota thirteen years before. Having afterwards received
from Mr. Sbaw a copy of Bell's Essay, (*♦ Idea of a New Anatomy of the Brain,") Magendie
ob;»erv'es :
**It is fteeo bj this quotation fh)m a work which I could jiot be acquainted with, ioaBmucb. as it had not boen pub-
Hthed, that Mr. Bell, led by his ingenious ideas concerning the nenrous system, was very near discoTering the fUnc-
lioDS of tbe spinal roots ; stili the foct tliat the anterior are deroted to movement, while the posterior belong more
particularly to sensation, 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 Pbysiologie, 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 Physiologic,
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-
nmns of the spinal cord. ^
Mr. Alexander Shaw, in his '* Narrativt of the Discoveries of Sir Charles BeU in the Nervous
Sffstem^*' published in 1839, states that a mistake of Sir Charles Bell's, in an experiment which
be had made to prove his doctrine, was discovered through (he joint labors of M. Magendie
and Mr. Mayo.
M. Magendie, in 1822, asserted that the posterior column of tbe spinal cord, and tbe poste-
rior roots of 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 application of galvanism to the posterior roots of the spinal nerves, after their separa-
tion from the spinal cord, excited contractions of the muscles, though they were but feeble :
while tbe same stimulus applied to the anterior roots, gave rise to violent muscular spasm
(J. de Physiologic, II , 276, Desmoulins et Magendie, Anat. Phj-siol. des Systems Nerveux,
Paris, 1826, p. 777).
Mailer remarks that Fodera's experiments were accompanied with such contradictory symp-
toms, that it is inconceivable how he could put them forth as confirmatory of M. Magendie's
observation. Neither can the claim of the Italian Physiologist, Bellingeri, be maintained,
although 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 in 1818, 1823. 4, and 5, and 1833.
The treatise of Professor Bellingeri, ** De Medulla Spinalis," published in 1823, contains im-
portant observations on the structure and functions of the spinal cord. In this work he
announced 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
cornua. The white, or medullary matter, is in the form of six cords or strands, two anterior,
divided from each other by a deep furrow, and one on each side of the cineritious matter.
These cords or strands are supposed tQ be connected with different parts of the encephalon.
tbe anterior with the cerebrum, the posterior with the cerebellum, and the lateral cords wiih
tberestiform process; these are termed respectively, the cerebral, the cerebellic, and the
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22 Introduetion to the Study of Diseases of the Nervous System.
restiform parts of the cord. The white or medullary matter he described as fibrous, and the
gray, or cineritious matter, as globular. Blainville. without apparently any knowledg^e of
Bellingeri's observationSf adopted an opinion of the structure of the cord, in many respects
similar, although less minutely developed ; and the same appears to have been the case with
Rolando.
Bellingeri's experiments (Exp. in Nerv. Antigonismum, 1824; Exp. Physiol, in Med. Spin.
1825), 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 t^his 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 JBcen by a comparison of these views of Bellingtri 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 th3 Itali&n' physiologist, yet when 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. Mailer,
of the University of Berlin, performed similar experiments in 1824, without success; auhge*
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 Miiller conceived that
the mode in which the investigation had previously been conducted was deceptive, from the
circumstance that 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
irritation 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 sepsitive, and not indued with motor power, they ought, when irritated
with the needle, to excite no contractions of the muscles ; while these ought to ensue from
the irritation of the anterior roots. That h*e might perceive the most trifling twitchioj^s.
Professor Miiller laid bare the muscles of the posterior extremities; experiments thus per-
formed yielded no certain results, since the shock produced in opening the spinal column had
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, MilUer began to doubt the possibility of obtaining a decided and satisfactory result from
all such experiments. Desmoulins and .Magendie themselves, had merely said, in the one case
nearly all feruationy in the other, nearly all power of motion is lost. 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 MOUer, 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 .Miiller, 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 Muller proved conclusively that it is quite impossible to excite muscular contractions
in frogs by irritating mechanically, the posterior roots of the spinal nerves ; while on the other hand^ th^
slightest irritation of the anterior roots ^ immediately gives rise to very strong actions of the mttscles. As
long as both roots of the nerves are in connection with the spinal cord, the traction experi-
enced by the cord itself, when the posterior roots are raised, may cause the produtaion of
muscular twitches in the limbs ; such effects however, are quite independent of the action of
the posterior roots, and depend solely on the irritation communicated to the anterior roots.
b}' the spinal cord, in consequence of the mechanical violence which this has suffered. Hence,
if tlie latter roots have been previously divided, no mechanical irritation of the spinal cord
itself, or of the posterior roots connected with it. excites the slightest muscular contractions.
The experiments of Professor Miiller. with the galvanic stimulus of a single pair of side
and copper plates were equally conclusive. The application of galvanism to the anterior roots of
the spinal nervex, after their connection with the cord is divided, ezcit s violent muscular twitchings:
the same stimulus applied to the posterior roots, is attended with no such effect. This result was
remarkable, for Muiler had imagined that, although the posterior roots are endowed with
sensation merely, they might still conduct the iralvanic fluid to the muscles, and when a
powerful galvanic pile is employed, this is inevitably the case (as in Magendie's experiments),
the strong galvanic current bein/ conducted by the posterior root of the nerve as by any
animal substance. The stimulus of a pair of plates, however, while it causes the anterior
roots of the nerves to give rise to muscular contractions, has no such influence when applied
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Introduction to the Study of Diseases of the Nervous System. 28
to the posterior roots. In this experiment, it is necessary to be very cautions that the plates
are broagbi into contact with no other part than the nerves. When the experiments were
performed on frogs in the manner adopted by Sir Charles Bell, and M. Mageudie, the resnlts
were as decided as in those just detailed. If in the same frog, the three posterior roots of
the nerves going to the binder extremity, be divided on the 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 oflT, the frog will give evidence of feeling pain by movements of all parts of
the body, except the right leg itself, in which he feels 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,
because, 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
Pbjsiology by J. MuUer, M. D. vol. I, pp. 692-5). The foregoing experiments of Professor J.
Mailer, leU no doubt as to the correctness of the theory of Sir Charles Bell.
Sir Charles Bell, in his article " On the Nervet^ giving an account of some experiments on their
ttrwture and functions^ which lead to a netv 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 tf system of great extent, comprehending cUl the nerves, which serve to combine the
muscles employed in the act of breathing and speaking. He endeavored to show, that some hundred
iDQScles 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
sod sustained by experiments upon animals, the following propositions :
When we minutely and carefully examine tbe nerves of the human body, and compare them
with those of other animals, a very singular coincidence is observed between the nwrober 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 nerve, however exquisite the sense or action may be ; but if two nerves coming from
different sources are di:ected 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 simple and
oniform, the other irregular and complex, in proportion to the complexity of organization.
Thus w|ien 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
tbe frame, the nerves are extremely simple ; they consist of two cords, running the length of
tbe body, with brnnches going off laterally to the several divisions of the frame. Here no
iairicacy is 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 the muscles, and to give them the concatenation necessary to locomotion. There is
the same uniform and symmetrical system of nerves in the human body, 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 upward:*, are observed gradually to
accumulate 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
sccordingly, 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, tbe
tetith or sub^occipital new/, and the .fifth or trigeminus of the system of Willis, constituted this
original and symmetrical system. All these nerves agree in these essential circumstances; they
have all double origins; they have all ganglia in one of theif roots: they go out laterally to
certain divisions of 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 (he surfaces of the body ; when
accurately represented on paper, they are seen to pervade every part ; no part is without
tiiem; .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
sensibility; while on the contrary nerves not of this original class or system, are compaia-
u?ely so little sensible, as to be immediately distinguished ; insomuch that the quiescence
of tbe animal suggests a doubt whether they be sensible in any degree whatever. If the Jifth
'*irve, and the portio dura of the 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
fosters sensibility. If the nerve of this original class be divided, the skin and common sub-
•PWlowphiCHl Tr»n«Mnions, Wil, pp. 398, 424.
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24 Introduction to the Study of Diseases of the Nervous System.
stance is deprived of sensibility ; and if a nerve not of this class be divided, it in no measare
deprives the parts of their sensibility to external impressions.
The nerves which connect the internal orfirnns 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 medulla ohlongatn and the upper part of the spinal
marrow ; and from this origin, they diverge to those small remote parts of the frame which
are combined in the motion ot respiration.
According to Sir Charles Bell, the Par vagum, (the eighth of Willis, the pneumogastic nerve
of the modern French physiolojzist,) which goes off from the common origin of the respiratory
nerves, at the lateral part of the mrduUa oblongata^ associates the larynx, the lungs, the heart.
and the stomach. These organs, however, are at the same time supplied with nerves from
other sources. Comparative anatomy sustains the inference that this nerve is not essential to
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 he 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, results from an impression on tbe respiratory
nerves, and that the muscles of the face are drawn into sympathy, solely by the influence of
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 nerve or system of
nerves, being universal, it had been supposed that it was the cord throufth which tbe relations
of the eye, nose, tace, throat, diaphragm, &c., 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. 284, 312,) ''On 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, afiirms that, whenever in examining the
comparative anatomy of animals, we find ribs rising and falling by respiratory muscles, we
ha 'e a medulla spinalis and the distinction of cerebrum and cerebellum ; and experiment and obser-
vation prove that the seal 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 spinalis^ 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. From 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 as they regulate the respiratory actions, proceeds from the
connection of the roots of these nerves with this column which is continued downwards, and
which throughout can be distinguished from the rest of the spinal marrow.
Sir Charles Bell concludes this paper with valuable observations upon the relations of tbe
respiratory system of nerves to certain diseased states, and dwells upon the fact that tbe res-
piratory nerves are 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 voluntary 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 entire 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, tbe
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
of t\\t portio dura of the seventh nerve, the spinal accessory nerve, and the external thoracic
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Introduction to the Study of Diseases of the Nervous System. 25
oenre, from their natural classification with the diaphragmatic or phrenic, has giyen rise to
rerj vagoe theories, and occasioned very inaccurate statements of pathological facts.
By these experiments and researches of Sir Chwles 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 Bicbat 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 :
** So Ao- to it tnm being tme that ganglia cat off Mnaation, that I have ascertained, and proved by experiments,
that all the nerres, without a single exception, which bestow sensibility from the top of the head to the toe, have
paglia on their roots; and those which have no ganglia are not nerres of sensation, but are for the purpose of ordeiv
iag d>e moscalar f^me. * *
** Thb noUon of a flak! moving backwards and forwards in the tubes of the nenres, equally adopted to produce
■ottoB and sensation, has perp^uated the error, that, the different nenres of sensation are ai^ropriated to their
ofloes by the texture of their extremities, that there exists a certain relation between the softness of the nerrous
extretaitiea, and the nature of the bodies which produce an impression on them. On the contrary, every nerre of
iense to limited in its exerdse, and can minister to certain perceptions only. Whatever may be the nature of an im-
pulse omununicated to a nerre, pressure, ribration, heat, electricity, the perception excited in the mind, will have
rafereiioe to the organ exercised, not to ue impression musde upon IV*
In 1826, Sir Charles Bell published his paper *' On the Nervous Circle^ which connects the volun-
tary muacUs with the Brain,*"^ The following analysis, presents the main points of his theory,
as well as the facts which he claims to have established.
In th€ 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 had discovered the composition of the roots of these nerves, he would have continued
to 8np(>ose, 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 foots
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
different 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
supplied to it. This fact coul t 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
recourse 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 nerves of different
functions, take their origin apart and run a different course, two nerves must unite in the muscles, in
wder to perfect the relations between the brain and muscles. In his first paper, the difference had
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
<rDtire. The muscles have no connection with each other, they are combined by the n rves ;
bat these nerves, instead of passing betwixt the muscles, interchange their fibres before their
distribution to them, and by this means, combine the muscles into classes. The question,
therefore, may thus be stated; why are nerves, whose office it is to convey sensation, pro-
fusely given to muscles in addition to those motor nerves, which are given to excite their
motions? and why do both classes of muscular nerves form plexuses?
"* expose the two nerves of a muscle; irritate one of them, and the muscle will act; irritate the other, and the,
moscle remains at rest Cut across the nerve which had the power of exciting the muscle, and stimulate the other.
* On the motion of the Eye by Sir Charles Bell, Phil. Trans. 182:), p. 16((, p. 289. On the Nerves of the Orbit. Phil
Trsna. 1823, p. 166-186.
tPhilosophica] Transactions, 1826, p. 163.
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26 Introduction to the Study of Diseases of the Nervous System.
which itt undivided— the aDimal will gire indication of pain; but although the nerve be ii^nred so aa to cause anl-
venml agitation, the muscle with which it is directly connected, does not move. Both nerves being cut across, wp
Hhall still And that by exciting one nerve the muscle is made to act, even days alter the nerve has been divided; but
the other nerve has no influence at all. r
" Now it appears the muscle has a nerve in addition to the motor nerve, which being necessary to its perfiect ftine-
tion, equally deserves the name of muscular. This nerve, however, has no direct power over the muscle, but circtii*
^ tously through the brain, and by exciting sensation it may become a cause of action.
** B^ween tJu brain and the mtuolM there i» a circle of nenm ; one nerve ooMMy* the Ui^flmeneefrom the brain to the wmeeke
anoOter give$ the mmm of the condition of the imMcfe 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 Bell, in bis important article, '* On the funeiiom of tome parts of the brain and on the
relations between the brain and nerves of motion and sensation," received by the Royal Philosophi-
cal Society, March 3d, and read May 15th, 1834, and published in the Philosophical Transac-
tions of 1834, pp. 471-483, extends the doctrine of a nervom circle or refiex action^ so clearly
announced in the preceding paper, to the spinal cord, thus announcing the doctrine claimed
and elaborated by Marshall Hall. Thus Sir Charles Bell, says :
" The spinal marrow has much resemblance to the brain, in the composition of its cineritious and mednllary mat-
ter, and in the union of tt^ parts. In short, its structure declares it to be more than a nerve, that is, it poestasti
properties independent of the brain. Another consideration presses upon us. Where are the many relation^ existing
between the different parts of the ftrame, and necessary to their combined actions established? There most t>e a
relation between the four quarters of an animaL If the juuscles of the arm or of the lower extremities are oombiaed
through the plexus of nerves in the axlla, and in the loins, what ccMnbines the muscles of the trunk, and more
especially, what Joins the extremities together in sympathy ? That their combined motions and relations are not
established in the brain, the phenomena exhibited in stimulating the nervous system of the deci^rftated animal safll-
ciently evince. They must, therefore, depend on an arrangement of the fibres somewhere in the spinal manvw.
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 respects gives direction to the volition of thcae
animahi.*'
In the last article ^* On the Nervous 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 nerves 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 and 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 Nerves of Motion and Sensation.
The diflSculties which attend the investigation of the structure and functions of the brain,
are manifested by Ihe ineffective labors of two thousand years, and from the extraordinary
and contradictory results often experienced in experimenting npon 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 spicula 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 symptoms
^parently as formidable will be produced by slight irritation on remote nerves: — water in
tne 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 of error, especially to the experimenter on the brain, is the disturbance of its circulktion.
* Philosophical Transactions, 1831, pp. 471-48:t; 18:i5, pp. 255-260.
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IrUroduetion to the Study of Diseases of the Nervous System. 27
for the brain depends more directly than any other organ on the condition of the circulation
within it ; by the mere raising of the sknll, as a necessary preliminary to most experiments,
there is an immediate disturbance of the circulation, which of itself may be attended with
insensibility or convnlsions. Another source of error, was the obscurity which hangs over
the whole sabject, 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 orig^in. On this plan he proposed to demonstrate that tentibUity and motion
hdong to the cerebrum^ — that two columns detosndfrom each hemisphere — that one of them^ the anterior ,
gives origin to the anterior roots of the spinal nerpes^ and is dedicated to voluntary motion — and that
the other (which from its internal position is less ibtotDfi) gives origin to the posterior roots of the spinal
nerves^ and 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, — that the columtu of sensation also Join and decussate i» the medulla oblongata.
Finally, that these anterior and posterior columns bear in every dreumstance a very close resemblance
to one another, — that is to say, the sensorial expansions of both are widely extended m the hemispheres :
tk^ pass through similar bodies towards the base of the brain, euid both concentrate and decussate in the
same manner, thus agreeing in 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 they 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
boundaries between the columns, which descending from the encephalon 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 olivari. In the light of his 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
cerebmm, 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
commences, 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.
The origin of the posterior roots of the spinal nerves — The posterior roots of the first, and conse-
qaently 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
iia 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
in 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
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28 Introduction to the Study of Diseases of the Nervous System.
1835, Sir Cbarlee Bell gives the foUowiog 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 ot the spinal nerves, came from the posterior columns of the spinal marrow, and conse-
quently 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 this idea ; the cords of condmunication 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 had 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 affSected: in all, the defects of motion has been
greater 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 accounte 1 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 influence of Che 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 Uas been entire. But he
does not let this fact militate against his conclusions, for the column in the tpinal marrow which
give* rise to the sentitive roott^ ie posterior to that from which the motor roots arise : but is not the pos'
terior portion of the spinal marrow
Mr. George Newport,* in an admirable series of investigations, upon the structure Of the
nervous system in the 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 func-
tions, volition, sensation, and involuntary motion, 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 by ganglia ;
these 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 v^rtebrAta.
Mr. Newport records the interesting observation, that while engaged upon the anatomy of
the lobster, he obtained 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 usual blackish purple.
Upon killing the animal and examining its spinal cords, the motor columns and nervea were
of the usual size and appearance, 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 spinal 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 insects^ observes that the inverted posi-
tion of the nervous cords in insects and other invertebrata 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
vcrtebrata, 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 hardly
*0n the Nenroufl 83-810111 «f the Sphynx ligustri, Linn ; and on the change which it uudergoet during a part of the
M*'tamon*hoBefl of the Ineecl, by George Newport, Eeq. Communicated by P. M. Roget, M. D. Sec. Buyal Society.
Read June 7th, 1832. Phil. Trans. 1832. pp. 383, 398.
Part II, Phil. Trans. 1834, pp. 389, 423.
On the Nervous System of the Sphynx lignstri. Phil. Trans. 1834, p. 406.
On the Respiration of Insects. Phil. Trans. 18.36, pp 529, 566.
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Introduction to the Study of Diseases of the Nervous System.
29
reconcile this opiDion with the tfict of their being situated along the ventral instead of the
dorsa! aspect of the bodj. The reason for thi? change of position of the cords in inver-
tebrata appears to be partly to protect the cords themselves and partly, that the nerves may
be supplied to the limbs without having to travel round the sides of the body, and thereby
be exposed 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
iovertebrata^ since we now find that they are composed each of two tracts, as in vertebrate
animals — it is important to obserre 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 articulata,
has 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
Gord, 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 the 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
fohamsj as applied to the motor and sensitive tracts of the nervous system, and whether it
would not be advisable entirely to ab>indon these terms, and designate the two columns external
and intemal, the sensitive the external, and the motor the internal column, since these terms
would be strictly applicable to the situation or position of the columns in all classes of
animals.
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
JDvertebral 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 n«rres in insects, clearly demonstrates the identity of the structures.
Dr. Marshall Hall, in his first paper on the Re/lex Function of the Medulla Oblongata^ and
MeduUa Spinalis^ which was read before the Royal Society of London, June 20th, 1833, and
published in the Piiilosophical 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
fnnction 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
mcKlulla spioalis, being excited by causes in a situation which is eccentric in the nervous '
sjstem, that is distant from the nervous centres.
According to Dr Hall, whilst many of the phenomena of this principle of action, as they
occur 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 oflSce of presiding over the
orifices and terminations of each of the internal canals in the animal economy, giving to them
iheir due form and action ; and, in the second place, in the instances in which the phenomena
of this function hare 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
denominated, instinctive or automatic. This property is characterized by being excited in its
action, and refiex in its course ; in every instance in which it is exerted, an impression made
apon the extremities of certain nerves, is conveyed to the medulla oblongata, or the medulla
spinalis, 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 /Irstj is that designated voluntary volition, originating in the cerebrum, and
spontaneous in its acts, extends its influence along the spinal mi.rrow and the motor nerves,
in a direet line^ to the voluntary muscles. The second^ is that of the respiration ] like volition,
the motive influence 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 fAi'r^ 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 u) tl^e nervo-muscular fibre itself. 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, a/ot/WA, which subsists, in part after the voluntary and respiratory motions have
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30 Introduction to the Study of Diseases of the Nervous System.
ceased, by the removal of the cerebrum and medulla oblongata, and which is attached to the
medulla spinalis, ceasing itself when this is removed, and leaving the irritability undiminisbed.
In this kind of muscular 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 by the application of appropriate
stimuli, which are not, however, applied immediately to the muscular or nervo-muscalar
fibre, but to certain membranous parts, whence the impression is carried to 4he medulla,
reflected^ 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 reflex function, exists as a conti-
nuous muscular action, as a power pi^siding 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 recognized by physiologists.
The three kinds of muscular motion previously known, may be distinguished in another
way. The muscles of voluntary motion and of respiration, may he excited by stimulating the
nerves which 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 superficial 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, ^quires the
counection 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 of action
not previously subsisting in the animal economy, as in the cases of sneezing, conghing,
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 varioas
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 upon the reflex function ; it can take place in
animals from which the cerebrum has been removed, as has been demonstrated by M. Flourens.
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, abd by the contraction of the pharynx. The completion of the
act of deglutition is dependent upon the stimulus immediately impressed upon the muscnlar
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
{Leput Cuniculusy) 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 {chelonia mydcu,) if the lower
part of the medulla spinalis be left in its canal ; but it becomes immediately relaxed and open,
if this part 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 three 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 ihem, 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
stimulus to the nervo-muscular fibre itself; on the other hand the reflex function, which is
different from any of those, remains attached to the-meduUa spinalis, when the cerebrum and
medulla oblongata are removed, it is not direct like volition, or the motive power of respira-
tion; its seat is the medulla generally, it ceases when the medulla is removed, leaving the
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Introduction to the Study of Diseases of the Nervous System. 31
imtabilitjr entire ; it is not excited immediately like the movements of irritability, but
mediately in a reflex coarse, through the medulla, from the part stimulated to the part
moTed.
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, preserying 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
convQlsion, 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 inhaling 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 iremain after the sources of the motive influence lof the voluntary and respiratory
motions are removed, with the exception of those of the heart, and other muscles which con-
tract upon the principle 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.
2. 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 fiinction of the different portions of the medulla presides over their corres-
ponding or^ns ; 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 '^Zi/e" 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 of 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 eceenlrie origin :
** One of the mott interesting medical sabjects, in relation to the reflex ftinction, ia that of dentition. Dentition
ii a aoTt of natanU experiment upon this ftinction. The general oonmlsion, the strabismus, the spasm of the fingers
and toea, the cronivlike affection of the resplmtlon, the repeated vomitings, the tenesmus, the stranffury, the invol-
antary dlschaige of urine and of the flnces, fh>m its operation, denote the influence of irritation of the maxillar}'
aerrca, through the medium of the medulla oblongata, upon the muscles of voluntary and respiratory motion of the
eye, the larynx, the sphincters, etc., in the human subject, and indicate so many arcs of the reflex functions. * *
** With the elTects of dentition in inflmts, some affections of the adult may be compared as chorea, some forms of
epilepsy, and some forms of asthma. The diseases to which these designations have been given, vary exceedingly in
dlflerent instances ; inasmuch as some cases are of centric and others of eccentric origin. * *
** l^yilep^ is plainly of two kinds : the first has a cenMc origin in the medulla itself; the second is an affection of
the reflex function, the exciting cause being eccentric, and acting chiefly upon the nerves of the stomach or intes-
tinee, which conseqnentiy form the fiist part of the reflex arc. * *
** True asthma, vis : that form of this disease which occurs in youth, and assumes a distinctiy spasmodic form and
oonne, like so many other morbid conditions of the reflex ftinction, f^uentiy arises from gastric or intestinal irri-
tation. • •
" With the effects of dentition, those of gastric or enteric irritation, in their multiplied forms may be compared.
" Teneemus and strangury are aflTections of other arcs of the reflex functions. * *
** Tetanus and hydrophobia appear equally to result from injuries inflicted upon the extremities of certain nerves,
by means of which the morbid influence is conveyed to the medulla, whence it is reflected through the motor nerves
to tiie muscular system. As tree lancing of the gums in dentition, so the early division of the wounded nerve or
amputation in tetanus, has at once checked the morbid affection. * *
** Certain poisons as strychnine, induce excess in the reflex function ; other poisons as the hydrocyanic acid, des-
troy it altogether. In both cases the musrular irritability remains perfect and undiminished. It is probably through
(he medium of the same functions, that many other poisons act upon thd animal economy.** * *
It is evident from the preceding analysis of the first paper of Dr. Marshall Hall, on the
Refiez function of the nervous system, that Professor Trousseau is to a certain extent in error,
when he claims for Professor Graves the honor of having anticipated by many years the dis-
coveries of Dr. Hall.
In Professor Trousseau's criticism on the ** Clinical Lectures on the Practice of Medicine hy the
late Robert James Oraves, M. D. F. R. 5.," etc.^ he-makes the following statement :
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32 Introduetion to the Study of Diseases of the Nervous System.
" On the other band, I cannot rafilciently commend the peniaal of the lectures, which treat of panOyMs; dk«y
contain a complete doctrine, and this doctrine hat deciffivelj trioraphed. The sympathetic paralyeef of Whytt and
Prochaaka, have now their place aseigned in science, under the much more physiol^cal name of reflex paralyses,
and the Dnblln professor is the first who has studied with exactness their ettological conditions, as he is the first who
has made known their pathogenic process. Anticipating by many reari the admirable works of Marshall Hall, he
has comprehended, he has seen that %n<Mnalous peripheric imprnuons may react upon any section of the medulla,
and determine at a distance disturbance of movement 6r of sensibility ; he has in a word, created the class of peri-
phericor reflex paralyses, and has clearly established the relations existing between these panlyses and aeate
diseases/^
" Unhappily, these remarkab e lectures have remained a sealed letter for the minority of French practitionets ; bat
it is time to render to the physicians of the Heath Hospital the Justice which is due to them ; it ought to be known
that Graves is the creator of this new doctrine, which has profoundly moJifled within a few years, the pathidogy of
the nervous system ; it is right, in fine, to refer to its true author the suggestive theory of the paralysis and the convul-
sions of peripheric origin."
The claim thus advanced by Professor Trousseaa, in behalf of Professor Grares, is wholly
untenable, as the first edition of the Clinical Lectures of the latter, was published in 1843, ten
yeays after the publication by the Royal Soci ty of Dr. Hall's paper.
The yiews expressed in the first paper of Dr. Marshall Hall, were finally expanded into
his elaborate work On the Diseases and Derangements of the Nervous St/stem, published in 1841.
The following \9 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 Hull, the nervous system must be divided into
I. The Cerebral, or that of Sensation and Volition
II. The True Spinal, or that of the Movements of Ingestion and Bgestion ; and
III. The Ganglionic, or that of the Movements of the Internal Muscular Organs, of Nutri-
tion, Secretion, etc.
TABLE OF THE NEBV0U8 SYSTEM.
I. The entire Nerwm»Sif$lem1*diKi$a>UU»lo
I. The Cerebral.
II. The True-Spinal.
III. The Ganglionic
II. The Cerebral Bgelem i»
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 Fstigue.
III. The True SpimU Sgdem.
y Mixed Functions.
Mixed in the <B»-
ph gus: the Rec-
tum.
I. The principle of Action is the Vis-Nervosa.
II. ItB Modes of Action are excited, and reflex or
direct.
III. The Reflex Functions are those of
1. Ingestion and Retention.
2. Egestion and Exclusion.
IV. The Direct Functions are
1. The Tone ) of the Muscular
2. The Irritability j Fibre.
IV. The OottgUoHic Syttem,
I. The Principle of Action is the Vis-Nnnrosa.
II. The Mode of Action excited, direct or imme-
diate.
III. The Functions those of
1. The Internal Muscular Organs.
1. The Heart and Arteries.
2. The Stomach an4 Intestines.
2. Nutrition.
3. Secretion, etc
V. The Sffitlem of Emotttmti^ theee are
I. Psychical Affections, acting through
II. The True Spinal, and
III. The Ganglionic Systems.
The cerfbnd system. «ompri*es ever}' part of the nervous system, which relates to »en»ation and voUtttm^ the nerres
of the «»iMii— the olfactory, the optic, the auditory, the gustatory, the nerves of touch, and the whole of the nerves of
Voluntary motion. Its centre is the cerebrum, including the C4*rebellum ; its sentient nerves run variously from the
organs of 8ens«>, and from the external surfaces, first wiUiout the cranium or spine, and then within the cranium or
nplne to thHt centre ; Its voluntary nerve pursue a similar bat retrograde course ./Vom that centre to the muscles of vol-
untary motion. • • , ^ J ,. , , ,
The oere.*ru-spinal sulnli vision of the nervous system, or as it would be more correctly deognated, the cerebral, is
the system of tteneation and volition. It is the system by which wi» are connected mteOechMOy with the external world.
It Is that by means of which we fei-l and perceive external objects, and by which we approach them and appropriate
them to our use entirely. My flnjcenj being In contact witli any object of moderate size, I feel, I perceive it, and by
an act of volition, I raise It fh>m tlie table. This apparently simiile op ration, required three portions of anatomy:
1. ('ertain nerves must proceed continuously, uniiUemiptedly, /rom the points of my fingers to the oerebmm, the
centre of this system ;
2. The cerebrum must be in a state of Integrity ;
a. Certain nerves must proceed fyoui the cerebrum to the muscles which are to be called into action.
There are, then, Uco sets of cerebral nerves ; at least there are cerebral nerves having two fnnrtione.
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Introdueti^n to the Study of Diseases of the Nervous System.
33
From tbe experiments of Sir GhArles Bell, BnsUined and extended by those of Professor MUiler, we msj conclude
that
L The AfluiglioBic nerres are the Tolnntary or motor nerves.
2. That the caagUa or general colamns are the centres of the incident and reflex nerves, and of the reflex actions.
It iisMisi to be ascertained whether the tmtiemi nerres belong to the gamgUomic colamns ; bat this seems most prob-
able. «
The osraftraj; er wmHtml er wuhifsrf division of the nenrols system, comprehends,
I. Sentieat nerres, leading to the posterior roots of the ttf&da] and spinal nerres, and the posterior colamns of
therainal marrow.
IL The cerebrnm, the centre of the qrttem.
HL Tlie Tolontaiy nerres imning from the anterior colamns of the spinal marrow and the anterior roots of the
trifMial and wpimal nerves.
The pkjfmalogg 0/ Ike emrtbnd ffitota, comprises sensation in all Its forms, perception, jadgment, volition, and volan>
taijModon.
"Rm senses are the smell, the sight, the hearing, the taste, the toach ; they convey to the mind all that we know of
the external world. Perception is derived from Aese. Jadgment is a parely mental act 80 is volition ; and of this
volantary motion is a Areqaent result. The motions Which result fliora sensation generally imptg volUiom ; but as voli-
tion m^ extot witiioat any previous sensation, the voluntaiy motions frequently are, and mag b« at any time upomta-
SensaMoB or some effSBct of the impression which produces it, must be oonveyed by an appropriate nerve uninter-
rupted to the cerebrum, — to the soul ; and thence the act of volition must act through a voluntaiy nerve, equally
■aiattrrupCed In Its course, fhim the cerebrum to the muscle or muscles to be moved. Thus we have a nervous arch,
«f which the cerebrum Is the kc^ystone.
Many attempts have been made to UoaiUe the fiin^tion of the cerebrum ; that is, to prove certain functions to be
attached to certain parts of that organ ; without, however, much success. The facts supplied by pathology certainly
lead OS to the conclusion that the hemispheres of the cerebrum and cerebellum regulate the vdUmkurff movements of
Che oMurfte side of the body ; whilst the medulla oblongata and spinalis eowMy the influence of stimuli to the corres-
ponding side. It has been asserted, ftrom similar fkcts, ^t the anterior lobes of the brain govern speech ; the cor-
pora mata, the inferior extremities ; and the thalaml. the superior extremities ; but these deductions are not snfll-
dently substantiated. The same remark must be made relative to the supposed connection between the cortical por^
tioa of the cerebrum and the intelleetaal fkculties, and the cineritious portions and the movements.
Tki\\\U$m oftkt Otrdnvi Bgtltm. The cerebral system being the system of the sensations, of judgment, of volition.
It is to it tkMX we must refer all morbid conditions of these mental acts or functions. Every derangement of the
flsnsM, every form of diierium or of coma, or of perverted Imagination or judgment, every act of violence must be
refBcred to the condittoa, ptimaiy or secondary, or the cerebrum or cerebellam.
THE TRUE SPINAL OB EXCITO-MOTOBY STSTEM.
This systeut, formeriy confonnded with the cerebral, under the designation of cerebro-splnal— -this system as a
rstcfli, Pr. Hall considers as having been entirely elicited by bis own laborious and persevering researches.
Jib ■■■fnwif laooloM a wgattem of iflrlssf, amd rttfiex aerset csiierterf ¥)Uk (ke lrme-«pUnd fmanrote «• tt««r cemtte ; mmtmovm.
IUpkgtiologgoomiiM»i» JwKiSoiu,aU0/vhiekar«performtd Utrough^ Them fuaetiotu e&mpri»e aU
Ifeodii e/immttomj o/rvtealioa, o/cj^paWsa, aad «/exalMioa, U Uu cuUmal eoonomg ; tkegareOum^ tker^fore^ouwhidk depend
L TheFretervatioH0/the OMeidmai, <md
II. The Carfi— «M« e/tke SpeeieK
AM tkam/wmdiom are re^fiex'tipimal fmmoUom 0/ toJbidk One idea did met formerly exhd ; ite pri$tciple 0/ aelioH in the vie-nervota
of BaBer, a imUor power, o/telueh^ there waa preeiomdjf no applieaUom le phg^iologp whatever; it» pathology oomprimm the
uhele dae$ 0/ ^Memedie dimmwet, amd ilt $mb-dicieiom iaio fkoee •/
L Incident.
J. Ceanric ,
Z. Beflex Origin.
TABLE OF THE ANATOMY OF THE TRUE-SPINAL STSTEM.
I. The Incident Motor Branches.
1. The TriAicial arising flnom —
1. The Eye-Ushes.
2. The Alse Nasi.
3. TheNostriL
4. The Fauces.
5. The Face.
!i The Pnenmogastric from
1. The Pharynx.
2. The Larynx.
.1. The Brondila.
4. The Oardia, — Kidney, and Liver.
3. The Glosso Pharyngeal?
4. The Posterior Spinal, arising from—
1. The General Surfhce.
2. The Glaas Pepis and aitoridis.
.'). The Anns.
4. The Cervix Vesicse.
5. The Cervix Uteri
III. The Reflex, Motor Branches.
The Trochlearis ) /»^^i,
TheAbducens. ;^""-
The Minor portion of the fifth.
The Facial, distributed to
1. The Orbicularis.
2. The Levator Also Nasi.
The Pnenmogastric or its Accessory.
1. The Pharyngesl.
2. The (Esophageal and Cardiac
3. The Laryngeal.
4. The Bronchial, etc
The Myo-clossal.
The Spinal Accessory.
The Spinal, distributed to the
1. Diaphragm, and to
2. The Intorcostal and ) TLr«-«i^
3. The Abdominal | Muscles.
The Sacral, distributed to
1. The Sphincters.
2. The Expnlsors, the E^laculators,
the Fallopian Tubes, the Ute-
rus, eto.
3
1.
*
2.
,r
3.
4.
li
!i
5.
?i
i's'
0 ^
e.
3 g
7.
2»|
8.
t%
00 9
«-< D
9.
3. a*
3 St
• 8.
All tiie nerves represented on the left side of this table are iRcideaf mfAar nertw. Some of them are mniimd; but
whether sentient or not diey are demonstrably excUo-motor, and whilst they are motor, they are incident. Reeplrii-
tion hss its primiom mobile In i$icidettt excUcMnotory iterim. By the cerebral system, we are placed In relation to the
external world pefehieaUg or mentaUif; but by the true spinal sy8t«m we are placed in a similar relation phg$iealljf. As
b; the former we imbibe all our Ideas, so by the latter we appropriate external otijecte to our very substance. On the
tree spina] system all ingestion, all retention, all expulsion, in regard to the animal frame and economy depend.
Cveiy such act is a tpimtu act, a true spinal act, reflex in its form and character, accomplished through the medium of
the iaddent and reflex nerves, and their connecting centre the true spinal marrow, and by the agency of the tie-itertoea.
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34 Introduetion to the Study of Diseases of the Nervous System,
TABLE OF THE PHYSIOLOGY OF THE TKUB SPINAL SYSTEM.
I. The Excited AeHtm--
1. Of |he Eyes, the Ihre-llds ; (and of the Iris?)
2. OftheOHnc-. {\ "S^SS^Jx.
3. Of the IngoBtion.
1. Of the food.
1. In Suction ;
2. In Deglutition.
2. Of the Air, or Besplration.
8. Of the Semen, or Conception.
4. Of Exclusion.
5. Of the Expnlaors, or of Egestlon.
1. Of the Pieces;
2. Of the Urine ;
3. Of the Perspiration ;
4. Of the Semen;
6. Of the Foetus, or Parturition.
6. Of the Sphincters.
1. The Cardia.
2. The ValruU Ck>U ?
3. The Sphincter Ani. *
4. The Sphincter Vesicsi).
II. The Dired Action or Ii^fluemce—
u: li;SelSSibnity,}<>'«»""«^8^»««"'-
The true spinal marrow may be correctly viewed as a distinct orgam, totally dilTerent in its properties and fnnctlons
from the cerebrum, and as the centre of a distinct system of nerres, diflTerent from the sentient and volnntaiy, and
pofweflsed of a peculiar and special motor power, which acts in incident as well as reflex directions for special pozpoMs
—Judging entirely fh>m experiment. It mav be receired as a principle that ereiy part of the nenroos system, wtai^
i» endowed with the exdto*motory pownr, belongs to this system, whether this power be excited in the dinction ot
the nerves yrom or towatrdM the nervous centres. * . * Each nenro of the excitonnotoiy system, with the exceptfoa
porhaps, of the pneumogastrio, is a compound nerve, having a cerebral, as well as a true spinal origin. * * The
most usual eflTect produced by stimulating incident nerves, is a motion of the limbs. But in other instances we have
acts of inspiration, of deglutition, of expulsion, of closure in the eye-lids, lamyx, phamyx, and the sphlndefs :—
interesting ibcts, which speak a physiologiGal language, and assign distinct and q>ecial oflloes to certain excitor-oerves
THE PATHOLOGY OF THE TBUE SPINAL SYSTEM.
The abnorflial and morbid actions of the vie^itervoea or exeUo-moloiy power, obey the same laws as in health.
The morbid stimulus may act upon the incident, the central, the reflex part of the excito-motoiy axe or arcs, and
Sroduce corresponding eflTects— corresponding diseases. To use words funUiar to the physiologists of Germany, we
ave a class of centripetal, central and centrifugal diseases. We may have centripetal or central epilep^, aiid we may
have spasmodic tic, and other affections, fhnn an affection of the reflex motor nerves.
In this manner, the clam oftoamnodio diaetuee is sub-divided into three sub-classes, a division of the utmost importance
in practice, and illusrated in the following table.
TABLE OF THE PATHOLOGY OF3THE T»UE SPINAL SYSTEM.
I. Diseases of the Incident Nerves.
The Growing Inspiration.
I. 1. Dental. I Irritation I 2. Strabismus, Spasm of the Fingers and
2. Gastric V in J Toes; Strangury; Tenesmus; etc.
3. Intestinal, i Infants, i 3. Convulsion.
) V.4. Paralysis?
\ C 1. Hysteria.
II. 1. Gastric / Irritation \ II. Asthma.
2. Intestinal. >■ in -< III. Vomiting; Hiccup; etc.
H. Uterine. \ Adults, i IV. Epilepsy.
J V. V. Puerperal Convulsion ; etc.
III. Traumatic Tetanus ; Hydrophobia ; etc.
II. Diseases of the Spinal Marrow itself.
I. Inflammation and other Diseases.
II. Diseases of the Yertebm and Membranes.
III. Counter-pressure, etc, in Diseases within the Cninium.
IV. Centric Epilepsy, Tetanus, etc.
V. Convulsions fh>m Loss of Blood ; etc
III. Diseases of the Reflex or Motor Nerves.
I. Spasm. II. Paralysisw
1. Spasmodic Tic.
2. Torticollis.
3. Contracted Limbs ; etc.
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Introduction to the Study of Diseases of the Nervous System. 35
00*
2
a
I If rrr f--.- lit
A 3 ^* 's n S
«e5 2 55 a
TABLE OF THS ACT OF VOMITINa
I. The Exciton and Motors which clo«e the Larynx,
n. The Exciton and Motors which open the Gardia.
III.
I. The Excltors, IL The Centric III. The Motors,
Organ
of Expiratory Effort.
i. The Facial branch of the Trifacial. j, • The Spinal nerves distributed
!. The Gastric, Benal, and Hepatic branches of Uie 0 § I. To the intercostal and
PneqmogasUlc. ® ^ • i. To the abdominal muacles.
t. The InteetiBal or Uterine branches of the Spinal X ® &
nenres. J ^ ^
Dr. MaiBhall Hall thus concludes his obserrations on the nerrons system in generaL
TUs 98tem is divisible into
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36 Introduction to the Study of Diseases of the Nervous System.
1^ The cerebral, or physicRl, or that of our relation to the external world mmUaUp.
II. The tme-BiHnal, or exdto-motorr, or that of the reflex action of the viMiervoM, or of oar appropriation of
certain ot(fecit$ of the external world pkymoatlff and in nuu$e$ ; and
III. The ganglionic, or the system of ittUmmal^ or ehmiical^ at atomie dianges of nutrition, secretion, etc., also
under the immwluite influence of the vi»-nerw>»a.
IV. Intermediate between the /Irti and $eeond of these is the influence of tmotUm^ pamUm. tie.
Y. Intermediate between the aecond and (Mrd are the Internal muscular organs, the neart, the stomadi and
intestines, etc.; and these are under the tmtMtHaU influence of the vU^»ervom and the irritabilUif of the muacular fibi*.
YI. Lastlv, the tone and irritability of the general muscular system are c<nutamt, and direct effects of the tnte-apioal
and ganglionic systems, and of the vm-mttom. Oft the dieeaeee and dercmaemetUe of the nervoue tytCem, im their prwmmrf
fonna and in their mod^cattone^bft age, tex^oomttitulionjhereditarjfpre'ditpoeitymtexcem diwrden and organic dimem;
by HaiBhall Hall, H. D., etc. London, 1841, p. I to 130.
It would be foreign to the object of this Historical Outline to extend the preceding analysis
to the application bj Dr. Ball of his views to the various diseases of the nervous system and
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 term reflex, by Dr. Rail, it has been observed by certain
critics upon his labors, that the same expression occurs in the works of Haller, Unzer
Prochaska, Fred. Arnold, Treviranus and others. I have already endeavored to do full justice
to the labors of Unzer, 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-theil
det vegetcUiven Nitrvenaystems, published in 1830, makes frequent use of the term reflexion ; thus
his experiments induced him to admit, that the action of light, does not take place immediately
upon the retina, but that it is reflected through the nervous expansion in the eye to the iris,
and that this biringitig back of the stimulus of light takes place through the brain. He also
distinguishes the motions of the tympanum which arise in consequence of an irritatio'n
reflected 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, he also accounts for on the principle
of reflexion. We fail to perceive in the views of Arnold any advance on the observationa
of Prochaska, who alludes to a reflex 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 views 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 known that the life of certain animals may continue for some time without
|i 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 fly 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 head 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 Irog 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 af«er 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 Mctions, 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 intervention of the sensorium commune, and
therefore withont sensation or consciousness. Trevirnnus ^s induced by experiments such
as these, to deny the assumption that the faculty of associavion is merely a property of the
brain. Le Gallois, states it as a well-known and proved fact, that birds, whose heads 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 his memoir published in 1812, also states 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 movements
* Professor Bellingeri's doctrine of nerwme antagonism, discussed in his **Oh»ertaaioni Pathologieke,^' bean worn*
resemblance to Dr. Marshall Hall's reflex function.
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Introduction to the Study of Diseases of the Nervous System. 37
betweeo the Anterior parts posterior to the section of thft cord; tnat is to say that, if the
tail, or, indeed, one of the hind-feet be pinched, 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 1B22, stated, that, in wounds of the spinal cord, the animal suffers pain and
Gonrulsions ; 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
mascles to which the nerves derived from it are distributed. The animal does not suffer pain,
for it has 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 from it, but
if the spinal cord be entirely destroyed in the interior of the vertebral canal, the paralysis is
perfect. (Rechercbes, exp^rimentales, sur le syst^me nerveux.) About the same time Mayo,
thus described the reflex function of the spinal cord.
"On the one harfid it is dear that an influence independent of the will, occasionally tbrowg Toluntary musciee into
actkm, M appean in tetanos and other spRsmodic dieeasee : and is shown remarkably in the pbysiologiod experiment
of iiritatlng the akin on the lower extremities, after the diYislon of the spinal cord in the back, when the occnrrence
ot action limited to Uie mnedes of the inferior extremities evinces that a connection exists Independently of the will,
between sentient snrfiaces and the action of voluntary muscles. I have varied this experiment by dividing the spinal
cord at once in the neck and In the back, npon whidi three unconnt* cted nervous centres exist ; and the division of
thedcin of either part (and especially at the soles of the feet, in the two hinder portions) produces a convulsive
action of the muiclee of that part aloue. The same influence may, ^*
to which these remarks relate." Anat. and Phys. Comm., Mo. 11, I8S
It has therefore with some reason, been affirmed, that the facts by which Marshall Hall
supports bis theory, were well known long before his time, and were employed to throw light
upon the functions of the nervous system.
It must be admitted however that great obscurity and confusion prevailed in the statements
ot most of the writers before his investigations, and the idea of an incident motor nerve did
Dot 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.ition and experiment,
logically connected and to a great extent adapted to the wants of the physiologist, patholo-
gist and practitioner of medicine and surgery. The labors of Dr. Hall have thrown a flood
of light upon many nervous diseases, and have tended to introduce order and harmony into
this difiBcult department of medical science.
Decided proofs that the reflex movements are independent of sensation have been afforded
by certain 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 faeces, will produce convulsive movements of
the feet and legs, even though they be perfectly devoid of voluntary power and sensation.
The first cases* of this kind adduced in illustration of the theory of reflex movement, 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 the 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 contents of the bUdder and rectum are expelled,) should be influenced by
volition, and that this of course, could only be accomplished by associating sensation with
the excitation of the impression.
Among the Germans the eminent physiologist J. Muller was the flrst who advocated the
reflex theory of Marshall Hall, and by some writers the discovery of the mechanism of reflex
action, has been given to both these physiologists ; but aside from the fact that the labors of
the 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 makes
no special claim to priority in this discovery, although conducting his researches indepen-
dently of, and differing on cenain points from Dr. Hall.
The views of Professor J. Miiller, may be thus stated, as finally matured and presented in
the second edition of his great work on physiology, J and after he had (as is evident from his
statement) carefully examined the works of Dr. Hall.
When impreuione made by the action of eztemal stimuli on sensitive nerves give rise to motions in
other ports, these are never the result of the direct reaction of the sensitive and motor fibres of the nerves
* BalTs Memoirs, p. GJ, Mr. Qranger*s Observations on the Spinal Cord, p. 93, Dr. W. Budd, Med. Chlr., Trans, vol.
zxU.
t Elements of Physiology by J. MUUer. M. D. Ist Ed. Trans, by William Baly, M. D., Vol. I, p. 721.
X Bleaents of Physiology, tid Ed.. London 1840, Vol I, pp. 754, 778.
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38 Introduetion to the Study of Diseases of the Nervous System.
on each other ; the irritation is eonoeyed by the sensitive fibres to the brain and spinal cord, and is by
them eomnwiicated to the motor fibres. The experiments detailed by Professor Muller, in support
of this proposition, render it evident that the general spasms excited in animals bj touching
points of the snrface, do not depend on a communication between the sensitive and motor
fibres in the nerves, but upon the fact, that the spinal cord is the essential link between the
centripetal impression conveyed by the sensitive fibres, and the centrifugal inluence of the
motor nerves. The facts established experimentallj by Muller, prove likewise, that the pheno-
mena of general spasms, thus excited, are not dependent on the sympathetic nerves, but that
they are owing to an irritation of the spinal cord, by virtue of which every impression con-
veyed to it by the sensitive fibres, even though quite local, is propagated through the whole
spinal cord and brain, and thus necessarily excites all the motor fibres given off from them.
The state of irritation of the spinal cord, here referred to, may be produced by the following
Qauses : by the mere division and contusion of the spinal cord; by. the action of certain
ppisons, as nux-vomlca ; by such causes as produce exhaustion of the brain and spinal mar-
row, by excessively exciting them ; severe local irritation of a sensitive nerve may, by the
intensity of the impression conveyed to the brain and spinal marrow, give rise to twitchings
of th^' muscles and tremors, as in severe local burns, extraction of a tooth, &c.; local irrita-
tion orf the nerves, from inflammation or ganglionic enlargements, frequently give rise to
general spasms and even to epilepsy ; irritation of the spinal cord, arising from local excitement
communicated by, sensitive fibres, as in traumatic tetanus ; great irritation of the sympathetic
nerves'in the intestinal canal, as in cholera and the Intestinal affections of children. Such
facts merely lead to the admission of the law, that whenever general spasms are excited by
local impressions, the phenomena depend on no other communication between the sensitive
and motor fibres, than what exists in the spinal cord. In very many cases, however, local
irritation of the nerves gives rise, not to general, but to local muscular spasms ; in this case
agaiii, according to Muller, the spinal cord is to be regarded as the band of communication
between 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 sanfe 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 influence of
light, the contractions ot 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 sensoriar impressions and the movements, the contraction of the
glottis and air passages excited by the contact of irrespirable gases, the movements of deglu-
tition, and the contractions of the sphincter ani and sphincter vesicae ; in spasmodic movements
of the organs of respiration, as sneezing, coughing, hiccough, vomiting, &c., in contraction
of the diaphragm and abdominal muscles, induced by irritation in the intestines or urinary
organs, and in the expulsion of the foetus 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 affects 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 is
reflected upon almost all the nerves of the trunk.
The preceding is the view of J. Muller as given in the first edition of his work, published
in 1833 and 1834, and it would appear that this theory was elaborated without any knowledge
of the labors of Marshall Hall.
Professor Muller agrees with Dr. Hall, as to the reflected motions which occur after the loss
of the brain, being no proof that stimuli applied to the skin are still able to excite true sen-
sations in the spinal cord ; the ordinary centripetal action of the nervous principle takes
place in these cases just as when sensations are produced, but here It does uot give rise to
sensation, since it is not communicated to the brain, the organ of consciousness. During life,
also, and in the state of health, many reflected motions are excited by impressions, which are
not, as true sensations, communicated to the sensorium, but nevertheless exert a strong influ-
ence upon the spinal cord ; as for example, in the case of the irritation of the faeces or urine,
exciting the contractions of the sphincters. But Professor Muller held that Dr. Hall goes
too far in admitting that, in the healthy state, every motion which follows true sensation is
voluntary, and that all irritations of sensitive parts which give rise to reflected motions are
unattended with sensation ; for the reflected motions of sneezing, coughing, and many others,
are consequent on true sensations. The rejected motions, and the involuntary not reflected
motions, must not be confounded with each other. If the glottis of an animal be touched,
says Dr. Hall, it contracts; 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 lon^r be mide to contract, while the action of the heart continues even after
the removal of the spinal cord. The heart is affectf^d immediately on the application of any
dttmulus, by virtue of its trrit ihility ; the impression mile by a stimulus applied to the larynx.
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Introduction to the Study of Diseases of the Nervous System. 39
on the contrary, must be propagAted to the medulla oblongata, and the contraction is effected
iodireetlj through the medium of the latter part.
It resalts from the foregoing obsenrations that spasmodic affections of the mnscles occurring
in diseased states, may have very different sources. There are spasmodic affections of which
the cause is seated in the motor nerres themselves, or in the bram and spinal cord ; but con-
Tvlsiona may also arise from the reflex action of the nervous system, their canse being
irritation of the sensitive nerves. Of the muscular spasms of the latter kind ve have instances
frequently occurring, in consequence of intestinal irritation, in dentition, odontalgia, and
from painful affections of the nerves generally, whether these be dependent on organic lesions
or not. X
All the phenomena hitherto described, agree according to Muller in the circumstances of
the spinal cord being the medium of communication between the centripetal nervous action
produced by the exciting stimulus, and the subsequent motor action of the nerves ; but the
different *< paths" of communication in the spinal cord may be more distinctly. defined. The
most common form of reflected motion is that, when violent impression on sensitive nerves
excites mnscnlar contractions in the same limb ; this is observed when the skin is burned,
sod in the first stage of narcotization of an animal, a stimulus applied to the skin excites con-
tractions most rapidly in the irritated parts ; thus also the stimulus of the food in the fauces,
excites the act of deglutition; dust on the conjunctiva, closure of the eyelids ; and irritation
of the urine and fseces, the contraction of the sphincters, fience, irritation propagated to
the spinal cord must readily affect those motor nerves which arise neatest to the roots of
the exciting sensitive nerves ,* in other words, that it is most prone to pass from the posterior
roots, or the 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
influence of the spinal cord is strongly excited by a sensitive nerve, that part only is affected
which is nearest to the root of the nerve; and the irritation of the cord, and of the motor
nerves arising from it, diminishes in proportion with the distance from that point. In the
tune way, in the brain the irritation is communicated from certain sensitive to certain motor
nerves. Thus the optic and acoustic nerves, and the sensitive branches of the fifth neive,
are prone to excite reflex actions of the ciliary branches of the third pair and of the facial
nerve. The sensitive and motor nerves which thus react on each other through the medium
of the brain and spinal cord, seem to stand in such a mutual relation, that a change in the
condition 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 the fluid in one branch of a bent tube makes it rise
in the other. The form of reflex action next in frequency to that just described, is the pro-
dnction of spasmodic contractions of the respiratory muscles from the irritation of the
moeous membranes. Hence, there must pre-exist in the medulla oblongata and spinal cord
some means of ready communication between the sensitive nerves of the mucous membrane,
(the fifth nerve of the nostrils ; the vagus nerve in the trachea, lungs, pharynx, cesophagus
and stomach ; the 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 (the facial accessory, and certain spinal nerves,)
on 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 the spinal cord and brain,
produced by the action of narcotic poisons, or other causes, in which every impression on a
sensitive nerve is capable of exciting the spinal marrow to a discharge of motor influence by
aU the motor nerves, even by those which are least prone to be affected by reflex action, —
namely, the motor nerves of the extremities. Volknfann has shown that even dividing the
spine longitudinally does not prevent the extension of the reflex motions to the muscles of
both sides of the body, so long as the two halves of the spinal cord remain connected at any
one point.
With reference to the question, how far true sensation is engaged in the production of the
reflex motions, Volkmann inclines to the opinion of Whytt, that the motions consequent on
iiBpressions are the result of an appropriate voluntary reaction of the sensorium excited by
sensation ; and Muller holds that this is indubitably the case in many instances, as in those
reflex phenomena which occur in an unimpaired state of the brain and spinal cord, vik: the
closure of the eyes under the stimulus of a strong light, and the action of the respiratory
mnicles induced by irritation of the mucous membranes of the respiratory organs, intestinal
canal, or urinary system. But the continuance of reflex actions, after division of the spinal
cord into several portions, each part if it still contain a fragment of the spinal cord, still
evidencing reflex motions, indicates that the preceding view is not applicable to all cases.
The reflex phenomena are observed also to occur in parts withdrawn from the influence of the
will, such 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 narcotization, do not in the slightest degree
^ resemble the phenomena of spontaneous reaction
Xiiller thus expresses his view of the reflex actions : — Irritation of tmm'tive fibret of a tpinal
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40 Introduction to the Study of Diseases of the Nervous System.
neroe excites primarily a centripetal action of the nervout principle^ conveying the impre$9ion to the
tpinal cord; if this centripetal action can then be continued to the tentorium commune, a true sauati^m
is the result ; but if on account of division of the spinal cord, it cannot be communicated to the senmnimmj
it still exerts its whole influence upon the spinal cord. In both cases, a reflex motor action may he ike
result. In the former case, the centripetal action excites, at the same time, sensation ; in the latter eate
it does not, but is still adequate to the production of reflex motion, or centrifugal reflection,
MuUer affirm^ that Dr. Hairs theory differs from that of Whjtt, as well as from his own,
and is pecaliar. In the first place Dr. Hall, limits the phenomena of reflex action to the
spinal nerves, 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 bj sensation, nor even bj means
of the nervous fibres. He maintains the existence of special nerves, or nervous fibres, endowed
with the ** excito-motorj " function ; and the reflex action he supposes to be conveyed, not bj
the nerves of spontaneous motion, but bj special fibres, which he calls '* reflecto-motory."
The posterior roots of the spinal nerves, and nerves of the medulla oblongata, according to
Dr. Hall, contai^n sensitive and excito-motory fibres, ; the anterior roots spontano-motorj and
reflecto-motorj fibres ; the vagus, too, he regards, not as a nerve formed cbieflj of sensitive
fibres, but as an excito-motory nerve ; for in an experiment performed bj 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 painful sensations.
Miiller distinguishes two principal grounds of reflex motion t —
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 prodnced
in the animal or organic nerves, in the external skin, or in the intestinal canal.
2. Reflex mptions 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 and spinal marrow from cerebral and spinal nerves, or may have proceeded
from organs, which are provided from the organic nervous system.
The laws of reflexion, which were established in the case of the cerebro-spinal nerves, hold
good, according to MuUer, 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 nerves. 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 norves. The reflexion also of efl'ects or actions, which
proceed from the cerebro-spinal nerves, are transferred to the spinal marrow, and from thence
to the sympathetic nervous system. A reflecting power in the ganglia, in the case of sympa-
thetic sensations, according to Miiller, 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 clearly to understand Muller'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, up wards in the spinal mar-
row, and 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 from the medulla oblongata. It may be supposed that, in this
part of the brain, the fibres of all the motory cerebral nerves and of the spinal nerves are
unfolded. The will puts these fibrilous 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. Mflller designates the brain as the source of sensations and voluntary
motions, when he says : the brain receives the impression of all the sensitive fibres of the en|ire
system, becomes conscious of them, and knows the place of the sensation, according to the
affection of the various primitive fibres ; the brain again excites the motory powers of all the
motory primitive 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 to Muller,
bears exactly the same relation to the brain, that all 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 still 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
fibres of t'le nerves of the trunk. The primitive fibres of the nervous stocks which enter
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Introduction to the Study of Diseases of the Nervous System. 41
into the spinal marrow, proceed in a direction parallel to each other, as in the stock 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 MuUer, if the primitire fibres of the nerves were bound together in the
spinal ' marrow, a local sensation in the trunk would be just as little possible, as a separate
ftod isolated contraction of separate muscles in the trunk. The seat of the sensations, is
neither in the nerres, which bring to the brain the oscillations or yibrations of the nervous
principle, necessary 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
serres not only as a conductor of the fibres of the nerves to the lirain, but appears also as
put of the central organ. As such it possesses the power of reflecting the sensorial irrita-
Uons 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 possessed by no nerve that is separated from the central parts. The spinal
marrow is capable of reflexion from nerves of sensation to nerves of motion without itself
possessing sensation.
Johann Wilhelm Arnold,* in his masterly examination of the theory of the reflex function,
urges the following objections against the preceding theory of Muller, concerning the
stmcture and function of the spinal marrow.
1. A careful anatomical examination shows no such structure of the spinal marrow, as
described by Muller. In contradiction to his assertions, it may be stated, that the spinal
marrow does not diminish downwards in proportion as it gives off nerres which would be the
case, if it were the union of the primary fibres of the spinal nerves ; the fibres of the spinal
nenres cannot be traced far into the spinal marrow ; the fibres of the spinal marrow, which
can be demonstrated only in the white substance of the same, cannot be traced up to a certain
potDt 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 of
the 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 theo^
concerning the conducting power of the spinal marrow is erroneous ; thus Yolkmann's experi^
ments have shown that a longitudinal division of the spinal marrow does not prevent the
eiteoeion of the reflex motions to all the muscles of both halves of the body, so long as any
one 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 pecnliarly 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 ; the same power still continues with respect to the impres-
sions from without inwards, if the upper part of the 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 the part of the spinal marrow lying below the section.
After cutting out a piece of the spinal marrow on the one side, an impression made on the
sound 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
catting out the 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 this 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-
motory system, and even confessed his inability to do so, he finds it unnecessiEiry to trouble
himself with showing the impossibility of the existence of such a system, by the known
simctnre 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
motionsr; further, that the irritants which affect the sensitive nerves belonging to the spinal
marrow, in like manner, occasion in this central portion of the nervous system, a state which
is followed by motions.
*1He Lehre von der Beflex— Function fUr Pbysiologen und Aerzte ; Dargestollt benrtheilt, von Johann Witbelm
Arnold. Med. Chir. Bev., Jan. 1843, pp. 33, 66.
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42 Introduction to the Study of Diseases qf the Nervous System.
According to Mr. Arnold, the facts, and the conclnsiong immediatelj to be drawn from them,
were long known to physiologists, and only the consequences which Dr. Hall considered him-
self justified in drawing, are new and also anfoanded. 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 each
a system is not sapported 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 ratienal 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 inyolyed 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. Hall, that both processes,
sensation and susceptibility of excitation on the one side, as well as voluntary motions and
reflex motions on the other, are effected 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 muscles. It is accordingly here the organ through which
conscious sensations are chiefly conmiunicated, 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 ai«d power of excitation. For as no portion of the
skin, however small, can be touched with the finest point of a needle, whfbh does not excite
sensation, and at the same time the so-called reflex motions in decapitated frogs, it must be
admitted, as Yolkmann has well observed, that every part of the skin of the size of a needle's
point contains two speciflcally different 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.
^d. 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 observcKl 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 after 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-
vomica 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 susceptibUity 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.
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Introduction to the Study of Diseases of the Nervous System. 43
From his experiments, as well as from the circamstance that the tetanus occasioned hj the
application of the nuz-Tomica still continues if the medulla oblongata is not removed until
after the action has set in, the following conclusion may 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 taken
place the so-called reflex motions still continuing after the removal of the medulla oblongata,
maj be considered as charges of the nervous fluid accumulated from the spinal marrow, pre-
Tiouslj transferred from the medulla oblongata. This view, however, is but partially cor-
rect ; for, besides the structure of the spinal marrow, and many physiological facts, it is\
opposed by the circumstance, that certain agents still act on it after the medulla oblongata
has been removed ; Strychnine, for instance, is still capable of exciting rigid spasms under
fSavorable circumstances.
Muller 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 nervous principle to the spinal marrow. If this can
reach the teruorium commune^ a conscious sensation is produced. But if it does not reach the
9e»$onum eomimme^ 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 flrst
ease, the centripetal action would be at the same time a sensation, in the latter case not, but
it is sufficient 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 Milller, 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 fiacts 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.
From 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 fcuiuUy of the spinal 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
tpinal 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 medulla oblongata previous to decapitation.
6. The degree of the perceptive faculty of the spinal marrow depends on a peculiar dispo-
sition of this organ, which is effected in it principally by the medulla 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.
*l. 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
8. That which takes place in the spinal marrow, during the perception of external influ-
ences, 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 oon-
Bcionsness and freedom of the will are wanting to it, whilst the character of suitableness and
of harmonious 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
nervous system, whereupon these organs re-act in a corresponding manner.
10. A mere transference of the nervous principle from sensitive to 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
ikow that it is In its total character, in its character as a whole^ that it imparts the condition.
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44 Introduction to the Study of Diseases qf the Nervous System.
in which it is placed on the one hand bj the brain and the mednlla oblongata, and on the
other hand by the nerves. After what has already been said, it can no longer be admitted
that the fibres of the spinal marrow conduct impressions separately and isolated! j, jast like
the nenrous fibres.
12. It is not the number of the muscles moved that the central organ determines, but tbe
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. Rev., January, 1843, pp. 33-55.)
It is evident therefore that the theory of Dr. Hall, that the nervous fibres engaged in the
production of the reflex or excited movements, are distinct from those which reach the centres
pf sensibility and volition in the brain, was not established by the facts which he hinoself
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. Sooie
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 by 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
Bellingeri 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 tbe accordance of Dr. HalUs 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 the reflex motor influence ; the principal sets of organs with which such ganglia are
connected 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 of 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. Yet, even where this is the
case, as in the higher MoUusca 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 f^om 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 tbe
impressions destined to produce sensations. Thus the nervous cord in the arm of the Cuttle-
fish, is composed, according to Dr. Sbarpey, of two fasciculi of fibres, in one of which ganglia
are formed at points corresponding to the prehensile suclters, 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 may act in unison,
these reflecting ganglia are connected by a fasciculus of commissural fibres, while at tbe 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 tbe
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Introduetian to the Study of Diseases of the Nervous System. 45
cephalic ganglia. The same remarks apply to the abdominal nervous cord of the Articalata,
which has been shown bj Mr. Newport (Phil. Trans., 1834) and Dr. Qrant, (Lancet, July, 1834),
te 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 voluntary power, while the inferior fasciculus has the function of
connecting the diiferent locomotive ganglia, for consentaneous action. In like manner, a part
only of the fibres given off by the nervous cord is supposed to reach the cephalic ganglia
through the medinm of the superior fasciculus, while another portion terminates in the local
ganglia which form their reflecting centres.
These views 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
describes and figures the fibres of the nerves which enter each ganglion of the ventral cord,
as being continuous in part with the longitudiual 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,
had found 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 iateral 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 h^ 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 prove 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
cUsses.
That the ventral 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 Uie abdominal cord just below the thorax, irritated the superior fasciculus of its
lower portion ; muscular movements were very frequently excited. He irritated the infe-
rior fiucicul us; no such result followed. The strongest and most extensive motions were,
however, produced when the abdominal 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 Muller'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 e](periments the fol-
lowing conclusions:
1. 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 compression of the
entire cord in the lobster, gave rise to muscular contractions in segments both anterior and
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46 Introduetion-to the Study of Diseases of the Nervous System.
•
posterior to that in which the irritated part of the cord lay, though the conyulsions were in
this case not so energetic as when the ganglia themseWes were compressed. Valentin states
alsO| that the struggles of the animal, when the inferior fascico Ins, or the ganglia of the cord,
as yet in connection with the cerebral ganglia were touched, erinced the tme sensitive
endowments of these parts. (Elements of Physiology, by J. MQlIer, 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 iuTertebrata as the special seats of
Yolition 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 Mollnsca,
must alone appear almost sufficient proof that a great part of the fibres entering and issuing
from the different nerrous centres of the body, are distinct f^om 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 the Strueturey Relations and Develop-
ment of the Nervotu and Ctrculatory Systemij and of the Exktenee of a Complete Circulation of the
Blood in VeseeUy in Myriapoda and Maerourotu Archnida,^^* which contained valuable additional
observations, bearing upon the reflex theory of Marshall Hall.
i^ccording to Mr. Newport, the formation of the great abdominal cord, in the Jnlidae, by
the lateral approximation of two distinct portions, is indicated in its upper surfkce 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. Each of these lateral divisions
of the cord in Julus, 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 IL, p. 408), ate 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 (fnauffural DiesertaUon on Nervotte System of fnverte-
brata)y in other Articulata, and applied by him to explain some of the reflex phenomena of
the nervous system, in accordance with the theory promulgated by Dr. Marshall Hall. But
besides these two sets of longitudinal fibres^ and the series that pass tranwereefy through the
gangUa^ 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 tides of the
cord, and enter into the composition of all the nerves from the ganglia, and are designated
by Mr. Newport %» fibres 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, that its sise is mainUlned almost uniformly throughout its whole length
in the elongated bodies of the Myriapoda. With reference to the identification of ibt fibres 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 brain. 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 most be regarded only as reflex ; entirely
independent of sensation, but capable of being excited into action by external causes. Mr.
Newport announced that the existence of the lateral fibres in the cord, folly 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 irritated.
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 office in the nervous
* PbU. Trans., 1843, p. 243-^*2.
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Introduction to the Study qf Diseases of the Nervous System. 47
system, that of being centres of growth and nutrition to the cords and nerves. The structure
^ the ganglia confirms these conclnsions, 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 themseWes are nourished.
Although Mr. Newport pointed ou^the existence of fibres in the neryous cord of Myriapoda
and Arachnida, which lead to the conclusion} that the doctrine of the indiTidualitj) or special
fonction of each fibre is correct ; that there are fibres in every nerre 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
fibres also exist in the same nerves, that have no communication whatever, with that organ ;
and farther, 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 tp be shown by experiment, w-hether 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
Mr. 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 Muller) on the same animal, and afterwards repeated by Dr.
Baly 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-
OBSophageal ganglia, the brain in these Articulata.
No experiments bad as yet been made on any of the Myriapoda with reference to these
inquiries, save only one, imi^rfectly described by Dug^s (Traite de Physiologic Compar^e,
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
ooe of the lowest of the Chilognatha {Julus terrettris,) and one of the highest of the Chilopoda,
{Lithobfus forfi€€tiu9. )
The questions which Mr. Newport proposed for examination, were :
Ist. 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 Yertebrata ?
These experiments lead Mr. Newport to the conclusion, that the seat of volition is solely in
the supra-oesophageal 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 when
they are severely wounded, and is greatly diminished even when only one is slightly affect^ed.
This latter fact is indicated by the loss or diminution of purpose, and by the gyratory move-
ments 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 reflex or excited,
and that these 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
not occur spontaneously, and that their intensity is greater in proportion to the stimulus
applied, and gradually diminishes until they entirely cease or are re-excited precisely as
already shown by Dr. Hall in the vertebrata.
The experiments, both on the Julus and Lithobins seem further to show, that the reflected
mofements 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
vben 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 f^om the body.
Many of the phenomena are precisely similar to those which have hitherto been observed in
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48 Introduction to the Study qf Diseases of the Nervous System.
the Crustacea. They agree in the circnmstance that yiolent cootractions of the aegments and
limbSi both anterior and posterior to a ganglion, are induced by irritation of that gaDglion,
both when connected with the brain, and when isolated Arom it, thus proving these moTe-
ments in the latter instance to be reflex ; but there is as yet no direct proof that sensation
does not also exists in these ganglia.
The general results of these experiments, tend to confirm 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 movements are instituted independently of this
organ. Mr. Newport, confirmed the correctness of these conclusions, by subsequent and still
more extended experiments upon the Goleoptera, Orthoptera, Hymenoptera, Neuroptera, Dip-
tera, and other Hexapod Insects. (Phil. Trans. 1843, pp. 243, 302.)
It has been long recognized 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. Hall's theory of the
existence of special incident and reflex fibres. Bven 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. Hall's theory might therefore be regarded as appli-
cable to these animals, there appeared to be no reason for the adoption of a different explana-
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 examine 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 MICROSGOPIOAL 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 difficulties were greatly increased, on account of the greater size and more eom-
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 difficulty that, under a
tolerably strong magnifying power, a single thread can be followed even for a very short
space) — lastly, the infinite number of tbe 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 im-
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 run
from their ultimate distribution directly through the spinal column to the brain ; and after
the brain and spinal cord had been shown by Ehrenberg to consist in their intimate structure
of minute tubes, the immediate connection of the nerves through tbe 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, frog^ and
fishes, and expressed the belief that the cerebral fibres took their origin from ganglionic cells.
In his work (Recherchet Microscopiques sur le Syst^me Nerveux, 1844), he shows the origin of
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Introduetion to the Study qf Diseases of the Nervous System. 49
ihe nerre fibres from the ganglioQic cells in the cortical sabstance, and states that the fibres
of the spinal cord descend perpendicularlj, and curving at obtnse angles pass over into the
roots of the nerves, the cerebral fibre and the nerve fibre having thus direct connection with
etch other. The transverse fibres he describes anew, without, however, having been able to
trace them to the periphery 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 A'om one to the
other tide of the cord. He was not able to detect these transverse fibres plainly in any of
the maounalia; 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 Wal-
lach on the other hand, inferred that the roots of the nerves ran transversely between the
white colnmns 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 fh>m the other side of the spinal cord. They considered that the will acted
chiefly through the gray matter. In their first essay ( Ueber die Textur det Ruckenmarks, 1842)
these observers appeared to confound the ganglionic cells with dilated blood-vessels ; but
the subsequent investigations of Stilling, (Ueber die Teztur der Medulla Oblong, 1843), were
much more complete and are regarded by competent anatomists to be correct. Stilling des-
cribes the multi-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
Stilling represents with the greatest accuracy, the origin of the nerve roots from the gray
sahstance, his investigations were on account of the low magnifying powers employed,
itfufficient 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 reflex 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.
Tolkmann argued 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 (Oroialiiu muLtu^) 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 the spinal cord are so adapted, that every stimulation applied to them must produce a
corresponding combination of movements. Since, he savs, the application of a stimulus to
the roots of the frog is sufficient to bring into motion all the corresponding motor fibres, there
ii 00 doubt tliat 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
doobt, that a single cerebral fibre is sufficient to bring into action all the motor fibres which
work simultaneously, 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 and other fibres of the spinal cord, he would certainly have left little for his
lucbessors 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
Tolaotary motions, or of the natural phenomena of reflexion, 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, Kolliker 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 greater tenuity of the nerve
filaments 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. KuIIiker 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
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50 Introduction to the Study of Diseases qf the Nervous System.
can be the case only with the most minute ramifications. He considers it to be irapossiUe,
that a prolongation of a central ganglionic cell should pass as cylinder axis into the doablj
outlined nerve fibre, although Wagner positiyely states that he has undoubtedly seen such to
be the case, and the careful and learned observer Schroeder Van der Kolk, has more than onee
decidedly confirmed Wagner's observation.
It would extend this introductory chapter into the magnitude of a large volume, if we were
to enter into a minute and critical examination of the labors of the various observers as R.
Wagner, Budge, Stilling, Kolliker 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 m«de 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 carefully during the period of ^everal years, and em-
ployed much time and labor in endeavoring to arrive at some well grounded and settled concln-
sion with reference to the difiBcult and intricate subject of the anatomical strnctare of the
spinal cord ; and his investigations were especially directed to a question of great interest and
physiological importance, viz : 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 brpnght forward
by Mr. Clarke, in his papers, published by the Royal Philosophical Society of London, may
correspond to the results of Dr. Stilling's inquiries, it is but just to state 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, Quinea pig and frog, reptiles and fish.
In his first paper, {Retearehes into the Structure of the Spinal Cordy Phil. Trane, 1851, pp. 607,
621), Mr J. Lockhart Clarke illustrated and established 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 tubetantia geUUinow^ there extends unintermpt-
edly across from one side to the other. The nerve fibres of the gray substance, including
those of the tuhetanUa gelaUnota^ are not gray fibres bearing nuclei, like those of the sjmpa-
tl^etic, but fine tubules. Two considerable columns of caudate vesicies, which Mr. Clarke
named the poeterior reticular columns, 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 size of the nerves. The column of vesicles into
which, in the cervical region, the spinal accessory nerve may be traced, extends down the cord
as far as the lumbar enlargement. A considerable branch of the spinal accessory nerve, after
entering the gray substance through the lateral column, may be easily traced to the caudate
yesicles 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 columns only ; and the anterior roots to the anterior columns only; bnt
fibres from both these roots, after traversing certain portions of the gray substance pass ont
again, into the white columns. Neither the anterior nor posterior columns are connected by
a transverse commissure.
The central portion of the gray substance, immediately surrounding the spinal canal, is
not a commissural structure, but a layer of fine fibrous tissue for supportihg the walls of the
canal, which is lined with a layer of columnar epithelium. Phil. Trans. 1851. p. 607.
Mr. Clarke in his second paper " On certain Functione of the Spinal Cord, with further Invett^"
tione into ite Structure,^* Phi}. Trans. 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 columns, and form the channels by which impressions are
transmitted to and from the brain, and also, endeavored to apply the results of his discoveries
to the explanation of the functions of the spinal cord.
Many physiologists and anatomists maintain the opinion, that part of the fibres comprising
the anterior and posterior roots of the spinal nerves, ascend longitudinally with the white
columns, without entering the gray substance of the cord, and transmit to and from the brain,
impressions which give rise to sensation and voluntary motion ; and in support of this doctrine,
Mr. Grainger, (l^inal Oord), Mr. Solly, {Human Brain), and Dr. J. Bodge (M&Uer's Archiv,
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1844,^k«Tt adduced the fact of htLving traced these fibres in the spinal cord of the VertebraU,
and Mr. Newport and Dr. Carpenter, (Phil. Trans. 1843), in the Invertebrata.
On th^ «lher hand, Todd and Bowman, (Physiological Anatomy, vol. 1, 1845), Stilling
(UntersQehvngen uber die Textur des Ruckenmarks, 1842), Yolkmann (Nenrenphysiologie,
in Wagner), lusd others, bold the opinion that all the fibres of the spinal nerve enter the graj
substance, and belong exclosiyely to the spinal cord.
In his first pap«r, Mr. Clarke showed unquestionably that to the posterior white columns,
the posterior roota, and to the anterior white columns, the anterior roots of the spinal nerves
are exclusively attached ; while the lateral columns, to which both these roots were formerly
supposed to be connected, are in immediate connection 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
transvers^y and pursue a very remarkable course. Each 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 appearance. It then bends round upon
itself at a right or more obtiise ansle, and running for a considerable distance in a longitudi-
nal direction down the cord, sends forwards, at short intervals, into the anterior gray sub-
stance, a series of fibres like those from the roots of plants. In this longitudinal course, it is
joined bj 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-
sunce, 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 t^warcU and dawnvjardt^ are seen sometimes to re-enter
the gray substance, and form with each other a series of loops, and sometimes to continue a
longitudinal course within the white anterior columns, amongst the fibres of which they
become lost. Whether the latter also ultimately form broader loops, with corresponding
fibres from the gray substance, it is impossible to ascertain. But even if those which,
MceM^ 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
become continuous with the fibretf 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
aumber 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-
uinty, and reserves the question for future investigatioA, The second kind of bundles which
form the posterior roots, and traverse the posterior columns transTersely, and with different
degrees of obliquity from without inwards, extend nearly as far as the posterior median
fi&sure. 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
through the posterior gray substance at various angles, and in compact bundles, which decus-
sate and interlace each other in the most complicated manner. Some of their fibres cross
oTer 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.
The 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
obliqnely. and chiefly- a^pirardlt, a small number only passing downwards. Interlacing at the
same time 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 brain, or whether they ultimately reach the gray substance of the cord. It is also
extremely difficult 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
ioterlace 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
boodles, may be observed to form loops by returning to the white columns.
The anlericr roott of the spinal nerves, as Mr. Clarke formerly described them, traverse the
aoterior 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
substance. Here their fibres diverge in every direction, like the expanded hairs Qf a brush.
Some near the margin, are easily seen to form loops with those of continuous bundles ; others
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52 Introduction to the Study of Diseases of the Nervous System.
ran outwards to the lateral colamns, and inwards to the anterior colamns after deouMatiBg
in the anterior commissure with corresponding fibres from the opposite side. A large nbmber
diverge equally downwards and upwards for some distance m the gray substance, while the
remainder pass more deeply backwards and are lost. In no single instance has Mr. Clarke
seen any 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.
They 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 obserrMl 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 aboot and
are gradually lost, mingling with the fibres of the anterior roots, and with those proceeding
from 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 ones
to its gray substance : and that if any of them ascend directly to the brain, it must be tkoM
only of the posterior roots which run longitudinally in the posterior columns.
Professor J. L. C. Schroeder Van Der Rolk, in the year 1847, detected a close connecUoa
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 throaghout
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-trunk, 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 : While the nerve gives off motor branches to the mua^ee, its
sensitive branches run to the part of the skin which is moved by the same muscles, or, in other words, a
spinal nerve gives its motor branches to the muscles as instruments of motion, and its sensitive branches
to the part 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 reasons, 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 spinal cord, especially, as
the numerous vivisections which had been performed, had led rather to greater perplexity
than to the establishment of fixed truths. Schroeder Van der Kolk, communicated the results
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 June, 1848,
and subsequently brought them more in detail, and illustrated by various preparations, Id
the autumn of the same year, before the Royal Netherland Institute. Professor Schroeder
Tan 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, 1853.; 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 ttotn the
valuable translation of the works of this anatomist and physiologist, ** on the Minute Strnc-
ture and Functions of the S^nal Oord and Medulla Oblongata," by William Daniel Moore, published
by the New Sydenham Society 1859, and which must not be considered as a mere translation
of the Essays, originally published by the Royal Academy of Sciences, at Amsterdam, in
1854 and 1858, but on account of the large amount of additional matter and alterations Air*
nished the translator by the distinguished author, should be regarded as a second and revised
edition of the original works.
The following conclusions were drawn by Professor Schroeder Van der Kolk, fh>m his inres*
tigations on the anatomical structure of the spinal cord.
1. The ganglionic cells, especially in the anterior horn, are connected with one another 1^
more or less ramified fibres of communication, and thus form more or less distinct groups.
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 cote-
monly two or more nerve-roots close to one another, and now leave the spinal cord in a
transverse 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 horn.
These cells are again connected with others more deeply placed, and so eventually with the
group of ganglionic cells, whence the motor nerve arises.
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Introduetion to the Study qf Diseases qf the Nervous System. 53
4. The Anterior loDgitadiaal colamns coasist of white, mostly parallel, medullary fibres
which pass into the transverse rays just mentioned, and so convey the orders of the will to
the ganglionic cells in the gray matter ; the longitudinal fibres, which are situated next the
gray horn, curve directly, in order to pass into a ganglionfc cell.
5. The posterior nerve-roots (iontain 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,
opwards 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, repiUr 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
among the longitudinal fibres or columns form several plexuses ; in part they press through
the scattered gelatinous substance of the posterior horn, to the mi' idle 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 fiilaments 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
horn 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
much greater number; whence it would appear that they do not run through the whole
spinal cord, but for the most part terminate in the cervical and lumbar expansions, where the
majority of reflex actions and movements are excited and combined ; they appear, therefore,
tbrongh 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
gani^ionic cells, partly into the cells which are present in the centre of the gray matter, while
tgain some fibres are connected with the marginal fibres around the posterior horn
11. Tbe anterior commissure forms a decussation ; its fibres push forward in order in part
to terminate directly as rays among the inner and anterior longitudinal columns ; in part they
proceed 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 tbe rays.
12. The fibres of both the anterior and posterior commissures are not directly connected
with the nerve roots, though they are probably connected with the anterior ones by means of
the nnituig 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-
thelial cells, and sometimes appearing to contain an albuminous fluid; in man it seems to be
narrower than in most animals.
The 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
muscles, appear to arise from a group of mutually connected ganglionic cells ; they receive
the 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-
tributed over all the cells of the group, produces in all the motor filamenu of the nerve
arising from it an uniform and simultaneous action.
2. The number of these anterior conducting filaments of volition must thus be proportionate
to the number of groups of cells, and the several combinations of which they are capable,
and must therefore be much less than the number of medullary filaments for tbe 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 the spinal cord in transverse sections.
3. Where numerous muscular nerves spring from the spinal cord, as for the extremities,
more numerous 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.
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54 Introduction to the Study of Diseases of the Nervous System.
4. Id animals whose mnscular moTements are more simple, as in fish, the spinal cord is
slighter, and the gray matter, as well as the ganglionic cells, is much more scanty, as fewer
combinations of movements are required.
5. Reflex movements take place, not by over-leaping or transverse connection, bot the
reflex nerves appear to terminate, partly in a central g^oup 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 nerre-
roots contain at the same time sensitive and reflex nerves, it is easily explained why thej are
nearly twice as thick as the anterior roots.
6. The posterior horns 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 harmonized 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 connected 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 inrolan-
tary harmony in reflex action, the equilibrium of the body, etc.
9. The two horns of gray matter appear to stand in the 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 inyestigatlons
n the structure and functions of the Medulla Oblongata:
OP THE MEDULLA OBLONGATA.
1. In the medulla oblongata, a perfectly unique organization 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 bypoglossus, the accessory facial and the small branch of
the trigeminus, lie near the raphe or septum ; the nucleus of the abducent is still uncertain y
the nuclei for the nerves of sensation, which are first distinctly seen in the medulla oblongata,
as the portio major trigemini, the vagus, glosso-pharyngeus and auditory, lie more to the
outside, and further removed from the raphe. In addition, auxiliary ganglia, or acceasory
nuclei, each of which has its own function, occur in the medulla oblongata.
2. Of the spinal cord, only the anterior columns pass, in the corpora pyramidalia, as con-
ductors of the orders of our will for the movement 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 the trunk, but only of the face, the tongue and the
extremities.
3. At the inferior boundary of the medulla oblongata, and above the termination of the
lateral columns just mentioned, a new system of fibres begins in the meduUa oblongata,
descending from the brain (the thalami, and especially the 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, curre to penetrate into the raphe, to decus-
sate there, and so to pass over into the nuclei of the nerves of the opposite side, as con-
ductors of the orders of our will, or for the communication of the impression of sensation
to the brain. The accessory ganglia also receive the conducting filaments by which they
communicate with the brain, frOm the same fasciculi.
4. The nerves of the medulla oblongata do not participate in the decussation of the corpora
pyramidalia, as they are situated higher up. They themselves do not decussate; but in the
manner described in the preceding paragraph, the conductors of the orders of our will
decussate here also, as in the corpora pyramidalia, for the movement of the extremities. In
the medulla oblongata the decussation is in the situation of the nucleus ; for the nerves of
tlie extremities is situated above the nuclei, in the known decussation of the corpora pyra-
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Iniroduetion to the Study of Diseases of the Nervous System. 55
midftllii; in both parts, therefore, there is perfect correspondence. In like manner 61aments
arise trim the nuclei of the sensitiye nerves, which decussate and convejr the received
impretsion to parts situated higher up. Now, as sensation appears to decussate, and the
nuclei of the aesaitive nerves lie on the same side as their termination, these nuclei cannot be
the seat of the paro^ion of sensation.
5. Besides this, tlwre axists in the medulla, oblongata a system of transverse fibres (fibrK
oreiMte), some of whick arise externally, surround the medulla, and pass into the raphe, while
others, m part, arise intemaUj from the corpora restiforma and the root of the trigeminus, in
pari from the nuclei of the nerres, and from the corpora olivaria. These transverse fibres
seem to Qnite the two halves most intimately, and to produce a bilateral action so eminently
characteristic of most nerves of the neduUa 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.
OP TBI inaVBB OP THS KttMaLLA OBLONGATA.
6. In addition to the above bilateral connexion, the nuclei, particularly of the facial,
accessory and hypoglossal nerves, are in part connected from behind near the fourth ventri-
cle, by a transverse comniissure, which appears to increase the bilateral action of the nerves.
7. Of all the nerves the auditory has in its central nucleus, the largest ganglionic cells,
and in it the connexion of the latter with the nerve filaments, and with one another, is very
easily seen* From this central nucleus fibres radiate in the direction of the nucleus of the
fseial nerve, 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 anditory nerve is also closely connected with the sensory root of the trigeminus, and
the two nuclei of the auditory, are intimately united by many fibrae arciformes, radiating
from thia point. The so-called roots of the auditory nerve in the fourth ventricle, do not
serve 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 unexpected sound, reflect
npon the whole muscular system, and place the body in an attitude of defence.
8. The glosso-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 taste 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
is an outward direction, the fibres of the facial nerve and a portion of the facial nucleus. It
does not as Stilling thinks arise from the latter, but merely perforates it, to pass posteriorly
and superiorly 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 fVom the nucleus
to the decHBiation. Perhaps it is more or less intimately united with the higher situated cere-
bral fibres, passing to the opposite nucleus of the oculo-motor, an arrangement which would
allbrd a simple explanation of the antagonism between the oculo-motor of the one side, and
the intemns of the opposite side.
10. The nervos trigeminus is one of the most remarkable nerves of the medulla oblongata.
While iis minor portion, aa a. muscular nerve, finds its nucleus very near the raphe, the major
portion perforates, in an obliquely descending direction, the whole medulla oblongata, tp the
iolinior border of the corpora olivaria. , In this course it passes all the other nerves of the
mednlla oblongata and their nuclei, and gives off fibres to every nerve, except the abducent;
consequently, 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
•ecessory. 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 excellence, whose
reflex filaments convey the impression they have received either directly to these different
oerve-nuelei, or indirectly give it up again to the auxiliary ganglia.
U. In every situation, where reflex filaments proceed from the roots of the trigeminus to
the nerre-nnclei, fresh groups of ganglionic cells arise in this root. It is even probable, that
in general, when a nerve filament determines a special action, the latter is communicated to it
through ganglionic cells.
OV TBI AUXILIABT GAHOUA.
12. 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
auxiliary 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
distingnished from other ganglionic groups by their peculiar structure and very small multi-
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56 Introduction to the Study of Diseases of the Nervous System.
polar ganglionic cells, whence fibres pass outwards and inwards, to unite as marginal fibres,
into fasciculi of different degrees of strength. Of these fasciculi, some run to the eeotrsl
nuclei of the nerves, and others to the raphe, to unite with the corpus olivare of the oppoaite
side. Besides these, there are appendages, or accessory corpora oliraria, which appear to agre«
with the former in structure and function.
15. The corpora olivaria are more intimately and closely connected with the nuclei of the
hypoglossus, than with the nucleus of any other nerve. This connection is accomplished by
a special tract passing out from the hilus of the corpus plivare, and terminating in the noelems
of the hypoglossus. The corpora olivaria are also united by other fibres with the nuclei of
the accessory nerve. Besides these connexions, the upper part of the corpus olivare ie
farther united with the nucleus of the facial nerve.
16. Through these connexions, the corpus olivare seems to serve as an auxiliary ganglion
for the hypoglossal and accessory nerves, for the purpose of regulating the innumerable oom-
binations of movements by the tongue, which, as appears from pathological observations, take
place in t]ie articalation of the voice during speech, and in deglutition. All these movements
require a bi-lateral action, which appears to be effected through the corpora olivaria. It wonld
appear that different parts of the corpora olivaria exercise different functions, according to Um
nerves with whose nuclei thev are connected by radiating fibres, for these several functions,
as expression, articulation of the voice, and swallowing, may be separately lost in disease.
17. Besides these corpora olivaria, another group of larger ganglionic cells occurs also in
man and animals as auxiliary ganglia, 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 trigeminas. This group appears to serve for* the reflex action of the trigeminus, in wink-
ing of the eyelids, which, as is well known, depends especially on irritation of the flflh pair.
18. The connexion of the nervus vagus and its nucleus with a bundle of longitudinal fibres,
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 importance. From the nervus vagus fibres pass
into this longitudinal fasciculus, where again ganglionic cells are situated at the seat of tran-
sition. This connexion appears to be subservient to respiration. Hence it follows, thai a
very strong centripetal acting stimulus to the vagus, brings all 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, oausinfr 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 ai the
fourth ventricle, as anteriorly by transverse fibres or' commissures and fibre arciformes
through the raphe, rendering respiration bi-lateral. A ^puncture or wound in the middle line
or raphe, destroys this connexion in action, respiration c^itses, 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 same
manner decussate, and then curve upwards; they terminate in. the lateral longitudinal 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 s<^ on the respiratory
organs.
21. With these longitudinal columns, and especially the nucleus of the vagus, the great
root of the trigeminus enters into very intimate connexion, so that in some piMes they seem
to be coherent. This state of things is apparently closely related to the known reflex action
of the trigeminus on respiration, exemplified in sneezing, etc.
22. Swallowing, when voluntarily excited, is also a reflex action, which is always accosi-
plished with rapidity, but is very complicated. The exciting stimulus appears to proceed
from the second branch of the trigeminus, namely the palatine nerve ; for division of the
lingual or glosso- pharyngeal nerve does not prevent swallowing. Bit the irritation seems to
be conveyed to the corpora olivaria inferiora in animals and to the corresponding parts in
man, whence it is reflected on the hypoglossal and accessory nerves, with which these cor-
pora olivaria are closely connected, and through which the act of deglutition is occasioned by
the simultaneous excitation of many muscles into bi-lateral action. Perhaps, also, the small
root of the trigeminus, by closing the mouth, participates in the act. The nuclei of the glosso-
pharyngeal also appears to be united with an auxiliary ganglion similar to that of the facial
nerve, which auxiliary ganglion is also closely connected with the trigeminus. Schroeder
Van der Kolk affirms that he is unacquainted with its action. (Professor Schroeder Van der
Kolk, Minute Structure and Functions of the Spinal Cord and Medulla Oblongata. New
Sydenham Society, London. 1859).
According to the view of Schroeder Yan der Kolk and Wagner, the brain and spinal cord
are nothing else than massive accumulations of primitive fibres, and multi-polar ganglionic^
cells ,' combinations of primitive fibres do not occur except through the interposition of
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IntroduetUm to the Study qf Diseases cf the Nervous System. 67
gAOglionic eells ; conteqneotlj all phenomena of innenration depend on combinations wittt
one another, and with central and peripheric nerve paths, of individnal ganglionic cells and
larger aggregates of the same^ as special seats of innervation of various physiological import- .
anee. For every separate movement, a special group of ganglionic cells must he present,
whence all the nerve filaments arise, which go to a muscle or system of muscles, always act-
ing simnltaneonsly. The sensitive roots divide, after their entrance into the spinial cord. Into
ascending bundles, passing upwards with the longitudinal columns ; and into transverse,
which dividing into different fasciculi, proceed towards the posterior horn of the gray matter^,
and after having 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 Schroeder Van der Kolk reflex nerves. This observer cannotj
however, wholly agree with Marshall Hall, who assumes excito-motor nerves, that is, special
nerves, said to accomplish the motions caused by reflexion. This, according to the views of
the learned professor of the Universltv of Utrecht, being an hypothesis which is based on no
certain foondation ; as it Is sufficient that the roots of the motor nerves receive the stimulus
to action ft*om the group of ganglionic cells, whether this be communicated through the will
from before, or through the reflex movements from behind. According to this idea, there-
fore, the groups of ganglionic cells, may be considered as constituting a battery with two
poles, or, rather, capable of being charged from two sides ; the one pole is connected by
means of the lateral rays, with the filaments which conduct the orders of our will, the other
pole, by means of dilferent combinations of ganglionic cells, with the reflex nerves, so that a
group is capable of receiving both psychical and physical stimuli. As, however, the posterior
roots, in this 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
transverse 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 horns into ganglioniii 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 horns, may be doubted,
because 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
through to the brain, as the posterior horns become so slight in the middle of the back, that
most of the ascending fibres nave in this situation disappeared. However it must be admitted
that the question is still wholly undecided, whether, when reflex sensation or sympathetic
sensation takes place, the proper sensitive filaments first communicate their action to one
another 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
parts, althcfugh, 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 Schroeder Van der
Kolk, 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
nerves of Marshall Hall. Wagner pnts it forward as doubtfol, whether the fibres conveying
voluntary stimulation to the muscles, and arising from the brain, unite with a peculiar system
uf 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 ad 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, Schroeder Van der Kolk anatomically decided tliis question.
Most probably the longitudinal slender fibres of the posterior horns consist of filaments of com-
munication, 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,
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58 IrUroduetion to the Study (/ Diseases qf the Nervous System.
M haa been alreadj obsenred, it U dlffioaltto andersUnd how the posterior horns shonld be so
mnch slighter and smaller in the dorsal than in the lumbar region, and contain fewer longi-
tudinal fibres, which applies also to the enlarged cenrical tract and higher part of the nock.
Bj reflex action the muscles are now first brought into motion, the nerres of which arise
nearest to the reflex nerres, where, therefore, the excitation of the reflex nerve, or of aooM
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 Van der Kolk, supposes the following
illustration. Let us suppose a simple case ; for example, that a person unexpectedly bams
his finger ; so soon as he perceives 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 it
flexed, and at the same time the humerus is drawn back, that is, the biceps and branchialis
anticus 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 anticus, and at the same time the group of cells, from which the netves for
the latissimus dorsi and teres migor arise. Thus through a combination of connecting fila-
ments by means of ganglionic cells, wherein the reflex nerves terminate, both groups are
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 ftrog 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 harmonized 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 jars 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 boms
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 refiex 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 refiex 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 symptoms, the dog falls,
becomes convulsed, or makes involuntary movements ; but these cease after soihe time, and
now the animal appears to be perfectly well. In such a case Professor Schroeder Van der
Eolk, 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 sufficiently 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 ; in
the latter case only a partial discbarge 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 excited to a
higher degree, a remote stimulus through a reflex nerve, distantly connected with this group
by means of filaments 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 snph for dis-
tinction's sake — whence the motor nerves arise, possess as it were two poles, that is they are
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Mroduetion to the Study iff Diseases qf the Nervous System. 69
eoanected on the one side with the eondnoting filaments of tlib will (anterior colnmns),
posteriorly with the reflex nenres hj means of other ganglionic cells. Now if these reflex
neiTes are connected through commanicating filaments with sereral groups of motor cells, so
that bj reflex action a harmonised movement, for example, a Jump, takes place, it maj be
assumed that bj m^ans of the anterior Conducting filaments of rolltion, the groups are most
easily brought harmoniously into action, whereby a combined or co-ordinated morement is
produeed. We hare indeed the power of Toluntarily moring a separate muscle, for which
separate conducting filaments may exist, but we can with equally little exertion or conside-
ration bring into action sereral groups of muscles, of which a step, a co-ordinated moTcment
is the result, and this is probably produced by a pre-arranged connexion, by means of the
communicating filaments of sereral groups, which are affected as by reflex action. That the
prodoction of harmonized raoTements, for example, talcing a step, is referable to the oiganiza-
tion and action of the spinal cord, that is to dlfi^erent intimate C()nnexions 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 rery young child, which when the mother takes
it up in her lap, rery easily begins to make the regular movement of a step, alternately with
the right and left foot ; and this is seen more clearly in a jonng 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 Ikilnres
in a saccessful election ; but the combination which is required for the purpose must already
exist, organised, and, as it were, pre-arranged in the spinal cord, so that a single impress is
sufficient to bring this combination into action. Our mind knows neither the muscles or the
instruments, 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 which the leg is capable, we were obliged, by practice, to learn to combine those which
l^odnee a step. The cause of the co-ordination of muscular movement is therefore situated,
as Volkmann 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 canse of this co-ordination lay in the cerebellum no harmonized reflex movements could
take place in a decapitated frog: In the opinion of Schroeder Van der Eolk, the experiments
of Plonrens, Hertwitch, and others are easily explained ; the motor fibres pass fh>m the cor-
pora pyramidalia through the pons varolii to the crura cerebri ; they here decussate with the
transverse fibres of the pons, and between both lies a tbin layer of gray matter, containing
small multipolar cells. If a part of the cerebellum be taken away, the violent irritation so
produced is reflected by means of the transverse fibres on the corpora pyramidalia and irre-
gular movements are the result. If the cerebellum was the seat of co-ordination, regular
movements would of necessity ensue on irritation of that organ. But in ulceration of the
cerebellum, when the irritation is more chronic and not so violent, Schroeder Van der Eolk,
has never seen irregular movements arise. He thinks tberefbre, that the diflicnlt phenomena
of reflex action may be satisfactorily explained by the theory of special 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 matter, 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 nerves, 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 spinal cord, appear to parti-
cipate more or less in the production of the reflex phenomena ; and it has in fact been shown
that the fibres f^ora the posterior commissures run for by far the greatest part transversely,
and in the middle between the two gray horns are lost partly in the same ganglionic groups,
in which the reflex filaments also disappear, and seem partly to terminate in the small group
of ganglionic cells situated at the side of the central canal : there is, therefore, every proba-
hili^ that the fibres of the posterior commissures serve for lateral refiex action, and are con-
sequently capable of transferring to the opposite side the impression received in the groups
of reflex cells, while those of the anterior serve to produce in one voluntary movement har-
mony and agreement between the 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 ftre more directly
connected on the inside of the anterior horn and the rays proceeding thence, with these lon-
gitudinal columns, which Schroeder Van der Eolk recognizes as conductors of the orders of
the will — the will must exercise more influence on the anterior commissure, and by this route
must the 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
that this arrangement may also influence the muscles, which either always or almost always
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Cf() Introduetion to the Study <^ Diseases qf the Nervous System.
are in the healthy state moved similarly oa both sides ; for example, the muscles sitosted is
the middle, the sphincters and levatores ani, the ischio-cavernosi, as well as the abdoniBal
and intercostal, and in great part the dorsal muscles, which hold the body in the eraei or
straight position ;. also the muscles for deglutition, those for the development of the voice, and
others which always act symmetrically. The posterior commissure seems to serve for tba
more involuntary lateral reflex actions, because its fibres appear to end in the middle of tbe
gray matter, where Schroeder Yan 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 motor
root is much closer, than with the fibres of these transverse commissures, since, as Pfloger has
shown, in extension of reflex movements, the latter ascend exclusively on the one side, antil
the irritation, having reached the medulla oblongata, passes over and produces general con-
vulsions. The posterior commissure may also serve for involuntarily preserving the equili-
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 itehing
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 it8 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. Pflfiger, 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 inffenions
arrangement of the tissue and of the structure of the cord, in which all these harmonized 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 fingers of a player. Schroeder
Van der Kolk, justly observes, that "such a view is sufficient to excite amasement at the inge-
nious nature of all these arrangements and wonderful combinations, but ii Is conceivable, and
in my opinion not so difficult to imagine ; while the idea of volition in the spinal cord, without
consciousness, with the entire rejection of the existence of a soul, as Pflfi ger suggests, is an
absurdity not to be thought of. On the contrary, the deeper we penetrate into the knowledge
of the mechauism 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 amazingly correct insertion,
size and combination of the muscles, and certainly not less the combination of the ganglionic
groups, whereby these muscles are harmoniously and suitably moved, are calculated 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 columus 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 Yan 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 matter
which in the situations where they are most fully developed, as in the loins, may pass into effiu-
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 sen-
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 copfirmed. A difficulty, however, still remains,
namely : that if the sensitive nervea 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 fllaments of the left, which as is well known decnasate
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 Foville's
observations have shown, that on the posterior surface of the medulla oblongata, behind
and above the 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 filaments do not remain on the same
side, Schroeder Yan der Kolk confesses that we are not yet in a position even to form a prob-
able ooigecture. He admits also, that the situation, where the impression of the sensation to
observed, can scarcely be determined with any certainty; probably however, it to in the
medulla oblongata, whither the fifth pair runs, while in fish, where the proper hemispheres
of the brain are wanting, there is no higher situation to which the seat of sensation can with
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ftny roASoii be referred Moreorer, it is well Jknown^ UmI ii^arj of the more highly aitaated
parts, eepeeiallj of the oerebran, occasioas no pain, And the cerebram is iDsensible to pain.
If from the preceding fisots it is laid down, that both horns of gray matter in the spinal oord
serve for motion, the anterior for more direct motion, the posterior for reflex action, and
coordination, it becomes intelligible why Tiyisections performed on animals, in which it has
heen attempted to cnt throagh only the posterior or the anterior columns, \^%ve lead to such
discordant results. It is indeed, eyident that it, is absolutely impossible to cut through these
columns, without wounding the gray horns, which project across them, the necessary result
whereof will be that different moyements must be produced by this i^ji^ry, whether of the
anterior or of the posterior horns, according to the diifereat groups of ganglionic cells, reflex
nerves, or filaments of communication which ar^ pounded ; so that this question can never
be solved in this way, and confusion, rather than light and knowledge, will have resulted to
physiology from such experiments.
B. Pflflger, from a great number of observations has shown, that reflex action ia at first
strictly unilateral ; furthermore, that if reflex action apises from a stimulus in the brain or
cerebral nerves, the reflex movements in their farther progress, extend to the nerves situ-
ated inferiorly, and thus to the medulla oblongata; that, on the contrary, if reflex action
arises from a spinal nerve, it extend^ in its further progress from be)ow upwards towards the
medulla oblongata, and not vice vena ; 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 nerves which
are very remote from the insertion of the sensitive nerve primarily aifeoted, these remote
motor nerves are always such as arise from the medulla . oblongata* Hence it appears that
the medulla 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
inve«tigations, that the medulla oblongata is the starting point from which epileptic fits arisC)
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, and based
upon bis extended and accurate microscopical, anatomical and physiological researches and
investigations, must be accepted as the last and most perfect expression of this doctrine,
which, as we have seen, had its origin more especially with Unzer and Prochaska.
Brown-S^quard* concluded, from his numerous experiments, that the posterior colnmns of
the spinal cord, are sensitive, and that they do not conduct directly to the brain : but convey
impressions 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 most part pass downwards and join the gray substance above the point of entrance ; and
that a still smaller 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 gray matter of the cord receives sensitive impressions from the posterior roots of the
nerves, conducts them onwards to the brain, or reflects them to the motor nerves. It is
itself insensible to mechanical or galvanic stimulus.
Brown-Sequard supports these propositions by numerous physiological experiments and
pathological observations.
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 subject.
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-
lum. Much relating to this subject has already been presented in the preceding pages, and
•BxpMimMital BfliMrcliflS Applied to Physiology and Pathology. Qy E. Brown-Mqnard, M. D^ etc New ToHe,
1853.
gar lee B^eultate de ia Sectlou et de la GalranlMUlon da Nerf Onmd SymMth«Uque au Ooa. Parte, 1864.
Bapporte ear qaelqaee Sxp6rtenoee de H. Brown-Mquard. Par M. Paol Broca. Parte, 1865.
Beazm^moiresBarlaPhysloIogiedelaMOelle Kplnl^re. 1865.
Becherohea Exp6rimentalee ear la Tranamteelon Groie^e dee ImpreeBlooa seneitlTes dans la Mobile Rplnidre. Parte,
1866.
Experimental and Clinical Beaearohea on the PltysioloffT and Pathology of the Spinal Oord and some other parts of
theHerroMiOeatrea. Blehaond, 1866. -^ -^ -^ •- •—
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62 IntrodMction to the Study af DUeages qf the Nervous System.
we hare recorded the riews of Tarions writers, as Galen, Alb'imis, Boerhaaye, Willis, Uiizer,
Prochaska, Sir Charles Bell, Marshall Hall, Scbroeder Vac der Eolk, Remak, Volkmanii and
others, with- reference to the relations of the cerebrum and cerebellam to sensation and
motion, and the reflex function of the spinal cord, and cranial and spinal nenres.
RESULTS OF INVESTIGATIONS, DIRECTED MORE ESPECIALLY TO THE DETERMINATION
OF THE FUNCTIONS OF THE CEREBRUM AND CEREBELLUM.
- In man the intellectual facnlties appear to be ^xolnsiTely confined to the brain, but as we
descend in the scale of rertebrate beings to those whose functions, and especiallj whose
nerrous functions are less perfect, it would appear that the spinal cord partakes with Uie
t^rain of certain of its faculties ; and in animals of the simplest organisation the brain
entirely 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 any degree of what can
properly be called perception ; and in this case it has been conjectured that the sole object of
its nervous system may be to convey impressions fh>m one part to another, which are neces-
sary for the functions of the animal, but which do not excite any ideas of conscionsness.
As the nerTous centres, and their gray or vesicular constituent more especially, appear to
originate the nervous force, and as certain nerves, termed motory and efferent, conduct it to
the tissues principally muscular, on which it acu by prodncing contraction, and other nerves
tensed sensory and afferent, carry the impressions received 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 affBrent 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 eilbrent nerve
to produce motion or a reflex action, which may then take place without sensation or voli-
tion. In the Lancelet (Branchiostoma) 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
sub- transparency) ductile and elastic. It is depressed or band-like along its middle third,
which is slightly grooved along the median line of the dorsal surface, and tapering to both
ends, but more gradually to the hinder 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. Th«y 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 baemiJ or ventral mus-
cular segments. The first pair of nerves, which Professor Qoodsir thinks might correspond
to the trifacial, passes to the membranonft 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
the 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, commnnicatin|^
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 the
Lancelet, as a nerve of association, it probably answers to both the trigeminal and vagal,
which in most bigher fishes combine to form the lateral nerve, with the same relations to the
spinal nerves and mediaji 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 the
central organs of the nervous system known in the vertebrate sub-kingdom. In all other
fishes, the fore part of the neural axis, receives the vagal, trigeminal and spinal sense nerves,
and develops and supports ganglionic masses, principally disposed in a linear series parallel
with the axis; this part is the brain (encephalon) ; the rest of the axis retains its columnar
or cord-like character, and is lodged in the canal of the spinal column. (Anatomy of the
Vertebrates. By Richard Owen. Vol. I, pp. 368-271.)
According to Professor Richard Owen, the average proportional weight of the brain to the
rest of the body in fish, is as 1 to 3000 ; a certain size being essential to the performance
of its functions^ as a recipient of the impressions ftom 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 size 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 the 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 : —
** The extensive gradation of the cerebellam betwoMi the extreme! of stractnre inreaented by the Myxlne woA the
Shark, ae might be expected, throws more direct light upon its faction. "With regaid to this, two views bare been
taken. According to one, it is the organ of amativeness ; according to the other it is the seat of the ma — *
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or tbe rtgalator oC Toliutaiy motioB. M Miy exp«rim0Bte in whkh the oereMInm htm bMn matilatad or remored
ftoB warm-Uooded ADimals, flonwrt the idea of ite intimate relation with the looomotiTe powers. Bat to the con-
' ' M fkxwB Oieee experiment, has been otjeeted the poialbility of the oonrnLsiTe muecnlar phenomena baring
fhwi the stimnlQi of the remaining eentree, oocaiioned by the mutilation or deetruction of the one in question ;
aad it maj w^ be doubted whether nature erer aneweneo tmurwiien put to the torture, ae she does when ipeftking
▼viteBtaiQy through her own experiments, if we may so call the ablation and addition of parts which comparative
aaatomy oBvn to oor contemplation.
If is refweBce to the sexual hypothesis of the cerebellum, we oontrMt the Lamprey with the Shark, we riiall be
led bj tiM mo^ larger pn>porti<mal siae of the generatiTe organs in the lower cartilagiiioas fldi, and from the
obeeirod ttnet of the male and female Lamiureys, entwining or wreathing themselTes entirely about each other,
■mtaally aiding in flie expulsion of flieir reqpectire generattVe products, and so absorbed in the passion as to permit
fhsweWee to be taken out d tiM water and replaced there, without interruption of the act, to expect a larger oere-
' ~ L in the Lamprey than in the Shark. But the Teiy rererae of this is the fhet: the Lamprnr has the smalleet,
e Shark the largest, cerebellum in the class of Ashes. If on the other hand, we compare the Cyclostome and
_ ifeoaw QartilaciBOUs Ashes, in reference to their modes and powers of locomotion, we shall And a contrast which
diiuelly aeeotda with thai in their oerebellar doTelopment. The Myxine commonly passes its life as the internal
paraaita of^^aome higher organised Ash ; the Lamprey adheres by its suctorial mouth to a stone, and seldom mores
mr froB ICs place ; neither teh possesses pectoral or rentral Ans. The Shark on the contrary, unaided by an air
bladder, auatalns itaelf at the surfiice of the sea, by rigorous muscular exertion of well developed pectoral and
ea»dal flaa* aoaia, as It were, in ^e upper regions of its atmoai^ere, is prorerblal for the rapidity of Its couive, and
snbaiala like the Eagle, 1^ pursuing and derouring a living i»ey ; It is the Ash in which tiie instruments of volun-
tary motion are beat dereloped, and In which the cerebellum presents its largeet siie and most complete stnu^re.
And thia atructure cannot be the mere concomitant of a general advance of the organiiation to a higher type for the
alaggiah Bnya, that grorel at the bottom, though they copulate, and have in most other respects the same grade and
type of stmctnre as the more active Squaloid Plagiostomes, yet have a much smaller cerebelium, with a mere crucial
iBdeatatioii instead of transverse laminsB. A more decisive instance of the relation of the cerebellum to the power
of loeonotion is giren by the Lefrfdodren in which with a more marked general advance of organiiation than In the
Bay or Shark, Oie cerebellum has not riaen above the simple commissural condition whidi it presents in the Lam-
ps^ : the generative qraton, however, of the Lepldoairea is as complex as in the Plagiostomes, and is more extensive ;
but fibe Ana are reduced to mere Alaments, and the Ash is known to pass half the year in a state of torpid inactivi^.
The eerebelhuB is large in the Ghinuera. In the heavy laden ganoid Ashes, the cerebellum is smaller than in the
wwii—rj uwuoos Ashes; the imbricated armour of dense enamelled bony scales must limit the lateral InAections of
the tall ; ao we And in Polyptems the cerebellum hardly more developed than in Lepidoslren, whilst in the somewhat
more acdre and predaceous Lepldosteus it is the smalleet of all the segments of the brain. In the grovelling Stur-
geens tbe cerebellum offers a grade of development abore that in tiie Lepidoalren. Finally, amongst the normal
omeoua flahea, the largest and highest organised cerebellum has been found in the Tunny, whose muscular system
appnMCheai, in aome of its physical characters, most nearly that of the warm-blooded class.
if we ooald enter the sensorium of the Ash and experience the kind of sensations and ideas derived (h>m the inlet
•f their peculiarly developed and enormous eyes, we might be enabled to understand the oflloe of the peculiar oom-
ptadtieo of their large o|rtlc lobes ; without much experience, we can at best only indulge in vague conjecture fkom
the analogy of our own sensations. We And, when nature reduces the organs of sight to such minute specks and
can ghra bvt a feeble idea of the preeence of light, sufllcient perhaps, to warn the AmUyopeis to retreat to the darker
receasea of the snbteriaoeaa abode, that the optic lobes are not reduced in the same proportion, but retain a form and
stoe, whkii aa compared with their homologies in otiier animals, are snfllciently remarkable to suggest a ftinction over
and abore tibat of reoeiring the impressions of risual niectra, and forming the Ideas consequent theveon.
The anatomical condition of the prosencephalon, audits homology with the hemispheres of the Mrd's brain expert-
I by Flovrens, would lead to the belief that It wan in this dirislon of tiie Ash's brain that Impressions become
, and that here was the aeat of distinct and tenable ideas ; of such for example as teadi the Ash Its safest
Inikin^i^lacea, and |^re it that degree of caution and discernment which requires the skill of the pncticed angler to
overmatch- If different parts of the prosencephalon were special seats or organs of different psychical phenomena, such
abenomena are sufficiently direrslAed In the class of Ashes, and are so energetically and excludvely manifested as to
justify the expectation on that physiological hypothesis of corresponding modlAcations In the form and development
of the hoaBQlognea of the cerebral hemispheres. Some species, a8.$>r example the Shark and the Pike are i»edatory
and ferocious: some, as the Angler and the Skate, are crafty ; some, as the Sword-Ash and Stickleback, are combative;
aoaae, as the Oarp and Barbel, are peaceful, timid orowsers ; many Ashes are social, especially at the season of ovlposl-
thm ; a few are monogamus and copulative ; still fewer, nIdlAcate and incubate their ora.
How, if we compare the proeenoephiila of the Shark and Pike, Ashes equally sanguinair and insatiable, alike
nnaociable, the ^ranU fespectftiUy of the sea and lake, we And that these parts of the brain differ more In shape, in
rslatire sfam, and in structure, than in any two Ashes. The prosencephalon of the FUke, Is leas than the cerebellum,
mnch leaa than the optic lobea; in the Shark, it exceeda in siie all the rest of the brain ; In the Pike the prosen-
cephalon consists of two distinct lobes brought into communication only by a slender transrerse commissure ; In the
Stork, the hemhn^eres are indistinguishabfy blended into one large sub-globular mass. If we compare the prosen-
ctahala of the Pike with tiiose of the Oarp, we And them narrow in the derourer, broad in the prey.
The Lophiua lurks at the bottom, hidden in the sand, waiting like the Skate for its prey to come within reach of
its >ws jthe diflisrence in the shape, sise and structure of their prosencephala^ is hardly leas than between the Shark
and tiie Pike. The combatire Stidcleback has longer and narrower prosencephala than the cowardly Oodgeon. The
nIdlAoalire and phllo-progenitire OcJKehtkgB has neither the antero-laterai, nor the posterior regions of the cerebellum
mora dareloped than in &e bony Aahaa generally.*' Anatomy of Vertebrates— London, 1866, Vol. 1 pp. 289-290.
Id the Brain of the Crocodile a marked advance is seen in the relative size of the cerebral
lobes, especially in regard to their breadth and height posteriorly, giving a pjriform
shape 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 sise of the cerebrum
and cerebellnm, together with the folding of the latter, which relates probably to the higher
locomotire powers of the bird ; it differs from the brain of the Mammal in the absence or
small beginning of the fornix, and of the lateral lobes of the cerebellum ; it differs from the
brain of every other class in the lateral and inferior position of the optic lobes.
In mammalia, the brain has a cerebellum, with large lateral lobes, and the gray superfices
mnch folded ; the commissural fibres form, as they cross the under surface of the brain, a
defined track or prominence, called pons varolii ; the optic lobes are medial in position, and
divided by a transverse furrow ; the cerebral lobes, are not only united by a round commis-
sure, bnt by a <* lyra " and hypocampal commissure, from which is developed in the majority
of the class, a " corpus callosnm," or great commissure. In the lowest types of mammals the
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64 Introduetim to the Study qf DUeases qf the Nervous System.
cerebral hemispheres are without folds, and leave the cerebellam, olfactorj lobes, and part
of the optic lobes exposed. In man the brain presents an ascension step in development,
higher and more strongly marked than that bj which the various lower clMses are dittin*
gnished from each other. Although in the highest mammalia, the t^erebrum may extend over
the cerebellum, in man not only do the cerebral hemispheres overlap the olfactory lobes and
cerebellum^ but they extend in advance of the one, and fiirther 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 ventricolar
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 horn-like 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 con-
sequence strikingly illustrate the value of the cerebral character, and sustain the position
that the Oentu Homo, is not merely a representative of a distinct order, but of a distinct sob-
class of the mammalia. While the human brain is exceeded in weight by that of the Elephant
and Whale, it is absolutely heavier than in all other animals ; on the other hand, in the pro-
portionate size of the cerebrum to the cerebellum, the human brain surpasses that of all
mammalia, being as 8 to 1.
In proportion as intelligence advances, the surface of the cerebral hemispheres become
more extensive and are thrown into more numerous convolutions, separated by deep snlm ;
thus indicating that there is a relationship not merely between the bulk of the brain and the
intellectual faculties, 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
progp*e88ive 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 organization of the nervous
system, the cerebral lobes become gradually more elevated and arched, and that their convo-
lutions 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 as by Comparative Anatomy,
that the human brain is distinguished from that of all animals, both by the size and elevation
of the hemispheres, and by the greater number of convolutions. .
The vast superiority of man over all other animals, in the faculties 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 doinestic 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 Aristotle^ that man has the largest brain in proportion to his body. Some more
modern physiologists, however, in foHowing 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 (somequadm-
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, Sdmmering furnished another point of comparison, viz : That of the ratio which
the mass of the brain bears to the nerves arising fk'om 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 paralyzed ;
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 ftac-
ture of some of the cervical vertebratse, 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, thoogh each of the organs of sense and motion may
be individually in a sound state, as has been so often witnessed in the effects of external
violence upon the brain, and in various diseased states either of nervous matter iuelf, or of
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other bodies in its Ticinity) such as tomors of the skull, thickeniii([ of Its membranes, or
eifased liquids of anj kind pressing upon the surface of the brain, or contained within its
cavities. Pressure is undoubtedlj, one of the most frequent causes of the loss of nervous
power; and this may take place, without any permanent injury to the part compressed, for
when the pressure is removed, the organ frequently resumes its ordinary functions.
The question was early raised by physiologists, whether when volition is exercised and mus-
cular contraction is produced, the first effect consists in some change in the brain itself, or
whether the will acts immediately upon the muscles 7 This question cannot be regarded as a
BMrely 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 favors 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
and ganglionic centres connected with the organs. Although this view has been generally
adopted by modern physiologists and sustained by anatomical research and physiological ex-
periments, a eontrary doctrine was maintained by many of the writers of the last century, and
especially by the Stahlians, who conceived that the Soul is co-existent with the different parts
of the body, 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, concluded 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
sat^ed with assigning the brain generally as the sensorium commune, 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
seat 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 as to the use of its individual parts. The doctrine was evolved from
such discussions coupled with anatomical research and physiological experiments, that not
only the various 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 degree 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-
Testing membrane, or the idea of DesOartes, that the pineal gland, is the peculiar organ of the
nervous function, and the teat of the eoul.
Those physiologists proceeded upon true inductive principles, who examined the brain after
it bad 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 faculties 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 organization, and a much greater variety of separate parts, all of which it was fairly
coBcladed 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
perceptive faculties. These results corresponded with those pathological observations, in
which abscesses have formed in 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 ; and 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 many
of the nerves may be traced to certain parts of the brain and to the medulla oblongata, no
special anatomical centre has been discovered, and the difficulties which were encountered by
the physiologists of the last century, were evident from the fact that Soemmering, fixed upon
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66 Introduction to the Study of Diseases of the Nervous System.
the halituB, or fluid in the yentricles, as the primary seat of sensibility. Such considerations,
led many 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 nerves and spinal cord.
Willis was amongst the first, to distinctly point out certain phenomena sustaining the riew,
that different portions of the brain are subseryient to different offices, as for example, that
some are more particularly connected with the organs of sense, some with the Toluotary
motion, and others with the different vital functions. According to Willis, the cerebrum or
proper brain, is the organ of the perception derived from the external senses, and of voluntary
motion, while the cerebellum is the source of the involuntary and vital functions ; 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, cansiders 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 from
that of volition.
There is every reason however, to believe that Flourens, was ignorant of the experiments
of Rolando, while be was pursuing his investigations, and their coincidence has tended to
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 Desmoulins, and
they moreover obtained to a certain extent the sanction of Ouvier. 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 Experimentales sur les Propri6tes et les Func-
tions du Syst^me dans 4<>i°aaux Yertdbr^s). 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 braiu, and the brain may
be considered as made up of the cerebrum, the cerebellum, the corpora quadrigemtna, 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 mednlla 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 hu injury
of the cerebrum or the cerebellum, is manifested by a loss of the functions of the opposite
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
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Introduetian to the Study of Disseises of the Nervous System. 67
act like the cerebram and oerebellam, while the spine and the medulla oblongata^ prodace
their effect on the same side with that on which they hare been iigured. One of the most
important points which Flonrens attempted to establish, was that the lobes of the cerebrum
are the exdusire seat of sensation and volition ; and yet it is evident from the result of the
experiment, that after the removal of these lobes, sensation, although rendered feeble or
obtuse, was by no means eztinguished^ while the functions which depended upon volition,
toch as the various kinds of locomotion, were still executed by the animal, although it was
difficolt 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
uervous function, but rather to the existence of the cerebellum, as a centre of the sympa-
thetic 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 cerebrum, for he found that animals, in whom this part has been
entirely removed, still gave evident marks of perception, and performed certain motions, which
have been regarded as depending on habit or instinct; he agrees, however, with Flourens, in
regard to the functions of the cerebrum. The view of the functions of the cerebrum advanced
by Flourens, are confirmed in the main by the experiments of M agendie and Pod^ra, whilst the
experiments of Desmoulins, which appear to have been equally direct with those of Flourens,
were attended with different results.
M. Desmoulins (Anatomic des Syst^mes Kerveaox des Animaux k Vert^br^s), observes that
there are three modes of becoming acquainted with the functions of the nervous system, and
assigning to each part of it, its specific office.
The first is that of experiment : by removing successively the several parts of' the brain
and its appendages, and by observing what effect is produced by these successive removals,
we attempt to g^in 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 anatomy and pathology.
Desmoulins remarks, that there are three distinct orders of nervous phenomena ; those
which produce muscular contraction, that which produces sensation ; and those which pro-
duce thought. The two first are seated both in the cerebral-spinal system and in the nerves ;
and in each of these systems every nervous function hns 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 volition
may constitute a fifth distinct nervous function. According to Desmoulins, if we successively
remove the whole 9f ^he cerebrum, then the optic tbalami, andjastly the whole of the cere-
bellum, so as to leave the insertion of the fifth pair of nerves uninjured, the animal retains
the consciousness of all the sensations which have their seat in the face, except those of sight ;
he is said to manifest the perception of sounds, odours, tastes, and mechanical irritation ; he
cries out 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
it removed ; and even the power of volition would appear to be not altogether destroyed.
But by the division of the spine below the lobe, all the functions are suspended, so as to indi-
cate that this is the place of the gathering and reunion of the sensations of the entire body.
And it further appears that 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,
that there is no foundation, for the opinion that has been embraced by Gall and others, that the
developmei^ 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 regelating muscular motion. The opinion which Desmoulins entertained with respect
to the specific use of this part was, that the mutilation and destruction of the cerebellum
^ nentralisent une force qui faisait 6quilibr6 avec une autre force produisant la tendance ti
reculer. Ce n'est done pas le cervelet lui-m6me qui est le si6ge de cette derni^re force, il
parait TStre an 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
dividing 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, and is
only prevented by a mechanical obstacle. The conclusion which Desmoulins draws from the
experiments of Magendie, is ''que deux forces an tagonistes circulent par lesdeux demi-cercles
lat^raux que forment le cervelet et sa commissure." A no less remarkable effect is stated as
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68 Introduction to the Study of Diseases of the Nervous System.
being the result of an injury of one of the optic tbalami ; this, it is said " entraine irreaisii-
blement ranimal dans nne course ou dans un toI circulaire ou de manege, sur le c6t^ dont on
a bless^ le lobe ; " and it is also stated that frogs and serpents " tonrnent sur le c6t£ oppose
au lobe bless6."
According to Desmoulins, the volume of the brain is not the measure of the intellect, and
the internal contour of the cranium Is frequently not parallel to the external surface, so that
the relative size of the different parts of these lobes cannot be ascertained by an examination
of the skull. There is, however, a mechanical structure which appears to bear* a regular
ratio to the perfection of the intellectual faculties, viz : the number and character of the con-
volutions of the hemispheres. Magendie ib stated to have been the first 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 by various facts in comparative anatomji
by the comparative state of the foetal 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 faculties, both in a series of species, and in the individuals of the
same species, are in proportion to the extent of the cerebral surfaces. With reference to the
hypothesis of Gall and Spurzheim, 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 mammlftre
la route d^ I'hemisphere cerebral et le corps stri6 ; aussitftt Tanimal s'^lance droit en avant
et court sans se d^tourner Jusqu'di ce qu'il cheque 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 Journal, t. iii., p. 157), the removal or
destruction of the cerebellum produced an irresistible tendency to retrograde motion, and
when one of the crura cerebelli was divided, the animal began to rotate with great rapidityf
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 of the brain was detected ; and Fod^ra also witnessed the same irresistible tendency %o
retrograde motion after the removal or mutilation of the cerebellum.
Bouillaud, (Magendie'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 intellctnal
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 conclusion
of Foville, that they are *Hhe 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. Bouillaud details a number of experiments, in which the
lobes of various animals, birds, rabbits and dogs were removed, cauterized or laid bare ; the
general results were that the sensations were not destroyed, but that the intellectual powers
were either destroyed or disordered. The removal of the cerebrum destroyed the power of
recognizing external objects and intellectual acts depending on this power, but the animal
still retained the power of motion and the use of the external senses; the destruction 6f the
anterior part of the cerebrum produced very nearly the same effect with the destruction of
the whole. The experiments of Bouillaud were supposed to afford clear proof of the diffbreat
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 Flourens were confirmed by Hertwig, who found that the cerebellum
itself was insensible ; that irritation ot it excited no convulsions; 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 cerebellum
had 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
Flourens were also repeated with similar results by Budge and Longet. The comparative
effects of removal of the cerebrum and cerebellum, were well shown by Longet, who says :
^* Take two pigeons, from one remove completely the cerebral lobes, and from the other only
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Introduetwn to the Study qf Diseases qf the Nervous System. 69
half the cerebeUum ; the next day the first will be firm upon his feet, the secood will exhibit
the untteadj and uncertain gait of drunkenness."
Lronget demonstrated the fact that both sight and hearipg are retained after extirpation of
the hemispheres, even more clearly than Bouillaud, by the following experiments : The hem-
ispheres were remoTed 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 brouht near the eyes, and the bird even followed with its head the motions ot a lighted
candle. The report of a pistol caused an animal to opeu 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. ( Traiie de Phynologit),
The weight of testimony based upon actual experiment, appears therefore to favor the
conclosion of Flourens, that the cerebellum possesses the power of co-ordinating the volun-
tary movements which originate in other parts of the cerebro-spinnl centre, whether ^hese
movements 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 Cyclopaedia of Anatomy and Phvsiologv, (pp. 720-723 ), and repro-
duced in the *' Phytiologieal Anatomy and Phynology of Many^ advocates the view that this
power is mental, or dependent tor 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
requires practice. Thus, he says, that the voluntary movements of a new-bom infant,
although perfectly controllable by the will, are far from being co-ordinate ; they are, on th^
contrary, remarkable for their vagueness and want of definition. Yet all the parts of the
eerebro- spinal centre are well developed, except the cerebellum, and the convolutions of the
cerebrum. Now, the power of co-ordination improves earlier and more rapidly than the
intellectual faculties ; and we find, according to Dr. Todd, that the cerebellum reaches its
development 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 deglutition 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
processus 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 that, that sense must materially assistv The cerebellum is brought into
union with each segment of the great nervoas centre upon which all the movements and sen-
sations 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 affirms that it would be difficult to conceive any function for which so elaborate a pro-
vision would be more necessary, than that of regulating and co-ordinating the infinitely com-
plex movements which the muscular system is capable of effecting; more especially, when it
seems highly probable that the antero-lateral columns of the cord, and the anterior pyramids
and olivary columns snpply all the anatomical conditions necessary for the development of
acts of sensation and volition.
Whilst therefore, F1onren*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 continned from the crus
cerebelli causes hemiplegia on the opposite side. This similarity between the effects ot
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
mesocephale would propagate to this segment the morbid influence of any deep seated lesion
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70 Introduction to the Study of Diseases qf the Nervous System.
of the cerebellum, and thas affect the adjacent pyramid, which again woald affect the oppo-
site half of the body just as if the morbid influence originated in the cerebral hemisphere. It
is then, this secondary affection of .either pyramidal body which obscnres the proper signs
referable to cerebellar disease.
Some cases of disease of the cerebellum hare however been recorded by M. Combette,
(Revue Medicate Avril, 1831) ; Magendie and CruTeilhier, (Anat. Physiologpque, Liv.. 15, fl. t.)
Dr. Todd, {Oyelopsedia of Anatouig and Phytiology^ p. 722, S.) ; Andral, (Cliniqne MMicftle,
1834 tome V.) ; Gnyot, Delamare, Gall (Snr les functions du Oerveau, Paris, 1823, tome III,
p. 341); Petiet, (Journal de Physiologie, Paris, 1826, tome VI, p. 162 et seq); Larrey,
(Memoirs on Military Surgery , Baltimore^ 1814 ; Obtervationt on Wounds j etc. Injuries, of the Osrt'
belhtmj Philadelphia^ 1823, p, 199, et seq)] Wagner and Laborde, ( Journal de la Physiologie,
Paris, 1861, tome IV, p. 386, p. 637); Fiedler, (Bin Fall von Verkummerung de« OerebelUsm,
Zeitsehrift fur rationale Mediein^ Leipzig und Heidelberg, 1861, Bd. XI. S. 250 et seq) ; Yulpian,
(Syst^me Nervenx, Paris 1866, p. 629) ; Bonvier, Hammond, (The Physiology and Pathol^p'
of the Cerebellum — Quarterly Journal of Psychological Medicine, New York, 1869, toI. UI,
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, 1873),
after a careful analysis of the 93 cases of disease of the cerebellum reported by Andral, and
of 16 additional cases, collected from various sources by himself, draws the following condu-
sions :
** We oome now to the nudu qaeetkm, whether or not in view of the resalti of vzperimeiitt od antmalii aad thm
phenomena obeenred in casee of diae«8e or ii^uiy of the cerebellam, this nerve centre presMee orer codrdloation ot
notion of the mnsclee^ which i« certainly neceuary to the equilibration, except the muscles of the &ce and thoee
concerned in speech. This question seems to us to be capable of a definite answer.
Krery oareftilly obsenred case that we have been able to find, in which there was an uncomplicated disease or In-
Jury of the cerebellum, provided the disease or ii^ury involved more than half of the organ, presented great disorder
in the general movements, particularly those of progression, * * *
We do not make the reservation that more than half of the cerebellum must be destroyed in order sncowftolly to
produce difficult in muscular ootfrdination, on purely theoretical grounds, but regard this point as podtivelj deoMm-
strated by oxpenments on animals. These experiments show that one-half of the organ is capable of performing the
function of the whole. We have an analogy to this In the action of the kidneys, one of v^lch is snflicient for the
elimination of the effete constituents of the urine, after the other has been removed.
Notwithstanding the oontrar>' views of many physiological writers, we are firmly convinced from experiments and
a careful study of pathological Ikcts, that there is no one point in the physiology of the nerve-cuntres more definitely
settled ttian that tne cerebellum presides over equilibration and the coordination of the muscular movements, par-
ticularly those of progression. In this statement we make exceptions in Ikvor of the movements of respiration deg-
lutition, of the face, and of those concerned in speech, as well as the involuntary movements generally. As another
example of a nerve-centre presiding over muscular coordination, we have the instance of the portion of the left
anterior lobe of the cerebrum, which coordinates the action of the muscles concerned in speech.
The theory that the disordered movements which follow it^juiy of the cerebellum, is simply due to vertigo Is not
tenable. In only three of the cases dted, is vertigo mentioned ; and in two, the word vertigo seems to be used rathsr
as an explanation of the phenomena observed, ^an in their simple description. There u a disease involTing the
semicircular canals, and ottier parts of the Internal ear, called M6n{dre*8 disease, in which ttiere is marked vrani of
equilibration and muscular coordination, attended with, and probably dependent upon vertigo. The vertigo is always
very distinct, and is mentioned in all the cases ; and though it U less in the recumbent p(Mition, It is never eotiiely
absent.** pp.38&-388.
Poville 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 sentient nerves, which might be inferred if it
performed the office in question, not one of the nerves of pure 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 craniologists or phrenologists. Pre-
cise facts, however, have not confirmed, and pathological data seems rather opposed to this
view. Baron Larrey was led by his extensive experience to conclude that ** the cerebellum
exerted a strongly marked vital influence on the genital organs." {Climque Cktrurgieale. tome
1. p. 297, 1829) ; and he cites the following cases to sustain this view:
** A young soldier of 18, received a blow upon the nape ot the neck. He became alarmingly 01 in conseqaenoo,
and only quitted the hoiroital after three mo iths* sojourn there. Fourteen yean afterwards this man presented
himself for discharge. Efe wu then pale and beardless, and his voice was piping and feminine. His genital organs
were reduced to the sise of tlrose of a child of a few months old ; — the testes were not larger than haricot beans. He
stated that since his accident, he had been without any sexual desire, although he had formerly been like the rest of
the comrades in this respect ; that his beard, which was well grown at the age of 18, bad fiulen out. His Intelleo-
tual fiftcultles had never been affected.
** An artilleryman received a musket shot in the neck, the ball traversing tiie nape and gnudng the oodpltal pro-
tuberances. The sight and hearing were mudi affected; the testes fell into a sort of atrophy, and the penis shrunk
in the same d^p-ee, and was altogether inactive." CUmique Okbrmyicak^ tome I, p. 306.
Gall's view rests on two assumptions ; first, that the instinct of generation or of reproduc-
tion is the most indispensable and rnost powerful of all the instincts ; and secondly that great width
ot the occipital region of the skull, and thickness of the back of the neck indicate great
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Introduction to the Study qf Diseases of the Nervous System. 71
derelopment of the cerebellam. It is by reason of the assumed 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 nrged against the hypothesis of Gall : The sexual instinct cannot be separated
from the emotions, and especially from those which are clearly instinctive in their nature ;
the same part of the brain would probably exercise its influence upon all the emotional
actions. But 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 ; snd 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
far 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 Gall's 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 animals ; but
this is by no means the case.
In fish, 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 on^
of the smallest 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
much 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 eerebellnm, may be opposed the results of the researches of M. Leurel^, who took the
weight of the cerebellum both absolutely, and as compared with that of the cerebrum in ten
ilallions, twelve mares, and twenty-one geldings, and obtained the remarkable result, that
castration tends to augment^ and not to reduce the weight of the cerebellum.
The few cases quoted by Gall, in which the injury in the neighborhood of the cere*
bellnm 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 fiicts 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). Dunglison observed priapism in a case of inflammation of the
cerebellum with serous effusion ; but destruction or irritation of the spinal cord in animals
also gives rise occasionally to erection of the penis ; the coincidence of disease of the spinal
cord with affection 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, Cruveilbier and others, in
which disease of the cerebellum was atteifded 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-
sistent erection and manifest exaggeration of the sexual appetite, would seem to imply that
the cerebellum may have other functions besides the equilibration and coordination of certain
muscular movements. M. Budge (Miiller'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, causes 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 irritation of the cerebellum. (Lehrbuch der Sped-
eUen PhyBiologie dee Meneohrty Leiptig^ 1862, 788). Hammond (Phytiology and Pathology, of the
OerebeUum; Quarterly Journal of Psychological Medicine, New York, 1869, vol. iii, p. 223,) also
Doted similar movements m cats just killed, and also movements of the intestines and of the
muscles of the abdomen, thigh and back.
It mnst be admitted however, that the physiological and pathological facts, are not suffi-
ciently numerous and definite, to sustain the doctrine of Gall, that thtf cerebellup 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 mat^ter
of the corpora striata, and of the optic thalami, the tubercula quadrigemina and the gray
matter of the tuber annulare, or pons varolii, and the ganglion of the medulla oblongata,
are generally recognized as distinct ganglia, having separate and distinct functions, which are
more or less completely understood.
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72 Introduction to the Study of Diseases qf the Nervous System.
According to J. Lays, (Recherehet mr U Sytthne Niarveux OfrSltro^Spinal taStruehtre^ 9e$ i
Uofu et $69 Maladies^ PariSj 1865), the gray matter of the cerebral hemispheres is composed of
a mass of mere cells, coooected together by their prolongations into a plexns, which in its
turn is connected with the fibres of the white substance. From this cortical cellalar plexus,
white fibres arise, which may be divided according to their direction and destination into two
classes. The first class consists of cnrred commissural fibres, which pass into the white sob-
staoce to a certain depth and return to the gray matter, connecting thus the gray substaDce
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 thalaml :
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 subttaoce
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 ar«
directed toward the corpora striata and the optic thalami. The limits of the irregular planes
of separation of the commissural and the converging fibres contribute to form the boandaries
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 region
of the cerebrum pass backward, and form distinct fasciculi which converge to the gray tob-
^tance 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 ft>om the posterior portion pass
from behind forward, and distribute 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 coo-
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 substance 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 ascend 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, or crura cerebri ;
and other fibres pass to the tubercula quadrigemina. As the bundles of fibres ascend fVom the
medulla oblongata, they become more and more numerous by reenforcements 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 cornua of the g^y
substance of the cord ; while the latter are large and resemble the so-called motor cells of
the cord, has led to the supposition that the large^ 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, in
which are found numerous bodies like free nuclei, called by Robin, Myelocytes. The external
layer, resembles that of the gray substance of the posterior lobes of the cerebrum, and is
divided into two or more secondary layers ; the most external portion contains 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 substance of the convolutions and their prolongations, the fibres of tbe cer-
ebellum converge to form the crura, or peduncles on each side. The superior peduncles pass
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 certain 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 cerebellum,
pass to the pons varolii, where they decussate, connecting together the two sides of the cere-
bellum. The inferior peduncles pass to the medulla oblongata, 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 from the cortical substance of tbe cerebellum all
pass to the corpora dentata and there terminate, being connected with the cells. Prom tbe
corpora dentata, new fibres arise, which go to form the cerebellar peduncles. Luys does not
admit the existence of commissural fibres connecting the two lateral halves of the cerebel-
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Introduction to the Study of Diseases of the Nervous System. 73
lam, And assames that the decuBsation between the two sides, takes place through a special
system of decossatiog prolongations from the cells of the cortical substance, which he
calls intercortical commissural fibres. Bj the superior peduncles, the cerebellum is con-
nected as are all of the cephalic ganglia, with the cerebrum ; by the middle peduncles, the
two lateral halves of the cerebellum are intimately connected with each other ; and by the
inferior peduncles, the cerebrum is connected with the posterior columns of the spinal
cord.*
It is now universally admitted that an animal deprived of the cerebral hemispheres, is in-
capable of a spontaneous voluntary effort. Thus Yulpian says with regard to a rabbit from
which he bad removed the cerebral hemispheres and the corpora striata, that it was com-
pletely deprived of spontaneous volition ; 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., {Sjfstime Nerveux, ParU, 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 lost 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
anurior lobe by Broca, Aubertin, Charcot, Falret, Perroud and Trousseau, and the limitation
of the lesion, by M. G« Dax, in 1863, to the anterior and middle part of the left anterior lohe^ and
the subsequent observations of Broca, Huglings-Jackson, Sanders, lloxou. Ogle, Bateman,
Bastian, Von Benedict, Braunwart, Austin Flint, Wilbur, Seguin and others, indicating that
the most frequent lesion, in aphoiia, 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
80 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
Rolando, 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 Fristch and Hitzig, 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 Hitzig, after ex-
posing 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.
Each galvanization produced movements restricted to particular sets of muscles ; but it was-
difficult to say whether the contractions were due to stimulation of the white or of the gray
sabstance. 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 passing an interrupted current through these parts, tetanus of particular mus-
cles was produced. In other observations, when the gray substance was removed at the
points mentioned, there was partial loss of power, but not paralysis, of the sets of muscles
corresponding to the centres operated upon. The experimenters regarded this as doe to a loss
of tmucular »en»e. In these experiments the action was always crossed. It was also found that
after severe haemorrhage, the excitability of the cerebrum quickly disappeared, which may
account for the negative results obtained by previous observers. No motor properties were
fonnd in the posterior portions of the cerebrum.
These experiments of Fritsch and Hitzig, 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 haemorrhage 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
bj these new methods of research. f
In the London Lancet, October 2 1st, 1871, No. xvii, p. 581, it is stated that the experiments
of Fritsch and Hitzig, 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
*The Physiology of Man -Nervous System, by Aastin Floret, Jr., M. T>^ pp. 317, 319, 360, 362.
tViitKh and Hitzig, Uber die electrische Erregbariceit des Grosshims: — ArchiT TUr Anatomie, Pysioloffie, nnri
Wiasenscliafllictae Medecin, Leipzig, 1870, 8. 300 et seq. The Physiology of Man — Nervous System, by Austin Flint
ix^ M. O. New York, 187:i, pp. 323-324.
lU
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74 Introduction to the Study of Diseases of the Nervous System.
excitability of the brain, but are reflex, the result of irritation of parts concerned in tactile
sensibility. *
More recently, Dr Edward Hitzig,* has published an account of the electrical exploration
of the brain of an ape, with the constant and inductile current, with the following general
results : The anterior central convolution is the general centre for the muscles of the body :
and the special centres for the different sets of muscles 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 seren millimetres farther in the same direction was the centre for the
parts innervated by the facial nerve. Finally, close to the sylvian fissures, be found the
centre of the muscles of the tongue, mouth and jaws. This last observation is interesting
from the fact that lesions in the same neighborhood are so frequently connected with aphasia
in the human subject.
Professor David Ferrier, f of King's College, London, has repeated the experiments of
Hitzig and Fritsch, with the following general results :
The research was commenced with a view to test the accuracy of the views entertained by
Dr. Hughlings-Jackson on the Pathology of Epilepsy and Chorea. As is well known, Dr.
Jackson regards localized and unilateral epilepsies as depending on irritating or discharging
lesions of the convolutions about the corpus striatum. In order to pnt this theory to the
proof, Professor Ferrier, determined to expose the brain in various animals, and apply irrita-
tion to the surface after the method of Fritsch and Hitzig, who as we have seen, had shown
that contractions of definite groups of muscles could be caused in dogs by passing gaWanic
currents through certain portions of the anterior regions of the brain. The progress of the
research ultimately led to the endeavor to establish the localization of cerebral functions,
not merely as regards motion, but also as regards sensation, and the other facnltiea of the
mind. The experiments were repeated before the British Medical Association, at Bradford, in
1873 ; an account of the experiments were first published in the third volume of the " West
Riding Lunatic Asylum Reports," for by the kindness of Dr. Crichton Brown, the snperin-
tendent of the Asylum, Dr. Ferrier was able to conduct his experiments there. An abstract
by the author of his 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 Reymond'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 Fritsch and Hitzig),
and in corresponding regions of non-convoluted brains, are localized the centres for the vari-
ous movements of the eyelids, the face, the mouth and tongue, the ear, the neck, the hand,
foot and tail. Striking differences, corresponding with the habits of the animal are to be
found in the differentiation of the centres. Thus the centres for the tail in dogs, the paw in
cats, and the lips and mouth in rabbits, are highly differentiated and pronounced.
3. The results were such as to indicate with a degree of exactitude the localization in
certain definite and easily defined regions the cerebral centres for various apparently pur-
posive combined movements of the muscles 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 parts of
the brain in advance of the fissure of Silvius, and the individual centres are marked off in the
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 extent
characteristic of the animal's habits ; the centre for the fore-paw in cats being much more
highly differentiated than in dog^ and rabbits.
The middle external convolutions govern movements of the eyelids, face and eyes, while the
inferior and the Sylvian govern various movements of the whiskers, angle of the mouth,
depressors of the lower jaw and tongue. In the convolutions posterior to the Fissure of
Silvius, certain movements are described as resulting from irritation, viz : of the ears,' eyes,
* Berliner Klin, Wochenschrlft, No. 6, Feb. 6, 1874. Also Chicago Journal of Nerrous and Mental Dfaeaee, Tol. I,
No. 2, page 232.
t Brittfh Medical Journal, ISTJ, Medical Timet and Gazette, August 20th, 1873, p. 233, West Riding Lmnatk
AsTlum Medical Beports, Vol. Ill, 1873.
Journal of Anatomy and Pbysiologj, November, 1873, p. 152.
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Introduction to the Study of Diseases qf the Nervous System. 75
etc There are indications of the sitaation in those regions of the centres of special sense,
sight, hearing and smell.
4. The action of the hemisphere is in general crossed ; bat certain movements of the month,
tongue, and neck are bilaterally co-ordinated from each cerebral hemisphere.
One of the most important conclasions drawn from the experiments, is, that the region
which goTerns the movements of the month and tongue in cats and dogs, is the homologue
of what 18 known as Broca's convolution in man, viz : the posterior part of the inferior fron-
tal. This is farther borne out bj experiments on monkeys. The pathology of Aphasia is
thas rendered comparatively simple. The memory of words is situated in that part of the
braiu which governs the movements of articulation. It is shown, however, by the experi-
ments, that the brain is symmetrical, and that the corresponding part of each hemisphere
prodocea exactly the same effects on opposite sides of the body. Qenerally 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,
because 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 be is unable to lay hold of the word which he
wishee to express. With the education of the other side, however, the individual recovers
the power of speech. During the interval of recovery of speech, only automatic expressions
or interjections 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 different epilepsies are, as Dr. Hughlings-Jaokson 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
muscles represented in the cerebral hemispheres, with (oaming at the mouth, biting of the
tongue, and loss of consciousness. When induced artificially in animals, the affection as a
rule first invades the muscles most in voluntary use, in striking harmony with the Clinical
observations of Dr. Hughlings-Jackson.
It was found that in rabbits, cats 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 unilateral 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 rale, they commenced in the
face, spread to the neck and upper extremity, and then invaded the bind leg and tail. Dila-
ution of the pupil, clonic spasms of Che jaws, foaming at the mouth, and loss of conscious-
ness, were induced when the fits were at their greatest intensity. Occasionally, spasmodic con-
rulsions 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 any affection of sensibility or consciousness.
6. Chorea is of the same nature as epilepsy, dependent on momentary and successive
discharging lesions of 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 pleurosthotonos, 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.
irritation of these centres causes rigid opisthotonos and trismus.
10. The cerebellum is the coordinating centre for the muscles of the eye-ball. Each sepa-
rate lobnle (in rabbits) is a distinct centre for special alterations of the optic axes. These
cerebellar oculo-motorial centres are brought into relation with the cerebellum as a co-ordi-
nating 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. Nystagmus, or oscillation of the eye-balls, is an epileptiform affection of the cere-
bellar oculo-motorial centres.
13. Irritation of the nates causes g^eat dilatation of the pnpils. The action is crossed,
bat powerful irritation easily acts on both sides of the body. Trismus and opisthotonos are
indaced when the ganglia are powerfully stimulated.
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76 Introduction to the Study of Diseases of the Nervous System.
At the Berlin Medioo-Psjchological Society in Norember, 1873, Dr. Hitzig,* the author of
the method of the examination of the brain bj electricity, made some remarks on the prece-
ding experiments of Dr. Ferrier, and called attention to the important discrepancy, that whilst
he and Fritsch had fonnd only one part of the convexity of the hemisphere capable of elec-
trical excitation, Ferrier extends this property to nearly the whole of it. This Hitsiff,
explains by saying that Ferrier has in his experiments used too strong currents, (the secoBd-
ary coil of Stdhrer's battery being pushed in to eight and even four centimetres), and has thus
excited the ganglia at the base of the brain, so that it is to them, and not to centres localised
in the cortex, that the movements noted must be referred. Another reason why Hitsig doabts
some of the effects of irritation in Dr. Ferrier's cases, is because, although, there is such a
remarkable anatomical similarity between the brains of the dog and the cat, the latter foand
that electrisation of the spot on the cat's brain corresponding to the centre of movement for
the tail in the dog gave no result. Hitzig has repeated several of the experiments in wkich
Perrier's results differed from his own, and declares that his own views are re-affirmed. M.
Carvillef presented on behalf of himself and M. Dnret, at the $eanee of the Soc, de BkHogity
Jan. 3, (Report in Gaz, Med. de Paris, Jan. 24), a communication relative to the excitability
of the cerebral hemispheres by faradio currents, in which he criticised the recent investi^-
tions of Dr. Ferrier, in regard to the location of th e functions of the brain. The effort is
made to show that the phenomena described by Ferrier and others, are not due to localized
excitation of cortical centres, but to transmitted irritation of the cerebral ganglia and pedan-
cles. M. Carville and M. Duret, repeated the experiments of Dr. Ferrier, and then afterwards,
endeavored to obtain the same results when the animal was completely under the influence of
anaesthetics, but found them altogether different. Thus, when the ansssthesia was imperfect,
it was possible by applying the electrodes successively to the surface of the convolntionSy to
reproduce some of the movements described by Ferrier. For example, the excitation of the
anterior portion of the external superior convolution, 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 s^ond and third external convolutions 'produced a rota-
tion of the head towards the opposite side. Some of these movements, 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 anaesthesia was complete, no effects were obtained by the excitation of the convolo-
tioDS 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 th6 eye-lids, were manifested by electric irritation.
These results are explained by the hypothesis, that the currents applied to the surface, act
only by exciting the jcorpns striatum and the peduncles ; or, in short, those portions of the cere-
brum which are known to be excitable. Anaesthetics affect the medulla, and through it gradually
suppress the excitability of the various organs. When, therefore, the animal experimented
upon 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 faradization, 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 hem-
ispheres, but acts merely by more or less diminishing the excitability of those parts of the
hemisphere which are universally recognized as excitable.
M. Dupnyt in a note presented to the Soc. de Biologie, January 3d, 1874, holds that :
The conclusions of M. Ferrier cannot be accepted because that observer did not attempt
to find out whether the electric currents (faradic, 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 localize 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 anesthetized, electrical irritation of the cortex causes no contractions ; while in
the same animal, and with the same electrical current, the direct irritation of the sciatic
nerve, previously laid bare, causes a contraction of the muscle to which it is distributed.
* Medical Times and Gazette, January 24th, 1874, p. 104.
t Chicago Journal of Nerrooa and Mental Disease, Vol. I, No. 2, April, 1874, p. 231.
X Chicago Journal, Nerroua and Mental DiMase, Vol. 1, No. 2, p. 232.
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Introduction to the Study of Diseases of the Nervous System. 77
Dr. Roberts Bartholow,* of Cincinnati, hns bad the boldness^to apply this method of cerebral
exploration to the human subject.
A woman thirtj-two years old and of feeble intellect, was admitted to the Good Samaritan
Hospital in Cincinnati, on account of an epethelioroa which had destroyed some two inches of
the top of the skull, leaving the dura mater exposed.
Dr. Bariholow, anxious to repeat in the human subject the experiments of recent investi-
gators of the function of the brain, proceeded to apply powerful galvanic and faradic cur-
rents to the dnra mater, and to the substance of the brain, by needles of various lengths
insoiated to near the points. The needles, during the three weeks of experimenting, were
introduced about ten times in each hemisphere, to the depth of ft'om a twelfth part of an
inch to an inch 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
introdnced, 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,
but 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, caused the unilateral epilepsy of the opposite side, of great violence.
The following experiment was made to test faradic re-action of the posterior lobes :
J an insaUtod needle Into the left posterior lobe, so that the non-insuUted portion retted entirely in the
i of the brain. The other in<mlated needle was placed in contact w)Ui the dnra mater, within one-fonrth of
SB tneli of the first. When the elrcnit was clom<l, muscular contraction of the right upper and lower extremities
eas«ed, aa in the preceding obsenrationa. lUnt but viatble contraction of the left orbicularis palpebanim, and dila-
tation of the pupils also ensued. Blary complained of a very strong and unpleasant feeling of tingling in both rixht
extremitiea, eepedally in the right arm, which she seized with the opposite arm and ruu>ed Tigorously. Notwith-
standiB^ the very erldent pain ttma which she suffered, she smiled as If much amused.
The needle was now withdrawn ftom the left lobe and passed in the same way into the substance of the right.
Whok the current passed, precisely the same fdlienomena ensued in the left extremities and in the right orbicularis
pslpebarom and pupils, when the needle entered the brain substance, she complained of acute pun in the neck.
In order to develop more decided re-actions, the strength of the current was increased by drawing ont the wooden
cylfaider one inch. When otMnmunication was made wi^ the needloe, her countenance exhibited great distress, and
she benn to ciy ; veiy soon, the left hand was extended, as if in the act of .taking hold of some object in fh>nt of
her; the arm preeently was agitated with clonic spasms; her eyes became fixed, with pupils widely dilated ; lips
were blue, and die ftx>thed at the mouth: her breathing became stertorous; she lost consciousness, and was violently
eooTulsed on the left side. The coBVulsions lasted five minutes, and were succeeded by coma. She returned to con*
sdooaness in twenty minutes from the beginning of the attack, and complained of some weakness and vertigo.
Two days later the patient was brought down for similar experiments with the galvanic
current: " She was pale and depressed, her lips were blue, and she had evident difficulty 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
autopsy 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 cerebral matter."
It is evident that precisely the same 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 Hospital! of Cincinnati, viz : That the currents
affected simultaneously all the ganglia at the base of the brain, being diifued to regions far
distant from those included between the points of the needles.
Prufessor Gudden,f of Zurich, has instituted important 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 eflects of
the lesion upon the subsequent development of the animal being carefully watched. By this
method of experimenting he has fixed the centre for voluntary motion in the anterior lobes of
the cerebral hemispheres, and in this respect reaching a result similar to that obtained in the
precedincr experiments with electrical excitation of the various portions of the brain.
MM. Fournie and Beaunis,^ in France and Nothnagel|| in Germany, have endeavored to
determine the functions of the brain by destroying circumscribed portions. Thus the
• Cladnnati Enquirer, March 24. 1874.
Chicaco Journal Nenrous and Mental Disease^ Vol. 1, Ko. 2, p. 233.
Ameitean Journal Medical Bcienoes, April, 1874.
Boston Medical and Surgical Journal, April 30, 1874, p. 433.
t Arcbiv. ftir P^chiarie und Nerrenkran kheiten. Band II, 1870, page 693.
i Becherohtfi Experimentales sur le Fonctionnement d*u Gerreau, per le Dr. Edouard Foumie, Paris, 1873.
{ Yiichow^a Aichiv. f Path. Anat. u f. KUn. Med., Band. 67, 2d heft., pp. 184-214.
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78 Introduction to the Study of Diseases of the Nervous System.
animal to be operated upon was generally put under the influence of chloroform, and a snuJl
hole was made through the skull, down to the dura mater ; a small but definite quantity of a
concentrated caustic solution was introduced, by means of a syringe, into that part of the
brain selected for the operation. A solution of chromic acid was used by Nothn&gel, ajid
one of chloride of zinc, deeply tinged with analine, by Fournie. Such injections caased
complete destruction of comparatively limited portions of the nervous substance.
According to M. Fournie, injection of many parts of the cortical substance led, apparently,
to loss of memory and of the cognitive faculties, and to disturbance in different gronpt of
muscles. Nothnagel found that destruction of a small portion of the rabbit's brain, at a
point corresponding to the outer end of the last frontal convolution, on the anterior lobe of
the brain, destroyed the muscular sense in the fore limb of the 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 the hemisphere, the injection of which to some
little depth led to paralysis of the extremities of the opposite half of the body. This gener-
ally disappeared at the 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 the aifected
extremities, but believes that the point of lesion lies in the direct path of transit of the motor
impulse, the ultimate seat of which must be sought elsewhere, and that there are other, bat
less direct routes from it to the nervous apparatuses, that are immediately instrumental in
exciting the muscles of the limbs to contraction, which routes are gradually opened in pro-
portion as the animal regains the use of the paralyzed 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 Notbnaj^l
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 ot the body. Fonmie
found that injection of the 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 the optic thalamus was the seat of lesion, various phenomena were noted, according
to the seat and extent of the lesion ; in case of total 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
the optic lobes was a sort of galloping motion of the limbs, which was often continued ontil
terminated by paralysis or death.
Professor Nothnagel has published in Virchow's Archiv., Iviii, 420, Nov., 1873, a continua-
tion of his researches into certain parts of the brain : in this series of experiments, nnmberinip
over a hundred, he has modified his former method of investigation, namely : the injection of
a few drops of a concentrated solution of chromic acid into the particular regipn selected,
because' so many animals died from escape of the acid into the fourth ventricle. He now
simply pricks the brain with an ordinary microscopic needle. Rabbits were the animals used
in these experiments. He describes a remarkable series of " exquisite, convulsive, 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
seized with convulsive movements of such frightful intensity, that Nothnagel believes that
they cannot be compared witb any known phenomenon of experimental nerve- physiology,
not even with the general convulsions occurring in injuries of the pons. The animal,
immediately after the prick, or, at latest, one or two minutes afterwards, is impelled either
forwards, sideways, or occasionally backwards in a series of leaps, in which it is sometimes
shot up two or three feet into the air, as if by a springy and even strikes itself against the wall
of the room in which the experiments are made. These symptoms rapidly disappear, and the
animals often appear quite healthy a few minutes after the operation. The exact spot in the
hemisphere (the priclr was always made on the left side) which must be penetrated to pro-
duce these convulsive movements, is in the hinder part of its apex. The spot lies over the
corpora quadrigemina, which would be reached if the needle were introduced too far.
Experiments made in parts of the hemispheres further backwards, so as to irritate the
region surrounding the hippocampus major in its lower half, gave absolutely negative results,
although the needles were pushed fk'om side to side, so as to lacerate the cerebral substances
In experiments upon the Optic Thalami : — if the puncture only entered the superficial layer,
of the thalamus, little or no effect was produced ; but if it went deeper towards the "base, 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 their head to the
opposite side; if the thalamus were transversely divided, the deviation of the fore legrs was
found 10 persist a long time ; in the 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 through
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Introduction to the Study of Diseases of the Nervous System. 79
the robstADce of \he thalamus, bo that injury to a part of them by the simple puncture is
compensated for by the others which remain intact.
Nothnagel's results with regard to the hippooampns major and optic thalamus, thus agree
in ouuij points, with those of Dr. Ferrier on the same parts, by the method of electrical irri-
tation, bat the latter found no motor disturbances on stimulating the thalamus.
I have tliQS endearored to pi^sent the general history of results of the following methods
of research which have been employed for the determination of the functions of the cerebrum
and eerebellnm.
1. Minute Stmetnre and Anatomical Relations of the Brain and Spinal Cord.
2. Comparative Anatomy and Physiology of the Gerebro-Spinal Nervous System.
3. Effects of Disease and Pathological lesions upon the component parts of the Gerebro-
Spinal System.
4. Disturbances of nervous ftinctions by sections of the different ganglionic masses.
5. Irritation or excitation of definite portions of the brain, by means of electric currents.
6. Dettruc^on of definite portions of the brain in young animals, and observations upon
the effects of such lesions upon the nutrition and growth.
7. Destruction of small portions of the brain, by the injection of corrosive solutions, and
by small oeedles introduced into its substance.
RELATIONS OF THE GEREBRO-SPINAL AND SYMPATHETIC NERVOUS SYSTEMS.
Whilst endeavoring to present a general view of the advance of knowledge with reference
to the ftiDctions of the Sympathetic Nervous System and its relations to the Gerebro-Spinal
Sjetem, we shall also record the facts illustrating the relations of the nervous system to
Natrition, Secretion, Girculation, Respiration and Inflammation.
As far as possible the plan of the preceding portions of this Ghapter will be carried out
and the more important facts and researches presented in the order of their discovery and
execation.
The observations and experiments of Rufus Ephesus,^ Galen, ^ Piccolhomini,* Riolan,^
Plempius,^ Wills, • Ghirac, Bohn,' Duverney, Vieussens,' Schrader, Valsalva, Morgagni,
Baglivi, Berger,* Ens, Senac, Heuermann, Haller,^^ Brunn,^^ Molinelli, Petit,^' Fontana,''
Graiksbank, Haighton, Meyer, Bichat,^^ Dupuytren,^^* Dnmas,^^ Blainville, Provencal,^*
Yesalius, Columbus, Riolan,^'Bidloo,^* Muralto, Gourten, Drelincourt,^' Martin, >o Emmet.
Portal, Prochaska,*' Winslow,** Le Gallois,** Philip, Lobsiein,** Reid,** Krimer, Arne-
mann, LoDget,'" Brodie,*' Ghossat,*' McGartney,** Nasse.'o Bernard,®^ Hall,»* Brown-
S^uard,"* and others, have demonstrated that to the nervous system is delegated the pro-
1 ApMllAtkmes, Part Hun. Corp. Orocd. Puiriif, 1654, p. 32.
5 Gftfenl Open. Yenetiii, apad Joataa. 1676, de Hippocr. et Plat, decretls, lib. U. cap. t1. p. 239.
3 AnalomiciB Praleotiones Archang. Fiooolhomini, Boina», 1686.
4 Opera Anatomica. LatetUe Parislomm, 1649.
6 randamenta Medieiiue. Loranii, 1644.
6 Opera Omnia, edente Blasio. 1682, torn. i. Nervorom Descriptio.
7 ChcaliM Anatom. PhyBiol. Lipal«, 1697.
8 Traati»e on the Heart, Tonlotue, 1716.
9 Phyalologia Medica, FianoofartI, 1737.
10 M CfDoiree tnr lee parties eenaiblei et Irritablee, torn. i.
II Commentarii de rebu in Scient. Nat et Medic. Lipfiae, torn. iv.
12 M^raoiree de TAcad^mie dee Sciences, an. 1727.
13 TimiU sor le Venin de la Tip6re.
14 Becherch. Phys. ear la Vie et la Mort
14a ItmiH dan»> Biblioth.:MMic., torn. ztII. p. 1. Physiological Researches .
on Life aad Death, by Xavier Bichat, trans, by F. Gold, London.
15 Joomal 0«n«ral de M^decine, par M. SMillot, torn, xxxiii.
16 Balletin dee Sdenoes lIMicales, torn. t.
17 En<^eiridiain Anatom Parisiis, 1668. Opera Anatomi.
.18 Ixercitationes Anatom. rhinug. Lugd. Batav., 1708.
19 Bxperimenta Anatom. Lngd. Batav., 1681.
ao Bnals et Ofaaerr. de MMedne de la Soci6t6 d*Bdimbonig, Paris, 1742.
21 Opera Minora. Yiennn, 1800, tom. ii.
22 Izpoaition Anatum. Traits des Neift.
23 Experiments on the Prindple of Life, and Particularly on the Principles of the Motions of the Heart, and the
seat of tiiifl Principle, by M. Le Oallois. Translated by N. C. and J. O. Nancrede, Philadelphia, 1813.
H Stmctare, Functions and Diseases of the Human Sympathetic Nenre, by John Fred. Lobstein. Translated by
<los^ Pancoast, M. D., Philad^ 1831.
25 ** An Experimental Investigation into the Functions of the Eighth Pair of Neives,** by John Beid, M. D.
Edinburg Medical and Smgical Journal, 1838.
26 TnlU de Pbysiologie, Paris, 1860, t ii.
27 Medico-Chirurg. Trans., 1837, toI. xx. p. 132
28 Memoirs snr nnfluence du s^t nerr. sur le chal. anim. Th6se de Paris, No. 126, 1820.
29 Treatfae on Inflammation, 1^. p. 13.
30 Untersochungen snr Physiol, und Pathol., 1839, vli.
31 Oaz. M«dic. de Paris, vol. viL No. 14.
32 Phil. Trans., 1833. On the Diseases and Derangements of the Nervous System, by Manhall Hall, M. D., London,
IMl
33 Experimental Researches applied to Physiology and Pathology, by E. Brown-S^nard. New Tork, 1863.
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80 Introdiwtion to the Study of Diseases qf the Nervous System*
perty of regalating the Action of the organs and apparatus, and thus regulating the amoont
of oxygen and blood supplied to the organs and tissues and apparatus.
The blood supplying the nutritive elements of the tissues and organs, and the materialt for
the secretions and development of the forces, and oxygen being the active agent in all the
chemical actions of living bodies, it is evident that whatever disturbs the constitution of
the nervous system, necessarily disturbs the functions of the apparatus and organs, and
produces corresponding alterations in their secretions and excretions.
As the integrity of the nervous system depends upon the integrity of the blood, in lik«
manner whatever alters the constitution of that fluid will produce aberrated action in the
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 nerrons
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 consider the distinction
between the offices and phenomena of the two systems of nerves, the cerebro-spinal and
sympathetic.
Long before Haller, the intellectual functions, sensation, and voluntary motions, had been
distinguished from those which are exercised without our knowledge, and over which oar
will has no command, such as 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 functions, and both orders of functions were known to be equally under the
control of the nervous power. Willis* asserted the distinction between the nerves destined
to voluntary motions and those which preside over the internal natural Yunctions which are
independent of the will. He placed the origin of the nerves of the external animal functions
in the cerebrum, and that of the nerves of the internal natural functions in the cerebellnm,
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 the
brain is intermittent.
Boerhaavef adopted the opinions of Willie, and in the action of the heart, in addition to
nervous action, he admits two other causes of its motions, and their harmony : the action of
the blood of the coronary arteries upon the fibres of the heart, and of the venous blood in
the internal surfaces of the cavities of the heart. Recent experiments^ have rendered this
opinion of Boerhaave more than probable.
In 1752, Haller published his experiments upon irritability, which tended to establish the
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 opini<^n 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 all 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 the 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 the
motions of these organs are not submitted to the will because they are independent of the
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 the independence of the heart
and the intestines of the nervous system ; and Prochaska,J| 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
commnnication between the brain and the heart, by the abandonment of the then generally
received opinion that the brain was the centre and only source of the nervous power, and by
the adoption of the opinion that the nervous power is produced in the whole extent of the
nervous system, even in the smallest nerves, and that it can exist independently of the brain,
for a certain time.
Willis^ and Vieussens^ acknowledged the general relations of the sympathetic 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. Willis opera omnia, edente Ger. BaUio. Anutelodaml, 1682. Tom. i. de Cerebri Anatome, cap. xt.
f Her. Boerhaave Inst Modictt, { 409. Vanswieten in Aphorismoe, etc. Lugdoni BataT., 1745. Tom. ii.
iBrown-S^qiiard.
I Commentatio de Fnnctionibns Systematis Nervosi, 1784.
1 Nenrorum Descriptio et Usui. Gap. xxtI. Opera Omnia. Geneva, 1695» (ome i.
2 NearoRtaph. Univers., lib. 3 de Nervis, cap. v.
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Introduetion to the Study of Diseases of the Nervous System. 81
lower parts of the abdomeo, and noticed the important pbjsiolosrical and pathological facts
that not on\j do the Tarions conditions of the brain affect the viscera, bat the affections of
the Tiscera atfisct the brain as well as the mind itself.
Dr. Robert Whjtt of Edinbnrg, to whose important ** Essay on the Vital and other Invol-
antary Motions of Animals," pnblished in 1751, we have alluded in the discussion of the
history of the doctrine of reflex adton, promulgated fourteen years afterwards in 1765, his
" Obserrations on the Natnfe, Causes and Cure of those Disorders which have been commonly
called NerToas Hypochondriac or Hysteric,'' a work which abounds with valuable clinical
fiicts illustrating the " Sympathy* of the nerves.
In the first chapter, in which he discusses the ** Structure, Use, and Sympathy of the Nerves,''
Dr. Whytt enumerates various instances of sympathetic actions and discusses the mode of
their production. Thus he says :
** 0«r bodiM are, by means of the nerrei, uot only endowed with feeling and a power of motion, but with a
remarkable sympathy, which is either general and extended through the whole system or confined in a great a meas-
s«re to certain parts.
That mwmj sensible part of the body has a sympathy with the whole, will sufllcienUy appear from the following
bets:
Gold water thrown on any part of the body that is warm, produces a sudden contraction of the whole Tessels and
poff«s of the skin, and by that memis fk«quently puts a stop to small hsBmorrhages. * *
When the bnUn is wounded, inflamed, suppurated, or otherwise hurt, almost every part of the body is liable to
mWKt atad vomitiBgs, tremors, oonvulsions, palsies, Ac., often <»nsue. In animals newlv dead, the whole muscles of
the trunk and extremities are strongly oouTulsed, when a probe Is pushed down through the spinal marrow. * *
' A fever, dtttriHm^ and violent oonmhions, have been pioduced by a pin sticking in the oeats of the stomach :(a)
I, affecting either this part or the intestines, occasion a surprising variety of symptoms.
SpUeptie fits have proceeded from a rough bone or cartilaginous substance, irritating the nerves of the great toe,
or the calf of the leg; and the wound of a tendon or nerve has been the cause of a fever, deUrim^ tremors, violent
coawlsions, a feftimn and death. * *
Besides this gaaeral ppiiiwiI which prevails throughout the whole body, there ta a particular and very remaikabla
sympathy batween several of its organs, by means of which many operations are carried on in a spund state ; and
pain, convulsive motions, and other morbid symptoms are often produced in such parts, as have no near connexion
wHh those that are immediateiv affected. * * Grief, vexation or fear, lessen the secretion of the soKvo, destroy the
apntite, and sometimes oocamm a loosMiess. The great consent between the brain and the heart appears fkom the
sadden and remarkaMe effects of the passions on the latter. When one eye is affected with an inflammation, a cata-
nct, or the gmUa wreao, the other Is often soon after attacked with the same disease. The contraction of the pupil li
not owing to light acting as a tttmulu$ on the irit, but solely to the sympathy between this membrane and the retina,
« • The noise of a file and other harsh sounds affect the teeth with an uneanr sensation. The whetting of a knife
has caused the gums to bleed. * * The effluvia of Hungaiy water, or nurlt of wine drawn strongly into the
nostrils, increase the derivation of the salival Juice into the month, and sometimes stop a tickling cough. The smell
of grateful food makes the mtUva flow iriien one is hungry. Sternutatories not only increase the secretion from the
Buae, but also fhmi the lachrymal vessels. * * A pain in the teeth often affects the cheek bone, one side of the head,
the throat, and the corresponding ear. Children, fkom the irritation of the gums in teething, are liable to vomiting,
pufKing, a cough, a fever and convulsions. * * A disordered state of the stomarh and intestines, with wind or
noxious humours lodging In them, will sometimes so affect the brain, as to deprive people of their reason. At other
times, the same causes will produce a vertigo, oaphaima, kmmeratiim^ '
poise, dUBcoity of breathing, sudden flushes of heat and sweating.
1 produce a vertigo, otphaima, kmmenmim^ elamu Ays(«r<0M, palpitations, intermissions of the
I or disagreeable sensation In the stomach makes the pulse quicker and smaller, raises a sweat, and some-
times greatly increases the secretion of the Mljea or urine. When the stomach is empty and affected witn a sense of
hunger, the salival Juice flows much more co]^ously into the moutii, than after a tall meal, or when the natural
appirtite for food Is wanting. « *
An Inflammation of the Intestines is frequently attended with vomiting and a suppression of urine.' An opialhotono*
or a ktammt is often occssioned in hot climates, by a retention of the meconimm, or other acrid humours, in the bowels
of infents. That itchlpg of the nose, which is a bommon sign of worms, seems to indicate a peculiar sympathy
between this part and the intestiues; and the many other symptoms produced by worms, which I shall have occasion
to mention afterwards, show a remarkable and extensive consent between the flrat passages, and many other parts of
the body. Stones irrit 'ting the blliaiy ducts, frequentiy occasion a noiMea and vomiting. * * A noasM, vomiting,
eosthreness and inflamniatk>n of the boweh^ are often produced by an inflammation in the kidneys, or stones in the
urethra. * * An irritatiou of the neck of the bladder, or extremity of the rectum, is the cause of a constant con-
traction of the diapfaragiu and abdominal muscles. A stranguiy and ten«$mm mutually occasion each other. * *
At the time of puberty, not only the voice, but the whole body undergoes a sensible change, which Is probably
ewinc to the HimuhiB communicated to the nerves of the genital parts by the temm ; for we certainly know that other
dimm a|N»Ued to the nerves of the nose or stomach according to their nature, will either instantaneously impart new^
vigw to uie whole body, or soon occasion a general iiupor and debility. It is owing to a sympathy with the gUxtw^
that the ee«<ealae mmimOm are contracted in time of coition ; and, when the membrane which lines the lower part of
the arwCkra Is stimulated by the semsa, the aeoaiaraloref minm are excited into convulsive motions.
The great varied of symptoms in the hysteric disease is the reason, why a more extensive sympathy has been
escribed to the womb, than to any other part, except the brain. * The vomiting which generally accompanlee an
inflammation of that organ, the moauea^ and depraved appetite after conception, the violent contraction of the
diaphngm and abdominal muscles in delivery, the headach, and the heat and pain In the back and bowels about the
time of menstruation, are sufficient proof of the amtent between the afenu and several other parts of the bodv. But
there is no part so much affected by the different states of the womb as the breasts, which become more turgid before
any appearance of the m«MMt, and subside after the period is over. The changes that happen to the breasts in time
ef pregnancy, and after delivery, are still more remarkable.** pp. 9-29.
The observations and researches of Winslow,^ Girardiand Fontana,^ Jacobson,^ Lobstein,^
\%\ WOdam, Ceatvr. H.. ObMnrat. 34.
1 Exposition Anatomlque, Trait6 des Nerft.
t Journal de MMecine, Chir. et Pharm., par Badher, tom. xciii.
a Acta regia» Sociotatis Hafbiensis Mediae, vol. v. Hafhin.
4 Structure, Functions, and Diseases of the Sympathetic Nerve, by J. F. Lobf»toin. Trans, by J. Pancoast. Phila-
delphia. 1831.
11
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82 Introduction to the Study of Diseases of the Nervous System*
Ribes,^ KilHan,' Lanmonier,' Gloqaet,^ Scarpa, Hasse, and others, established the stmetore
and distribution and communications of the sympathetic system of nerves, and laid the fonn-
dation for the philosophical generalizations of the physiological and pathological phenomena.
Scarpa demonstrated by actual experiments, that the sympathetic system receives nerves
from all parts of the nervous system, the brain and spinal marrow, and that all the viscera
receive nerves composed of many separate filaments from different sources.
Wdrtzel 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.
. Prochaska 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 caritiet 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 g^glions, which he appeared to consider
as knots and ligatures, tight •enough to intercept all communication in the calm and qaiet
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 efl(ect of the passions is felt upon the heart.
In common with Winslow, Winterl, Johnstone, and others, Prochaska 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 Prochaska and Unzer, and
directed attention to the fact, that the former writer, noticed the influence of the nerroos
system 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.
Pourfour du Petit [1712 and 1725, MSmoire dam lequel U ett dimontrSqm In nerfi mUrcoMimux
foumment det ramcaux qui portent de8 eapriU dam lea yeux. MSmoiret de Vaeadiniie rayaU dm
$eienesa, AnnSe^ 1727, Paria^ 1729, p, 5 H aeq,'] demonstrated that the division of the trunk of the
sympathetic nerve, which he termed nervut intereoataUi, opposite the fourth or fifth eerricml
yertebrse 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 coiynnctiva, a flow of tears, and ultimately with ulceration and destnsc-
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 definite knowledge of the functions
of the sympathetic system, although they illustrated only the influence of the cervical portion
upon the eye. The investigations of Pourfour du Petit, were subsequently repeated and extended
by various observers, as William Cruikshank,^ Ameman,* Dupuy,' Dr. John Reid,* Magen-
die,« Molinelli,io Mayerof Brun,^* Braschet,^' Brown-S6quard,»» Claude Bernard, »* and
other physiolog^ists.
William Gruikshank, in 1776, performed important experiments upon the par-vagum, and
Intercostal or sympathetic nerves, [Phil. Trans. 1795, p. 177], with the following results
Section of the right par-vagum and right intercostal [sympathetic], was followed in a d(^,
by heaviness, slight inflammation of the right eye, difficulty of respiration, sullenness, 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 left par-vagum 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 saliva,
was ropy, increased in quantity and flowed from the mouth, the pulse was increased to 160
1 Dictionaire des Sdencefi MMicales, torn. ItI.
2 Anatomiiche Untemichnng nber dM Nennte Hirnnerrenpaar, Patth, 1822.
3 Joomal de M6decine, Chinu^e et Pharmade, par Bacher, torn, xciii.
4 Trait6 d*Anatomie DMcripUve, torn. ii.
5 Kxperiments on the Nenres. partionlarlj <« their Reproduction ; and on the Spinal Marrow of Liring Aaioials,
by William Croikshank. Phil. Trans. 1795 p. 1T7.
6 Gotteneen, 1787
7 Journal de M^d^cine, Chimnie, etc., Deoembre, 1816, tome xxxii, p. 340.
8 Edinburgh Medical and Surgical Journal, August, 1839.
9 Anatomiedee Systemes Nerveux, eto^ tome xi, p. 716.
10 Oomment Barroniensiftome iii, 1756.
11 Journal du Ohirurgie, 1827.
12 Becherches Bxperimentales, sur lee FnnctionB,da SystAme Nerreux Ganglionairi.
13 Sxperimental Researches, applied to Physiology and Pathology— Medical Examiner, Phila. August, 1852, Hew
8eries,Tol. 8,p. 487.
14 Comptes Rendns de la Society de Biologie, Paris, 1851, tome iii, p. 163.
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IiUroiuction to the Study of Diseases of the Nervous System. 83
per miniite. NotwithstondiDg: these symptoms, the dog ate and drank even voracioaslj at
times. Id breathing, the inspirations were lo^ and deep, the expirations were attended with
repeated jerks of the abdominal mascles. The seventh day after this second operation, the
d4^ was found dead, and upon post-mortem examination, everything seemed to be normal, but
the lungs, which contained little or no air, were of a red-brown color and resembled more
the substance of liver than of hiiamed lungs, and sank to the bottom when thrown into water
The inner surface of the trachea and its branches, appeared to be exceedingly inflamed, and
covered with white fluid, in some places resembling pus, and in others ropy, and more of
the nature of mucus.
In another experiment, in which the par-vagi and intercostals of both sides were simultane-
ously divided, the eyes of the dog beoame instantly dull and heavy ; he tottered as he walked ;
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-
ing, Mr. Cmikshank, found the dog apparently dead ; but on examining more attentively,
found that he breathed still, though exceedingly slow, his pulse was gone, he felt cold, and
his iimbs were stretched out. When placed before a warm fire, the dog revived to a son-
stderable extent, and manifested phenomena simBar to those exhibited just after the operation.
In the afternoon the dog died, having survived the operation twenty-eight hours. The lungs
IB the dead body, were loaded with blood, but not to such an extent as to cause them to sink
in water.
Ur. Craikshank, repeated the experiments upon other animals, with similar results. In
his experiments upon the division of the spinal marrow in the cervical region, Mr. Oruikshank
observed that there was a decided fall of temperature.
The idea that the sympathetic was a distinct nerve, appears to have been originally
broached by Sdemmering ; 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 as a cerebral nerve, or with Petit as a spinal nerve.
Bichat, as 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
his statements aud 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 lifis 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 Gallois.
Le GflJlois, by an extensive series of experiments, arrived at the following conclusions : —
** Life ts produced by an impreation of the arterial blood made upon the brain and medolla ipinalis, or by a princi-
fill fMoltins ftrom this Impreeilon.
** The prolongation of lire depends upon the oontinued renewal of thli imprenion. * *
** It L» this iinprenion, this principle formed in the brain and ipinal marrow, which, nnder the name of nerroas
power, and through the medium of the nerres, animates all the rest of the body, and presides over all its ftinctions.
** The heart derives all its powers flnom this principle, as do all the other parts, the sensation and motion with which
tbsy sr>e endowed, with this difference, that the heart derives its power from every point of Uie spinal marrow, without
exc^ftlon, whilst every psrt of the body is only animated by a portion of that medulla (by that by which it is supplied
ytHh nerves) ; a difference which may serve to explain the intensity of the power of the heart, and its uninterrupted
eontinaaace from tiie moment of conception, till the hour of death.
** From the great sympathetic nerve, the heart receives its principal nervous filaments ; aud it is only through that
nerve that it can receive its energy from every part of the spinal marrow. The great sympathetic must, therefore,
have Us origin in this medulla.
* Tvom tike same principle, we can no loagor admit the assertion of Bichat. though pretty generally adopted, that
there is in the same individual two distinct Uves, one animal, the other organic; that the bimin is the only centre of
animal life ; and that the heart, independent of the brain, and of the nervous power, is the centre of life.
** It must, however, be observed, that there is a real and very important distinction to be made between the organs
that receive their nerves from the grsat sympathetic, and those which receive theirs immediately from the medulla
obioagataand spinal marrow.
"The former receive tiieir principle of action from the whole nervous power ; their functions are not submitted to
tiM will ; they are exercised in every instant of life, and, at most, suffer only remissions.
*The latter, on the contrary, have their principle of action in a limited portion of the nervous power; their Ainc-
tiMs are submitted to the will ; they are temporary, and can only be repeated after complete intermissions of l<mger
or shorter duration.
**Thfs distinction comprises neariy the same organs as that of the two lives; but it Is evident that it rests upon a
basis entirely different, since the organs of oiganic life, which, in the system of the two lives, is considered as inde-
pendent of the brain and of the spinal marrow, are precisely those which receive the most powerftil influence
nom it. f
** Numerous anatomical, physiological, and pathological fticts can only be conceived and accounted for by this dis-
tinction. 7or instance, it is known that certain pains in the bowels cause debility, prostratfon of strength, and great
daorder throughout the animal economy. This tucty which is unaccountable in the system of the two lives, Is
readily understood, from the m<nnent we reflect that the intestines derive their principle of action from all parts of
the nervous power, through the great sympathetic, from which they receive their nerves ; and that consequently,
their affections ought to react immediately upon every part of this same power.
** Kxperlments on the Principle of Life, and particularly on the Principle of the Motions of the Heart, and of the
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84 IrUrcduetion to the Study of Diseases qf the Nervous System.
8Mt of the principle,*' by M. Le Oalloif, M. D. P. Traadfttad by M. C. Mid J. O. VMierede, M. D^ PhlUdelpldft, ISU,
pp. U8*14».
Mr. WilU^pa Clift, from a series of experimeDts upon the braio, spinal cord and heart of Uie
Oarp, (Philosophical Trans., 1815, pp. 91-96), similar to those performed bjM. Le Oallois.
drew the following conclusions :
1. That the muscles of the body of a Carp, four hours after the brain and heart are
remoFed, can be thrown into powerful action.
3. That the moment that the spinal marrow is dettrojed, the muscles loae all powar of
action.
3. That when water is admitted into the pericardium, and the fiah allowed to swim aboat,
the action of the heart ceases sooner than when the organ is exposed to the air, and the fiah
kept quiet.
4. That whether the heart is exposed or not, its action continues long after tba spinal
marrow and brain are destroyed, and still longer when the brain is remored without injury
to its subsunoe.
5. That the action of the heart is accelerated for a few beats bj exposure of thai •rgaa ;
bj exposure of the brain ; injury of the brain ; destruction of the spinal marrow, while eon-
nected with the brain ; bj the connection between the brain and spinal marrow being cat
off; while remoring the whole brain produces no sensible offset upon the heart's aetion, and
destroying the spinal marrow after it is separated from the brain, renders the action <yf tha
heart slower by a few beats.
Up to the time of Haller, the opinion preTailed, that the muscles derive their power from
the nervous system. Haller, on the contrary, taught that the power ot the muscles depem^a
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 tba
application of one peculiar stimulus, unconnected with the nerrous syatem, are wholly inde-
pendent of it. This opinion seemed confirmed by its being generally admitted, that tke
action of the heart continues after its removal from the body, and that it cannot be influeaced
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, nnd
another of the blood-vessel system. Gertain 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 miuntained, that althoni^b tke
heart is independent of the brain and spinal marrow. It may be 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 mainulned that tke
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 from 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 brain, on the
contrary, its acfion is unimpaired : from which he inferred, 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^*
interruption of the nervous influence upon the heart in any otner way, and which in his
opinion misled Haller and his followers, as movements without force, incapable of supporting
the circulation, and analogous to flhe 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 experimenu will illustrate the mode in which Dr. Wilson Philip, successfully
combatted the views advanced by Le Gallois.
A rabbit WB0 deprived of seontloD and volantary power by a stroke on the occiput. When a rabbit is killed in thie
ray, the reeplratioii immediately ceasea; but ^e action of the heart and of the drcnlation continue, and mav tw
supported for a considerable length of time, by artificial respiration, as practiced fint by Fontana, and after
ChiraCjBrodie Le GallcAB, and othen. In the present experiment, the drcnlation was supported by artificia]
tion. The spinal marrow was laid bare, from the occiput to the beginning of the doTMl vertebm. The chest' was
ChiraCjBrodie Le Gallon, and othen. In the present experiment, the drcnlation was supported by artificial reqiim-
tion. The spinal marrow was laid bare, from the ocdput to the beginning of the doTMl vertebm. The chest was
then opened and the heart found beating regulariy, and with considerable force. The spinal marrow as far as it
* Experiments made with a view to ascertain the prindple on which the action of the heart depends, and the
ralation which subsists between that oii^ and the nerrous systen. Philosophical Traosactiooa, 1815, p. 66-90.
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Introduction to the Study of* Diseases of the Nervous System. 85
kad beeft laid ten, wm now wholly rMMTod, Imi wittioat in the leait aflnMJtIng the notien of the heart. After this,
the artttdal leapiration bein^ fVeqnently diacontinued. Dr. Wllaon Philip, repeatedly ww the action of the heart
bccoBM IsDgnld, and increaae on renewing it. The sknil waa then opened, and the whole of the brain removed, so
ttat ao part of the nenroas system remained above the dorsal vertebm, but without any abatement of the action of
the heart, whieh still continned to be more or leas powerftil, as the artiflelal respiration was discontinued or renewed.
Tkii being for a considerable time discontinued, the ventricle ceased to beat aboat half an hour after the removal of
tte brain. On renewing the respiration however, the action of the ventricles was restored. The respiration was
apda diseontlnned and renewed wi^ the same effects.
In oth«r ezperimeots in which opium and other poisons were applied to the exposed brain
and spinal marrow, and in others still, in which the sadden and complete destrnction of the
brain and spinal marrow, were effected by 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,
as without 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 certain applications, to the exposed brain and
spinal marrow, as spirit of wine, tintcture of opium and tobacco, caused an acceleration of
the action of the heart. Dr. Philip attributed this increase in the number and force of the
ksart beats, to the transmission of the excitement, from the nenrous centres of the brain and
spinal cord to the central org^an of circulation. But the fact that in the senes of experiments,
the same results followed, wherever the stimulus was applied, whether to the brain, the cer-
Tieal, 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 muscular fibres of the heart. Dr. Wilson
PhiUp, coecladed ftom these experiments, that the peristaltic motion of the intestines, obeys
the same laws as the action of the heart.
Aeeordiiifir to this observer, his first set of experiments proved that the power of the heart,
is 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
opon its motions ; the second set proved, that the action of the heart may be infiuenced by
•gents applied to any considerable portion, either of the brain or spinal marrow.
From another series 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
stimuli." 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
and 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,
by which, the great objections to Haller's doctrine are removed. His views are still farther sus-
tained by certain epperiments which showed that if either the brain or spinal marrow be
iastantly crushed, the heart immediately feels the shock, the action of the heart and circula-
tion becoming very feeble for a time, but, if artificial respiration be continued, the organ
gradually regains its lost power ; *^ precisely as a muscle of voluntary motion, will by rest
recover its excitability, although all its nerves are divided, if its circulation continues."
Dr. Wilson Philip,* subsequently performed various experiments, illustrating the effiects of
division of the eighth pair of nerves, upon the functions of the lungs and stomach: and he
found from repeated trials, that both the oppressed breathing and the collection of phlegm,
caused by this operation, may be prevented by sending a stream of galvanism through the
lungs : and he was thus led to the successful application of ffalvanittn in the treatment of habitual
asthma. Soon after the operation, the animal begins to breathe with difficulty, and this
sympton gradually increases, and is at length evidently the cause of death. On inspecting
the lungs 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
less according to the time the animal has survived the operation, every trace of both tubes
juid cells is obliterated, the lungs both in color and consistence, assuming much the appear-
ance 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 affects of Galvanism in Bestorinf the due aetion of the Lungs. Phil. Trans., 1817, pp. 22-31. An Experi-
■wntal Inqniiy into the Laws of the Vital functions, etc "Philadelphia, 1818.
Some positions, respecting the influence of the Voltaic Battery, in obviating the effects of division of the Eighth
Piyr of Nervea. PhiL Trans., 1822, pp. 22-23.
Scnae observations on the effects of dividing the nerves of the lungs, and subjecting the latter to the influence of
TollBic electrlei^. PhiL Trans., 1827, pp. 29T-300.
Some observations relating to the Function of Digestion. Phil. Trans., jMrt 1, 1829, p. 137. Some observations on
the Tonetiona of the Nervous Syatem, and the relation which they bear to ihe other vital functions. Phil. Trans.,
Iiart II, 1880, p. 281. On the Nature of Sleep. Phil. Trans., 1833, p. 73. On the Relation which subsists between
the KervoQS aibd Muscular Systems in the more perfect animals, and the nature of the influence by which it Is maln-
tsteed. PhU. Tnuis., 1883, pp. fU-7S. On. the Nature of Death. Phil. Trans., 1834, p. 167. On the Sources and
SatDie of the Powers on whi<^ the Oircalatlon of the Blood depends. Phil. Trans., 1831 , p. 489.
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86 Introduction to the Study of Diseasei of the Nervous System.
the nerves supplying the lungs are divided and the ends separated, if the proper degree of
VoUaie electricity was transmitted continuously through the lungs, by those portions of the
nerves, which remained attached to them, no affSection of the breathing supervened, and the
lungs after death were found quite healthy, provided that the current of electricity had been
properly applied. When the electrical current was too powerful, or has continued for sacb a
length of time as to excite inflammation, the appearances were entirely different from those
produced by simple division, without the galvanic current. In the same manner it was found
that when the nerves supplying the stomach were divided, digestion was altered and finalllj
arrested ; but when the electrical and galvanic current of proper intensity was passed tbroagb
the nerves attached to the stomach, digestion was performed as in a healthy organ.
From fuch experiments Dr. Wilson Philip concladed, ** that the effects of dividing the nerres of « vital oilman, aad
separating the diTided ends, is not merely tiiat of deruiging its secreting power, but aU thorn power* cm wMcA U» hmMk§
ttmokure depmd$ ; and that the ^tet of VoUaie «leotricUf^ U thai ofpiimivimg aU timepowen. * *
The nervous power is essential to the Amotions of secretion, and the other asidmilating proceassa of the aalmal
body ; and that Voltaic electricity applied in the same way, as IStur as possible. If capable d sapplying its force In
these processes.** Phil. Tnana, 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, bmt
equally with the heart capable of being influenced by either stimulants or sedatived applied
either to the brain 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 natnre.
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 impreesiont
made upon the ganglia of the sympathetic system, Dr. Wilson Philip caused the performance
of the following experiment :
** Mr. Field partially divided the spinal marrow near the head in an ass, in such a manner as to destroy the sen-
sibility, as fiu* as the experiment was concerned, but not to interrupt the respiration, thos bringing the animal into tte
best possible state for the experiments. It lay as still, and suffered as littie during It. as an animal quite dead In the
usual sense of the word, while the circulation was more perfect than it could be under any artifldal inflation of tbe
lungs. In another respect, the state of the animal was particulariy ikvorable, for Mr. Field succeeded in expoalns
the semilunar ganglion and its plexuses with a very trifling loss of blood, not, I believe, four onnoea The heart wns
then found to pulsate sixteen times in ten seconds, as ascertained by the pulsation of the arteries in the neiighboAood
of the ganglion. The ganglion and the plexuses were then irrits^ by the point of a scalpel, and at length emt
in various directions; but, although, the beats of the heart were repeatedly counted during these operatioos,
iontinued uniformly of the same frequency. Spirit of wine was then Mpplled to the wounded ganglion and
they continued uniformly of the same frequency. Spirit of wine was then applied to the wounded ganglion and
* Bxuses, but without the least change in the beats of the heart A strong infusion of tobacco in water was noiv
plied, but with the same result, the beatings of the heart being still sixteen iu ten seconds; nor could any varia-
"* The conclusion was drawn fhnn the experiment, that we cannot influence the organs supplied by the ganglionic
nerves by causes affecting the ganglions and plexuses, independently of the brain and spinal marrow ; and the Infer-
ences fh>m this and the preceding facts are unavoidable, that the former organs make only part of the <diannel
through which the influence of the latter Is conveyed ; and that the peculiar office of the gangilotis and ^exnsea la
to combine the influence of the nerves which terminate and aro blended in them, and send off nerves endowed with
their combined influence, in consequence of which the parts which receive the nerves proceeding fh>m therai, beooie
su^ect to every part of the brain and spinnl marrow.*' Phil. Tran., 1833, p. 61.
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 voluntary and involuntary motion is Independent of the nervous lystwi ;
hut that both are subjected to its influence, this influence being the constant stimulant in the functions of the fiw^
mer, but only an occasional stimulant in those of the latter, which, in their ordinary functions are excited bj stimn-
lants peculiar to themselves.
** That to the muscles of voluntary motion it is supplied from those parts of the brain and spinal marrow, ttam
which the nerve of the particular muscle takes Its rise; to each of the muscles of involuntary motion, fttMn every
part, both of the brain and spinal marrow.
** That these organs are the only active parts of the nervous system, and that the cerebral and spinal nerves on the
one hand, and the ganglionic nerves with their ganglions and plexuses on tbe other, are only the diannels throng^
which their Influence is conveyed, the power of both systems of nerves being at all times proportioned to the excite-
ment of the brain and spinal marrow, and soon ceasing, and not to be revived when their influence b withdrawn,
and being uninfluenced by causes acting independently of these organs on either set of the nerves themselves or on
the ganglions and plexuses.
** That the ganglionic system of nerves, with their ganglions and plexuses, is the means of combining the inflnenee
of every part of Uie brain and spinal marrow, and bestowing It on the muscles of involuntary motion, as well as on
the various secreting and other assimilating organs, these muscles being subservient to the runctions of these organs,
which it appears, fkt>m direct experiment, require for their due performance the combined Influence of every part of
the brain and spinal marrow.
** That the manner in whfch the nervous influence affects the muscular fibre Is not essentially different flrom that in
Which it is affected by other stimulants and sedatlvee.
'* That this influence is not an agent peculiar to the nervous system, but capable of existing elsewhere, and cottee>
quently not a vital power property so oUled ; which further appears finom an agent which operates in inanimate aar
ture being capable of all Its functions.
"That thi' brain and spinal marrow therefore, so lar tnm bestowing en. the muscular fibre, its power, only Mq>ply
an inanimate agent which, like all other such agents^ capable of affecting it, acts on it either aaa stimulant or se4^-
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Introduction to the Study qf DUeases qf the Nervous System. 87
lira, AoeoidtBg to tbe degree in which it ie Applied ; and that the whole of the foots relating to this agent, proree its
identity witii voltaic ele* tridtj which has been fonnd experimentally to be capable of all its ftinctions.
"We cannot roYiew the phenomena of the auimal economy without being ftmck with the extent and Tariety of
the nervona inflnenee. We not only find the interoouree between the animal and the external world maintaioed by it,
the heart and Tceeels tulittected to its control, and secretion and the other assimilating processes immediately depen-
dent on it, bat tiiat by its means the animal body is formed into a whole, every part of it being capable of influencing
erefy other.*' Phil. Tvans., I83:i, p. 70.
Dttriog more than a hundred years, tbe import of tbe DumerooB branches connecting the
sympathetic with the cerebral and -spinal nerves, has been made the subject of a number of
conflicting theories. Many physiologists with Haller and his school, hare supposed that the
primitive fibres contained in their connecting cords arise from the cerebro-spinal nerves, pass
through the gaaglion, and subsequently radiate into its branches. According to this view
the sympathetic is essentially a cerebro-spinal nerve; — presided over by the brain and spinal
cord, JDSt as the peripheric organs are by tbe other nerves. Hence, the physilogical pecu-
liarities of its branches, would depend solely on the numerous ganglia that are interposed in
their course. Other physiologists have followed the theory started by Petit, and developed
by Bicbat, according to which the sympathetic or ganglionic system constitutes a nervous
system independent of the brain and spinal cord, its peculiar fibres supplying the intestines,
the blood-vessels, the glands,, and in general terms — ^l those tissues, which are destined to
subsenre the phenomena of nutrition, and the unconscious and involuntary ftinctions. Ac-
cording to this theory, the sympathetic is a special visceral, vegetative, or organic nervous
system ; which has an authority independent of, and co-equal with its animal counterpart,
composed of tbe cerebro-spinal nerves, which effect the' conscious feelings of sensation and
pain, and the voluntary movement. This question has been examined anatomically, physio-
logically and pathologically by Prof. John Fred. Lobstein, who appears to have anticipated
many of tbe results of recent experiments and research, and advanced doctrines which have
since been claimed as original by others.
The following quotations from the elaborate work of Lobstein upon the Structure^ Funclum,
mid Diteutet of the Syti^athetie Nerve embody the most important results and generalizations
established by this author, and illustrate in a forcible manner the relations between the cere-
bro-spinal and sympathetic systems. The author sums up in the following manner the theo-
ries of Reil and others : —
"Tlie cerebral nerrons ^ystMn to formed differenfiy ftt>m that of the qrmpathetic system. The branches of the
tnaer converge fnmx the perlpheiy of the body towards the cerebrum, and are inserted into it by their roots, as the
roots of vegetables are in the soil ; that system, therefore, has bot one centre, which is in the encephalon. The latter,
ea the ooBtn»y, is not effected into any centre ; it has no fbcus of action, but exercises its functions over a wide
The qrmpathetio system connects the oigans together In three different modes : 1. It forms networks around the
wis, which ontnaoe die uteriee with their slender and minute branchlets (as the ivy clasps the stem of a tree),
and pen^rates with them to the oraans. These networks are known under the name of plexuses, twelve of which
an enumerated, appertaining to different parts. * * 2. These plexoses are connected to the brain and me-
dulla spinalia by branches which Beil calto conduoton. * * 3. These branches, the conductors of the plex-
uses, apvear to form a perfoct connection between the animal and vegetable systems ; every commotion which the
tower rmoera suffer would be conveyed to the seosorlnm commune, and viM-oena — the will would exercise a perfect
eontnri over the organs of the thorax and al>domen, were not these movements intercepted by enlaigements in the
oondnctoTB called ganglia.**-^n>. 72, 73.
** When the two nervous syHems by which the animal is rendered more perfect are considered physiologically, each
■My be eeteemed a sphere of activity in which the vital actions are differently performed. In the animal sphere,
{fiuX is, in the cerebrum, the medulla q>inalis, and their nerves), the determination of the will and senses, when
taoflferrsd to the common sensorium, become impressions instanter, and, as it were, at a single impulse. In the
vegefestive sphere, the nervous energy is slowly, steadily, but obscurely diqtersed into the organs. These are con-
nected together, act according to their peculiar laws, and compose a system separate from ttie animal sphere, over
vtdch apympriate laws preside. Thto system also possesses the fitculty of perception — namely, it receives impres-
rions, and reacts upon them ; but this perception abides in its own region, and Is not communicated to the brain. In
a healUiy state, the system «f ganglia exerts no manifold influence upon the cerebral system, from which it is divided
by the aeparaiory or isolating apparatus, the series of ganglia in the sympathetic nerve. But the case Is different in a
slate of disease, for when the vital energy to increased in the communicating nerves of the plexuses, the condition of
^ ganglia to dianged ; they transmit^ impressions which the extremitlm of the nerves in the viscera receive, and
become conductors, whilst before ttiey were non-conductors or isolators/* * * pp. 74, 75.
** In tbe foetus, none but the sympathetianerve to in vigorous action ; it extots previous to the secretory and nutri-
ent organs; it sustains the energy of the heart; and breaks in sometimes upon the cerebral sphere, and determines
tiMMe aatomatic motions which the infant, when closed in the uterus, performs with its muscles. Acephalous foetuses,
destltnte of oereforal and spinal medulla, and hence wanting the nervous centre from which emanates the principle of
mnacnlar contractions, perform, nevertheless, muscular movements which can be in no other way excited than by the
vital Influence of the sympathetic nerve, which to Joined by an anastomoeto with the spinal nerves.*' — ^p. 77.
"Ihnlng the extra-uterine life of mao, when there extots some immediate internal sense inherent to the
stomach, tiito nerve forms a remarkable intercourse between the cerebrum and the viscera of the thorax and abdo-
men, as to proved by numberless phenomena. Then, as in the embryo and foetus, it governs the svstem of capillary
vsssils, and directs the ftinctions of assimilation and nutrition, through the influence of the vital plastic power,
which Bronssato calto vital chemistry.** * * p. 77.
After this general statement of the facts established, and theories i)roached by others.
Lobstein proceeds to give the results of his own investigations :
" According to a corollary of the greatest importance, there existo a relation between the sympathetic nerve and
the par vagnm — to-wtt, that one may take upon it the fhnotions of the other ; for in tbe inferior vertebrated animals
th« par vagnm appean to be more prollflc in branches distributed to the intestines, as the sympathetic nerve to less;
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88 Introduction to the Study qf Diseases qf the Nervous System.
and it is found that in some vertobratmi animala no qrmpathetlc nwre ezlats at all, and in which it* AuiditMtf «fv
performed by the |jar raguro only. Whence it foUowe that the par Tai^MB ihoald be daaead under the mw lav aa
the sympathetic Itaelf, with the nerreeot vegetatiTe life. In fine, in all orden of aniaiala, the ^mpatbade amrwe ia
alwayi fonnd, In regard to its development, to ooireqHmd with tiie pre-eziating Taacalar appantaa; wbkk pro^aa
that it owes its delicate construction to the wants of the Teasels.
'* A nerrons system which exists In the lowest scale of animals is pecoUar to the nntrient otgaDa, aod psorfimBi
especial functions of Its own, which, prior to the appearance of the bn»ln, oonatitated a nenrona oratre, aod whUk^
when the cerebral centre is formed in animals, is inter-oonnected only, and never oomposea with it on« andividad
^paratus, but always retains its pristine form and habit— that sudi a syatem is endowed with the greataat fkmotkHMl
importance, is self-evident." — p. 81.
*' As to the forces, the branches of the mrmpathetic nerve are undoubtedly endowed with the same power aa nervaa
in general ; that Is, fh>m the vital principle t^ which tone, strength and eneigr are maintained in the orgaaa over
which they preride. It does not seem Improbable that the ganglia whidi diveraujr the tmnk ought to be ciunwiili red
as the laboratories of that principle, whicA the internal or egredient branches conduct to the viscenK asd of tbe
nature of which we are entirely unacquainted. In the cerebral voluntaiy nerres, as wMl as in the ^mpaUMtie iMrre,
the nervous principal tmveises In both directions ; to-wit, Otom the trunk into the branches, and again tmm tke
branches Into the trunk.'*— p. 82.
'' But the branches of the sympAthetic belong principally to the arteries which they enrelop, while the flneai flln*
menta which follow the arterial branches into the organs arp terminated in the external coat. Hence It la niaalffnst
that the vessels are primitively constituted under the government of the nerves, and that from them the isroe aad
eneray are borrowed with which they operate in the functions of nutrition and secretion.*'— i> 83.
** From all that has been hitherto produced, we are at liberty to conclude tliat there is no essential dUTereooe bc>
tween the sympathetic nerre and the encei^ialic mass and sptniJ nerves, but that ttie two nervous syatema are ao Ihr
distinct that both are peculiarly situated aoooniing to the diflereat oonditioBS in which they exist in body.
** In the anatomical part of this treatise it was first demonstrated that the trunk, bt»nohes and fllam— fa of tke
^mpathetic nerve have the same structure as the cerebral and spinal nerves, the same plexifinm division, and, wrlken
examined widi the microscope, the same composition ; to-wit, medulla and neurilemma. On the other hand, I know,
flrom attentive observation, tnatthe sympathetio nerve transmits the imprsssionsit receives to the oonunon aensortani
in the same manner as the oersbral and spinal nerves. Thus an irritant alBlcting the prinM Tit» is pewetved lanB»>
diately by the brain, as the following demonstrates : 1. The tormina occurring in varioua diseaaes. 2. A calcolns
lodging hi ^e biUaiy duets, the pelris of the kidneys, or the ureters. 3. An irritant near the hepatic plexus, fhiai
whidk an animal was seen to suffer, by Haller. 4. The galvanic agent producing intense peristaltic motMNi, aad
secretion of intesUnid fluid, according to the experiments of Orapeiigeiser.**— p. 87.
** The sympathetic nerve presides over the fhnction of nutrition, not only oecanaa it imparts many narraa to tke
ohylopoietic organs, and sustains their energy and influence, but because it Is also distributed to the arteriea, wklch
oarnr the nutrient Mood.
"Let us suppose the nerrous power destroyed in the abdominal plexuses; the tone of the stomadi, gnatiU, ami
intestinal digestion, and the functions of the liver and spleen would be impaired.
** That this indeed may take place, is taught by numberliss instances of mental disease, vriiich, when thrown upon
the solar plexna, soddenly dlatnihs the whole ftinctlon of digestion.
" The abnormal action of the al>dominal nerves exercises an influence over the organs. In regions very distaat trotm
each other, from which it Is manifest that the functions of assimilation and nutrition are under its sul]||ection .
Recently one of my intimate friends, who is about thirty years of age, after being suddenly terrified by the bamlng
of his bouse, had his hair to turn white in the course of a few days. Was it not the mental solisring he expert— ce^
which, by the unanimous consent of physiologists, deranges the abdominal nervea, that in this case produced t^
' change by disordering the force and functions of these nerres ? and did not this disordersd action aflSsct the nntritiott
of the capillaries?
** Physiologists hare long since acknowledged the great influMice of the nerves over the oapiUaiy and notrisnt
vessels. Thus, if it Is enhanced, the action of the latter is increased ; if diminished, weakened ; if utterly deftciant,
destroyed; hence it Is as they are maintained to supply this olBce, that they have not any control beyond It. la It
not then evident, that when the nerve^are injured, nutrition would be frequently destroyed? The experimants of
Dupuy upon horses, in which the superior cervical ganglia wero cut away from either side, furnish good pcoof oC
this: contraction of the pupil, redness of the coi^unctiva (phenomena since observed by P. Petit), emaciation of the
whole body, oedema of the feet, and an univemU cutaneous inflammation followed the operation.** — pp. 8ft, 90.
** What I have said of nutrition in general, holds good in the secretions of the fluids, iMcause the saae merhanisi
supports secretion.**— p. 91.
'* As we are considering physiological and pathological phenomena, we will ask If there be any ignorant that Ihc
secretion of the fluids In the glands may be increased by the effects of the imagination alone.
** Who can deny that the maternal milk, the bland and sweet nutriment of inlknts, has been suddenly changed by
mental affections to an atrodous poison? No other instruments certainly exist but the nerves, by whoae aid IIm
psychologind Irritant can act upon the organs.
" The sympathetic nerve governs the action of the heart and the drculation of the blood.
'* The cardiac nerves have the same relation to the flbres of the heart, as the cerebral and spinal nerves with the
voluntary muscles.** — pp. 92. 93.
" The sympathetic nerve forms an admirable chain of connection between the prindpal organs of the huMsn body.**
This proved anatomicalW and physiologically and patliologically. ** The sympathetic action is by no meana dreoas-
scribed to the cavi^ of the abdomen ; on the contrary, it spreads itself wider, and connects the separate parU of the
body in dose union with Itsdt
** Jfoit of (ftspksiMtiMaa, tedesd, iMy 6e ooNtJdrracf OS eoNMMMol, i» toJUcAC^
end tnfariacJN^ of tits nenm. Itt, TUiUatiim of the nom prodmem snmun^, (mmmm the nomI mtms of Ck« yfcwn psisifiii
ganglion are oonn«ded (krougk the medktm of the deep-eealed amd mtperfidal vman nervety with the mmpathetie ; from mkitk
the iUaphragmaiie plexw oriMt, whieh U joined by anaelomoeie of the phrenic nrnve. 2d. An interne Ugm aieo egeUeeemeemmg^
for the imprewjoa Mng perceived 6y the retiao, and tran^erred inetmUiif to the cjl joiy nerrm^ it ooHve§ed to the %MipiHrfii,
and bv the naeai branchy and the remaimitg naeal nervee of the fifth pair. M. The attattomoeie of thie nerve (mu^pmAMie)
with Ae fifth pair^ accomttUfor the gritting of the leeth^ and itching of the noee, la the vermimoee dieentee of chSarem ; rmeei
caleuliy or nephriUe^ produce vomili$^i, or other dieorder$ of the etomaeh, tahitel the atimmlating eanee, if eet^fimtd lo the Msdiiw,
rarely exeitea gattric derangemenL For the nervous commnnicatluns are more conqiicuous and more numerous betaeen
the kidneys and stomach, than between the stomach and urinary bladder. 5. The observations of celebrated
practitioners instruct us, that many laboring under diseases of the abdominal viscera, suffer cloudiness of rision, that
the retina Is also drawn into consent"- pp. 96, 97.
" But the medium through vfhieh the connection of the nerrea it ehi^ made, i» the par vagum, the primeipal rmnvktmoeie of
which wUh the intereoetai nerve^ in the neck^thorax, and abdomen^ form mauff ptexuaet, upon lehieh the action of the agmpathetic
nerve depend*, and through the medium of which, chiefiif, that admlraMe interoouree exitte between the head and abdomen^ kmoteu
to ph^eidane in atf agea.**—p. 97.
^ In this respect the fiiKla oommunicans of Wrisberg Is of great Importance, and which, in mv Judgment, rai|dit be
more aptly named, the great abdomino-cepluilic anastomotic branch, for by it the animal life Is connected wWk the
nutrient or vegeUtive, so that the muUtiuns of one may be immediately felt within the domains of the other, per-
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Introduetian to the Study qf Diseases of the Nervous System. 89
cekr9A by th« mind. Mid vfee mtm. I ibAll allese loine CMes of Abdominal dlMMe in tbe tbird section of this work,
in whSdk this sympathT is saflldently mnnlfest m the morbid state.**— p. 98.
**The nmta bj whi^ tiie deioending or ascending impression goes and retnms, to none other than the abdominal
or the abdomino<iei^lic anastomotic branch. Tnto alone, and anlntermpted bj ganglia, forms the inunediate
intevooame between the cerebrum and abdomen.'*— p. 99c
** In reflecting npon the natnre of intermittent fevers, I have thought that it might, perhaps, be found in the
dtoiwdi and perverted action of the abdominal nervous sjstem, and there i^ipear, indeed, to be sufficient grounds to
tmdttT this optakm pcobiMe.** • *-p. 121.
**The paioxjoM of intermittent fever are tied down to a regular ihythmus, in consequence of their being radicated
in the nervous system, upon wtiich nature has impressed a law, according to which they must perform their functions
pertoAcally.**— pp. 121, 122.
** iMsh nervous system, therefore, to obnozlons to Its own diseases. But the mode in which the cerebral and spinal
■«!<■» and the nerves of the abdominal plezusee and ganglia are affected by disease, to the same. As in the various
kinds of convulsions, epUep^Ti tetanus, etc., there to disorder in the voluntary nerves, even when no organic lesion can
be discovered in tti«n; so the nerves of the thoracic and abdominal viscera may be affected without any alteration
peseeptlble to the senses. As the perverted action of the cephalic brain to -reflected with great fbrce upon the abdo-
minal brain, so in turn does the ueitter relict upon and overwhelm the former; and finally as the cerebral n^stem,
when it to fCapefled, as it were, by the violence of disease, deBtroys life, in like manner, I believe, an analogous
sOect takes plaoe in certain diseases in the solar plexus.**— p. 122. Connection of the simpathetic and cerebro-s^nal
^ysleiua, flioatrated by numerous pathological conditions. Effect of blow upon eplgaatrium, p. 122. Effects of the
rfrmninn of BiiUaiy exanthemata in fnoduoing abdominal paialysto or apoplexy, bemicranto excited by hypochon-
dria aod hysteria, p. 122. Belations of affections of the head to the state of the gan^onic system and the boweto, pp.
IM, ISS. Ezidanation of delirium and of the action of cathartics in modifying tne phenomena of fever, pp- 122,
U»-6. ** Sympathy between the teeth and abdominal nerves,** p. 127.
*^ Thtjf mmmiaJmettomof (ft« 5nri» <• iy mo nmom etrcmttorOt^d U> the catftiif <tf Uu ermtimm ; Ui» ^ximtdad to ditUmU regions
^f Am mmm , iMsnoe o^^bmo duessM ort vnoncetU
** 4/ttr Udcm of the 6rals Ifcire it mtdomUedlif a d^ummie Mtarder of the ntrvoM apparatita of the Ufor, amieeedmU to Urn
iK^kMimtaliom m»d mtffmrtdhm of that orgats. Foriow kj/potkttm have bom faswlnf IP <ayto<a the eotmooHom fcfliwtiii eto bnria
m^ hmmtitt tgtttm, worn* of wkkk hamatpolboomatau aalJ^faeloiTf. Imajf with bettor rsosoa, r^er U to tkOomtmmSeaHm of
tk§ riMt par oogmm wUk tko ootar vteciu, bjf wkkh tko eorobrwn is eomtedod to the right mmthmar gamgUon^ from whonee
m«mte amoeOg tho poiderior iMr*e».*^p. 131, 132.
Lobstein ilI«Mtrited the relations of the sympathetic and cerebral system of nerves, and abo the connection of the
■errous system with dtooaips, by numerous paUiologlcal fttcts. The notes added by Dr. Josefdi Fancoast abo contain
tetenstlng corroborative ^hcts.
" A Treattoo on the Structure, Functions, and Diseases of the Human Sympathetic Nerve,** by John ITred. Lobstein.
TttMlated flnom the Latin, with notes, by Joseph Pancoast, M. D., PhiladeliiLla, 1881.
In the 7%trd (Pathological) Section of his work, Lobstein gives Tarioas observations, illus-
trattng the connection of certain fevers and inflammationSi with dlsease4 states of the sympa-
thetic ganglia and nerves. Thas he attributes the oppression of the chest, shortness of breath,
strictare of the prscordia, and sensation of aniiety which precede the appearance of the
eniptioB in varioas diseases, as scarlatina and smallpox, to the action of the poison upon the
gaaglionic sjstem. Be sustains the view that intermittent fevers are caused by the disorder
and perverted action of the abdominal nervous system, on the following grounds : Ist. The
cases of this disease are very rare, in which the functions of the abdominal organs continue
vigorous and entirely unaffected. 2d. The commencement of the paroxysms is often marked
with vomiting. 3d. We experience daily that this disease is mitigated, and very often en-
tirely 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
appears that this remedy makes an impression upon the solar plexus, of an opposite nature to
that which has produced the fever. 5th. When the disease is either maltreated, or left to
itself, congestions are produced in the abdominal viscera, induration of the liver, intumescence
of the spleen, etc., and tbe general morbid state is changed into a topical affection. This
metamorphosis appears to prove that the morbid action prevails at first in all the plexuses, and
afterwards migrates from one to another. For it is first apparently disseminated in the whole
territory of the ganglionic system, before it runs with much impetus into a single plexus,
whieb is commonly the splenic; and as the vessels are under the influence of the nerves, it
oanoot be otherwise than that congestions should be produced in the vessels. 6th. The
paroxysms of intermittent fever are tied down to a regular rythmus, in consequence of their
being radicated in the nervous system, upon which nature has impressed a law, according to
whieh they must perform their functions periodically. According, therefore, to Lobstein, the
morbid cause of intermittent apoplectic fevers (pernicious intermittent of Alibert), is seated in
the ganglionic system of the abdomen, for be found no mention made by authors of any
remarkable disorder 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 senses, yet Lobstein affirmed that he was convinced, by attentive autopsic researches,
that phlegmasisB positively occur in that nerve, corresponding to various diseases ; and he
expressed himself as fhlly convinced, that other organic changes might be foand in this nerve,
if the cultivators 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
structural alterations of the sympathetic, and their connection with diseased states of the
organs, and of the general system. This was not a mere matter of conjecture, but his opinion
was based upon his own direct pathological observations. Thus, in a careful autopsy of a
pregnant woman, who died apparently from obstinate vomiting, distressing pain in the back,
and rapid emaciation, the stomach discharging black vomit towards the end of the disease, tbe
12
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90 Introduction to the Study of Diseases of the Nervous System.
brain aud organs, and the u terns, which was in the fifth month of pregnancy, and the foetvs
which it contained, were found to be normal ; the only lesions were observed in semilunar
ganglia, which were intensely red and inflamed.
In the body of a girl six years of age, who had been seized with epidemic pertussis, 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 be
in a natural condition. He also quotes the testimony of Autenrieth, the celebrated Professor
at Tubingen, who, on examining the body of a girl who had died from pertussis, found the par
yagum 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. Professor
Autenrieth also asserted that he had seen the abdominal nerves (sympathetic) a little changed
in subjects who had died from Typhus 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-cartilaginous tumor,
loosely attached to the dorsal spine. The second case was that of a woman thirty-six years
old, who, in her second pregnancy, was subjected to vomiting, which continued throughout
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 villous 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 miliary
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 highly
inflamed between the eighth and tenth ribs, with a phlogosis of the ninth and tenth thoracic
ganglia, and their two anastomatic branches from the costal nerve. Lobstein records also
various alterations of the sympathetic nerve, in diseases of the lungs and heart, and gives
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 much dilated,
and the sympathetic nerve three or four times larger than usual from 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, had deg^en-
erated into tubercular substance. Lobstein proved, by observations undertaken for the pur-
pose, that the nerves may not only be increased in thickness, but likewise in number, as in
cases of hydrosarcocele, in the spermatic cord, organic disease of the epididymus, and hyper-
trophy of the thyroid gland ; and he also showed that in certain diseased states, the reverse
condition may exist, viz : decrease in the number and size of the nerves supplying the diseased
organ.
The physiological and pathological relations of the sympathetic and cerebro-spinal nervous
systems have also been subjects of investigation by the late Dr. Samuel Jackson, formerly
Professor of the Institutes of Medicine in the University of Pennsylvania.
The following quotations f^om his work on the Principles of Medicine, published more than
forty years ago, will show that his views were expressions of those relations of the nervous
system, which are now being recognized by the profession :
** ConslderRtioiu, based on the ftoatomical ftruoture, lead to the following inferences m to the ftractloot of tW
ganglionic system : —
a. " It is not Independent of the cerebrotipinal nervous system, but derives its nenrous activity from iti oonnectioa
with that system.
h. ** It is connected throughout its whole extent by the numerous nervous filaments passing from one gai^Uoa to
another, and uniting together the different plexuses.
c. *' The organs of the head, neck, thorax, and abdomen, with the genital organs, which receive nervous filamentf
fVom this system, are placed in a communion of actions and impressions, which are transmitted from one to the other,
and it is thus the principal instrument of the qrmpathies between those organs.
d. ** Supplying the thoracic and abdominal viscera and genital oigans vrith nerves, and communicating with ^c
oerebn>«pinal nervous system, it is the medium of communication between these organb and the nervous systeoi of
relation.
e. ** Supplying the abdominal and thoracic viscera and genital organs with numeitMis nerves, this system mosi b^
the chief agent in maintaining the exercise of their functions.
/. **From the quantity of nerves which it distributes to the arteries, the closeness with which these vesseUarr
invested with those nervous filaments, and which are lost in their coats, it must exercise an active agency orer their
circulation, and in this manner influence the secretions and nutrition.
g. ** The muscles that receive nervous filaments fh)m this system have this peculiarity, that they act without voUtioo.
or even consciousness. They must, consequently, receive the nervous stimulation for this purpose ftvm the gangttonir
system.**— p. 37.
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Introduction to the Study of Diseases qf the Nervous System. 91
** From plijiiological and pathological Atcts w« derive a oonflrmation of theoe prindplca, and obtain additional light
io airiTiDg at a knowledge of the ftanctionB of this system.*^ * * — ^p. 37.
**Tbe gai^lionic syatem fnrniahing the principal nervoos inpply to the snriigtoee, where are seated the instinotiTe
mmaXa of the organian, we hare in ^e above &cta: Ut, that the ganglionic system ti the nervous appaxtftus of the
iBstiBctB and internal senses; 2d, that it communicates to the nervous system of animal life or relation the wants of
Ae eeoooBiy ; and 3d, is amiable of compelling that system to command the acts necessary to supply these wants.
** Hm inteiTc^ation of pathol(^cal phenomena will f^urnish additional elucidation to this sul^ect.
** Irritatkma excited in the mucous tissue of the stomach and small intestines by the impreasions of irritating agents,
vill ex<dte irritationa in the biain, and sometimes roinal marrow.
"The acute inflammations of the gastro4ntestimd mucous tissue rarely, it may be asserted never, fidl to occasion
corebral or spinal inflammation. Hence, they are invariably attended with headache and delirium, pains in the back,
and olten neorslgic pains in the extremities; they fluently occasion coma, apoplexy, hydrocephalus, convnlsions,
and parmlysia. The chronio inflammations of the same tissue are also productive of chronic inflammations of the
eerebiml organs, and hence we find mania, monomania, catalepsy, and hysteria, are fireqnently connected with that
state of the digestive organs. The connection between the oerebro-spinal oigans and the mncous tissue of the
stomach and small intestines, by which the actions of the one are transmitted to the other, is most probahly effected
through the nerves of the guiglionic system, and the inosculation of the solar plexus with the par vagum." * * —
p.iOL
"None of the viscera that are placed under the influence of the ganglionic system of nerves, exercise so decisive
and prominent an action over the cerebro-spinal nervous organs as the stomach and small intestines, eq;>ecially the
** With leas promptness and lees constancy the other organs in this connection respond to the morbid irritation of
the gastric moeous snrfiue. Ah example is afforded in acute gastritis, in which the eye is always injected with blood,
the Ihoees and tongue are arid and inflamed, the lungs often partake of the disorder, and respiration is impaired or
<ienttiged. The liver, the kidneys, the genital orMns, all display more or less of disturbance in their fhnctions, oor-
nsspondlng to the degree of the gastric disease. The acute irritation of these organs are attended, in a like xnode,
vltti disorder and distnrbanoe of the stomach and its functions. Thus, inflammation of the kidneys, uterus, liver,
and sometimes of the eye, is productive of an irrital^le state of the stomach, produdng nausea and vomiting.
**Tlie above patiiological phenomena exhibit: first, a close connection between the stomach and the brain, by
whidk they mntoally reflect their irritatious on each other ; and second, that the difliBrent organs to which the gang-
lionic system sends nerves, possess a free communion in their actions, which is most extensive and active between
those organs most abnndantiy supplied with nerves.
** The ganglionic system, from these fiicta, would utpear to be the medium of the sympathies that bind together
the viscera of the splanchnic cavities — ^the cranium, thorax, abdomen and the genital organs.** * * pp. 40-42.
** ¥rhile it cannot be doubted that the organs of the moral faculties and passions are situated in the brain, neither
can it be denied that the viscera are not entirely pamive in their exercise.
" What is the exact part they perform, it is not easy to divine ; but every one is conscious of sensations of a peculiar
kind, having either a pleasurable or iMnfiil character, experienced in the epigastrium. In the chest, and sometimes
in other parta, while under the influence of moral emotions of an agreeable or distressing nature.
** Sympathy Is the medium connecting the organic actions of the different organs, and oonslstB Ui the transmission
to a remote organ, and Ihe repetition in that organ, of the same mode of action which had been previously excited in
some other organ. One organ Is in this manner an exciter or stimulant to the actions of other organs, and concurs by
this aneans to the maintenance of the vital activity of the whole organism.** * * p. 690.
** In the ■Mwea, we have the positive demonstration of the transmission of impressions from one organ to another
distant organ. * * A reciprocity and identity of action, it Is apparent, prsvalls between the organs of the senses
oa the extmmal sur&ce, the recipients of external impressions, and the internal cerebral 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
series of phenomena corresponding exactiy with those coustitnting the sympawies, an action excited in one oigan
trawmitled to and reiterated in another.
**Illnstrations of a yet stronger character are furnished by the phenomena of the nervous apparatus, exemplifying
ia a more vivid light the character and mode of production of the sympathies.
** A mental impreasion, an Idea, the excitation of a moral emotion, exdtes or modifles this movements of tiie oapil-
laiy dreolation, or disturbs the regular function of some important organ. The deep suffusion of the mautlmg
blood in the face of the modest female, the eloquent langunge of the unuttered thought, is a striking exempUflca-
tionef the influence of cerebral excitement over the capiUary circulation. The efl^eots of the pi '
I on the heart,
so frequently disturbed in its mode of action by moral emotions ; the disorders of the biliary secretion, and deranse-
mtm% of the digestive action of the stomach, induced by profound mental operations, are strong evidences oftne
taasiort of impressions by the nervous system. A still more impresrive example is found In the erotic ideas ia
dreams, sq stimulating the genital organs as to provoke in them the actual senmtions of the venereal act, and the
^colatioA of the seminal Bqnor.
** In these axamples is manifested an exdtement transmitted by nervous communication from one organ, in which
it b developed, |q another organ, to which It is transported, and to which It Is imparted.** * * p. M2.
** The power of tnuismlssion is common to all the nervous apparatus, and Is the means connecting Its different
paitio— . Bat for tHe transmlaslon of the excitement of the organic actions a spedflc nervous appaiatus is provided ;
it is the gaogllonlo system, or the sympathetic— the nervous system of the viscera and organic Ufe. By the arrange*
■Mat and diatribntion of this system a nervous appartus Is provided, independent of, yet most Intimately connected
with the cerebro-spinal nervous system. It Is endowed with the same fbrce, nervous activity, fluid, or whatever
name it mmj be known by. It possesses an analogous mechantom; nervous oncans, or centres (the gangliaX nervous
cords of oommnnicatlon or of transmission and receptive expansions in ttie viscera. Its actions and mfluences are
in a rfmilar BM>de— Impressions received, excitement of nervous activity, and transmisrion of excitement ; and it
exereises a controlling and governing Influence over all the splanchnic viscera, to which It Is distributed, similar to
that exdted by the cerebro-spinal sf^iaratus over the organs of locomotion, expression, sensation, the Intellectual
and moml fhcolties. • « pp. &92, 593.
"The two important centres which have been indicated as existing in the nervous system are immediately con-
neetod to each other, and by this connection the two apparatuses are placed In communication, and direct relations
fStsMiahod between them. This communication is established by the eighth pair, par vagum, or pneumogastric.
Arfslog from the mednlla obloitgata, it sends branches to the ganglia of the neck and thorax, but is prlncipuly ex-
pended in anastomoees with the solar plexus and semilunar ganglia; so that it may be either described as proceeding
fbm these ganglia and terminating in the medulla oblongata, or, arising fh>m this last. It terminates in the ganglia.
**The commniilcation formed by the par vagum or pnenmogastric between the centres— the mednlla oblongata and
smiilaaar ganglia— establishes the Intimate relation and Immediate connection uniting the two apparatuses of the
oervoos organs — the cerebro-spinal and ganglionic or organic. By this connection impressions are mutually reflected
(mm the one apparatus into the other; and consequently the Impreasions of the viscera, especially those of the abdo-
•en, which have no direct communication with the brain, reach that organ, while those viscera experience themselves
mrfiflfations fh>m the influence of cerebral exdtement.*' * * —pp. 594, 596.
**In the natural state of tbe organism the correlation and mutual play of the organs on each other, through the
nedinm of the nervous system, and by the radiation of its ingenerated nervous activity, are not characterised by
lieatarM so striking as to be readily seised on and established. They nevertheless do exist, and are what is to be nn-
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Introduction to the Study of DUeases of the Nervous System.
dentood property by the synergl* of wrtten. Id the pstholoffioftl itote the evldeaoee of this mode of
influence are too apparent to be misanderBtood. The pathoTogloal {dienomoDa are, howerer, no mor
atione of the physiologloal phenomena. When' an organ, in a state of aettve irritation or aoate inl .
on anothef and distant orcan, affects tt in ^e same manner, oommnnlcates its own eonditloa, it Is not timt a oosbMi-
tion is eetaUiflhed which did not before prerail, or a mode of action and inflaenoe is bitmtvt into play vbkh an-
rionsly had no existence. The connection was already there : the action and influence already had beiac t ^^d as
from this natural <x physiological connection and influence tne organs harmonise aad correspond to each other ta
health, so from the saaie cause are they pardoipaats of the same condition in disease. It is from this aataral, flzed
connection and influence that an organ pathologically excited, cenerating in Itself; by the aenroas eieaseata oC Its
structure, an excess of nerrons actiTlty, becomes a morbid or patholof^cal excitant to the other organs embraced la
the range of its nerrons circle, or with which it is in most intimate nervous condition.** * *-iPP* M9, 600.
The views of the eminent physiologist, J. MuUer, conceraing the Laws of Action of the
sjmpathetic nerve and the propagation of impressions in it, may be gathered from the fol-
lowing propositions, consolidated from the Second Edition of bis Elements of Pbjsiology.
or THB AOTIONS OF *THI STM PATHITIO MIBTI IN INYOLUNTABT MOTIOHS.
I. All the parts subject to the influence of the sympathetic nerve are incapable of rolna-
tar J motion.
II. The parts which are supplied with motor power by the sympathetic nerve still continne
to move though more feebly than before, when they are separated from their natural connec-
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 sjnpa-
thetic, are, in a certain degriee independent of the brain, and spinal cord.
IV. The central organs of the nervous system can, however, exert an active influence on
the sympathetic nerves and their motor power.
V. The experiments of Dr. Philip tend to show, also, that distinct parts of the sympatfaetic,
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 tbe
contrary, that the brain and the whole spinal cord, or every part of it, can exert an inflnence
on the motions of the heart.
VI. The movements excited in organs which are under the influence of the synpaUi^tic
nerve, by irritation applied to them or to their nerves, are not transitory and momentarj con-
tractions ; they are either endaring contractions, or they consist of a long-continued modifi-
cation of the ordinary rythmic action of the org^n : hence, in these organs, the reaction con-
sequent on the irritation is decidedly of longer duration than the action of the stimoloi.
The motion of the nervous principle in the sympathetic nerve then is slow, and iu rate
capable of being measured.
YII. The immediate cause of the involuntary motions, and the cause of their type, Ifes
neither in the brain, nor in the spinal cord, but in the sympathetic nerve itself; even the
influence of the ganglia is not uecessary ; the branches of the sympathetic going to an organ
may be entirely removed, the twigs distributed to the substance of the organ only being left.
and the motions will be continued as before, the reciprocal action between the muscular fibres
and these ultimate nervous twigs being apparently adequate to their production.
VIII. Although from the foregoing 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 tho gan-
glia themselves when in a state of irritation, exert an influence on these morements as long
as the contractile organs are connected with them through the medium of the nerves. The
brain and spinal cord, are however, also to be regarded as the source of the power of tbe
sympathetic itself, which would without them, become exhausted.
IX. It results from the facts already stated, that the sympathetic nerve is charged as it
were with nervous power by the brain and spinal cord, which may be regarded as the tonrcas
of nervous influence ; but that, when once charged, it continues to emit this influence in tlie
manner peculiar to itself, even when the further supply is for a time diminished. This affords
an explanation of a part of the phenomenon of sleep.
X. The influence of narcotics locally applied to the sympathetic nerve does not extend to
the distant organs which the nerve supplies ; but these organs may be paralysed by tbe direct
narcotisation of the minute nervous fibrils which are distributed in them. In this respect
the sympathetic resembles the cerebro-spinal 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 iniBxplicable, difference 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 no effect,
or, at all events, a very slow one ; the rythmic motions of the heart of the frog, removed from
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-
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Introduction to the Study cf Diieases cf the Nervous System. 93
flMBts are permaneotlj arrested, freqaentlj in a few Beconde after the application. Of this
feet, first obeerved b.y Dr. Henrj, (Bdinburgh, Med. and Surg. Jonr., 1832,) Professor Mflller, '
has satisfied himself bj repeated experiments on frogs. This obserration explains the rapidity
of nareotio poisoning, when the poison has once entered the blood and reached the heart.
XI. Tha laws of reflexion, previonslj unfolded, prevail likewise in the actions of the
sympathetic nerre ; strong impressions on parts supplied by the sympathetic nerre may be
propagated to the spinal cord, and gire rise to motions of parts which derive their nerves
from the cerebro-spinal system.
XII. Impreesions on parts of which the nerves are derived fVom the sympathetic are com-
Buaicated to the spinal cord and brain, and excite the motor influence of the sympathetic
nerve by reflexion, although the reflex action is here less marked than in the case of the
eerebro-tpinal nerves. When we compare the reflex phenomena presented by the cerebro-
spinal serves, with those in which both the original excitation and reflected action are seated
in parts under the inflnence 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, sneezing, vomiting, etc., how much more numerous are the reflex
phenomena in the cerebro-spinal system, compared with those presented by the organs
governed by the sympathetic I The circumstance, also, that inflammations of the intestinal
canal do not affect the pulse— that is the heart's action, — so quickly nor to so 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.
Xin. 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.
XIY. Can refle^L 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 the cerebro-
spinal 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 irriuted, neither the whole muscle, nor even the entire length of the muscular fibre, con-
tracts, but merely the part directly affSected 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 Muller they will not ; on
the contrary, the irriuted parts only will contract; indeed, on pinching the intestine with
forceps, there does not even follow a circular contraction of the whole tube,, but merely a
limited contraction at the part pinched, while the opposite side of the canal remains quite
flat and undisturbed. Volkmann obtained the same result from similar experiments. Benle
obtained a diffierent result, from that of the experiments of Muller and Volkmann, which
seemed to prove that the reflex movements of the intestines can be excited only through the
medium of the spinal cord. Even in intestines separated from the body of the animal, (a frog,
rabbit or guinea-pig), he was able to excite circular contractions, which extended progres-
sively in one or both directions, and sometimes were accompanied by contraction of the
Umgitttdioal muscular bands. Henle therefore, admits that the ganglia are centres of reflex-
ion, which is also the opinion of Mr. Granger, (On the Spinal Cord, p. 133). Valentin, (De
FoactSon : Nervor, pp. 92-96), denies that the ganglia of the sympathetic can reflect the im-
pressions of contripetal fibres upon centrifng^ motor fibres, but he believes that they in
•one way render the centripetal fibres more prone to excite refiex motor action in the spinal
cord. ELeflex movements are excited, he says, with the greater facility, the more numerous
the ganglia which the nervous 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
action.
XV. We are at present entirely ignorant as to whether irritation can, through the medium
of the sympathetic nerve, give rise to movements in another; since all the sympathetic phe-
nomena of this kind can be explained on the principle of reflection from the brain and spinal
cord. •
XVI. It is not proved (and several facts have been observed which are opposed to the be-
lief,) that the ganglia can exert an insulating action so as to impede the transmission of motor
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94 Introduetion to the Study of Diseases of the Nervous System.
influence from the brain and spinal cord. It is not roluntary inflaence, bot motor influence
generally, which is here referred to ; for every one is aware how readily and qnickly an im-
pression on the brain and spinal cord influences the whole sympathetic system ; bow qnickly
a mental emotion alters the heart's action, and gives rise to movements of the intestines, to-
gether with borborygmi ; how a hysterical fit, in which the central organs of the nerrons
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 sjmpa-
thetic nerve being withdrawn from the influence of the will.
XVIII. In certain organs, which are subject to the influence of the sympathetic and of the
spinal nerves 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 communicated involuntarily to them, just ma in
the associate motions of voluntary muscles.
XX. The motions of organs which derive their nerves from the sympathetic system, h*Te
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 nerree
of the organs themselves.
OF THE SENSITIVE FUN0TION8 OF THE SYMPATHETIC NBBVB8.
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 sensorium, the organ of consciousness. The action
of a sensitive nerve continued to the spinal cord, may give rise to 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 maj give
evidence of its affecting the cord by other signs than sensation, namely, by reflex motion.
III. The impressions which give rise to reflex motions, when conveyed to the spinal cord
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.
IV. The ganglia of the sympathetic nerve do not prevent the transmission of centripetfti
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 sympathetic nerve
being unattended with true sensation.
VI. In many cases, irritation of a violent nature in organs supplied by the sympathetic
nerve, gives rise to sensations in those parts ; in other cases, the irritation being less violent,
the sensations in the parts affected are indistinct, while distinct sensations are present In other
parts supplied with cerebro-spinal 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.
OF THE OROAHIC FUMOTIOITS OF THE SYMPATHETIC NEBVE.
"" We are most anacqtiaioted with the laws of the orguiic action of the mrmpathetio nerve: for we have b«i jaM
learnt that there are in all nerves, even in the cerebro-epinal, peculiar gray necicali, or organic filwee, on whi^ de«
pend the organic actions of the nerves in secretion and in nntiltion. We have now to enquire whether fn thest
nerves the mo^n or oscillation of the nervous principle can be fHropagated only in the oentriftagal direction &om the
trunks and ganglia to the branches, or in the oontrair direction also ; or whether the action of the nervoms ptiiiciiile
in them can be exdted In all directions, a particular fibre of these nerves being capable both of transmitting a vtvi>
tying influence to a gland* Mid of exercMng a reflex action so as to communicate the initation in one gland to other
organic nerves. It vrould be desirable also to know whether the organic nerves are, by virtne of their snastoMuaus,
enabled to re-act on each other in such a manner that increased secretion from a whole snrlhce may be excitad by
Irritating one point, or whether all such reflex actions are affected through the medium of the spinal cord. The &cts
known relative to this sut^ect admit of two explanations, and it cannot t>e determined with certain^ which is the
correct one. There are certain cases, however, in which either one or the other theory is more probable.**
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 communicated to the organic fibres by the ganglia of the roots of the sensitive DMreSr
which are travened by fliH-es of the ^ympathetio ; or it may be reflected on the ovguAe flbrea by the q»lnal oovA. The
latter is evidently the most probable view, since the reflex action of the spinal oora in the reflected motioiis is a de-
monstrated foct, but the reciprocal action of the different flbree in the ganglia of the sensitive nerves on each other
a mere hypothesis. The cases of sympathetic affections of organic nerves here alluded to are very flnequent. Impree-
^ions on intenutl mucus membranes,— for example, by drinks, — ftvqiiently give rise immediately to a general sweat.
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Introduction to the Study of Diseases of the Nervous System. 95
▼ioleat iiB|»ra«ioiM on Miisitiye nerves are somettmee followed by syncope, and with a cold sweat The latter pheno-
nena are eridently the resalt of an influence reflected by the spinal cord, since the symptoms in syncope sometimes
affect an extent of the system so great as to be explicable only in that way. In some other cases of this kind, it is
DMre doabtful whether the phenomena may be explained in the same manner. Irritation of the coi^nctiva of the
eye and eye-lids, attended with sensations, gives rise to a flow of tears ; stimuli applied directly to the mucus membrane of
the Boae, or volatile stimulants affecting the same mucus membrane, when taken into the mouth, producing violent
•eMatiooa in the nose, likewise give rise to an effusion of tears. Mustard and horse-raddish have this effect some-
times even when taken in the mouth. It is usual to explain these phenomena by supposing the irritation to be com-
rnnnkated by the ethmoidal nerve to the trunk of the first division of the fifth nerve, and to be thence reflected upon
the UOTTiis lachiymalis: the secretion of tears frmn irritation of the conjunctiva has been explained in the same man-
ner; the irritation of the conjunctiva being communicated to the first division of the fifth nerve, has been imagined
to be thence again reflected upon the lachrymal branch ; in both these cases however, the explanation is defective ;
for, inaamoch as the fibres of a cerebrospinal nerve are wholly distinct in their entire extent, an impression on oni^
portion of ita fibres cannot be reflected upon others. Again, the same phenomena have been BU|q;»osed to be thf
result of sympathy of the Schneldcrlan membrane with ^e lachrymal gland through the medium of the ganglion of
the spheno-palatine, which has been stated by some anatomists to be connected with the ciliai7 ganglion by meanH
of ■ympathelic fibres. Now, since the ciliaiy or lenticular ganglion, by its long roots, is connected with the nasal
aerre, and thus with the trunk of the fixst division of the fifth, which gives off the lachrymal nerve, an immediate
connectioii vras thus found to exist between the spheno-palatine ganglion and the latter nerve. But the same objec-
tion must be made to this explanation as to the former ; for, unless the fibres in the fifth nerve communicated with
each other, an irritation conveyed through the ciliary ganglion and nasal nerve to the first division of the nervui'
trigeminns eoold notJM reflected upon the lachiymal branch. There are other physiologists who imagine the im-
praeion in the noee to be communicated to the Gasseriap ganglion on the trunk of the fifth nerve, and to be thence
relkct^ upon the flivt division of the nerve and its lacnrymal branch. No objection could be made to this explana-
tion of the phenomena, provided that we knew that the Gasserian ganglion, the ganglion of a sensitive nerve, were-
capable of giving rise to igrmpathy and refiex action ; if it Were proved that centrifii^ nervous currents can takf
idace in senaitive nerves, such as the lachrymal nerve ; and if it were demonstrated that the lachrymal nerve really
snppUea the lachrymal gland which regulates its secretion. Slnc^ the secretion of tears, like other secretions, \»
detemined probably by fibres of the sympathetic nerve, the most simple explanation would still be that which
supposes the irritation to be conveyed fh>m the nose backwards to the spheno-palatine ganglion, and, by means of the
connection of all the organic nerves with each other, to be refiected in some way or other through the medium of
organic fibre* upon the lachiymal gland. But whether such a reflex action horn, sensitive nerves directly upon
ofganic nerves, without the intervention of the brain and spinal cord, can occur, is a questionable point; and I know
no other argument in Ikvor of its possibility than the impossibility of proving that it cannot occur. A very frequent
instance of reflex action of the secreting ftinction ftom irritation of a sensitive nerve is the increased flow of saliva
often coming on quickly when food is taken into the mouth. The mode of explaining the phenomenon is equally
as uncertain here as in the former case. The assumption tiiat the brain and spinal cora form the medium by which
tiie irritation of the sensitive nerve is enabled to excite the organic action is at least favored by the analogy of simi-
lar reflected actions of sensitive or motor nerves, through the intervention of the central organs."
II. There prevails a concert of action between the different parts of a secreting mem-
brane; thus the state of one spot influences the condition of the whole extent of a serous
membrane. Here it is more simple to explain the phenomena by commanication of the
organic fibres with each other.
III. A particular state of one organ, such as inflammation, or a secreting action in it,
sometimes canses the production of a sityilar state in other parts. In this case we have an
instance of reflected action of the organic fibres of one part upon those of another.
I of the testicle may be replaced by inflammation of the parotid ; eiyslpelatous inflammation of the
akin may be transferred to the membranes of the brain ; sui^ression of the secretion of one organ may give rise tu
incri— ed secretion in another. All such phenomena are probably attended with changes in the organic flbres
belonging to the sympathetic system, which accompany the blood-vessels. And here, again, the question arises,
whether such reflexions are produced through the medium of the sympathetic alone, or whether the brain and spinal
oocd are the medium of reflexion between the centripetal and centrifugal actions. There are no facts which enable
OS to decide this question; but in many cases it is probable that the sympathetic nerve alone is engaged in the
prodactloB of the phenomena. In Mayer*s experiments, l!g4tnre of the sympathetic nerve between the first and
seeoad cervical ganglia, was sometimes followed by an affection of parts which appear to be under the infiuence of
the first cervical ganglion, namely, by inflammation of the eye. The peculiarity of the organic nerves, namely, the
difllenlty of distinguishing either origiu or termination in them, their want of arrangement into trunks and branches,
and the increase which they firequentiy undergo in their course, is certainly in fttvor of the possibility of their actions
being popagated in all directions fh>m the central points of the ganglia, and not conflned to centripetal and centrifu-
gal cmrents. This view Is also Savored by the circumstance, that when an organ ceases to be supplied with organic
fibres bom one source, the supply may be furnished bv another. Ligature of an arterial trunk, without doubt in-
jmres the oiganlc nerves which accompany it ; nevertheless, no death of the part, atrophy, or cessation of secretion in
it ensues; so that it appears as if ttie nerves accompanying the collateral vessels were able to supply the lost
taifluenee, or that the new supply is ftimished by the organic fibres in the spinal nerves. On the other hand, the
infloenoe of the spinal nerves may be lost without atrophy ensuing. In V. Pommer's experiments, too, it was ob-
served that division of the mnpathetic nerve on both sides of the neck, gave rise to no iQjurious consequences, so,
i^t perteps the influence of the divided portions of the nerve had been supplied ftom other sources, as, fur instance,
by the fibres accompanying the vertebial arteries. The metastasis of a morbid process, however, takes place in all
cases towanU the organ which is predisposed to it; thus, in poisons, with tendencv to pulmonic affections, the metas-
tasis takes place ftum the skin to the lungs; in patients liable to hepatic disease, from the skin to the liver ; and in
ochen, with irritable bowels, from the skin to the intestinal canal, and so on. In considering the laws of equilib-
rium, to which the secretions are subject, not only the nervous system, but the nature of the mfferent secretions, and
their relations to the components of the blood, and to one another, are to be attended to.
IV. The ganglia appear to be the central part« from which the vegetative influence is dis-
tributed to the difl'erent organs. Inflammation of the eje and even the general phenomena of
impaired nutrition, hare been observed 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 bram and spinal cord, since the embryo may be developed while the brain and spinal
marrow are destroyed.
VI. It appears, however, that the brain and spinal cord are the main source whence the
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96 Introduetion to the Study of Diseases of the Nervous System.
power of the organic nerTes is gradoallj renoTated, since certain affections of the brain aod
spinal cord, attended with paralysis, are likewise productive of atropbj. — Elements of Pbjti-
ology, Vol. 1, Sec. Bd., pp. 778-803, 1840-1842.
Professor J. Muller illustrated manj of the preceding propositions bj experiments, aad be
is entitled to the credit of having first systematieallj and philosophically applied the laws
governing the action of cerebro-spioal nerves 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 nerve. MfiUer not only applied the doctrine of reflex nervous action, as devel-
oped by Marshall Hall and himself, to the phenomena of secretion, nutrition and infl*mma-
tion, and to the actions of the sympathetic or organic system of nerves, but be also mceom-
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 Muller had been properly studied and recognised, there woald
have been no subsequent controversy as to the priority of discovery of the reflex actioiu of
the sympathetic system and of the so-called exeUo'seeretory system of nerves.
Dr. Henry F. Campbell, of Augusta, Oeorgia, published in June, 1850, *^^n Afoy imAe
Inflttence of Dentition m Producing IHsease."^ in which he endeavored to sustain, not by experi-
ment, but by references to well known anatomidkl, physiological and pathological facte, and
more especially by the experiments of Pourfour du Petit, Dnpny and J. Reid, on the sympa-
thetic, the proposition
** That in the uiatomy and phniology, •■ well •■ in the dependent analyii* of the prooeas of dentition, ve lad
ample cronnd for the c^nion, uiat the diaeaeee pertaining to this period, may be dependent and in many iiirtanww
are enttrely so, upon the local iiritation attending the proce« being tiansmitted thnragh either the c<nili>u ssiinel
t^stem of nerree, producing convnliiTe disease in the motory apparatus, or through the sympathetic, "^— ktg dissr*
raagement in the secretory organs, partienlarly the alimentaiy canal, by the sway which it ezendses over the actatial
system fhnn which these secretions are eliminated.**
A similar theory was applied by Dr. Campbell, to Typhoid and Typhus fevers, in a paper
presented to the American Medical Association at its session of May, 1853.' Thus he says:
** After the most care Ail and laborions consideration of the phenomena, relationship and events of this truly aiysie-
rioos disease, keening in view at the same time as well as we were able, the enMrv physiologioal dependencies of such
an intricate question, we are induced to regard the typhoidal state, manifested both in the typhoid and typhus fieven,
as a morbid affection of the whole or portions of the ganglionic systems of nerves, known also as the great sjmp»>
thetic nerve, but of the exact nature of which, and how produced, we know not.**
Dr. Campbell admitted, however, that the preceding hypothesis rested upon no pathologi-
cal observations of his own :
** We are fUlly aware that our views of the pathology of typhoid fevers woulji be greatly coirobo rated, could there
bo discoTsred any appedable k$tom in the ganglionic nervous centres, in sutdects who have died during thair pro-
gress ; but, like the penological anatomy of all the nervous qrstem, this would be an investigatioB stteadad vNh
many dilBculties. * * These dianges, then, are i»obably molecular and inappreciable with our present menus ot
investtgatton-**
Dr. Campbell's views with reference to the reflex relation subsisting between the cerebro-
spinal and sympathetic system of nerves, were farther expanded and illustrated by the more
recent experiments of Claude Bernard and Brown-S6quard, in his *< Prise Essay, The Excito-
Secretory System of Nerves; its 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. Marshal] Hall published in the London Lancet, 1857, an article, in which he annoanced
the discovery of a system or sub-system of ExdtO'Secretory Nerves, which he regarded as
not less extensive than the Bxcito-Motory System of Nerves, which he had previously
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 aod sympa-
thetic system of nerves.
1 Southern Medical and Suiglcal Journal. June, I860, pp. 321-S38.
2 An Inquiiy into the Nature of Typhoidal Fevers. Trans, i
. Am. Med. Asso., May, 1863. QympatheCic Nerve ia
Reflex Phenomena. Trans. Am. Med. isso., Tol. vi, 1863.
3 TruM. Am. Med. Asso^ 1867.
4 Trsns. Am. Med. Asso., 1868. Claim of Priority in the Discorery and Naming of the Exdtory-Secretoiy System
of Nerves, by H. J. Campbell. 1869.
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Introduction to the Study of Diseases of the Nervous System. 97
KXPERIMENTS ON SECTION OF THE NERVES, ILLUSTRATING THE RELATIONS OF THE
SYMPATHETIC TO NUTRITION, SECRETION, CIRCULATION, RESPIRATION AND ANI-
MAL TEMPERATURE.
The effects of section oi tht par vagvm npon the conjunctiTfti membrane of the eye, when
practiced upon those animals where the sympathetic is so closelj connected with this nerve, that
the one cannot be divided without the other, have been noticed by Tarious phyisologists. At
ft longer or shorter period after the trunks of the par vagum and the accompanying sympa-
thetic nerres were divided, the conjunctiva became red, swollen, and projected over the
cornea. The pnpil 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
have said, was the first who observed these effects upon the eye after the section of the par
no^voi, and justly attributed them to division of the trunk of the sympathetic : for he was per-
fectly 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 the par fo^um in the neck in quadrupeds. We have also shown that Crulkshank in
like manner noticed this inflammation of the conjunctiva in his experiments upon the par
Tsgnm.
That Petit was right in supposing this inflammation of the eye to arise from section of the
sympathetic and not of the par vagum^ was fully demonstrated by the experiments of Dupuy,
(Joomal de M^decine, 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
Dapny were confirmed by those of Brachet (Functions du Syst^me Nerveux, Ganglionaire,
Chap. ix. 1830.)
This inflammation of the eye frequently takes place with great rapidity after section of the
aympathetic ; in one case Dr. John 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 upon the cornea ; and in the fourth experiment of Dupuy upon the horse,
it is stated, '* Aussitot apr^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 depending 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
dissection found the inflammation apparently restricted to the conjunctiva.
Dr. John Reid did not, however, consider it fairly ascertained that the inflammation is con-
fined merely to the surface of the eye. In the experiments of Dupuy and Brachet upon the
effects of the removal of the superior ganglion of the sympathetic, the same phenomena pre-
sented themselves as far as the eye was concerned, as when the par vagum is cut in the neck .
Dr. John Reid held that this inflammation of the conjunctiva from section of the sympathetic
in the neck, cannot, 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 wfthout 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-
niously suggested, from the arrestment of the usual secretions which protect the conjunctiva
from the irritating effects of the external atmosphere, as seen in various cases when the nerves
of secreting surfaces are cut. (Alison's Outlines of Physiology, p. 148. 1833).
Dr. John Reid,* who has enriched physiological science with several valuable memoirsf in
which numerous experiments upon the nervous system are detailed ; after having frequently
rerified the observations of Petit, Gruikshank, Dupuy, Brachet and others, carefully eyam-
med 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
• Ob the Efleeta of Leaion of the Tnink of the GangUuaic SyHtem of Netres in the Neck upon the Eyeball and ix»
AppendAM Bdinborgh Medical and Surgical Journal, August, IS:)0.
t On the Relationf between Mnecular Conttactili^ and the Nervous system— Kd. Monthly Journal Med. Science,
3U7,1841. Order of SuccearioB in which the Vital Actions are arr««ted in Asphyxia— Sd. Medioal and Surgical
Jovnal, 1811. Effects of Venesection in renewing and increasing the Heart's Action, under certain circum>
tucet— Ed. Medical and Surgical Journal, April, 1836. An experimental Investigation into the Functions of the
Ei|)ith Pair of Nerves, or the Olosso-Pharyngeal, Pneumo- Gastric, and Spinal Accessory— Ed. Medical and Surgical
Jovraal, January, ISiS, April, 1839. On some Points In the Anatomy of the Mednlki Oblongata— Ed. Medical and
SmficyJoamal, January, 1841. On the Anatomical Relations of the Blood- Veewls of the Mother to those of the
FcFtiis in Human Species— Ed. Medical and Surgical Journal, No. 140, January, 1841. Ii^iection of the Vessels of the
Fcetus, to show some of the peculiarities of the Circulation— Bii. Medical and Surgical Journal, January and April,
IS36. Sensational and BmotioDal Reflex Actions. On some Points in the Anatomy and Physiology of the Heart—
f'jclopadia of Anatomy and Physiology. Tables of the Weights of some of the most Important Organs of the Body
at diflovnt periods of Life— London Ed. Journal Medical Science, April, 184.3. Observations on Phlebolites— Ed.
Xsdifcal and Surgical Jonmal, April, 1835. Physiological, Anatomical and Pathological Researches, by John Reid,
M. D., etc, Edinburgh. 1848.
13
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98 Introduction to the Study of Diseases of the Nervous System.
freqaentlj accompanies inflammation of the conjunctiva. Bj a series of experiments per-
formed during 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, over the cornea, and the partial approximation of the ejelids to each other,
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
removed 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 membrane over theinner partof 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 very few minntes, but generally
after a longer interval, by inflammation of the conjunctiva, which is occasionally so terere
that this membrane presents an almost uniform redness, and is covered by pnriform mncna,
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 hand, in the experiments which he
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 miu-
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 ocuU 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 give 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 branch^
of the superior sympathetic ganglion in various animals, to give some plausible 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. xxiii), when the
right carotid, the vagus 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 dizziness in the head, and swelling of.
and discharge from the mucus membrane of the left nostril. From the direction the shot had
taken. Dr. Jewell was certain that it had injured, if not divided both the sympathetic and
pnenmo-gastric nerves on the left side. Dr. Jewell also reports the case of a gentleman
who came under his care, with severe erysipelas of the right side of the face and neck, coot-
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 Anally occupied all the spaee
between the two points named. There was extensive sloughing and erosion of all snbcntaae-
ous structures, leading, finally to fatal haemorrhage. But during the latter half of his illness,
the phenomena, such as follow division or destruction of the sympathetic were developed;
there was extreme redness of the corresponding side of the face and head ; increased heat S5
compared with the other side ; reddening of the eye ; contraction of the pupil, etc. There wa»
also at times, very irregular action of the heart. The patient died from haemorrhage aad
blood poisoning (Chicago Journal of Nervous and Mental Disease, Vol. I, p. 15). Willebaadt.
Gairdner, Coates, Ogle, Heineke, Yerneuil, Bulenberg, Poiteau and others, have reported cases
of compression of the sympathetic by means of tumors, aneurismal, glandular and otherwise.
* ChlcMgn Jouraal of NenroiM and Mental Disease. Vol. I, No. 1, Jan., 1874, p. 14.
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Introduction to the Study of Diseases of the Nervous System. 99
io which Bimilar phenomeoft have been observed. Dr. William Ogle, (Medico. Obir. Trans.,
Tol. iii, p. 151), has reported an instance of probable destrnction of the right cervical sympa-
thetic bj abscess, in which the eyeball was retracted, the palpebral fissnre narrowed, the
pupil contracted, the right side of the face redder and hotter than the left during repose, but
after Tiolent exercise or fever, colder; the left side of the face alone sweated, and the right
nde of the month and tongue were complained of as being dry. Dr. S. Weir Mitchell, in his
recent ralnable work on the Injuries of Nerves, Phila., 1872, pp. 318-321. (Also, Gunshot
Wounds and Other Injuries of Nerves, 1864, pp. 39-44), gives the following as the only
known cases of direct mechanical violence to the sympathetic nerve reported by the staff of
the U. S. A. Hospital for injuries of Nerves, etc.
Wpmmi of Hy>l lympaftgtfc iienw ; vtommd fcinleJ fa mx wetlm; oer06rol %mptofiM ; oonlraotod fmpH; pto§i$; locJbryma-
mmmm ^ JfooMy. Aged tweiity-fovr ; wounded at ChaDcelloriTllle, May 3d, 1863 ; was standing erect, and looking
towanla the left side, when a ball entered his right neck, one and half inches behind the ramus of the Jaw at the
antnior edge of the stemo-cleldo-maftoid musoMi passed across the neck, rising a little, and emenged immediately
bck>w, and a half inch in front of the angle of the Jaw on the left side. He fell senseless, and may have remained so
during half an hour. On awaking, he found his mouth full of clotted blood, which he pulled out; the bleeding had
rossrd Alter a short rest he was able to walk nearly three milee to the rear, where his wounds were dressed with
cold wat^. On his way he diMovered that his speech had become hoarse, difficult and painftol, and that deglutition
gaverifv to great unesknessand to burning pidns. * * After flye days of great suffering and utter insMIity to
raallow. he obtained some relief; but for a month or more was forced to take a little water after every mouthftil of
food, nie power to swallow gradually improved, and is now as good as it ever was. A week after he was wounded
he was aUe to articalate without pain, although hoarselv. This difficulty also lessened bv slow degrees. * * During
his reooreiy, whidi was rapid the wounds healing within six weeks, he had a good deal of pain in the back of the
He says that he had headache, whenever, after the injury, he attempted to walk fiir, or exert himself About
ooth tfter he wa9 hurt, a comrade noticed the peculiar appearance of his right eye, and called bis attention to it.
A little later it begiin to be troublesome in bright lights, and has remained so ever since, with of late some change
Ibr the better.
July lAth, 1863. — Tu^ of the right eye is very small, ttiat of the lelt unusually large. There is a slight but very
disdnct ptosis of the right eye, and its outer angle appears as though it were droppwl a littie lower than the inner
sB^ The ball of the right eye looks smaller than that of the left. These appearances existed whether the eye was
opMi or dosed, and gave to that organ the look of being tilted out of the usual iiositlon. The conjunctiva of the
f^l^ eye is somewhat redder than that of the left, and the pupil of the right eye is a little deformed, oval rather than
iDoad. * * The left eye waters a good deal, but has the better vision, the right eye having becoihe myopic. In
•uiHght he sees wdl at first, but after a time, observes Ired flashes of light in the right eye, and finally, after long
•xpcenre, sees the same appearance with the 1^ eye also. * * Has lost fiesh 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
fmad no abnormal external i^ppearancee. Mooney walked ftttm Dr. Dyer*s office to the hospital, an unusual exertion,
«he was weak, uid avoided exercise, on account of the headache it caused. An orderiv who was with him on this
nrsriiia, reoiaiked to one of the hospital staff upon the singular appearance which his mce presented after walking
in the hnst It became distinctly flushed on the right side, and pale on the left. This &ct was afterwards observed
•new by one of me. The patient had used exercise and had Just come in. The right half of the fisoe was very red.
The %uA extended te the middle line, but was leas definite as to its limit on the dUn and lips than above these
potets. He compiainsd ot pain over the right eye, and red flashes in that organ.
A careftil thennometrie examination, made dirimg rspose, showed no difference in the heat of the two sides within
the month or ear. * * Under a tonic course of treataient he gained ground rapidly. The eyes became less sensi-
tive, the pupils more nearty aUka, the line of the lid siralghter. * * He was at last able to return to duty October,
ISUw
Eulenberg and Guttman*, refer to two cases of injury of the sympathetic of similar kind.
Whilst in the preceding cases, injuries of the sympathetic nerve were attended with con-
traction of the pupil and congestion of the canjunctiva, as in the experiments, upon certain
animals, detailed by Reid and others, it is worthy of note that the changes did not result in
the destrnction of the eyes by inflammation as occurred in some of the experiments of Petit,
Dupuy and Brachet, but indicated rather marked circulatory disorder in the muscular struc-
tores of the blood-vessels supplied by the sympathetic. Brachet relates several experiments
to show that injury of the sympathetic or destruction of its superior cervical ganglion is
attended by great vascular congestion of the anrterior and middle lobes of the brain, producing
drowsiness and stupor ; the experiments of Dr. John Reid, however, did not confirm those of
M. Brachet. It is 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.
Contraction of the pupil, consequent upon lesion of the sympathetic in the neck, is not
noticed in the experiments of Gruikshank,^ Arnemann,' Mayer' of Bonn, and Brachet, whilst
this effect is described by Petit,^ Molinelli,* Longet* Valentin ^ and others. In the experi-
menls of Gamerer,* and Pommer,^ detailed in the treatise of Stilling^^ on spinal irritation,
• Die Rathologie des Sympatheticns auf Physiolo^lscher Grundlage. Berlin, 1873. Pages a.9.
I no. Tiana., 1796. Part 1.
t Tersuche Uber die Begeneration der Nerven, S. 69-102. Gottingen, 1787.
3 Joonial der Chimrgie, Von Graefe und Walther, Zehnter Band, 8. 418, 1827 ; and Functions du Systeme Nerveaux
GaacUonairs. Owpter Ix, 1830.
4 llimoire dans lequel 11 est I>6montr6 que les Kerfs Interooetaux Foumissent des Bameaqx, qui »e Portent dcs
<apriti les Teux ; dans 1* Historic de *1 Acad6mie Boyale des Sciences, AnnA, 1727.
5 Comment Bononlensi, -tom. ill, 17S5, p. 280.
6 Anatomie et Physiologic du Systdme Nerveux, etc, tom. ii. p. 363, Paris, 1842.
7 De runcftkmibus Nervorum Cerebralium et Nervi Sympathetlci. pp. 109, 114, Bemii}, 18.39.
8 Tennche liber die Natur du Krankhaften Blagenerwelchung, 1828.
9 Beitnge znr Natur, und Heilknnde, 1831.
10 Phydologisehe, Pathologlsche und Medidnisch-Practische Unterauchungen Uber die Spinal Irritation, 8, i:)e,
140, Leipsig, 1840.
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100 Introduction to the Study qf Diseases of the Nervous System,
no change was observed upon the eyeball in the rabbit ftfter section of the sjmpatbetie and
vagus in the neck ; similar results were obtained by Arnold, in his experiments npon hens and
pigeons, and he concludes that the effbcts upon the eye, which follow lesion of the vagus in
the dog, depend upon the injury of the sympathetic and not of the vagus, as had been cod-
clusiyely esUblisbed by the experiments of Reid on the cat. Longet also determined that in
the rabbit, the contraction of the f)upil was dependent upon section of the sympathetic and
not upon that of the vagus. From his careful and extensive experiments, Valentin concluded,
that the iris derives its motor filaments from two sources — from cerebral and from spinal
nerves ; its cerebral motor filaments come from the inferior branch of the motor oculi nerve ;
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 vag^s (granglion inferius.)
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-
lyzed, 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
arrangrement 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 onlj
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. Hughlings-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 cilio-spinal portion of the spinal cord. This region, as we have
just seen, was first indicated by Valentin, and subsequently more fully investigated by Budge
and Waller and extends from the first cervical to the sixth dorsal vertebra, or even so low as the
tenth, according to Brown-Sequard. Within these limits irritations of the cord net on the
pupil, precisely as do similar agencies addressed to the sympathetic nerve itself.
M. Claude Bernard, in 1862, laid before the French Academy his remarkable experiments
on the sympathetic system. (Comptes Rendus, vol. xxxiv., p. 471 ; Premiere Semestre.
Fevrier, 1852.) Having divided the sympathetic in the neck of a rabbit, this distinguished
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 natural 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, but 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 vital heat — the last in fact to die. No signs of inflammation
or of any other disorder exhibited themselves, to which this augmentation of temperature
might be reasonably referred ; for although, in the first instance, it was accompanied bj
increased vigor of the circulation and vascular turg^escence, yet these conditions subsided in
a few days, while the temperature itself, showed no symptoms of diminution. When the sym-
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 small 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 hyperacmia, which i?
the immediate result of the operation, subsides considerably in a day or two ; but the eleva-
tion of temperature is much more persistent, lasting in rabbits 16 to 18 days, in dogs 6 weeks
to 2 months. Bernard has shown, that not only the superficial parts, but the deep-seated,
and even the blood returninj? by the jugular vein, is hotter than the corresponding parts of
the healthy side, or than they themselves were previously. Both Bernard and Brown-S^uard
*Mediciil Times and Gazette. HUrch, 18&I.
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Introduction to the Study of Diseases of the Nervous System. 101
have obserFed that the temperatnre oa the sound side falls below its previous figure, tbe
difference in one experiment amounting to 5^^ F.
Tbe important circumstance has also been noted, that the phenomena just described are
more prominently 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
cerrieal 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
nncbangred ; 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 tbe normal and the operated side becomes more prominently marked; 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-Sequard,* 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 usual, arrives there in greater quantity, there-
fore, nutrition 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-Sequard, has seen as M. Claude Bernard has, that the ear exhibits sometimes, one or
two degrees Fabr. 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-S^uard based his opinion in part upou 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 sound side. Brown-Sequard concludes, that the only distinct effect of the section of the
cervical parts of the sympathetic, is the paralysis and consequent dilatation of th^' blood-ves-
sels ; that the cervical sympathetic sends motor nerve fibres to many of the blood-vessels of
tbe heart; and that the blood-vessels are contractile, and that the nerves are able to put
them in action.
It was long known that certaii^ injuries of the nervous system might be followed by a par-
tial or even general elevation of heat. Chossat found a considerable diminution in tbe tem-
perature of dogs, aft^r the section of the inferior portion of the spinal cord ; but in two cases,
where the spinal cord was divided at about tbe levej 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 F.: in the other from 105«.98 F. to 109*^.6 F. (M^m. 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 tbe temperature of the
paralyzed parts after the division of the sciatic nerve, or after the partial destruction of the
spinal cord, (Vutersurchunger Zur Physiol, und Pathol., 1839, v. ii, p. 190.)
Brown-Sequard 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. George'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
vert«braiis, 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.
Tbe patient died at the end of twenty-two hours ; and for some time previous to his death,
he breathed at very long intervals, the pulse being weak and the countenance liirid. 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 scrotum and the thigh, the mercury rose to 111° of
Fahrenheit scale. Immediately after death, the temperature was examined in the same man-
ner, and found to be the same. In more than twenty experiments, Brown-S6quard, only
once found an increase of temperature of the leg of a guinea-pig, after the section of the
sciatic nerve. This increase lasted abont two or three days after the operation, and amounted
to 2° P. After a complete transversal section of the spinal cord in the lumbar region, in birds
and mamraiils, Brown-Sequard, found repeatedly, an increase of one, two or three degrees Fahr.
in tbe 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
found only in the paralyzed part. Brown S6quard never found any increase of temperature
after a complete transversal section of the spinal cord, either in the cervical or the dorsal
* Medical tlxuniner, August, 1862. See also Experimental Researches, applied to PhysiologV and Pathology, l*v
E. Brown-^^quard, New York, 1853, p. 9. p. 73.
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102 Introduction to the Study of Diseases of the Nervous System.
region. After a section of a lateral half of the spinal cord, at the lerel of one of the three or
fonr last dorsal Tertebrse, he almost constantly fonnd an increase hk'^the temperature of the
posterior limb on the side of the section, the eleration varying from one to fonr degrees Fahr.
but on the contrary, there was a diminution of from one to five degrees Fahr., in the temper-
ature of the other leg. In some cases, in consequence of the increase of temperature on oee
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 witb the diminution of temperature
in the other limb, there is also a diminution of sensibility.
From the preceding facts, Brown-S^quard drew the following conclusions :
1st. An injury of the nervous system may produce in the parts, which then become par-
alyzed, either an increabe or diminution of temperature.
2d. The sympathetic nerve and the cerebro-spinal 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. It is a fact hitherto unexplained, that the arteries and capillaries may be either
dilated, normal or contracted in paralyzed parts. (Bzperimental 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 bas
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° C. (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 circo-
lation. Bernard has also recorded the important observation, which has been confirmed by
G. Hanfield Jones,* Weber, S. Wier Mitchell,t 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 sick, either spontaneously or from
the effects of other operations, the mucus membranes of the eye, and nose on the operated
side only 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 mwo-motor
and calorific nerves.
Bernard| thus formulated his ideas: —
1. Division of nerves of sensation, besides producing anesthesia, diminishes the temper-
ature of the parts supplied.
2. Division of the motor nerves, besides causing paralysis, gives rise also to eoldmeu m Ike
paralyzed parts.
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 althongh
mixed with this system are derived fVom 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
* Indies on FuncUoaftl NervouB Disorders, London. 1870, p. 20.
t IiOories of Nurves and their ooosequences, Philadelphia, 1872, p. 32.
X Le9on8 but la Physiologie et la PaUiologie, des Systime Nerveox, Vol. li, p. 490, (1858).
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Introduction to the Study of Diseases of the Nervous System. 103
prodaction of beat ; the section of the nerve merely causing hjpersemia, the consequence of
which is, that the normal blood-heat is more perfectly attained and exhibited by the parts
thas more richly supplied with blood.
With reference to the third question, if the movements of the vessels depend upon the
eerebro-Bpinal system, then the tympatketie is not the special vaso^motor nerve.
Brown-S^uard* has shown by subsequent 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 vascular before the operation, there
was no decided increase in the vascularization and in the temperature of the face, and in
very cold weather the extremity of the ear of rabbits, on the side of the section of the sym-
pttthetic nerve, remains cold. And as we have seen, it results from the experiments of Brown-
S^aard, and from the observations and experiments of Brodie, Ghossat, H. Nasse, Macartney
and oUiers, 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 increiise 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-S^quard has shown, however, that these two effects, viz : increase
and diminution of animal temperature, may follow an injury of either the sympathetic or
the cerebro-tpinal nervous system ; and in both cases, the increase may exist, at first, and be
followed by a diminution.
Badge} 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 Ruyter,l| noticed no alteration of temperature which could not be explained
by the increased access of blood : and Dondersf remarks, that in these experiments the temper-
ature of the ears very seldom exceeds that of the rectum, that it is high Justin proportion to
the amount of blood sent to the ears — that it diminishes when 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. In 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 difference 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-
vessels, 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
exclusive vascular nerve of the head, but that the cervical, auricular, the facial, and the tri-
geminus 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,
because those of the head and trunk both meet there. He 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 estab-
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
the hands and feet, and of the lower part of the fore-arm, and of the leg (below the knea) of
* XxpeTimental Bafearctaes applied to Physiology and Pathology, pp. 75-76.
t Gai, Med. de Paris, Vol. 7, No. 14, p. 227 .
t Oomptea Bendna, xxxri^ 377.
I GompCee Bendna, xxxri, 378, 1868.
1 Diaert, de Actione, Atropn Belladonnn, 1853.
fAantee Kingen Yan het Ob, Oetr., 1853.
** Uatennehnngen sor Physiologie, dee Nerres SystemR, i, 124.
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104 Introduction to the Study of Diseases of the Nervous System.
the left side, and on the other side (the rig^ht), those of the trnak, the arm (abore the elbow),
and the upper part of the thigh are paralyzed. In sabseqaent experiments, SchilT,* excited
fever, by the injection of pns into the pleura, or into the rascular system in animals, in whom
he 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 suflfering 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 (tbe
nerves of which were divided), were colder than the corresponding parts of the other unin-
jured side. He concluded from this, that the paralytic hypersemia, 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 nenrea
of the blood-vessels, such elements as, when stimulated, cause an active dilatation ; bnt
after section of the nerves, this is no longer possible.
Kussmaul and Tenner,* reduced the increased ivarmth of the ear, of the side on which tbe
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 llgrating or compressing the caroUd
on the same side, they iilso 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 lif^ore
of the subclavians, produced parallel results, whether the sympathetic was ptoviously 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 tbe
elevation of temperature, and not mere hypersemia, or increased functional activity. SchilT J
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, ob-
served uniformly, a suppression 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 overfulness 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 ftom the surface of the body. When however, be divided the
mednlla-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 fVom 102**. 92 to 104^. 18 F. ;
after an hour, it rose to lOS**. 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 aifd a half, the temperature reached 107^. 96, F. ; 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 ceaseless
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
• Allgen WIemer, Med. Zeitg., l>«9, p. 318.
t Moleschotts Untersuchungen Zur Natiirelhii des Men«clien und dvr Theori, 1856, p.90-l:)2.
* Gasetti LomtNii^ 1H67, Kos. *25-.33.
} Vntenuchiingen, p. 100.
Rpichert'B Arcbir., 1866, p. l.'i^.
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Introduction to the Study of Diseases qf the Nervous System. 105
wms dirided, than when the section was 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 qninine, 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. Breuer and Chrobok,* have investigated the question, whether the nerves of a part
supply the stimulus which causes the febrile elevation of temperature in an inflamed 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 up 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 «ystem to the temperature of (he body ; but Wunder-
lich, after an elaborate review of many of the facts just recorded, considers the following as
analogous spontaneous conditions :
1. The local alterations 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 effects 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 th^ end of tetanus and other fatal
oearoses.
According to Wunderlich, these facts are favorable to the theory, that a large share in the
regulation 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 sately assumed, that alterations
in the amount 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,
particularly 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
remarkable alterations of temperature occur with profound disturbances of the nervous
system, without corresponding anomalies of circulation, and according to Wunderlich, it is
perhaps not too much to aflSrm, that the integrity of certain parts of the central nervous
apparatus is more necessary for the regulation of animal heat, than that of any other part of
the body.
Samnelf has advanced the hypothesis of the existence of fibres, distinct from the motor
nerves of muscles and vessels, as well as from the sensory, whose office is to preside over
Bstrition, and which are divisible into a centrifugal and centripetal set ; the centrifugal when
excited, increase nutrition, when paralyzed, decrease it; on the other hand, paralysis of the
eeotripetal fibres, is the cause of the diminished resisting power of ansesthetic parts to injuries.
Samuel, 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-
uted. Weber has strongly controverted the views of Samuel, and concludes that the influence
of nerves upon inflammation is nothing else but the influence exercised by them upon the
blood-vessels, and that inflammation cannot be caused either by paralysis or irritation of
nerves. Whilst it must be admitted from the various facts recorded by different observers
conducting independent investigations, that certain nerves, when stimulated, do excite an
inflaence in the districts to which they are distributed, in the way of increasing the amount
of blood circulating through the tissues, by antagonizing the ordinary vaso-motor nerves
accompanying the arteries, whose activity induces the opposite condition ; at the same time it
• Wicaer Medic, Jahibttcker, XIV, p. 3, 18S7.
t Die Trophiflce Nerren, Leiprig, Wigud, 18(Mi Oaast. Jahr., toL 11. p. 6ft-«7, 1861.
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106 Introduction to the Study of Diseases of the Nervous System.
is doubtful whether the so-called trophic nerves are indeed a special set, or whether th« i
effects may not be produced through ordinary motor and sensory nerves.
Against the doctrine, that the oerebro-spinal and sympathetic nervous system, may directly,
by means of special systems of .nerves, as the vtuo'tnotor^ trophie and inhibitory directly increase
or diminish animal heat, and directly increase, diminish or alter nutrition and secretion, the
following facts and arguments may be opposed.
The well known and almost universally acknowledged facts, that no nervo cells or nerve
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 io
perfection ; that in the lowest or most simply constituted animals, in which development,
digestion, nutrition and secretion take place, as in the more complicated animals, no nerves
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 animals,
and the apparent impossibility of reproducing the more highly organized tissues in the most
highly organized animals, when destroyed : may be regarded as satisfactory proofs, 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 process
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 vital action. The fact is true of the animal kingdom in its
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 various 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 mnsdes.
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 foetus, 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 sjttem.
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 nervoas
system. Chemical change in the organs and apparatus, and chemical change in the nervons
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 mosca-
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 due to the chem-
ical changes of those elements which have been separated from oxygen and elevated into a
state of force (capable of chemical change,) by the forces of the sun, acting through 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 oonseqaeat
generation of the forces, and the greater is the necessity for some special apparatus, which will
bring all the complex organs and apparatus, and actions into harmonious relations. Unless
the actions of different organs can be telegraphed (so to speak) to each other, contusion in a
complex organism will necessarily result. Thus if the amount of blood circulating through
any organ be too great or too little, there must be some medium of communication, and sobm
means of regulating chemical and physical actions, through that special apparatus by which
the circulation of the blood which furnishes the elements of chemical change may be increased
or diminished. The nervous system forms the medium of communication between the intel-
lectual faculties and the exterior world, it connects together and influences the various orgaus
and apparatus, it regulates secretion and excretion, and the consequent development of the
animal forces, by regulating the circulation and respiration, and it excites and controls the
dynamic muscular apparatus, not by the possession or emission of a peculiar force generated
de novoy 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 regelating
the /action of the circulatory and respiratory apparatus, and thus it controls the amount ot
oxygen and blood supplied to the organs. 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
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Introduction to the Study of Diseases of the Nervous System. 107
erident that whatever distarbs Ihe constitation of the nervoos system, necessarilj disturbs
the fancUons of the apparatus and organs, and produces correspondiag alterations in the
secretions and excretions. As the inlegritj of the nervous system, depends upon the integrity
of the blood, in like manner, what^Ter alters the constitution of that fluid, will produce
aberrated action in the nervous system, and in turn, this disturbance may extend indefinitely.
The view which has been held by soqm physiologists, that the. production of animal heat,
is uwentiaUy dependent on nervous agtncjf^ independent of chemical change, is evidently errone-
oqSy for the following reasons : Heat is generated in the vegetable kingdom during the
eheaiieal changes of the nutrition and growth of the cells, without the intervention of nerves;
so also in certain diseases, a large amount of heat is generated after death, and the cessation
of all nervous agency. The elevated temperature of inflammations and fevers, is attended
with a corresponding increase of chemical chanffe in the blood and organs, as is evidenced
by the greatly increased amounts of urea, phosphoric 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 deoomposltion 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 fbroe and motion from nothing ; it must
arise from pre-existing motion or force. The chemical change of the human body, have been
shown by careful experiments, to be sufficient in amonal and character to develop and main-
tain animal temperature. When the true calorific equivalents of carbon and hydrogen, are
naed in the calculation, and the relatively minute quantities of phosphorus and sulphur, are
alto included, the heat produced by the various chemical changes in the animal body, is
adequate 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 transpircfd
through the skin and lungs. The nervous system may influence the amount of heat, by
influencing the respiration and circulation, and possibly also by the conversion or transmuta-
tion of its peculiar physical, nervous or electrical force into heat. Depressions and elevations
of the animal temperature, may also be due to chemical changes of an abnormal character in
the blood and in the nervous and muscular structures, excited by morbific. agents, which act
chemicallj upon the organic constituents ; whilst at the same time, they may produce such
deranipement in the actions of the muscular and nervous systems, as to lead to a state of actual
prostration and depression.
The view held by certain physiologists, based upon the results of the old experiments of
Petit, Cruikshank, Dnpuy and Brachet, upon the sympathetic, that the nervous system pre-
rides absolutely and wholly over secretion, and is capable of producing all the phenomena of
iafiamasation, 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
inflneoce 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 examination 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 tuts 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
mass of the nervous system. Thus Bidder carefully removed the arches of the cervical ver-
tebrsB of frogs, so that little blood was lost during the operation, and then completely de-
stroyed the spinal cord. Frogs treated in this way often lived six weeks, and sometimes ten,
the circulation in the web of the foot remaining at the same time active and not differing
fh>m that of uninjured frogs. The heart beat powerfully and quickly ; in a freshly killed
frogf in winter, the heart 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
■tnate. When the brain and spinal cord were destroyed, the medulla oblongata being left,
firegs were retained in life until the sixth day ; and when the entire central organs of the
oerrous system were removed, they lived until the second day ; the rapid ensuing death in
the latter case being due according to Volkmanc, to the effects produced upon the respiration.
Within a few 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
produced in them by application of chemical or mechanical stimuli ; the heart, however, in
such cases still continued to pulsate eleven times in a minute, and retained its property of
responding to external stimuli. The intestinal canal, in like manner, retained its irritability ;
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. 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
fbr 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,
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108 Introduction to the Study of Diseases of the Nervous System,
eren in animals when the spinal cord had been destroyed twentj-siz days previonily. The
secretion of nrine also continues ; when in animals in which the brain or spinal cord has
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 mentioned. It had been observed by Valentin and Stilling, that after destruction
of the spinal cord in the frog, different derangements in the nutritive processes ensued ; there
were frequently observed dropsical swellings, especially of the limbs. On these also sores
formed, which often penetrated as far as the bones. In reference to these results, Volkmann
states, they are, as shown by 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 grass,
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 Yolkmsnn, opon
the difSculty of sufiSciently keeping up the respiration by artificial mefins, as well as apon the
loss of blood and diminution of animal heat, (Cyclopoedia of Anatomy and Physiology, YoL
V. p. 457.)
The frequent 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 apon
nervous agency. In order to test this doctrine, the distinguished physiologist, Dr. R. Brown-
S6quard, about the year 1849, performed the following experiments : He divided the sciatic
nerve in a number of rabbits and Guinea-pigfs, 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, hay and old clothes. In a fortnight, the former set exhibited an obvionslv dis-
ordered action in the paralyzed limbs ; the claws were entirety lost ; the extremities of the
feet were swollen, and the exposed tissues were red, engorged and covered with fleshj grana-
lations. At the end of a month these alterations were more decided, and necrosis had saper-
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 had been kept living for foar, 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 cnt oC
so that reunion was nearly impossible, and did not take place. Experiments made npon
pigeons gave the same results. It is obvious, from these experiments, that the patholo|cical
changes which occur after the section of the sciatic nerve, do not proceed directly from the
absence of nervous action, but that they are consequent upon the friction and continued 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^qnard
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-S^quard made researches on the influences produced on the capillary circulation
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 nerves.
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. Guinea-pig or pigeon, the palsied limb continues 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 also found 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 bums,
wounds and ulcerations existing in parts palsied in consequence of the section of their
cerebro-spinal nerves, are cured as quickly and as well as those in sound parts. According
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 nerves), b
not necessary for the change of color of the blood in the capillaries, and that the nervous
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 fol-
low section of the cervical sympathetic, in the celebrated experiment of Claude Bernard, are
mere consequences of the paralysis, and therefore of the dilatation 6f the blood-vessels ; the
blood finding a larger way than usual, arrives there in greater quavtity, 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 full of blood, it is very
easy to understand why it has the temperature of the blood. A great many facts prove that
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Introduction to the Study of Diseases of the Nervous System. 109
the degree of temperature and of sensibility of a part is in close relation with the quantity of
blood eircnlating in that part. We have already dwelt npon the great importance of Ctie fact,
discovered by this observer, that if galvanism be applied to the superior portion of the sympa-
thet|6 after it has been cut in the neck, the vessels of the face and of the ear after a certain
tiiBe 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 the
sensibility diminish in the face and the ear, and they become in the palsied side the same as
in the sound side. When the galvanic current ceases to act, the vessels begin to dilate again,
and all the phenomena described by Dr. Bernard re-appear. Dr. Brown-S6quard concludes
fh>ra these experiments, that the only direct effect of the section of the cervical part of the
sympathetic, 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-Tessels of the head. Certain experiments prove that the 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 donbts that the effect of dividing the sympathetic is to paralyze the
arteries, and so cause their dilatation ; and r^ards it as an anomaly that arterial paralysis
should promote greater activity of the circulation. That paralysis of the arteries should
promote a greater activity of the circulation, is, however, evident, when it is established
that arterial contraction has necessarily the opposite effect, and diminishes the afiSux of blood
to the 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. Europ., 1859, No. 29, p. 282 ; Syd. Soc. Qen. Book, 1861, p. 29),
demonstrate very clearly that paralysis of the sympathetic nerves inlereases 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
millim ; 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. C. Uandfield Jones, in his valuable and profound <* Sttuhes on Functional
Nervmu Diaordert^-^ 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 cardiac action, with a want of arterial."
Ackermann and Bergson (Syd. Soc. Year-Book, 1860, p. 131, Virchow'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
thus enabled to observe the varying state of the vessels of the brain : section of the right
jcerrical nerve was found to sause injection of the diplo6, and of the cerebrum of that side ;
and three hours afterwards when the left nerve was divided, the injection of the correspond-
ing cerebral 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
parL only of the spleen is affected. In the experiments of Samuel upon rabbits, dogs and
cats, the hypersemia of the intestinal mucous membrane produced by extirpation of the
cseliac 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 the same degree
as in a violent diarrhoea. After removal of the lower part of the spinal cord and the roots
of the 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 the ischiatic
nerve be divided on one side, the result is, that the skin of the extremity subjected to the
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
found 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
manner the control of the sympathetic nerves accompanying the arteries over the circula-
Uon, and through the circulation upon the nutritive actions.
The vaso-motor system of nerves 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
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110 Introduction to the Study of Diseases of the Nervous System.
there is » marked elevation of temperature in the central organs. The great redaction of th«
temperature of the surface and extremities is eridently due* to the withdrawal of the blood
by the contraction of the minute arteries ; but it is not clear, that the deration of the blood
in the central organs, is due to the nerrous influence, for it maj be the result of the ipcreaeed
trequencj of the respiration and heart beats and the action of a specific poison, indocini^
destruction of the fibrin and blood corpuscles.
In those cases of Traumatic Tetanus, in which a sudden and great rise of temperatare pre-
cedes death, other causes as actual inflammation of the spinal marrow, the geperation of
pyogenic compounds, and the retention of carbonic acid from impeded respiration, maj h%
active in producing this remarkable phenomenon. The same observation 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 ent»>
neous excretions in the various conditions characterised 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 Humoral Pathology, and locate the origin of inflammation and even of Cancer,
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 Gonheim 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 circalatlon, bnt
that stimulation of the fifth pair and of the facial produces a greatly increased flow of sallT%
while at the same time the circulation of the gland is accelerated.
The essential idea of the inhibitory theory^ is that a peculiar kind of impression made on a
centre may disorder or paralyse 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 galvanizing the medulla oblongata or the pneumogastric nerve. (Lemons snr le
8yst^me 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 mascl«'S of
the limbs were thrown into spasmodic movement Such experiments 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 hearths action. Slight irritation of the spinal cord increases,
while powerful irritation diminishes the frequency of the heart's action. We are scarcely
justifled from such experiments to conclude that the dilation of the vessels is an actire phe-
nomenon and dependent upon a special system of nerves, the so-called van iHaiort and mm
contractors : neither can the view of Euienburg and Landois be adopted as proved, that there
are four systems of so-called inhibitory nerves, viz : the cardiac, the respiratory, the intesti-
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 and
elevation of temperature, to simple paralysis or loss of vascular tonus. It must be clearly
borne in mind that, relaxation of the muscular flbres 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 increased action in the muscular structures proper to the heart
itself. A complete investigation of the so-called Inhibitory actions, should embrace a nunnte
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-S6quard 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 after 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 galvanic current be applied every day to the palsied limbs on one side, these gal van-
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Introduction to the Study of Diseases of the Nervous System, 111
ised limbf retain their oatoral dimensioDS, whilst the palsied limbs not galranized become
atrophied. Moreover, if the application of galvanism in made on the palsied limbs of very
▼oang animals, and continaed every day until they arrived at adnlt 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 paralyzed muscles,
takes place mostly, because they remain without exercise, and partly, because when nervous
actian is deficient the respiration of the muscles is not carried on as well as when the nervous
system acts upon them. Qalvanism applied to a palsied limb acts partly in producing the
transformation of arterial blood into venous blood, i. e. what Oustav Liebig calls the respi-
ration of the muscles. Brown-S6quard has seen frequently, the venous blood, in palsied
Uabs, becoming as black as normal venous blood, after the application of galvanism, and he
attributes this change of circulation, not to a direct chemical influence, exerted by galvanism
on t^ blood, for if galvanism be applied to blood in a vase, no change of color is produced,
but tmmm interchange between blood and the living tissues. From the preceding facts, Brown -
S^qaard ^oaclndes, that Nervotu Action is not necettary for Nutrition. (Experimental Re-
searches, applied to Physiology and Pathology, pp. 6-12).
The researches made before those of Brown-'S^quard, as to the influence of the spinal cord
on 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 bad been completely destroyed Uom the eleventh to the twelfth costal
vertebra to its termination. This cat lived all that time in apparently good health, and its
urine 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 ef the spinal cord. Brown-
Sequard has also shown that the opinion of Krimer, that the urinary secretion depends upon
the modalla 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 Sfcretion depends.
Browit-d6qaard has in like manner shown that the opinions of Segalas, W. Philip, Krimer,
Chossai, Longet and others, about the influence of the spinal cord on the functions of organic
life, are quite 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 had been cut oflf, were reproduced,
the fnnctions 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 toolc 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 the influence of the medulla oblongata on the functions of organic life, Brown-S6quard's
experiments on cold-blooded animals, have proved, that the functions, (except, of course,
pulmonary respiration), may continue to exist, without any appearance of disturbance.
(Experimental Researches, pp. 13-15). After the complete transverse section of the dpinal
cord in mnmmals or birds, it has also been shown, that the ulcerations which take place
around 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 faeces.
M. CI. Bernard, by his wisely devised and carefully executed experiments, has shown, that
in certain 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
distinct 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
easy to be understood, between the chemical changes which the blood in the organic tissues
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112 Introduction to the Study of Diseases qf the Nervous System.
undergoes, and the mechanical conditions of the capillar/ circulation, which are under tke
immediate influence of the nerves. The experiments which led to these results, were mad*
upon the submaxillary gland of the dog, which is particularly adapted to this kind of research,
on account of the intermittence in its act of secretion, exhibiting very clearly the Tariaiions
in the color of the Tenons blood. The nerre which causes the Tenons blood to appear red ia
the veins of the submaxillary gland, is a small branch which arises from the posterior portion of
the lingual branch of the fifth pair ; but it is only in contact with the fifth pair, comini^ really from
the seventh, and is principally formed by the chorda-tympani ; whilst the nerve which renders
the venous blood in the submaxillary gland, black, is derived from the great sympathetic,
and accompanies the arterial branches of the carotid. When the vein and nerves of the gland
are exposed, and an impression upon the nerve of taste is produced by dropping a little rine-
gar in the mouth, the blood rapidly reddens in the vein, because the impression of taste pro-
duced upon the tongue and carried to the nervous centres, has been transmitted by r^ex
action through the corda-tympani. The proof of the truth of this interpretation of the phe-
nomena, is immediately furnished, for when this nervous filament is cut at the point where it
separates from the lingual nerve, the venous blood of the gland remains black, and from that
moment, notwithstanding the application of vinegar upon the tongue, and the impression npoa
the nerve of taste, the red color of the blood does not appear, because the nervous medinm by
which the modifying infiuence of the blood was conducted has been interrupted. But if the cat
extremity of the nerve next the gland, be irritated by means of galvanism, the blood in the
glandular veins becomes red, and resumes its black color when this excitement ceases. If all
the filaments of nerves which go from the great sympathetic to the gland be cut, the reaoas
blood loses its black color, and takes a russet color, which becomes permanent, because the
influence of the great sympathetic nerve has been interrupted and does not reach the ^and«
But if the action of this nerve be re-established, by applying galvanism to its glandalar ex-
tremity, the venous blood becomes very black, and again resumes its red color, as soon as the
galvanic influence, ceases to act upon the nerve. Thus the variations in the color of the
venous blood in the gland, are due to two nervous influences, well marked and perfectly dis-
tinct. In endeavoring to understand the mechanism of the influence over the blood, it is
evident that there in no anatomical continuity between the nerves and the globules of the
blood, and that it is necessary that there should be other phenomena intermediate between
the nervous 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 ^ich
nerve produces in the capillary circulation of the gland. The mechanical conditions of the ,
capillary circulation, produced in the submaxillary gland, by the tympanico-lingual, and the
great sympathetic nerves, are exactly the opposite of each other. When the tympanico-lin-
gual nerve is excited, the venous blood appears of a red color, and at the same time, there
comes on a considerable activity in the rapidity of the circulation ; in proportion as the
venous blood becomes redder, it flows more and more rapidly, and the quantity which flows
through the vein is 'much increased. When the Influence of the great sympathetic predom-
inates, the venous blood is blackened in color, and at the same time its circulation becomes
sluggish, the blood flows through the vein, with a current slow in proportion to the intensity
of its color, and even if the action of the sympathetic nerve, is sufficiently excited, the corrent
of the blood may entirely cease, to re-appear the moment the excitement of the nerve ceases.
and again accelerated if the tympanico-lingual nerve is irritated. The red and black color
of the venous blood is a fixed relation to the activity of the circulation in the subaaxillaiy
gland. But this rapidity in the circulation of the blood cannot be produced directly by the
nerves, for they have no direct and intimate action on the blood itself. The contraction and
expansion of the blood-vessels of the gland, can also explain the modifications in the proper-
ties of the blood. Bernard has proved by experiments, that one of the two nerves of the
submaxillary gland dilates the vessels, while the other contracts them. When the action of the
tympanico-lingual nerve is intense, the increase in the calibre of the capillary vessels is so
marked, that the blood passes from the artery into the vein without losing the impulse of the
heart, and makes its exit from the vein of the gland, with an interrupted Jet as of a true
artery. This venous pulsation disappears, as soon as the action of the tympanico-lingual
nerve diminishes or entirely ceases. The sympathetic nerve, on the contrary, contracts and
narrows the calibre of the glandular vessels, in the most marked manner.
These experiments of Bernard, established the important fact, that the nerves act only as
agents of the dilation and contraction of the blood-vessels ; and although the nervous influ-
ence in secretion does not differ from that of the motor nerves m ffeneral over mmteuiar fmiM,
nevertheless, by a very natural connection of phenomena, it produces a series of physico
chemical changes in the blood. When the sympathetic nerve, the constrictor of the vessels
is active, 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 nerve which dilates the vessels is active, the passage of the blood through
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Introduction to the Study of Diseases of the Nervous System. 113
the gland becomes rer/ rapid, the modifications of the blood which take place in the contact
of the blood-globnles with glandular tissue are accomplished with a different result, and the
blood comes from the vein with a very red color and preserres the appearance of arterial
blood.
Thus has this physiologist shown, that even secretion may be referred to chemical
sad physical laws; and that the special nervous 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 nervous modifications of the capillary
cirenlatioo take place, in situ and without the least disturbance, to the neighboring organs,
still less to the general circulation ; each part is connected with the whole, by the common
states of the general circulation, also by means of the nervous system, and each part may thus
have ita appropriate circulation and physiology.
Whilst the experimental researches of Bernard, on the Great Sympathetic, instituted to
detarmiQe the relations of this nerve to the organic changes taking place in living tissues,
establish that section of the nerves of sensation is attended with abolition of sensation and
dimination of temperature, that of the nerves 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 vessels, and with an aucpnentation of temperature, section of the spinal mar-
row and nervous tracts enclosing the commissures of the nerves of sensation and motion and
of the sympathetic, paralysis of movements, and sensation and dilatation of vessels, and
augmentation of heat; at the same time a careful comparison of the results of these experi-
menu, have 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 cervical sym-
pathetic,'the dilatation of the arteries and afflux of blood accompanied by elevation of tempera-
ture and corresponding congestion and redness, resembling in all respects similar manifesta-
tions in inflammation, may exist for days and weeks and even months, without any apparent
change in the tissues, or the increase of the parts by inflammatory exudation, or through the
eAued serum. By its distribution to the arteries, the sympathetic, as a compound nerve of
sensation and motion, exerts a power over the passage of the blood through the vessels by
inflaencing the contractility of their muscular fibres. It thereby affects the rapidity of cir-
ealation, and also regulates the entire rate of secretion. The entire digestive tract and its
dependencies, as the salivary glands, (Esophagus, Stomach, Pancreas, Liver and Intestines,
sre 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 views which prevailed for nearly a century with reference to the so-called
nervo-pathological inflammations and nervo-ftecretory (excito-secretory) actions.
If the statement of Jacubowitsch be accepted, viz : that sympathetic cells exist in certain
parts of the spinal cord ; and if the observations of M. Luys, indicating the existence of a con-
tinnoos 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 vaso
motor centres in the cerebro-spinal system, indicated by the experiments of Budge, Waller, Claude
Bernard, Brown-S^uard, Schiff, Masius, Salskowsky, Ludwig, Tbiry 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 vaso-motor phe-
nomena, would be simplified by such a view ; and certain pathological phenomena, as the
increase of heat and increase of the capillary and general circulation might find a ready ex-
planation. Thus the introduction of a poison, or of the product of inflammation into the
blood, might induce paralysis of the vaso-motor centres of the sympathetic system within and
without the cerebro-spinal axis. Tbe central organ of the circulation, that is, its muscular
structures being excited to increased action, by the increased supply of blood, and the blood
being driven more rapidly through the entire course of tbe circulation ; and the muscular
apparatus of respiration, being at tbe same time excited to increased action ; all the essential
conditloos of fever, viz : the rapid introduction of oxygen and its rapid distribution through
tbe dilated vessels ; rapid chemical change and elevated temperature, may thus be established
by tbe action of a morbific agent upon the vaso-motor system of nerves. According to this
view, the increase in certain excrementitious products, result from increased chemical changes
resulting from the establishment of those conditions of the respiration and circulation favor-
aMe to tbe rapid transformation of the elements of the blood and tissues into crystalloid pro-
duets : and the relations of the nervous system to these changes is indirect, that is, by its
action upon the apparatus devoted to the aeration (oxidation oxygenation) and circulation of
the blood.
Whilst admitting that the ganglia of the sympathetic constitute centres of nervous excita-
tion, from whence the organic muscles and other contractile tissues receive the motor im-
pulses, 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
cerebro-spinal ganglionic masses ; we are not justified by the experiments of physiologists
14
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114 Introduction to the Study qf Diseases of the Nervous System.
upon the cerebro-spinal neryes, nor by those directly upon the orgmnio system, in adopting
that qaalification of the nenro-pathological doctrine, which regards the sympathetic as pre-
siding over, 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
wilh find that there is no broad line of demarcation between the cerebro-spinal and sjmpa-
thetic nervous systems in their relations to secretion. The relationship of muscular motioB,
secretion, nutrition and excretion to the cerebro-spinal system, is fully admitted ; and as we
have shown the tendency of the more recent experiments is to establish a close relationship
between the sympathetic nervous system and nutritive aotions, secretion and excretion and of
the muscular apparatus of the circulatory system, and of the alimentary canal and its associated
organs, and to limit the action of the sympathetic nervous system chiefly to the excitation
and control of the movement of the muscular apparatus which directly ministers to the organic
functions, and to the control of the movements of the heart and of the blood-vessels.
The phenomena following Bernard's celebrated experiment, of irritating the mesial line of
the floor of the fourth ventricle, in the centre of the space, between the origin of the anditoiy
and pneuroo-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 exeited
action of the heart, deranged respiration and afflux of blood into the capillaries of the liver
and spleen, in consequence of the irritation of the vaso-motor centres of the nerves snppljing
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, bnt also by punc-
ture of the olivary bodies, and of the cervical portion of the spinal cord, shows that the
hepatic tissue 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 sngar
is due to the result of the irritation of the general vasso-motor centre of the whole body,
which Kronecker, of Leipsic, has definitely fixed in the floor 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 flfth pair of nerves, if the various disturbing influences aifecting 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 resulting changes
denominated Pneumonia and Pnemnonie Inflammation, are due to the entrance of irritating buc-
cal mucus through the paralyzed rima-glottidis, and a great part of that which had been
called pneumonia, was nothing more than such an obstruction of the air cells, and hyper-
aemia of the blood-vessels, as prevented the proper ii^troduction of oxygen, and elimination
of carbonic acid, and ensured the slow poisoning and final death of the animals. Snch 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 foreign 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 movensents
which have been seen in minute 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 Msions, 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 iropfue 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 th'is
force, together with heat, it follows as a 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 nervous
matter, or reflected from the circumference, may be propagated by changes of the molecules
of the nerves, and reproduce its original effects, by transmission to distant organs. The
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Introduction to the Study of Diseases of the Nervous System. 115
effects of this transmission would rary according as the nerres terminate in, or are connected
directlj with the moscolar apparatus of the respiratory and circulatory and dynamic appa-
ratus of the liring organism, or with the excretory and secretory cells of the various organs.
We would thus have an example of chemical change in the periphery of the nerres, and in
the Tmrioos organs, whether muscular or secretory, to which they are distributed, analogous
to that which takes place at the terminals of the galranic 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 virtue of the neryous connections between the two systems ; and thus the gaugli-
oaic cells of the sympathetic become in turn excited, and the organs to which this system is
distributed, as the kidney, liyer and alimentary canal and heart, are in turn affected.
According to this view the function of a nerve would be limited by the nature of the struc-
ture in which it originates, and that of the ganglionic centre in which it terminates ; but all
nerrous action would consist essentially in molecular changes of the afforent and efferent
nerres. The nervous force being in all nerves the same form of physical force, the functions
of each nervous 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 have 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
convey 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 m the frog's nerves, at a temperature of 52 to 70^ P., nerve force moves at a rate of 81
to 126 feet per second, in man in motor nerves, 200 feet per second, in sensory nerves, 110
ftet 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 doubtfhl, 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-
tions of oriranic matter, and that at least it may be correlated with electricity, heat, and
other modes of physical force.
HYPOTHETICAL DISCUSSIONS AND INVESTIGATIONS CONCERNING THE NATURE OF THE
NERVOUS FORCE.
Three 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 ser^e as the medium of communication between the
different parts of the nervous system ; the second supposes that this transmission is effected
by means 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 different parts of the
'aervons system has generally been ascribed to Descartes,* who reduced it to a regular form,
and contributed by his authority to its general reception, although traces of this supposition
may be 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 brttin through the whole body by means of the nerves, and in this doctrine
he was followed by Galen, Vesalius, Feruelius, and others.
Galen, who refuted the doctrines of Aristotle, as to the functions of the brain, held that
the animal spirits are not contained in the ventricles only, but are diffused throughout the
whole substance of the cerebrum and cerebellum ; he had, 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 nerves 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
certain 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
open by the spirit contained in the cerebrum ? Thirdly, whether this spirit be innate in the
* Deacitm Tmctatiu de Homfne. Amst, 1677, Sec 14.
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116 Introduction to the Study of Diseases of the Nervous System.
nerves at all, but rather, when we seek to more a limb, whether it does not flow from the
brain into the nerve 7 Fourthly, whether the matter of the spirits flows into the nerves from
the brain in any way? or is it not rather its force, virtue or faculty, just as the substanee of
the sun remaining motionless, its light-giving property is poured forth into the ambient air?
He observes that he only proposes these questions for general discussion, as he was onable to
decide absolutely on them.
Caspar Bauhin was amongst the first who denied that the ventricles are the laboratory and
storehouse of the animal spirits, and who taught that they are generated in the substance of
the brain, and dispensed directly firom thence through the nerves to the organs of sensatkra
and motion. Caspar Hoffman opposed the ancient doctrine as to the use of the ventricles in
preparing and retaining the animal spirits, on the ground, that all the nerves of the body and
cerebrum arise from the spinal cord, either within or external to the cerebrum ; that the
ventricles are lined internally with the pia-mater, which prevents ingress and egress ; that
since the two superior ventricles open into the third, and the third into the inftindibaliim,
and this into the palate, there is no reason why the spirits might not pass out this way ;
that the ventricles are not continuous with the nerves, 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 vesaeU,
no force is known which compels them into the straits of the nerves after having entered into
the ocean of the ventricles ; and finally, that the ventricles have already a function incom-
patible with that of the spirits, namely, to collect and excrete the effiete matters.
These arguments were sufficient to lead many from the doctrines of Galen, and to convince
them that the ventricles 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 ventricles, 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 ven-
tricles are moved by the will acting through the pineal gland, and distributed thence through
the nerves to all parts of the body.
The principal ground of this hypothesis, seems to have been the idea that the brain is a
secretory organ, an idea which was suggesed by the great quantity of blood sent to it, and
by some supposed resemblance in its structure to other secreting glands. Yet, 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 that Des-Cartes wrote, everything that could not be otherwise explained, 4ras referred
to the agency of some kind of refined spirit, an idea which appears to have been originally
derived from the alchemists, and after being incorporated with t)ie metaphysics of the age,
gave rise to a long train of mysticism.
The doctrine of the nervous fluid, or animal spirits, not only became a subject of popular
belief, but their existence was assumed by many medical writers as an ascertained fket, 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 familiar.
Haller devotes no less than ten pages of bis great work. El. Phys., x, 8, 11, 16, to learned
discussions respecting the nature of this imaginary agent f 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 tpiritm rectus of plants, a substance nearly as little under-
stood as the one which it is intended to illustrate.
Riolanns, the son, tried to weaken and explode the arguments of Hoffhian, and, while he
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 ventricles in prodncing
and retaining the animal spirits.
The animal spirits, being ejected from the ventricles, were placed in the cerebral substance;
and Marcellus Malpighi, Thomas Willis, Sylvius 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
secreted they are received into the medullary substance, and distributed thence through the
nerves 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, imagination
and memory, were banished from the ventricles, together with the vital spirits, and were
• Benati Des-CHrtos Tnctotns de Homlne et de Formatione Foetus. Qaoram Prior NotU Peipetatt LodoTid dr>
La Forge, M. B., Illastratur. Amstelodaml, Apud Danielem BIseTirinm. I6r7, xir, pp. 24-26.
TmctatDs De Mente Humana, By us Facnltatibus et FnnctioDibus, Kec Non De HlJusdem Unione Cum Corpora;
Secundum Princlpia Benati De»<?artes, Autore, LudoTico de la Forge, Medidnw, Apud Salmurieosea Doctore. A»-
telodami, Apud Danielem ElMTirium. 16Q9 .
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Introduction to the Study of Diseases of the Nervous System. 117
located bj some in the solid masses of the brain ; by others were affirmed to be properties of
the immaterial, rational soul alone, and in no wise dependent on the body*.
it woold ioTolTe a useless expenditure of time to enter into a detailed account of the Tari-
oos hypotheses propounded and earnestly advocated by Malpighi, Willis, Boerhave, Ruysch,
Albinus, Mayow, Mayer, Whytt, Kaauw, Astruc, Haller, Meckel and others, as to the nature
of the animal spirits.
The hypothesis of ribration had been imperfectly stated by many of the earlier physiolo-
gfista, but it was so much detailed and embellished by Hartley, as to be by common consent
coBBocted with his name. The hypothesis of ribrations, 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.
According to this doctrine, the action of the nerves consist in a vibration of the particles
of which they are composed, by which impressions are transmitted along them, and conveyed
to and from the brain, in perception and volition respectively.
This hypothesis embraces two suppositions, viz : either that the particles of the medullary
matter itself are the agent, or else, that there is diflfused or dispersed through them, a subtle
etker, which acts the sole or principal part.
Hartley adopted the supposition of the intermediate action of the ether ; Dr. Young on the
other hand, substituted the electric fluid for the hypothetical ether. Blumenbach admitted
the plausibility 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
Kther, Hartley, " very ingeniously explains the association of ideas, and again by the assist-
ance of this, most of the functions of the animal faculties.'' (Physiol, 2 226).
It has beetf 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 l^ ultimately referred to motion. A smart blow on the eye, friction and pressure
upon the ball, and electricity, all produce this effect.
Sir Isaac Newton, concludes his Principia with the following remarkable hypothesis :
^^ And now we might add something concerning a certain most subtle spirit which pervades
and lies 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, redacted, 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, from the outward
organs of sense to the brain, and from the brain into the . muscles." (Priucipia, Book iii,
General 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
nk 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 Oalvani, Aldini, Von Humboldt, Philip, Matteucci, Nobili,
Dubois Reymond, and other Continental and English physiologists.
It has been well known from remote antiquity, that certain fish, possess the property of
communicating 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 exists between the electric fluid thus secreted or
excited by these animals, and any of the other modifications of Blectricity.f When electric
phenomena 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 its explosions; and after the discovery of galvanism, an elaborate attempt was made by
Valli,^ of Pisa, to account for muscular action by supposing that the muscles consisted of
an arrangement of parts, analogous to that of the elements of the galvanic pile. Yalli's
speculations on the action of the two metals upon the parts of living auimals, led him to as-
• DlMertatioB on the Fnnctioiii of the Nenroos Sjvtem, by Oeoive Procbaeka.
• Hanter,Phfl. Tmas., 1773. Dr. John Davy, Phil. Trans. 1832, 1834. Gay-Luaiac, Ann. de Chlm., Izt., p. 15, Joint
Baner with Hoiaboldt. OoUadoB, Stencea de 1' Aoad. de Sciencea, Ootob. 1836. Matteucci, Stencea de 1' Acad, de Sdenee,
1836. Bndolphi, Abhand, du Acad. y. Berlin, 1820, 1821. Walah, Phil. Trans., 1774. Ingenhouse, Yermlscbte,
8dirill«n, p. 272, Vienna, 1782. Humboldt, Bonpland and Faraday, Phil. Trans., 1839. Rudolphi, Abhand Acad.,
Bertin, 1824. MUUer, Handbuch der Physiologie dee Henchens, i, p. 66, Coblenz, 1837.
t BxperimentB on Animal Electricity, with their application to Physiology, by £. Valli, Brit Crit : March, 17M ,.
Joor. de Fby. t. xli, passim.
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118 Introduetion to the Study of Diseases of the Nervous System.
sert the identity of electricity and of the neryous fluid, and the same opinion waa to a certain
extent countenanced by Dr. Young,* Dr. Abernethy, and others. Valli believed the nenro
electric fluid to be secreted by the capillary arteries supplying the nerves, by which it became
conveyed to the muscles, which he believed 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 stimnlus of electricity at their origin first,
retaining it longest at their extremities ; and on this hazarded an opinion that probablj the
distal extremities are really the origin of these structures.
Galvaui really discovered, not only the/undamental 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 jar, and together with the blood- vessels,
it supplies the muscles with electricity. The experiments of Galvani, although commenced
in the Summer of 1786, were not published until 1791. Volta, in order to determine whether
the positive electricity existed in the nerve or in the muscle, discharged through a fro^ a
very slightly charged jar, at first from the spine to the muscles, then in the contrary direc-
tion, and finding that contractions resulted in the former case, and not in the latter, he
concluded that Uie 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 sorface
of the muscle with positive electricity. Subsequent observations by Du Bois Reymond, and
others, have established the correctness of this conclusion. Volta, however, abandoned the
view of an animal electricity, and instituted those remarkable experiments upon the elfects
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 Galvani's
method, is taken, and the nerves are cut off close to their exit from the spine. Then witboot
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-conductor and letting them fall 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 muscle, 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, Ist,
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, 1798, 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, Nobili demonstrated
the Electro-Magnetic Current of the Frog. CBrsted, in 1822, discovered the deflection of the
needle by the galvanic current ; this led to the construction of the Oalvanometer, By the
judicious application of Amperes astatic double needle, Nobili discovered that deflections of
the needle when present, always indicate that a positive current' was passing from the mnsele
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 influences,
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 Electric 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 1837 and
1838, 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
* Lee. V. 1 p. 740.
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Introduction to the Study of Diseases of the Nervous System. 119
and remftrkable iDrestij^tions of the distingaished philosopher, DuBois Rejmond, in 1842 ,
who has shown that both the nerves and muscles of Hying animals are endowed with electricitj;
whieh obejs definite laws and relates the two systems to each other. In the Galvanometer
emplojed bj DoBois Reymond. in the investigations npon the mnsonlar current, the wire is
3280 feet long and 67*1000ths of an inch in diameter, and coiled 4650 times aronnd the frame.
In the more delicate instrument employed in investigations on the nervous current, the cop-
per wire measures 5584 yards, or 3.17 English miles, and is al^out 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 paper on the frog-current alone. Mattencci'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.
This discovery entirely overthrew the old Voltaic doctrine, and Nobili's theory of thermo-elec-
tridty, 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 Matteucci*s **E8sai sur les Ph^nomenes eleotriqnes des Animaux," as the sixth chap-
ter of the second part of that book, forms the starting point for the researches which Dn
Bois Reymond has made in animal electricity. He obtained his first results in the Spring
of 1842.
The following conclusions 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 matcles, and which may be 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 natural transverse sections, may show their electro-motive
power without being divided.
2. Brery minute particle of the nerves and muscles act according to the same law as the
whole nerve or muscle.
3. The currents which the nerves and muscles produce in circuits of which they form part,
must 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 dilTerent contractile tissues, the electro-motive power, is always proportioned to
the mechanical power of the tissue. Other animal tissues may, indeed produce electro-motive
aetion ; but it is neither so strong as the action of the nerves and muscles nor so regular ; nor
does it 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
notion 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 «ute, 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 deaths and severe injuries of the muscular and nervous tissue, cause other
modifications of the electro-motive power of the nerves and muscles, of which some are per-
manent, and connected with the total extinction of that power, others are only transitory.
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120 Introduction to the Study of Diseases of the Nervous System.
9. The electric phenomena of motor and sensitive nerves are identical. Both clmsses of
nerves transmit irritation in both directions.
If a nerve or mnscle be brought into a state of functional activity, (either by mechanical,
chemical or electrical stimulation), it is found that the current passing through the galvano-
meter is diminished in intensity, i. e., the diflference between the electrical ' conditions of the
longitudinal and transverse sections becomes less. This is known as the negative variation
of the nerve or muscle-current. By 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 is
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 Bernstein,
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 state,
and the 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 ware of
negative variation in nerves^ agrees quite closely with the value found by Helmholts for the
rapidity of nerve force, viz : 26.4 metres in V^, This value 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 fh>m 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 stimulation, clearly indicates that a very
close relation exists between the manifestation of nerve force and the change in the eleetricid
condition of the nerve, and may even be considered as fhrnishing a sufficient reason 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 due to the same force:
and it has been shown 6y 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 beat ; 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
state of physiological science, unsatisfactory. Thus at so late a date as 1837, the physiol-
ogist, J. Miiller, after an extended and elaborate examination of the facts and experiments,
bearing upon the question of the nature of the nervous force, arrived at the following
conclusions :
l0t. ** That the rital actions of the nerves are not attended with the development of any galvanic oun«ntB ^
our instruments can detect.
2d. '* That the laws of action of the nerroos force, are totally different from those of electrid^.
3d. ** To speak therefore, of an elecUlo current in the nenres, is to use quite as symbolical an expcosrtoo, mUw
compared the action of the nervous principle with light or magnatism. Of the nature of the nervous principle, we ars
as ignorant, as of the nature of light and electricity : while witli its propertiee we are nearly as well acqoiuated as
with those of light and other imponderable agents. Hovrever much, uese various prlnci|dee differ fh>m each other,
the same question applies to all ; namely, are their effects produced by currents of an Impotftderable matter traveling
through space, or by the undulations of a fluid ? The discussion as to which theoiy is correct, in the case of tiie
nervous principle, is at present a matter not affecting the study of the laws of its action ; Just as the laws of optks,
must remain the same, whichever theoiy of the nature of light be adopted.**
The doctrine of the unity and correlation of forces, propounded by Dr. J. -R. Mayer, shortly
afterwards, in 1842, not only led to the recognition of the essential unity of the so-called
imponderables, viz : the chemical forces, heat, light and electricity, and motion, but also slowly
but surely revolutionized the theories of physiologists, and led to the reference of all chemi-
cal physical and vital forces, or processes, to a single force or power, which originally appeared
as light from the sun, and excited in inorganic matter and living organisms, heat, mechanical
motion, chemical change, electricity and nervous und muscular force. The labors of Mayer
and Helmholtz, Qrove, Faraday, Joule and others, have led to the annunciation of the
theory, that there is in reality, but one single force which runs through an eternally changing
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Introduction to the Study of Diseases qf the Nervous System. 121
roond, in dead or inorganic, as in organic liring nature. As far as the knowledge of man
extends, matter and force, are indestructible ; Force changes its form ; heat is changed into
motion : chemical action derelopes force in accordance with the amount and character of the
matter altered, and in all chemical and physical changes, the resulting power maintains a con-
stant magnitude : — animal heat is dependent upon chemical changes, and the resulting forces,
heat and motion, and muscular and nervous force, are dependent upon, and are equiyalent to
the sum of the power of the simultaneously produced chemical processes.
Professor Owen, in his recent work on Ootr^aratwe Anatomy and Phytiologyy thus applies
these riews :
*'KeiiiM^ is not electricity. anT more than magonidty ; boUi are peculiar modei of polar force. Any point of
the Miftoe of a aerre. It podtlTe m relation to any point of ttie transreree eeotion of the fame nerre, Jnat ae any
pofat of the rarliMe of a mnacle to poeitiTe in rdatlon to any point of the trantrerBO section of the same mosde.
ligatare of « nerre arrests the nenrons cnrrent, not the electric current : a divided nerre connected bv an electric
oond actor, traosmiti the electric cnrrent ; but the nerrous current excited by stimnloos aboye the section. Is arrested by
the deotric coadnctor. Kenridty to conTertlble into myonidty and into other forms of polar force, Jnst as myonidty
or the mnscolar force, may be disposed of by conTersion into heat, electridty and chemldty, the latter shown by the
evohition of oaibonic add. Molecular change in nerrous and in muscular fibre attends the exercise of their reqpect-
One of the most striking facts, with reference to the true nature of the muscular and ner-
rous forces, has been furnished by Gomparatire Anatomy, viz : that the peculiar instruments
found in certain of the lower animals, have the property of accumulating and concentrating
the subtle mode of force, applicable to the communication of electric shocks. The currents
generated 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
they decompose chemical compounds 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
is evolved in the thermo-electric pile, by the conflict of two polarities inherent in two differ-
ent degrees of temperature ; whilst in Uie Qymnotus, it is produced, as in the Voltaic pile, by
the 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-
monstrated by the galvanometer, that the direction of the electric current, was from the
anterior parts of the animal, to the posterior parts, and that the person touching the fish,
with 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 availing himself of this test. Professor Faraday
showed that any given 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
spark obtained.
An analogy has been pointed out by comparative anatomists, between the row of compressed
cells, constituting the electric prism of the Torpedo, and the row of microscopic discs of
which the elementary muscular filamenu 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-
cial lobe at their origin, beyond that origin, in the Torpedo, they have no ganglion. An im-
pression on any part of the body of the 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
is conveyed along the electric nerves to the organs, and produces the shock ; in muscular
contraction, the impression and volition take the 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-
rupted, and no irritant to the body has any effect on the electric organs, any more than it
would have under the like circumstances on 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 the end of the 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
action, like that of exciting the muscular 6oBtraction, is exhausted by exercise, and recovered
by repose ; it is also augmented by energetic circulation and respiration ; and what is more
significant, of their close analogy, both powers are exalted by the direct action, on the nerv-
ous centres, of the drug strychnine ; its application causes simultaneously a tetanic state of
the muscles of the fish, and a rapid succession of involuntary electric discharges.
We propose in the next place, briefly to examine some of the most important facts, illus-
trating the nature and relations of the muscular and nervous force, without any special refer-
ence to their chronological arrangement, in the history of physiological. science.
16
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122 *Introduetion to the Study of Diseases of the Nervous System.
It is now well established that animal life, is not possible without constant chemical and phy-
sical changes in the molecoles of the body ; and since such disturbances are always accompanied
with the liberation of electricity, it would not be unphilosophical upon this general view, to
infer that electrical currents exist in all living animal structures, and that the intensity of
their electrical actions, varies with the amount and character of the chemical and physical
actions of the tissues.
The experiments of Brown-S6qnard 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 rari-
ous animals after rigor-mortis had been established, as well as the similar experiment by Pro-
fessor Stannius, upon the power of arterial blood, not only to overcome rigor-mortis, bat also
to restore muscular 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 mnscnlar
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 electro-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 iu 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 mas-
cles and nerves, including the brain and spinal cord, are endowed during life with an electro-
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 measured 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 mnscles, nor does it vanish with the vital properties of the tissues,
nor does it undergo the sudden variations of intensity and direction which characterize 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 after the death of the animal, and after the separation of the
muscle from the body ; the electric power of a nuscle 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 excitabitity of the muscle ; both the electro-motive force, and ezcitabllity
have the same termination, that is, the rigor-mortu^ caused as BrQcke has proved, by the co-
agulation 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 muscular 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
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Introduction to the Study of Diseases of the Nervous System. 123
motor nenres, and may b« expressed thus : the motor nerves are not excited by the absolute
amount or density of the current, but merely by the variations which occur in the density of
the carrent, from one instant to the other, and the more considerable the variations in the
density of the current, the greater the physiological effects. It results from this, that unsta-
ble conditions of the closed muscular and nervous currents dependent upon derangement of
the chemical and physical properties and actions of the molecules of the muscles and nerves
woold be necessarily attended by deranged muscular and nervous actions ; variations in the
density of the currents circulating in the motor nerves, maybe attended with either exaltation
or depression, or alternate exaltation and depression of muscular action.
We will examine, in the next place, the important question, whether eontractiUty, be inhe-
rent in the muscles, or whether it be entirely the result of a force communicated to the mus-
cles by the nerves.
The controversy with reference to the inherent contractility of muscle, independent alto-
gether of nervous influence, carried on from the time of Haller to the present day, may now
be considered as settled in the afiSrmative.
The experiments of Bernard, Kolliker, Althus and other physiologists with woorara,
demonstrating that this poison kills the motor nerves without destroying the power of the
musdea 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
muscles or to the nerves ; and lastly the important microscopical observations of Mr. Bowen,
showing that the fragments of the elementary fasciculi of voluntary muscle, which he had
isolated 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.
That muscles do not derive their state of tone or power of contractility fVom the cerebro-
spinal and sympathetic nervous systems, and especially from the spinal cord, but possess
within 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
afrangement of muscles adapts them for contraction and expansion, whilst the large supply
of blood which they receive furnishes the essential elements and conditions for the continuous
maintenance of those chemical changes which develop the muscular force ; the mechanism
of muscular 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-
tability of tbe nerves and muscles may be destroyed or suspldnded, independently of each
other, by the action of certain poisonous substances, which have the power of destroying the
irritability of the muscles and nerves by a direct action upon their tissue.
The results obtained by Dr. E. Harless, (Muller's Archiv., 184*7, p. 228); from 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 muscles, is not necessary for the excitement of muscular contractions, and
that the muscles 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
movements of their bodies could be excited even by means of galvanism, they were killed by
opening the carotid arteries, and tbe brain and spinal cord exposed. On galvanizing these
nervous centres, not the slightest movement of the body resulted, but when the galvanic
sUmulas was applied to the muscles of the trunk, violent contractions at once ensued. Gal-
vanizing the crural nerve, produced not the slightest action of the muscles of the corresponding
leg, bot these muscles were thrown into immediate contraction when the stimulus was applied
directly to themselves. Similar results were obtained by galvanizing the nerves and then the
muscles of other parts of the body. Tbe 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
was 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
paralyzed 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
nerve is irritated, the irritability being manifested in this experiment only through that of the
muscle, and that of the muscle being called into action through the nerve. If a frog's leg be
prepared as above, and tbe 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
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124 Introduction to the Study of Diseases of the Nervous System.
to exifltf but if the gaWanic discbarge be passed directly through the muscles, contraction at
once takes place ; the muscular irritability has survived that of the nerves.
Snlphocyanide of Potassium produces paralysis of the muscular tissue, while the nerves of
the same part retain their irritability ; woorara destroys the irritability of the motor nerves
without affecting that of the muscles, and at the same time the sensitive fibres retain their
power of transmitting impressions ; in poisoning by strychnine the sensitive filaments of the
nerves 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 coniine, undertaken by E511iker. According to Edlliker. the action of confine is nearly
equal to that of woorara.
Dr. J. Althus has obtained similar results with woorara, and he 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 tidd ; this nerve, when
galvanized, sets the muscles in play. But if the electric stimulus be directed to the mnscnlar
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, a?
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, after 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 prodnce
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 f^om 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, bnt
which communicated freely with the sciatic nerve, is followed by a strong and healthy reae-.
tion. But at the moment when the irritation is applied to the poisoned limbs, though bo
visible 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. WhiUj therefore^ the muscles of the poisoned limbs have been dirteUy
paralyzed^ the nerves of the same 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 place in the poisoned limbs ; bnt 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 sufficient 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 cause,
such as accidental movement of the bed-clothes, the shutting of a door, or the sudden pae-
sage of a current of air. Such slight causes of irritation, which would be entirely inadeqaate
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 conmlsions.
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 fhnctioas
of the brain. Its effects will show themselves, consequently, without essential modification,
after the head has been removed. If a decapitated frog be poisoned with a moderate dose of
strychnine, the body and limbs will remain quiescent so 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, as, for example, the contact 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
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Introduction to the Study of Diseases of the Nervous System. 125
stiycbniDe are always of a reflex character, and neyer spontaneoas, i8 shown by the following
&ct, first 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 untouched, death takes place,
as nsnal. but is not preceded by any convulsions. In this instance the convulsions are
absent, sinnply 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. But if the anterior roots, or the motor nerves themselves be galvanized, con-
tractions immediately take place in the corresponding muscles. In this case, therefore,
the sensitive filaments have been paralyzed, while the motor filaments and the muscles have
retained their irritability.
Such facts justify the conclusion, that there is no direct dependence of the muscles upon the
nervous 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
nervous 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 gradually, and with this change in the chemical actions, the contractility diminishes ; but,
if on the other hand, the musde 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 ihe 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
sondition 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 muscles of one of the paralyzed limbs, by a weak galvanic current, while
the muscles of the otlier 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
bulk, 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.
The nerve possesses of itself a certain electric state, which is modified by long 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 muscle, there must necessarily be established a certain
electric equilibrium, 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
itructure 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
contractions : — 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 causes their negative poles to turn downward, and their positive upward, or recipro-
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126 Introduction to the Study qf Diseases of the Nervous System.
call J ; it foUoiprs then from this, that these particles, haring their eontrarj poles placed all
near the others, in the same rectilinear direction, which is the direction of the length of the
fibre, they mutually attract each other, which caoses the discs to approach, as actaallj takes
place in contraction.
In endeayoring to explain the mode ot action, and nature of neryous and mascolar force,
and the relations of the neryous to the muscnlar system, by the aid of the &ots and laws
already recorded, and which as we have before stated, haye bC'^n established by actual experi-
ments of the greatest delicacy and accuracy, we shall avail ourselves of the fbrmnUitioB,
extension and perfection of the theory of DuBois Reymond, by the philosopher De La Rira,
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 itposseMes
the two electricities in a free state. M. DuBois BLeymond conceives, that these molecoles,
which may be of any form, but which he supposes to be spherical, have each a positiTe
equatorial zone, and two negative polar zones. He supposes, moreover, that thej are so
arranged, that the diameters which pats 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 that
the organic molecules have but two electric poles, one positive and the other negatiTe, ao
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 inorgaaie
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 traaa-
verse section of the muscular bundle, the positive poles of the molecules are turned oatward,
and the negative poles inward. The positive and negative electricities of the molecales of
each section, which radiate from the centre to the circumference, neutralize 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 sM 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, by 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 fmay 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 assumes,
which renders it fitted for conveying to the muscles, or to the nervous centres, those modifi-
cations thatwe recognize under the form ofmotion or sensation, is due to a molecular polarization
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 we 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 in
the nerve, each from the juxtaposition of two bipolar molecules. De La Rive considers that
it*is enough to suppose that these molecules are bipolar ; and that under the influence of the .
vital principle, they are in the nerve, as in the muscle, arranged in such a manner that their
positive poles are turned exteriorly, and their negative interiorly. This arrangement explains
for 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 means whatever, and an electric current applied directly, acts m
the same manner upon a muscle. It is theretore probable that it is by a modification in its
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 a
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IfUroduetian to the Study of Diseases of the Nervous System. 127
cerUun eleetrical state, which physiologists hare succeeded in determiniag ; moreoTer, this
electric state is modified' bj every excitation exercised npon the nerve. The muscle has,
likewise, a natural electric state, which is modified eyerv time there is a contraction. In the
tbience of excitation exercised upon the nerve, and of contraction produced upon the mus-
cle, there mnst necessarily be established a certain electric equilibrium, which consists in the
drenlation of internal electric currents, in relation with the chemical phenomena that are
accomplished in the living muscle. De La Rive does not afiBrm by this that these phenomena
are the cause of the electric currents ; their cause is in the vital force, which gives to organic
molecnleSt naturally bipolar, the arrangement necessary for the establishment of this current ;
bat 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 chemical 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.
Matteucci has observed, they are more powerful when the muscle is contracted than when it
is not. Thns, 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
doe 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
studjring 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 farors the contraction much more than
▼hen 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.
If, instead of coming from the brain, the action exerted upon the nerve comes from the
mnscle, 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-
mit 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, can no 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
arrests 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 ib 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-
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128 Introduction to the Study of Diseases qf the Nervous System.
tioo, which is the caase of it, last only an instant, on account of the electricitj proper of the
fibre, and the particles replace themselves at their former distance. However, there is an
important difference to be noted. When muscular fibre is contracted bj the effect of a cob*
tinuous electric current applied either to its nerve, or immediately to itself, the contraction
endures, it is true, but for an instant ; but the particles of the muscle, while still regainioi^,
by virtue of elasticity, their former relative distance, preserve their electric poles tarned 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 BomuJ
position, and this return is accomplished by a new displacement of the particles, and conse-
quently by a new contraction. The reason why th^re 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 constitute* tetanus ; however, as may be seen by the galvanoscopic frog, the con-
traction is really intermittent.
It remains to know, how it may result from a modification in the electric state of the nerree,
that any .particular muscle is modified so as to produce contraction. It would be necessarj'
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 abate upon
an elementary fibre ; then it is not astonishing, that if this nerve is polarized by a cense of
excitation, 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 suffer 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, which causes the muscle itself to be so also. In sensation, it is the muscle whoee
normal electric state is disturbed, which polarizes the nerve, so as to act upon the brain. In
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 transmisston
of motion and sensation. De La Rive, conceives it to be very important, in order to fonnd
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 reciprocal 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 animal
may be regarded as the seat 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 experiment. But when by the effect of the will, or of another canse
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, the more considerable circuit of
which comprehends then, the nerve and the 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 hU the particles of inorganic and organic
matter. This philosopher, is moreover, forced to admit, that, under the infiuence 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 ae the
cause of their mode of grouping, and consequently indirectly of the phenomena that reeolts
from it. Let life indeed be taken away, and the particles, still preserving their electric pro-
perties— that is to say, their polarity — are grouped quite differently, so ae to obey the condi-
tions of equilibrium of the forces that are proper to them, and no longer present anght, but
the ordinary phenomena that inorganic matter offers us.
M. Matteucci, while still recognizing that organic currents are 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-called, and arterial blood in contact with it, and conse-
quntly 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-
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Introduetion to the Study ^f Diseases qf the Nervous System. 129
nected with a difTerence in the state and in the natritire power of these tissues, so that the posi-
tire element of the organic pair wonld be always represented by the part of the tissue- whose
natritire power is the stronger. As is apparent, M. Matteucci, agrees with De La Rire, in
this respect, that it is from the vital for<!e that he makes animal electricity depend in the first
instance ; only according to him, it is only indirectly in compelling nntrition to operate that
the nerres, intermediate between vital force and the mnscles, would develope electricity,
whilst according to De La Rive, the action would be more direct ; the transmission of vital
action from the nerves to the muscles being brought about by the very electricity with which
the nerves are primarily endowed.
De La Rive, 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 electricity to proceed, which
i^pears to be pre-ezistent to the causes that determine its manifestation, as well in the living
organism as when inorganic matter is in question.
If then the propagation of nervous action, be due to a natural and progressive modification
in the arrangements of the particles by virtue of their electric polarity and the closed circuits
of electricity in the quiescent state ; the two most formidable objections to the identity of
nervona force and electricity, viz : the arrest of the nervous current by a ligature, and the
slow rate of the transmission of nervous force, as shown by the ingenious experiments of M.
Helmholts and DuBois Reymond, receive an easy explanation. The ligature destroys the
nataral arrangement of the molecules of the nerves, upon which the transmission of the weak
nervons carrent depends, and transmission of nervous excitation through the nerves neces-
sarily requires a sensible duration longer than that of a simple and more powerful extraneous
electric carrent, because of the progressive alteration and re-arrangement of the molecules
composing the nervous and muscular structures, during the transmission of sensation and
motion and the performance of mechanical acts.
We have thus presented, from various portions of iiis great work on Electricity, and in the
very language of its learned author, the theory of De La Rive, which embraces with slight
modifications, the theory of DuBois Reymond, and rests for its truth upon the extensive re-
searches of this accurate and skillful observer, and also upon the results of the labors and
exponmoBts of Oalvani, Yolta, Aidini. Humboldt, Matteucci, Nobili, Marianini and others.
If this theory be true, it results, that the nervous and muscular phenomena of certain dis-
eaaes, as tetanus, must be due to disturbances in the electric condition and relations of the
molecules of the nerves and muscles.
If in the state of health, the molecules of the nerves and muscles are restrained in a par-
ticular arrangement by the vital force, and if under the action of the will, or of other causes
deteraiinining 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 every cause however
slight, capable of disturbing the electric equilibrium, and even beyond all coiitrol of the will,
and even so powerful in its effects, as to rend asunder the muscular structure, there is either
a want of proper action of the vital force in preserving the mutual, and definite relations of
the molecular forces, or an undue activity in the molecular changes in the nerves 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
conclude, that tetanus is due not only to a disturbance in the electrical conditions and rela-
tions of the nerves and muscles, but 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 contractions of the muscles in tetanus, are far more violent and prolonged than those of
health, excited by any cause whatever, internal or external, by the will or by mechanical
stimuli, so violent in fact that the muscles are frequently ruptured, and that too, against no
other points of action than the long bones, and in no other action than in that of simple in-
voloBtary contractions ; and by the equally striking fact that a continuous current of elec-
tricity, may when passed in a certain direction, relieve the spasm of tetanus. Nobili discov-
ered that frogs affected with violent tetanus, became quiet if a continuous current was sent
throagh their limbs in a given direction, while the tetanus continued undisturbed if the cur-
rent moved in a contrary direction. M. Matteucci, observed similar effects of continued
currents upon frogs tetanized by strychnia, when they were subjected to the action of a
c«Hitinaous galvanic current, the tetanus disappeared very soon, and did not return, although
the flrogt 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
tetanos in man. Matteucci, actually tested the therapeutic effect of the continuous current
in traumatic tetanus. In conjunction vrith 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, in consequence of gun-shot wound of leg, in the direction from the sacrum to
17
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130 Introduction to the Study of Diseases of the Nervous System.
the nape of the neck. The eflfects were marked, the mnscnlar contractions and conTulsiooa
were greatly diminished, the patient was enabled to open his mouth, the circulation knd tr&D-
spiration were re-established, and the relief appeared to be great. The patient died howerer,
afterwards, in conseqaence of the irritation kept up by foreign bodies in the wounded limb.
DuBois Rejmond, has remarked, that in a tetanized limb of a frog, the gastrocnemius mtiB-
cle became quiet, as soon as the sciatic nerve was laid upon the tendon of the muscle ; that
is, if the inverse current proper of the muscle was made to pass through the nerve ; bat that
tetanus continued unchanged, when the nerve touched the flesh of the muscle, that is, when
the direct current proper of the muscle traversed the nerve.
Professor Ecklard, of Giessen, has been led by an important research to the conclofioD,
that if a constant continuous current of a certain intensity and direction be made to pass
through a nerve, the excitability 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 ; ^ut 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 sufficient 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 intensity 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 molecular 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 such manifestations as that of tetanus.
We conclude this introduction by some general observations upon the
PHYSICAL AND INTELLECTUAL 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^omposed of inorganic elements, prepared and grouped
into definite compqunds 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 size of its organs,
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 size of our globe, and its relations with tbe
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
of force 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 f^om the same common origin, the cell, and like plants and animals passing
through various stages of development ; possessing in common with all animals, and in con-
tradistinction to vegetables, a nervous system, endowed with special sensibilities relating the
various organs and apparatus to each other, in such a manner, that amidst an innumerable
number of complex actions, unity and harmony result ; and relating the mind with the ex-
terior world in such a manner, that it is capable of obtaining a view of its ever-changing
relations— endowed with intellectusJ and moral faculties capable of receiving impressions
through the nervous system, and of exciting the forces by which they ara surrounded, and
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*
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Introduction to the Study of Diseases of the Nervous System. 131
It ifl a aaiTorsal law, that the component parti ^ of the Uniyerse have not in themselyes
the entire aim or reason of their existence— every form of matter is, definitely related to
every other form of matter upon the face of the globe, and the combinations of these various
relations and actions and re-actions of terrestrial masses, form the essential conditions for the
maniibstation of the designs of the Creator.*
As a man is composed of inorganic elements, and governed by all the laws, physical, chemi-
eal and astronomical, which govern the exterior world, it follows as a necessary consequence,
that the peculiar constitution and relations of the inorganic elements of the crust of our
globe, must 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
made for the soul. 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
and mental development of the human race.
The endless circulation of matter resulting firom the combined actions of the forces of the
sun, and 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
ocean, or depressed the level of the continents — every volcano which has poured forth the
liquid contents of the interior of the earth — every flood which has swept over the ancient
continents — has contributed, more or less, to the formation of a suitable soil for the mainte-
nance of plants and animals, and the development of the human race.
The examination of the mutual relations of celestial and terrestrial bodies, and animated
beings, 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
would destroy the conditions necessary for the existence and manifestation of the phenomena
of man — that the forces of man are resultants of the forces of the sun and fixed stars,
which 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,
physiological, 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
wish thoroughly to undertand medical, (physiological, pathological and therapeutical) phe-
nomena, we must analyze the component phenomena of man, and commence the study with
the most general, unrestricted and simple phenomena, and then rise gradually to the knowl-
edge of the more complicated and restricted phenomena, and finally attempt to gain an emi-
nence of thonght, from which we may survey the phenomena of man in their mutual rela-
tiocs, and in their relitions 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-
verse. The material part of man has also been constructed with exact reference to the
structure of the intellectaal 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
instrument for the manifestation of the Spirit breathed into it by the Creator of the
Universe. 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 nervoas system, and accomplishes various mechanical actions, by
which 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
system, are developed by the chemical changes of the elements of the moscles and nutritive
fluids. The office of the digestive and circulatory and respiratory systems, is to prepare
materials which will readily enter into chemical change, and thns generate the forces by which
nnder 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,
so as to accomplish definite effects.
In whatever manner the intellect of man be regarded, whether as an indivisible immaterial
agent, or as a product or secretion of the brain, many metaphysicians have found it conve-
nient, if not absolutely indispensable, to divide and classify its powers or faculties. Thns,
for purposes of systematic study, analysis and comparison, metaphysicians have designated :
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132 Iniroduetion to the Study qf Diseases cf the Nervous System.
I. The Simple GognitiTe Facalties, bf which we attain the knowledge of individnal object*
in tbeooncrete, aa, (1.) SenBe-Perception, by which we know materiai sabstances in oertaia
modes, or in the exercise of certain qualities; and, (2.) Self-Conscioosness, bj which we
know self in certain states.
II. The Retentire and ReprodnctiTC Powers, as, (1.) Memorj, which recalls what baa beaa
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 possess an Imaging, or Pictoral power. When this might fail, we hare, (3.) the SjosboUc
power, which enables ns to represent objects by signs.
Abore the presentatire and representative powers, we have ;
III. The Correlative faculties, discovering such relations as that (I.) of whole and parts ;
(2.) of sameness and diflference, in respect of such qualities as space, time, quantity, and
active property, and, (3.) of cause and effect.
ly. The Moral Faculty, determining in regard to certain mental states, that they are right
or wrong.
Associated with the exercise of these powers, we have :
y. The Emotions, attaching us to certain objects, and withdrawing ns from others.
yi. 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 socceasion
of the states produced by these various powers.
Science is the interpretation, by the mind, of the actualities of existence. The ideas of
the mind are science or truth, only when Uiey are correct expressions of the phenomena and
laws of the universe. The end of science, and the proof of its truth, is the power
which it confers upon man, of predicting future events.
For the 4i8covery of truth and the establishment of science, we roust have a mind endowed
with special faculties, capable of analyzing 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, analyzing, 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 unaltered, 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 the
Creator. If the love of Truth was not a fixed disposition of the human mind, it would be
impossible to receive auy 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 remain un-
altered, the discovery of truth would be impossible.
It is evident, therefore, that imperfections of the senses, imperfections of the nervous appa-
ratus, and peculiarities of mental endowments are the first sources of error in the prosecutioa
of knowledge.
The mind has no direct communication with exterior bodies ; its relations with the exterior
world are through the nervous system, endowed with special sensibilities, and developed
upon the exterior into the organs of sense. The organs of sense are nothing more UMin por-
tions of the nervous system i^apted by conformation, and the addition of peculiar apparatus,
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 cognisanoe of the
excited states, modifications or disturbances in the apparatus endowed wit^ special senn-
bility, when acted on by the impressions of external bodies ; and if all the organs of sense
were absent, the mind would be shut up to itself, and would never acquire any knowledge of
the various forms of matter, and of the various aflfections and motions of matter in the exte-
rior world.
The phenomena, or associated facts of the exterior world are innumerable ; matter is eerer
at rest ; it is constantly undergoing alterations of form, appearance and constitution — per-
petual change is written everywhere ; even the sun with his planets are sweeping ButjeMic-
ally through space, around a distant, unknown centre ; these changes of states, lorma 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 activity
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 t-annot penetrate beyond, and are therefore limited in their respective
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Introduction to the Stut^ of Disea$$s qf the Nervous System. 133
capacities to the reeeptioo of sioiple ideasi and eaa nevor give aoj iaformatioD of the immu-
tabU laws which govern matter ; the trae nature, therefore, of exterior objects, the laws
which regnlate the phenomena of matter, and the relatione between the component member <>
of the universe, are problems which the reasoning powers of man, and not his senses, can
solve.
After the observation of the facts aad phenomena of the exterior world, the intellectual
faculties, bj their powers of analysis, synthesis, c^iaalion and judgment, separate each fact
from dissimilar facts, and arrange the simple id^as into species, genera and orders ; thus
acquiring a knowledge of new phenomena and associations of facts inaccessible to the exter-
nal senses. By decomposing phenomena into their component facts, bj analysis and com-
parison of these facts, the intellectual faculties form abstract ideas, which sum up the princi-
ples and laws of associated facts. The perfection of every science will, therefore, depend
upon the dilligence and care with which iu cultivators study the simple properties and rela-
tions of bodies, and analyse, and decompose, and compare the more complicated phenomena.
In the language of Bacon, " Man, as the minister and interpreter of nature, does and under*
stands as much as his observations upon the order of nature permit him, and neither knows
nor is capable of more."
The neglect of this, the only true method of acquiring a knowledge t>f the laws governing
inorganic 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
ancients reared immense superstructures, 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,
demonstrates that ia the pursuit of knowledge, and in the direct study of nature, facts aloue
do Bot constitute science, and reasoning alone does not constitute science. We must have
(or the construction of science, the exercise of the senses, furnishing the primary ideas, facts
and phenomena of the exterior world ; and then the exercise of the reasoning powers deter-
mining in virtue of their constitution, and relations through the senses to the exterior world,
the fixed relations or laws of these facts and phenomena.
To the formation of science two things are requisite : Observation of things without,
and an inward examination, decomposition, analysis and comparison of the results o' observa-
tion.
It has been well said ** that true knowledge is the interpretation of nature ; and therefore
it requires both the interpreting mind and nature for its subject; both the document and the
ingenuity to read it aright. Thus invention, acuteness, and connection of thought are neces-
sary, on the one hand, for the progress of philosophical knowledge ; and on the other hand,
the precise, and steady application of these faculties to facts well known and clearly
perceived.
The great end, therefore, of all human knowledge and investigation is to determine the
fixed relations or laws of the universe ;' so that the precise condition of things at any future
time may be predicted with absolute certainty : and so that the human mind may appreciate
iu relations with the universe, and with the Greater of the universe.
h it evident from tkeu prmeipUtj that tdueaUon thould eammenee with the exerdte and dieeipUne of
the mneee. The intelUdual faeuUies should be taught, eare/uUy to observe and note the properties and
relationM and forces of surrounding^ bodies, and to arrange and das^fy the phenomena.
In the first exercises of the senses and intellectual faculties, we should imitate, in a man-
ner, the action of the human mind in the first dawn of science, when it first began to observe
phenomena, and accumulate facts ; and the method in which at the present time it originates
and develops new sciences. Man commenced the construction ot science, by viewing gen-
ersl classes of phenomena ; the chronological commencement of science, therefore, is with a
ooBiplex mass, whilst the logical development is with the individual elements. Thus,
Astronomy, which is conversant with the sublimest and most striking phenomena in nature,
had the earliest origin ; its first cultivators were shepherds, who confined their attention to
noting the most obvious phenomena of the motions and eclipses of the sun and moon, and
the rising and setting of the stars. These, the first builders of Astronomy, slowly accumu-
lated materials for the formation of science, and in due time the reasoning faculties com-
pered the individual facts with each other, separated the dissimilar and combined the similar,
and thus arrived at a knowledge of the fixed relations or laws which sum up and express the
whole detail of associated facts.
It is evident from the mode in which the mind obtains its ideas and constructs science,
that soienee is the result of patient and hard labor. The first knowledge acquired by the
•odents consisted of isolated fitets ; gradually facts were accumulated, complex phenomena
observed, decomposed, and their component elements arranged and compared, and the errors
of the senses corrected, and it was not until after many ages that the great fundamental laws
of Astronomy and physics were established.
We have thus endeavored in this physiological outline to sketch the general relations of
man to the exterior universe, and to give a comprehensive demonstration of the extent and
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134 Introduetion to the Study of Diseases of the Nervous System.
complexity of his pheDomeoa ; and we are thus led to conclude the subject with some gea -
eral obserrations upon the extent and imperfeeiione of Pathological mvettigationt^ thus conneeting
the preceding physiological studies with the succeeding pathological iuTestigations.
If man be related to celestial and terrestrial bodies — if the existence of man be dependent apon
the adjustments of the solar system, the seasons, the climate, the action of the Tegetable
kingdom, the soil, and upon the great circulation of matter, kept up by the forces of the snii —
if the derangement of only one link in this complicated chain of phenomena would retnlt in
the destruction of the human race — if the phenomena of man in health be thus compUcAted,
how much more complicated must be the phenomena of disease, when the constitution of the
complex solids and fluids of man may be altered in many ways, and the relations between the
physical, chemical, vital and nerrous forces, and intellectual and moral faculties maj be cor-
respondingly deranged ?
In Tiew of the immensity and complexity of physiological and pathological phenomena ; io
view of the fact, that no single man, even during a long lifetime, is capable of investigatiBg
thoroughly the phenomena presented by disease, the investigator should state clearlj his
yiews of the extent and bearing of physiological 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 and brief manner, to point out the sources of diaeaae.
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 io 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 these
changes. As the sun with his attendant planets are progressing continuously throufirh space,
it is not unreasonable t^ 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 luminoas and thermic ribra-
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 periodti 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 careful 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 those who are specially charged with the investigation of the nature
and causes 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 f^om the sun is a
fixed quantity, it is nevertheless true that, owing to the peculiar constitution of the atmos-
phere, the nice adjustment of its forces (the ease with which one mode of force may be con-
verted into another, as heat into electricity, and vice versa), 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 masses 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 g^reat extent, by
meteorological phenomena. The value of the determination of th^se relations in the inrestl-
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
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Introduction to the Study of Diseases qf the Nervous System. 135
of the soil woald be attended by deficiencies in the constitution and composition of the
food, elaborated by the vegetable kingdom, and by corresponding disturbances of the consti-
tution and phenomena of man. Corresponding changeis in the constitution and phenomena
of plants may be induced by meteorological phenomena. Hence, in the inyestigation of the
origin and phenomena of disease, it is necessary to determine the chemical and physical con-
stitution of the soil, and its relations to the Tegetable kingdom.
4. The salts 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 excess ; and other abnormal noxious, saline and organic matters may exist in the
water. Each of these causes may be a source of disease. Hence the necessity in pathologi-
cal iuTesUgations of a careful examination of the water.
5. Any one of the normal 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 resulting derangements may he correspondingly numerous. The forms of this class of
disease may be as numerous as the diflferent positions which the elements may t>e made to
assume towards each other.
6. Any ODe of the elements of the body may be in excess or deficiency, and the diseases
may be as numerous as the elements themselves, 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
abaormal 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,
tod tibe forces of the sun. The number of diseases of this class will correspond to the number
of distisei norbific agents.
Gombinationf 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 i 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
disturbances in the component members of the human organism.
9. The Creator has associated the vital force with a definite constitution of matter.
Whatever 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,
and the generation of the physical forces which work the machinery, and the manifestation
of the nerrons, intellectual and moral phenomena, correspondingly altered.
10. 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 in the animal kingdom, and in the foetus of the higher aniiaals, subsequently to the
grouping 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
systems, demonstrate unequivocally, 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 guidance of the*vital principle. Hence diseases may arise independently of the nervous
sjstem. Hence we may have chemical and physical changes of the elements of all the orgaps
and systems 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 oflSces
of the nenroas system. The nervous system is the last and best work of the forces of matter
directed 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-
flaence the Tarious, organs and apparatus ,* and is destined to regulate secretion and excre-
tion, and 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 generated de novo, but rather by a modification of physical force generated by the mu-
tual chemical reactions of the blood and nervous system.
That the nervous force is not capable of itelf of carrying on the acts of nutrition, secretion
and excretion, is demonstrated by the fact that plants, and the simply constructed animals,
which are devoid of a nervous system, are capable of carrying on the offices of generation,
development, digestion, assimilation, nutrition, secretion, excretion, and of preserving a defi-
nite form amidst unceasing chemical changes. Many of the simply organized animals,
although without a nervous system, still possess sensation and voluntary motion. The
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136 Introduetion to the Study cf Diseases of the Nervous System-
nervous sjstem appears only when the parts of the machinery are complicated, and need
special means of commnni cation. \
The development and perfection of the nervous system correspond exactly to the develop-
ment, perfection and complication of the organs and apparatus. This fact is true of the ani-
mal kingdom in its successive degrees of development, and alto of the snccessive stages of
the development of the solids and fluids of each individaal highly organised animal. Physical
and chemical actions take place in a similar manner in all animals, simple or complex ; they diftr
only m 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 neces-
sity for some special apparatus which will bring all the complex organs and actions into
harmonious relation.
Unless the actions of different organs can be telegraphed (so to speak) to each other, con-
fusion m a complicated organism will necessarily result. Thus, if the amount of blood drcQ-
lating through any organ and thf chemical actions are too great, how can they be regulated
without some medium of communication, and some means of regulating the chemical and
physical actions 7
The true relations of the nervous system to dilease 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 ; but also upon the relations of the intel-
lectual faculties to the nervous system, and through the nervous system to circulation, respi-
ration, secretion, nutrition and excretion. If the views promulgated by Prochaska and Gall
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 faculties
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 structural altera-
tions ef the nervous apparatus devoted to the reception and transmission of sensational Im-
pressions ; just as an aberration or cessation of respiration would point to a structural or
functional alteration existing either in the nerves or in the apparatus of respiration. Whether
the views of Prochaska and Gall, and of their followers, the phrenologists, be true or false, it
would be nevertheless true that if the action of the intellect, when manifested by motioDi,
or sensations, or consciousness, is always attended by chemical and physical changes of the
nervous structures, then aberrated intellectual action would point to organic or ftinctloDal
changes in the nervous system. As in the case of aberrated motion and sensation, and of
secretion and excretion, circulation and respiration, the cause of the aberration may lie en-
tirely without the, nervous system, in chemical lind physical changes of the bloo-1, induced bj
the catalytic action of morbific agents, so also, in the case of aberrated intellectual actioo it
may arise f^om chemical and physical changes in the blood, arresting or altering the nonnal
chemical changes of the organs of the intellect.
11. In investigations into the causes and effects of disease, the pathologist shovid 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 nervous system. Thus, In mala-
rial fever, the poison, whatever it be, destroys the blood corpuscles, destroys the ferment in
the blood, which converts the animal starch, elaborated in the liver, into grape sugar, and
produces profound alterations in the structures, blood and secretions of the liver and spleen.
Now, in the beginning, these effects may take place entirely independent of any alteration in
the nervous system In this case the nervous system will be secondarily affected, and its
action serionsly disturbed, and this disturbance will give rise to a distinct s t of phenomena ;
but it is evident 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 universe and in the structures of animated beingrs 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 cn^at antagonistic principles of good and evil. Every Individaal
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 covered with
the damp and decay of ages, still points to a hand Divine. The pleasant sentient emotions
excited in the nervous system by benevolent actions and the strict adherence to truth, prove
that the cultivation of the virtuous affections is favorable to health. While, on the oUier
hand, the irritation, weakness, and morbid excitability of the nervous system produced by
the indulgence of the evil passions, envy, jealousy and revenge — the haggard countenance,
the withered, blasted form of vice — prove that the indulgence of the principle of moral evil
injures and wastes the body ; prove that the intellectual and moral fkculties act upon the
material body by which they are environed ; prove that the material body may be rendered unfit
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Introduction to the Study of Diseases of the Nervous System, 137
for the normal exercise of the moral and intellectual faculties ; prove that the knowledge of the
physician should extend not merely to the physical, chemical, physiological and pathological
phenomena of the body, but should embrace the structure of the intellectual and moral facul-
ties, and their relations to the material body by which they are environed.
It 18 evident, then, that the complete investigation of the origin, causes, effects and treat-
ment ot disease demands an examination of the relations of man, during health and disease.
to astronomical phenomena ; demands an examination of the relations of man to the distri-
bution of the terrestrial masses, to the soil, climate and waters, not only at the present time,
but in the past history of the relations of man to astronomical and terrestrial phe-
nomena ; demands an examination of the structute and relations, and alterations of the solids
and fluids of the organs and systems of organs, and tissues, and blood, and secretions,
and excretions; demands an examination of the physical and chemical changes, and tlie
relations of the physical, chemical, vital, and nervous forces ; demands an examination of
the relations of the physiological and pathological alterations of the nervous system to secre-
tion, excretion, sensation, motion, and intellectual and moral actions.
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INVESTIGATIONS
OS
THE NATURE, CAUSES, RELATIONS,
AND TREATMEISTT OF
TRAUMATIC TETANUS,
II^LUSTRATED BY
Obsem^cilio/vs on VcLvions ^Jjiseases of tKe Newoizs
Systerrh, curhd by ^j^perirrterbts ore
Ijivtrtg jlTLirtxals writTt
Certairt Poisorts.
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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.
OB8EBVATION8 ON THE KATUBAL HlfeTOBY OF TRAIMATIC TtTAKUS. CHANGES OF THE PULSK.
UB8PIRATI0N AND T£MP£BATUBE. CHABACTEB AND CHANGES OF THE
URINABY EXCBETION.
Observations on the Natural History of Traumatic Tetanus. Changes of the pulse, respira-
iion and lemperattire. Characters and changes of the urinary excretion,, qualitative and
qunDtitaiiTe. Cases illustrating the Natural History of Traumatic Tetanus. The essential
pbi^oomena of lever and inflammation, absent in Traumatic Tetanus; the symptoms exaggerated
maDifeeiaiions 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 establishment, appears to be dependent upon an undue excitability and increased action
o{ 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 Trau-
matic Tetanus. Historical notes upon the condition of the animal temperature in this disease
Observations of Hippocrates, Aretseus, Paulus ^gineta. Celsns, John Brown, William Cullen,
Lionel Chalmers^ Benjamin Rush, John Hunter, James Currie, Bebjamin 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
tbe fatal issue, referred to several causes, as 1st, the effects of the violent muscular contrac-
tioDs 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 i-xiension 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.
Tetanus essentially consists in such a state of exalted functional activity in the nerve cells, as
15 attended with the constant generation of a larger supply of motor force, 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 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 Trau-
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142 Observations on the Natural History of Traumatie Tetanus.
matic Tetanus. Intermitteot action of the heart — observations upon spasm of the heart in
this disease. Function of the skin activity performed ; bowels constipated. Mutual relations
of cerebro-spinal and sympathetic systems in this disease. Changes of the urine daring the
various stages of Traumatic Tetanus. Hypothesis as to the nature of the disease.
NATURAL Hi;3T0RY OF TRAUMATIC TETANUS.
In the first case of Traumatic Tetanus reported in this Chapter, the yarious phe-
nomena were closely observed and noted, the urine carefully analysed, the ▼arious
^enomena 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 circumstanoes, and
in similar constitutions, each well marked case of disease, will present characteristios 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 fix^ characters and laws of disease, it is at the same time
admitted, that observations should be extended to the &rthermost possible limits, because
diseases may present differences, as distinct as the varieties of the human constitation,
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 firequentiy enabled to gain an insight into the working of hidden laws.
No disease presents more uniform, or more stronglv marked characters than Trau-
matic Tetanus ; and hence we can, with the more confidence, attempt to settie, general
principles, firom isolated cases. ,
Ooue No. 1 : Illustrating the Ndturcd History of TraumaUc Tetanus,
Qillstrap, Confederate soldier ; age 37 ; dark complexion ; dark hair and eyes ; height, fife
feet six inches ; weight, 145 lbs ; athletic and strong in health ; muscles well dcFeloped ; has
been in the military service of the Confederate States six months ; previous to this time his
occupation was farming.
At the battle of Secession Fille, on James' Island, South Carolina, June I6tb, 1863, 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 muscles, between the ulna and radius, splintered both bones, without however,
fracturing them across.
The wound suppurated freely and appeared to be doing well, until July 6th, when the sup-
puration sensibly diminished, and the patient complained of spasmodic twitchings, and pain-
ful sensations in the muscles of the wounded arm and corresponding side, and along the spine,
especially between the shoulders, and in the region of the cervical and brachial plexos ; stiff-
ness and uneasiness about the muscles of the Jaws, and a painful sense of tightness about 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 muscles 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 sleep,
preceded the well marked symptoms of tetanus.
The expression of the countenance is that of distress, and even of pain, and the muscles of
the face are greatly distorted daring the paroxysms.
Daring the night and following day, (July 9th,) the pain in the arm and between the shosl-
ders, and at the prascordium increased, and in like manner the stiffness of the jaws ; the
tetanic spasms became more violent and frequent ; opisthotonos became more marked, and the
iisturbance of respiration was progressively increa^ei daring the paroxysms.
Administered in the morning, ten grains of calomel, which was followed with half a fluid-
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Observations on the Naturdl History of Trmmatie Tetanus. 143
oance of castor oil, in four hoars. These purgatiyes failed to moTe the bowels. At bed-time,
sdninistered forty drops of tinctare of opium, (Laudanum) ; and as this dose failed to produce
sleep, thirty drops more were administered two hours afterwards. After the second dose the
patient rested somewhat bett^ ; the spasms appeared to be slightly moderated, and the patient
tlq>t a little between the severe spasms.
July 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 Tiolent, Pulse 82, soft and fbll ; respiration quiet and
regulftr between the paroxysms, but disturbed and almost arrested during Uie spasms.
Tempermture of hand, ST^.B C. (99^7 F.): of axilla, 37o.9 C. (100®.3 F.)
SummaHoH of Urine— B\gh colored and scanty : amount excreted during sixteen hours,
(from July 7tb, 8 o'clock, p. M., to July 8th, 12 m.,) 4823 grains (Troy) ; if from this data, the
amount of urine be calculated for twenty-four hours, it would be equal to 7234.32 grains.
Specific gravity, 1021.66. Reaction, strongly acid ; Color deep orange inclining to red: Urine
dear 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 Tege-
table cells. I hare seen a similar thick scum, rise on the urine of typhoid fever after stand-
ing for some time ; but neyer upon the urine of malarial fever.
The composition of the urine is given in the following table : —
Ko. 1. — Anafyns of Urine passed during 16 hourSj from July 7tA, S A, M. to July 8tA, 12 M,
Amounts expressed in Troy Orains,
i
UriBA Muned dv- AaowntMidooai- ATcng* unouit
ring 16 D'n, July potltioB «r Urine aad oompotitloB of
Tth, 8 ▲. at. to July calealalodtBrMh'i Uriao pMMd OMk
6ih IS M. hoar.
Amount of Urine 4823.00 7234.32 301.43
Water 4644.20 6816.24 284.01
Solids 278.74 418.08 , 17.42
Urea 146.60 218.40 9.10
Uric Acid 3.73 6.62 0.23
Free Acid 9.26 13.68 0.67
Phosphoric Acid 10.89 16.32 0.68
Sulphuric Acid 7.01 11.28 0.47
Chlorine 21.13 31.68 1.32
Equivalent Chloride of Sodium,. 34.67 61.84 2.16
Fixed ) Entire Saline Constituents 67.49 101.04 4.21
Saline VPhospatesofLime and Magnesia 8.76 12.90 0.64
Constitu'ts j Sulphates, Chlorides and Phosphates
of Alkalies 58.73 88.08 3.67
Upon consultation with Surgeon L. D. Ford, it was determined, to administer internally,
sulphate of quinia, and a mixture of equal parts by measure of chloroform, sulphuric ether
and tincture of opium.
R. Qoinise Sulph : Grains XX ; divide into four powders, and administer one powder at
12 M., 2 p. M., 4 p. M., and 6 p. m.
R. Cbloroformi.
j£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
mixture to be continued, ten drops every hour.
July 9th, 12 M. Continues much the same ; pulse 74 ; skin in a profuse prespiration. Sur-
face &els cool. Tongue coated with white fur. The chloroform mixture appears to have
dightly diminished the intensity of the spasms ; they are however, very severe and frequent,
and the suffering of the patient is very great.
Temperature of hand, 37.<>65 C, (99.<>6 F.) ; of axilla, 37.^86 C. (100.*>2 F). Continue chloro-
form mixture : — 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.
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144
Observations on the Natural History of Traumatic THanus.
Examination of the Urine — Dark brownish red color; Sp. G. 1023; reaction slronglj acid;
the microscopical examination yielded similar results to those previously recorded: In like
manner, the thick scum formed upon the urine after standing.
No 2. — Analym of Urine parsed during 24 hours^from July Sth, 12 M. to July 9th^ 12 M. Amount*
expreued in Troy Grains.
Amount of Urine J
Water
Solids
Urea
Uric Acid
Free Acid
Phosphoric Acid -
Sulphuric Acid
Chlorine
Equivalent Chloride of Sodium
Fixed "I Entire Salinj8 Constituents
Saline > Phosphates of Limj and Magnesia
Constituents j Sulphates, Chlorides and Phosphates of Alkalies
Nine o'clock p. m. No improvement of symptoms. Continue Chloroform Mixture, twelve
drops every hour; administer at once ten grains of Blue Mass (Pill Hydrargyri), and folloir
in four hours with one fiuidounce of Castor Oil ; and in the morning administer five grains of
Quinine at 5 ▲. m., 8 a. m. and 11 a. m.
July 10th, 12 u. Tetanic spasms have increased in frequency and violence ; bowels obsti-
nately constipated ; the Blue Mass and Castor Oil have had no eflfect. Fifteen grains of Quinioe
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.)
Examination of Urine. — Brownish red color. Sp. Gr. 1025.25. Strong acid reaction.
No. 3. — Analysis of Urine passed during 24 hours ^ from July 9th, 12 M. to July lOM, 12 Jf.
Urine paMed da-
ring 24 fioan. Julj
»th,12M. toJaljWb
12 m.
Urine p*««e4 e»cb
hour.
GRAINS.
o&Aim.
10444.83
435.20
9852.65
410.53
592.18
24.67
381.35
15.88
4.09
0.17
27.61
1.15
39.96
1.66
21.24
0.88
45.22
1.88
73.84
3 07
148.94
6.20
13.29
o.o5
135.65
5.65
Urine pBMed du' Arermc* ..
riJtg 34 hours, Julj and OompodOm t>t
9th. 12 M. to Juljr Urine pmmmea • "
10th, 12 M. boor.
QRATNS. ORAntS.
Amount of Urine 11,625.76 901.07
Water 10,962.17 873.43
Solids 663.59 27.64
Urea 466.56 19.44
Uric Acid 11.45 0.47
Free Acid 33.88 1.38
Phosphoric Acid 45.76 1.90
Phosphates of Lime and Magnesia 16.00 0.66
Nine o'clock p. M. No improvement. Administered an enema of : molasses, one fluidouoce.
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 thirtr
drops of Laudanum, and o.'-dered this dose to be repeated in two hours. Continue the Chloro-
form Mixture; and in the morning administer, five grains of Quinine, at 5 a. m., 7 a. m., and
11 A. M.
July 11th, 12 M. Continues to grow worse; bowels still without any movement ; has taken
Hfteen grains of Quinine this morning. Pulse 84 ; Respiration 15 ; Temperature of Hand 31°
a C. (99° 7 F.,) of Axilla 38° C. (100° 4 F.)
Continue Chloroform Mixture.
Ezamnatlon of Urine. — Light red color; after standing 48 hours, notwithstanding the heal
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 surface.
The urine emitted a distinct smell of Chloroform. Sp. Gr 1024.75.
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Observations on the Natural History qf Traumatie Tetanus. 145
No. 4. — AnaU/na of Urine passed during 24 hows^ July 10^, 12 M, to July IKA, 12 M.
Amoant of Urine
Urea.
Uric Acid
Free Acid .'. •.
Phosphoric Acid
Sulphuric Acid
Chlorine
EqniTalent of Chloride of Sodium.
Phosphate of Lime and Magnesia
Urine paMod da*
ring Si boon, JoIt
lOth, la M. to July
lltb, ISm.
GRAINS.
6,457.50
302.62
5.40
21.60
16.94
. 15.56
10.59
17.37
10.39
ATenge Amoant
and Compodtlon of
Urine paMed daring
each hoar.
0BAIN8.
269.06
12.60
0.22
0.90
0.70
0.64
0.42
0.72
0.42
Nine o'clock p. m. The tetanic spasms have greatlj 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 ourses, are required to support the patient during the intermissions, and to hold
him firmlj during 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 head backwards towards the heels. At one time, when the spasms came on
violently, the patient was projected with force fiver 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
connteoaDce 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 discharge 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 had several terrible spasms, during which he emitted sharp and
piercing cries.
The pulse vas intermittent during these violent spasms, but became regular again after a short time,
Qfler tkey had passed off. The intermission in the action of the heart did not take place until the estab'
Uikment of the spasm^ and continued for soms^ time after the intermission of the spasm, the disturbance
in the action of the heart teas 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
irith 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 12th, 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
Quinine this morning. Thus far I have observed no beneficial effects whatever from the
Quinine; on several occasions it has appeared to aggravate the spasms; whilst, on the other
hand, improTement 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
hour.
Examination of Urine. — Deep red color. Sp. Gr. 1024.5. Strong acid reaction. During
twenty-four hours, from July 11th, 12 u., to July 12th, 12 u., has passed only 4026 grains of
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Observations on the Natural History of Traumatic Tetanus.
The patient affirms, and his statemeDt is- confirmed bj the nurse, that this is the entire
amount passed during this period. During the severe spasms, it was impossible to void the
urine, and the difficultj is still great. After standing^a thick scum rose upon the snrtace.
No. 5. — Analysis of Urine passed during 24 hours^ July. lUA, 12 M. to July 12<A, 12 M.
Amount of Urine
Urea .».
Uric Acid
Free Acid
Phosphoric Acid
Sulphuric Acid
Phosphates of Lime and Magnesia.
Urine puwd do-
ring U houn. Joljr
12tii, 12 M. u> July
Wth, 12 m.
Ar«n«» Am
ud OompiMitk
UriM pMMd
hour.
QRAIM8.
mjLtMB,
4,026.28
177.50
167.77
7.39
3.26
0.13
16.37
0.64
12.87
0.53
9.67
0.37
5.03
0.20
Nine o'clock p. m. There appears to be a slight improvement of the symptoms.
Pulsi^ 88. Has passed no urine this day. Bowels obstinately constipated. Paiated 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 Chloroforfn Mixture, and ordered this dose to be repeated in two hours, and also
the continuance of the Mixture, fifteen drops each hour.
July I3th, 11 A. M. Appears somewhat more quiet. The second dose of Laudanam and
Chloroform Mixture, administered last night, induced some rest, and the patient slept two
hou{8. The Tetanic spasms appear to ha^re lessened a little in severity, and the woaod 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
five grains of Quinine at 12 m., 2 p. m., and A p. m.
Nine o'clock p. m. Has passed more urine than usual this day.
The symptoms have changed for the worse — the paroxysms are more violent, 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 previously described ; the action of the muscles also,
ip drawing tbe'head towards the heels, is similar, and fully as powerful. Pulse 90 in the
sitting posture.
During the spasms^ and for some time after ^ the pulse beats irregularly. One powerful impuUe, fol-
lowed by two feeble impulses^ and then a complete cessation of action ; no imp^e whatever.
When the spasms are delayed, the heart gradually returns, between the paroxysms, to its
normal regular action and the pulse resumes its regular beat.
I carefully examined the relations of the perturbations in the heart's action to the Tetanic
spasms, and found that they succeeded, but never preceded the spasms ; thus indicating that,
either an influence was transmitted from the medulla oblongata, through the Pnenmogastric
nerves to the ganglia and nerves of the heart, causing spasms in the muscular fibres sitnilar to
those excited in the muscles under the control of the volition, by the peculiar state and force
of the spinal axis and motor nerves ; or else the sudden contraction of the muscles and the
suspension of respiration, not only suddenly forced much blood upon the heart, bat also
forced blood improperly oxygenated, and abounding with Carbonic Acid, upon the heart,
and thus deranged its actions by distending the cavities 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 entires cessation of the spasm ; and farther,
because muscular exertion, and the presence of venous blood accelerates, rather than retards,
the action of the heart. A fact stated by physiologists, that on stimulating the cervical
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 trunk or
branches of the sympathetic, its pulsation is always accelerated, would strongly support this
view.
Twenty-five 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 five grains of Quinine at 5 a. m., 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, although a most comfortable chair was fixed, which
afforded the opportunity of resting in the sitting posture. The chair could not be used, on
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Observations on the Natural History qf Traumatic Tetanus. 147
accoant of the great contraction of the muscleB 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 by
two strong soldiers. Pulse 98, in sitting postare. Respiration natural between the paroxysms.
Soiface of the skin, as usual, bathed in perspiration. Temperature of Hand 38^ C. (100^. 4 F).
It was difficult to determine the temperature of the axilla, on account of the violence of the
spasms ; it appeared, however, to preserve the same relations to that of the hand previously
noted, being a little less than one degree Fahrenheit above the latter.
Daring the intermissions, when the spasms are delayed for some time, the pulse was regu-
lar; during 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. Magnesise Sulphatis one ounce; Aquae Distillate, six fluldounces; make a solution,
and administer at once.
R. Chlorofbrmi« one fluidounce ; Pulv : Camphorse one ounce ; Tincturse Opii, one fluid-
ounce; Olei Olivse, four fluidounces ; 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 over the region of the nerves connected 3vith
the injnred textures. «
Examination of Urine. — More abundant, and not so highly colored, being a deep reddish
orange. Strong acid reaction. Specific gravity, 1022.
A&r standing, the urine presented the same characteristics as those previously noted.
No. 6. — AnalytU of Urine passed during 48 hours^ July I2th, 12 if. (o July 14^A, 12 if.
* — -
Urine puaed da- Arerage Amount ATcrage Amotmt
ring 48 boon, Jolr and CompMitkm of .and Compoottlon of
ISih, IS M. to July Urino poied eneh U , Urine piiMed each
14th, 12 M. hour*. boor.
GRAINS. 0RAIM8. OfcAINS.
Amount of Urine 24,139.64 12,069.82 502.90
Water 22,651.58 11,325.79 471.96
Solids 1,488.06 744.03 30.00 '
Urea 1,042.20 521.10 21.71
Uric Acid... 13.46 6.73 0.28
Free Acid 98.43 49.21 2.05
Phophoric Acid 78.02 39.01 1.62
Sulphuric Acid 67.47 33.73 1.40
Chlorine 77.66 38.83 1.61
Equivalent Chloride of Sodium 127.41 63.70 2.65
Fixed ] Entire Saline Constituents 188.96 94.48 3.93
S&lioe [ Phosphates of Lime and Magnesia 33.06 16..53 0 68
Constituents | Sulphates, Phosphates and Chlo-
J rides of Alkalies. ^ 155.90 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 affbrdedsome slight relief to the pain between the shoulders ; at
present, however, the spasms are not so severe as they were this morning. I have again care-
fallj 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, cause the intermittent action of the heart, although they produce a certain amount of
distarbance in its action.
Administer at once, forty drops of Laudanum and twenty drops each of Chloroform and
Salphuric Ether, with one ounce of Sulphate of Magnesia, dissolved in six ounces of water.
Continue chloroform mixture and liniment.
July 15th, 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.
Teoiperature of the extremities and trunk quite uniform, and about the same as last recorded.
Sajs that he 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.
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148
Observations on the Natural History of Traumatic Tetanus,
Examination of Urine. — Deep red color; Sp. Gr. 1026. The arine apon Btaoding seTer&I
dajB, presented similar phenomena to those previonslj recorded.
No. 7. — Analym of Urine passed during 24 hours j Jvly I4<A, VI M. io July Ihtk, 12 JT.
Amount of Urine.
Water
Solids
Urea
Uric Acid ,
Free Acid
Ph osphoric Acid ^^...
Snlphnric Acid ~......»
Chlorine «
Equiyalent Chloride of Sodiam
Fixed Saline Constituents (Entire).
Phosphates of Lime and Magnesia....^
Phosphates, Sulphates and Chlorides of Alkalies..
Amoant and Goa*
atttacDU of Urine
psMed daring M
OBAIMS.
8,074.62
7,585.46
489.16
386.00
8.81
40.40
37.86
38,34
16.53
27.13
* 88.14
14.93
73.21
ATermce i
of Ol»Mt«
Urine peeM
OSAnrs.
336.44
316.06
20.38
16.08
0.36
1.68
1.59
1.59
0.68
1.12
3.66
0.62
3.05
July 16th, 10 o'clock, a. m. Patient appears to be 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 I6dine.
Examination of Uxine. — Light red color; Sp. Gr. 1025.10. In tweUe hours a deposit of
Triple Phosphate fell ; this is the first deposit thrown down in so short a period ; heretofore,
a heavy scum formed upon the surface of the urine, previous to the formation of a deposit,
and in fact, itself afterwards became a larg^ portion of the deposit, in consequence of por-
tions sinking down after remaining on the surface for several days.
No 8. — Analysis of Urine passed during 24 hours, July 15<A, 12 if. to July 16M, 12 M.
Ajnoantand Coo-
ttltaikm of Urine and Owapteltfan <f
puaed daring Si h'e. Uriaa ■■■■■■ eaek
Jaly 15Ch, 19 m. to kov.
Jnlyiadi, ISM.
OlAUrS. GBAWB.
Amount of Urine 9,840.96 410.04
Urea 646.26 22.76
Uric Acid 7.48 0.31
Free Acid 23.62 0.98
Phosphoric Acid 16.37 0.68
Sulphuric Acid 77.67 3.23
Fixed 1 Entire Saline Constituents 57.60 2.40
Saline !- 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 spasmi.
Twenty-five drops of Laudanum, and an equal quantity of the Chloroform Mixture, with one
ounce of French Brandy, diluted, were administered with good effect ; and this combination
repeated in half an hour, vesulted 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 morning.
July 1 7th, 10 A. M. Continues to improve, rested much better during the night than at asj
previous time. The spasms continue to diminish in frequency and force. Pulse in tittiog
posture 82, full, soft and good. Tongue coated with light white fur. Temperature of Hand
37^.95 C. (100«.3 P.) Temperature of Axilla 38<» C. (100*>.4 P).
Continue Chloroform Mixture.
Examination of Urine. — Only 4,029 grains of urine haf« been collected during the Uit
twenty -four hours. The patient affirms that this is the whole amount passed ; he is a most
reliable man, and I have every reason to believe that this is the amount, as both he and hii
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 inquinei-
Four injections of salt and molasses were administered during the night, which failed entirely
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Observations on the Natural History of Traumatic Tetanus.
149
to produce Any effect upon the bowels ; daring the action of these the patient maj possibly
hare lost some urine, he insists, however, that none was lost at anj time.
Color of Urine much lighter; deep orange.
Reaction of Urine not so acid. ^
Specific Graritj, 1025.3.
The following is the Gompositlon of the Urine passed during twentj-four hours.
No. 9. — AnabfsU of Urine passed during 24 Aourt, July 16tA, 12 M, to July 17<A, 12 if.
Amoont and Com- Arermge Amount
podtfam of Urine and OontUtation of
pMMd during U Urine paued each
noon. hoar.
AmoQDt of Urine
Urea
Uric Acid
Free Acid : ,
Phosphoric Acid
Sulphuric Acid ,
Chlorine
Equivalent Chloride of Sodium
Phosphates of Lime and Magnesia..
OBAIN8.
ORAINB.
4,029.42
167.64
183.36
7.64
6.29
0.26
8.10
0.33
5.67
0.23
^2.57
2.98
5.25
0.21
8.63
0.36
8.64
0.36
Nine o'clock p. m. Suffering somewhat more severely this evening. Ordered Brandy two
finidounces, Laudanum one fluiddrachm, Chloroform thirty minims, sweetened water, six
flnidounces ; mix, and divide into two parts ; one to be taken immedi-ately, and the other at
the end of one hour. Continue the Chloroform Mixture, as before.
Pulse 90 in the sitting posture.
July 18th, 11 o'clock ▲. m. Much better ; says that he feels ^' like a new man ;" rested well
during the night ; the expression of his countenance has greatly improved.
Pnlse 86 ; Respiration 14 ; temperature as in previous observations. Twenty drops of
Laudanum, with a similar.nnmber of Chloroform, were administered ; and this dose was repeated
at the end of one hour. Continue Chloroform Mixture.
Etamination 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;
that 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. 10. — Anahftk of Urine passed during 24 hours^ July nth, 12 if. toJtUy 18M, 12 if.
Amount tnd Com- ATerafo Amount
poelUon of Urine and Conttltation of
paiMd during U Urine pasted each
noun. hoar.
Amount of Urine
Urea.
Uric Acid
Free Acid
Phosphoric Acid.. f
Sulphuric Acid *. »
Chlorine
Equivalent of Chloride of Sodium
Fixed ] Entire Saline Constituents
Saline V Phosphates of Lime and Magnesia
Constituents j Phosphates, Sulphates and Chlorides of Alkalies
oEAnre.
OlAINg.
7,722.54
321.77
314.97
13.12
7.56
0.31
18.89
0.78
12.64
0.52
45.39
1.89
23.17
0.96
38.02
1.58
36.28
0.77
17.69
0.73
18.59
1.51
Nine o'clock p. m. Is now asleep ; appears to be improving. Pulse 80. When the patient
awakes, administer twenty-five minims each of Chloroform and Tincture of Opium, with three
flaidounces of Brandy. •
July 19th, 11 A. M. Continues to improve, has had only three spasms this morning.
Poise 72. The patient had a light spasm, whilst I was counting his pulse ; this did not
however aflSect ihe pulse and the action of the heart, as in the previous severe spasms.
Exmmnattan of Urine, — Deep orange color; Sp. Gr. 1016.5. Urine more copious, the
amoiTDt passed during the last twenty-four hours, being 10,876.55 Grains.
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150 Obseratiom on the Natural History of Traumatie Tetanus.
No.. 11. — Analynt of Urine passed dttring 24 hours^ July 18M, 12 M, to July \9th 12. M.
Amoant and Oona- „.
^ pMltkm of VriB* and OonpaiMM tt
T puMd daring M Urine pawd eaek
iMran. konr.
OBAIIU. OBAOra.
Amount of Urine 10,876.65 453.18
Urea 388.47 16.18
Uric Acid 8.56 0.35
Free Acid 30.44 1.26
Phosphoric Acid 20.59 0.85
Sulphuric Acid 30.32 1.26
Chlorine 37.82 1.57
Equivalent Chloride of Sodium. ..« 62.05 2.58
Phosphates of Lime and Magnesia 21.40 0.80
Nine o'clock p. m. Pulse 76 ; sleeping quietly ; the examination of the pnlse excited two
slight spasms, which did not affect the rythm of the pnlse.
July 20th. Much better; sitting up. Pulse 88.
Continue Chloroform Mixture.
R. Olei Ricini, one fluidounce.
July 2l8t, 1 o'clock p. M. Continues to improve; the oil acted once during the night;
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 previous
action, contained hard balls of foecal matter.
Pulse 80 ; Respiration 16; Temperature of Hand 38°.5 C. (101®.3 F.) Temperature of
Axilla 380.6 C. (101^5 F.)
At the present time, the patient does not appear quite so comfortable ; had several spasms
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 2l8t), the
first free evacuations from the bowels, since the sixth of July.
Examination of Urine. — Light orange color. Sp. Gr. 1010.
No. U.^Analysis of Urine passed during 48 hours^ July 19M, 12 M. to July 2\st, 12 M,
Amount of Urine
Urea «
Uric Acid « ...«.
Free Acid
Phosphoric Acid
Sulphuric Acid -.
Chlorine ,
Equivalent Chloride of Sodium^
Fixed ] Entire Saline Constituents
Saline j- Phosphates of Lime and Magnesia
Constitu'ts j Phosp'es, Sulp'es and Chlorides of Alkalies
Amoant and Com-
pMttlon of Urine
Mu«d daring i8
Avenge Com-
portion or Urine
eaohMbonn
Aren«e0Ma-
porftfanerCriM
cnchkMT.
GRAINS.
OBADtS.
OEAIM.
21,018.40
10,509.20
437.88
489.03
244.51
10.18
17.26
8.63
0.35
50.95
25.47
1.06
41.57
20.78
0.86
27.81
13.90
0.57
84.85
42.42
1.76
139.70
69.60
2.90
117.52
58.76
2.44
9.36
4.68
0.19
108.16
54.08
2.30
Nine o'clock p. m. Much better. Wound discharging pus, which presents a thick, healthy
appearance.
July 22d, 9 p. M. Pulse 80 ; has had a few light spaacis, but, upon the whole, has beeo
quite comfortable. The muscles of the jaw have gradually relaxed as 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 Enema. Administered thirty drops of Laudamun aod
Chloroform, with one fluidounce of Brandy ; and ordered an Bnema of Salt and Molaaaes io
the morning.
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Arence Am't
and Oonatlt'tion
of Urine oMttM
ATerage Am't
of Urine pMsed
eMh hour.
0RAIK8.
OBAIN8.
15,580.26
649.17
303.60
12.65
15.35
0.64
21.25
0.88
15.77
0.65
68.70
2.86
112.75
4.69
116.46
4.85
17.01
0.70
99.45
4.14
Observations on the Natural History of Traumatic Tetanus. 151
Jalj 23d, 12 M. Mach better; has had no general spasms, onlj slight twitchings of the
arm : rested well during the night Pulse 80. Repeat Enema of Salt and Molasses, and
contioae chloroform mixture.
Ezammation of Urine. — Dark Red Color, Sp. Gr., 1015.
No. 13. — Analysia of Urine passed dttring 48 hours, July 2lst, 12 M. to July 23rf, 12 if. '
AmoonC and
Oonstltntlon of
Urine pMieddu*
ringw hours.
OftAIMS.
Amount of Urine 31,160.50
Urea 617.21
Uric Acid 30.70
Phosphoric Acid 42.51
Sulphuric Acid 31.54
Chlorine 137.40
Equivalent Chloride of Sodium 225.41
Fixed ^ Entire Saline Constituents 232.92
Saline >- Phosphates of Lime and Magnesia 34.02
Constitn'ts I Phosph'e8,Suiph'e3 and Chlorides of Alkalies 198.90
The increase in the constituents of the urine, was no doubt due in great measure, to the
increased amounts of food and fluids consumed. During the active stages of the disease,
but little solid or fluid nourishment could be taken, hence all the constituents of the urine
were diminished, and this excretion in the present case, was produced under a state approach-
ing starvation.
The physical conditions induced bj the peculiar nervous and muscular derangements, inde-
pendent of any 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 signification 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
various 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, ftiU 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, (Pulv : Ipecac, et Opii), to be administered at
once, and repeated in two hours, if rest is not induced.
Continue 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
evacuate the bowels.
Pulse 76 ; Temperature of Hand, 37<».6 C (99«.8 F.) ; oif axilla, 38^4 C. (101«.2 F).
This morning, for the first time during his illness, the patient has complained of *' feeling
hmffryy
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, bav
iog evidently impinged against the bone ; for small fragments of bone were impacted in the
ieaid. This particle of lead was most probably detached from the ball during its passage
through 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
and 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
wound 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.
Gbloroformi, one fluidounce; Pulv: Camphorae, four ounces; Tinctures Opii, four fluiiJ-
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Amount and Con-
stltotion or Urin«
paued during M
ATcrace MMoal
•BdCoapoaidOTor
UriM pMMdeMk
bovr.
OBAim.
16,724.18
325.32
656.16
13.55
20.83
0.85
17.79
0.74 •
23.97
0.99
107.79
4.49
326.00
13.58
22.20
0.92
303.80
12.65
152 Observations on the Natural History of Traumatic Tetanus.
oances; Olei OliTae, three fiaidounces ; dissolye the Camphor in the Chloroform and mix well
with the other ingredients.
Has taken no Chloroform since 3 ▲. m. this morning. Ordered, (hat the Chloroform Mixtnre
be stopped.
Examination of Urine. — Deep Yellow Color, Sp. Gr. 1019. Heavy deposit of Urates and
Phosphates upon standing a few honrs. Reaction, after standing twenty-four hours, strongly
alkaline.
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. — Analysis of Urine passed durmg 24 hours^ Jtdy 23rf, 12 if. to July 24M, 12 if.
Amount of Urine
Urea
Uric Acid „
Phosphoric Acid ,
Sulphuric Acid „
Chlorine
Fixed 1 Entire Saline Constituents
Saline >-Phospatesof Lime and Magnesia
Constitu'ts j Phosphates, Sulphates and Chlorides of Alkalies.
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 return of the spasms appeared to be due to the discontinuance of the Chloroform tfix-
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 f. m. The Chloroform Mixture has produced good results. Ordered twelve
grains of Calomel to be takeu at once, and to be followed with one fiuidounce of Castor Oil
in the morning. Continue the Brandy and Chloroform Mixture.
July 26th, 12 m. The Calomel and Castor Oil produced the desired effect, and are still act-
ing ; patient says that he feels mnch 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 size. Pulse 80.
Examination 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. Gr. 1016.
With the improvement of the general symptoms, there have been concurrent 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.
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Observations on the Natural History of Trtmmatie Tetanus. 153
Ko. 15. — AnalynM of Urine passed during 48 hoturs^ July 24<A, 12 M. to July 2l8iy 12 M,
Amoont and Com- Average Am't Average Am't
poeltton of Urine aad Ounporitton andOompodtloB
paaaed daring 48 of Urine during of Urine paeeed
noon. S4 hoar* each boor.
0EAXN8. 0BAIN8. ORAIMS.
Amount of Urine 33,665.12 16,832.66 701.35
Urea. 745.76 372.87 15.53
Uric Acid 16.63 8.26 0.34
Pbotphoric Acid 27.97 13.98 0.58
Snlphnric Acid 26.41 13.20 0.66
Chlorine « 128.07 64.03 2.66
Bqniralent Chloride of Sodium^ 210.10 ' 64.03 2.66
Fixed ) Entire Saline Constituents * 508.40 254.20 10.59
Saline V Phosphates of Lime and Magnesia 46.40 23.20 0.96
Constitu'ts j Phosp'es, Sulp'es and Chlorides of Alkalies 462.00 231 .00 9.62
Nine o'clock p. m. Has been taking only ten drops of the Chloroform Mixture, each hour
during the day, and has intermitted sevend times, so that not more than sixty drops have
been administered.
The pains, and contractions, and spasms of the arms and legs and back have commenced
again ; the diminution of the Chloroform has been attended with a return of the spasms. The
symptoms, however, have been very 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 b> assist-
ants. Pulse 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 27th, 1.0 o'clock a. m. Rested well after midnight ; all the symptoms appear to have
improved ; pulse 76 ; urine light colored.
Continue Chloroform Mixture, ten drops each hour.
July 28tb, 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."
Elimination 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. — Analysis of Urine passed during 48 hours, July 26M, 12 -¥. ^o July 28<A, 12 M,
AoMNinland Com- Average Amouit Average Amoont
poelUon of Urine and CompodUon of and Oompoaltion of
' during 48 Urine paaeed eaek 14 Urine paeaed each
" hour.
QBAIHS.
oaAixs.
9,920.43
830.01
432.26
18.01
11.81
0.49
28.76
1.19
11.87
0.49
94.56
3.94
155.08
6.46
186 81 .
7.74
19.66
0.81
OEAIHS.
Amount of Urine 39,940.86
Urea •. 864.60
Uric Acid 23.62
Phosphoric Acid 67.53
Sulphuric Acid 23.75
Chlorine 189 13
Equivalent CHloride of Sodium 310.16
Fixed ] Bntire Saline Constituents 371.62
Saline I Phosphates of Lime and Magnesia^ 39.12
Constituents {Chlorides, Phosphates and Sul-
J phates of Alkalies 332.50 166.25 6.92
P.M. Continues to feel *' Quite comfortable." Complains only of a slight cough, and
pain in the muscles of the back — most probably the result of the severe tension of the mus -
des during the previous spasms.
July 29th. 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), Orams,
51,206.70. Specific gravity, 1016 ; normal yellow color.
»'
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154 Observations on the Natural History of Traumatic Tetanus.
p. M. Has taken no Chloroform this day ; Brandy in small qaantities 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 0. (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 in
appearance ; has taken no Chloroform during the last two days ; takes nothing but a tea-
spoonful of brandy every three or four hours.
August Ist, 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. — Analym of Urine paued during 24 houra^ July 31«^, 12 M. to August \9t\2 M. (24 Aottrt.)
Amoant Mid Oon- ATcrace Awwat
position of UriiM — ^ " '"^ -'
passed during M Uriso
, noon. hour.
V OBAI1I8. OBAOn.
Amount of Urine 28,060.10 1,169.07
Water 27,190.53 1,132.84
Solids 869.57 36.23
Urea 543.48 22.64
Uric Acid 11.46 0.47
Phosphoric Acid 15.98 0.66
Sulphuric Acid 20.62 0.85
Chlorine • 120.30 5.01
Equivalent Chloride of Sodium ; 197.47 8.22
Fixed ] Entire Saline Constituents .'. 296.52 12.34
Saline [- Phosphates of Lime and Magnesia 18.64 0.77
Constitu'ts j Phosphates, Sulphates and Chlorides of Alkalies 278.08 11.58
This patient continued to gain strength ; the wound healed up ; and he was sent home oo
a furlough, ten days after the preceding observation.
This patient was treated in the General Hospital, Augusta, Ga.
The following observatioDs and coDclusioDs 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 essential phenomena of Inflammation and Fever were absent ; the t^mptonu
were exaggerated manifestations ofnervons and muscular actions^ rather than results of
structural alterations ; aii irritation in a distant nervous branchy teas propagated to the
spinal cordy and the disease after its establishment, appeared to be dependent upon an
undue excitability, and increased action in the entire spinal ganglia as manifested in the
greatly exaggerated reflex actiowt ; the disturbance or increased activity of the gam-
glionic cells of the spinal cord, was reflected to the sympathetic nervous system, inducing
deranged action of the heart, obstinate constipation of the bowels, and increased activity
of the skin.
TEMPERATURE 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 iDcreased
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Observations on the Natural History of Traumatic Tetanus. 155
chemical change in the nervons and muscular structures, without corresponding eleva-
tion of temperature. The temperature remained stationary or varied within small
limits from those of health, and the normal relations, hetween the temperature of the
trunk and extremities were preserved, and none of the perturbations of temperature
characteristic of the various forms of fever and inflammation were at any time observ,ed
m 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
manifested in the constitution of the Urinary excretion. The slight elevations and per-
turbations of temperature may be accounted for, by the increased actions of the muscles.
I have produced (as will be elsewhere shown,) similar slight elevations and perturbations
of temperature in animals, by exciting tetanic spasms of the muscles, by the administra-
tion of strychnia, and by passing strong interrupted electrical currents through the spinal
axis. In these experiments as well as in the present case, the elevation of temperature
during the muscular agitation, was slight, and not at all like the great elevations and
changes, and in some cases depressions of temperature characteristic of Fevers and
Inflammations.
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 therelbre, manifested as heat. Without
this 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 change, and nervous muscular or electrical
action.
In the elevation of temperature in Fever and inflammation, there is in like manner
increased chemical change, but it takes platie chiefly in the blood, and results in the
development of heat, 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 in Fever and inflammation, the resulting nervous and muscular forces are irregular
in their applicatiou and manifestations, because the chemical changes 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^rular and depressed character of the forces in fever and inflammation. According
to 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-
phshment of such results, as sensation, locomotion, circulation, excitation and con-
trol of secretion, by the control of the supply of blood circulating 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-
neterisdc 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-
tion 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
cases.
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156 Ohserations on the Natural History qf Traumatic Tetanus.
Case No. 2 : Traumatic Tetanus ; Treated with Bromide of Potassium and Oanmabis
Indica ; Recovered,
C. E. I. — Negro coachman ; age tweDtj-one years ; strong and well built. May 7th, 1873,
received an injary, (penetrating wound) of sole of left foot ; wound healed, apparently, in
about one week.
May 24th, lower extremities got wet whilst driring in the rain ; May 24, symptoms of Tetanos
appeared, viz : Trismus, difficulty in swallowing, and contraction of- abdominal musclea.
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 sardouicus). Abdominal
muscles contracted. Bowels obstinately constipated ; urine scant ; tongue coated. One-
third of a grain of Sulphate of Morphia was injected hy'podermically, and repeated at inter-
^ vals, but without apparent benefit. The muscular contractions Qf the muscles of the abdo-
men and back increased, with frequent spasmsi, and decided opisthotonos. Was thrown into
violent spasms whenever the attempt was made to lie on the left side. The attending
physician placed the patient, on 31st of May, upon full doses of Bromide of Potassium and
Tincture Cannabis Indica: From half a drachm to one drachm of the Bromide of PotassiuD,
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 eflfects of the treatment appeared to be manifest during
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
intervals ; and the patient is able to«leep continuously from 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 dress 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 P.; Pulse, 88; Respiration, 30. p. m:, Temperature.
101° F.; Pulse, 96; Respiration, 44.
June 7, A. M., Temperature, 99^.5 F.; Pulse, 92 ; Respiration, 34. p. m.. 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° ; Pulse, 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.
June 16, Temperature, 100°.4; PuUe, 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 urinary excretion was comparatively abundant, varying from thirty-two to sixty fluid-
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 preoeding case, notwithstanding the existence of well marked symptoms ci
Traumatic Tetanus, the highest point which the temperature reached was ooly
101^.4 F.
Cme No. 3 ; Traumatic Tetanus ; Treated vnth Sulphate of Morphia and Ptarpa-
fives ; Recovery,
J. D., age twenty years ; native of New Orleans ; laborer. Admitted to the Charity Hoi-
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Observations on the Natural History of Traumatic Tetanus.
157
plul, Jane 4th, 1873, with incised wound of left foot, caused by jumping from a steamship
on a nail.
The iron nail passed through the shoe. A piece of leather was taken out of the wound,
and the patient discharged on the 5th. Re-admitted to Charity Hospital June 19th. Patient
says, that after leaving the hospital, he slept in a low, damp rbom, on bare wooden floor ;
June 1 7th, experienced pain in the small of the back, radiating to back of neck, jaws and
side; June 18th, stiffness of jaws, slight spasms, diflSculty in swallowing,' restlessness and
sleeplessness ; 19th, Trismus ; tongue coated ; bowels obstinately constipated ; skin bathed
in profuse perspiration ; slight spasms excited by movements of any kind. The spasms
commence with a quivering of one or the other leg. Urine scant and high colored ; intellect
clear.
The patient was placed upon Sulphate of Morphia, from one-sixth to one half grain every
two, four or six hours, according to the symptoms. The effort was made at the same time to
keep the bowels open, by the use of purgative enemas and the internal administration of
Gruton Oil. June 20th, Opisthotonos well marked, patient perspiring profusely ; the spasms
and opisthotonos continued with varying degrees of intensity, until the 5th of July, when
tber^ was marked improvement. The following is the record of the Pulse, Temperature
and Respiration.
DATX. PULSX.
mnnaA-i
TIOM. 1
TSMnB*TUmB
AXILLA.
AMOUNT
OF
spBoinc
OBAVITY
BE M A RKS.
•««• A|A
8
6
8
6
VRINS IW
OF
A.1I.
P.M.
A.M.
P.M.
PLUnMUWOIS
vaniB.
Juie '2o\ i 80
100 r
Proftiae Penpiratlon ; Bed clothes drenched.
21
72 84
22
22
101.6
101.6
16
1024
22
90
92
18
24
102
99.6
18
1026
BowelH moTed ; Proftue Penpiration.
23
84
84
22
22
100
lOOJS
16
1024
Muiolet of Bftck greatly Contracted ; body arched.*
24
96
86
24
28
100
101
16
1026
25
86
86
28
24
101
100
16
1025
2S
80
84
28
•30
101
101
16
1025
DellrlooB daring night, with inToIuntary twitchi'gs
27 82 90
32
24
101
101
16
1026
Intellect dear; Opisthotonos less; appears better.
28 80 86
22
24
100.6
101
16
1026
Blight improvement.
Slept weU daring the night.
29, 84 86
26
26
100.6
101
20
1026
3U
84 84
26
24
99
100
16
1025
Continnee qniet comparatiTely ; Spasms less.
Muscles more relaxed ; Beaotion of Unne Alkaline.
Joly 1
84 94
24
28
100
100.6
30
1015
2
88 86
24
26
100
lOU
22
1025
Urine has been acid np to this date.
3
86 ; 88
26
24
100
100
U
•1015
Mnscles of body and neck relaxing gradually.
4
88 1 88
28
26
lOOJi
101
48
1016
6
80 , 86
30
26
100.6
101
136
1026
Bespiration not so proftise ; Urine abundant.
6
88 1 88
24
26
100
100
136
1025
Improving ; hsAnorrbage tnm nose.
7
88 ' 88
30
28
100
100
112
1025
Muscles relaxed ; Improving ; Urine Hbundant.
Convalescent, suffen only from muscular pains and
8
88 ' 86
32
30
100
101
48
1016
9
88 88
28
28
100
101
72
1016
Convalescent. [sttflbess in back.
lu
84 86
30
28
100
100
104
1020
11
86 86
28
28
101
100
120
1015
M It it U
.12
88 86
26
26
100
99
128
1015
u u u u
13
86 ; 88
26
28
100
99.6
128
1015
Sat up in chair for four honra.
14
88 1 86
28
26
100 1 99.6
76
1010
Continues to gain strength.
Patient up and walking around the ward.
15
86 86
26
26
99.6 100
120
1015
16
88 ; 86
28
28
100
100
110
1015
Patient up and walking around the ward.
17
86 86
24
26
100
100
88
1010
18
88 1 88
28
28
100
100
80
1010
19
88 84
28
24
100
WJ>
86
1015
20
84 , 84
26
24
99
99
64
1020
21
84 , 86
26
26
99
99.6
48
1025
22
86 . 86
26
22 99Ji
100
80
1015
23
84 : 84
24
24
100
100
72
1020
24
84 , 80
22
20
100
100
64
1015
25
80
80
20
20
100
99
04
1015
26
80
78
20
20
WA
99.6
64
1020
27
76
76
20
20
99
99
64
1020
28
76
74
20
20
WA
99.6
64
1015
29
74
74
20
20
99.6
99
44
1026
On the 31st of July, this patient was discharged from the hospital at bis own request.
The clinical notes of this case were taken for me, at my request, by Dr. William Martin,
of New Orleans, at that time Resident Student of Charity Hospital.
Id Case No. 3, the highest point of temperature reached, was 102^ F., and this eon-
tbned only for a short time. As in the preceding 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
characteristic of Tetanus, as observed by others.
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158 Observations on the Natural History of Traumatie Tetanus.
That Hippocrates* had carefully observed the pheDomena of Traumatic TetaoiiB, b
evident, from the prognostic, or aphorism, that " Spasm supervening upon a wound, is
mortalj^^ and " Such persons as are seized with Tetanus die within four days, or if
they pass these they recovery
In those cases of Tetanus which Hippocrates recorded in his Treatise on Epidemical
Diseases, lie 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 io
the following quotations from his works :
Case No. 4. — " Scamandras, in Larissa had a mortifieaUon in his hip, and an abMcets of long
standing at the bone. A large incision being made, even to the bone, and astion ased after-
wards, a convulsion began the twelfth daj after the incision, and held him strong, reaching
^rom the leg to the ribs, and affected 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 convulsion, he died in another. The cure was carried on bj apply-
ing warm boUles and fomentations of tares to the whole body, not omitting a glyster ; bj which
the faeces that had been long detained came away in a small quantity. He also drank a
bilious purffe, and even a second ; from which, indeed, there was a discharge, but to no advan*
tage. After a little sleep, he took another strong purge of the like kind, and in the ereniBg
died about sunset ; but in all probability might have held out a long time, had not the phjaie
been too strong for him."
Case 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, he
was drawn and distorted backwards, as in the opisthotonos. 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 be died."
* Case No. 6. — '^ The Master of a great ship had the fore-finger, and the lower bone of bis
ricrht hand broke to pieces. An inflammation came on, a mortification and a fever. The
fifth day he was purged moderately; the heat and pain abated, and part of the finger fell off.
After the seventh, a little gleet came away ; and after this he said be could not pronounce his
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.''
Case 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, seized him. What
he spit was frothy, and came from him through his teeth with difficulty. The third dav he
died."
Case No. 8. — ''Zeno, the son of Damon, had an ulcer abo'it 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 Air, Water
and Situation. Epidemical DiseaseSy and upon Prognostics. • Trans, by Francis Clifton, M. D.,
London, 1734, pp. 166, 167, 199, 200.
I
In the following directions for the treatment of Tetanus, it is evident that Hippo-
* (Economia Hippocratis, Alphabeti Serie Distincta. * * Anntio Fcesio Mediomatrico
Medico Authore; Francofurdi, apud Andrese Wecheli heredes : 1588.
The Works of Hippocrates, in Latin and Greek, edited by Anutio Fcesio, and published at
Frankfort, by Andrae Wecheli herdes; 1595.
Hippocratis Coi Ascelpiadae gentis sacrse Coryhaei Yiginti duo commentarii Zabnlis illns-
trati ; Graecus Contextus ex doctis. Y V. Codicibus emendatus, etc. Theod Tningeri Bas
Studio et Conatu, Basileae Bpiscopiorum Opera Atq. 1579.
Hippocratis Coi Aphorism! Graced et Latind Johannis Heurnii. Raphelengii. 1607.
Magni Hippocratis Coi Opera Omnia Graece and Latine edita, etad omnfes alias Editiones
accommodata. Joan Antonidse Yander Linden, Doct. et Professoris Medic tnie Practical
Primi in Academia Lugduno, Batava, 2 vols. Lugduni Batavorum, Apud Danielem Abra-
hamum etAdrianum & Gaashbeeck. 1665.
Hippocrates Upon Air, Water and Situation ; Upon Epidemical Diseases, etc. Trans, by
Francis Clifton, M. D., London. 1734,
The Genuine Works of Hippocrates ; Trans, by Francis Adams, LL. D., 2 Vols., London.
1849.
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Observations on the Natural History of Traumatic Tetanus. 159
crates considered Fever as an unusual symptom in the disease, and as in no manner
connected with its production.
" When the loins are in a tetanic state, and the spirits in the veins are obstructed by mel-
ancholic bamours, venesection will aflford relief, bat when, on the other band, the anterior
tendons are strongly contracted, and if there be sweats about the neck and face, extorted by
the violent pain of the parched and dried tendons of the sacral extremity (thescr are very
thick, sustaining the spine, and giving rise to very great ligaments, which terminate in the
Icet), 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
rob 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 sacrnm, are to be wrapped in a skin smeared with wax ; this must extend to the parts
beyond, 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
moTed. 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 atTusion, and in^ediately afterwards let him eat boiled bar-
ley meal in a tepid state, 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." The Oenttme Works of Hippocratet. Trans, by
Francis Adams, LL. D., Surgeon. Vol. I, p. 326.
Aretaeufl the Cappadooian, in his aocorate and el^ant 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 assafoBtida as anti-spasmodics. ' *
Panlus .^Igineta, not only makes no mention of increased heat and fever, amongst
the symptoms, but quotes Pelops, to the eflfect that the most potent remedy/ /or all the
varieties of Tetanus, is a fever supervening when there was none at the commencement.
Hippocrates, Plato, Oalen, Horatianus and Avicenna agree in stating that a fever
coming on tends to remove the tetanic affection ; CsbUus Aurelianus however, seems to
question the truth of this ancient aphorism.
However imperfeet 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 noany 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-spasmodics as Castor and Assafoetida, by Octavius Horatianus, Avicenna, Mesne,
Senipion, Haly, Abbas, Rhases, and other Arabian and Oreek physicians, in the treat-
ment of Tetanus, that they regarded the disease as essentially different from fevei:s and
inflammations.
Thus A. Cornelius Celsus, treated Tetanus as a spasm of the nerves by local applica-
tions, 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 Btimnli possible, and continue their use without regard to quantity, not even to that of
opium itself, till tbe whole tumult of the disease is allayed." Elements of Medicine, DCLII.,
DCLIV., DCLV.
William CuUen, held that Tetanus is seldom attended with fever, and the blood drawn
in this disease never exhibits any inflammatory crust.
Dr. Lionel Chalmers,'" refers the more frequent occurrence of tetanic complaints in
* Ab Aooonnt of the weather and dieeMes of South Carolina, by Lionel Chalmers, M. D.; London, 178G ; pp. 23-^1.
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160 Observations on the Natural History of Traumatic Tetanus.
Autumn, to the lax and irritable or depressed state of the system, induced by the effects
of climate.
Benjamin Rush* held that Tetanus
« Is seated in the muscles, and, while thej are pretematarallj excited, the blood veMeU
are in a state of reduced excitement. This is evident from the feebleness and slowness of
the pulse.. It sometimes beats according to Dr. Lining, but forty strokes in a minate. 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, by equalizing it, cures the disease."
John Hunter, regarded 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 prind-
pie 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 Hanter,
edited by James F. Palmer, London 1837, vol. 1, pp. 583-689.
According to James Lind, Tetanus occurs most frequently in ho{ countries ; and
there appears to be no fault in the blood in such cases, 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 Es$ay on Diseases IncidenUU to Europeans in Hot UlimaUs.
London 1768, pp. 257-259.
Dr. James Currie, who more than sixty years ago, advocated strenuously, and fre-
quently employed the thermometer in the Diagnosis and treatment of diseases,
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
inflammatory nature, and that there are even now, physicians who treat it by veneseciioB.
It is in my mind decisive against this supposition, that though the general system is so power-
fully affected, the animal heat is not increased which, it uniformly is, so far as my observa-
tions exten 1 in all cases where there is an inflammatory affection of the system, whether
originating or terminating in local phlegmonic inflammation. The same consideratioo is
decisive with me as to the supposed inflammatory nature of hydrophobia, a n<^tion 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 these
terminated fatally. Hydrophobia has some resemblance to tetanus, but is however in my
judgment obviously and essentially different.*' M:d!.cal R*.portSy Philad., p. 133.
The cases of Traumatic Tetanus reported by Benjamin Traversf in his Inquiry con-
cerning Constitutional Irritation^ were unattended by fever, and the blood presented do
marks of inflammation, and both his pathology and treatment are based upon the view
that It is essentiaUy a disease of function^ and destroys by exhaustwny if not by sttdden
translation of the spasm to the heart.
The late Dr. Robert Bently Todd, in his valuable article on the Nervous System^ eon-
tained in the 3d volume of the Cydopmdia of Anatomy and Physiology, and in his
more recent Clinical Lectures on Diseases of the Nervous 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 exdtement ; 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. 0. 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 interesting
* Medical Inqairies and Obflervations. Vol. 1, pp 256-267.
t A Farther Inqniry Gonoeming Oonttltotiooal Irritation, by Bet^amin TraverB^ Loodon, 183S, pp. 890, 838.
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Observations on the Natural History of Traumatic Tetanus. 161
case of Traumatic Tetanus, (Richmond and Louisville Medical Journal, November,
1871, pp. 484-493,) 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
exception of three days, the absence of aay thing like afebrile condition^ and that the
heat of the patient " was rather sub-normal than the reverse." The highest point
reached in this case was 100^. F. on the 6th day, and the temperature of the axilla
from the 25th of August to the 8th of September oscillated, with the single exception
mentioned from 97 to 99°. 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
writings of many distinguished Army and Navy Surgeons, as Pringle, Blane, Trotter,
Hennen, Abernethy, Guthrie, Larrey, Baudens and Macleod.
The weight of medical testimony is therefore to the eflfect, that the symptoms of
Fev^r and InJlatnmaUon, are almost universally absent in Tetanus.
That in some cases of Traumatic Tetanus, the temperature is elevated considerably
above the normal standard, is evident from the following observations :
Cask 9. — Traunvitic Tetanus ; rapid rise of Temperature a short period before death.
M. B., laborer ; native of New Orleans, age 21. Patient received November 24th, 1873, gun-
shot wound through right foot ; the ball making a hole of about half an inch in diameter on
the dorsum, and about two incites in sole of foot, metatarsal bone of big loe shattered. Edges
of wound ragged. Entered Charity Hospital, November 24, a short time after the reception
of the wound. The splinters 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-
plained of pain in the foot, and stiffness of the jaws. The wound has never discharged
laudable pus, but has exuded an offensive sanlous discharge. R. Tinct. Cannabis Indicae three
fljtd drachtn; ; Pota^sije Bromldi half oun;e ; Syrupi simplicis four fluidounces ; tablespoou-
ful every 3 hours. December 4th, symptom? of Tetanus well marked; trismus; rigid abdo-
men; opisthotonos; occasional spasms, p. m., Temperature, 99°. Respiration, 25.
December 5th. Symptoms more intense, bowels obstinately constipated. Temperature of
Axilla in the morning, 99°. 5 ; Respiration 24. Urine scant, only two fluidounces during the
24 hours. In the evening the temperature of the axilla had risen to 108°. F. The patient died
at 3 o'clock A. M., the next morning, December 6th.
The clinical notes in this casa, were taken at my request, by Dr. C. Fred. Knoblauch, of New
Orleans, and at that time Resident Student of Charity Hospital.
In the pree2ding case, it is worthy of note, that the case terminated fatally shortly
after the temparature reached 10S°. F. It is probable that the temperature of the
internal organs, was between 110 and 111°. F.
Case 10. — Ti-aumatic Tetanus ; rapid rise of Temperature^ sudden Jatal termination.
Reported by Dr. Y. R. LeMonnier, of New Orleans,
X, age 26 years, brick-layer; entered Hospital Pitio, Salle Si. Louis, Paris, June 22nd,
1869; died, July loth. 1869. This man entered the Hospital, for a dislocation of the thumb
of the right hand, with a perforation of the bone through the skin. The dislocation had
been reduced, and the wound was healing kindly, when on the evening of the 7th of July,
(16 day of injury,) the first syra^jtoms of tetanus showed themselves by an inability to com-
pletely open the mouth. Wuen we saw the patient for the first time in the morning of July
9th, about 18 hours after the appearance of the first sym^^toms of Tetanus, opium and mor-
phine, by the mouth and subcutaneously, had been freely administered. It was resolved to
use woorara by 3ubcutan30us injections. At 9 a. m., the axillary temperature 103**. 8 ; at 10
50 A. M. when the first injection of woorara was made, the pulse was 124 large, and com-
pressible; Rectal temperature 106°. 8 F.; Respiration 40, short and intermittent. The spasms
recurred every two or three minutes, between which the patient was able to rise and flex the
extremities, and also to drink and urinate. The temperature was very high during the last
36 boars. The patient died on the 10th of July; at the hour of death the pulse was 168
and thready ; respiration 44, and diaphragmatic , face cyanosed ; general muscular con-
tractioas less marked at inferior extremities j pupils dilated ; skin intensely hotto the
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162 Observations on the Natural History of Traumatic Tetanus.
touch, and apparently from 108®. to 110®. P. Having obtained no sedative effects from
the subcutaneous injections of woorara. morphine in the same manner was again used oa the
last day, July 10th.
The following tables show the number of subcutaneous injections of Woorara, and the
state of the Pulse Respiration and Temperature on July 9th :
10:45 A. M., two Sub. C. Injections Woomara J grain, each in fifteen minims of water.
11:47 A. M., two Sub. C. Injections Woomara J grain, each in fifteen minims of water.
No marked effects, spasms continuing.
9. A. M., Pulse, ; Temperature Axillary, 103®. 8; Respiration, — .
10:50 A.M., Pulse, 124; Temperature Rectal, 106®. 8; Respiration, 40 per minute.
11:20 a.m., Pulse, 120; Temperature
12:15 p. M., Pulse, 118; Temperature Rectal, 105®. 8 ; Respiration, 44 per minute.
12:30 p. M., Pulse, 118; Temperature Rectal, 105°. 4; Respiration, 42 per minute.
1:20 p. M., Pulse, 112 ; Temperature Rectal, 105°. 4 ; Respiration, 40 per minute.
1:45 p. M., Pulse, 114.
The temperature continued to rise, and the pulse to increase in frequency, an(i at the mo-
ment of death, on the 10th of July, it was estimated that the temperature ranged between
108° and 110° in the rectum ; the pulse was 168, and thready ; respiration 44, and diaphramfttic
Dr. Le Monnier desired to determine the changes of temperature after death, but throagfa 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 post
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 «
cream-like substance^ for a distance extending from the fourth to the sixth cervical nerves, 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 aijainst a rough, bony surface on the external side of
the inferior extremity of the thumb. Tliis extremity had been denuded by the accident. The
head of the metacarpal bone, at its palmar surface, was partly fractured.
The case just recorded, is important in that an elevated temperature and rapid, fiital
result in Traumatic Tetanus, were attended with rapid circulation and respiration, and
with inflammatory softening of the cervical portion of the spinal cord.
Dr. Le Monnier informs me that he observed a similar condition of the spinal cord
in one of his dogs, which died from the eflfects of Traumatic Tetanus, caused by a
penetrating wound of one of the fore-legs. Although the temperature in the animal
was not accurately noted by the thermometer, it nevertheless appeared by the sense of
touch to be considerably elevated above the normal standard.
Case No. 11. — M Prevost, of Geneva, 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 ori^nal
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. James Copland* observes, that the "amount of animal
heat necessarily varies in diflferent 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 on the
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 diflferent authors. This has been
owing chiefly to the different states of the heart's action in the several states or stages of the
disease, and the varying grades of frequency in th^ acute and sub-acute cases, as well as in
the idiopathic and symptomatic forms of the malady. Dr. Morrison, Hennen, Macgregor and
others, have remarked that the pulse is seldom much eflTected ; but the greater number ef
writers have stated the pulse to be very much accelerated, and most remarkably so ta acnto
« Pictfoury of Practical Medidae. Hew Tork ; 1859, YoL Ui, p. IIML
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Observations on the Natural History of Traumatic Tetanus, 163
cftses. This is the result of my own observation in the numerous cases which I have had an
opportanity of observing in France and Germany, in 1815 and 1816, and Eubsequently in
warm climates. In an acute case which I attended in 1820, the pulse 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 paroxysms, but the degree of
frequency varies in diflerent cases, as well as in the course of the disease. The treatment
adopted has often a considerable influence in quickening the pulse, and towards a fatal issue
this 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
poise 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 his valuable Treatise on Tefanvs^ 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-
existmg 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
medulla 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.*' Treatise on Tetanus; Phila., 1837 ; p. 19.
Cases 15 and 16. — It: a case of Traumatic Tetanus, which occurred in the prac-
tice of Mr. T. Holmes, of London, (reported in the article on Traumatic Fever, by
Mr. John Crofl; 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
injury, when the temperature had reached 104°.8 F. ^
In 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 afler the appearance of tetanic spasms, was due to the supervention of
this disease. It would be more reasonable to rel'er tjie 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
traumatic 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 1(13°. 6 F., on the morn-
ing of the third day, when trismus appeared. The temperature fell, upon the evening
of this day to 100*^.4 F., and rose again to 102°. 6 F., on the morning of the fourth
day, descending in the evening to 101°. 5 F., and continuing to descend and falling to
100*^*8 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 tlie 14th day, when the trismus as 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
thermonoetric 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 case, 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-
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164 Observations on the Natural History of Traumatic Tetanus.
ture 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 eon- ,
firmed by several observers, (Billroth, Leyden, Kbmier, Fcrber, Erb, Quincke, and
Monti); namely, that in the last stages of fatal neuroses, and more particularly in tetanus,
although met with in very many other disorders of the nerve-centres, (of the brain,)
the temperature begins to rise, and rises in the briefest space of time to extraordinary
heights; to heights indeed, which are only exceptionally reached in diseases which are
of distinctly febrile origin, sometimes to 4:i° C (10i)°.4 Falir.) or even to above 44° (\
(111°.2 Fahr.) and in one case of Tetanus to 44°.75 C. Ci)'l''^^y Fahr.), which Is
usually succeeded by a still farther post-mortem rise of temperature^ amounting to a
few tenths of a degree. Fifty-seven minutes after death, the temperature in the e;ise
of Tetanus observed by Wunderlich, amounted to 4r>°.:^7r) C. (IKi'^.tJTr) FahrS
Lehmann, noted 44°.4 C. (111°. 9 F.), in a case of tetanus just before death. Her
Hofrath Unterherger^ Professor of Vetinary Surgery in Depart, informed ProfeRs<»r
Wunderlich, in a letter, that he had observed temperatures of above 42° C. (107°.6
Fahr.,) in fat^l cases of Tetanus in Hoi*ses.
Such elevations of temperature have been but rarely observed in disease : Currie
found a temperature of 44°. 45 C. (112° F.) in a case of Scarlet Fever; Simon observed
44°.5 C. (112°.l F.) in a case of Variola Ilaemorrhagica, although, indeed the tempe-
rature was taken after death ; Quincke 44°. 3 C. (111°. 74 Fahr.,) in a case of Acute
Bheumatism ; Brodie in a case of destruction of tlie lower cervical portion of the spinal
marrow, 43°.9 C. (111°.02 F.) Wunderlich has seeii several similar cases to that of
Brodie, where the temperature reached 44° C. (111°. 2 F.); and Dr. Woodman, the
English translator of the work of Wunderlich, has recorded some fatal cases of Scarlet
Fever, in which the temperature amounted to 115° F. (46°. 1 C.) In two ca.ses of
Pneumonia, which recovered^ under my treatment in the Charity Hospital, during the
Winter of 1873, the temperature in the axilla reached 109°, and was probably about
112° F. in the int^ernal organs. These cases were of interest as illustrating the fact,
that this degree of temperature is not necessarily fatal. I have observed a temperature
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 restlessness of
this patient, prevented the thermometer being well held in the axilla; the actual tem-
perature was therefore somewhat above 108°, and probably reached from 110° to 113°,
in the cavities of the heart. Dr. William Arnold has recorded a temperature of 110**
F., in several fatal cases of Yellow Fever. In a case of Small-Pox attended with violent
delirium, and with expansion of one pupil and contraction of the other and which
terminated fatally, and which occurred in my private practice during the month of
April, 1874, the temperature just before death as indicated by placing the bulb of the
thermometer between the scrotum and the thigh, was 110°. 5 F. The temperature of
the internal organs in this case probably reached 113° F., and over.
Wunderlich* conceives, that the very high temperatures observed by hini.«elf and
others, with the equally extraordinary high temperatures, which are observed in tissuo
changes of the brain and upper part of the spinal cord, ajipear to show, that there are
moderating centres or apparatus in the brain, the paraly.sis of which is succeeded by a
morbidly increased action of the processes which produce warmth. This observation is
of practical importance, because it indicates that any considerable elevation of tempera-
ture in patients suffering from neuroses, when no particular rca.«on can be assigned for
the fever, which is developed, affords the worst possible prognosis.
It must be* observed, however, that these observations of \yunderlich and others^
relate only to the last stage of fatal tetanus.
In the case reported by Wunderlich in which the temperature reached 44°.9, a short
time before death, the disease was of six days duration, and during the first five days
* On the Temperature in Diseases ; a manual of Medical Thermometry, by Dr. C. A Wunder-^
lich. Trans, ^'^w Svd. Soc, London 1871, pp. 204-425.
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Observations on the Natural History of Traianatie Tetanus. 165
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
elevated, reaching 45°. 5 C; and in one hour and a half after this observation, the tem-
perature descended to the point at which it stood at the moment of death, viz : 44°. 9
C. It has been shown by the experiments of Bernard and others, that in warm-blooded
animals, a temperature ranging between 45° and 46° C, destroys the contractility of
the muscles, thus mechanically as it were causing death, by the arrest of circulation and
rwipiration. And Kiihne has shown that the rigidity of the muscles is due in such
rasey to the coagulation of a special constituent. In a case of Tetanus observed at the
Hiispiial Pitie, by M. M. Peter,* the temperature remained normal (37°. 3 C.) during
the first-five days, although the pulse was 120; on the morning of the sixth day diffi-
culty of respiration and asphyxia, commenced and the temperature was elevated 3°
(40°.3) in eight hours, and the pulse was only 100; during the next ten hours the
temperature rose to near 1° C (41° C. ); in eleven hours and five minutes, at the
moment 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 be referred to the following causes :
Ist To the effects of the violent muscular contractions and agitatJbns.
2d. To impeded respiration, causing, a less rapid cooling of the blood in the lungs
by the inspired air and by the loss of caloric in the expired air ; and also causing the
retention 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 Fneumoma.
4th. The translation or extension of the irritation of the gray matter, and especially
that portion in connection with th^ motor nerves, into true inflammation, attended with
softening of the nervous structures.
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 sympathetic or vaso-motor system of
nerves, either through the branches connected with the diseased structures, or through
a reflex action from the cerebro- spinal axis.
7th. The chemical and physical alteration of the blood, either by the pervertod
actions of the muscular and nervous systems, or by the genenition within the living
system of some poison which acts as a ferment, or by such impeded elimination of the
elements of chemical change, as leads to an alteration of the normal cycles of chemical
combinations and decompositions of the blood.
It might at first be supposed that the 7th and last hypothesis, was sustained by the
fact that in certain cases of great elevation of temperature at the moment of death, the
lemperature of the body had slowly risen, a degree or the fraction of a degree, during a
short period ; but this slight post-mortem rise, may be explained by the sudden arrest
of the respiratory process, and also to a great extent of the transpiration from the surface,
thus 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 hypotheees.
There are facts to sustain the fourth hypothesis, and in a subsequent portion of this
investigation, we will show by the results of post-mortem examinations, that the spinal
cord, and even portions of the brain undergo structural alteration in many fatal cases of
Tetanus ; and we must regard the rise of temperature, as not characteristic of Tetanus
3? a disease, (that is, for example, as certain oscillations of temperature, chraraterize
JIalarial ^ever, Yellow Fever and Small-Pox,, and distinguish them from each other
♦ (J^zette Hebdqnpadaire, 26 J^mvier 1872, p. 54.
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166 Observations on the Natural History of Traumatic Tetanus.
and from a]l other diseases, ) but as indicating structural alterations in certain portionB
of the Cerebro- Spinal Nervous 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 Travmaiic letanvs is not necessarily accomjyavied
by fever ^ that it is not related to the Febrile Diseanes ; and at the same time it dfffer* in
some important sympions Jum frve injiammation. The rapid rise of temperature
observed in certain cases of Traumatic Tetanus, is evidently a i>henomenon engrafted
upon or added to the uncomplicated disease.
The weight of testimony, ancient and modern, sustains the view, that in uncompli-
cated Traumatic Tetanus, fever^ (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 the one hand, nor to the Phlegmasise, on the other, whilst under certain
circumstances, both fever and inflammation may be engrafted upon it, has an important
bearing upon the tr^tment of the disease.
PORTION OP THE NERVOUS 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 modern, 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 Aie 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 nostrils, partially open mouth,
with the angles of the mouth drawn backwards and a little upwavd^^, exposing the teeth,
is manifestly dependent upon the involuntary contractions of the muscks of the face,
and the expression of uneasiness and apprehension is not dependent upon mental dis-
turbance.
Even in the remarkable case recorded by Professor E. Geddings in the Charleston
Medical Journal, July, lb52, although the tetanic spasms appeared to be caused by
the fracture and depression of the cranium, and was relieved by trephining, and eleva-
tion of the bone, the dij^case was unattended by cerebral disturbance.
Dr. Geddings acknowledges his indebtedness to Dr. H. R. Frost for the following
notes of this case :
Case 17. — Traumatic Tetanus.
On the 17th August. 1851, Mr. M received a severe blow on the upper part of the right
side of the forehead, with the end of an iron belaying pin, \<hich ^ as thrown at his), end
foremost. The scalp was dividtd to a limited extent, and, as was subsequently discovered, the
cranium fractured and driven down upon the dura-mater.
As no unpleasant symptoms, except those of an evanescent character, were manifested, the
case was submitted to simple treatment, and the wound continued to heal kindly for several
days, although it was found on introducing a probe, that the bone beneath was denuded.
On the 13ih day after the injury, a feeling of uneasiness was experienced about the jaws,
with R stiffness and inability to open the month. The symptoms of Traumatic Tetanus thus
declared, extended by slow steps to the muscles, tongue, neck, shoulders and back; to the
diaphragm and abdominal muscles; and those of the hips and thighs. On the Hth day the
jaws were so firmly closed, that he could not masticate, aad the tongue felt so large and stiff
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Observations on the Natural History of Traumatic Tetanus. 167
that he coald scarcely protrude it from the mouth. 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
scorbicalns cordis next succeeded, which extended to the muscles of the small of the back
and legs. The muscles of the face, particularly about the eye-brows, were also much
affected.
All the above symptoms gradually increased in intensity, until the I2th of September,
thirteen days from their inception. The mental faculties even at this late period, were not in
the slightest degree disturbed, but the unfortunate patient was under the full influence of
general opisthotonos. He complained of extreme weakness 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 the countenance that peculiar expression of distress
so commoQ 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.
During 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 un ible to rise. The family greatly alarmed at this, sent for the attending
physician, and on entering the room, the patient was found to be ^ected 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 scorbiculus 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 slig^htest 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. Geddings found the bone bensath 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-
nium 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
countenance 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 diff'used 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
much improved. There was no longer any excitement, or general spasms ; had rested quietly
during 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 ;
pnlse, 100.
14th. The tetanic spasms still gradually subsiding. The night was spent for the most
part, in a state of sleepless disquietude, but some sleep was obtained towards morning. The
pulse, 80 ; slight heat of skin ; with trifliag soreness and pain in the wound. The spasms
occasionally recur in the muscles of the back, in those about the eyes and face, and his jawB
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168 Observations on the Natural History of traumatic Tetanus.
can be only partially separated. He moves himself freely in bed ; assists the nurse in
adjusting his position, and feels so much better, that he craves for animdl food ; but his diet
is still restricted.
Afternoon. Condition of the patient nearly the same ; pulse, 80; spasmodic twitchings still
take place down the back with rigidity of the jaw ; wound partially united and healthy.
15th. Improvement progressive ; spent a comfortable night ; pulse 80, and regular; slight
twitches still experienced in the back. Afternoon ; no unfavorable changes, wound healing.
From this time, the patient continued to improve without interruption, and by the llith day
after the operation, the tetanic symptoms had entirely subsided.
In the preceding case, the tetanic spasms, were diminished in intensity, but not
immediately and completely removed by the operation, and in fact the symptoms did
not subside until the 19th day after the operation. The tetanic spasms were caused,
either by the direct pressure of the fractured bone upon the brain, or by the transmis-
sion of the irritation to the medulla oblongata and spinal cord, through the nerves
connected with the injured parts. If the first supposition be correct, the irritation was
transmitted from the surface of the brain, through its structures, to the medulla oblon-
gata and spinal cord, whilst at the same time, those portions of the brain which are
supposed to be connected with the intellectual faculties appeared to remain unaffected.
Baron Larrey has recorded a case, in which tetanus supervening upon a lance wound
in the right side of the forehead, was relieved by an operation, whilst the cerebral
symptoms increased in severity, and the patient was destroyed by the inflammation of the
brain. The following is the history of this interesting case, as detailed by Baron
Larrey.
Case 18. — Traumatic Tetanus,
In a charge of Cavalry, Mr. Markeskl was wounded by a lance on the right side of the
forehead, the point of which glanced obliquely upwards and inwards, making a deep
fissure m the os-frontis. One of the branches of the frontal nerve was divided by the cutting
edge of the lance. Nine days passed without the appearance of any unpleasant symptom, and
the 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 total loss of sight in this
organ. He had slight delirium, acute local pain, locking of the jaws, and emprosthotonos
was evidently about to take place. I first applied emollients, on the wounded part, and pre-
scribed opiates and diaphoretic drinks ; they procured no relief, and the disease advanced
with such an alarming aspect, that I doubt not he must have died in twenty-four hours.
I probed the wound and soon ascertained its direction. The probe produced great pain, and
I was induced to lay open the wound from one end to the other, with a bistoury and grooved
director ; with a single cut I divided the frontal muscle, nerves and vessels.
He was instantly relieved, and in less than twenty-four hours all the tetanic symptoms had
disappeared. I now thought he might recover, but on the twenty-6fth day, spmptoms of
inflammation of the brain and its meninges with the characteristics of effusion appeared. 1
had been prepared to expect these consequences from the delirium before noticed, which is
never a symptom of Tetanus. But at that time I had discovered only a small furrow in the
external table of the os-frontis, made by the point of the lance. I now applied a large vesi-
catory over the scalp, and prescribed cooling drinks and anti-spasmodics. The disease still
advanced, the fever increased, delirium followed, and he died on the 2Tth day.
On inspecting the cranium, we found the internal table of the frontal bone detached at the
end of the fissure, and a consideriible effusion of bloody purulent matter under the right
anterior lobe of the brain, which was here also in a state of suppuration. When the first
symptoms of compression appeared, after those of tetanus had subsided, I proposed the appli-
cation of the trephine on this fissure, but was induced to omit it from the decision of several
of my colleagues, who were of opinion that no'effusion would follow so small a fissure. I
regret that I did not pursue my first intention; occmio prxceps judicium difficili. Memoirs of
Military Surgery, Vol. II, p. 309.
It would appear in the preceding case, recorded by Baron Larrey, that the irritation
causing Tetanus was transmitted to the medulla oblongata and spinal cord, through the
injured nerves rather than through the cerebrum ; for a clear division by the knife of
the injured nerves relieved the tetanic spasms, but had no effect whatever upon the sub-
flequeat inflammatioa of the brain.
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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-
ranixed in the living animal, without exciting any convulsive movement or any apparent
sensatioQ ; 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
aie lo^ ; in lesions of the cerebral substance, the earliest and most constant phenomenon
is the impairment or loss of the mental powers ; and the development of the mental
Realties in man and animals, is in proportion to that of the cerebral hemispheres. The
investigations of physiologists, and more especially of Longet, have established that the
application of Caustic Liquids, of galvanic currents and mechanical irritation to the
ol&ctory ganglia, the corpora striata, optic thalami, tubercula quadrigemina, and to the
white and gray substance of the cerebrum and cerebellum, are without any manifest
excitation and do not causQ 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
sur&ce 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
nervous impressions, are therefore regarded as being destitute of both excitability and
sensibility ; 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
of the experiments of MM. Fournie and Beaunis, in France, and Nothnagel, in Ger-
many, upon the effects of destroying Small Parts of the Brain, have been fully unfolded
in the preceding chapter, (Chap. 1st, 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 localized so as to act alone upon the parts svhjected to
experimental investigations ; and if it be clearly established that certain definite regions
of the cerebral centres preside over the voluntary and combined movements of the
musdes of the face, eyes and anterior and posterior extremities ; it is clearly manifest
that the proposition that in Traumatic Tetanus the cerebrum is \inaffected, cannot be
folly sustained.
Thaf 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
coordinates all the voluntary movements of the fttime ; and from its extensive connec-
tions with the cerebro-spinsd axis. In the experiments of Flourens, during the removal
of the superficial layers of the cerebellum, there appeared only a slight feebleness and
want 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 ; after the removal of the deepest layers, the animal lost completely
22
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170 Observations on the Natural History of Traumatic Tetanus.
the power of standing, walking or leaping, or flying, and when placed upon 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 movement.
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 those 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 with 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 s^ment of the great
nervous centre upon which all the movements and sensations of the body depend — it is
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 Tetadus, which is as follows :
Case 19. — Traumatic 7'etanvs.
A light horseman, of verj amorous disposition, received a sword-cut, which dirided tbe
skin and all the convex portion of the occipital bone, through to the dura mater. Tbe right
lobe of the cerebellum was seen through the opening of the dura mater, and the slightest
pressure upon this organ caused giddiness, fainting and convulsive movements. The patient
loses sight and bearing of tbe right side, expieriences acute pain in the course of the dorsal
spine, and tingling in the testes, which in fifteen days were reduced to the size of a bean. Tbe
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 stiffness 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 grin ; the forcible
contraction of the pharynx and oesophagus, the fixed and elevated larynx, the harsh
altered voice, the pain at the praecordium, theffyrcing forwards of the shouldtn^ 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 convul-
sive respiration ; together with the violent tonic spasms of all the various rnusdee, 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 contracted ; were aU 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 cases of Tetanus, the first symptoms which attract the attention of the pl^sician.
after the reception of the injury, is a complaint on the part of the patient, of stiffness
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 extremities.
In such cases it would appear that the state of functional exaltation, first manifested
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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
pair) of nerves ; that is in the region of the junction of the peduncles of the cerehellum,
with the medulla oblongata, and of the restiform and olivary bodies, and of the gray
substance of the fourth ventricle, where the tension of the nervous force of the
cerebellum 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
dep^idence 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-
bellnm 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 successive spasmodic contractions by sudden discharges of the nervous force gene-
rated in the cerebellum and medulla oblongata, afler the manner of successive electrical
discharges, through the different diastaltic arcs of the spinal system In thb manner
when the irritation commences in the medulla oblongata, we may explain the gradual
invasion of the different ganglionic centres of the spinal axis, and the gradual generaliza-
tion of the convnlsive mani^tations.
It would be an error however, to refer the manif^tations 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
or localized 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
nerves of the 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
not involve seriously the medulla oblongata and cerebellum, the comparatively harmless
disease 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
such means as will tend most surely to arrest the propagation of the disease to the
various s^ments 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 ^e 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 view of the older anatomists, that the spinal cord was nothing more than a bun-
dle 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
resulte of anatomical explorations, as well as by the teachings of experimental physiology ;
and physiologists now regard the spinal axis, as devoted to the manifestations of excito-
motor phenomena, and as coordinating the movements of the trunk and extremities.
Whilst It is true, that when the spinal cord is severed from the encephalon, it takes no
share in the mental perception of sensations, and in voluntary actions ; and that when
united to the encephalon, its integrity is necessary to the perfection of the sensori-
voluntaiy actions ; it is on the other hand well established, that it is itself a ganglionic
centre, capable of generating nervous force for the excitation of movements independently
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172 Observations on the Natural History of Traumatic Tetanus.
of volition or sensation, in parts 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 roots, to the gray matter of the cord, and is from the
ganglionic cells, reflected back along the motor fibres of the anterior root, until it fioaU j
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 akin,
or organs, into a motor impulse, which is sent out again to the muscles ; and this
^^ reflex action,^^ 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 its proper s^ment of the
body, and connected by longitudinal commissures, to the other ganglionic masses of the
cerebro-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 elements of the spinal cord, which are accumulated throughout
the central portion of the cord ; the former arising from the cord itself, taking th^
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 medul-
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 radides
or rootlets, one set of which at the posterior part of the cord ascends immediatdy in
the white substance and appears to proceed directly upwards into the brain, thus con-
stituting the channel of sensation, whilst the other portion of the posterior or sensitive
nerve roots 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 rejlex
action^ directing their stimulus, through the group of ganglionic cells, with which Uiey
appear to be connected, into the ganglionic cells of the anterior horn, from whose plexus
of cells, the filaments of the motor roots arise. The posterior nerve roots include two
descriptions of nerve fibres, the one for sensation proper, the other for reflex acti(»i.
The different groups of ganglionic Cells are united throughout the cord, by longitudinal
fibres, and through the commissures, coordination of motion is effected. The roots of
the motor nerves, thus receive the excitement or stimulus to action, from the ffanglionic
cells in which they originate ; and these ganglionic cells receive their sdmmus either
anteriorly from above, from the gray matter of the cerebellum and cerebrum under the
guidance of the intellect ; or posteriorly through the reflex filaments of the s^isifie
nerves, or from the peripheral parts of the body, through the sensitive nerves. The
ganglionic cells of the motor nerves, are therefore susceptible to psychical as well as
physical stimulus. Reflex action therefore takes place, by a definite channel, its operation
being regulated by the communicating fibres which unite the different plexuses of nerve
cells and secure coordination and combination of movements.
By this arrangement, sensitive or motor impulses, may be propagated from group to
group of ganglionic 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
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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
control of the will.
According to this view. Tetanus essentially consists, not in an inflammation of the
nerve oells and structures, nor of the membranes of the spinal axis, but in such a state
of exalted functional activity in the nerve cells, as is attended with the constant gene-
ration of a larger supply of motor force, than is necessary for the maintenance of the
normal healthy relations between the nerves and muscles. We wUl 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
Stiychnine, 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
symptoms and manifestations of Tetanus, may continue throughout the disease without
the establishment of true inflammatory 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 engrafted 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 consequence from that law of\he 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 affected in Tetanus is limited,) that the progressive exhaustion of the patient by
the enormous 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 a
wound, may be reflected from the periphery upon the central ganglia of the spinal
axis.
Our knowledge of the mode in which the nervous irritation oric;inates in the injured
ports, 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. The 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 of 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 papillae 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 eflbrts 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 Krause in similar
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174 Observations on the Natural History of Traumatie Tetanus.
investigatioDS, 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 struetores.
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 ftdly 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 &rt 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
beautifiilly 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, Ynlpian,
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 SchultsK, tlie
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 essential
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 I'Anat. et Phys., 1869, p. 269,) by
exposing the nerves to a peculiar treatment with nitrate of silver, reached the condu-
sion that the axis cylinder is composed of disks superimposed and isolated by a substance
differing from them in composition. Dr. S. Wier Mitchell, of Philadelphia, (Injuries
of Nerves and their Consequences, p. 17,) has verified these observations on the sciatic
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 longitudinal striae, 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, (Microscopical
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 mintUe granules about j^^ MM. in diameter, which are armm^
in regular rows and united by a komogeneous interfibrillous substance, and thus form a bundle of
grantUar JibriU. Each axis cylinder is, therefore, according to its thickness, composed of a
number of these granular fibrils which united into a bundle, are enclosed within a disiiHc(
delicate membranous sheath. The difference between the view of Max Schultze and my own, con-
sists therefore only in the nature of the fibrils and the interfibrillons subsUnce, and idse io
the absence and presence of a sheath. * *
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Observations on the Natural History of Traumatic Tetanus. 175
The granalar fibrinous strucVure of the axis cylinder is very 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 tts surface and take part
in the formation of other processes. The course of the rest I must leave untouched for the
present. * * In examining, therefore, the surface of a gaufrlionic 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 poljgonal bodies with a dark point in the centre. As such I had also regarded them
antil 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 farther evidence of the granular-fibrillous bodies and their processes, I may be per-
mitted to point to the observations of Prommann and Orandry^ 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 continned exposure to light, this property also manifests itself in the granules and causes
the coloring of the whole specimen.
In comparing the granular-fibrillous 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
grannies is here, like the axis cylinders, only sparsely represented, in consequence of which
the latter almost touch each oth^r. 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,
the 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 the striated muscular fibres in a state of activity, are similar to those observed in the
nerves, 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
farther, if we consider those so-called sarcous elements of Bovmann as the elementary bodies or
agents through which the contraction of the muscular fibre is effected, we might, judging from
the above mentioned analogy of structure, also look upon those grannies, composing the
fibrils of the axis cylinders, as the true nervous elements^ i. e. those anatomical elements through
which thQ 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 white covering, 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
sensitive surfaces. The sensitive nerves may be traced for the most part to a plexiform
series of loops which underlie the skin and other sentient surfaces, and which according
to Beale, and some others, constitute the true periphcrdl termination of many senuitive
nerves, which, returning again to their central cell connections, form, as it were, a
neural circuit.
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176 Observations on the Natural History of Traumatic Tetanus.
If we accept as true, the recent observations of Professor Lionel S. Beale, of Lion-
don, (An Anatomical Controversy; the Dutrihvtion 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 mosde,
divide at length into^a vast number of exceedingly fine, pale granular fibres, which
ramify upon the external surface of the sarooleinma, connected with which fibres at cer-
tain intervals, are oval nuclei, and that these fine fibres, afler an extensive and in man j
cases very circuitous course, are 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 Tarious
kinds of nerve centres, justify the inference that the fundamental 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 central nerve ceUs, and peripheral nerve cells^ generally termed nadet,
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 Ktihne, who holds that the nerves termi-
nate in ends beneath ths sarcolemma, and are in fact, continuous with rows of nncl^
which lie among the contractile tissue ; and from those of Kolliker, who agrees with
Kiihne, 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, Waldejer,
Engelmann, Letzerich, MM. Conheim and Yulpian, all admit the existence of a terminal
plate, and its entire independence of any nervous network. According to M. Rooget,
the terminal division of the axis cylinder of the motor nerve fibre, constitates 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 fibrillar, and on the other hand, with the intersticce
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 dear
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 Traomatic
Tetanus, we observe :
1st. The nerves in their ultimate branches and ramifications, form a net-work of
great 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
cells.
3d. A local injury or irritation is capable of producing a state of super-functional
activity in the nerve cells of the periphery of the sensitive and motor nerves. As these
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Observations on the Natural History of Traumatic Tetanus. 177
cells exist in immense numbers even in comparatively small portions of structure, and
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 irritation might be readily
transmitted from the periphery to the central ganglia. Thus a local nervous exaltation
of nervous function 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 to 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 nerves.
The fact that the neural* arteries and nerves, are not met with in the sheath of the
tdlimate nerve fibre, 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
axis, and lead to increased supply of blood to the central ganglionic cells, and increased
eicito-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. BeaJe, to the ex-
planation 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
return to the central ganglionic masses.
Thus, 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
close 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 ner\'es.
Schwann observed that the nerves in the web or fin of the tadpole's tail, and in the
mesentery of the amphibia, divide into numerous fine fibres destitute of the white sub-
stance, without any dark outline, and presenting little enlargements, from whence deli-
cate fibn» spread out in various directions, and connect themselves in the form of a
delicate and extensive net- work. The subsequent observations of Quain, confirmed by
those of Schwann, also showed that the smallest nerve fibres presented here and
there along their course elongated corpuscles, like cell nuclei. The researches of Ru-
dolph Wagner upon the distribution of the electrical organs of fish, in like manner
establish the doctrine, that the peripheral nerve fibres divide and sub-divide, and
reunite, and are distributed in a plexiform manner, like the ramifications of the capil-
laries. Her Bilharz has shown that the small nerve which supplies the electrical organ
of the electrical Silurus, ( Malapterus), keeps continually dividing, until it finally resolves
itself into an enormously great number of ramifications, which spread them82lves out
upon the electrical organ, thus allowing of the sudden diffusion of the nervous influence
over the whole extent of the electrical plates. The investigations of Meissner and Bill-
roth have shown that the sub-mucous layer of the intestinas is, as Willis had long
before declared it to be, a nerv^ous tunic. The afferent nerves of the intestine, after
having divided, finally break up into extensive net-works, presenting, at certain points,
nodules, having the appearance of ganglia, from which the nerve fibres spread out into
ioterlacements, like the net-work of capillaries. This arrangement not only enables us
to understand the nature of peristatic action, but it also offers a ground-work for the
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178 Observations en the Natural History of Traumatie Tetanus,
explanation of tetanic spasms, and convulsive affections, arising from irritating sub-
stances in tlie alimentary canal, similar to that afforded by the distribution of nerve
fibres to voluntary muscles.
We are enabled by such facts to understand how a local irritation may excite super-
functional activity in the adjacent nervous centres, and there, in virtue of their com-
munications with other nerve 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 as 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
te 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 CIRCLLATIOX AND RESPIRATION IN XRAUMATIC TETANUS-
In the First Case, the respiration was disturbed during the paroxysms, but between
the paroxysms it was performed as usual ; thus affording a striking contrast to the res-
piration of fever 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 actions during the intermissions.
When the heart was uninfluenced by the nervous and nmscular 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 nerves of the heart, causing spasms in it*;
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 suspension of respiration, not only suddenly forced much blood upon
the heart, but also forced blood improperly oxygenated upon the hearty and thui^
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
irregular action of the heart lasted after 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 casual observation and bare record.
The intermittent action of the heart appeared to be immediately associated with the
violent disturbances of the cerebro-spinal nervous system, and resembled the disturbance
produced in the action of this organ, by the transmission of electrical currents through
certain po^^ions of the cerebro-spinal and sympathetic systems.
The heart as is well-known is supplied with nerves from the sympathetic and par-
vagum ; 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 recurrent
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 sensitive filaments received by the
sympathetic from the oculo-motorius nerve, inferior and superior maxillary, opthalmic
and lingual branches of the fifth pair, facial nerve, and from the spinal nerves, establish
a relationship between the heart and cerebro-spinal system. The Pneumogastric (par-
vagum) nerve, by its origin from the lateral portion of the medulla oblongata, in the
groove between the olivary and restiform bodies, and by the branches which it receives
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Observations on the Natural History of Traumatic Tetanus. 179
from the spinal accessory, facial, sub-lingual, and anterior branches of the first and
second qenricals, 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. We are thus enabled to understand that it is possible to trans-
mit a ner\*ous impulse from the cerebro-spinal system, and more especially from the
medulla oblongata to the heart.
The following experiments establish a clo.sc 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 oblongata and Pneumogastric nerves.
E. H. and E. 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 hehrt arc 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 sensitive 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 bo
continued, the heart after 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 antaj*bnism is often 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
tension of the arterial blood is considerably diminished, although it finally remains at a
considerable height. Ou 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 exxiitement. The corpora callosuni, 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
to new contractions, from the spinal cord as from the sympathetic. In the application
of a rapid succession of electrical shocks, the same contrast is repeated between the
medulla oblongata, and the upper part of the spinal cord, as between the vagus, and
sympathetic; the former arresting, and the latter quickening the action of the heart.
When a defined portion of the vagus has been stimulated for some time continuously,
the heart again begins to pulsate ; when a portion of the nerve above this point is now
stimulated, no effect is produced ; when, on the other hand, the stimulus is applied to a
portion further down, nearer the heart, a cessation of it«h movements is again produced.
The circumstance that the heart, aft^r the stimulus has 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 nerve, 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
* Text book of Physiology, § 1754, 1787, 1800, 2003, 2005.
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180 Observations on the Natural History of Traumatic Tetanus.
80 for a considerable time after the stimulus had been withdrawn, and then again
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 stimulus
to the pneumogastric. Moreover, the nerves which are sent to the heart of the frog,
do not present the arrangement which Weber has described. No other filaments than
those which pass from the vagus, are distributed to the heart of this animal, at least,
no others have been demonstrated. The vagus ner\'e becomes united with the sympa-
thetic in the ganglion, which is situated about one line from the rcots of the pneumo-
gastric ; and from this ganglion which contains fibres of the vagus and sympathetic,
springs, amongst other branches, a slender filament, which is destined for the heart.
This runs downwards on the inner aspect of the lungs, and passes along the veins to the
auricle and ventricle, the former receiving the greater number of the nerve fibres- The
branch in question contains fibres derived from the pneumogastric.
Again, such a restraining power must hold an opposite relation to the moving power
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 (^ the vagus nerve ought, did it exert the restraining power in question,
to be followed by an acceleration in the movements of the organ, which is not the case.
Budge, therefore, seems to regard the fibres which are 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 the
groove between the auricles and ventricles, this effect cannot bo counteracted by apply-
ing them to the bulbus arteriosus. The phenomenon of the cessation of the heart's
action, produced by the application of the galvanic stimulus to the pneumogastric, he
explains, by supposing that its fibres are in a state of activity during the systole of the
corresponding part of the heart, but quickly became exhausted, thus allowing the dias-
tole to take place : thereafter, their activity being again renewed, a second systole
results. When, therefore, strong galvanic stimuli arc applied to the nerve, the state of
exhaustion continues longer, and in the same proportion the diastole, or cessation of the
heart's action, is also longer.*
On the other hand. Dr. Brown-S^quardf has obser\'ed that section of the pneumo-
gastric nerves, is followed by paralysis and dilatation of the blood-vessels of the heart,
and that the excitation of these nerves, (by galvanism or otherwise), produces contrac-
tion of the blood-vessels. He explains by this contraction the stoppage of the heartV
action, when the medulla oblongata, or the pneumogastric nerves are galvanixed. as in
Weber's experiments. The heart, according to Dr. Brown-S^quard's theory, owing its
contractions to an excitation produced by some element of the blood existing in the
small arteries and veins. Now, if we suppose that galvanization of the par-vagum
produces a complete constriction of the capillaries of the heart, it is easy to understand
why the heart is stopped ; it is because the excitation cannot take place, on account of
the expulsion of the blood from the capillaries. If it be objected to this view, tha^
the effect of galvanization is immediate, and that the arteries and veins possessing only
fibro-muscular cells cannot contract suddenly, it may be answered that it is a fact, that
although there are only organic or non-striated muscular fibres in their vessels, they do
contract immediately when the pneumogastric nei-ves are galvanized ; and Brown-
S^quard has discovered that the capillaries of the face and ear are constricted when the
sympathetic nerve is galvanized in the cervical region. It is known that the nerves of
the heart are distributed much more to it« blood-vessels than to its muscular tissue.
By this supposition, the stopping of the heart's movements is placed among the well
known facts, that an excitation of a motor nerve produces a contraction of the muscles
* Wagner's Handworterbuch der Physiologic, band iii; Astherbiing, ii, p. 15; band iii, p.
415; Cyclopaedia of Anatomy and Physiology, Vol. v, pp. 400, 461.
t Experimental Researches Applied to Physiology and Pathology, pp. 77-19; Principles of
Hitman Physiology, by William B. Carpenter, M. D., etc, Phila., 1856 ;. pp. 2,43^ 244.
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Observations on the Natural History of 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
contractions.
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 to find that the heart will
beat, if, during the stoppage produced by galvanization of the medulla oblongiita, we
substitute for the missing excitation, (in consequence of the expulsion of blood from the
artereies 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
fact has been discovered by Dr. Brown-S^quard, which he considers very important.
When a galvanic current is applied to the heart, or to the pneumogastric nerves in the
neighborhood of this organ, it is known that its pulsations arc not stopped by it, and
that sometimes, on the contrary, they appear to be quicker and stronger. Now, if the
theory of Dr. Brown-S^quard be right, how is this to be explained ? In this case, the
vessels 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
as the missing excitant expelled from the vessels. The truth of this explanation appears
to be proved by the fact discovered by Dr. Brown-S^quard, that if the galvanic current
\a 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 galvanfc excitation
hi applied to the medulla oblongata of a frog, for ten, fifteen or twenty minutes, (some-
times five minutes are sufficient), the heart, which had stopped, at once resumes' it«
action.
This fact, discovered by the brothers Weber, and unexplained by them, is thus ex-
plained by Dr. Brown-S^quard.
The vessels of the heart, as well as the vessels of any other part of the body, cannot
remain contracted a very long while, their contractility diminishing gradually during
their contraction. Dr. Brown S^cjuard 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 jiradually became dilated, although the ex-
citation of the nerve was continued.
Whilst therefore it is true that the ordinary movements of the heart arc but little
dependent upon nervous influence of any kind, as may be shown by the continuance of
its action after destruction of the entire cerebrospinal nervous system and even after
its complete separation from the chief centres of the sympathetic system, and removal
entirely 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, pneumogastric and sympathetic, the depressing effects of sudden emo-
tions, of shock, of crushing suddenly the spinal marrow, or of a limb, the fatal effects
of sudden and violent blows upon the epigastrium, and the eft'ects of the tetanic spasms
in arresting or accelerating its motions, all establish the fact, that the action of this
oi^n may be influenced 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
dthers they are vastly accelerated, without any corresponding elevations of temperature,
as in the rapid action of this organ in fever. And it is a question worthy of investi-
gation, how far the fatal termination in Traumatic Tetanus, may be due to disturbances
in 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
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182 Observations on the Natural History of Traumatic Tetanus.
to the state of the heart, which he imagines becomes exhausted, and first loses its vital-
powers. (Cases of Tetmuis and Rabies Contagiosa, p. 81).
Mr. Benjamin Travel's held that the ultimate tendency of the disease, is to travel into
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. (Fnrtlter inquiry
concerning Constitutional Irritation^ and the Pathology of the Nervous St/stem. pp.
332, 333).
Dr. (-urrie remarks, that the patient when the case terminates fatally, probably die:*
at last from spasmodic affection extending to the heart. (Medical Reports, vol. i. p.
118). Dr. Currie in common with other observers, refers the fatal issue in a certain
proportion of cases, also to arrest of respiration.
Case 20: Traumatic Tetanus.
Mr. Howship published a case (Med. and Phys. Jour, xxii, p. 185, London 1809.)
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 bcdy being still waim, 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 shortened frcm the basis to the apex. Upon prct^
sing the muscular ventricles, they gave the resistance of a very firm and even homy
substance, rather than of mere fleshy* cavities. The auricles as well as the ventricles,
were greatly contracted, and felt unnaturally fiim. The sides of the left ventricle were
found in the closest contact, ho much ^o, that Avhen a section of the heart was made, the
exact situation of the cavity was not immediately to be perceived. About half au ounce
of blood still remained in the right ventricle. The auricle on the right side, contained
about an ounce of blood, that on the left, a much less proportion. The heart was
removed from the body, and upon being examined a few houi*s aflerwards, it was found
to have become completely relaxed, was much larger and softer, as well as very flaccid,
having entirely lost that very peculiar and remarkable state of tone which it posses«sed
at the time of its being fii*st inspected. ^Ir. Howship describes no other morbid
appearance, and concludes, '' that it was on every side clear, that the muscular structure
of the heart had in this case become at length subject to the same affection which, during
the earlier stages of the disease, was confined principally to those parts of the l>ody
subservient to voluntary motion."
Whilst we have no anatomical data, by which to determine the relative fre<iuency of
such a condition of the heart, as that describe^d by ^Ir. Howship, it is however established
that it is by no means uniformly present in death from tetanus, and may also be pregenl
when death is caused by other diseases. Thus Dr. John ReiJ, after describing the
morbid appearances in a case of Tetanus, observes, that
"The difference of the gjinjrlionic system from the spinal was well marked, by ihe influence
of the disease not extending in a similar manner to the muscular organs of both systems.
This is marked by the muscular part of the heart and intestines being paler than naiur«l,
while the muscular organs belonging to the spinal system are remarkably florid and red.'' On
the Xature and Treatment of Tetanus and Ilifdrophofiia, etc. Dublin, 1817.
Dr. James Copland states that in two acute traumatic ca.scs, which he examined
afler death,
»*Thc heart did not present any appearance different from that observed in cases of sudden
or rapid death from other causes. Both these cases terminated in asphyxia.'' Dictionary of
Practical Medicine. New York 1857, vol. iii, p. 1103.
Dr. Curling says :
** That ia other diseases, the heart wUcn examined wiihiu a few hours after death, may often
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Observations on the Natural History of Traumatic Tetanus. 183
seem exceedingly rigid and closely contracted, in consequence of irritability remaining in the
mascalar fibre after life is extinct." Treatise on Tetanus, Philad., p. 14.
It ha^ also been supposed that the uiistriped muscular tissue of the arteries may be
affected with spasm in tetanus. Thus in a case of amputation on account of Tetanus
supervening upon a lacerated wound, perfonned by Mr! Liston; the vessels contracted so
completely that^there was no haemorrhage, and ligatures on the mouths of the divided
vessels became unnecessary (Ed., Med. and Surg. Jour, xxi. p. 202). Whilst the con-
tractile power of the arteries was evinced to a remarkable extent, this appears to be an
isolated ease in the history of Tetanus, and Mr. Curling affirms that he has witnessed
it in almo.st an equal degree, 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
nerves, is rendered still farther manifest by the effects of great muscular exertions and
spasms 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 frequency 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-
mission of an impulse through the sympathetic nervous system, which, as has been
bhowD, acts in a manner the reverse of that of the electrical and nervous impulses
transmitted 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
pulse. Thus, he says :
" If in an adult the pulse, by the fourth or fifth day, does not reach one hundred, or perhaps
one hundred and ten beats in a minute, I believe the patient almost always recovers. If on
ihe other band, the pulse on the fourth day is ouc hundred and twenty or more in a minute,
few instances will, I apprehend, bo found in which he will not die."
It is well established however, that the danger in Tetanus, is neither proportional to
the intensity of the spajmis, nor to the rapidity of the action of the heart, but is depen-
dent rather upon the particular class of muscles affected. Thus, if the muscles of the
throat and chest, the muscles of respiration, be early and decidedly involved, the great
danger is asphyxia, from the sudden arrest of respiration as well as from the injurious
and depressing effects of the impeded respiration.
Dr. Parry's rule cannot with our present knowledge be adopted as a guide for accurate
prognosis, not only because the action of the heart, may l>c greatly influenced by the
remedies employed, but also because the rule is not sustained by the testimony of other
writers, as Sir James Macgregor, Dr. Morrison, Dr. Hennen, Mr. Curling and others.
In many fatal cases, the pulse has 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
recovered. In all the cases witnessed by Mr. Curling, the action of the heart, as well
as the respiratory movements were in some degree accelerated ; and during the paroxysms
there was generally a further increase, of about ten or twelve pulsations in the minute,
whilst towards the close of the disease, the pulse became feeble, irregular and sometimes
intermittent. The circulation in tetanus does not therefore present the marked and
uniform acceleration and slight oscillations, characteristic of certain diseases, as Yellow
Fever, Malarial Fever and Small-Pox.
FINCTION OF THE SKIN ACTIVELY PERFORMED; TONGIE BIT SLKJHTLY FURRED:
BOWELS OBSTINATELY CONSTIPATED, DURINO THE ACTIVE STAOES OF TRAU.VATIC
TETANUS.
As a general rule, in Traumatic Tetanus, the function of the skin is actively performed,
and the patients are frequently bathed in perspiration.
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184 Observations on the Natural History of Traumatic Tetanus.
It does not appear to be necessary to refer the profuse perspiration of some cases of
Tetanus, to deranged nerv^ous action, either immediately, or as the sole cause. ThL*»
increased activity in function of the skin, appeared to be the result in- great measure of
the increased muscular actions. Without doubt also, the pressure of the muscles upon
the internal organs and vessels, and upon their own veins and capillaries must impart u»
the fluids a peripheric impulse. As far as our knowledge extends, the cutaneous secre-
tion in Tetanus, \s not '* critical,'' and its amount and character, furnishes no grounds
for a favorable or unfavorable prognosis. In those cases which recover, we have no
reason to suppose that any poison is either wholly or in part, eliminated by the skin in
this diseiv^e.
In the FIRST CASK, the tongue was but slightly furred, and at no stage of the disease
did it present the dry funed appearance so common in many fevers and inflammations.
The bowels were obstinately constipated. This constipation precceded the violent
spasms, and was not therefore the result of muscular pressure. This state of the bowels
was most probably connected with disturbance in the nervous system. Closure of the
anus by the spasmodic action of the sphincter ani, would not account for the constipa-
tion, because it preceded the stage of rigid contraction of the muscles; neither will the
violent pressure of the muscles upon the alimentary canal, in conjunction with the great
transpiration from the skin, account for this symptom, for a similar reason, that these
were subsequent to the establishment of constipation.
Without doubt, the pressure of the abdominal muscles, the profuse perspiration, and
the effects of the opiates administered, all tended to render the bowels torpid ; but the
fact which we wish to establish, is that this state preceded these conditions, and could
not therefore be more than aggravated by them. Whether the constipation was due to
spasm, or persistent contraction of the unstriped muscular fibres of the bowels, thus
preventing all peristaltic motions, or to derangement in the secretory and excretory
apparatus of the mucus membrane of the alimentary canal, or to both causes combined,
cannot in the present state of our knowledge be accurately decided ; it is however well-
known, that in other diseases of the brain and spinal cord, besides Tetanus, the bowels
are torpid.
Whether we incline to the opinion of Bichat and draw a broad line of demarcation,
between the cerebro-spinal nervous system, as presiding over the functions of animal
life, and the sympathetic, as providing over the involuntary movements, and over the
processes of secretion and excretion, the functions of vegetation and reproduction, and
regard the sympathetic ganglia as entirely independent of the cerebro-spinal ; or to the
view of the older physiologistvs, which has been revived and ably advocated in recent
times, that they are not independent systems of nerves, but that the sympathetic L<
dependent upon the cerebro-spinal f«)r its pro{)erties and forces, and must therefore be
regarded as one of its systems of nerves : we are in either case justified by such well
estiiblishcd facts, its the disturbance and [>erversion of nutrition by mechanical injuries
and pathological alterations of nerves, the mutual actiims of the digestive, urinary and
generative organs, the variations under nervous excitation of the circulation and secretions
in the various abdominal organs, the production of convulsions by the presence of undi-
gc*sted matters in the alimentary c-iuial, nausea attending pregnancy, temporary' amaurosis,
double vision and even hemiplegia following deningement of digestion, diarrhoea and
inflammation of various internal organs following exposure to cold and wet, disturbances
in the action of the heart and in the digestive functions by moral and mental emotions,
dilatation of the pupil under the impression of terror, sudden injection of blood into the
capillaries of the face as an effect of ment4il emotion, and other similar facts, in holding
that reflex nervous actions may take place, through the sympathetic system from one
organ to another, or from the organs through this system to the cerebro-spinal, and
through- this portion of the nervous system to the voluntary muscles and sensitive
surfaces ; and also that they may take place from the exterior sensitive surfaces, through
the cerebro-spinal system to the sympathetic, and through it again by reflexion, excite
the involuntary muscles and various abdominal organs.
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Observations on the Natural History of Traumatic Tetanus. 186
These well established physiological and pathological facte, and these mutual relations
and interchange of impressions, between the sympathetic and cerebro-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
eoaununication 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 ceuB ^te
now said to exist in the gray matter of the spinal cord. According to M. Jacvbowitsch,
straotures which are analogous to the ordinary ganglionic cells of the sym^thetic, occur
in the middle of the spinal marrow, and in seyeral part^ which are regarded as belonging
to the brain. This observer has distinguished three kinds or forms of cells, in the
gray matter of the cord, which he affirms He generally in separate groij^ps, and which
he distingaishes as motor, sensitive and sympathetic. It follows from the observations
of Jacnbowitsch, that the whole cerebro-spinal nervous system (the spinal marrow, the
elongated marrow, the quadrigeminal bodies, the brair), and the cerebellum,) and the
entire ganglionic system, consist in a general way of four kinds of nervous elements ;
the cellules 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 c^rebro-
^inal system. The difierent cells are the roots of the nerves of the skme nature as
theoisdves. 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 ^reat
sympathetic have their roots in the ganglion cells. Large multipolar celb are accumu-
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 comua and gray matter of the medulla spinalis, but
not io 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 Jacnbowitsch has called sympathetic, are larger than the sensitive cells, have
fewer branches, and are distinguished by a greater roundness of shape. The bjpohir 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
centra] 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
eonsiders them as the origin of the sympathetic roots which run from the spinal
marrow to the main trunk of the sympathetic.
According to Professor Jacnbowitsch, the axis cylinders proceeding from the multi-
polar cells form the nerves of motion ; and it is for this reason that they are cabled cells
of motion ; the axis cylinders of the fusiform cells, form the nerves of sensation, and
these cells are termed the cells of sensation ] the axis cylinders of the bipolar celk,
are in relation with the great sympathetic, and the cells are termed ganglionary
cells.
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
commissure, or rather this commissure is formed by the intercoming in every 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.
(6.) The cells of sensation communicate from one side to the other, by the posterior
u
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1S6 Observations on the Natural History of Traumatic Tetanus.
commissure, or rather they constitute that commissure ; but they remaio parallel to emdi
other and do not intercross. Those of the same side communicate directly. ^
(c.) The axis-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 tbc
other species. Communications also take place between those of the same side.
((/.) Communications moreover take place between the different varieties of cells ;
btU Jacubowitsch has only met with them in the cerebellum ^nd in the corpora ouadri-
gemina, in which the three varieties of cells occur. The diffefent species of cells are
not equally abundant in all the regions of the medulla sjpipalis, Thus in the cerrical
and. lumbar regions, the cells of motion predominate, while \n the ^orsal region those of
sensation arc not numerous. The medulla oblongata, according to the riews of Jaeabo-
witsch) is purely and simply a prolongation of the medulla spinalis; a proloae^ion
entirely fojmed of cells of sensation, containing in their centre, a nucleus of gan^iooic
The cerebellum, according to this observer, is formed of four eltments, vis : Fint, of
the elements constituting the white substance, and which are prolongations, by means
of the peduncles of tbc pyramidal bodies which furnish tho elements of the cells of
motion, of the restiform bodies, which furnish the elements of sensation, and of the
ganglionary element, which enters with each of tho other two. Second. Besides these
three elements, the periphery, or coritical substance of the cerebellum, is formed of
characteristic pyriform cells peculiar to this organ. From these pyri&rm cells pro-
longations, are sent to the surface of the organ, forming a Uyer, termed by Jacubo-
witsch, Conche en baguettes.
The corpora qmidrigemina, formed by the proloncations of the pedundes of the
cerebellum, bv the restiform bodies and by the horse-shoe-shaped commissure, contain
the three vaneties of cells, which they derive from their various origins. But this is
the last point where these three varieties are found together, Above this, in the
hemispheres, as already stated, the cells of sensation, of which the corpus callosum
forms the commissure, are alone met with.
With the exception of the optic, the olfactory, the auditory, the vagus, glosso-pharyn-
geal, and the hypoglossal nerves, which only consist of cells of sensation and ganglionic
cells, 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 from these facts : /
1st. Tho three entirely distinct functions of the nervous system, motility, seosi*
bility and organic action, are not only exercised by the different orders of nerves, but
morever, these orders of nerves take their origin in different central anatomical de«
ments. ' ^
2d. The meduUa spinalis, whence arise the general nerves, contains equally and
naturally the three orders of elements, but the brain, the qrgan of the intellect, contains
but the elements of sensibility, (which abound according to the intelligence of the
animal), and the nerve of tho 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*
ipation can detect no material lesion, such lesion may, nevertheless be considerable,
rince one or more of these orders of elements may become greatly altered in their
form, or even ucdergo 'destruction. (Moniteur des H<5pitaux, !5ept. 8, 1857. Am.
Jour. Med. Sci., N. S., 1858 ; Vol. 35, p. 237.
The preceding results of the investigations of M. Jacubowitsch, if ftilly confirmed hy
competent observers, will not only explain the mode in which irritation of structures,
as the mucus 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-
pears to be charaoteristic of the disease in the traumatic form, in all climates mid ages^
vis : That the iutelUat. is uuaffeqted in Traumatic TetauujSs
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tfbservatiohi oh the Natural History of fraumatie Tetanus. IS?
fiy the light of theso physiological and anatomical investigatioDB. we are led to inier,
that io TnuiDAtic TetaDua, the motor and ganglionic cells are chiefly, if not entirely
iDTolved ; and the fortner to a greater extent than the latter.
The intimate relations of the two great systems of nerves, is still farther shown \>j
the fiict that the pneumogftstrio nerve, which aids in forming three of the sympathetic
plexuses, the pharyngeal, cardiac, and solar, gradually predominates over and supplies
the place of the sympathetic in the lower animals, and this gradual substitution of the
former for the latter goes on in the descending sevies, until in the Cephaldpodous
mollasks the sympathetic almost entirely disappears, and the pneumogastric occupies its
pkoe and performs its office.
The intimate mingling of the elements of the two systems would seem to indicate
that the difference in the functions of individual nerves cannot be referred so much to
differences of structure, as to the peculiarities of the structures with which they are oon-
aected ; that is, the functions of the ganglionic central organs, and the nature, struc-
tare and fbnctions of the organ in which the nerves terminate, as well as the arrange-
ment of the periphery or distal apparatus of the nerves afford the ground for the deter-
miaation of their 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 cab-
Dot therefore be codsidered as an isolated self-acting system in a highly organized
animal ; 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 constant renewal of its force.
By these anatomical and physiological principles we are enabled to understand, not only
the mode in which a nervous influence may be transmitted from the cerebro-spinal system
to the sympatheUc, and through it to the unstriped muscular fibre of the alimentaty
canal, thus causing obstinate constipation, by the arrest of peristaltic action, but also
the mode in which tetanic spasms may be induced by the irritation of undig^ted mat-
tere, and by the presence of worms in the alimentary canal. When tetanic spasms aiffe
iodnced by irritating matters' in the alimentary canal, the irritation extends from the
macQs surlhce of the alimentary canal, to the surrounding net-work of nerves in the
sttb-mucos layer, and ftom 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
we sent out to the motor nerves and muscles.
These changes without doubt take place slowly in iuany cases, and hence it is not
necessary to assume, as some have done, that the obstinate constipation of Traumatic
Tetanus stands in the Irelation of a cause to the spasms.
We are also led to this practical conclusion : That whilst, in the treatment of Trau-
matic Tetanus, we should hope to derive some benefit from the free evacuation of the
bowels, at the same time, when the disease is dependent upon an injury of the nerves^
the constipation is dependent upon the excited state of the spinal ganglia, and doc^ not
flUod in the relation of k cause in the production of the disease, jind will be soonest
ofereome by those remedies which have a direct effect in controlling the exalted aotton
of the ganglionic celk of the spinal axis.
We will dose this portion of the inquiry with a single observation, — in those dis-
eases, as Typhoid Fever^ where there b great loss of excitability and power in the ccrebh)-
apinaJ and sympathetic nervous systems, we find a reverse condition to that which exists
in Tetanus ; instead of ati exaltation of the reflex actions of the cord attended with
obstinate constipation, there is general insensibility to impressions, mental dullnesis,
depression of nervous and muscuhr power, and la3S of tone in the unstriped muscular
fibres, and tympapites, and profiisc diarrhcea.
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188 Observations on the Natural History of Traumatic Tetanus,
CHANGES OF THE URINE DURING THE VARIOUS STAGES OF TRAUMATIC TCTANUS.
The changes in the amount and character of the urine were important, in fumishiog
data for the establishment of the relations 'of the disease to fever and inflammatioo.
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 for July 13th and 14th, grains,
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 spasms,
and consequent increased ability to take solid and fluid food, the watery element of the
urine increased greatly ; thus, the following amounts of water were excreted daring
oonvalescdnoe : Average amount of water excreted each day, July 22d and 23d, grains,
15,D35 ; 24th, grs., 15,028; average amount July 25th and 26th, grs., 16,204; aver-
age amount July 27th and 28th, grs., 19,245 ; July 31st, grs., 27,190.
This isoncentration of the urine during the active stages of the tetanic spasms, ap-
peared to have been due 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 eause
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 bj the
kidneys.
We have thus dwelt upon the concentration of the urine in Tetanus, beoaude this |Ae-
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 elemeot
of the urine, in Intermittent, Remittent, Pernicious, Yellow and Typhoid Fevers, in
Small Pox, Pyaemia and Hospitaf Gangrene, in Pneumonia and Pleuritis.
It is evident that the cause of the diminution of the watery element of the urine io
Traumatic Tetanus is dependent upon well defined causes, which will not aoooont for a
similar diminution in fevers and inflammation.
(6). Urea. The urea was increased during the active staget of the disease.
In determining the truth of this proposition, it should be borne in mind, that doria^
the severe spasms, the patient was able to take only fluid nourishment, and that in Bmcb
smaller quantities than in health : in fact the patient was in a state of partial starvatioB.
The following amounts of urea, were excreted during the active stages, in 24 hours :
Julv 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 ; 16lh,
grains 546.
The average amount of urea, excreted daily, from July 8th to July 16th, induaive,
(9 davs,) was grains 413.39 ; whilst the average amount of urea excreted daily daring
convuescence from July 17th to July 31st, (13 days), was only grains 342.46, noiwith-
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 oessatioB
of the severe spasms the urea sank to a low figure, and continued thus for several 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 doriag
twenty-four hours, by adult men, vary within wide limits ; but the variations ipay,
however, be reconciled by referring them to the differences of methods of analysis, and
to the different circumstances and conditions of rest, exercise and food.
Becquerel'*' estimated the amount of urea excreted by h^thy adults at from 225
* Becquerers and Rodier's Pathological Chemistry.
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Observations on the Natural Bistory of Traunudic Tetanus. 189
to 270 giBiDB in twenty-four honrs^ Golding Bird"*" places the average amount excreted
bj healUiy men during twenty-four hoilrs, at 270 grains. The following are the results
deduced by M. Lecanu from a series of 120 analyses :
Maxlmqm Mmd Minlmom
Oittins. OnUiift. Grain*.
Adolt Men 610.36 433.13 357.5
Adolt Women 437.15 295.15 153.3
OW Men (84 to 86 years) 293.16 125,23 61.0
Children of Eigh^ Yeart...-^ 264.20 207.99 161.7
Childrenof Four Years.,.' 81.83 69.65 75.2
Aeeording to Ijehmann^f a healthy man excretes during twenty-four hours, from 340
U> 600 grains of urea. This physiologist obtained the following results from experi-
ments upon himself:
Urea Bteretii i« Twenty-four Jlow».
Mixed Diet ^ ^^.Qralni, 501.76
Aaimal Diet 821.37
Vtgetable Diet ^ ^ 347.10
NoB-Kilrogenoos Diet. ...^.. .v. 337.90
In the first set of experiments Prof. Lehmann adoptied an ordinary mixed diet, and
took no more solid or liquid aliment than was needed to appease hunger and thirst, and
abrtained from fermented drinks. Every two hours he took exercise in the open air^
but aroided immoderute exertion of every kind ; the result given upon the first line repre-
sents the average amount of urea passed, under these circumstances, for fifteen days.
In the soooud set of experiments, Jrrofessor Lehmann lived for twelve days on an ex-
dusively animal diet, which, during the last six, consisted solely of eggs; he took
(hiity-two eggs daily ; which contained 2929 grains of dried albumen, and 2431 grains
of fi^y matter, or about 3532 grains of carbon, and 465.5 grains of nitrogen. From the
taUe it in seen that the urea increased from 501.76 grains to 821.37 grains, and con-
tained more than five-sixths of the whole amount of nitrogen ingaited. In the third
set, the experimenter lived upon a vegetable diet, and during this period the average
dafly amount of urea fell to 347.10 grains. In the fourth set, the diet consisted en-
tii^ of pnre farinaceous and t>leagenous substances, so that the asotised matter of the
urine (orea) must have been solely the result of the disintegration of the tissues ; and
it is seen to have undergone a rapid and marked diminution, for this diet was used only
two days ; the health of Professor Lehmann was so seriously afieoted, that be waa
ttnaUe to continue this die^ longer.
Dr. John G. Draper found the average quantity of urea excreted during twenty-four
boars to be 408 grains. Bischoff * places the average for adult men at 540 grains.
The average daily amount of urea excreted by adult males, between twenty and
forty years of age, has been given at the following figures by the difierent observers :
Ptates,* 371.5 grains; Benke,' 378.2 ; 8cherer,Ml 6.8-460.4 ; Moos,M44.6; Booker,
444.9; Sehneller,* 458.2; Neubauer,^ 511.2; Kaupp, 535.1 ; J. Vogel,* 540.0; V.
* Urinary Deposits ; Joarnal De Pbarmacie, 1839, t. xxv, p. 681.
I Pbysiological Gbemistrj, (Cavendish Soc. Ed.) Vol. ii, pp. 450-452.
1 Hamstoffals Mais der Stoffwecbsels, 1853.
3 Compoiition of Urine.
3 Die WeikoDf des Nord— See Bades, 1855, p. 30.
4 Wnrabarg Verbandlaogen, Band iii, p. 184.
6 Henle's Zeitt, fflr rat.iMed., Band vii, p. 291,
6 Talentin's Beport on Pfajs. CansUtts Jabresb, fur 1855, p, ]08,
1 Arcbiv. des Vereini Air WIss. Heilk, Band iU, p. 03.
8 Neabaoer's Anleituog, 2d Ed 1855.
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190 Observations on the Natural History of Traumatic Tetanus.
Franque; 541.3; Beigel, 551.0; Mosler/^ 658.9; Kummel," 563.6-605.2; Keroer,"
588.2; Ranke," 656.0; Hammond," 670.6; Gentle, 512.4; Warnecke," 520;
Haughton,** 575.8 grains. Dr. Edmond A. Parkes," in his work on " The Com-
position of the Urine in Health and Disease, and under the Action oj Remedies^^
gives as 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 genenilly drawe fropa
more than six, and oflen ten to twenty days), at 5L2.4 grains during tweoty-foor
hours. Dr. Thudichum.in his work on the Fatlwlogtf of tlie ^i us, affirms that naneroiis
experiments have shown that a healthy man, who lives well, IKseharg^ from 30 to 40
grammes (463 to 617 grains) of urea in twenty-four hotirs. The discropancies in these
results are referable chiefly to differences of chemical processes, and in the diet and
modes of living of the subjects of the experiments. Thus, the process employed bj
Becquerel (the separation of the urea as a nitrate, yields lower results than the Toin-
metric method of Licbeg), which was employed by most of the observers, whose resnhs
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 First Case of Traumatic TBtaHVB, lo
addition to this, the subjects of Becquerers experiments were Frenchmen, who, ftom.
their size and diet, appear to yield a less amount of urea than Englislimen^ and pooba*
bly also than Germans. Professor Lehmann, according to his statement of the aoKMnt
of food consumed during his investigations, evidently excreted more urea than nsnal ;
and the average founded upon his experiments would bo somewhat higher than the
average with Americans. If wc adopt the standard of Dr. Thudichum, which is JUl
high for Americans, and too high for Confederate soldiers during the American ctTil war,
1861-1865. when they were compelled to dispense with all the luxuries and super-
fluids of diet, it is evident that notwithstanding the state of almost absolute starvation
to which this patient wus subjected during the active stages of Tetanus, the iirea, so &r
from being diminished, maintained very nearly' the standard of healthy meii acdvelj
employed and supplied with full diet.
If we compare the amounts of urine, excrete4 during the same paroxysms, with the
ain6unts excreted by Prof. L3hmann, in a vegetable diet (347 grains) and on a non-
nitrogenous diet, (232 grains,) it is evident that it was greatly increased.
In the experiments of Dr. Williain Hammond, we have still more valuable data fbr
determining definitely the increase or decrease of the ureia. At the time that these
experiments on the tautritive value and physiological effects of albumen, starch and gattk
were performed. Dr. Hammond was 28 i years of age, 6 feet 2 inches in height ; 38}
inches around the most prominent parts of the chest ; weight ranging from 215 to 230
pounds; temperament sanguine-nervous; habits temperate, usin^ ndther aloohoGc
liquors nor tobacco. As to his exercise. Dr. Hammond states: "l^rose from bed at
6i A. M., and retired at 10} p. M. : eight hours of the twenty -four were aoeordin^j
passed in inactivity, the remaining sixteen was apportioned ih the following manner :
eight were Occupied in conducting the necessary analyses, and in other wwk in the
laboratoiy ; four were given to chemical and philosophical studies ; and four were ti^en
up with this duties of his profession, physical exercises, recreation, etc. The exerds^
was quite limited, consisting of walking about one thousand yards per day.*'*
9 Scherer'8 Report on Pliys. Clieni., Canstatt,s Jahresb, 1855, p. 206.
10 Arcbiv des Vereins, Bund iii, p. 431.
1 1 Wurzburg, Verhandlungcn, Bund v.
12 Archiv des Vereins, Band iii, p. 027.
13 Composition of Ihe Urine, by Parkes; London, 18C0, p. 8.
14 American Journal Medical Sciences, April, 1859.
15 Dublin Medical Press, July, 1859.
16 Dublin Journal, Aug., 1859.
17 Composition of tJrine, pp. 7, 8.
* Experimental Researches relative to the value and Physiological Effecti of Albuaea,
Starch and Gum, when singly and exclusively used as food, etc. By William A. Ha
M. D., etc. Trans. Am. Med. Ass. 1857.
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Observations on the Natural History of Traumatic Tetanus. 191
Upon a diet exelusively of starch, amount of urea excreted 1st day, grains 421 ; 2d
day, 369 r^^ 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 dilys 215
grains.
Vfoa a diet exclusively of gum, amount of urea excreted Ist day, prrains 330 ; 2d
301 ; 3d 282 ; 4th 275 ; riving a daily mean of 279 grains.
The effectlB of this insufficient diet upon the excretion of urine, in this observer, is
{ihced in a clear light, when compared with the results of the examination of his urine
in liefiKh, tinder ordinary diet, and under a diet exclusively of albumen. Upon a full,
g^w6s diet, the average daily amount of urea, excreted by Dr. Hammond, was 694
gnuns ; 'and upon a diet exclusively of albumen 715 grains. Dr. JIammond upon a
previous oocasion determined the amount of urea excreted during exercise and rest ;
during mbderate exercise 682 grains of urea were excreted during 24 hours ; increased
exercise 664 grains; and during no exercise or rest, 487 grains.
If now we consider that Dr. Hammond weighed from 70 to St pounds more than
Uiis patrent, and fturther, that during the active stages of the disease the patient suffer-
VM wHh Tetanus (Case No. 1) did not consume as much food as Dr. Hammond did,
wnen upon the starch diet : and still farther, that during his experiments. Dr. Ham-
Bumdwas actively exerting his muscular and nervous energies, whilst the Tetanic patient
W8A at rest, as &r as his voluntary motions were concerned ; we must come to the con-
dorioD, 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 star\'ation,
withomt 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
area duninished in amount, notwithstanding that large amounts of food were consumed.
The rapid diminution of the urea below the standard of health, ailer the disappear-
ance of the spasms, appeared to be due, chiefly to the cessation of the muscular and
nervous actions ; or rather to that chemical change of matter by which the muficiilar
and nervous forces are generated. After 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, although food was liberally supplied, it was moi^t 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 forces ; and as the forces during
this period were feeble, so also the changes necessary to the generation of the forces,
were conrespondingly feeble, and the amount of matter altered correspondingly small.
It 'should be carefully noted, however, that the urea was not increased during the
acdye "stages of the violent Tetanic spasms, to that extent which is common in Fevers,
and acute 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 1236 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
Increased ; and in those cases in which the lesions of the kidney are so great as to lead
to the suppression of the urinaiy excretion, the urea is in like manner formed in large
amount, and accumulates in the blood, and induces symptoms of uremic poisoning.
Whilst, then, in the case of Traumatic Tetanus, (No. 1), the urea was increased
above the standard of starvation, it was not increased to that extent which is common
in fevers and inflammations.
This fact sustains f\illy the conclusion previously announced, that uncomplicated
Tetanus should be classed neither with the Pyrexiae nor with the Phlegmasiac.
(c.) Vrtc Add: The uric acid was diminbhed during the active stages, and was
increased during convaloBeence^
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192 Observations on the Natural History of Traumatic Tetanus.
This constit^tent of the urine, therefore, presented the reverse change to that of the
urea. This result corresponds to that obtained by some physiologists daring active ex-
ercise of the muscles, ana during rest. Thus, Dr. Hammond found, that whilst during
active exercise, only 8.7 grains of uric acid were excreted during twenty-four hoiini,
during moderate exercise, 13.7 grains, and during perfect rest, 24.8 grains were exereled
during a similar length of time. Lehmann and other observers have obtained sioMlar
results. The change from partial starvation to full diet, during convalescence, without
doubt, as has been conclusively shown by the experiments of I^hmann, Hammond and
others, caused an increase in the amount of uric acid : it appears, however, that the
state of rest, after the paroxysms, had as much to do with the increase of the uric aetd,
as the increase of food. If the rektions supposed to exbt between uric acid and urea
in their origin in the animal economy, be assumed as establbhed, it might have been
inferred that the reverse condition should have been manifested, tliat is, thai Uie dis-.
turbanoe of respiration during the paroxysms, should have caused toe increase ijf the
uric aeid ; it should be remarked, however, that the disturbances of re^iration dnrii^
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 powerful
spasms, sufficient oxygen was received into the lungs.
(rf). Free Acid, If we receive as true the statements of Vogel, tjhat the firee acid,
during health, may range from 30 to 61 grains during the twenty-four hoars, it is
evident that in this case, if due allowanoe be made for the effects of the hot weather,
and for the fact that the determination of the free acid was frequently neeoonarily
delayed for hours after the urine had been voided, it is evident that no roecial diange
in the amount of this constitutent can be discovered. And even if Bnea change 1^
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 reaetaon ol*
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 0U|^)osition is oerUunly correct in some diaeases, as malarial fever, in aomc
stages of which phosphoric acid almost entirely disappears ; whilst the urine still pre>
serves a strong acid reaction.
The rapid disappearance of the free acid in the urine of convalescence, a few boon
after it was voided, was by no means an index of an absolute diminution in its qoanti^,
but was rather^he result of th^ rapid changes of the urine. Induced by the hot weather^
and of those changes in this excretion which were dependent upon a fM diet The
increased susoeptibUity to change in the urine in convalescence, may also arise from the
more unstaUe. constitution of the urinary excretion, during that state of the synten,
whicb is characterized by a return of appetite, an arrest of the waste of tissue, and the
formation of new, living or organized matter.
(e). PkoipJioric Acid, The phosphoric acid was^lncreaaed during the active stages
of the disease, and gradually diminished in amount after the cessation of the qpasms.
The increase of phosphoric acid was coincident with the spasms ; the decrease was
coincident with the cessation of the spasms.
After the relaxation of the jaws, and the return of the appetite, the amount of phos-
phoric acid excreted by the kidneys greatly increased. Thus, during the active stages of the
disease, the following amounts of phosphoric acid were daily excreted : July 8th, gn.,
16.32 ; July 9th, grs., 39.96 ; 10th, grs., 45.76 ; 11th, grs., 16.94 ; 12th, grs., 12.87 ;
average amount for Julv 13th and 14th, grs., 39.01 ; 15th, grs.) 37 ; 16th, 16^ gn.;
thus giving an average during the nine days, when the spasms were in greatest intensify,
of grains 28.03.
During convalescence, on the other hand, the following amounts of pho^ric acid
were daily excreted: July 17th, grs., 5.67 ; 18th, grs., 12.64; 19th, grs., 20 Ji9;
average July 20th and 2l8t, grs., 20.78 ; average July 22d and 23d, grs., 21.26 July
24th, grs., 17.79 ; average July 25th and 26th, grs., 13.98 ; average Julv 27th and
28th, grs. 28.76 j July 3l8tj grs.^ 15*98 ; average for these 13 days, grs., 18.63-
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Observations on the Natural History of Traumatic Tetanus. 193
In settling definitely, whether the phosphoric acid was increased or diminished daring
Uie different stages of Uie disease, it is necessary to establish the amount of phosphoric
add which is excreted under similar circumstances of rest and starvation. By these
data we wUl be able, not merely to determine whether the phosphoric acid was actually
increased 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
diaease.
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
first individual, grains, 47.86 ; in the second individual, grains, 24.70 ; average for
twenty-four hours, grains 36.28 ; Hosier, first series, 37.05 ; second series in the same
individual, grains, 57.12 ; average grains, 45 ; Dunblkenburg, grains, 32.94 ; Kau{^,
35.46 ; Bencke, 39.21 ; Ranke, 41.53 ; Aubert, grains, 43.23.
The meap of twenty-five sets of observations collected by Dr. Parkes, was 48.8
grains 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
geiierouslv, 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 drimk
thirty-two ounoes of wateh ^o other food, solid or fluid, was taken into the system.''
Under ordinary exercise and intellectual work the average daily amount of phosphoric
acid excreted during ten consecutive days was, grains, 43.66 ; during a simUar period,
under increased mental exertion, grains, 66.15; under diminished mental activity,
grains, 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 indicate, 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-
dnsioDS, however, can only be drawn from a comparison instituted upon results obtained
widi individuals similarly situated.
Abstinence 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 large portion of this acid
excreted by the kidneys, is derived from the portions of food which accomplish their
offices without entering into the actual composition of the various structures, still the
porUon, which varies according to definite laws, is derived from the changes of those
structures, 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 &ots for
comparison, are still more striking than those just referred to, and enable us to set-
Ue definitely the question of the increased production and excretion of phosphoric acid
in Traumatic 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 increased in frequency, and upon the ninth day a
serious diarrhoea, with thin, dark brown discharges commenced, and was attended with
loss of appetite and disturbed rest ; and upon the 10th day the diarrhoea continued with
increased 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 add were excreted daily: First day, grs., 36.17 ; second, 34.17 ; third,
25
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194 Observations on the Natural History of Traumatie Tetanus.
48.21; fourth, 22.29 ; fifth, 17.25; sixth, 18.45; seveoth, 13.17; eighth, 11.08;
ninth, 10.52 ; tenth, grs., 9.15 ; average amount of phosphorie acid excreted daUy
during the ten days' subsistance 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 bowrfs, 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.M :
seventh, 5.70 ; ei^th, 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 waa tlie
article used, and nothing farther than distilled water, or rain water, was taken. Tke
injurious effects arising from this article of diet were far more rapid and obvious tliaii
those previously recorded ; hunger, pains in the bowels, face, and ^re»t debiUtj induced
Dr. Hammond to discontinue the experiments upon the fourth day. Amount of phoe-
phoric acid excreted during the experiment upon .gum : First day, grains, 24.14 ;
second, 13.35 ; third, 7.09 ; fourth, 4.55 ; average amount of phosphoric acid for fimr
days, grains, 12.28.
If It be borne in mind that Dr. Hammond weighed over 225 pounds, and at leasl
one-third more than the patient (case 1st) suffering with Traumatic Tetanua, 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 laiger snpplieB
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 Traumatie
Tetanus, must be referred to the increased nervous and muscultgr actions.
( f\ Sufyhuric Acid, The sulphuric acid, in like manner with the phosphorie
acid, Dut in a less degree, was increased during the active stages of the disease.
The following amounts of sulphuric acid were excreted daily during the ae^e stages :
JiUy 8th, grains, 11.28; July 9th, 21.24 ; 11th, 15.56; 12thi 9.57 ; 13Ui and 14th,
daily average, 33.73 ; 15th, 38.34; 16th, 77.67. A portion of this sulphurio acid,
especially in the highest figures, was, without doubt, derived fVom the sulphate of
ma^esia, adminstered as a purgative ; the sulphate of quinia, dailv administerod, nuiy,
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 sulphmrie
acid of the sulphate of magnesia, and if we accept the results of the observations of
CUre, Oruner, Neubauer, Parkes and others, and place the daily amount of sulphurio
add excreted by healthy men, at between twenty and thirty-eight 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 fiurther consideration of the amounts of this constituent of the urine excreted
during circumstances similar to those in which this patient was placed.
The experiments of Lehmann, Vogel, Clare and othere have shown that the charac-
ter and amount of the food influences the amount of sulphuric acid dischaiged bj tlie
kidneys ; animal food increasing, and vegeteble food diminishing the amount of sul-
phuric acid.
The experiments of Dr. Hammond furnish 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, 23.65 ; third, 29.18 ; fourth, 21.18; fifth, 15.12 ;
rixth, 12.18; seventh, 10.73 ; eighth, 11.24; ninth, 8.96; tenth, 8.36 ; average ^
ten daySj on albumen diet, grains 16.92.
Upon starch diet, first day, grains, 30.45 ; second, 19.68 ; third, 12.07 , fbuHli,
10.56; fifth, 6.70; sixth, 4.12; seventh, 3.81 ; eighth, 3.09; ninth, 2.60; tenth.
2.26 ; average for ten days on starch diet, grains, 11.12.
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Observations on the Natural History of Traumatic Tetanus. 195
The comjMuriaon of these results demonstrates conclusively that the sulphuric acid
tcvu mereated during the active stages of Tetanus.
Recent investigations have not confirmed in all respects, the observations of Ber-
leliuB and others, with reference to the presence of sulphuric acid and sulphates
in any considerable amounts in the juices of flesh ; and they point to the kid-
D^ and blood as the positions where these chemical changes are completed, in the
fiflial conversion of the sulphur of the albuminous compounds, into sulphurio 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 nitiH^genous tissues which contain sulphur. It is reasonable to suppose
that the increased amount of the sulphuric acid eliminated during the active stages of
this ease of Tetanus, was due to the more rapid chemical changes during the severe
i^Msms.
(^). Chhrine — Cldoride of Sodium. The chlorine was diminished during theaodve
stages, but gradually increased, and finally attained the usual standard during eonva-
ksoBnoe.
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
daj, 38.83 ; 15th, 16.53. A portion of the chlorine, and perhaps a greater part of it,
may baye been derived from the chloroform administered mtemally. This statement,
howeyer, would admit of extensive discussion, and perhaps the ultimate facts as to the
amount «id character of the transformation of chloroform in the living body are
wanting.
Danng eonvalesoence, the following amounts of chlorine were excreted: July 17th,
miBS, 5.25 ; 18th, 23.17 ; 19th, 37.82 ; average daily amount during July 20th and
2l8t, 42.42 ; average 22d and 23d, 68.70 ; 24th, 107.79 ; average July 25th and 26th,
64.03; 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 circum-
stances, as the character and quality of the food, aside altogether from the effects of
disease. We must, in setUing this question, determine the effects of circumstances
simihir to those in which this patient was placed, upon the excretion of chlorine in the
wine of healthy men.
Hegar, from a series of accurate observations upon eight young gentlemen, students
St the University of Gteissen, found the average daily amount of chlorine disdiarged in
the urine to be 161.96 grains.
Aoeording to Parkes, the daily amount of chlorine dischai^ed by healthy men,
ruig» from 51.87 to 58.05 grs. J. Yogel gives 92.06 grs. as the daily average ; and
Boekhdm, 105.6; Mosler, 108.23; Bischoff. 134.32; Neubauer, 136.87 ; WUde,
145.60; Hammond, 154.80; Kaupp, 155.94: Kemer, 156.71; Bencke, 162.12;
Genth, 173.23 ; mean of the results obtained by these observers, grains, 126.76. If
the whole of this chlorine were united to sodium, it would make nearly 210 grains of
cbk>ride of sodium ; an amount which Dr. Parkes considers as too large ; and this dis-
tinguished observer believes that it is safe, with Vogel, to put the amount of chlorine
tt 7 grammes, which would give nearly Hi grammes, or 177 grains of chloride of
aodium in twenty-four hours.
K 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, Thudiohum, and others, have shown that in Pneumonia, and in fact in
acute febrile diseases, generally, the amount of chlorine discharged in the urine, rapidly
deereaaes, and even dioippears entirely for a short time, and then as the diseased action
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196 Observations on the Natural History of Traumatic Tetanus.
abates, the amount increases during convalescence. Viewed in this connection, tliis
fact would seem to oppose the view, previously recorded, and to indicate that there wis
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 wis
placed by the disease, and the consequent absence or diminution of chlorides in the
food. It is now well established that the chlorine dischai^ed by the urine, is almost
entirdy derived from the chlorides (chiefly Chloride of Sodium,) of the food, and
consequently diflfers in amonnt in different individuals, and varies in the same individ-
ual in acooidance 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 m^ij
almost entirely disappear. Thus, Dr. Hammond, upon a diet of Albumen, excreted
the following amounts of chlorine during twenty-four hours : First day, grains, 30 J^ ;
second, 21.54 ; third, 10.45; fourth, 5.37 ; fifth, 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, grains 8.86 : upon an exclusive diet of starch, with pure water for drink, as in
the previous 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 chlmne
in the urine, during the active stages of the Jirst case of Traumatic Tetanus, wis doe
to the limited amount of food, ana consequently, the limited amount of chlorides eon-
sumed by the patient, and not to any inflammatory condition, similar to Pn^unonia,
and the acute stages of certain febrile diseases, as Typhoid Fever and Small-Pox.
From this extended examination and comparison of the phenomepa maniftsted
during the progress of the first case of Traumatic Tetanus, for the condnnons invest-
igation of which we enjoyed unusual advantages, and to which a large amount ct time
was devoted, we draw the following general conclusions :
1st. The essential phenomena of inflammation were absent. The phenomena were
exaggerated manbfestations of nervous and muscular actions. An irritation in a dii-
Unt nervous branch was propagated to the spinal cord, and the disease, after its estab-
lishment, appeared to be dependent upon an exalted excitability 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 stru<^ure8, 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 exoq>tioB to
the law, that for the production of definite physical, and the so-caUed vital actions 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 TeCanns
were caused by a pre-existing change in the conditions and relations of the mnsoles, or
whether they were directly traceable to the transmission of the irritation ftom the
wound ; but will confine our attention to the examination of those fkcts which throw
light upon the physical phenomena of the nerves and muscles, during their Tioleat
manifestations in Tetanus.
We have discussed at length, in the Physiological introduction, the relations of the
muscular and nervous forces : and shown tb
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Observations on the Natural History of Traumatic Tetanus. 197
a. There is a dose anak)gy between the structure and mode of aotion of the elec-
trie organs of certain fish, and the nerves and muscles of living animals.
h. Animal life is not possible without constant chemical and physical changes in
the molecoleB of the body ; and since such disturbances are always accompanied with
the liberation of electricity, we infer that electrical currents exist in all living sl^ructures,
and thai the intensity of these electrical actions, varies with the amount and character
of the physical actions of the tissues.
«. Electrical currents circulate in all tis^es 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 OMMt sadden variations in intensity and direction in the nerves and muscles.
d. There exists, both in the musdes and in the nerves of all animals, a natural
deotrieity, which is manifested under the form of closed circuits, circulating along the
nraades, or nerves of the animal, and of which we can collect, but a very smidl derived
portion, by the assistance of our instruments ; and the preservation of this free electricity,
» sabordinate to the state of life of the animal, and disappears with the cessation of
the MHrmal chemical and physical changes characteristic of life.
e. An electro-physiological law of great interest, in the study of the phenomena of
TettOQS, has been established by DuBois Reymond, for the motor nerves, and may be
ezprased thi|s : the motor nerves are not excited by the absolute amount or density of
the eunrent, 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 current, the greater the physiological effects. It results from this, that unstable
conditions of the closed, muscular and nervous 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 dther exaltation or depression of muscular action.
/. Contractility is inherent in the muscles : and is not the result of a force commu-
nicated to the musdes by the nerves. The muscles do not derive their state of tone,
or power of contractility from the cerebro-spinal and sympathetic nervous systems, but
possess wiUiin themselves, all the conditions necessary for the generation of their
pn^)er force.
y. The muscular force results from the chemical changes involved in the healthy
nutrition of the muscles ; the chief influence of the nervous system, therefore, upon
the muscnlar system, is by the disturbances of the electrical condition, and by an influ-
enee upon the nutrition of the muscle, through the variations of the amount of blood
eirealating through the muscular structures.
A. If in the state of health, the molecules of the nerves and muscles are retained
in a particular arrangement, by the vital force, and if under the action of the will, or
other causes determining muscular contraction, or relaxation, this arrangement is modi-
fied, so as to become similar to the condition of a conductor transmitting an electric
carrent, it b probable that when derangement of the molecules is caused by almost
every cause, however slight, capable of dirturbing the electric equilibrium, and even
beyond all control of the will, and even so powerful in its effects, as to rend asunder
the muscular structures, there is either a want of proper action of the vital force, in pre-
serving the mutual and definite relations of the molecular forces, or an undue activity in
the molecular changes in the nerves and muscles. We have previously demonstrated,
that during the active stages of Traumatic Tetanus, there is an increased chemical
diange of the nerves and musdes ; we must condude therefore, Uiat the disease is due
not only to a disturbance in the electrical conditions and relations of the nerves and
nnscleB, but chiefly to a great augmentation of the intensity of the electrical actions in
both nerves and musdes. Thb view is further sustained by the fact, that the contrac-
tiona of the musdes in tetanus are far more violent and prolonged than those of health,
excited by any cause whatever, internal or external, by the will, or by mechanical
stimuli — so violent in fact, that the musdes are frequently ruptured, and that too,
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198 Observations on the Natural History of Traumatie Tetanus.
against no other points of actic/n, than the bony levers, and in no other action, than in
that of simple involuntary contractions ; and by the equally striking fiot, thiit a con-
tinuous current of electricity may, when passed in a certain direction, relieve the spasms
of Tetanus.
{, If it be true, that the nervous force is electricity, or a modification of eleotricity,
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, ^r reflected from the
circumference, may be propagated by changes of the molecules of the nerves, and
reproduce its 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 varioiis
organs, whether m.uscular or secretory, to whidi they are distributed, analogous to that
which takes place, at the terminals of the galvanic battery.
In Tetanus, where there is an exaltation of the acts of the ganglionic oelk of the
gray matter of the spinal axis, constant impulses are sent out to the volunt&ry musdes,
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 organs
to which this system is distributed, such as the kidney, liver, and alimenti^ cana] and
heart, are in turn affected.
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CHAPTER III.
OHKBTATIOKS OM THl PATHOLOGICAL ANATOMY OF TRAUMATIC TETANUS. COMPARISON OF
THE PATHOLOGICAL CHA1|G|» IN THIS DISEASE WITH THOSE OF INSANITY, EPILEPSY AMI)
PARALYSIS. GENERAL COI^OLVSIONS AS TO THE NATURE OF TETANUS AND ITS RELATIONS
TO CLIMATE AND CHANGES OF TEMPERATURE.
ObserTatioDS on the Pathological Anatotnj of Traumatic Tetanus. Comparison of the
Paihological changes in this disease, with those of Insanity, Epilepsy, and Paralysis. Gen-
eral conclusions as to the nature of Tetanus, and its relations to Climate and changes of
Tfmperature. Cases illustrating the Pathological Anatomy of Tetanus. Blood-vessels of
frniT matter of spinal cord congested and dilated. Discussion of the cause of the congestion
and dilatation. Analysis of the investigations of various anatomists and physiologists, upon
the effects of congestion of the blood-vessels of the spinal axis: more especially of S. Weir
Mitchell and Benjamin Ward Richardson. Analysis of the labors of various pathologists-
wiih reference to the lesions of Traumatic Tetanus, as Morgagni, Rokitansky, Larrey, Dupny
ircn. Pellitier, Hennen, Craigie, Curling, Copland, Parry, Travers, Sandwith, William Aitken,
Lockbart Clarke, Dickinson and others. Comparison of the lesions, characteristic of Trau-
matic Tetanus, with those of Insanity, Paraplegia, Hemaplegia and Epilepsv. Cases. Rela-
tions 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.
PATHOLOGICAL ANATOMY OP TRAUMATIC TETANUS.
In the preoeding chapter, I eadeavored carefully to investigate the pheDomepa pre-
sented by a typical case of Traumatic Tetanus, and to interpret the characteristic mani-
festations, by the light of Physiological and Pathological observations, experiments and
researches.
We desire in the next place, to determine, whether any pathological aUeratiom arc
reeogniiable ailer death from Traumatic Tetanus, which can be associated with the
abnormal manifestations during the progress of the disease.
In this inquiry we will endeavor to pursue the inductive method, first presentini^
our own observations, and then comparing them with the facts recorded by other patho!(>
gists.
Gate 21 : Traumatic Tetanus ; Life of the patient preserved temporarily hy Marshall
HaUs Ready Method; post'tnortem examination. Structural Alteration of Cord.
J. A. Rouk, Company K., 1st Alabama Cavalry, Hagan's Regiment ; private ; age, twenty-
one; black hair; fair complexion ; nervous temperament ; admitted in the Third Georgia Hos-
pital, Augusta, Ga., February 11, 1865. Was wounded February 2d, in a skirmish, qcar
Alendkle, S. C, by a ball from a Spencer rifle. The ball passed through the abdominal mus^
ties of 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
passed 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, he 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, and kept moist with a wet rag. Patient felt well during
h
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200 Pathological Anatomy qf Traumatic Tetanus.
that time, but when entering the hospitn], complained of cramps ( to use the patieni*s owi
expression ) in the wounded side and back.
On the 12th of February) Opisthotonos gradually commenced. From 10 a. m., one tea-
spoonful of Laudanum (Tincture of Opium) was administered every one and a half hovrs,
until 6 o'clock p. ic., (the whole quantity of Laudanum given up to this time was about one
wineglassful, which produced no perceptible effect.) No medicine given during 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-spoonful of Chloroform, and another of Landannmi administered
internally every three hours, until three doses were taken, when the trismus increased to sach
an extent as to prevent deglutition. The Chloroform appeared to diminish the volume of the
pulse. Respiration during the day, tolorably easy. The tongue, as far as eonld be teen,
natural. Condition of skin natural, sometimes moist. Bowels constipated. Urine natural
in color and quantity.
February 14th. Trismus and opisthotonos increased. Respiration more labored. InJectioB
of Turpentine and Castor Oil given with no effect. One tea-spoonful of Chloroform, Lauda-
num and Ether, mixed in equal quantities, were given by the mouth, every three honrt, with
no perceptible effect.
February 15th. Tetanic symptoms increased. Respiration more labored — no evacuation
of the bowels. An 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 difficult — 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. In 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 mntcles.
At length, however, these muscles also became involved, and respiration ceased entirely.
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 up for a
few minutes, when the patient gradually revived. The spasms of the respiratory mosdet alto
gradually relaxed, and after sometime, the patient commenced to breathe again nato rally.
At this time-two ounces of whisky with one tea-spoonful of Chloroform, were admiBittered
by enema. This was kept up with the addition of half a pint of beef-tea, every two hosrt natil
the evening; with the exception of the Chloroform, the supply in the hospital baring given
out.
Evening— patient more quiet — pulse 100 ; respiration more easy — conversed and swal-
lowed half a glass of water. Patient remained in this comfortable condition, alfeeted
with an occasional slight spasm. About 3 o'clock, a. m., he asked for water — a little was
given him, wl^ich brought on another slight spasm, during which he expired about ten min-
utes 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 viewing the Tetanic spasms of this patient, we were forcibly reminded of the
graphic description of Aretseos'*' the Cappadocian.
Sixteen Ceiitwries have not impaired the accuracy or force of this picture,
Autopty tix hourt after <lea^A.— Spare but muscular man ; rigor-mortis very strongly marked-
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 Bar-,
row, to the wound, were also carefully dissected and examined in situ. The entire mass of
flesh surrounding the wound, was then examined, and together with the spinal cord and its
nerves and muscular attachments were removed.
Condition qf the waund.-^Tht 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 stmctarct
without lacerating them.
When the tetanus first manifested itself, the discharge from the would is said to hav«
*Th6 Extant Wotki of Aretveus, pp. 247—249.
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Pathological Anatomy of Traumatic Tetanus. 201
graati/ diminiBhed, and almost entirely disappeared. Several days before death, however,
and ap to the close of life, the wound secreted small qnantities of pus. When the entire
tract was laid open, it was found to be granulating throughout its entire extent. The gran-
alatioDS were carefully examined with a magnifying glass. They were small and rather pale
The wound was dryer than usual, that is there was less discharge than in healthy wounds.
Under the microscope, the pus presented an unhealthy appearance. The corpuscles wen^
imall, few in number and imperfectly formed, and amorphous granules abounded.
The wounded surface was surrounded or underlaid by a thick fibrous wall, the result cf
iaflaminatory action.
In the track of the ball, numerous sharp filaments of wool, were found sticking into thc:
granulations, and passing in some cases, entirely through the fibrous wall, to the muscular
itmctares beneath.
yerv€9 tupplying the Seated parts, — These were dissected, and traced into the parts immediate
ly sarronnding the wound. These nerves presented no distinct evidence of congestion or
iDflammation.
Spinal Marrow. — The nerve leading from the diseased and wounded part, was the last dorsal.
This sent off a branch to the lumbar pUxus; 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
eqninae 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 varioli, to the termination of the spinal cord, and the gray matter
presented a pinkish, deep colored congeste4 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 :
1st. The restoration of the patient, after apparent i^eath, 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
moscles. If artificial respiration had been practiced the second time, it is probable tha^ the
patient would again have been restored. The narcotic effects of the Carbonic 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 this
terrible disease.
2d. The granulations and the pus of the wounded surface were imperfectly formed ; and it
it not unreasonable to suppose that the irritation of the injured nerves may have arisen in a
measure from these unhealthy products of inflammation. The particles of wool penetrating
the tissues, may also have been exciting causes of the peculiar nervous disturbances. It is
important that the most carefhl examination should be instituted of the wounded parts and
products of the consequent inflammatory action.
3d. The gray n^atter of the spinal cord, was decidedly congested with blood ; and the
coogestion was so great, as to render this portion of the cord of a decidedly reddish pink color.
Tetanic spasms were attended with great waste of the nervous and muscular elements, and
especially of the former, as I have shown by careful analysis of the urinary excretion in this
disease.
The gray cells of the spinal cord, and medulla oblongata, during the stages of action,
excitement and change, need an increased and sufficient supply of blood.
4th. 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 22 : Traumatic Tetanus ; death ; cei'ebro-spinal st/steni examined after death p
structural 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^
iffid tetanic symptoms manifested themselves.
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202 Pathologieal Anatomy of Traumatic Tetanus.
Entered the Charitj Hospital, New Orleans, March 19th, two weeks after the receptioo of
the injury, external wound healed. Locked jaw and tetanic spasms, body drawn towards the
left arm and side ; that which had been injured. Patient complained of pain in left arm,
shoulder and side.
The attending physician administered Opium and Bromide of Potassium, beef-tea and
brandy. One grain and a half of Opium and ten grains of the Bromide of Potassium every
three hours. The opium appeared to quiet the spasms, and the patient enjoyed some rest.
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 asphyxia. The preceding facts
• were furnished by the attending physician.
• Autopsy six hours after death. — The brain and entire spinal cord were removed from this stout
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 ereatly congested with blood ; the con-
gestion was 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
uniTersally 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
blbod-tessels of the fourth ventricle were not only greatly congested, but a small quantity
of blood was 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 carefiil examination presented nothing abnormal,
with the exception of the dark colored blood resulting from the sudden arrest of the process
of respiration.
The long on the leftside, was congested with dark blood and presented a marked difference
in this 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
eontraotion of the muscles upon this side, and the consequent interference with respiration ;
bnt it is also probable that the impairment of the function of the pneumogastric nerve on
this side, may have been one of the causes.
The seat 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.
Continuing the incision downwards, an abscess, with indurated walls, filled with about two
drachms of thick foetid bloody pus, or rather grumous fluid, apparently resulting from the
liquefaction or disintegration of the textures was revealed, occupying the upper sarface of
the biceps 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 minnte
dissection.
This case presents the following points of interest :
1st. The strychnine accomplished no good, and appeared rather to aggravate the symptoms.
2d. 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 life, ir
might have been possible to relieve the patient by laying it open, and exciting healthy
sapparation.
3d. The muscles were most affected upon the side to which the injured arm was attached*
The nerves 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
ttpon those muscles supplied with motor and sensitive nerves from the same lateral half of
the spinal cord.
4th. The nus, or rather fcetid fluid contained in the abscess differed widely from the pro-
duet of healthy inflammation, and the absorption of this matter, may have been one of the
exciting causes af the tetanic spasms.
Sth. The medulla oblongata, and spinal cord, exhibited palpable lesions, in the congestion
of the blood-vessels, and the softening of the white matter.
In both the preceding cases, the Wood-veesebs of the gray matter of the spinal cofd
were dili^ ai^d con^ted with blood. Th^t the congeetion. was not dependent npon
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Pathological Anatomy of Traumatic Tetanus. 203
cbimgeB induoed during the last hours of life, or subsequently to death, were clearly
shown ly the fact that the patients died suddenly before the powers were exhausted,
and also by comparative examinations of the cord ai^r death ^m other diseases.
Two questions immediately present themselves for discussion :
1st. What was the cause of the dilatation and congestion of the blood-vessels of the
spinal cord and medulla oblongata ?
2d. Did the dilatation 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 iuUer, and the tem-
perature is raised by the increased, quantity of blood which runs through: i^d that
when, on the other hand, the same branches are excited by an electric influence, 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 cut,
the small arteries become paralyzed and proportionally relaxed, whilst, on the otjier
hand, exciting the action of the sympathetic by galvanism, causes such a constriction 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 considered 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 influence supplied to the arte-
rial walls is cut off", the vesseb dilate, because the yellow tissue still exerts its elasticity,
while the muscular coat is paralyzed. By these means, the distribution of the blood,
which is sent out in an intermittent manner by the heart, is regulated by th& 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
Circulation, etc.. Journal de V 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
condition the contraction of unstriped muscular fibre is rarely spasmodic or in mass,
hut continuously alternate, wavy and vermicular, and they argued that the blood in the
auricles was most probably passed on by a movement similar to that which propels the
contents 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 paralyzed by
poisons, such as chloroform or alcohol, the temperature is found highest on the side
where the sympathetic has remained untouched; thus showing that the small arteries
possess a power over the circulation of the blood independent of that of the heart, and
that the action of the sympathetic is 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
Claude Bernard. It is thus rendered probable that the movements of the microscopic
arteries are consecutive upon reflex action ; that is, the impulse communicated to tho
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204 P&thologieal Anatomy of Traumatie Tetanus.
oolumn of blood by the h^art, progressively dilates the arterioles, the sensitiTe fibres of
the sympathetic distributed to their walls transmit the impression to the giuiglia, aod
the motor fibres acting on the contractile coat of the vessel, just as the digestive canal
progressively presses onwards the digestive fluids and materials. According to this
view, there is no necessary antagonism between the rythmical action of the heart and
the peristaltic motion of the microscopic arteries. By this theory, also, we are enabled
in a i^ner 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 agente, as well as morbid products and poisons, may act upon the nerves of
the blood-vessels, and by reflex action cause a diminution or augmentation of the dureot
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 are regulated by a distinct department of the
nervous system, external forces acting upon the nervous system may transmit thm
effects specially to these organs, and induce deranged secretion, nutrition and excretion,
and such derangem ents may in turn, act upon the nervous system. If the controlling
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
partial dilatation of the vessels has occurred from a slight d^ree of arrest of the peri-
staltic action of the unstriped muscular fibres, the powerful action (vi$ a tergo) of the
heart drives the blood more fully and freely than is natural into the small arteries and
capillaries, and active hypersemia is established, which may be temporary or perma-
nent, according 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 degi-cc of hyperasmia, from the sudden
and temporary 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, trans-
migration of colored and colorless corpuscles, and even rupture of the capillaries ; and,
oninie other hand, such a d^ree of spasm of the unstriped muscular fibre of the minute
arteries, as induces the diminution of temperature, and bloodlessness of the sor&ce in
the cold stage of fevers, and especially of Intermittent and Congestive Fevers. 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 i^stem 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
iff succeeded by the hot stage, which is attended by increased respiration, circulation,
chemical change and secretion. In malignant malarial fever, we may have fiital para-
lysb of the vessels of the brain, leading to coma, or of the liver, leading to destructive
Jaundice and alterations of the colored blood cofpuscles in the capillanes of the liver
and in the spleen, or of the kidney, leading to hsematuria, and complete arrest of the
urinary excretion. In a similar manner the suddenly fatal effects of »un-9tToke^ have
been referred mainly to paralysis of the blood-vessels of the brain and spinal oord,
induced by the effects of increased heat and the altered blood loaded with carbonic add
gas. In some cases of sun-itroke^ the temperature of the body attiuns an extraordinary
degree in a short period of time, ranging from 110 to 115^ F. Such a degree of heat
must necessarily prove fatal, from pandysis of the muscular fibres of the heart and
arteries, as well as from the necessary alterations of the blood and derangementa of the
cerebro-spinal and sympathetic nervous systems.
We are thus led by the researches of Legros and Onimus, to consider in a more
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Pathological Anatomy of Traumatic Tetanus, 205
fiiTorable light, the views of Stahl, Hoffman and CuUen, who perceived the importance
of the nervous system as a factor in disease.
We are therefore compelled in view of these facts, to regard the dilatation and oon-
geitton of the small arteries of the spinal cord and medulla oblongata in l^etanus, as of
great importance, and as indicating not only an increased functional activity (secretion)
in the oeniral ganglionic cells, but also, paralysis or arrest of the action of that portion
of the sympathetic nervous system, which presides over the circulation of the medulla
oblongata and spinal cord.
The second question, viz : Did the dilatation and congestion of the blood-vessels of
the spinal cord and medulla oblongata, bear any relation to the tetanic spasms ? now
presents 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
congestion upon the production of spasms and exalted reflex actions. I have repeated
the most important of these experiments, and obtained results similar to those announced
hj 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
ID a prolonged research on the cerebro-spinal fluid, and the influence of pressure in
producing convulsions. When the small end of a tube, twelve inches long, and two
millimetres wide, (open at both ends, and drawn to a point at one extremity, and
expanded fVinneMikc at the other), was introduced into a minute opening through the
membrane which fills the occipito-altoid space, previously exposed by an incision in the
middle line of living rabbits, and pressure was made upon the medulla oblongata and
spinal oord, by means of water poured into the upper end of the tube, held upright, it
was possible, in this manner, to pour through the tube into the spinal canal, at least
kail/ cut ounce o/jiuid.
At a certain point, usually when there was a pressure of ten inches in the tube, oon-
Tolsions ensued and checked the experiment. Experiments were instituted to deter-
mine the effects of water at different temperatures, and it was found that grefiter
pressure, 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
upon 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 fact,
exhibited every variety of convulsive action, in remarkable perfection. Thb effect
seemed to be due to the direct influence of cold on the medulla oblongata, sinoe like
elEBcts were produced when a morsel of ice was laid gently upon that organ, or when it
was 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 ftinctions
of the central ganglia by the use of cold ; and after numerous unsatisfactory experi-
ments with ice and ice in salt-bags, applied to the spines and brains of rabbits, Oumea-
pigs, and kittens, in 1863 and 1864, he finally made use of the valuable method of
causing local anaesthesia by cold, invented by Dr. B. W. Richardson, of London, and
obtain^ the following important results :
The method of research was much the same in each case : Richardson's atomizer was
neoessary when SDther was used, in general, however, Rhigoline was employed with the
aid of a cross jet of air ; in some instances, the atomized fluid was thrown upon the
skin, in others, upon the bony case of the nerve centres, and more rarely on the nerve
substance previously laid bare, or merely guarded by a thin patch of Caoutchouc ; the
animals 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
shivered 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,
began to move suddenly backwards, as if by its own will, and .before each motion of
thb kind, squatted close to the floor, and as he began to move, threw the tail up and
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206 Pathological Anatomy of Traumatic Tetanus.
the head down, and to one side in a spasmodic manner. In the intervals between the
backward motion^, the bird sought a corner, and sank into a stupid condition, or eke
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 appeared to be in
full possession of all its faculties. The backward movements, at length became vinble
only as sudden checks which overtook the pigeon now and then while wajking forwards.
The delay, before any noteworthy phenomena were seen, the sudden ons^ of a
strange form of convulsive movements, the state of partial stupor foDowing, and the
healthy appearance of the animal, in the interval, reminded Dr. Mitchell of the symptoms
of certain epileptic cases, and induced him to repeat the observations.
When the jet of rhigoline, was thrown lower down, so as to more exactly inflnenoe
the cerebellum, the results were similar, with the addition of rapid somersaultfi back-
wards.
With the exception of the temporary cessation of spasms, these experiments devd-
oped no new facts, in addition to those previously established by mechanically injuring
the cerebellum, but the following experiments opened a new field.
" A pigeon, whose cerebellum had been previously frozen nianj' times, was chilled oa both
sides of the neck during one minute^ by a double jet of rhigoline^ at the level of both cerrieal
vertebra, just above the junction of the neck to the body. M^ben 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-
saults, or an effort in this direction. At the second minute, the backward motioa begfan to
be seen, as the general spasms and the somersaults ceased. The stupors also appeared, aad
alternated with the running backward, until within an hour, the animal gradually recovered
its usual health."
After witnessing the remarkable result of the production of general convulsions and
backward spasms from injury to the spine, below the medulla oblongata. Dr. Mitehdl
repeated the experiment again and again upon a number of pigeons, with precisely the
same results, sometimes obtaining backward somersaults, and at others, only retrograde
movements, alternating with periods of stupor and intervals of apparently full control of
all the normal movements : he also endeavored to determine by a series of experiments
commencing at the cerebellum, the limits of the region, which being chilled, will, gire
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, resembling
those which have been previously produced by mechanical injury of the cerebellum ;
these abnormal actions are, in extreme cases, backward somersaults, follow;ed by spelb
of backward walking, and accompanied with spasmodic movements of the head ; in
milder cases only the backward walking occurs, (both of these forms of constraiaed
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 onlj
weakness, violent tetanic spasms of legs and tail, and tetanic rigidity in the 1^^, coming
on some time after the freezing, and reaching a maximum in ten minutes, are observed.
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 at
least doubtful. Two facts, or two sets of facts, led Dr. Mitchell to think it po^ible,
that it was in every case the cerebellum or the medulla oblongata which was the oigan
finally responsible for the production of the spasms of retn)grade motion. The first of
these facts is the well known and valuable discovery by Brown -Setjuard, that in Guinea-
pigs, mechanical injury of certain regions of the spinal cord, from the seventh dorsal
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
spasms began about the face, so that the spinal wound, (partial section), most have
produced an over-excitable condition of the ner^'e-centres above the point of injury. In
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Pathological Anatomy of Traumatic Tetanus. 207
Dr. Mitehell*s 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
causing an undue excitability of organs within the skull. The second set of facts which
made Dr. Mitchell hesitate in assigning to the point of the spine injured by the cold
the entire responsibility of producing the retrograde spasms, were the backward somer-
saults and violent movements, sometimes continuing for days after certain deep injuries
of the cerebellum, as observed by Magendie and other physiologists. The spasms
caused by cold applied to the spine, were also of this retrograde nature, and we are
therefore furnished, 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
chilling of the spine, I)r. Mitchell could not attribute the spasms from cold to the spine
alone, 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 ; for it is plain that this is a state of system in
which the cerebrum is affected, and for a time loses its functional activity. If, there-
fore, chilling tbe spine determines a marked cerebral disturbance, there is no reason
why we might not assume, with logical propriety that the cerebellum may be ultimately
TDsible for the backward spasms.
. Mitchell terminated his important inquiry by experiments designed to determine
the nature of the injury done to the spine or brain, by cold applied through the skin
or directly. It was seen throughout his experiments, which reached ninety in number,
that in tJmost every case an appreciable interval — and often a long one — existed be-
tween the close of the freezing and the access of the spasm. This period varied from a
few seconds to twelve minutes. If there was any primary effect it was merely feeble-
ness or disorder of movement. It was suspected at once that what is seen on the skin
after freezing 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 ;
inde^, it is most difficult to freeze the pigeon's entire breadth of spine ; when this does
occur in the upper cervical region, 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
on his own skin.
To determine whether the congestion actually took place in the nerve-substance. Dr.
Mitchell laid bare the cerebellum of a large pigeon, and carei^lly noted the color of its
tifisue, and the number and position of the chief vessels of the meninges. The jet of
rhigoline was then used directly upon the part. The visible vessels were instantly
firoKn, with their contents. As the part thawed, it became intensely congested, the
brain darkening dbtinctly, and the vessels of its transparent coverings increasing in
siae and number, so that those which could before be seen were larger, and new ones
previonsly unseen, came into view. This experiment was repeated several times, with
up esB^tially different result. After the careftil removal of the membranes, the bare
cerebellum protected with thin caoutchouc was chilled. As it thawed, an intense oon-
g^on appeared, with numerous points of much deeper color. This condition increased
daring several minutes, but caused no notable disturbance of function. Similar
appearances were noted in the spine. Dr. Mitchell concluded, that the singular con-
vulsions 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 undergone previous ex-
treme ooutmotiou ; the congestion from cold, whether in the nerve tissue or the skin,
is most intense at a certain time after the part has been thawed, and it is then in the
centres that the excitation becomes such as to determipe a convulsive attack.
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208 Pathological Anatomy of Traumatic Tetanus,
According to this view, the congeation must be regarded as the essential parent of the
nerve changes, which finally result in the spasm or stupor.
We should not lose sight, however, of the possibility of the nerve subetanoe being
itself directly altered by the intense cold, to which it is subjected ; for the nerve cdb
may be most seriously affected during the physical changes of condition, which grcit
alterations of temperature occasion.
In order still farther to elucidate the relations of the congestion to the abnonual
phenomena, Dr. Mitchell instituted numerous experiments, and finally succeeded in
causing by irritants, spinal congestion and backward spasms ; that is to say, the saaic
train of symptoms which succeeded the use of cold. The Tincture of Capsicum gave
the most striking results.
It thus appears from these experiments, that the backward movement and convulsive
affections and 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 tiasue ;
it is also worthy of note, that as in spasms ^m cold, in like manner in those caused
by an irritant, attacks appear only after an interval has elapsed, and are therefore not
due to primal^ alterative influences, chemical or physical.
The foilowmg conclusions may be drawn from the preceding facts :
Ist. In Traumatic Tetanus the blood-vessels of the cerebellum, medulla oblongau
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-vessels ; and the congestion thus produced, is attended with exalted and
aberrated action of the gray cells, increased reflex action of the spinal axis, and spasms
of the voluntary muscles, resembling the abnormal nervous actions characteristic of
Traumadc 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 careAil
physiol(^cal experiments, they appear to be dependent upon some arrest or alterataon
of the nervous influence supplied to the unstriped muscular fibre of the minute arteries
leading 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
spinal oord are thus supplied in Traumatic Tetanus, with an increased and s^normal
amount of blood, even when there is no increase in the force or fref|uency of the heart's
action.
4th. The symj^athetic nervous system which regulates the circulation of the blood
in the mijiute arteries, appears to be involved in Traumatic Tetanus as well as the cere-
broHnnacyi system.
5th. Whilst it is difficult to determine the exact relationship of the disturbances in
the two aystems of nerves, viz : whether the irrritation is reflected from the wounded
surface first to the ganglionic cells of the cerebro-spinal system, and secondarily to those
of the sympathetic in me spinal axis, as well as in the ganglia of organic life, in Tiitae
of the intimate relationship of the two systems, and in virtue of the dependence of theleeeor
upon the greater for a continuous supply of nerve force ? or whether the influence affects
primarily the ganglionic cells of the entire sympathetic system ?— ^at the same time ive may
deduo&iSrom such facts important therapeutic principles, which 'will be discuased more
fiilly hereafter, in a separate section of this inquiry. It would appear that after the
estdi)lishment of the state of increased functional activity in the ganglionic cells of the
spinal axis, there is at least an enfeeblement of the sympathetic system, and eepeciallj
that portion which presides over the circulation of the central ganglionic maaees ; and
the question ariises, whether this impairment of its normal functions be due to a divernoa
of the nervous force ordinarily received by the sympathetic from the oerduro-spioal
system ? The question also, as to whether the condition of the nervous system 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 accuracy ; the
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Pathologieal Anatomy of Traumatic Tetanus, 209
facts bearing upon this question will, in like manner, receive special investigation in a
distinct division of the inquiry.
In connection with the preceding facts and conclusions, it is important that we should
examine the results of the laboi-s of pathologists, with reference 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, Aretaeus, (^Isus, Paulus, iKgineta, Aetius, Ehasos and others, for any facts
illustrating the pathology of Tetanus.
Mr. Curling remarks with truth, that,
^'Xotwiibstandiug the labor and attention which have been assiduonsly directed to patho-
logical investigations of late years, both in this country and on the continent, such researches '
bare, 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 most part, taken but a partial and confined view, too often attributing the
Uiseiise 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 muoh too
limited ; for, not only is it essential to examine minutely the brain and spinal cord, but the
investigation cannot be considered complete, until the sympathetic system, and the whole
ulimentary canal have been accurately inspected, and the nerves traced from the seat of
injury to their apparent origin. The execution of this necessitates much time, and do slight
degree of labor, and when the task is accomplished, the results 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 acquainted, is found in the writings of John Baptist Morgagni, and is
IS follows: .
f'//.s/' ,^'J : Traumatic Tetanus.
** A young 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
but 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 days, the neck and the back became
ngid ; so that, as if he had been seized with a kind of Tetanus, he could move his limbs, in-
deed, but could not move either his neck or his back. To this was added, that, at intervals,
be was shaken by the most violent tremors of the whole body. And all these symptoms
going on in this manner for twenty days or more, his senses being always perfect, he having
thrown up 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 was
found to be almost healed.
The abdomen, which was turgid, being opened, a small quantity of water was seen to be
extravasated therein ; all the intestines and the stomach itself being sound, but distended
with air to a very great degree. Within the colon, near to the appendicula vermiformis, was
a round worm, dead.
The thorax also had a small quantity of water effused in its left cavity ; the lungs of that
cide were hard posteriorly, and of a substance like that of the liver. There were polypous
concretions in the large vessels, and in the ventricles of the heart : in the right of which
cavities, there was blood also, together with airy bubbles.
rpon opening the cranium, in the right lateral sinus of the dura-mater was coagulated
blood ; in the other was seen a fluid blood, not without some pretty large bubbles. There were
many bubbles, also, under the pia-mater, especially nbuut the left anterior lobe of the cranium.
Tnder the same membrane was water besides; the taste of which water seemed to one
vbo was willing to taste it, nothing at all. or at knst nothing more than a slight saltiness.
Iq the ventricles of the braiu was a pretty large quantity of water. .And no small quantity
was discharged from the tube of the vertebra, csj>ecially when I ordered the loins and the
OS sacrum to be raised up. The cerebellum was lax, the cerebrum firm ; and the sangurifer-'
o«8 vessels, that crept through the venti ivies of the cerebellum, and the plexus choroidcs, were
not at all of a white color." The Seats and Causes of Phea^ies. London, 1769; Vol. iil, pp.
237-238.
The author of '* Recherches et Ohservutioiia Fathologitjues sur le Spinitis, ou Inflam-
mation de la Moelle ^pini^re, faitcs a L'Hotel-Dieu dc Marseille," published in 1820,
2T
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210 Pathological Anatomy of Traumatic Tetanus.
under the auspices of the Professors of the Faculty of Medicine of Montpellier, ad-
vanced the view that hoth Tetanus and Epilepsy were due to, or dependent upon, an
inflammation of the spinal marrow. The proposition with reference to the first dis-
ease was sustained by two cases, furnished by M. le Docteur 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 :
Case 24 : Idiopathic Tetanus.
Joseph Toy, 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
sodden exposure to the cold air, and the consequent check of perspiration^ was followed bjr
violent chills, and pain, and spasmodic contractions of the muscles of the jaw, back, abdomen
and chest. The pain was severest about the ensiform cartilage. The next day the young
man attempted to resume his occupation, but the diflBculty 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 Dieu. On th'e 4th of Octo-
ber, the patient presented the following symptoms : Jaws firmly locked, head immovable and
inclined backwards ; permanent rigidity of the muscles of the posterior portion of the neck,
back and abdomen ; obstinate insomnia ; pain in region of xiphoid cartilage ; anorexia ;
tongne somewhat furred ; bowels constipated ; respiration irregular and spasmodic ; pulse
bard and frequent ; perspiration not abundant.
These symptoms increased in intensity, and were attended by sudden clonic spasms of the
mnscles of the trunk, followed by violent pain in the back and neck ; also, by violent spasms,
which were provoked 'by the slightest movement or noise.
Venesection was fully practiced, but without any apparent good effect. The perspiration
became abundant on the Y.th day, and urino scant.* On the 9th of October ( lOth day of dis-
ease) the spasms were so severe that the patient rests only on the heels and back, of the bead.
October 10th, eyes fixed and projecting ; spasms, constipation and interrupted respiration ;
subsultas tendinum ; skin hot. During the night of October 10th, emesis and catharsis were
induced by antimonial ptisan. Skin hot ; urinary excretion suppressed.
October 11th, (12th day), miliary eruption over the whole surface of the body; eyes im-
movable ; spasmodic contraction of the angles of the lips ; respiration diflicuU and impeded.
Daring the night the patient experienced a violent convulsion, and died a few moments after.
Autopay; J^demal Appearance : 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 ; cellular tissue beneath the skin reddened and congested with sanguineous infiltrations ;
these changes greatest over muscles of neck and back.
Vertetiral Canal: Engorgement, congestion, and sanguineous infiltration of the cellular tis-
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 the
spinal marrow, in the region of the first cervical vertebra, and the inferior portion of the
Inmbar. Serous membrane of the cord more inflamed than the nenrilemma, which presents
a purplish color; serous effusion, and false membranes in the intervals of the nervous tninks
composing the cauda equina.
Chest and Abdomen: Traces of phlogosij upon superior surface of diaphragm and upon stir*
face of heart.
Case 25 : Traumatic Tetanus^ following after the extirpation of a stnaUj CancervtiM
Tumor.
Pierre Fournier, age 56 years, admitted into the Hotel Dieu, of .Marseilles, with a cancerous
ulcer occupying the right commissure of the inferior lip, which had made rapid progress, and
invaded the neighboring parts. Arsenical paste was applied without success ; the diseased
parts were then iocised, 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 out,
and the edges of the wound pulled asunder. As soon as the considerable inflammation which
followed the operation, had subsided, the lips of the wound were again united by the inter-
rupted suture. On the 2d day after the last operation, violent pains were felt in the cervi-
cal region, and were accompanied by violent and convulsive contractions of the maaseter and
temporal muscles, and the fever, which had been abated during the first day, augmented,
and was attended by paroxysms ; the v»uscles of the abdomen became hard and contracted.
The moBcblar spasms became general^ and the life of the patient was continually threatened
by suffbcation« Yeuesections, opium, camphor ^n,d tj^u^slj^ were tri.ed, bu^t without apy appre
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Pathological Anatomy of Traumatic Tetanus. . 211
cUble effect. So tbe saperficial muscles were affected one bj one, the contraction being
most marked in the flexors.
The stitches of the suture were torn apart by the violence of the spasms, and on the 3d
daj the needles had been completely torn out of the lips of the wound. The contraction of
the muscles and the retr^tion 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 for several
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 lem rigid. Nevertheless, the dorsal
muscles and thoracic muscles remained rigid, and the difficulty of respiration continued
extreme. The patient, enfeebled by the continued and abundant loss of salita, by the diffi-
culty 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.
Amtopty Three Hourt 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
effbsed matter was denser towards the lumbar region, and was mixed with false membrane.
This matter was denser, and of a lardacions character iu the lumbar region, and contained a
greater proportion of false membrane, which united in one mass the larger nervons trunks
given off from the lumbar portion of the spine.
The author of the Researches on Spinitis, concludes that the Idiopathic Tetanus, so
common in warm climates, was similar in it« patholgy with Tetanus arising from
wounds and injuries, hoth being dependent upon '^ inflammation of the spinal m/irroto,"
" The profound alteration in the actions of the muscles, which characterizes Tetanus,
eannot be explained without admitting that the centre, whence the nerves spring which
go to the muscles of animal life, is itself affected.'' ♦ ♦ u ^pj^^ fatality of Tetanus
can only be explained by the importance of the organ (spinal marrow) which is its
seat" — Recherches, etc., pp. 41-50.
The testimony of Carl Rokitansky, with reference to the condition of the cerebro-
spinal nerrous system, after death from Traumatic Tetanus, as contained in his Man-
ual of Pathological Anatomy, is not so clear as in many other diseases, the pathol^cal
lesions of which have been so ftdly illustrated by his extraordinary labors. Thus,
under the head of Diseases of Texture of the Spinsd 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 with an equal degree of congestion of the brain."
When describing the diseases of the texture of the nerves, this pathologist calls
special attention to the following condition of the nerves in cases of Trauinatic Teta-
nus, which he affirms to be the only real fact which has bean made out m such cases
after death :
*' Froriep has ascertained, that, besides the inflammation which is seen in the nerve at the
spot which has been injured, a rosy red is produced at irregular intervals in its course, by
the injection of its neurilemma, but it is unaccompanied by any distinguishable products.
The reddening is moFt confined to the surfftce 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, four, five or more times in the course of the tibial and sciatic nerves, up to the sacral
plexus; 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
in the 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.
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212 Pathologieal Anatomy of Traumatie Tetanus.
Baron Larrey based an important portion of his treatment upon the vidw 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 exere-
tiODS. This is to be effected by suitable incisions in the waund made before io flam matioo
takes place, for, should this be much advanced, incisions are useless, and even daaj^roas :
when necessary, they should include as much as possible of the wounded nervous cords and
memt^ranes ; but incisions at the articulations are injurious, and appear generally to inerease
the symptoms ; I have seen examples of this. Caustic applications to the wound may be made
with advantage on the first apjiearancc of the wound; provided the same rule be observed as
in case of incision?."
The unexpected and complete success that followed the amputation of a wounded
limb of an officer attacked by Chronic Tetanus, induced Baron Larrey to propoee the
query, whether, in this disease, which arises 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 Tetanas
appear, than to rely on the uncertain resources of nature and art to affect a cure ? ♦ * Ampo-
tation of the limb being made on the first appearance of the symptoms, all communicatioi
with the origin of the evil is cut off. This operation unloads the vessels, removes the
twitchings of the nerves, and convulsive motions of the muscles. The first effects are fol-
lowed by a general collapse, which 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 incision of the nerves and amputation of the injured limbs. Baron
Larrey affirms,
" That amputation performed at a proper time, is the most certain means of arresting teta-
nus, when it is produced by a wound in the extremities."
In one case in which tetanus had supervened and proved fatal afh;r the amputatioB
of the arm, Baron Larrey found that the median nerve was included in the ligature
with the humeral artery, and was tumefied below the ligature, so as to resemble a
mushroom, it was also much swollen above the ligature, and of a red color. On
inspecting the body of another soldier, who had died of this disea^, and whose leg
had 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 its causes, viz : by cutting the ligature of an artery in which a nerve is
included, and to which the patient refers all his pain, and where tlie nervous irritation
takes its rise. This division of the ligature arrested the disease in its forming stage
and expedited the cure of the wounds, there being no danger of haemorrhage if the
vital powers be not debilitated ; — a few houi-s of direct compression bringing the walk
of an artery into contact, being sufficient to induce adhersive inflammation.
Baron Larrey also records several cases illustrating the cure of Traumatic Tetanus,
by the application of the actual cautery to the wounded surface, and to the extremities
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 very rob*
stance of the cubital nerve.
John Hennen, in his Military Surgery, mentions that in one case he found the 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, communicated to
the lioyal Academy at Paris, a Memoir in which he attempted to show that in all ctses.
Tetanus originates in inflammation, extending from the neurilemma of the nerves of
the part injured, to the membranes or substance of the medulla spinalis.
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Pathological Anatomy of Traumatic Tetaruis. 213
Castes 26 and 27 : Traumatic Tetanus.
In a case where Tetanus occurred after a compound fracture of the humerus^ M.
PcUetier found the neurilemma of the cubital and .median nerves red and inflamed,
as also the envelopes of the brain and spinal cord ; and it was remarkable, that the
appearances of inflammatory action were confined to the 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, after an incision made into a carbuncle
on the innei^ part of the left leg, on dissection, forty hours aft«r 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 site of the carbuncle, was encircled by a vascu-
lar network.
Oiae 2tS : TraHmntic Tetanus.
M. Pelletier also communicated to the Academy of 3Iedicine, the particulars of a
third case of fatal Tetanus, supervening upon amputation of the leg. A lad fifteen
years of age, and of a feeble constitution, had his left leg removed, in consequence of a
malignant affection of the heel. He went on very well for three days, and the wound
partially 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-
withstanding he was largely bled, the disease proved fatal on the eighth day, aft«r the
amputation. On dissection, a small depot of purulent matter was discovered in the
8tamp 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, being much
injected 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
previous 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
spinalis, 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
ramollissement. Stance, October 12th, 1826 : R^vue M^dicale, 1827, tom iv, p. 183,
Journal de Progres, 1828* Archives G^nerales de M^^decine, tom ii, Second Series,
Treatise on Tetanus by Curling, p. 41.
Case ;?.V : Traumatic Tetajnis.
In the case of a femule, ID years of age, who died of Tetanus, conseq^ient upon a wound
in one of her fingers from a splinter of wood, which inflamed, and was followed by the forno-
ation of an abscess, it is stated that on inspection of the bod}' by Dr. Hesselbach, in some
{ilaces the nerve of the arm was remarkably congested, and between the dura-mater and
arachnoid was contained a pretty lar;;^e quantity of bloody serum, the vessels being much
injected with extravasation of blood throughout the whole course of the spine. (Glasgow
Medical Jonrnal, vol. iii, p. 101).
Case *>() : Traumatic Tetanus,
In the 2d volume of the Glasgow Medical Journal, a case of Tetanus is reported of a boy
that was scorched on both legs. After death the nerves were accurately examined. The
cutaneous nerves of both legs, particularly the communicans tibialis, the communicating
branches 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 flbuia, there again it was distinctly
Tascniar, thus leaving an intermediate portion perfectly free from the appearances of inflam-
mation. The vascularity seemed to be confined to the sheath of each nerve ; the deep seated
branches appeared to be quite natural.
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214 Pathological Anatomy of Traumatie Tetanus.
Case SI : Traumatic^ Tetanus.
In another case reported in the same journal, the patient bad the ring and middle fingers
of the right hand much lacerated and injured by machinery, and the last phalanx of the mid-
dle finger being adherent to the second only by a siQall slip of skin, it was remoyed accord-
ingly. It was discovered on dissection, after death, that the nerves on each tide of the
remaining phalanx of the ring finger were very vascular. On tracing upwards the ulnar
nerve from this point to the elbow, it was of its natural color j but here again it became
very vascular 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
healthy.
Tracing the median nerve in the same way as 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 an
inflamed appearance for the extent of one inch and a half. The portion of it interveoiDg
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.
Cases 32^ 33^ 34, 35 : Traumatic Tetanus.
Mr. Curling, in a case 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-tendinous muscle, driving a piece of wadding before it, found 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 its
neurilemma unusually vascular, In the dissection of a patient of Mr. Ewbanks, who had
died of Tetanus, after a wound of the leg by a pitchfork, the prong was found to have pene-
trated to the peroneal nerve, which was bruised, and implicated in the inflammation set op
in the part. (Treatise on Traumatic Tetanus, p. 39, Medical Gazette, vol. ii, p. 346.
In a case of Traumatic Tetanus following laceration of the hand, which was amputated br
Mr. Liston, as soon as the tetanic symptoms made their appearance, the branch of the roediao
nerve going to supply the thumb, was found torn two-thirds across, and its exlremitr
inflamed and thickened for nearly an inch.
Dr. Murray, as quoted by Mr. Curling, has related a case where the wound giving rise to
the disease, was a severe laceration of the integuments of the leg, with fracture of the UbiA
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 its ramifica-
tions in the directions of the fracture, some of them being enlarged. Treatise on Tmumatic
Tetanus, pp. 39-40.
Cases 30 and 37 : Traumatic Tetanus.
In two cases mentioned by Dr. David Craigie, in his EUmenU of General and Patkoicfkei
Anatomy^ in which the injuries were similar, viz : fracture of the middle phalanges of 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, tascular 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 had been
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
space of between one inch and a half and two inches. So far as he could determine, this
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, Dr.
Craigie inferred that the injury done the finger, and the subsequent inflammation, especially
of the digital nerve, and its nerve coat had been reflected, as it were, to the spinal origins of
these nerves, and thus induced inflammation and irritation of the spinal marrow then soften-
ing ; and that these were the efficient causes of the tetanic symptoms and their fatal tenai-
nation.
In the second case in which the patient died under the care of Dr. Paterson, of Leith, the
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Pathological Anatomy of Ttaumatie Tetanus. 215
cootosed ends of the nerve were red and softened, and its tunic in like manner red, injected
aod 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 distinctly reddened and
softened, indeed qnite creamj, while the rest of the cord was firm and of normal consistence.
The spot thus affected with softening, corresponded very accurately with the origins or spinal
connections of the cervical nerves, which contribute to form the brachial plexus.
I>r. Craigie* affirms that he had repeatedly seea the nerve or nerves of parts injured
and contused 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
tipinal cord in any other case.
In view of the preceding cases (36 and 37), Dr. Craigie expressed his belief, that
in Traumatic Tetanus, the irritation is propagated fro^u 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 some
time always elapses between the date of the infliction of the injury, and that of the
tetanic symptoms ; that is 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 patholc^ts, as
Broussais, Larrey, Magendie, Recamier, Professor Frank Brera, Dr. Reid, Dr. Kenedy,
Dr. Craigie, Mr. Clarke, Dr. Aitken, and others ; and inflammation in these textures
has been viewed by several writers as the cause of tetanus.
Baron Larrey states, that in the numerous inspections of the bodies of the soldiers
who died of Tetanus in the hospital of Lou vain, after 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 efiusion more or less of a reddish color within
the sheath. ' C Unique Chirurgicale^ torn 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 spinal cord, medulla obloni^ata, brain, and their membranes, have frequently pre-
sented changes, more or less decidedly morbid in tetanus and trismus. I believe that these
changes are rarely 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
OD its free surface ; hardening or softening of one or more of the columns of the cord, or of
the medulla 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 in 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
congestions of the ycins and venous sinuses of the spine. These changes may extend
more or less generally along the cord and medulla oblongata, often also to the pons
rarolii, and even to parts in the vicinity of the latter, and surrounding the fourth
ventricle. They were thus observed with several ossiffic plates in the arachnoid, in an
acQta case of tetanus, 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-
stance 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 spinal fluid is abundant and somewhat altered or turbid. In
rarer instances, a puriform exudation is found between the membranes, and the softening of
a portion of the cord presents a puriform infiltration, with capillary injection. In still rarer
cues, 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. iii, p, 1107."
• £leai«atB of Gei^Bna and Pathalogical Anatomy, Sec. Kd. pp. 386-387.
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216 Pathological Anatomy of Traumatic Tetanus.
In a paper published by Dr. Copland, in the Londoo Medical Repository for May,
1822, Dr. Copland suggested that the ganglia and sympathefic nerves were the seat o.-
pathological cause of tetanus, and especially of the idiopathic form of the mahidy.
He contended that the ganglia, or the organic system, is the source of irritability iu
contractile tissues : and that when this property is inordinately excited, without th ;
control of the will, that changes should be looked for in this systeyi.
Some years subsec|uently, Mr. Swan directed attention to the sympathetic etystem in
Tetanus, and stated that the ganglia were pretematurally injected in this disease ; aod
appearance said to support this statement, were obser>'ed by Andral, Aronssohu. ami
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 dbcovercd disor^nization of these ganglia, and of other nervous trunks iu
horses that have died of Tetanus. In Ploucquet's Literatura Medica Digesta, a case
is referred to by Meyer, in which Tetanus is supposed to have been induced by an obki-
fication of the pleura, irritating the splanchnic nerve. In the same work, there in
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. With reference to such
observations, Dr. James Copland remarks, that it should not be overlooked, that the
ganglia are often 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 inflimimation 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 con-
founded with cerebro-spinal menengitis. Thus iu a case which occurred at Udina,
and which was at the time brought forward to show that tetanus '' is inflammation uf
the spinal cord,'' and as confirming Mr. Bell's idea, that movement depends on the
anterior, and seiisation on the posterior roots of the spinal nerves, the disease arose in
a woman, without any external injury, and as the consequence of over-exertion and
cold. On examination after death, the brain was found in a healthy state ; the verte-
bral canal w^ filled with a bloody serum ; the anterior portion of the spinal cord was
of a yelIowi|ih 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 spot* ; the pos-
terior part was healthy ; the posterior roots of the spinal nerves had a very different
appearance from the anterior roots ; the latter were evidently softened, and presented a
yellow color ; the former were perfectly healthy. Annali^ Univ. di Milano, London
Lancet, Vol. i, 1828-9, p. 136.
In two cases of Traumatic Tetanus reported by Dr. Parry, in the Glasgow Medical
Journal, February, 1831, morbid appearances, irregular congestions, and " inflammation
at the seat of injury," were observed in the norves connected with the injured parts.
In one case, a considerable quantity of partly fluid and partly coagulated blood, existed
between the theca and the vertebrse, and both lobes of the cerebellum presented a
congested and ecchymosc d appearance.
Ca$e SS : Traumatic ^letanm.
In a case of Traumatic Tetanus, terminating fatally in Westminster Hoapiial, ten days
after the manifestatioD of Tetanic symptoms, which appeared tea days after the foot qf the
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Pathological Anatomy of Traumatic Tetanus. 217
Ud bad been pierced by a nail, the following alterations were observed iu the brain and
spinal cord :
** Immediately after death, the body was placed prone, to prevent the gravitation of the
blood towards the spine. Twenty hours after the demise of the patient, he was laid on a
dissecting table, and his spine was opened. There was slight sanguineous extravasation
between the bony sides of the vertebral canal and the theca vertebralis. On opening the
tbeca, 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 were injected.
In the cranium, the brain and its meninges were more than naturally distended with blood,
and in each lateral ventricle, half an ounce of a pink-colored serum was found; the velum
ioterpositum 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.
Case 39. — Traumatic Tetanus.
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 death, the body was opened in the presence of Mr. Guthrie and several medi-
cal men. As soon as the breath was out, the body had been placed prone, with a view of
preventing the gravitation of the 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 between the pia-mater 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,
fxtravasated blood was found. The pla-ma.ter 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. 1. 1833-
1834, p. 380.
Oi$e JfO : Traumatic Tetanus.
Dr. William Wallace describes the nerve leading to an injury in the right leg inducing
Traumatic 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
membranes of the cerebrum, cerebellum, medulla spinalis and oblongata were very turgid.
Great effusion between the pia-mater and arachnoid — particularly on the superior surface
of the hemispheres. An efi'usion of blood on the 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 firm and over- vascular.
London Lancet, 1835-1836, Vol. 1, p. 847.
Case Jfl : Traumatic Ictanus.
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 Britohistle, in a case of Trau-
matic Tetanus, following a gun-shot wound of leg. London Lancet, 1836-37, Vol. 1, p. 298
Case i2 : Traumatic Tetanus.
At the autopsy of a patient wjio died in the Hotel Dieu, of Paris, with Tetanus superven--
logon fracture of the leg. numerous ecchjmosrs were found in the fibrous sheath of the
spinal cord; ond exteinal to that mcrabrare n collection of black and liquid blood occupied
•he lower part of the vertebral cnnal to the height of five or six inches. The spinal cord
ilsclf was softened througout its lower two-thirds, and closely adherent to its pia-mater ;
lod the ramoUissement continued, though in a less degree, to the occipital foramen, termin-
ating just below the corpora pyramidalia.
Within the cranium, the pia-mater wasolFcivtd to Le greatly injected, and there wj«s
extensive softening of the left anterior and middle Icbcs of the brain. In the sciatic nerve
of the right side, (the side of the fracture), ecihjrooscs and inflammation were perceptible,
I'Ui there was neither in the nerve of the opposite side. Archiv. de la Med., April, 1813.
London Lancet, 1842-33, Vol. ii, p. 508, July 8lh, 1843.
Case 4*^: Traumatic letanus.
In an interesting case of Tetanus, given by Dr. Kcid, iu the •' Trausactions of the Associa-
38
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218 Pathologieal Anatomy of Traumatic Tetanus.
tion of Physicians in Ireland," Vol. i, p. 113, great vascularity, .and an effusion of blood
were found' round the spinal marrow.
Case 44' Traumatic Tetanus,
In another case detailed by Mr. Brayne, of Banbury, in the " London Medical ttepository,"'
VoU xi^i P- Ij two or three inches of the inferior dorsal portion of the spinal miirrow, wer«
suffused by a continuous blush of inflammation, and three small, hard, white luminae were
seen between the arachnoid and pia-mater.
Case 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 extensive lacerated wound of
the integuments of the fore-arm, performed in Guy's Hospital, by Dr. Hodgklu, revealed
softening of the gray matter throughout the greater part of the cervical portion of the spinal
medulla. The softening was more particularly observed in the right lateral medulla. Lon-
don Lancet, November 24th, 1827, p. 325.
In 62 deaths occurring in Guy's Hospital, from Tetanus, during a period of thirty-
two years, from 1825 to 1857, 18 were not examined, and of the rcmilbing 44, in
only 34 were inspections recorded. The brain was examined in 20 cases ; Ih 11 it was
healthy and firm, with nothing morbid in color or consistence ; in 9 it was congested,
darker than natural, dark and flabby, pinkbh, with ulcerations on undet surface of
anterior lobes, and decomposed. The spinal cord was examined in 19 cflBde; in a few
it was redder than natural, congested and softened, but in the greater nutuber nothing
abnormal was recorded. The condition of the ner\^es 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, after
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 importance was' noted
in the condition of the other organs of the body. Out of 7 cases, theW Was unusual
post-mortem rigidity in 6, and in one case this was observed, five hours after death,
and in another fifty. (Guy's Hospital Reports, 3d Series, Vol. iii ; AW. Jour. Med.
Sci., Oct., 1858 ; Brit, and Foreign Med. Chir. Rev., April, 1858.)
Mr. Benjamin Travers, whilst holding that "the evidence before the public to
establish that Tetanus has its origin in inflammation of nervous structure* has failed ; '*
and that " even the common statement of increased vascularity and efftision beneath
the investing membranes, are as common in other acute diseases as in this, and thej
are by no means universal in Tetanus,*' nevertheless, records several caseii occurring in
his own practice, which illustrate the fact that the disease is characterUed by certain
lesions of the spinal axis. Thus, in a fatal case (46) of Tetanus occurring Dec,
1820, in a porter, after fracture and amputation of the middle finger,
**0n exHminfition, half an ou'.ico of reddish serum issued from the spinal canal, and tb«
medulla spinalis was pulpy.*' *
In another case (47), caused by compound fracture of the right leg, (Oct., 1822)»
" The vessels,'- of the brain, *' were turgid, and a considerable effusion of serum was found
between the opaque arachnoid, nnd the pia-mater ; the membranes of the cord presented
universal vascularity."
In the Case (48), of a lad, March, 1828, "some effusion under the arachnoid, and
general increased vascularity of the cerebral and spinal membranes.'*
Case 4^ ' Traumatic Tetanus^
In a case of violent tetanic spasms, which supervened two da^cs after a blow on thccerfical
vpiue^ and which proY^<Jt f<i^tal in iwcijty-^Qur hours, the cervi«al,^artiQp.Q£ the spinal cord
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Pathological Anatomy of Traumatic Tetanus, 219
wm loftenetl to the extent of an inch, whilst the membranos of the gpiaal cord were Inflamed
and tbickenad.
In his " Further Inquiry on Constitutional Irritation," Mr. Travers records only a
liogle post-mortem in this disease, in which no special lesions of the cerebro-spinal
syitem were observed. He says that after the occurrence of a certain case of Tetanus
in Guy's Hospital, in which he observed, after death, that the arachnoid coat of the
bnin 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
fire out of ei^ht, some morbid disposition was discovered in the substanoeaf the arachnoid
tanic covering the medulla. With one exception, thej presented the appearance of distinct
osseous patches, chiefly on the lower part of the cord, or cauda equina, so brittle as to
crackle oh pressure, and of the thinness of silver paper. In the exception referred to, the
deposit had 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
pathol<^ 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 npon
Tetanus, lose much of their interest if unaccompanied by dissections. Some recent occur-
rences, and particularly a case detailed by my friend, Mr. Webster, Surgeon of the 5lst Regi-
ment, in the Medico-Chirurgical Journal, for October, 18 lY, have determined me to lose no
opportunity of minutely examining the spinal cord and the theca vertebralis, in all future
cases of acute Tetanus, or of a disease in many points very analogous to it, — hydrophobia ;
a determination in which I am strengthened by the opinion of tlie author of the excellent
paper in the Medico-Cbirurgical Transactions above referred to. I have already had many
comma nicatioos on the subject, and while some of my informants assert that they have found
ibe 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. From some of my correspondents,
I 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 into the canal in tetanic cases, there can be no rational doubt."
Traces of inflammation and congestion about the brain and spinal marrow were
observed in a case of Traumatic Tetanus, resulting from injury of the fingers of a
young man aged twenty-seven, recorded in Guy'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 :
Case 50 : Traumatic Tetanus.
Mary Henson, aet. 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 inliammation had
existed upon its investing membrane, the vessels of the pia-mater being very conspicuous,
numerous and greatly distended. Nothing remarkable in the aspect of the tunic arnchnoidea,
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,
nothing indicative of congestion, or extravasation.
Case 51: Traumatic Tetanus.
Rebecca Peterson, aet. 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*
tuoica 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-
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220 Pathological Anatomy of Traumatic Tetanus.
HUB in dogs, by the introduction of irritating bodies 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, 184(), p. 578.
Xovember 22d, 1840. — Introduced minute tack points into the muscular spinal nerre of
dog Qumbo, at the point where the nerve passes over the lower end of the radias; and oo
the same day, into the ulnar nerve of the dog Watch, at the point at which the nerve pastes
over the upper head of the os ulna; passing the tacks completelj into the nerves, burjiog
both e:xtreniitie8 within the ihcca. 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 iiealihy for six weeks.
On the morning of the 5th of January, 1841, Gumbo was found convulsed, with bis javj
firmly clenched. Nothing was done in the case until three o'clock p. m., when the whole mus-
cular system had become rigid, respiration difficult, the abdomen retracted, and a bloody-
looking sai&ies flowed from the bowels. In this condition, with the assistance of Dr. Finley,
he was trephined, without evincing sensibility to the operation. On compressing the brain
with the ball of the thumb, complete relaxation of all the muscles was effected in the coarse
of a few seconds. In about an hour and a half the spasms recurred, when they were again
relaxed by the compression, the animal recovering some degree Of sensibility daring 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 lo 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 unasaally
uneasy and restless ; the following morning he was missing, and has never since been
heard of.
Such experimente strongly support the view that Tetanus has its origin in local irri-
tation of the nerves. Mr. Poland has shown that lacerated wounds are much more
frequently attacked with Tetanus than incised wounds ; thus, at Guy's Hospital, the
disease occurred only in one case out of 1364, where the wound was made by a sharp
knife, but it ensued in one out of 55, where the nei-ves were injured, as in accidents.
Cases have been recorded in which the spasms were almost entirely limited to the
side injured. Three cases recorded by Langenbeck, sustain the view Uiat 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, 1863, p. 220) ; the
removal of a ligature, which had been tied en masse, after castration, at once stc{>ped
all the symptoms in the second case ; and in the third case, the reduction of a fractore
which was attended with great displacement, had the desired eflPect. Hasse states that
very frequently the lodgment of splinters of bone, or the like, among the tissues, has
decidedly influenced the development of Tetanus ; and Mr. Krichson says, that he his
never failed to find the nerve running from the wound more or less inflamed, and often
for a considerable distance, whenever it has been looked for. Dr. Packard, of Phila-
delphia, found fatty degeneration of the ulnar nerve, in a case of Tetanus, in whidi
the fore-arm was amputated two and one-half inches below the elbow. The Tetanus
had been preceded by extensive sloughing of the tissues :
*' By the sloughing, was laid bare a portion of the ulnar nerve, which was excised by Dr.
Pancoast, with a faint hope of arresting the symptoms. A portion of the excised bit of nerre
seemed to the naked eye to be healthy, the rest was abnormally vascular. The former, under
the microscope, was proved to be actually in a normal state ; the latter was throughout in a
condition of well marked fatty degeneration." North Am. Med. and Chir. Review, Jan., 1859,
p. lOY.
The preceding post-mortem examinations which we have recorded, as well is the
observations of Froriep and others, supplied undoubted proofs of the origin of Trau-
matic Tetanus in nervous irritation, and we have merely introduced these facts as cor-
roborative evidence.
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Pathological Anatomy of Traumatic Tetanus. 221
Br. Humphrey Sandwith has recorded the following interesting observations on the
ptthology of Tetanus :
"Having lately witnessed the post-mortem examinations of the spinal cord in Traumatic
Tetaoas, in all of which there were traces of hjpersemia in the nervous mass or its mem-
braneSi and io which, though topical depletion of the spinal column was employed, the chief
reliance had been placed on morphia und cathartics. I resolved on the adoption of a tnore
decidedly antiphlogistic course at the first opportunity. All the three cases alluded to, had
occurred at the Hull General Infirmary, anJ in one of them, Mr. Wallis, (who intends to pub-
lish an account of them, with colored sketches of the medulla spinalis and its investments),
contrasted the spinal marrow o^ 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 this and in the other tetanic cases, there was increased vascularity of the cellular mem-
brane, surrounding the theca-vcrtebralts, together with increase of fluid, within the theca,
and the tunics, as well as the substance of the medulla, were extremely vascular. But when
transverse sections or slices of the spinal marrows of the tetanic and non-tetanic patients
were both submitted to a microscope of immense magnifying powers, the greatest difference
io the two structures became apparent. In that of the tetanic patient, the vascularity was in
excess as well 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 bad a more granular appearance ; whereas, that of the tetanic, on the contrary,
had a more areolar or reticular aspect, and looked softer and more spongy. Thus we had
presented to us not only palpable hypertemia, (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
the very system of nutrition of the nervous tissue.
•'1 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 hyperaemiu, of any part of the nervous
system in Traumatic Tetanus. Thus Dr. Gerhard of Philadelphia, states that he has ex-
amined the brain 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 neutrnli%iiig this allegation, both of which appear to me of great weight. In the
first place, to adopt the language uf Dr. Cowan, (spoken generally, and not in reference to
this particular subject), the narrow limits of unaided sense are again marvellously enlarged
ly microscopical discovery, our past acquisitions regarded as elementary and incomplete, and
tbe whole subject is again to undergo renewed and unexpected revisions.} In short, the
refined examinations of the nervous structure commenced by Ehrenberg, 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
mach too limited, the l)raln and spinal marrow having been usually alone examined, and
other portions of the nervous system having been comparatively seldom explored. Before
the doctrine of hyperaimia 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,
inabypersmic condition. ' In the greater number of observed cases,' says Dr. Dunglison,
'hyperaimia of the medulla or its membranes, has been found on dissection.' Even Mr.
Carling admits that 'serous efl'usion, with increased vascularity, is generally observed in the
membranes investing the medulla spinalis, and also a turgid state of the blood-vessels about
the origin of ihe 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 supply 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 are free from turgid vessels. Ed. Med.
and Surg. Jour., vol. xvi, p. 474.
"The 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 hyperiemic theory of Tetanus. Irritation set up in
those ganglia, obviously disturbs the capillary circulation in them, and hence, probably the
*DoDglbon'« Practice of M«llcin<% vol. I, p. 74.
fUaDglison'B Practice of Medicine, vol. ii, p. 3.3(1.
tTnnactfoos of tbe Provincial Medical and HiirK- Association, N. 8., vol. i, p. 4.
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222 Pathological Anatomy of Traumatie Tetanus.
spasms. In the case wliioh illustrates Mr. Swan's remark, — one of acatc idiopathic teiann^,
— ' the villoas coat of the small intestines throughout, had the marks of having bcca in »
state of great irritation, many very vascular patches were observed on it. and it was loaded
with a green and yellow slime and mucus.' Along with these appearances in the small iotes-
tines, he records that < in all the ganglia of the grand sympathetic nerve, tber« existed
decided marks of irritation.' The vessels usually pale and colorless were injected with red
blood, and the same was observed in some of the intermediate portions of the nerre. The left
semilunar ganglion exhibited a few vessels, but the right was injected In a beautifully minute
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 morbid anatomy. The
phenomena in both cases, threw the strong light of analogy on the assumed hyperiemic con-
dition of the nervous centres, or of the sympathetic system, or of the nerves immediately
connected with the seat of injurjy 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 regarding the
structure and functions 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 formidal>|e mal-
ady. The lesion discovered by Dr. Aitken, was not manifest to the naked eye, but was
determined to exist with certainty by an examination of the Specific Gravity of the
cord substance. For this purpose, the cord was separated from its nerves, and divided
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 1.036.
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 gravity, and tlie
difference became mddmly and not gradually^ manifest at the fourth inch. In the third case,
a very marked difference was apparent when the cervical region was compared with the rest
of the cord ; and the dilTcrence was suddenly marked, where the roots of the cervical and
first dorsal nerves left the cord to form the brachial plexus. The wouni in this instance was
on the fingers.
" Mr. Lockhart Clarke has since examined the cord in tetanus cases microscopicHlly. .^nd
has found peculiar lesions of a most minute kind, scattered throughout its substance. Ued.
Clin. Reports, August, 1865.
'< In the last case the difference was suddenly manifested in the lowermost part of the cor4,
corresponding to the region where the nerves were in communication with the lower limbf,
which were the seat of the injury." Glasgow Medical Journal, No. iv, January, 1864.
Science and Practice of Medicine, Am. Ed. from 4th London Ed., vol. ii, p. 479.
According to the more recent labors of Rokitansky and Demme (Schmidt s Jahr-
bucher, vol. cxii), tetanus has a constant anatomical lesion, consbting in a proliferation
of the connective tissue of the whole medullary substance, of the medulla oblongata,
of the inferior peduncles of the cerebellum, of the crura cerebri, and of the spinal
cord, producing a viscous mass abounding in nuclei, and never progressing to the form-
ation of fibres. It is frequently mentioned, that great congestion of the brain and
spinal cord was observed, a condition on which the lesions of the connective tissue just
described, are believed to depend. (Southern Medical and Surgical Journal, edited by
Joseph Jones, M. D., July, 1866, p. 116).
In a case of Traumatic Tetanus, occurring in a German Butcher, aged 45, which
proved fatal on the 4th day, reported by Dr. Jlssbine Mason, acting House Surgeon of
Bellevue Ilaspital, (Am. Med. Times, Sept. 1, 1860, pp. 150-1): there was considei-
able effusion over the membranes of the spinal cord, which were very much congested.
The cord was also exceedingly softened. The dura mat?r of the brain was natural ;
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Pathological Anatomy of Traumatie Tetanus. 223
superficial vessels very maeh injected and of arterial hue. Bmin substance very much
softened, as well as the medulla oblongata. There was no effusion in the ventricles,
the other organs were not examined.
Mr. Lockhart Clarke, in his communication On the Pathology of Tetanus^ 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 extend.
According to this observer, the pathological alteration seems to consist of disintegration
and 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
lew granular, holding in suspension the fragments and particles of the disintegrated
tissue, but in many places it is perfectly pellucid. Mr. Clarke asks, whether the struc-
tural lesions, and dbintegration of tissue are the effects of the iiinctional 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 sole 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
disintegrations of tissue, precisely similar in character, to those discovered in the cord,
in many ordinary cases of paralysb j and on comparing together the lesions and symp-
toms of both kinds of diseases, he arrives at the following conclusions : 1st. That the
lesions 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 state 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
by 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 reflex action, is
the same which is subsequently the source of that irritation, by which the reflex action
is excited. (A System of Surgery, edited by T. Holmes, 2d Ed., vol. i. Studies on
Functional 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
given a very accurate description of the spinal cord, in a case of Traumatic Tetanus, in
a man, aged 25 vears, who died in eighteen and a half hours. The following are the
alterations deecnbed by this writer. The cord presented three remarkable enlarge-
ments, one in the cervical, and two in the lumbar region. The morbid changes were
Ist, 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 grav matter. The blood-vessels of certain portions of the cord, were replete to
distension with the natural contents, and in some situations, blood corpuscles had
escaped from their proper channels, and diffused 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,
in conjunction with the effusion described, caused the swellings which were so con-
spicuous on the surface of the cord*
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224 Pathological Anatomy of Traumatic Tetanus.
Both Mr. Clarke aud Mr. Dickinson 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 existence of
such lesions in the cord, after recovery, may account for the persistence of certain
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 are very suggestive of persistent spasm of the vaso-
motor and musculo-motor nerves, which must depend on some abiding lesion.
Dr. Clifford Allbutt has recently reported several cases of Traumatic Tetanus to the
Pathological Society of London. Comparing the appearances of the cord in the several
cases, it was seen that they were similar, only differing in degree as regards softening ;
in two out of the four cases, meningeal haemorrhages 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 in
two cases haemorrhage into the cord in different places. Both in the pia-mater and in
the central gray matter similar vascular changes were observed. The central canal of
the cord was stuffed with epithelial matter in over-abund&ncc. There was nuclear pro-
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 in
part to exudation about the vessels, but also to changes id the cells themselves. The
cells were the subject of yellow disintegration, beginning in 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 Mty mass, these masses giving rise to the appear-
ance of smajl 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. Allbutt 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 LESIONS OP THE CEREBRO-SPINAL SYSTEM IN TRAUMATIC
TETANUS, WITH THOSE OBSERVED IN VARIOUS DISEASES OF THE NERVOUS
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 diseases
of the nervous system. Whilst we have observed a large number of diseases dependent
upon functional and structural alterations of the nervous system, we shall, in illustrat-
ing this comparison, confine ourselves to those cases which We have had the time and
opportunity to study during life and to examine after death. In thi? country it is
rarely within the power of the physician io make careful post-mortems in fatal cases
occurring in private practice, and many of the most important casos of nervous disease*,
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 and oercbro-spinal
meningitis, have unavoidably been la*<t, without that final minute post-mortem examin-
ation, which would have given precision and value to the careful observations durio^
life.
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Jtelattons of Tetanus to Various Nervous IHseates. 826
I shall, tber^ore, in selecdng 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-
ence of the patients within the walls of an hospital.
Gue 52: Loss of Mental Power (partial insanity ^^ ending in Comdj Delirium and
Death, and attended with Structural Alterations of Brain,
* Cbarles U., aged 28 jears ; a native of Dublin, Irelirad ; has been in the United States
Army for seren&l rears, served during the recent war, and worked his way up from the ranks
to tlie position of Ist Lieutenant; was mustered out of service at Greenville, in March, 1868,
at which time he moved to New Orleans, and entered the family of Mrs. A. Patient assisted
Mrs. A^-in various wajs, doing work about the house as directed. After a time, about six
months before his final illness, it was noticed that the patient exhibited less intelligence than
formerly. The intellectaal powers appeared to fail gradually, and the patient became '* unre-
liable," and when sent on an errand, would go to some other place than the one specified.
Three weeks before his entrance into the Charity Hospital became delirous and insensible,
with short lucid intervals, when he ap'peared to recognize Mrs. A. and her family. Bowels
constipated, and during three weeks, is said to have had only one action from the bowels. The
attending physician applied a blister over the head, and administered purgatives, but with*
oat any apparent benefit. .
Entered Charity Hospital 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,
cannot 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.
Purgatives were freely administered, and a blister was applied to his head ; these measures,
however, produced no perceptible benefit, and the patient died on the fourth day after his
admission.
Autopty eight hourt after Death, — The Brain and Spinal Marrow were carefully removed. The
pift-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. .
Pit-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 softened. 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
the changes in the membranes of the brain were of slow development, and dated back in
their origin, weeks and even months.
The two hemispheres of the cerebrum, were so completely adherent, that the longitudinal
fissure could 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 lunge 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 standing and bad no connec-
tion whatever with the fatal attack. The liver and spleen, 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
sUnctoral alteration of the brain and its membranes.
Cau 53: Temporary Insanity^ occun-ing occasionally during a period of years,
followed finally by Loss of Mental Power, Paralysis and Death, Structural
AkeratioHs 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, and has a wife and family.
29
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226 Relations of Tetanus to Various Nervous Diseases.
Twelve years ago attempted to take the life of his partner, without anj known canse, and
sioce that time has had occasional fits of temporary insanity, although he has continued in
business.
Three years after the attack on his partner with fire-arms, he killed his horse, cutting its
throat in the road, whist harnessed in his buggy, without ( as in the first instance ), any known
reason for the outburst of passion. The patient is said to have continued in a wi\,d delirious
state for several days after these violent manifestations. During the war lost his property, and
at its close roamed about the country in a demented but harmless state.
At the time of his entrance into the hospital, walked with great difficulty, — spoke slowly
and with effort, mind obtuse, and p;itient 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 his 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 discharges of urine. The bed-sores were dressed with a cerate
composed of one drachm of crystallized Carbolic acid mixed with one ounce of Simple cerate.
The internal treatment consisted of one-twentieth of a grain of Strychnine, and fifteen drops
of the tincture of the Sesqui-Chloride of iron, three times a day, together with the most
nutritious diet afforded by the hospital ; under this treatment, with attention to the state of
the bowels, and to the personal cleanliness of the patient, with occasional blisters to the back
of the neck, the general health improved in a marked manner ; there was a temporary increase
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 fuUv. This improvement, however, was only temporary,
and in the early part of February, the difficulty of walking became so great, and the tendency
to fall, even when sitting in the chair, so constant, that the patient was compelled to lie the
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 muscular power in the 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 applications.
The students had daily opportunities of witnessing the gradual and progressive failure 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 supports on
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 incr€n«e of
respiration or circulation, 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 insanity was dependent upon some ttrueiyml mlier'
Qtion of the brain; and that the alteration^ degeneration or softening of the brain has gradually
extended to, and affected the spinal system.
This case presents a progressive failure of the intellectual, nervous and mnscolar forces,
without any sudden paralysis or contraction of the muscles, and the only sudden and violent
nervous agitation with which the patient was afflicted since his entrance into the hospital
was a slight convulsion about noon on the I2th of February, after making unusual efforts at
sitting up and attempting to walk. So far as could 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 progressively to fail ; lay in an unconscious condition, occaaionallj
groaning and crying aloud, especially at night, when he disturbed the entire ward. Oae
fourth of a grain of Morphine, was tried at bed-time, without any special benefit. The patient
does not reply when addressed, and appears to be wholly unconscious of any thing passing
around him, and is oblivious of his distressing condition. Urine and feces passed in bed;
bed-sore forming upon back over sacrum ; circulation sluggish ; surface of the skin in depen-
dent portions of the body, of a purplish red, mottled appearance. Patient unable to turn
in bed, or to move his lower extremities. When the feet and legs are pinched, the patieat
contorts the face, and evidently suffers pain.
The patient continued to sink ; gradually lost the power of swallowing, and could take no
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Relations of Tetanus to Various Nervous Diseases. 227
nourishment ; breath became very offensive, nnd the teeth loaded with sordes ; foar days
before death, the right thigh was contracted and drawn up towards the trunk. Patient
tppeared to saffer pain when the attempt was made to straighten the limb.
Died Match 3d, at 8 o'clock, p. m.
A carefal autopty was made the next morning, at 8 a. m., with the following result :
ExterioTf full and not wasted ; heart normal ; lungs pale, but perfectly healthy, with no
deposits ; alimentary canal and all the abdominal organs, lirer, spleen, and kidneys normal
in appearance.
nead. — Welt-formed and large cranium, with symmetrical arch. Nothing peculiar, however,
was noted with reference to the cranium.
Ihtro'mater^ firmly adherent to the bony structure ; pia-mater, greatly congested and tbick-
eoed; the arachnoid was in like manner thickened, and presented much more of an opalescent
appearance than usual.
Brain, 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
as great in 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 iht gray matter o{ the convolutions and of the optic thalami, giving to those collections of
ganglionic matter a pink high-colored appearance.
The blood-vessels of the brain tit aU partSy were larger and more numerous and more con-
gested, than in healthy brains. The blood-vessels were not only morie congested, bat th'ey
were permanently enlarged.
The large size of the small blood-vessels and even of the capillaries, as well as the state of
congestion, imparted to the gray matter a deep pinkish tint.
Under the microscope ^ the ganglionic cells of the gray matter, and ganglia of the brain appeared to
be diminished in number, whilst the capillaries were increased in size, with thickened walls. Exudation
wrpuscUs were observed amongst the brain structures, and especially along the tracks of the blood"
WMe2f.
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, enl^orged
with blood. The blood-vessels appeared to be fourfold more numerous than In 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 colnmns), 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 be 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 corpuscles, were
also seem in the neighborhood and around the capillaries ; and both in the spinal cord, and in the brain^
sowie 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 enlarge^ capillary
circulation. The temporary nature of the fits, as well as their violence, would indicate that the primary
lesion existed in the circulatory apparatus of the brain and spinal cord.
In this case, we have as in the preceding one, an instance of the connection of
deranged mental action with structural alterations 0/ the' brain.
It is of great importance to the science of medicine, that every case of insanity,
should not only be subjected to the most rigid investigation during life, but also that
the most careiiil 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
Qigan of the intellectual faculties, it makes a vast and important difference in oiir
pmological views and therapeutical principles, whether we regard insanity as connected
with and dependent upon structural alterations, or as a disorder of the intellectual
ftculties and moral power.
Whilst various 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 ^ntrol the forces of matter, and even immaterial agents ; it is certainly of
^reat 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,
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228 Relations of Tetanus to Various Nervous Diseases*
directors and attending physicians of the various Insane Asylums in Uiis countiy.
Each case of insanity should be subjected tp rigid scrutiny ; accurate measarements
should be made of the cranium, and all peculiarities of conformation and of physiog-
nomy should be noted and compared with the peculiar phases of the insanity ; and tlits
careful examination should be completed by a thorough examination of the brain after
death. If a small portion of the ^nds of each State Asylum were devoted to the care-
ful investigation and delineation of the peculiar conformation of the cnmium and coun-
tenance (by photography), and to the publication of the annual results of the patholog-
ical labors conducted by competent men, important results would be achieved for the
science of medicine.
The researches of Pathologists are gradually undermining the theory or belief, so
long held, that Insanity is an affection of the mental and moral nature, or immaterial
principle, independent altogether of structural alteration of the material instruments
bv which the mind manifests itself. The question as to the relations of path(^ogical
alterations of the brain, to aberrated moral and intellectual manifestations, cannot be
determined by any process of reasoning, but must be settled by care^l pathologic^
researches.
*The belief that in Insanity, the encephalic nervous textures are primarily implicated,
gains ground, and is now ably supported by such men as Van Der Kdk, WinsloWt
Bushnan, 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 in the dead body, throw any light on the nature and course cf
the disease:
^* And I do not remember to have performed daring the last twenty-five years, the dissec-
tion of an insane person, which did not afford a satisfactory explanation of the pbeoomena
observed daring life." Minute Structure and Functions of the Spinal Cord and Medalla
Oblongata, etc. New Syd. Soc. 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 encepha-
Ion, or of its membranes.
Bayle opened one hundred corpses of paralytic insane, and Calmeil forty-seven ; these
observers found the meninges of the convexity of the cerebral lobes opaque, injected,
hardened, infiltrated with serosity, and offering frequently granulations or fiaJse m^n-
branes.
M. Linas opened one hundred and fourteen bodies of paralytic insAne : in twdve
cases the pia-mater was excessively 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 con-
volutions and the meninges. In seventy-four cases the meninges were infiltrated^
ojpaque, and as tough as a fibrous' membrane ; the cortical substance of the brain>
sometimes violet, sotdetimes yellowish, according to the degree of the paralysis, alwaya
softened, loss thick than in normal brains ; the white substance injected, and sometimes
infiltrated ; the convolutions meagre, and the whole mass of the brain more or less.
atrophied. In thirteen cases besides the preceding alterations, there was one or many
small circumscribed places where the encephalitis hacibeen more violent than dsewherc
In eight cases, there were also effusions of blood.
From these facts, it appears that paralysis of the insane depends upon a chronic in-
flammation of the brain and its meninges. Whether the disease b^ns in the membrane
as Bayle has 8aid> or in the brain itself, as M. Calmeil maintains, is a question of com-
paratively little ipiportance. The great point is;^ that the brain is always inflamed. M.
Calmeil has ascertained with the microscope,, that in doubtful cases, where the brain
did not seem to be WAJcU ^Jtere-d to the najced eycj, there were neyertibeleas, all tjie.
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Relations of Tetanus to Various Nervous Diseases. 229
microecopic appearances of inflammation. M. Lines has recorded cases to prove that
an acnte oephialitis 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.
Ga$e 54 : Insanity caused hy Syphilis : Structural Alteration of Brain.
The case was that of a white female, who had had syphilis, and the mental derangement
came oq, after the supervention of constitutional symptoms, and appeared to be directly
referable to the structural changes induced in the brain by the syphilitic poison.
It was observed during the life of the patient, that she was insensible to bad odors. Thus ,
M 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 oflFensive odor.
After death, it was found that the structures of the brain, were extensively softened and
altered in the neighborhood of the origin of the olfactory nerves.
The alterations of the brain and the symptoms of insanity, in this case, were referred
to the action of the 83rphilitic 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,
gammy 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 soften-
ing, and cases have been recorded, in which white and red softening of the cerebral
substance have been caused by sjrphilis.
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 S3rphilitic origin of many nervous 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
impossible. I fully endorse the opinion of Dr. Thomas Buzzard, that if the physician
waits 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
eonible nervous disease.
During the past twenty years I have treated a number of cases of insanity, epilepsy,
paralysis, sciatica, and various forms of neuralgia in hospital and private practice, which
had 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-
cory, 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-
cufision 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
space afforded by an entire volume would be scarcely sufficient to discuss these relc-
tions. I will therefore dismiss this subject, with the observation, that I have derived
the greatest benefit ft-om 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 scruples of the
Iodide of Potassium) three times a day. The followbg is a convenient formula ; R,
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230 Relations of Tetanus to Various Nervous Diseases.
Hydrargyri Bin-iodidi, four grains ; l^otassae lodidi, one ounce ; Aquae distallatas
eight fluidouDces ; mix ; sig.; teaspoonful in wineglassfull of water three timeB a dmj-
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. Potassae iodidi, one
ounce ; Tinct. iodinii, two fluiddrachms ; Syrupi Ferri lodidi, one fluidonnoe; sympi'
Zinziberis, seven fluidounces ; mix ; sig., teaspoon^] in wineglassfull of water three
times a day. In 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 : R. StrychDiae snlpb.,
two grains ; Quinise sulph., two drachms ; Ferri et Quiniae citratis, four drachms ; Actdi
Citrici, three drachms ; Aquaa distillatae, eight fluid ounces ; make a solution ; sig.,
teaspooufuU in wineglassfull of water, three times a day. Also, as a sfubstitate for the
preceding : R. Strychniae sulph., three grains ; Acidi Arson iosi, two gnuns ; Qniois
sulph., three drachms ; Ferri redac, two drachms ; Extract Rhei, 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 three 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 taeatmeot
of such cases frequently arises from the irregular and timid use of mercurials and the
Iodide of Potassium.
Case 56 : Dementia, Paralysis and Death ; Clots in Corpora Striata and Optic
Thalamic
Id this 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 mascnlar
movements, and it was said by her companions that she had been the victim of sorcery or
witchcraft. The disease was said to have been suddenly induced in a slate of health, bj an
aged negress, who practiced witchcraft.
After death, it was found tl\at blood-vessels had been ruptured, and blood extravasated
into the gray matter and nervous structures of the optic thalami and corpora striata. The pa-
tient was a large, stout old woman, apparently near seventy years of age, and the ruptured
blood-vessals were found to be degenerated, having undergone fatty degeneration. It is pos-
sible that the rupture of the blood-vessels may have been the result of some unusnal mealal
or physical effort.
As the practice of sorcery and witchcraft amongst the negroes in certain sections of
the South, is thought to have been revived and extended since the war, we reproduce
one of the fullest and most accurate accounts of the superstitious practioeB of the
negroes.
The following very curious account of the extraordinary superstition 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 Obeah^ Obiah, or Obia, (for it is variously written), we conceive to be the a4i^^*
ive, and Obe, or Obi, the noun substantive ; and that by the word Obia — men or women — are
meant, those who practice Obi. The origin of the term we should consider of no import-
ance in our answer to the questions proposed, iT, in search of it, we were not led to disqui-
sitions that are highly, gratifying to curiosity. From the learned Mr. Bryant's* commeBUiy
upon the word Opb, 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 8«rpeBt
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. The woman at Endor
is called Oub or Ob, translated Python issa ; and Oubaios (he cites from Hortu AppoUo), was
the name of the Basilisk or Royal Serpent^ cn;\bl^m of tUe Qun, and an ancient oracular deitj
• HytholQgy, ToK 1, pp^48, 476 awl 478^
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Relations of Tetanus to Various Nervous Diseases. 231
of Africa. This derivation, which applies to one particular sect, the remnant probablj of a
Terj celebrated religions 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 class of what are called Myal-men, or those who, by means of a narcotic potion,
Bade with the juice of an herb (said to be the branched calalue or species ofaolanum) which
' occasions a trance or profound sleep of a certain duration, endeavor to convince the deluded
spectators of their power to re-animate dead bodies.
As far as we are able to decide from our owjt experience and information, when we lived in
^ island, and from the current testimony of all the negroes we have ever conversed with on
the Ml^^ct, the professors of Obi are, and always were, natives of Africa, and none other ;
sad thn^ 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
usaally 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.
The 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-
eovery 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
accomplices 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 Obeah-men agaiqst any who
ihould betray them ; it is very difficult therefore, for the white proprietor, to distinguish the
Obtohpro/euor from any other negro upon his plantation ; and so infatuated are the blacks in
general, that but few instances occur of their having assumed courage enough to impeach
these miscreants. With minds so firmly prepossessed, they no sooner find Obi tet 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 is then made known among his fellow blacks, that Obi is tet for the thief ; an^ as soon as
the latter heara the dreadful news, his terrified imagination begins to work, no resource is
left but in the superior skill of some more eminent Obeah-men of the neighborhood, who may
cooDteract 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 sensation 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. Steep*, appetite and cheerfulness forsake him, his strength decays, his disturbed
imagination 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 ill, inquires of the
ObeaA-moH 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
•jrmptoms, which originate from causes deeply rooted in the mind, such as the terrors of Obi,
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
powers !of Obi 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
among the negroes of Jamaica to this fascinating mischief."
'* The Obi is usually composed of a farrago of material, most of which are enumerated Id
the Jamaica law,* vis : blood, feathers, parrots' beaks, dogs' teeth, alligators' teeth, broken
hottles, grave dirt, rum and egg-shells."
1760.
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232 Relations of Tetanus to Various Nervous Diseases,
Pert LabcU,* in his history of Martinico, has mentioned some iustanccs of this pnicUc*
which are very remarkable.
** It may seem very extraordinary, that a practice alleged to be so frequent io Jamaica,
should not have received an earlier check 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 io the
last century, have mentioned particular instances of it. The secret and insidiom maimer
in which this crime is generally perpetrated, makes the legal proof of it extremely difficult.
Suspicions therefore have been frequent, but detections rare ; these muderers have sowufumet
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 tncks 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 inhabitiints 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 ia
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 suppres^on and punishment. But neither the tenor
of this law, the strict investigation whictr4kas 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 ColoDies b
the West Indies," (1806, vol. ii, p. 303), quotes the following narrative from a planter
in Jamaica, whom he characterizes as a gentleman of the strictest veracity :
" Upon returning to Jamaica, in the year 1775, he found that a great many of bis negrors
had died during his absence ; and that of such as remained alive, at least one-half wer« 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 began
to decline under the same symptoms. Every means were tried by naedicines, and the most
careful nursing, to preserve the lives of the feeblest; but in spite of all his endeavors, this
depopulation went on for above a twelve months longer, with more or less intermission, and
without his being able to ascertain the real cause, though the 06MAj9rae6fe« was strongly
suspected, as well by himself as by the doctor, and other white persons upon the plantattoa,
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 any
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 very great secret, and acquaint him 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 could
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 forc-
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,
♦ Tom« 11, p. 59, 447, 499, 506.*
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Relations of Tetanus to Various Nervous Diseases. 238
close covered, was found concealed under her bed. It contained a prodigious quantitj of
rouod balls of earth or claj of various dimensions, large and small, whitened on the outside
and rariouslj 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* teeth and claws, or with human or dogs' teeth, and some glass beads of differ-
ent colors ; there 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 bouse
was instantly pulled down, and with the whole of its contents committed to the flames,
flDiidst 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 imaginatioD,
and the power of fear over the animal economy ; because it is well established, that the
nervous 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 worid, and balancing and
cJordinating 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, Schenckius relates the instance of a noble Spaniard, Don Di^o Osorio, who, being
in love with a young lady of the Court, had prevailed 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
was a capital offence 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
person young and old, being turned gray, as in those stricken in years. Moved at the
sight, 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 Emperor Caesar, who was also detected in an intrigue, cast into prison, and sen-
tenced to be decapitated on the morrow.
Dr. Marshall Hall has recorded the case of a gentleman, who was suddenly affected
with epileptic seizures, the effectof fear — the fear of the cholera. After each epileptic
seizure, the hemiphl^c paralysis of die ri^ht 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
slightly opaque, the ventricles containing serum, whilst in the left corpus striatum there
was the remnant of a small clot of blood in a cyst slightly discolored. The arachnoid
was raised in one part by serum, resembling a vesicle, and a small vesicle was attached
to the plexus ch oroides.
On the other hand, the effects of strong mental and moral emotions, as the heroic
enthusiasm 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 patients, at the height of their excitement, seemed to have had their external*
senses literally sealed. " While dancing," says Hecker, " they neither saw nor heard,
being insensible to external impressions through the senses."
Under the influence of fear and fHght, paralysed muscles and limbs that were useless,
have suddenly been thrown iftto ^Uoa, hawnonhaj^oa hftYQ bocn iustautaneously checked.
^
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284 Relations of Tetanus to Various Nervous Diseases.
and fite of the gout, ague, and other disorders of a periodic character have been
cured.
Auger accelerates the progress of the blood, hurrying on the circulation wiUi such
fearfiil impetuosity, as to threaten the brain, and the organs contained in the cheat ;
grief depresses the action of the heart, and causes serous accumulaticflis in ^e large
vessels 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 oil in a slow and
unequal manner ; even excessive joy has been known to occasion as itrange and fiUal
results as anger and grief.
Fienus mentions an instance of a malefactor who was carried out^ as he conoeivedf
to execution ; and in order thereto his cap was pulled over his ey«l, and a cold, wet
cloth being struck hastily about his neck, he fell down dead, under the conceit of his
decapitation. A similar case is recorded by Charron ; — ^a man hftving his eyes cov-
ered to be put to death, as he imagined — ^being condemned* — and uncovering th^n again
to receive his pardon, was found reaUy dead on the scaffold.
It is said, and the statement has been often repeated, that a petson was directed to
be bled to death ; his eyes wwe blinded, and he was made to beMeve, by water trick-
line down his arms, that the sentence was being carried into effect. The miHiiciy is
Miid to have produced death as effectually as would the real op^ation ; the powen 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^ which was crowned with such success, that he died through joy;
Chilon, of Lacedemon, died from joy whilst embracing his sctti, who had borne away
the prize at the Olympic Games ; Juventius Thalma, to whom a triumph was decreed
for subjugating Corsica, fell down dead at the foot of the altat, 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 doubtless to be attributed to the effects produced by the nervow
system upon the sanguiferous system. Dissection has shows that in a laree prc^rtioa
of such cases, the heart and large blood-vessels are either structurally alteied or en*
goiged with blood ; in some cases, death is clcarlv referable to effusions upon the braim
and especially at the base of this organ in the neighborhood of the origin of die respira.
toiy nerves.
I have, by numerous experiments upon living animals, demonstrated to the Medicd
Students of the University, the sudden fatal effects of the ^rrest of the circulation and
respiration, by destruction of the respiratory ganglia, and by 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 abeolut^y
by fear and terror ; but it will be sufficient for the illustration of this subject, to reooid
some instances illustrating the effects over disease of the imagination.
Mr. Coleridge related the following anecdote to Dr. Paris :
As soon as the powers of Nitrous Oxide were discovered. Dr. Beddoes at once ood«
duded 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 accustomed to do upon such occasions, to ascertain the degree
of animal temperature, with a view to fhture comparison. The paralytic man, wh<d]y
ignorant of the nature of the process to which he was to submit, but deeply impressed,
from the representation of Dr. Beddoes, with the certainty of its success, no sooner feh
the thermometer under his tongue than he concluded the talisman was in fhU coen-
tioD, and, in a burst of ^E^tfeusiasm, declared that ho already experien^ the eflkct&oC
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JtelatUm§ of Tetanus to Various Nervous Diseases, 235
Ha benign influence throughout his whole bodj ; the opportunity was too tempting to
be lost ; Davy cast an intelligent glance at Coleridge, and desired his patient to renew
his Tisit on the following day, when the same ceremony was performed, and repeated
evCTy 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 exceedin^y anxious to breathe the gas ; and Professor Woodhouse administered
to Uiem, 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, diz-
nneas, 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 certain 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.
Br. Ha^rgarth 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 ben^tted,
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 nours. 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 lift their arms and 1^, 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 its regulation or repair. Intellect is not omnipotent ; but its actual power over the
organized 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
caQed idiosyncrasies, in any individual case, ought to be regarded as one of the most
essential branches of a medical education.
Plato says : " The office of the physician extends equally to the purification of the
mhui and body ; to n^lect the one, is to expose the otner to evident peril. It is not
only the body, that by its Sound constitution strengthens the soul, but the well regu-
lated soul by its authoritative power maintains the body in perfect health."
Hippocrates admitted that^ that physician perfi}rmed most cures, in whom the patients
placed the greatest reliance.
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236 . Relations of Tetanus to Various Nervous Diseases.
Cvae 66 : Epilepsy ; Death ; Atrophy and Induration of the CefebeUttm.
The patient, a young man, died suddenly in an epileptic fit; or rather the patient became
comatose after the convulsions 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 white matter hardened.
The gray matter of the cerebellum was greatly diminished in amount, and the hardening
was of the mos^ marked character. A large amount of serous fluid, was effused between the
dura-mat(T 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
over the surface, and throughout the secreting structures; the surface 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 hare been preserved in the
Pathological Department of the Museum, University of Louisiana.
The reeulte of the autopsy in this case are interesting, 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
r^arded as merely Hinctional, 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 being
indurated, or softened, the seat of various structural diseases, as abscess, cancer or
tubercle, the latter being inflamed, thickened or ossified ; and Weuiel has stated that
the epileptic state has been invariably found associated with a morbid state of the ^ihrt-
tary body, in the celia tursica.
The occurrence of the epileptiform convulsion in this case, in connection 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 bloocL
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 polarised state of the brain, or of certain parts 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 deariy 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 also 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 wiU
be found upon a careful study of the disease, that a certain per cent, of cases, get well
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 males masturbation and
excessive venery 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 ; whilst a certain proportion
of cases are dependent upon structund alterations of the kidneys, and upon both stnio-
tund and functional derangements of the cerebro-spinal nervou^ system, and often
march steadily on to insanity, idiocy or sudden death, uninfluenced by the most potent
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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 is uncertain, and many cases are wholly uninfluenced by it. In the case of a
stout young man, twenty-six years of age, afflicted 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 aqy 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 Assafoetida, fluid extract of
Valerian, and Acetate of Ammonia, had also given satisfactory results in the treatment
of delirium tremens.
Arsenic, Nitrate of Silver, Atropia and Iron, deservedly hold the first place in the
treatment of epilepsy, especially when combined with proper exercise of mind and
body, change of climate, 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 Der Kolk. He directs the attention of the physician, to
the condition of the medulla oblongata, in cases of epilepsy ; and affirms that he has
frequently succeeded, where the disease has not been of long duration in procuring a
recovery through derivative applications to the nape of the neck ; while the pathologi-
ta) changes resulting from protracted epilepsy are not unfrequently manifested by
induration of the medvUa oblongata.
Professor Schroeder Van Der Kolk concluded his Essay on the Spinal Cord, published
by the Royal Academy of Sciences at Amsterdam, in 1854, wJlh the following general
conclusions :
"The medulla oblongata is the principal centre, whence the more general reflex move-
ments and convulsions, derive their origin. I have for years been accustomed to seek in it
the starting point of epileptic attacks, and consider that to it the physician should direct his
special attention. Even though the primary irritation may be remote, for example, in the
intestines, a morbidly elevated sensibility and irritation in the medulla oblongata, always
Torm the foundation of such attacks, and render the organ in question more capable of, as it
were, discharging itself in involuntary reflex movenients.
'^ An accurate examination of the minute structure of the medulla oblongata, and especially
of the pathological changes produced in it by epilepsy of long standing, which I have often
observed under the form of hardening, yet in reference to which no microscopical investiga-
lions have been made, may still throw much light upon the subject. I have not. yet had
opportanity to put in execution these investigations, to which 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
treatment, which is still 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 upon a better acquaintance with the functions of the medulla oblongata, whence
we must endeavor more accurately to trace the nature and essence of the disease.'^
Impelled by the wish to contribute his share in the solution of this difficult question
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 experience as a pathologist, the microscope ; and after having
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238 Relations of Tetanus to Various Nervous Diseases,
examined the medulla oblongata in not less than fourteen epileptic patients, he brott2:hi
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 oerebroHspinai
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 th^ ganglionic cells, as the puts of
the nervous system whence all action proceeds, and which is conveyed tJirough 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 acca-
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 sadden
spark. Or, perhaps, a comparison with the phenomena in electric fish is still bett^ ,
when, likewise, a violent discharge takes place, which requires some time, 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 ia
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 qoickly
on stimulating through the reflex filaments, and at least when the gangliooAc cells
are discharged some time is necessary befope the reflex action manifests itself anew. If,
however, the action has once begun, the muscular contractions follow ruridly. as in
sneezing, swallowing, coughing, etc. The more irritated the condition of tne cell now
is, the more quickly does the reflex action take place, and the slighter will be the
stimulus to the reflex nerves required to produce a reflex action. If the cell is ex-
hausted, some time is necessaiy, 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 offer 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 state of
strong or weak tension, while, in reflex action, the power of the cell is 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 unexplained fatet,
and infer that the action of the reflex nerves on the ganglidnic cells differs 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 these reflex
cells, as in swallowing, the action rapidly interrupted, is performed by way of discharge.
It has, however, been clearly ascertained, that for the restoration of this activity a cer-
tain quantity of arterial blood is required, on the effect 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 haemorrhages ; but here Van Der Kolk con-
ceives that so many causes co-operate to produce a change in the cell, that we are not in a
state to follow with sufficient accuracy the whole course of active causes and effets 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 medullaiy matter, which consists of conducting filaments. Nowhere did Van Der
Kolk find the quantity of capillary vrssels so great, and presenting such a dense, inter-
woven tissue as in the corpus ciliare of the corpora olivaria ; this body, in fast, affords
one of the most beauti^l capillary net- works to be met with in the system, the vessels
existing here in much greater number than in the gray comua of the spinal cord itself.
Thus also it has been observed that the other groups of the ganglionic cells occurring
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Relations of Tetanus to Various Nervous Diseases. 239
in the medalla obloDgata, as those of the hypoglossus, vagus, etc., with the accessory or
aaxilliary ganglia, are uncommonly rich in blood-vessels.
From these facta the mferenoe was deduced, that more arterial blood flows in the
ganglionic groups of the medulla oblongata, and thus also a more active metamorphosis
of tissue takes place there, than in the gray horns of the spinal cord. Whilst admit-
ting the great vascularity of the arbor-vitae 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 ; ^nd whilst it must
be admitted that many points relating to the functions of these important portions of
the nervous system are not yet settled, still sufficient is known from the results of
direct physiological experiments upon various portions of the brain, to show that these
portions 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 blood supplied to them, are directly relatea to the intensity of their action. The
eapocity for reflex movements is thus promoted by a strong arterial afliux of blood,
which increases the vital actions of the ganglionic cells ; as, however, the ganglionic
groups in the medulla oblongata receive the most vessels, the reflex movements should
also, by preference take place here ; and this again agrees with the function, for exam-
ine, of the corpora olivaria, whereby such different reflex movements as we observe in
no other part of the nervous system, are produced, or with the constant reflex move-
ments, which are incessantly developed from the vagus on the lateral columns of the
medulla, for r^ular breathing. Van Der Kolk hence infers that, other things being
equal, where there is general excitement of the vascular, an increased activity of the
nervous system, involuntary reflex phenomena should, perhaps, ailer the application of
a slight stimulus, first arise in the part in which vascularity is greatest, and where the
natural capacity for reflex phcnpmena is strongest, namely, in the medulla oblongata.
And he regards this extremely probable conjecture as having been converted into cer-
tainty, by the important experiments of Brown-S^quard.
Thus, Brown-^quard found, that if he injured the spinal cord in mammalia, especi-
ally by cutting through one-half of the cord, or the posterior columns and posterior
horns of the gray substance (wherein, as Van Der Kolk has shown, that very fine lon-
gitudinal 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
mnrived this dangerous operation, after the lapse of three weeks, convulsive movements
were excited, quite agreeing in every respect with epileptic attacks, at the same time
^e 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 left side of the face,
pccasioned convulsive movements, while, if applied to the right side, they by no means
had this effect.
This capacity for reflex movement did not manifest itself until after the third week
from the receipt of the injury. The convulsions extended over the whole body, with
the exception of the part paralyzed by the transverse section, and were, consequently,
not unilateral. After some time these convulsions again ceased, and. were subsequently
repeated. The convulsions sometimes arose spontaneously, without any external stimu-
lation ; but among all parts of the body, there is only one where slight irritation was
snfficient 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
above by a line drawn from the eye to the ear ; anteriorly, by one drawn from the eye
straight down to the under jaw ; and inferjorly, by one passing from hence to the ear,
and the lateral parts of the neck, sometimes even to the shoulders ; it consequently
corresponded to Uie 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 bo irri-
tated with impupity^ mi pinched without any result, But if both posterior columuH
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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.
In 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 medulla
oblongata, which is far removed from the injured part. Van Der Kolk hence inferreJ,
that the irritated condition developed by the injury of the inferior dorsal or lumbar por-
tion of the spinal cord, extended slowly upwards to the whole cord, and particularly to thy
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 spa^^ms
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-S6quard has thus, by his experiments, produced an exact picture or mani-
festation of a violent attack 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 affiact the life of
the animals so much that they die before this change in the medulla oblongata has
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 be
first and most violently aflfected 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 uot competent to excite
these convulsions, but according to Brown-Sequard, only irritants, directly applied to
the medulla oblongata are capable of producing such eff*ects. Even irritants applied to
the paralyzed foot, which on unilateral section of the spinal cord, changes into a condi-
tion of hypersesthesia or increased sensibility, do not produce these convulsions.
Van Der Kolk points out the agreement of these investigations by Brown-Sequard,
with the results previously deduced by Pfluger, from a great number of observations,
his conclusion being that, on irritation of a sensitive nerve of the brain, {trigeminus),
the progress of reflex movements is downwards, or towards the medulla oblongata, while,
on irritation of a spinal nerve the progress of reflexion is inverted, from below nipwards,
that is, likewise towards 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. Consequently, a higher degree of irritation
is necessary for the transferrence of the spasms to the opposite side, than for Uieir
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, both
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
r^ard the medulla oblongata as the proximatj starting point in convulsions, such as
t'lose which occur in Epilepsy and other nervou ? aff*ections ; and that iu the m^ority
of cases, the most violent action takes place on the side whence tho irriti^tion 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 arteriaJ blow! is required during its increased activity ; on thQ oA^
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Relations of Tetanus to Various Nervous Diseases, 241
hind, in reflex movements, its activity is commonly rapidly exhausted, and the con-
vulsive motions set at rest ;— to begin again subsequeptly, or to be continually, repeated.
The experiments of Brown-S^quard have shown, that aAer the infliction of a wound
in the inferior part of the spinal cord, a certain morbid condition has been slowly de-
Tdoped ; that is, inflammation has arrived, as a necessary result at the seat of injury,
and a state of exalted sensibility has gradually been communicated to the entire cord,
and finally to the medulla oblongata ; and although the exciting cause, the irritating
wound inflicted on the spinal cord, and the moreexcit^bl^pta^of the medulla oblongata
80 produced, are constant, the phenomena are nevertheless intermittent.
From a great number of clinical facts, it has been shown, that to produce epilepsy,
no disorganisation is necessary, no great change in the tissue, but only increased 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
spinal nerve, the sympathetic and the vagus efiect the same ; thus, in children, oonvul-
rioDS 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 oonti^ the dilator
of the pupil is placed. Thus a stimulus applied to the sympathetic or vagus, from the
Btomach and intestines, acts as 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 iq the medulla
oblongata, as in all parts of the body be kept up ; but if the blood it«elf 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 iron or hsematin appears to be
deficient, and the lymphatic blood globules predominate. By the admini0tration of
ferruginous preparations, and by good feeding, all the nervous phenomena cease, and
even the epilepsy may be dissipated. The same thing is seen in the administration of
strychnia, when the blood is poisoned by the absorption of this powerful agent ; but
al^ough strychnia, which is taken up into the blood, circulate? in it, and therefore
comes in contact and interchange with the medulla, the phenomena are not persistent,
but 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 exhausted ; 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 thiB
ndiation of power, once more attains the heighth, at which only a slight stimulus^ or
even 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-
quently observed, that if an epileptic patient has been attacked by a severe fit,^ he
remains proportionally much longer free ; but if he \i»s had only a slight attack, this is
repeated afier a shorter time, often on the following day, ip a more violent form, and
now again the patient continues longer exempt. Lven the exalted irritability of the
nervous system, and especially iu the medulla oblongata, and in the brail^, which are
reciprocally so closely connected, manifests itself in the epileptic patient before the
attack, very often by greater restlessness and increased tendency to passions, and sohie-
times in an unpleasant sensation, from which the sufferers are again delivered fot a
^e, 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 it« influence to t]ie vaso-motor nerves of the brain, and
this altered, or more or le^s disturbed state of the circulation is^ in the opinion of Van
31
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242 Relations of Tetanus to Various Nervous Diseases.
Ber Kolk, the cause of the loss of consciousness during an attack of epilepsy ; while it
is incorrect to suppose that this loss of consciousness always precedes the attack. He
iieely admits, with Kussmaul, that in an epileptic attack the whole brain participates
more or less in the change ; but the commencement 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 Tessels
of the bndn, while consciousness may in some slight attacks even be maintained, or else
may be lost without convulsions being produced.
We have thus presented in full 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 an exalted sensibility, and excitability of
the medulla oblongata, 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 frequent, it may proceed from irritants which excite it, in involnntaiy
reflex movements, as from irritants in the intestines. In children, worms in the intes-
tines, acidity, 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
very much on the medulla oblongata, and must be regarded as a very frequent cause
of Epilepsy. Amenorrhoea, chlorosis, plethora of the uterus, hysteria, etc., are afco
to be enumerated.
In the commenoement 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 groups
are too strongly irritated, and too quickly overcharged. Every attack then becomes a
renewed cause of a subsequent attack, and the vascular dilatation is afresh promoted by
every 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 ncr\'e filaments is mani-
fested, which may first cause more or less hardening, and may subsequently give rise to
fatty degeneration and softening. In addition, dilatation of the arterial capillaries, and
thickening of their walls ensue.
These blood-vessels in the medulla oblongata run chiefly in the region of the hypo-
glossus and vagus, as well as in the septum, and in the corpora olivaria. The posterior
half of the medulla oblongata in epileptic subjects, appears on a transverse sectipn. red-
der and more hypersdmic than in the normal state, whether the sufferers died during
an attack or not.
Epileptics may be divided into two classes : Those who bite their tongues during the
fit, and diose in whom tb\a never, or extremely rarely occurs. In the former, the capil-
lary vessels are usually wider in the course of ths hypoglossus and corpora olivaria ; in
the^ latter, in the course of the vagus. In these last, the disease is, on account of the
greater tension in the organs of respiration, more dangerous, and the patients die daring
a fit, most frequently in oonseauence of arrest of respiration, which appears to occur
less frequently in patients of tne first class.
This mcreased vascular dilatation, with thickening of the walls, whereby the afflux
of arterial blood is augmented, and the ganglionic cells are more rapidly charged, and
the altered exudation of intercellular fluid, appear Ux constitute the proximate causes of
the incundbility of many long-standing cases of Epilepsy. Lastly, increased exudation
of albumen onoues fcorft tl^e pf>w constantly distenc^eci vea^els, wha^e walls at the a^n^
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Relations of Tetanus to Various Nervous Diseases. 243 •
tiine become thickened, producing increased hardness of the medulla, subsequently
paasiog into fatty d^eneration and soflening, and rendering the patient incurable.
WiUi these changes, vascular dilatation of the brain, and particularly in the cortical
substance, goes hand in hand. Tho small ganglionic cells, which are here present in
such abundance, become compressed by the dilated vessels, and perhaps aJso in conse-
quence of the more albuminous nature of the intercellular fluid. Dullness and loss of
memory are the results ; or if after a fit, im 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 dementia, differs
very much from 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
i^ains his former powers of mind, although not always in a perfect degree, which
depends on the amount of the affection. The dilatation of the vessels, kept up by
no fresh attacks and convulsions, begins by d^ees to disappear, the vessels contract,
r^n their tone, the albuminous exudation becomes absorbed, and the patient
recovers.
In cases, however, of dementia after acute mania, the state of 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 ; they have become rich, play with
millions, are generally kings and emperors, prophets or embassadors from heaven.
There then ensues a formation of cells and granular 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,
and the cortical substance begins to atrophy. It becomes paler and thinner, and true
dementia, which is absolutely incurable, follows the previous sxcitement
Thus, although the phenomena may be the same, as in both cases, there is compres-
sion of the cortical substance, the latter, aft;er mania and the. co-existins inflammation,
passes lapidly into degeneration, and the disease becomes incurable ; while in Epilepsy,
the vascular dilatation, which is only occasionally promoted by an attack, may last for
a long time without producing active degeneration. Patienta have completely recovered
irom 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 an3rthing, 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
moch the more does dullness ensue. — (Professor Schroeder Van Der Kolk, on the
Minute 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 the labors and
views of the latter, as contained in his Researches on Epilepsy, published in the Boston
Medical Journal, November 1856 to November 1857.
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244 Relations of Tetanus to Various Nervous Diseases.
Dr. Brown-S^uard deduces the following conclusions from his experiments, upon
the artificial production of Epilepsy.
1st. That an injury of the spinal cord, may give rise to an epileptiform affeodon.
2d. That there is a relation between certain parts of the spinal oord, and cerCaia
branches of a portion of the nerves of the face and neck. 3d. That epileptiform eon-
vulsioDS may be the constant effect of slight irritations of certain nerves. 4th. That
even lichen an ^ileptiform affection has its primary cause in the nervous oentif«6, some
cutaimous ramifications of nerves not directly connected with the seat of injury in these
centres have a power of producing convulsion^, when other nerves even direotJy oonneetod
with them, have not. 5th. That the ramifications of certain nerves may have the
power of producing convulsions, while the trunks of the nerves have not this power.
In regard to the division of Kpilepsy, into centric and pen'plieral, Brown-S^nard
endeavors to show that even in cases where the disease appears, most certainly, to be of
peripheral origin, it may sometimes be, in reality, of centric origin. To determine
the* fact during the life-time of the patient, is oflcu impossible.
Dr. Brown-S^quard, adducos a nnmbcr of observations from different writers on nw-
vous diseases, which would seem to show that, in the human subject, the peculiar distur-
bances of the cerebro-spinal axis, which constitutes epilepsy, may be generatod by
alterations of different parts of this nervous axis, and by many nerves ; and arrives al
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 diest,
of the face, and in the blood-vessels of the brain proper, showing tluit the disease is
ordinarily seated in the encephalon, 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 spasmodic contractions in one of the limbs, other
the inferior or superior. After the first spasms, all the muscles of the body may be
attacked with convulsions ; so that if loss of the actions of the brain proper, be alone
regarded, there b ground for thinking that the seat of the disease, is both in those ptita
of the cerebro-spinal axis, where reside the faculties of perception and volition, and ia
those endowed with the reflex faculties ; but according to Dr. Brown-S^qoard, this view
is correct only in appearance. Thus he attempts to show, that the loss of pero^)tioo and
volition, does not prove, that epilepsy has its seat in the brain proper, bat 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 suftcient for the production of fits.
Dr. Brown-S^uard believes that Epilepsy is always the result of an excitation of the
cerebro-spinal axis. This excitation he supposes, may, in some cases, arise fton
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^qaaid
admits that such may be the case, when the functions of the kidneys, liver, skin or other
depurative or^ns are suspended, and, in consequence, certain deleterious matters are
allowed to accumulate in the blood, and also in cases where poisonous substanoei are
admitted from without, as lead, strychnine, Cyanhydric acid. Nearly all of these Utter
poisons act only as causes of convulsions by increasing the reflex faculty of the eeiAto-
spinal centre — they give to the nervous centres, the faculty of causing oonTokaons
when they are irritated, but they do not irritate. He knows of no poison which otases
convulsions, by a direct irritation of any part of the nervous system, excepting caiixNiic
acid, when it is allowed to accumulate from any cause in the blood. While it seeoB to
destroy the reflex power of the cerebro-spinal centre, the decari>oniied Mood at the
name time, irritates violently this centre, and therefore causes directly powerfol con-
vulsions.
While he admits that in epilepsy, there is very generally, perhi^ always an increased
reflex excitability, with or without an increa.sed reflex force, he, recognizes also, thai
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Relations of Tetanus to Various Nervous Diseases. 245
there is, in a great many oases of epilepsy, a special kind of excitation acting on the
nerroos centres.
According to Brown-S^uard, there are therefore three distinct elements for the pro-
dncdon of a fit : Ist, Increase of the force of the reflex property ; 2d, Increase of the
exdUbility of this property ; and 3d, An excitation of a special nature, or of a very
violent one. Of these three dements, the last two are the most frequent, and perhaps,
the first of these two ib 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 so to the head, are irritated and pro-
duce a contraction of blood-vessels. Of course this contraction expels the blood, and
in consequence the iace 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 phcDomenon is easily explained, by admitting that the excitation
in the nervous centres takes place near the origin of the third and fifth pair of nerves,
and not of that of the cervical sympathetic, as is the case when the pupil dilates. The
paleness 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
state of amhyxia. The cause of the obstacle to the return of the blood from the head, is
not only tJie 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 b the case in the experiment of compressing the
chest, made by E. Weber and others, and it acts on the veins in preventing the circula-
tioQ in them. Although %»mpressed, and unable to beat ft^ly, the heart quicklv
recovers an apparently great strensth ; the blood losing its oxygen ai I becoming black
acts as a powerAil irritant upon me central organ of circulation, so that palpitations,
sometimes very violent occur. Nevertheless the pulse often remains weak, because the
quantity of blood sent to the arteries by the heart is smaller than usual, partly on
account of the venous circuladon.
Dr. Brown-S^quard, 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 banning 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 contnction 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 svncope. Now as it has been well proved by the researches of
Kellie, Abercrombie, John Reid, Henle, and Folits, that the quantity of liquid, in the
cranio-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 ^inal cord.
Id consequence of the impediment to respiration, the blood sent to the encephalon, as
well as to other narts of the body, contains but little oxygen, and is charged with car-
bonic add, so that the large quantiUes 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-
S4quard has shown that such blood possesses ; i. e. to excite convulsions. It may be as
Henle, has supposed, that the basis of the encephalon, is also excited to cause oonvul-
sioDs, in consequence 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
blood, which circulates in it
Brown-S^quard illustrates, by mesans of the following table, the mode of production
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246
Relations of Tetanus to Various Nervous Diseases.
and the interchangement and sequence of the most interesting phenomena of a com
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
th^ face.
3. Contraction of the blood-ressels of
the Brain proper.
4. Extension, of the Excitation of the
excito-motory 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.
9. Laryngismus, trachelismus, and the
fixed 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.
EFFECTS :
1. Contraction of the blood-resse^s 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 laryngeal,
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 from the
head and spinal canal.
9. Asphyxiw:
•■■/
10. Clonic convulsions everywhere jcon-
' traction of the bowels, of the bladder ; of
the uterus ; erection ; ejaculation ; increase
of many secretions, efforts at inspiration.
1 1. Cessation of the fit ; coma or fatigae;
headache; sleep.
11. Exhaustion of nervous power jrene-
rally, and of reflex excitability particularly,
except for respiration. Return of regular
inspirations and expirations.
We have thus endeavored to present with accuracy and minuteness, the most important
results of the labors of Schroeder Van Dar Kolk and of Brown-Sequard.
Whilst Marshall Hall treated of epilepsy, as an affection of the medulla oblongata,
he failed to point out the distinctive pathological changes characteristic of epilepsy, and
the various diseases of the nervous system, which he classed with it, as apoplexy,
|)aralysis and mania : Van Der Kolk, on the other hand first investigated and disclosed
the organic changes undergone by the nervous system in epilepsy and mania, and thus
placed the pathology of convulsive diseases, upon a firm and scientific basis. Such
labors reflect light upon all the various affections of the cerebro-spinal nervous system,
and they especially furnish material of the greatest value for comparison, and especiaUy
for the elucidation of Tra^umatic Tetanus.
The recent investigations of M. Gonzalez Echeverria, have sustained the accuracy of
the pathological observations of Van Der Kolk, and he has been led to embrace a theory
of the disease, which does not differ materially from that of Van Der Kolk, viz :
" 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-incident with
sudden depression of the cerebral circulation and with loss of consciousness, with or witboot
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 autopsies
of epileptics.
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Relations of Tetanus to Various Nervous Diseases. 247
The observations of this pathologist upon the lesions of the sympathetic are important.
Granular d^eneration, 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 disturhance, 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
fifteen 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
the injured ganglionic cells and those of the medulla, or in thd middle and between the
corona 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, suflBcient 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 clympathetic cells. Neither did he arrive at distinct results every time; on
iovestigating the net-work or nervous plexus around the cerebral arteries, participating
in advanced cases of tho 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 paralyzed muscles, in cases of epi-
lepsy, attended with paralysis, to the lesion of the sympathetic. The fact is principally
exhibited by tho 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 ganglion ary roots and peripheral extremities of the
dorsal nerves, in a case in which a herpetic eruption of zoster encircled the base of the
breast.
Thei 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 r^ons. As to the nerves connected with the eruptive patches,
they had undergone a fatty degeneration of the primitive fibres, with the same rank
growth 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 skin commonly observed with epileptics. These phenomena are in accordance with
those pointed out by Recklinghausen and Baerensprung, in the case of an infant with
unilataral zona* on the breast ; more recently, Charcot and Cotard had likewise reported
ft case of alteration (neurits), of the right cervical . plexus, and corresponding spinal
gang^ionio 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
EpSepsy. Thus, he says : -
"There appears from the onset of the epileptic disease, a disturbed action, and wbetber due
to the slowness, or complete stoppage in the supply of blood, or to a priraaTj trouble in the
nenrous elements, it soon brings a structural modifieation of the blood-vessels. And it is
not less positive that' the metamorphosis commences with paralysis and dilatation, and closes
with a retrograde or fatty degeneration 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
contraction in the calibre of the blood-vessels, on account of the lengthening associated with
it, which could proceed only from a' lack of tonicity in the vascular walls. Even when a
thrombus or migratory clot obliterates an. artery, causing stagnation of bipod, the aneuris-
mal dilatation acknowledges as cause, in great part, the weakening of the vascular walls.
However, in this latter circuibstaftce, there are two more important elements to take into
account; the increased .tension of iSlood, in consequence of the obliteration of the vessel, and
the reflux' of venousi bh)od from wart t of mt-a-tergo in the artery, as imagined by Vircho^.
To the impedimeot iu the local circi^l^tion musf be r^ferre(i thecltct^nft^ctibi^^ 'ftbRormJ^Utiea
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248 Relations of Tetanus to Various Nervous Diseases.
in the stracture of the nervous centres, and the thickening or growth of granuUtloDs and
adyentitious patches in the cerebio-spinal membranes. These adyentitious deposits do not
belong, as generally supposed, exclusively to old age. I have not seldom eneonntered then
in indiyiduals dying in the prime of life from epilepsy or other cerebro-spinal affections." —
(On Epilepsy, Anatomic, Pathological and Clinical Notes, etc., New York; 1870, pp. Ill-
178).
It would be foreign to my purpose to enter into any critical examination of the vari-
ous views which have been propounded, with reference to the nature and causes of epi-
lepsy ; the preceding analyses of the labors of those observers 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 diaiinct
and reoogniKable lesions have been detected in the cerebro-spinal and sympathetic
nervous systems. The following cases will, in like manner, establish the existence of
ttructural lesions of the nervous system in various forms of paralysis :
Owe 57 : Loss of Muscular and Nervous Power — Paralysis — Death ; Stmctural
Lesions of Nervous System,
The history of this case resembled, in some respects, that of the succeeding ; the subject
being, in like manner, a negro man, faged 50 years), who bad been working during the last
two years upon a rice plantation, his duties compelling him to stand in water abore bis
knees. Previous to this occupation, had been a healthy, stout 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 extrVmities was grad-
ually lost. The paralysis appears to have begun in the lower extremities, and the lower ex-
tremities were said to have been oedematous before being paralysed.
In the month of August the power of locomotion was lost, and the patient becane bed-
ridden.
The cedema of the lower extremities disappeared during rest ; the rheumatic pains, bow-
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 sisc. Has bad no
trouble in defecation or urination.
At the present time, skin warm and moist ; temperature of axilla 99^.5, and patient lies on
his back; subsultus tendinum, 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 jpmdually im-
proved since his 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 appears 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
confined to bed.
The flexors of the fore-arm were firmly contracted ; and the muscles of the for«*anBt and
legs wasted considerably. Strychnine and Iron appeared to accomplish no good in this case,
and death occurred March 31st, 1869. Up to the time of death, there was no alt«ratioB of
sensation, notwithstanding the paralysis of motion.
Autupty, five hoyrs after death, — The brain and spinal cord were carefully removed. The
gray matter of the brain and spinal cord was of a deep reddish gray color. Blood-vessels of
arachnoid and pia-mater congested with blood. The arachnoid of the medtilla oblongata
^nd superior portion of the spinal cord was 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 gray matter softened*
The brain and spinal cord of a patient that had c(ied with phthisis pulmonalis were remoreU
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 soft^tied. Liver pf sl^t^ and bi^nu
color, with a patch of incipient fatty ^^g^n^ration^
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Relations of Tetanus to Various Nervous Diseases. 249
Mkrotfopkal Examination of Xervout Structures. — The colored portions of the spiaal cord
were doe to a deposit of coloring matters in the form of grannies or crystalline masses in and
uroQod the meshes of the blood-vessols of the dnra-mater. The coloring matter appeared to
b«re been derived from the colored blood corpuscles.
. The gray matter of the cerebellum, medulla oblongata and spinal cord was entirely changed
in its Appearance, as in the case of insanity and tetanus. It presented a deep reddish^ gray-
ish tod pink color, from the great enlargement and increase of the capillaries. The gangli-
onic cells had disappeared to agreat extent, and their place was occupied by enlarged capil-
laries. Masses of hseroatin were also discovered amongst the nervous structures. Many of
the oerve cells were filled with granular matter.
Comparative examinations were made with a healthy brain and medulla and spinal cord,'
ind 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-fourth as
Domerous as in healthy nerve-structures.
We have here, as in the preceding cases, grounds for referring the aberrated nervous phe-
nomena and paralysis during life, to palpable structural alterations of the ganglionic cells
and capillaries.
In the followiug case, which occurred in my hospital practice, Elevhanttaiis of tli6
lower extremities was accompanied with paralysis agitaru aqd atrophy of the tpttttl
ctsrd'. 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 nineteen days. When the patient entered Ward 13, on the 19th of October, 1871, .
both legs, from the knees downwards, and the feet were much enlarged, and the surface
of the extremities presented a nodulated and livid appearance. The enlargeBtent of
the extremities was due to the hypertrophy of the integuments, and I re^irded 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 whefl the
patient made any motion. Stephano walked with difficulty, with a tremulous, uncer-
tain 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, aod ai the end of eight months from
his entrance into the Hospital, was permanently confined to his bed, from a totaljna^
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 gradually decr«^ed in size, and at the time of
death the integuments presented a shrivelled appearance. The intellect appeared to be un-
affected throughout the disease. After death, I exposed the spinal cord, and found it to be
hardened and atrophied. The gray cells of the cord were diminished in number, and
the white commissural matter was much harder than normal.
G/te o8 : Patult/gfs; progressive failure of muscular and nervous poioer ; Death;
Stntciiiral Lesion in Spinal Cord.
Negro man ; aged 45 years ; native of Louisiaun ; liailhved and worked all his life on a
sagar plantation, where he was often necessitated to work in water, and was subjected to the
Action of malaria.
Admitted to the Charity Hospital, January 8th, 18G9; patient states that be has suffered
dariog his life with frequent attacks of malarial lever, of the intermittent form; last July,
whilst working every day in deep water, often without eating food until night, began to suffer
Vith pains in different parts of bis body, but more especially in the lower extremities; these
pains grew worse from day to day, and about Christmas he found that he had lost the power
of nsing his legs, not being able to walk without great difficulty.
Daring the summer and fall months, tha patient, had suffered much with cephalalgia and
>nter!nittent fever. Has never had syphilis. At the time of his admission suffered from con-
stipation of the bowels; but the bowels were reguloted under the use of Strychnia, Iron and
Aloes.
Magneto-electric shocks, seemed rather to inor^s^Q? than to benefit the loas of nerxoua
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250 • Relations of Tetanus to Various Nervous Diseases.
power, and this agent was conseqaently abandoned. The patient had been kept upon small
doses of Strychnia and Iron, with benefit. At the present time, the patient has but little os«
of the lower extremities, cannot raise himself from a sitting to a standing posture, except bj
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 btep, without holding
to a support ; by the aid of two walking canes he can walk slowly across the floor, by rooT-
ing his feet about two inches at a time, dragging his toes along the floor. Paralysis of the
flexors of his legs in his efforts to walk, the feet appear to be raised by lifting the entire leg,
by means of the muscles attached to the hips ; subsultus tendinum in left leg. General sen-
sation and reflex action, unimpaired ; no failure of special senses; intellect as bright as nsual
in his race ; digestion normal ; thoracic and abdominal viscera in healthy condition.
In this case, 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, subsultus
tendinum 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. The powers gradually failed, and he died
apparently from exhaustion of the circulatory and respiratory systems.
The brain and spinal cord, were taken out and carefully examined. Nothing special was
noticed in the cerebrum and cerebellum, but the 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 hsematin in the cellular tissue.
The blood-vessels of the pia-mater of the spinal cord, appeared to be larger and more
numerous than normal.
When a section of the cord was made, the 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 fllled with colored granular masses, and some also contained 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. The change in the capillaries was marked.
Casi 59 : — Negro man, aged 63, a cooper by trade, who had been quarterea 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 the first chill, and these have gradually Increased
in intensity. During the last four weeks the patient has gradually lost power in the upper
extremities.
February 6th. The patient complains of sensations uf cold in arms, and keeps them
wrapped up in flannel ; pains in lower extremities and back, in lumbar region ; some sub-
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
unsteady, swinging gait; complains of stiffness in the back, and of inability of standing
erect; unable to arise from the sitting posture; unable to retain his water and faeces ; invol-
ifQtary micturition and defecation occurring, if ho does not obey the calls of nature at once ;
arcuB senilis present ; some enlargement of the parotid gland on the right side ; no loss ot^
sensation ; tongue moist ; back of tongue coated with yellow fur, tip and edges clean and red ;
appetite ^oo(i[, bowels regular ; slight cough, with bronchial expectoration; sounds of heart
feeble, and not well defined; pulse soft, weak, irregular 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 ]^5th of February, when he had a chill
followed by fever. On the night of the 15th, th,e patient took tei;^ gtaiixs of Blue Mass, which
was followed by fifteen grains of Sulphate of Quinia, ox^ the 16th. The bowels were «^ve4
frequently, f^nd the discharge passed involuntarily; and the patient appeared much ex:haiut-
ed ; and Id sleeping the left cheek appeared flabby, and there was a puffing of the lelt tec^
cinator during respiration.
Stimalanti au4 QQtrUi.QVi? 4Ut (^PR^&red to exert no beneficial effects, and t^he patient gradax
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Relations of Tetaius to Various Nervous Diseases. 251
•Iljgank and died on the I8tb. Consciousnesi aad iDtelligence were retained to laetthe
moment.
Avtop^f three kour$ after death. — The poBt-mortem was performed three boars after death,
and the brain, and spinal cord and viscera, exhibited to the Medical Class. Stractares
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-
colar fibres were generally healthy in appearance, and presented well marked strie; 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 anaemic condition of the blood, and to incipient fatty degeneration.
All the cavities of the heart contained clots firmly attached to the muscular columns and
Tslrular cords. The right auricle was especially distended with an enormous clot, which,
vhen removed, presented a complete cast of its interior. These clots were composed of two por«
tioDs, a well defined, fibrous, light-colored, dense, elastic portion, and coagulated blood. From
their compound and laminated structure, they had evidently been partly formed daring 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 affected muscles were exhibited, and presented « red, healthy appearance, quite differ-
ent from that of muscles undergoing fatty degeneration, or progressive atrophy. After eare«
fal microscopical examination, it was impossible to discover any marks of disease in the
mascles, even in those which had been most completely paralyzed.
The entire bruin and spinal cord were exposed. To the naked eye no structural altera-
tions could be perceived upon the exterior. There were no marks of inflammation of the
membranes, and no deposit, or tumor, or abscess, which woul^ 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 difiBculty is experienced in such examinations, as the modes of hardening the nervous
structures, 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, patholo-
gists have failed to detect well marked lesions of the cerebro-splnal system, in the paralysis of
lead-poisoning, of mercurial cachexia, and in the tetanus produced by wounds and strychaia.
The cerebral function in this case was unimpaired, and sensation and reflex action wer^
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 boms of
the spinal cord, which may be considered as the origin of the anterior roots of the motor
nerves.
Microscopical investigation was directed to tbe determination of the condition of the
ganglionic cells of the anterior horns of the spinal cord ; it appeared that they were
diminished 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 larger, aad
their walls thicker than in healthy nervous structures.
GENERAL CONCLUSIONS AS TO THE NATURE AND PATHOLOGICAL LE&IONS OF TRAU«
MATIC TETANUS AND OTHER DISEASES OF THE NERVOUi SYSTEM.
Prom the preceding investigations and researches into the patholc>gical 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
most 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 reddenitig is produced at irr^ular intervals in its course
by the injection of its neurilemma.
2d. in Traumatic Tetatius, the blood-vessels of tbe cerebellum, medulla oblongata
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262 General Conclusions on Pathology of Nervous Diseases.
and spinal cord, and especially of the gray matter of the medulla oblongata and spinal
cord, are dilated' and congested.
' It is possible, by cold and irritants applied directly to the cerebellum, medulla oblon-
gata aod superior portions of the spinal cord, to produce dilatation and congestion of
the blood-vessels, and the congestion thus produced, is attended with exalted and aber-
rated abtion of the cerebellum and spinal axis, an'd spasms of the voluntary muscles,
resembling^ the abnormal nervous actipii characteristic of Traumatic Tetanus. We are
therefore compelled, in view of these facts, to regard the dilatation and congestion of
the small arteries of the cerebellum, medulla oblongata and spinal cord in Tetanus, as
of great importance, and as indicating, not only an iiicrijased functional activity in
the central ganglionic cells, but also paralysis or arrest of ths action of that portion of
the sympathetic nervous system which presides over the circulation of the ccrcbdhim,
medulla obloi^ta and spinal cord.
3d. When the dilatation and congestion of the blood-vessels of the cercbelluiu and
X'nal axis, characteristic of Traumatic Tetanus, are examined in the light of careful
ysiologi<»d experiments, they appear to he dependent upon some arrest or alteration of
the- influence supplied to the unstriped muscular fibres of the minute arteries, leading to
dilatation of. their diametres, and enfeeblement, if not complete arrest of the normal
peristaltic actions. The gray cells of the cerebellum, medulla oblongata and spinid cord
are thus supplied in Traumatic Tetanus, with an increased amount of blood, even when
there is no mcrease in the force and fre<|ueiicy of the heart's action. The sympathetic
nervous system, which regulates the circulation of the blood in the minute arteries,
appears to be involved in Traumatic Tetanus.
4th. It is difficult to determine the exact relationship of the disturbances in the
two systems of nerves, viz : Whether the irritation is reflected from the wounded «ur-
faoe, first to the ganglionic cells of the cerebro-spinal system, and secondarily to those
of the sympathetic in the spinal axis, 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
lesser upon the greater, in highly organized animals, for a continuous supply or renewal
of nervous force ? or whether the influence affects primarily the ganglionic cells of the
sympathetic system ? It would appear that after the establishment of the state of in-
creased functional activity in the ganglionic cells of the spinal axis, there is at least an
enfeeblement of the sympathetic system, and especially of that portion which presides
over the circulation of the central ganglionic masses ; and the question arises, whether
thb impairment of its normal functions be due to a diversion of the nerve force ordi-
narily received from the cerebro-spinal system?
If the vaso-motor nerves be connected with the motor and sensitive ganglionic cells,
as well as with sympathetic ganglionic cells in the spinal cord ; and if the arteries are
normally kept in a due state of contraction, and the capillaries duly retentive of their
contents, by the influence propagated continuously from the sympathetic ganglionic
oeUs, then it is evident that if ths motor and sensitive cells be over-excited, the
nervous influence may be withdrawn from the sympathetic cells, and through them
from the vaso-motor systsm, and engorg^mjnt, elfusijn and alteration of narvous struc-
ture result.
When, therefore, the condition of superfunctional activity is established in the motor
and sensitive cells of the spinal axis, by the transmission of the irritation along the
nerves connected with the injured parts, this very exaltation of nervous acUon tends
to propagate and perpetuate itself by withdawing the nervous influence from the
vessels upon which the ganglionic cells depend for the proper supply of nutritive mate-
rials. We are thus enabled to understand why a certain length of time elapses between
the reception of the injury, and the manifestation of the tetanic spasms.
By these inquiries, and by this chain of reasoning, we are led to the conclusion that
the irritation is transmitted along the injured nerve to 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 oblongata and ganglionic masses at the base of the
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General Conclusions on Pathology of Nervous Diseases. 253
brain are involved, and the gradual exaltation of the nervous force in the motor and
sensitive cells is attended with a corresponding 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 congestion 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 organizable material from the congested blood-vessels ; proliferation of the con-
nective tissue of the medullary substance of the madulla oblongata, of the inferior
peduncles of the cerebellum, of the crua cerebri and of the spinal /;ord, producing a vis-
cous mass abounding in nuclei and nerves progressing 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 distension with their natural con-
tents.
The pathological lesions of the spinal cord in Tetanus, are frequently of surprising
extent, consisting of disintegration and softening 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,
bat sccDndary ; they are the results of, 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
medulla 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 preceded the establishment of the
diseaded action. The lesion of the spinal cord in Tetanus, consisting of exudations and
dimDt^ip*ations, are similar in character to those observed in Insanity, Paralysisi and
Epilepsy ; 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
spasms ; 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 :
Ist. Peripheral irritation of the injured nerves
2d. Extension of the peripheral irritation to the ganglionic cells of the segment of
the spinal cord, connected with the injured nerve.
3d. Extension of the irritation to other segments of the spinal cord, and especially
to the medulk 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.
5th. Congestion of blood-vessels, hypersemia, and morbid state of blood-vessels of
spinal axis, and especially of gray matter of medulla oblongata and superior portion of
spinal cord.
6th. Exalted reflex actions, morbid excitable conditions of gray substance of cord
and cerebellum, and tetanic spasms, trismus, emprosthotonos, etc.
7th. Exudations and transmigrations of colorless corpuscles from the distended
vessels, and structural alterations of nerve cells and fibres.
8th. The character and extent of the pathological lesions discovered in the spinal
axis after death from Traumatic Tetanus, will depend in large measure upon the duration
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254 Relations of Traumatic Tetanus to Climate.
of the disease. Thus, if the patient dies, in the earlier stages, from sudden s{>asiii i*t
the respiratory muselcs, or of the epiglottis, little else will he discovered besides dilata-
tion and congestion of the blood-vessels of the injured nerve, and of the medulla
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 (• large
number including all those who have made careful sections and microscopical examina-
tions of the cord, holding to the existence of distinct recognizable lesions ; others who
have only superficially 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^ a« sudden changes of temperature, extremes of
heat and cold, and variations in the moisture of the atmosphere, appear evidently to
induce such changes in the toound, and in the nervous system, and in the entire organism,
as favor the development and progress of the disease.
RESEARCHES PROSECUTED WITH THE DESIGN OF DETERMINING THE RELATIONS OF
CERTAIN EXTERNAL CONDITIONS, AS CLIMATE, SCDDEN CHANGES OF TEMPERA-
TURE, EXTREMES OP HEAT AND COLD, AND VARIATIONS OF MOISTURE TO THl
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 oftener
in sultry than in temperate climates, and prevails more at the hot seasons, or during
sudden changes from hot to cold, especially in a moist 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 after gun-shot wound. Anion;;
the wounded in the battle of the Pyramids, five were attacked with tetanus occasioned
no doubt, by the humidity and coldness of the night. Afler the combat of El-Arieb,
the wounded were put into tents, on a damp soil, exposed to continual rains. Eight
were seiied with tetanus, which presented itself under all its symptoms, and terminated
in death, on the fiflh 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 seiied with tetanus. Its rapid progrefis
and the situation of the wounds, in the head, trunk, or superior part of the thigh ren-
dered all assbtance of no avail.
Baron Larrey observes that :
** In cases in which cold contributes to the development of tetanus, the irritatioo truns-
mitted from the wound to the nervous system, is augmented by the suppression ofcutaneosi
perspiration, which extends its effects to the organs and principally to the paru 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 anastomosef
render them liable in the slightest impressions, to violent irritability which causes the con*
traction of the muftcles of these regions, in such manner, as quickly to interrupt deglutiiioa
and respiration."
Baron Larrey remarked, both in Egypt and in Germany, that Tetanus was not often
t(AUsed by Wounds, unless the temperature of the atmosphere pass suddenly from one
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Relations of Traumatic Tetanus to Climate. 255
extreme to another. The wounded who were exposed more especially in the spring, to
the cold 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-
tare of the air was nearly uniform. Hence he concluded that this change of temperature
a & predisposing cause of tetanus, and that surgeons should guard against it in their
treatment of the wounded.
Dr. R. Huck, physician to the English Army, in the last century, states that of
thirteen wounded men, whom he had seen afflicted with locked- jaw ^ 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 very wet weather, which had
sncceeded a continuance of dry, most of those wounded by fire-arms were attacked by
Tetanus on the 14th day.
Dazille, Campet, Rush, Chalmers, Curling and 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 $pecies of tetanus or locked jaw^ 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 perish,'^
Vol. ii p. 352.
Sir Gilbert Blane, in his Observations on the Diseases of Seamen, thus attempts to
explain why Tetanus
"Is more frequent in hot than in cold climates. External beat, even when it exceeds that
of the liTiDg body, has 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 general mass of the bodj, all the effects produced by it
must depend on impressions made on the surface of the bodj and lungs ; and the skin which
inajr be considered as a large expanded tissue of nerrous fibres endowed with universal sym-
pitby and great sensibility, affects every organ and every function of the body, according to
ihe state of the air, in contact with it, whether cold or hdt, moist or dry, p0re or vitiated.
The same 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 are open, that the impression of the air on the skin produces catarrhs, rheumatisms,
sod internal inflammations in cold climates ; and the external temperature in hot climates,
being such as to keep the pores almost always open, this seems to be a principal reason of
that oniversal irritability 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 diarrhoea, and this as quickly disappearing a pain in the foot would rise like an attack of
root. All this would happen in the space of a few hours. (Observations on the Diseases of
Seamen, ad Ed. 1799, pp. 564-566).
The same circumstances appear to induce the disease in animals.
Harirel d'Arboval relates, that twenty-four horses were castrated on the same day, at
Bee, in the department of TEure. They were afterwards le4 four times in the day,
dmrogh A pond of water supplied from a very cold spring. Sixteen of them died,
between the tenth aud fifteenth day after the operation. At Reqnes, a horse after
castration was exercised, 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 V^t^rinaire, torn, iv, p. 263).
After the battle of Bautzen, the exposure to a very cold night, produced over a
hundred cases, and after the battle of Dresden, when the wounded were placed in like
circumstances, t^ey lost a very large number from tetanus.
Baudens, gives a very interesting instance from his African experience, showing the
iofloence of cold and moisture, in producing this disease : forty slightly wounded men
were placed, in the month of Docewber, apd during the preYaleq<?e qf ^ northeast wind,
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256 Relations of Traumatic Tetanus to Climate.
in a gallery on the ground floor, winch was open to the north ; fifteen different cases
of tetanus appeared in a short time —among this number, twelve died. The remainder
were removed to a more sheltered place, and these were no more attacked.
Opposite extremes of temperature, appear to cause similar effects ; thus in the Indies,
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 178*i,
thirty were seized with tetanus, and seventeen died.
Dr. Kane, during his explorations in the Arctic regions, 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 his " Report upon the Cases of Tetanus in the Jamjetzee Jejeebhoy Hospital.
Bombay, from January, 1845, to December, 1851," Mr. J. Peet, Assistant Surgeon to
the Hospital, states that during these seven years, 195 cases of Tetanus were adndtted
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 26f).
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 is
much more frequent in Bombay than in other parts of the world, and that, contrary to
the experience of the disease in other places, it is more severe and fatal than the tran-
matic species ; and that it is often traceable to direct exposures at those seasons, daring
which there are the greatest alterations of temperature. — ^Trans. Med. and Phys. Soc-
of Bombay, No. 1, N. S., Bombay, 1853.
Mr. Waring, in his " Notes on the Diseaseas of India," has recorded valuable ob-
servations upon the relative frequency of the occurrence of Tetanus, of which the fol-
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 hi seen by a perusal of the following statement, showing the deatlu
from. Tetanus in the town of Bombay, for a period of three years, 1851, 1852 and
1853:
TOTAL
DEATHS.
I DEATHS I
; FROM PUOPORTION.
TETANUS.
1851 1 ] 4,724 332. One death from tetanus to 44 from all canseg:
1852| 13,763 341 '• *' 40 »* '*
18531 14,164 I 239 *• " 39 '• , '*
I 42,651 I 912' |One death from tetanus to 46 from all causes. _^
Large as this number is, both absolutely and compaiutivdy, it is sUH below the
mark, as under the heading of total deaths are included still births, whikt under thit
of Tetanus is excluded that peripheral form of the disease, which is both irequent and
fatal in Bombay. There is no means of comparing the proportion of tetanic dea^
in Calcutta and Madras with those of Bombay, but tf an opmion may be formed firom
hospital returns, it appears that the disease is not of so frequent occurrence in Calcutta
as in Bombay. Thus, in the Calcutta General Hospital, (Dr. Jadcson ; India Annab
of Medical Science, No. 1, 1853, p. 58), during five years, (1847-51), only 56 were
admissions mth Tetanus, whilst at the JamjetJiseo Jejeebhoy Hospital, (Mr, Peet, Bom-
bay Med. Trans., No, 1, N, S., 1853, p. i;, in Bombay, during a period of seven ymSy
(1845-51), the admissions under this heading, amounted to 195.
Compared with more temperate climates, the ratio of deaths from Tetanus apf«(
Still more striking ; thus we find the following proportioa to QWt;
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Relations of Traumatic Tetanus to Climate.
257
liOndoD....
Ireland ....
New York
Bombay...,
PBRIOD.
1850-3-4
1831-1851
1819-1834
1851-1853
TOTII,
DBATHS.
DBATH8
TBOM
TBTAKU8.
224,515
1,187,374
83,783
42,651
73
238
112
912
PBOPOR^H
1 in.307.5
1 in. 4987
I in. 748
1 in. 46
The proportion existing in Bombay, taken in this light, cannot bat be regarded as
very formidable.
Influence of Seamm. — 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 lc)cality during the^ period of its pifevalence? 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.
MO NTU 8.
February ...
March
April
May
Jane
Jaly
AogQSt
September.
October
NoTember..
December...
Janaary ....
Total
1851 1852
32
35
36
22
34
21
24
28
24
35
29
21
1853
332 341 239 912
Total.
74
85
83
75
76
69
70
77
79
86
82
50
Total Deaths in Quarters,
and. per cent.
y 242, or 26^5 per cent.
>-220, or 24.1 per cent.
► 226, or 24.9 per cent.
\ 224, or 24.8 per cent.
This table shows that in Bombay, seasons per se^ exercise no influence on the mor-
tality in Tetanus, each quarter presenting very neiu*ly the same proportions of death.
A slight increase is observable in the month preceding the rains, (May), but nothing
sufficiently 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 are, equally with Bombay, very slightly elevated at>ove 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. Banking and C. B. Radcliff, July,
1856, pp. 55-56.
From an important " Report of Seventy-two Cases of ^fetanus, occurring in Guy's
Hospital," ^m 1825 to 1857, by Alfred Poland, we extract the following statistics,
illustrating the relations of Tetanus to climatic causes :
In 32 full 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 11,052 total deaths, or 0.56 per cent. Of these, all but three had a co-existing or
previous lesion of the surface ; they were called Traumatic, and hence might be ranked
and included under the surgical class of oa^ea* Thus^ there will be 96 cases of Teta-
nus, with lesion of surfke, to 64,368 cases ^dmitt^ Yrith external lesion and surgical
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258 ^ Relations of Traumatic Tetanus io Climate.
disease, being 0.107 per cent.; and 61 deaths from Tetanus, to 4,218 cases of dettbs
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 admissioDs
were of Tetanus, and 3.9 per cent of the total deaths. Dr. Leith, R^istnr 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 yean, ia
345,132 total deaths, 110 of Tetanus, or 0.031 per cent. In England, in the sane
space of time, the total deaths are 2,431,602, and 759 are of Tetanus, being 0.031 per
cent.
A reviewer, in the October number of the American Journal of the Medical Sdeooes,
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
36 were males and 14 females ; the total deaths during the same year beine, 28,568, we
have one death from Tetanusin 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 ), we have, that from the Ist of Januaiy,
1807| to the 1st of January, 1827, in a total of 53,004 deaths, in Philadelphia, 125
wore ttom Tetanus, giving 0.236 per cent. ; from 1st of Januaiy, 1827, to the lit of
Janaarv, ISSO, there were 29 cases, in 16,579 deaths, giving 0.175 per cent. ; from 1830
to 1840| there were 51 cases, in 49,686, giving 0.103 per cent. From these data, the
disease would appear to be ooming less common in this dty. In Massachusetts, in Ife
years, the total number of deaths fh>m all causes, was 104,873 ; of these, 55 wereftoa
Tetanus, 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-
tions than in England. In Charleston, S. C, in 1856, in 1,428 total deaths, 57 wen
from Trismus Nasoentium, and 6 from Tetanus, giving for Tetanus a percentage of 0.43,
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 exam^e, from April,
1857, to April, 1858, there were 8 deaths fVom Trismus, and 2 from Tetanus, amoog
the whites, and 37 fit)m 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. xxxvi. N. S. 1858, p. 476.)
I have careflilly 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 relative mortality from Tetanus, aud the relations of thb disease to CiioMte.
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Relations of Traumatic Tetanus to Climate.
259
Deatkt from Teteumi tack month, and total yearly deaths from all catues, in Saoannah^ Oeorgia^
among$t the white inhabitants, during a period of fifty years j 1804-1853, inclusive.
IPOPULA-
TBAR. TION,
WHITES.
Jan.
Feb.
Mar.
Apr.
May
Ja'e
July
Aug
Sept
Oct.
Not.
Dec.
Death
from all
Caases.
1804
2799
1
207
238
159
230
219
183
163
212
226
214
300
233
272
461
211
510
817
385
291
268
136
126
235
1805
1806 •
1807 ^
1808 3010
1809 «
1810
1811
1812
1813
1
1814
1
1815
1816
1817
1
I
1818 •••••.••
1819
1
1820;.
2
1821 ^
1822.,
1
1823 1 :
1
1824
>
1825
1826
1
1
1
1827
321
146
1828
1829
209
1830
1
159
147
1831
... . 1
1
1832
1
216
1833
202
1834
197
1835
228
1836
1837
1
249
358
1838
331
1839
1
1
I
367
1840
5888
380
1841 ,..
1
±
305
1842
1843....,._
272
256
1844
2
1
1
1
1
247
1845
1
1
1
1
1
1
229
1846
1 1......
1
1
1
240
1847
1
3
210
1848
7250
1
3
298
1849
1
1
1
2
357
384
1850
8395
1
1
1851
1
414
1862
1
642
1853
1
1 1 1
1
1
1
470
ToUl, 60 y'rs,
1804-1853
9
4 4
4
3
4
8
4
7
5
3
3
14,332
In Savannah, Georgia, during a period of 50 years, 1804-1853 ; out of 14,332
deaths occurring amongst the whites, from all causes, 58 are recorded as caused hy
T^us, under the several heads of Tetanus, Locked-Jaw and Trismut Nasceotium.
fhi8 would give amongst the whites, one death, from Tetanus, in 229.8 deaths Awn aU
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260
Relations af Traumatic Tetanus to Climate.
causea. These st«tiiti08 do not, however, represent the entire number of deaths from
IteniiB, and especially from Trismus Nasoentium, for a large number of deaths oocarriog
j& Jii&iiey^a short period after birth, are recorded simply under the head of Spasnu and
Convuhionty as will be seen from the following table :
DtaUuJrom Spa$mt and Convidsiont amongtt the w.Mtai in Sdoann ih, Oiorgia^ durinj a period of
fifty years, 1804-1853.
■•
«-4
S
CP
p*
;
:
IT
2.
•-1
c
>
a
:
:
?
T3
0
35
0
<
Total
Death!
from
SposmB.
R B M A R K 8 .
1804
1
2
2
1
2
2
1
2
1
1
0
Ij 2
"2;"l
11
7
10
13
1805
I
2
1
1
?! "
1806
1807
2
1
1
1
1
...
1
1
2
2
2
1808
5 i
1809
1
2
1
4
4
8
2
3
10
3
4
9
8
6
14
9
7
11
18
10
6
9
3
11
7
13
6
8
8
11
7
5
13
6
7
14
15
25
27
26
33
21
24
37
69
65
1810
1
1
1811
*i
2
3
1
1
....
One case, 3 days oM.
One case, 8 days old.
Two cases, 10 days old.
1812
3
1
...
...
1
1
U13
1814
...
1
2
*1
I
1
1
....
1815
1
2
...
1
1
1816
1817
3
1
"l
1
1
1
...
1
1)818
1819
1
...
1
1
'2
1
1
1
4
2
3
4
3
1
4
1
1
3
1
4
"2
2
5
2
1
"2
1
1
1
2
1
1
"1
1
1
1
1
1
3
1
1
Two cases, 8 days old.
One case, 7 days old.
One case, 4 days old ; one 7, and one 14.
One case, 13 days old.
One case, 7 days old.
Two cases, 9 days old.
Two cases, 6 days old.
One case, 3 days old ; one 7, and one 11.
1820
1
...
...
2
"1
1
1
1822
..!
'l
2
1
1
1
1
1
1
2
3
...
1823
1824
...
1
1825
1826
1827
1828
1
1
1
*i
1
1
1
3
1
1
2
1829
1830
...
2
...
3
2
Three cases, 5 d'ys old ; one 1 1, and one 3 w'ki.
1831
1832
1833
1834
2
1
2
2
1
1
1
1
1
1
1
1
1
2
3
1
4
1
1
1
3
1
1
1
2
1
1
1
4
Three cases from 5 to 7 days old.
Two cases from 1 to 10 days ; one two weeks.
One case, 6 days old ; one 7 ; one 7 weeks.
One case, 4. days old.
Two cases, 7 and 8 days old ; one 5 months.
One case, 12 days old.
Two cases, 6 and 8 days old ; one 16 days.
Two cases, 9 days old ; one 2 weeks.
One case, 12 days old ; one 5 weeks.
Two cases, 6 and 7 days old ; two 6 weeks.
One case, 10 days old ; one 4 months.
One case, 1 day old ; two 2 months.
Nine cases from 2 to 12 days old ; one 6 weeks.
Four cases from 1 to 10 days old ; one 2 w'ks.
Ten cases from 2 to 10 d'ys old ; five 4 to 6 w'ks.
Nine cases from 1 to 15 ds. old ; six 5 to 10 nos.
Fourteen cases were 14 days and under; six
[6 weeks.
1835
3
2
2
i
1
1
3
2
1
4
3
4
1
"i
1
1
2
I
1
2
1
1836
1837
X
1
1
2
1
1
1838
...I 1
11 1
1
1
2--
1839
1
1840
1
2
1
2
5
5
1
2
2
5
6
3
9i R
1841
184?
'2
1
I
1
2
2
2
1
2
2
2
5
2
2
3
2
1
1
2
1
5
2
4
2
3
5
21....
1
....
1843
1844
1
3
3
2
4
4
4
2
7
7
1
1
10
4
2
5
2
4
9
11
3
2
2
2
"s
5
7
19
6
3
3
1
2
2
1
}
3
8
4
1845
1846
1847
1848
1849
1850
1851
1852
1853
1
2
2
5
1
1
5
4
7
1
3
3
1
1
3
2
3
3
1
2
1
'2
3
3
42
57
33
34
32
48
50
56
82
95
81
43
656
Six hundred and fifty-six deaths were recorded as due to convulsions and spasms, ia
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Relations of Traumatic Tetanus to Climate.
261
Savannah, amongst the whites during a period of fifty years, (1804-1853,) out of a
total of 14,332 deaths from all causes ; or one death from spasms and convulsions in 20.8
deaths from al( causes. Nearly one-half of these deaths recorded as due to spasms and
coQTulsioDS, viz : 314, occurred during the months of August, September, October and
November, in which period it is well known that malarious diseases and especially inter-
mittent, remittent and congestive or pernicious fevers, prevail with the greatest intensity
io this city, which is surrounded with marshes and low lands lying along the sluggish
tnd muddy river. Whilst therefore a certain proportion of these deaths may have been
caused shortly after birth by Trismus Nasoentium, the greatest proportion 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 careful examination of the records, I found them
to be so imperfect, that no reliable data could be gathered for an accurate judgment and
comparison. It appeared to be generally admitted, however, that the negro children
were much more liable to Infantile 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
determination 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.
Death from Traumatic Tetanus in CharUtton^ South Carolina^ amongst White, Black and Colored
Inhabitants^ during a period of fourteen years.
Deaths from Trismus Nascentium in Charleston, South Carolina, amongst the White, Black and Colored
Inhabitants during a period of fourteen gears.
W H ITK8
1
BLACKS AND
COLORED.
Total
from
andB
\li
Proportion
of deaths rm
all causes to
population.
Tear.
f
1
1
1
1
1
"i
"i
1
3
1
3
1
...„
41
7
8
11
9
14
26
22
10
120
f
cr
:
|5
3
2
3
1
1
2
3
5
6
1
5
1
33
>
1
3
3
i
6
5
1
2
4
3
6
4
1
40
1
:
3
..*
3
7
1
3
4
3
2
3
1
34
e
0
?
3
1
3
2
1
3
I
5
2
4
6
3
33
C
:
2
2
"i
4
5
2
4
1
8
7
3
2
6
47
>
2
1
1
4
6
5
4
4
6
3
8
2
6
6
■J:
2 3
5 3
1 6
4 2
4 6
4 4
4 6
9 A
0
1
deaths
a all
dealhs"
Tris.
Whit'B
lacks.
IMA
1
"4 "4
32
28
20
24
37
47
47
48
40
34
44
48
43
23
35
29
20
24
42
61
54
56
57
42
58
74
65
33
607
.•548
617
798
922
1(j82
1876
1088
1237
1922
1033
1472
1380
2068
I in 47.71
1847
1 ! ' '
1
"i
3
3
3
3
4
2
6
6
8
1
61
2
2
1
3
3
4
t
1
1
2
6
35
1
4
3
3
8
6
4
1
2
4
3
3
48
1
3
"2
4
3
3
2
1
4
2
25
59.74
1848
1849
1861
"\
r::::-l:::l:::
i
1
"i
]
"i
I
1
2
1
2
3
2
15
2 4
2.:.
li 1
■!■■
.. 43.11
.. 36.34
.. 44.46
18M
1864
...2
1...
1 -
1 1
.. 27^1
.. 23.4
1866
2
2
"i
2
1
To
1
.. 45,94
1867
1868
1
3
1
1
1
...!...| 21...
1'...! 1 1
...t i: 4 3
2 3l A! 2
6
4
5
4
2
4
5
59
.. 42^7
26.14
186«
1860
...
"i
1
8
2
.. 48.40
.. 37;i8
1861
2 2
2 1
2j 3
4
2
2
2
12
.. 16.09
1866
.. 9.70
TbUI
10
s
T 8
16
13
58
58
520
040
17150
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Google
2 62 Relations of Traumatic Tetanus to Climate.
Deathtfrom ConvuUiomHn Charleston^ South CaroUna^ amongst the White ^ Black and Colored Iithah'
ilantSf during a period of fourteen years.
From the preceding tables, the following conclusions may be drawn :
Ist. Daring a period of 14 years, in Charleston, Soath Carolina, amongst (he
whites, the largest number of deaths from Traumatic Tetanus, occurred during the
months of June, September and October, the total for these three months being 16 out
of 39 for the entire period: amongst the blacks and colored the largest number of
deaths occurred during the months of March, April, July, October, November and
December, 61 deaths occurring during these six months out of 93 deaths during tbe
entire period. It is evident, therefore, that we can trace no special relationship between
the climate and the occurrence of Traumatic Tetanus from these mortuary stitistics
furnished by Charleston, South Carolina.
2d. The total number of deaths from Traumatic Tetanus, occurring amongst both
races during this period was 132, out of a grand total of 17,150 deaths from all causes;
or one death from Traumatic Tetanus in 129 deaths from all causes.
3d. The deaths from Ti-aumatic Tetanus were relatively much more frequent amongst
the blacks and colored.
Thus, amongst the .whites during a period of 14 years, 39 deaths from Tnininatic
Tetanus occurred, out of a total of 8080 deaths from all causes, or one death from
Traumatic Tetanus in 207.1 deaths; amongst the blacks and colored, during the same
period 97 deaths from Traumatic Tetanus, in 9020 deaths from all causes, or one death
from Tetanus in 97 deaths from all causes. This fact indicates that the black and
colored race, is more liable to Traumatic Tetanus than the white race.
4. During a period of 14 years, the deaths from Trismus Nascentium, amongst
the whites, numbered 120, and amongst the blacks and colored 520 ; total deaths
amongst blacks and whites 640, out of a total of 17,150 deaths from all causes ; or
one death from Trismus Nascentium in 26.1 deaths from all causes. »
5. If the deaths from Trismus Nascentium be added to those of Tetanus, we
have a total of 772 deaths, or one death from these various forms of Tetanus in 22^2
deaths from all causes.
6. The largest number of deaths from Trismus Nascentium occurred amongst the
whites in the months of July, August,September, October and November, 76 detths
out of 120, occurring during these months ; amongst the blacks and colored, the
largest number of deaths occurred during the months of January, July, August, Sep'
tember, October and November, 332 deaths occurring in these months out of a total of
520 deaths.
7. Trismus Nascentium, in like manner with Traumatic Tetanus, caused a niach
greater number of deaths amongst the colored and black race than amongst the whites;
thuS) amongst the whites, out of a total of 8080 deaths from all causes, 120 were
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B^dtions of Traumatic Tetanus to Climate.
263
caused by Trismus Nascentium, or one death in 67.3 ; amongst the blacks and colored
this disease caused 520 dq^ths, or one death in 17.2 deaths from all causes. It is
eyident, therefore, that Trismus Nasoentium is much more frequent and fatal amongst
the black and colored race.
8. Convulsions and spasms, so called, caused during the period of 14 years, 245
deaths amongst the whites, and 402 deaths amongst the blacks and colored, giving a
total of 647 deaths : or one death from convulsions and spasms amongst 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 increased
mortality from these convulsive diseases, may therefore be referred to the increase of
temperature and the more potent action of malaria.
The following results of my examination and consolidation of the mortuary statistics
of New Orleans, Louisiana, will illustrate the relative mortality caused by Tetanus,
Trismus Nascentium and Convulsions, in this city, situated on a low, alluvial, damp mala-
rious plain, 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, 1860, 1863, 1864, 1865, 1866,1867, 1868, 1869, 1870',
1871, 1872, 1873, the total deaths from all causes in New Orleans, amounted to
165,435; of this grand total during the periods just specified, Tetanus caused 1727
deaths, or 1 death in 95.7 from all causes ; Trismus Nascentium, caused 3627 deaths,
orl death in 45.6, deaths from all causes; Tetanus and Trismus Nascentium, together,
eaascd 5354 deaths, or 1 death in 30.9 deaths from all causes ; convulsions, caused
6364 deaths, or 1 death in 25.9 deaths from all causes ; Tetanus, Trismus Nasoentium
sad Convulsions, caused during the period specified 11, 715 deaths, or 1 death from
these convulsive diseases, in 14.1 deaths from all causes.
The relative prevalence of Tetanus, Trismus Nascentium and Convulsions, amongst
the white and colored race, may be gathered from the following table embracing the
jcara 1849 and 1850.
Ikaiha from Tetanus each months amongst Whitey Black and Color sd Inhabitants of New Orleans ^
during the years 1849 and 1850.
Deaths from Convulsions each month, amongst Whites and Blacks in New Orleans,
1849, 1850.
Op.
a »
So o
Hi
1SI9..
1»0..
Total
., 30 13 31 2^
1217 23
2017
3936 31
248
291
4 2
310
360
641
684
|4St26
639
61710
660
1125
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Google
264
Relations of Traumatic Tetanus to Climate.
Deaths caused hy Tetanus^ Trismus Nascentium and Convulsions each momth^ uwd
Total Deaths from all causes in New Orleans^ during a period of 10 years,
embracing the following years : 1849, '50, '52, '53, '67, '69, '70,
'71, '72, '73,
Year.
s %
e
DEATQS CAC8BD BT TETANUS IN NBW ORLEANS.
1849.
1850.
1852.
1853.
1867.
1869.,
1870.
1871.
1872.
1873.
ToUls 49 52 45 50 72 77
3
2
10
3
15
11
17
10
4
15 i 1
90 I 77 99 90 86 66
10 I
11
4
5 I
18 I
12
8
Si
7
49
71
66
49
138
134
119
79
73
74
842
DEATHS CAUSED BT TRISMUS NASCENTIUM IN NBW ORLEANS.
1849
1850
1852
1853
1867
1869
1870
1871
1872
1873
Totals
21
9
6
12
10
5
13
21
10
17
9
8
13
8
20
16
13
10
9
12
6
10
7
22
10
9
6
8
8
5
14
13
29
13
19
22
10
26
12
20
6
4
6
7
2
9
20
21
16
16
6
8
8
11
21
25
24
10
23
13
9
18
23
37
17
22
13
9
21
15
16
22
26
10
16
14
18
16
27
34
172
120
113
133
104
122
174
231
24
; 172
15
163
35
177
16
' 144
28
246
14
136
20
186
19
234
21
231
23
W
1945
DEATHS CAUSED BY CONVULSIONS AND SPASMS IN NBW ORLEANS.
1849
1850
1852
1853
1867
1869
1870
1871
1872
1873 ,
Total?
36
18
36
40
22
25
20
16
14
20
26
21
20
27
17
^4
49
55
22
16
22
38
42
53
13
16
18
28
13
26
16
13
24
52
25
34
28
19
16
17
22
28
21
16
18
19
16
26
23
21
8
14
35
39
23
18
16
15
30
27^
222
180
189
280
280
334
24
16
38
44
24
33
20
26
12
45
24 21 , 30
68 , 47 ! 42
51 I 44 ! 38
107 I 39 26
42 56
15 ; 25
13
22
22
9
29 ! 21
29 , 23
24
23
39
26
20
21
26
8
15
10
310
350
449
465
341
307
248
224
248
361
282 I 390 307 298 243 211 J 3224
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Relations of Traumatie Tetanus to Climate.
265
TOTAL MOMTHLY AMD YBARLT DEATHS IN NIW ORLEANS.
1849
1850
1852
1853
1867
1869
1870
1871
1872
1873
ToUls
1182
582
486
581
397
360
494
477
447
642
601
425
477
463
302
323
456
381
630
556
1396
840
462
456
401
435
634
525
430
603
1068
481
502
532
350
590
580
471
418
600
997
601
627
671
316
631
651
444
713
930
870
479
1163
656
561
560
712
585
572
562
435
584
769
2216
551
588
529
522
483
773
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
623
899
890
712
959
473
596
624
430
500
630
756
762
844
720
609
670
476
473
504
9862
7836
9693
16633
10096
6001
7391
6059
6122
7605
5648 4674 3153 5592 7681 6720 7450 12156 9068 8085 6605 6335 86198
From the preceding tables, coDsolidated 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
deadis 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 de^th
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
Nascentium. It is therefore in like manner evident, that thb 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
causes in the white, black and colored races: 1945 deaths were caused by Trismus
Nascentium, 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.
3d. The largest number of deaths from Tetanus occurred in the months of June,
Jaly, August-, September, October and November, reaching the maximum, vis : 99 in
September; total for these six months 519; whilst in the remaining six months, viz:
December, January, February, March, April and May, the mortidity 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
caused 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, viz :
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
June, 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 statistics of cities
situated within the interior of the Southern States, in more elevated localities than those
34
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266
Relations of Traumatic Tetanus to Climate.
of Savannah, Charleston and New Orleans. At a great expenditure of time and labor,
I have consolidated from the mortuary record of the various cemeteries of Nashville,
Tenne^ee, and Augusta, Georgia, the following statistics. In these labors, I was ablj
assisted by my friend and former Assistant, Dr. John Watson Morton, Jr., (formerly
ColoneVand Chief of Artillery in the Cavalry Division of Lieutenant General Forrest,
C. S. A.)a whifct I held the position of Health Officer of Nashville, Tennessee, 1867,
1868.
Total Deaths, and Death* caused by Tetanus, Tris-
mus NascenUum and O^iivulsions, amongst the
Whites, Blacks and Colored in Augusta, Ga.,
during a period of bQ years, 1817-1866.
WHITES.
BLACKS AMD COLORED.
Total Deaths in tfie City of NashviUe, from aU
causes, consolidatecl by Joseph Jones, M, D,
Health Officer, from aU the records of the tw-
rious Cemeteries, 1822 to 1867, with oMnnal
death, rate, and per cent, of deaths to limng
inhabitants.
in
t
9
M?
9 C
••k
S^
B e.
5 5*
n
.^8
£f
44
2^
46.7
2.1
388
20!
68.7
13
47
2a
3U
2Ji
31.7
U
sett
3.4
i«j
6.9
34 J»
2J
18.5
5,4
jaui
3>
33t.»
3.
35.9
2-7
33
S.
31
3J
27.2
3.6
36.6
2.7
3:^.4
2.9
27.1
3.6
37.4
2.6
25
4.
20.9
4.7
18J»
5.4
14.4
6J»
12.6
7.9
29.7
Z^
22.5
4.4
29.2
a.4
20.7
4.8
29
3.4
32.6
3.
29.2
3.4
30.6
3.2
25.5
3.9
21.2
4.8
27.S
3.6
„.«...-.
...
I
In Augusta, Georgia, up to the year 1846, the record of diseases causing death is
•Record of Ditesset impei'fect.
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Relations of Traumatic Tetanus to Climate.
267
?ery imperfect, and no separate record of the diseases causing deaths amongst the blacks
and colored, appears until 1842. If therefore we exclude the mortuary statistics from
1817 to 1845, and regard only those relating to the succeeding 22 years, viz: 1845 to
1866, indusiye, we have a total of 6645 deaths amongst the whites ; 15 of which were
dac to TeUinu8,.oT one death in 443 deaths from all causes ; duripg the same period,
^' Cbnvulfiongy Spasms and FitSy'- (including Trismus Nascentium, only one 4ieath
daring 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 gnmd total of 4240 deaths, Tetanus caused 19 deaths, or one
death in 228.4 deaths from all causes ; " Convulsions, Spasms and Fits,'' (including
Trismus Nascentium, only one death being referred to this disease,) caiwod 240 deaths,
or one death in 17.6 deaths from all causes amongst the bhicks and colored : Tetanus
caused 34 deaths in a grand total of 10,885 deaths from all causes amongst whites, blades
and colored, or one death in 320 deaths from all causes. Jt is evident fVom these
statistics:
First, That Tetanus caused relatively a much larger number of deaths amongst the
bkioks and colored than amongst the whites, in Augusta, Georgia.
Second, That Tetanus is much less frequent and fati^l, both amongst the whiteaand
colored races, in Augusta, Georgia, than in Charleston, South Carolina, Saivaaaaih,
Qeorgia, and New Orleans, Louisiana.
With reference to the mortuary statistics of Nashville, Tennessee, I fdund upon
careful investigation, that records had been kept by three different 'congreggatioos
or societies, separate from those of the large grave-yf^rd (City Cemetery), viz: by the
Oiitholics, and the two Hebrew Synagogues, who failed in many instances to leoerd the
diseases causing death. It was therefore impossible to obtain complete statiaticB «how-
ing the total number of deaths from Tetanus, Trismus Nascentium and Con^ubions.
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 fktal or
caused relatively to the total number of deaths, twice as great a mortalitv amongst the
bhusks and colored. Tetanus caused relatively a greater mortality in Nashville, than in
Augusta, Ga., but much less than in Charleston, S. C. and New Orleans, Louisiana.
From the preceding statistics the following table has been constructed :
London, England
Ireland
New York, U. S. America
Bombay, India
Gay's Hospital, London
Philadelphia, U. S. America
Philadelphia, '*
Philadelphia, '* ,
Massachusetts
Sarannah, Georgia, WhJte$
Charleston, South Carolina, Whites
Charleston, " Blacks
Charleston, " WkUes and BVks
New Orleans, La., Whites and Blacks
New Orleans, La., Whites
New Orleans, La., Blacks
Aagmta, Ga., Whites
AagQSta, Ga., Blacks and Colored,, ,.««,
Aogasta, Ga., Whites^ Blacks and Colored, ^^^,,
NashTJlle, Tenn., W hites. Blacks and Colored^,,
Period.
ToUl
Deaths.
1850-3-4
1831-1851
1819-1834
1851-1853
1825-1857
1807-1827
1827-1830
1830-1840
5 years.
1804-1853
1846-1865
1846-1865
1846-1865
1847-1873
1849-1850
1849-1850
1845-1866
1845-1866
184!U1866
1838-1848
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
165,435
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 3075
1 in 4987
I in 748
I in 46.
1 in 194
1 in 424
1 in 573
I in 974
I in 1907
1 in 229.8
1 in 207.1
1 in 97.
1 in 130
I in 9i).7
1 in 149
1 in 99.4
1 iu 443
1 in 228
1 in 320
1 in 180
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268 Relations of Traumatic Tetanui to Climate.
The preceding 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 r^nla-
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,
generally proved fatal from an attack of Lock-Jaw, whereas at the present day, in mili-
tary and naval practice the disease is comparatively rare.
There are facts to show, that foul air tends powerfully to promote the occurrenee of
this disease. Thus in the Dublin Lying-in-Hospital, by means of improved ventiktioo,
etc., the mortality from tetanus in the in&nts, was reduced to nearly one-tenth of what
It bad been. Tetanus seems at times to assume an almost epidemic character. Dr.
Benjamin Ward Richardson says, that he knew one surgeon, whose operations, it once
followed for some weeks, as diough he carried the cause of it with him. In some
hospitals it appears to hav^ been much more prevalent than at others ; at St. Marka, it
IS mentioned that amongst 1763 operations performed upon hsdmorrhoids, with the
ligature, 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 hospitalB, from
18f^ to 1865, more than 800 operations have been performed, but no case of Tetaoas
has resulted.*
11. Many of the changes observed in the Abdominal and Thoraoio Viscera, in
Traumatic Tetanus, are manifestly due to the mode of death, and the oompreeaen of
the organs during the violent spasms. The congestions of the pharynx and g^tis,
appear to be caus^ by spasms of those parts, consequent upon the exalted reflex actions
of the medulla oblongata and upper portions of the spinal cord.
In some cases, however, morbid appearances have been observed in difierent porliooa
of the digestive canal, which cannot be viewed either as the results of the malady, or of
the mode of death, but must be considered either as sources of irritation, or as con-
curring aids to irritation.
A chronic case of idiopathic tetanus, recorded in the Philosophical Transaodons for the
year 1764, was apparently caused by worms in the intestinal canal ; Sauvages relates a
fatal case of Tetanus, in .which the intestines were perforated by worms ; Morsinna,
has recorded an instance of trismus in which the disease was cured by the expvlsion of
a single worm, ten ells in length ; Dr. Thompson of Jamaica, mentions several caaes of
Chronic Tetanus in negro children, arising from the irritation of worms, and they wero
so often met with in the stomach and intestines by M. Laurent, a physician of coo-
siderable experience, at Strasbourg, that he was induced to attribute the disease in all
cases, to their presence ; worms arc noticed as causes of tetanus, by Morgagni, Stohl,
Foumier, Percy and others, whilst Baron Larrey, frequently found after death, from
this disease, lumbrici in the small intestines, without any trace of inflammation;
increased vascularity and inflammatory state of the mucus membranes of the alimehtary
canal, were found by Mr. Swann, in all the cases of Tetanus, in which he found unusuil
appearances of the sympathetic system ; Dr. McArthur discovered inflammation of tbo
Bt<Mnach and inte9tines, in four fatal cases of tetanus ; and Andral has recorded a ctfc,
in which on dissection, he found unequivocal marks of gastritis : such facts show the
importance of making accurate examinations of the alimentary canal in tliis disease;
and whilst endeavoring to estimate the influence of such a cause as worms, it should be
borne in mind, that they are frequently present in the bodies of those who have died of
various diseases, and that they are frequently present in the intestines, without inducing
any disturbance of health.
It should also be considered in this connection that the most varioua kinds of ulcers
scarcely ever give rise to tetanus; syphilitic sores, primary and secondary, tubercnloua,
*An Xnay on the Most Effectual Means of Preserving the UQath of the Soamoi^ o^ ^o B^yal Natt, 1757,
•H eOicia TImw «nd 0««9ne-. September 2d, 1866^
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Relations of Traumatic Tetanus to Climate. 269
caTiUes, pulmonary gangrene, the intestinal lesions of Typhoid fever, and dysentery,
nrely if ever develop this disease ; and in glanders and farcy, snake-bite, malignant
pustule, sibbiens, leprosy, small-pox and syphilis, the phenomena appear to be dependent
lather upon profound changes of the blood and upon depression of the circulation, than
apon nervdus excitement.
Such fiicts stand in opposition to that theory, which would regard Tetanus as resulting
from the absorption of morbid secretions, or matters, from wounded and diseased sur-
faces. 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
and cerebrospinal nervous system, as may predispose to the tetanic condition.
Lesions of the muscles, fractures of the bones, and even dislocation of the vertebra,
which have been recorded by various observers, as Baron Larrey, Baron Dupuytren,
Desportes, Foumier, Pescay, Mr. Curling and others, are clearly referable to the violent
aad sudden spasmodic contractions of the muscles, during the powerful spasms charac-
teristie of severe cases of this disease.
The engorgement 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 the muscled, by which the blood is
forced upon the internal organs, and also to the state of asphyxia, in which the disease
so freqnenUy terminates.
We cannot apply this explanation, to the engorgement of the capillaries of the cerebro-
spinal system, l:He«tuse thb congestion of the gray matter, is much more marked thad
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 iUso worthy of note, that the post-mortem rigidity of the muscles is greater iu
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
sometimes 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
similar to that which is active in the coagulation of the blood.
Some authors have held, that Tetanus like Hydrophobia b due to blood poisoning.
This view has been sustained by the fact, that a condition so nearly resembling Tetanus
as to be with difficulty distinguished from it, may be caused by the direct introduction of
strychnia into the blood. It b true that both in Traumatio Tetanus, and in the Tetanic
Spasms induced artificially, the disease is chiefly located in the spinal cord, which b an
organ, both for the generation of nerve force, and the conduction of impressions to and
irom the brain. In tetanus and in the action of strychnia, there is increased action in
the ganglionio oelb of the spinal cord, as manifested in the great exaltation of reflex
excitability. It b well known that in some cases of disease, in which the amount of
bkwd in the cord b increased, yery small quantities of strychnia produce the characte-
ristic phenomena of stiffness in certain muscles, and of augmented reflex excitability.
These facts, as well as the results of the experiments and post-mortem examinations of
Schroeder 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 convubions hy exaggerating the sensibility
of certdn parts, it also dauses reflex movements ; the point of departure being in the
sensitive system, for when the posterior roots of the nerves arc cut, the animal dies
without convulsions. An experiment performed by Frofessor Hammond,f of New
York, and Dr. S. Wier Mitchell, of Philadelphia, appears to show tb»t the ^tion of
*Le$oM mir lee KfTeta dM subtUmccs t««l<^nc9 M6<JUcti(nei^teu8c8, Paris, 1857, p. 386^
t Abi. Jour. Hed. Science^ J0I7, 1869^
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270 Relations of Traumatic Tetanus to Climate.
Strychnia is to destroy the nciTous excitability from the centre to the pmphery, ind
that ita influence must therefore be first excited on the spinal cord. Und^ the skin of
a large frog, whose left sciatic nerve was previously divided, a few drops of a sdtMi^
solution of strychnia wore introduced. Tetanic spasms ensued in two minutes. AAcr
forty-five minutes -the nerves were irritated by galvanism ; that of the left side which
had been cut responded energetically, while no motions could be produced through (be
uncut nerve. The former remained excitable for two hours later.
The spasms excited by strychnia, therefore, as well as those of Tetanus, are probtUy
due to similar causes, viz : the congestion of the cord and increased nutrition and fiiDc<
tional activity of the ganglionic cells ; and in both cases the oongestion may be 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 tbeor}',
that Tetanus is caused by a poison in the blood.
The increased prevalence of Tetanus in low, hot, moist, malarious r^ons, may he
accounted for upon the same principle as the increased prevalence of Neuralgia uinier
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.
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CHAPTER IV.
EXPERIMENTAL INVESTIGATIONS ON THE ACTION OF PHYSICAL AGENTS, AND OF CERTAIN
POISONS. UPON LIVING ANIMALS, INSTITUTED WITH THE DESIGN OF THROWING LIGHT
ON THS MODE OF ACTION OF FEVER POISONS, AND ON THE PHENOMENA OF CONVULSIVE
DISEASES.
Experimental investigatioDS ou the action of physical agents, and of certain poisons upon
I'lTiDg animals, institnted with the design of throwing light upon the nature and mode of
action of unknown fever poisons, and on the phenomena of convulsive diseases.
BxperimeBts iUostrating the action of physical agents, abstraction of blood, electricity,
mechanical iignries 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
liring vegetables. Experiments illustrating the action of various poisons, as Prussic Acid,
Cjaoide of Potassium, Strychnia, etc., upon living animals. General conclusions, drawn
from 185 experiments with poisons. Practical applications of the results to the Therapeutics
of Tetaoos. ^
EXPERIMISNTAL ILLUSTRATIONS OF CONVULSIVE DISEASES.
The manifest influenoe of dimate, and especially of the vicissitudes of heat and cold,
in moist, 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
depoidence 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 deraDgements in the blood and excretions, and in the actions of the excretory organs,
resolting 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-
sal poison into the blood, also led to the belief that the former might, in like manner, result,
m some cases, from the generation of an animal poison, either within the blood itself, or
within the wounds, or fVom the irritant action of retained and altered secretions and
excretions. 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 sinall quantities, are capable of exciting the most violent and fatal forms of tetanic
spasmg.
The greater tendency of penetrating and dosed wounds to cause Tetanus, has been
soggestive of the actbn 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 aflked, whether the link between chilled wounds and spasmodic par-
oxjBDiSy 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
capaUe 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
says:
"In this disease, the poisoD, in ray opinion, is first developed in the wound, as a result of
decomposition. Thence carried into the circulation, the new substance, without any neces-
Mry increase of its own parts, excites a Zymosis, ending in the production of an alkaloid or
ailuUiDe bodv, which has all the power of exciting symptoms of spasm, as much as Strych-
nine iUelf." '
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272 Experimental Illustrations of Convulsive Diseases.
Whilst this theory does not account for the occurrence of Tetanus in some casjs and
not in others, and does not define the connection of the acknowledged cau^^es, ould,
damp, vicissitudes of temperature and wound ; and it is not at all neoessaiy
to the rational explanation of the mode of oriffin of the disease ; at the same
time, the phenomena of Tetanus in the human being should be illustrated bj well
conducted experiments upon animals, and should be especially compared with tetanic
spasnis, artificially product 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 temperature, secretion and exac-
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
afler death ; fourth, the relations of the changes produced by poisons, with pathologic^
states, and especially with the pathological conditions produced by fevers and inflam-
mations.
. As numerous facts indicate that fevers are due to special poisons, whilst at the nme
time, these poisons have not been isolated, and, therefore, many of their aottona an
involved in obscurity, I supposed that light might be thrown upon the character and
effects of fever poisons, by carefully invesiigatins and comparing the effects of poisoitf
whose chemical constitution and relations are Known. The field of experiment hat
opened is of boundless extent, and each experiment may be discussed in various r^
tions ; in the present inquiry, however, I desire to present those experiments mhkk
bear most directly upon the phenomena and pathological alterations of Tetanus and its
associated diseases of the nervous system.
It b important that we should first investigate the changes of temperature, circula-
tiQn, respiration, nervous and Muscular actions of the organs and tissues, induced by
what may be called physical or mechanical agents, in contra-distinction to the action of
poisons. It is evident that we can form no distinct ideas of the effects of poisons,
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 combining and
varying these experiments, important physiological &cts and principles may be estab-
lished, which form data for the comparison of the experiment^:) upon poisons.
The appearance of the organs and tissues of hedthy animals afler death from me-
chanical means, should also first engage the attention ; for it is evident that it would
be impossible to ascertain with accuracy the true characteristics of any patholo$ici<^
alteration, or determine the effects of any poison upon the animal structures, without
knowing wherein they differed from the appearances of health.
PRELIMINARY EXPERIMENTS ILLUSTRATING THE ACTION OF PHYSICAL AGENTS.
Experiment 1 : Effects of Abstraction of Blood vpon Animal Tetnperatwre^ antlitpnn
the Color and Appearance of the different Viscera^ and especiaify upon the
Amount of Blood contained in the Blood- Vessels of the Brain and Spinal Otrd,
Medium-sized, active, Wcll^conditioned dog, (cross between bull and cor). Temperature of
surroundiDg atmosphere, 19° C (C6°.2 F). Temperature of rectum of dog: (The bulb and
glass stem of a delicate thermometer having been introduced into the rectum and retained in
this position until the temperature assumed a stationary point), 40^.3 C, (104^.6 P).
An attempt was made to sever the left carotid artery. As soon as the integuments were
severed, the dog struggled violently for several minutes; during these struggles tbeteropert-
lure of the rectum rose 0®.22 C. The attempt to sever the carotid artery was abandoned,
until the thermometer ceased lo rise, as we Wished to observe the effects of mechanical efforts
upon the animal temperature. The thermometer did not rise abovo the point just mentioned,
and remained stationary at 40^.55 C (106° F).
The left carotid artery was then severed ; the blood gushed out in a full stream, and in six
minutes after the severance of the artery, all signs of life were extinct. During the loss of
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Experimental Illustrations of Convulsive Diseases. 273
blood the thermometer remained stationary at the point last indicated. Tweuty-seyen fluid-
ounces 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 that it had in
the experiment, vh : 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, tIz : 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®.56 (105® F) ;
fourteen minutes after death, 40^.55 C ; twenty-six minutes, 40^.50 C; forty-nine minutes,
40*>.25; fifty-five minutes, after death, 40® 0 (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®.l 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 C. (35® .0 P). During
the twenty-six minutes immediately following death, the loss of temperature was 0®055 C, or
0^.0046 C. per minute, during the succeeding twenty-three minutes, 0®.25 C, or 0®.0104 per
minute ; during the next six minutes 0®.25 C, or 0®.415 per minute ; next thirty-one minutes,
•i**.75 C, or 0®.024 per minute ; next thirteen minutes, 0®.39 C, 0®.030 per minute; next forty-
seven minutes, 1°.107 C, 0®.023 per minute ; next one hundred and eighty minutes, 4®.75 C.,
0®.026 per minute ; next nine hundred and fifty minutes, 8®.l C, 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.®6C .
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.
Autopw ttrentt/ hours after death. — The blood-vessels of the arachnoid, dura-mater aiid 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»
peftrance ; the stomach, although containing matters in a state of partial digestion, presented
a pale, bloodless appearance, both upon the exterior and interior. Careful colored drawings
were made of the brain and spinal cord, and viscera, for future use and comparison.
Experiment 2 : Effects of Abstraction of Blood,
Thin, medium-sized dog ; Temperature of surrounding atmosphere, 19®.5 C. (67®.l F).
Temperature of rectum, 40®.lo C. (104®. 28 F). The thermometer was placed in the rectum
so as 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
thigh of the hind 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 C. 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 plug 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. Could not stand up. Respiration labored and pant-
ing ; drew long sighs, and emitted several feeble cries ; and finally died, thirty-five minutes
after the commencement of the bleeding.
During the bleeding, the thermometer remained stationary, and, at the momant of death, it
indicated a temperature of 40®.2 C. (104®.4 F). Twenty-two fluidounces of blood were lost
before death. The thermometer in the rectum indicated an almost immediate fall in the tem-
perature after death. The following arc the actual observations on the temperature. Tem-
perature of rectum at mctment of death, 40®.2 (104®.4 F.) ; 25 minutes after death, 38® C,
(100°.4F); 38 minutes after death, 37®.7.5 C, (99®.9 F.); 85 minutes after death, 36® C,
(%'°.8 F.) ; 265 minutes after death, 31®.33C., (88®.4 F.) ; 383 minutes after death, 29®.25 C,
(840.6 F).
The rate of cooling was as follows : During the first twenty-five minutes after death, the
thermometer fell 2®.2 C, or 0®.088 C. euch minute; during the following 13 minutes, 0®.25
C, or 0®.019 C. per minute ; during the following 47 minutes, 1®.75 C, or 0®037 per minute ;
daring the following 180 minutes, 4®.87 C, or 0®027 C. per minute; during the following 108
minutes, 2®.08 C, or 0®.019 C. per minute. During the first 373 minutes after death tho
temperature of the rectum fell from 40°,2, to a9®,25 ; loss 10®.95 C, (19®.8 F).
-The next morning, twenty hours after death, the thermometer in the rectum indicated tk
temperature fit 22® Q., \?l^i^st the tenxperftture of the f^tmoapherQ VRS 23®.(i C The temper^
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274 Experimental Illustrations of Convulsive Diseases.
ftture of the surroundiDg atmosphere had risen during the morning, from the kindling of a fire
io the adjoining room.
Autopty twenty hours 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
Tery 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 and
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 : Illustrating the Effects of Electricity vpon Living Animah,
Small female pointer. Temperature of surrounding atmosphere, 26*^ C, 78^.8 P. Electric
shocks from a large Leyden Jar, of the capacity of one gallon, were passed through the head
and through the 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, the dog cried out, and then became io-
sensible, and the shocks from the Leyden Jar then produced no effect, except a very slight
convulsive movement, and spasms of the muscles of the back and neck, causing the bendiag
back of the neck.
Shocks from the Leyden Jar, charged continuously by a large plate glass electrical machiDe,
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
the 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''.1 P., showing a loss of 0^6 C.
Forty minutes after the cessation of the electrical shocks, (ninety minutes after the fir^t
shock), the dog recovered from his stupor, raised its head and looked around ; at this time the
temperature of the rectum was 40°.4 C. ; showing that it had continued to descend after the
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 conscioai-
ness, and was capable of walking about. Temperature of rectum at this time, 40^.4 C; tbe
temperature after the return of consciousness, remained stationary up to this time, and grad-
ually ascended, and three hours after this observation, stood at 40^.45 C.
At this time, 5} hours after the first experiment, shocks were again passed through the
head and neck in various directions, as before ; the shocks appeared to exert less effect, and
the dog appeared to suffer less, and insensibility was not reproduced as fully as in the ftrti
experiment.
The temperature of the rectum, as in the first experiment, descended during the passage of
the ahocks through the brain and medulla oblongata, and in liftccn minutes stood at 40M C,
showing a lose, in this time, of 0^05 C.
The dog was now released from the operating table ; It appeared to be very feeble, oooH
scarcely walk, muscles trembled, and it hung its bead down. The animal subsequently reGOT«
ered its usual strength.
Experiment 4 • Jllustraling the Effects of Electricity^ (Interrupted Mogneto- Electric
Ouirent) upon Animal Temperature.
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
bulb of another thermometer was placed, and so arranged as to express the temperature of
the turrouftding parts. Previous to the passage of the interrupted current, the temperature
ivaa earefolly determined : Temperature of atmosphere, 25^.6 C, 78^2 P.; of left hand. 37^.^
O., 990.5 P.; of right axilla, 38°.8 C, 10P.9 P.
After the passage for -seven minutes, of as strong a current as I could well bear, there was
a very slight rise in the thermometer in the axilla, but none whatever in the thermometer in
the hand.
During 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 frequency. 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 expert*
meat, violent twUching^ Qf ^|;\e ^u^^les qf \i,Q a^QS and chest ,* no ^^cct was nrodnced upoi^
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Experimented Illustrations of Convulsive Diseases. 275
the temperature of either hand or axilla, — thej remained stationary ; and no effect was pro-
duced upon the respiration.
Experiment 5 : Illustrating tlie Effects of Strong Magneto- Electric Currents upon a
Living Animal,
Fiue, jonng, male cur dog, fat and in good condition. Temperature of atmosphere, 2*7^ C,
80<».6 F. Temperature of rectum of dog, 41** C, ia5*».8 F.
Temperature of surface of large muscles of back, (the skin being cut, and the bulb of a
thermometer introduced), 38° C, 100®.4 F.
Temperature of surface of large muscles of fore-leg, (the bulb of the thermometer in like
minner 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
iBcisions 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 4I°.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-
crease of 0°.33 C; and the temperature of the surface of the large muscles of the fore-leg,
38°.5C., 101°. 3 F., shoTiring an increase of 0°.5 0.
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 violence
of the spasms and struggles of the dog.
The ele<5trical 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 struggles 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 minutes, the interrupted magneto-electric current was again
applied with greater energy. At the moment of the application, temperature of rectum 42°.l
C, 107°.8F.; of muscles of loins, .38°.5 C, 101°.3 F.; of muscles of fore-leg, 38°.Y5 C,
101^8 F.
Violent muscular contractions were again excited, and at the end of five minutes the ther-*
moDDeter ii^the rectum stood at 42°. 2 C., 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 G.
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
during these violent convulsions, of 0°.2 C. Temperature of the surface of the loins, 39° C,
102**.2 F., showing no increase.
The temperature commenced to fall immediately after death, and at the eud of five minutes
the temperature of the rectum stood at 42°.2 0., and that of the muscles of the back, at
38°.5C.
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,
loins, 38°.5 C; 30 minutes, rectum, 41°.27 C, muscles of thigh, 37° C; 45 minutes, rectum,
410 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°.o'4 C. per minute ; next
23 minutes, 0°.]3. or 0°.005 per minute; next 15 minutes, 0°.27, or 0°.0l9 per minute ; next
30 minutes, 1° C, or 0°.033 per minute; next 150 minutes, 4°.6 C, or 0°.03 per minute.
In 225 minutes, the rectum lost 7° C, 12°.6 F., and in the same period, the muscles of the
loioslost 5°.25 C, and of the thigh, 7°.2 0.
At the time of the last observation, three hours and forty minutes after death, the tempera*
tore of the atmosphere was 28°. 5 C. Gadavaric rigidity well marked at that time.
PoU-mortem Examinaiion^ 4 hours after death: Strong electro-magnetic currents passed in
erery direction, from the nervous centres to the extremities, and through the individual mus-
cles, 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 of
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276 Experimental Illustrations of Convulsive Diseases.
the serum was not so perfect as is usual in the case of the blood of healthy dogs. Under the
microscope no alterations were observed in the structure of the colored blood-corpuscles.
Head: The blood-vessels of the dura-mater were filled with black blood. Blood-vessels of
pia-mater filled with dark, almost black venous blood.
The spinal cord and its membranes 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 that some blood had been efl^used npon the sur-
face of the cord in the cervical portion of the position i\t which the nerves are given off which
supply the forft-^legs.
The dark color of the blood in the brain, spinal cord, and in all parts of the body, appears
to have been due to the effects of the electrical excitement in arresting respiration dnring its
passage through that portion of the medulla oblongata which presides over the respiratory
function, and by the powerful tetanic spasms of the muscles of respiration, resembling in all
respects those produced by Strychnia.
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, normal in appearance ; bladder firmly contracted and void of
urine.
Lungs greatly congested with blood, presenting a dark purplish appearance ; Thymus and
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, I discovered no altera-
tions which could be referred to the action of the interrupted electrical currents.
Exjyeriment 0; Effects of Mechanical Injur t/ of Cerchro- Spinal Nervous System;
Injury of Medulla Oblongata.
Fine, large, full-fleshed cur dog. Temperature of atmosphere G4° F. Temperature of Rec-
tum I02<^ 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 medalla
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 howerer, 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 twitchings 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. Examination after death, showed that it took rery much the
course of the first incision, and enlarging the wound of the left side of the spinal cord, jut
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 pupil although
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 they had
subsided, and indicated a temperature of 103.2 F., showing a rise succeeding the second ii^nry
of 0^.45 F. The action of the heart at the time, 25 minutes after the first injury by the sted
shaft, was full and regular — 64 per minute; respiration, 13 per minute. Fifteen minntes after
this observation, and 40 minutes after ihe first introduction of the steel shaft, temperature of the
rectum 103° F. ; action of heart, 60 per minute ; respiration, 13 per minute. Twenty minutes
after this observation, and 60 minutes after the first injury, the action of the heart was strong,
spasmodic, irregular, 58 beats per minute. By the beats we mean the impulses 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 m all the large arteries of the trunk and
limbs.
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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 muscles of the throat.
Temperature of Rectum, 102®.9 F.
A strong, interrupted magneto-electric current, was next passed from the roof of the
mouth to the anus. Violent convulsions w«re excited in all the muscles of the trunk and
extremities ; during these convulsions the thermometer in the rectum rose from 102°. 9 F.
to 104«.75 P.
These strong electrical currents exhausted the irritability of the muscles rapidly, and in the
course of a few minutes they ceased almost entirely to respond to the galvanic and magneto-
electrical corrents—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 observation, and sixty-five minutes after
death, the temperature of the rectum was 104.°0 F. showing a fall during the last 20 minutes
of (f.lb 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
minutes after death, 104 ; loss in 20 minutes 0.75, or 0°. 037 F.; 80 minutes after death, 103°.5
F., loss in 15 minutes 0.50, or 0.033 per minute; 200 minutes after death 99°, loss in 120
minutes 4°.5 F, or 0°.037 F. per minute.
Po9t'fnortem 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 T^ith dark blood. The appearance of the brain after the removal of the dura-
matter 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
in 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 the 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
ruptured when the atlas was punctured by the steel instrument. Tue stomach was filled with
partially digested matters, and the mucous membrane presented an injected, purplish and red-
dish colour. Mucous membrane of Small Intestines, pale.
Experiment 7 : Division of Medulla Ohlongata^ Artljicial Respiration.
Urge, thin, lean pointer dog. Temperature of atmosphere, 58° F. Temperature of rectum
of dog, 40 33, C, 104.6 F. A knife blade was quickly passed through and across the fourth
ventricle, severing in two completely the medulla oblongata, and also at the same time, the
vertebral arteries.
The respiration ceased imme^diately, a profuse haemorrhage took place from the vertebral
arteries, 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 which appeared
to equal 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, 39°.9
C. (103.8 F.)
Loss of temperature during 30 minutes of artificial respiration 0°.43 C; loss of temperature
^acb minute, 0.0143. The abdomen wa^ 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
exposed to the atmosphere. This exposure of the internal organs, together with the profuse
haemorrhage greatly increased the rate of cooling in this lean dog.
Temperature of rectum 120 minutes, after severance of medulla oblongata, 35.45 C, 95°.8
P.; 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 find 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 loss was due to the cooling of
the body by the air freely introduced during artificial respiration, and also to the free
exposure of the viscera.
Temperature of the rectum 240 minutesafter the severance of the medulla oblongata, 30°.55
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278 Experimental Illustrations of Convulsive Diseases.
C, lo83 of temperature during the last 120 minutes, 4«^.9 C; loss of temperature each minute
0.0408 G. The loss of temperature each minute during artificial respiration was only U.OUJ
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 certain increase
of heat, which notwithstanding that it was counterbalanced hy the cool air thrown in large
volumes iuto the lungs, and also hy the loss of the blood and the exposure of the warm
internal organs, was ' nerertheless an actual increase as evidenced hy the increased rate of
cooling after the discontinuance of the artificial respiration.
Experiments 8y 9, 10, 11, 12, 13, IJf, Repetition of Experiment 7 : Division of
Medulla. Oblongata, Artificial Respiration.
General results similar to those detailed in Experiment 7.
Experiment IS; Introduction oj Air into the Venous System; Deaih.
The external Jugular vein of a large male bull dog was exposed, and a small inciaion aade
through the coats of the rein, and the small end of a silver blow-pipe introduced. Air was
then blown forcibly into the vein, the dog gave a few spasmodic struggles and a load crj, ani
died almost immediately. Air was found after death, mingled with blood in both cavities of
the heart, andan mafiy 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 thai
in poisoning by Prussic acid.
Experiments 16, 17, 18, 19, 20; Repetitions of Experiment 15 ; Introductum of air
into Venous System ; Death ; Results similar to those recorded under 15.
If small quantities of air 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 rapidly
as in cases of poisoning with the most potent and rapid agents as Hydrocyanic acid aod
Cyanide of Potassium.
After careful investigation, I have been led to the conclusion, that the forcible intro-
duction of air produces death, by arresting the circulation of the blood in the ci^illarieg
of the lungs and of the brain, medulla oblongata and spinal cord, and of the heart; and
we are inclined to view the suddenness of the fatal issue, when the air is driven in witli
great force, chiefly to the mechanical arrest of the circulation of the medulla oblongita.
When considerable force was used in driving in the air, the organs presented a higUy
congested appearance, similar to that characteristic of poisoning by Hydrocyanic acid ;
but in the former case, the congestion was clearly referable to the effects of mechanical
pressure, suddenly exerted upon the blood within its vesatjels, and the combination with
this pressure of mechanical arrest of the capillaiy circulation.
The following conclusions may be drawn from the preceding experiments, iUustratiog
the action of physical agents.
1st. Violent muscular exertion and tetanic spasms, excited by injuries of the nenrous
system, are attended with an increase of temperature, both in the central organs and io
the muscles.
2d. The violent tetanic spasms excited by the interrupted electro-magnetic current,
are attended with an elevation of animal temperature.
3d. When an animal has been killed by the interrupted electrical currents of bijA
tension, and which have caused violent spasms during their application to the lifing
animal, the cerebrospinal nervous system (brain, medulla oblongata and spinal oord,) is
congested with blood, and this congestion extends not merely to the investing membranes,
but is well marked in the nervous structures, and especially in the ganglionic tracts o{"
the brain, medulla and spinal cord.
4th. The temperature progressively falls after death from injuries of the nervous
system, from haemorrhage, from electricity and from the injecUon of air into the venous
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 median,
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Experimental Illustrations of Convulsive Diseases. 279
the sixe and condition of the animal, whether lean or fat, and the character of its
coTering, whether wool or hair and whether thick or thin.
These ftcts are of interest in their connection with those cases of Tetanus, Acute
Bheumatism and Yellow Fever, in which observers have recorded a rise in the tempera-
tare alter death.
We will proceed in the next place, to present certain observations frpm our experimental
investigatioDS, upon the action of poisons, instituted with the design of throwing light
upon 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
EXPERIMENTS UPON THE ACTION OP PRU88IC ACID (HYDROCYANIC ACID) AND
CYANIDE OP POTASSIUM UPON PLANTS.
The plant selected for these experiments was rice, ( Oriza Satira), If grains of rice
be 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
extraneous 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.
Expei^nient 21 ; Action of Hydrocyanic Acid on Rice.
Ten drops of officinal Hydrocyanic Acid were added to half a fluidounce 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 fiifal
deTelopment of the young plants. The degree of retardation was determined by conducting
limaltaneously experiments with rice and pure water.
Experiment 22 : Action of Hydrocyanic Acid upon Rice in Closed VesaeU.
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.
When 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
germination and growth, and were repeated upon more than one hundred grains of
riee.
If we compare the two experiments, and consider the surrounding circumstances, it
is evident that the different results were due to the fact that when the rice was sub-
jected to the action of dilute Prussic Acid in open vessels, the poison, from its volatile
patore, was evaporated in great measure, before it produced any deleterious effects upon
the riee ; in the confined space, on the other ^and, whilst the seeds had all the essen-
tial conditions of germination, viz : heat, moisture, and a sufficient, if not abundant
supply of oxygen, in the confined air, still the absorption of the Prussic Acid continued
uumpeded, and arrested the process of germination in its earliest stages, for the seeds,
in almost every instance, presented upon the exterior an unaltered appearance.
Experiment 23 : Action of Hydrocyanic Acid upon Germinated and Growing Rice,
When 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 one hundred stalks of growing rice,
with rimilar results,
A<^ion of Cyanide of Potassium upon Plants.
In the experiments with this salt, as well as in those of- Hydrocyanic Acid, ricp was
the plant selected, and the surrounding c^ditions of temperature were the same.
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280 Experimental Illustrations of Convulsive Diseases.
Experiment 2Jf. : Action of Cynnlih of Potassium upon the GermtncUwn of Rlcf,
Both in closed and unclosed vessels, solutions of Cyanide of Potassium arrested complctclr
the process of germinatioa. The word arretted i^ here used, because it is difficalt in sucb
experiments to affirm that not a single change took place in the organic elements before the
complete arrest of the process ; it is certain, however, 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 25 : Action of Cyanide of Potassium upon Growing Rice,
^Solutions of Cyanide of Potassium in erery instance arrested the growth and caused tbe
death of the growing rice; and the rapidity of its action corresponded with the amoonl of
the poison added.
These ezperimcnis were in like manner repeated upon more than one hundred stalks uf
growing rice.
The following conclusions may be drawn from the preceding experiments :
I. Plants, as well as animals, may be destroyed by certain minend and v^etabk
substances denominated poisons.
II. As the vegetable kingdom is without nerves, muscles, or any special circulatory
apparatus similar to the automatic apparatus of animals, it is evident that these poisoiis
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 distinct products from the surrounding nutritive materials, and as this power '^
destroyed by poisons, we must conclude that the functions of secretion, growtb and
nutrition may be influenced directly by poisons, without the intervention of the nervous
system.
IV. As, therefore, poisons may act directly upon the individual living cells of veg-
etables, arresting the process of germination in the seed, and of the acts of secredon,
nutrition and growth in the fully formed cells ; it is reasonable to infer that poisDos
may act upon the individual living cells of animals. Thus poisons may act directly
upon the muscular fibre, or upon the ganglionic cells of the sympathetic and cerebro-
spinal system, or upon the secreting and excreting cells of the liver and kidney, or upon
colored and colorless corpuscle 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 OP HYDROCYANIC ACID ON COLD-BLOODED ANIMALS.
Experiment 26 : Action of Prvssic Acid upon Siren Lacertina, — Linnaeus,
1 placed a large male ^e>^ Lacertina^ one and a half feet in length, and recently capture
from a rice field in Liberty county, Georgia, in a glass jar, and after pouring over its bead,
j^ills and back, three fluiddrachms of the officinal solution of Prussic Acid, [U. £. P]., added
twelve fluidouuces of pure water. The experiment was performed in the early pari of Jnie,
when the weather was warm, the thermometer indicating during the day, an average temper-
ature of 80^' F. ; at this temperature, the motions of the Siren Lacertina, are active aod
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 Prussic
Acid, at'successive intervals of fifteen minutes, and at least, two floidounoea of tke officinal
solution of the acid, were poured over the head and gills, and into the mouth and over tbe
back of the reptile. Two hours after the first application of the poison, the Siren com-
menced of its own accord to struggle violently — would leap up with great violence— tho
body was contorted, and the animal writhed as if in pain, and at intervals, the muscular lys-
tern was seized with violent tetanic spasms. Simultaneously with the appearance of the9^
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Experimental Illustrations of Convulsive Diseases. 281
Fpasmodic actions, there occurred profuse secretion of mucous from the slltny skin of the
reptile, causing the water in which it was immersed to resemble thick mucilage. These strug-
gles continued for one hour, and then the reptile became quiet, and would struggle feeblj only
when aroused bj a foreign body. The head appeared to be especially sensitiye. Sensation
and the power of motion gradually diminished, and four hours after the application, there
irere but very slight movements of the feet and tail when actively stimulated, and aroused
bj mechanical means ; and at the end of six hours, all signs of life were extinct.
PoMl'mortem Examination : 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, and
mechanical stimuli failed to excite contractions in any of the muscles. The heart had ceased
to beat, 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
mascles, 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-
scope, 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 granules. The blood-vessels of the stomach'and inlestincs were
loaded with blood.
Experiment 27 : Action of Uydrocyanic Acid on Coluber Quadrivittattts.— Holbrooke
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 aqy other
injury, than cutting through the integuments. Action of the heart 68 per minute. ' 6y the
term action of the hearty 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
vfRtricU* in warm-blooded animals] ; and therefore, the term action of the hearty as now used ,
signifies only the number of impulses, nnd does not give the collective expansions and con-
tractions of all the cavities.
Several drops of a solution of Prussic Acid were introduced within the peri-oardinm, so
as to come iu direct contact with the exterior surface of the muscular structures of the
heart.
The effects were manifested 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
it evident derangement in the relations of the expansions and contractions of the different
cavities, 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 effects upon the action of the heart occurred imme'
diatefyj whilst the effects upon the voluntary mtiscles were not manifested until a sufficient length of time
M elapsed for the absorption and conveyance of the poison by the blood to these structures and the
gMgUoHic centres from which these nerves were derived.
Fonr minutes after the application of the poison to the sunface of the heart, its Miction is
2G per minute, and very irregular, the dilatations are much longer than the contractions — the
rentricle 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
coold not be aroused by either mechanical stimuli and injuries, or the strong, interrupted
magneto-electric currents ; the auricles, when pricked, and when excited by the electrical
shocks, contracted very slightly, presenting the appearance, more nearly resembling a slight
tremor, than a well marked contraction. The voluntary muscles qn the other hand responded
readily to both mechanical and electrical stimuli.
Experiment 28 : Action of Hydrocyanic Acid on larje Coluber Gattatits. — Linn,
This experiment was performed in the month of June, and upon the same day with tiio
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 Acid
applied to the exterior surface of the heart. The effocts of the poison upon the heart wei^
evident in a few seoondsi 8^t\d iu three minutes the aotm of thQ begirt was recMiced to 28 per
30
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282 Experimental lUusfrations of Convulsive Diseases.
minate, and spAsmodic contractions of the muscles were excited. At tbe end of this lime a
strong Bolation of chlorine in water was applied to tbe exterior surface of the heart, prodaciof
a much stronger and fuller action in the auricles and yentricles. The excitemeot of tbe
chlorine, howerer, 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 polsatioiis of tbe
heart were 20 per minute. The heart continued to beat slowly, with diminishing freqaeocy
and power for one hour, and at the end of this time, it could be aroused to action^ neither by
mechanical meang nor by strong interrupted electrical currents. The voluntary muscles on the other
handy 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 Bydrocyanic Acid on Emys Serrata. — Damlin.
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 infiltrated 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 lonp: 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. Tbe
heart was flabby in its structures, slow and feeble in its actions, and the Etructures offered but
slight proofs of excitement, when pricked with the point of the knife. The application of
Prussic 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, wCfe the same, the actions of
the heart were rendered spasmodic and their synchronism destroyed, and the frequency gra-
dually diminished until all action ceased. Spasms of the muscled were excited before death.
The heart in this case unlike the previous cases continued to beat, after the voluntary
muscles had lost all irritability under the action of mechanical stimulants.
Prom these experiments we may, with reason conclude, that Hydrooyanic Acid exeita
a specific influence upon the structures of the heart, 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 waa
absorbed and acted upon the heart only through the cerebro-spinal nervous system, from
whence, according to some physiologists the heart derites all its powers. However
plain the teachings of these ejcperiments may be to ouf own mind, it is neverthekss
unportant that we should, before proceeding further, consider the relations of the actkm
of the heart in cold-blooded animals to the cerebro'spini^l nervous syst^n, imdthQ f^^
patheUc or organic system.
BELATIONS OF THE ACTION OF THE HEART IN COLD-BLOODED ANIMALS, TO TWl
CEBBBKO-SPINAL AND SYMPATHETIC NERVOUS SYSTEMS.
The relations of the heart to the cerebro-spinal and sympathetic nervous systems, ara
highly complex, and their complete development would require an extended examioatioQ
of the nature of muscular irritability and nervous excitation, and the relations of respi-
ration, capillary circulation and the chemical composition and changes of the bloody
to the hearths action ; and we shall now present only such well established fkots and
experiments as will enable us to decide whether Hydrocyanic Acid acts directly or
indirectly upon the heart.
'The ract that the heart and the muscular system generally, would in cold-blooded
animals, continue to act for a considerable lenp^th of time after the removal of the brain,
has been known for more than two-thousand years. Aristotle alluded to the independence
of the action of tbe heart and the motions of tortoises ; and Pliny in his great work oa
Natural History, in the sixty-ninth Chapter of the eleventh book, not only states the
&ot that the heart is formed first among the viscera of the foetus, and is followed bj
the formation of the brain and other organs, and last of all, by the eyes, but asserts that
the heart is the last of all the organs to die. Pliny considered the heart as the prin^pil
seat of the heat of the body, the primary source and origin of life, and as containiog
within itself ih^ primary receptacles for the spirit, ancl the blood \xx its sinpus cavities,
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Experimental lllustraticns of Convulsive Diseases. 283
where the mind also, he supposed had its abode ; and affirmed that while all the other
riscera are injared, vitality may still remain in the heart. Bed! found that tortoises
lived and were even able to walk for six months after he had completely removed their
brains. Marcot, Wepfer, Stalpart, Brinius, Morgagni, Haller, Brodie and others, have
recorded accounts of foetuses without brains. Yesalius more than three centuries ligo,
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^ fkbrica, Basilece,
1555, p. 824 ; ) and thereby demonstrated the dependence of the action of the heart
upon respiration. Hook, in 1667, presented to the Philosophical Society of London,
*• An account of an Experiment of preserving annuals 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 Phystohgie and in his
Primst lAaeft 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, fifty-second letter, and twenty-seventh Chapter of his
work on " T%e Seats and Causes of Diseases investigated hy AnaJtomy^^ has given
experiments performed by himself, and has brought forward the examples of footuses
developed and delivered, not only without the cerebrum and cerebellum, but also
wtihout the medulla oblongata and spinalis, which prove the independence of the action
of the heart, of the cerebro-spinal nervous system. John Hunter (Proposals for the
recovery of persons apparently drowned, Phil. Trans., Vol. Ixvi, rwui March, 1776 :
Observations on certain parts of the Animal Economy, 1786;) Edward €k)odwyn
(Connection of Life with Bespiration, etc.;) William Cruikshank, (Phil. Trans., Vol.
lxxxv,p. 177,) and Sir Benjamin Brodie (Phil. Trans., 1809, p. 161, 1811, p. 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 action
upon the supply of arterial blood, but also its independence of the action of the cerebro-
spinal nervous, system.. Zavier Bichat has in like manner, recorded observations and
experiments, which prove the independent action of the heart. The fact that the heart
of cold-blooded animals will act for some time after its removal from the body, is now
uoiversally known and acknowledged, and I have witnessed this phenomenon in
Dumerous experiments, which I have performed, upon Fish, Batrachians, Amphiumas,
Sirens, Ophidians, Chelonians and Saurians.
Spallanzani from an extended series of experiments upon the circulation and respira-
tioQ 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
aninuils. 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 progressively diminishes, and the pulsations of the heart and the respirations become
correspondingly feeble and less frequent, and when the absorption of oxygon ceases, the
pulsations of the heart and the respirations, also cease. Spallanzani concludes from his
namerous 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. Spallanzani also showed
that the action of the heart, and the development of the red color, in the blood of the
chick, even whilst enclosed in the egg, is due to the chemical action of oxygen ; and
that whilst 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 becomes animated, has its
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284 Experimental Illustrations of Convulsive Diseases.
parte evolved, ^nd p^dually arrives at a state of maturity ; and when od quitdDg the
shell, it ceases in this way to receive its usual supply of the priuciplc, it imniedialdj
receives it by the lungs, which the oxygen gas has put into motion. (Memoirs on
Respiration, by Lazarus Spallanzani, edited from the unpubHshed manuscript of the
author, by John Senebier, London, 1805.)
The experiments of Spallanzani, Sylvester, Humboldt and Provincal, on the inflaeooe
of the air coutained in water on the life of fishes; the experiments of Smith and Hum-
boldt, showing the dependence of muscular action upon chemical change ; the experi-
ments of Hunter, Spallanzani, Mangili, Pruuellc, and Dc Saissy and Edwards, upon
the hibernation of the bat, hedgehog, marmot and dormouso ; of (joodwin, Buffon, Le
Gkdlois, Bichat and Edwards, upon asphyxia ; the experiments of Crawford, DeUrocfac
and Edwards, upon the amount of oxygen consumed, and of carbonic acid gas evdved
at different temperatures ; the experiments of Allen and Pepys, of Dulong, and of Ed-
wards, upon the chemical changes of respiration ; the expcrimeut^ of Spallanzaui, Vaa-
quelin, Vogel, Brande, Sir E. Home and Edwards, showing the formation of cmrboDic
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 in the animal economy depend ultimately upon the
chemical changes of the structures.
From the results of an extended examination of the progressive developmeut of the
organs and tissues of animals, and of a series of experiments upon the chemipal changes
of the constituents of animals, I was led to the following conclusions with reference to
the action of the heait :
1st. The forces which work the heart, like those which are active in every muscle,
are developed by the chcaiical changes of the constituents of the heart and blood
2d. The cerebro-spinal nervous system adds no force or actual motive power to the
heart, although it may influence it^ action, through the ganglionic system proper of the
heart, and through that portion of tha vaso-motor system of nerves which reguktes
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 after its separation from the oerebro-qunal
nervous system and from the organs and general circulatory system, is due to maoy
causes besides the mere deprivation of any nervous force supplied by the oerebro-qunal
system, viz : the changes induced in the blood of its capillaries, and in its muflcakr
fibres, the products of which changes are deleterious to the living tissues. In Uie living
animal the blood supplying the heart is constantly purified from these products by
special organs, as the liver, and kidneys, and lungs. If the chemical composition of the
blood circulating through any organ be greatly changed, derangement and final ooai
tion of the action of the organ must necessarily ensue. In the living animal, the integ-
rity of the blood is constantly preserved by various organs j the liver forms the birth-
place of its corpuscles, elaborates its crude compounds, supplies it with grape sugar and
albumen, and removes various deleterious coloring matters and salts ; the spleen exerts
certain effects upon colored and colorless corpuscles ; the kidneys continually remove
fVom it such products of chemical change as urea, uric acid, the phosphates, sulphates,
chlorides and extractive and coloring matters ; and the lungs supply the great donent
of chemical change, oxygen, and at the same time eliminate the poisonous cmrbonic
acid. If the heart be removed from the body, its actions will continue as long as the
elements of chemical change are supplied in the proper portions, and until its muscular
structures and ganglionic cells, 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 important that
they should be examined by the light of direct experiments upon the action of the
cerebro-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 io
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warm-blooded animals will receive further examination, as the phenomenon is more
complicated in this class, notwithstanding that the principles which we have just
examinedjand the experiments which we are about to recount, apply also to the relations
the nervous and muscular of forces in all animals.
Spallanzani performed numerous experiments upon frogs and salamanders, to deter-
mine the relations of the circulation to the ^inal marrow and brain. He found that
irritation of the brain and spinal marrow was attended with violent convulsions of the
nrasdes ; 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 a£fect the circulation in any appreciable manner. — Experiences sur le Circula-
tion ; ouvrage par J. Tourdes, Paris ; Exp. cvi-cxviii.
Fontana placed the source and principle of life, and of all animal motion, in irrita-
bilitv, and contended that the circulation is independent of the brain and spinal marrow.
He 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
heart, 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 Vcnin, dc la Vipcrc; Florence, 1771; Tom. I, pp. 81, 1)0, 93,289; Tom. II,
p. 169.
Dr. Whytt, allcr decollating a frog, destroyed its 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
after decollation, it moved 40 times in a minute. After half an hour, it made 36, and
after fifty minutes, only 30 pulsations in the minute, which were now also become very
small and feeble. This observer, afl«r 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
8{ttnal marrow, the thorax was opened and the heart observed, beating 30 times in a
minute. One hour and fifty minutes aft^r decollation, the heart made 20 pulsations in
a minute ; three hours and twenty minutes, when the room was become warmer by the
shining 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 tim$) 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
anricles of this frog'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 itimului. Ten minutes after this observation, the ventricle seemed
to be quite dead, but the auricle continued its motion. Three hours aft«r the ventricle
had beien without motion, the auricle which was very near as much filled with blood, as
when the heart was first exposed, beat 11 or 12 times in the minute; its pulsations,
however, were not so regular, 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
especially into the heart, is not necessary for their contraction. Edlnhxtrg Physical
Essays, vol. ii, pp. 282-285.
M. lie Gallois, 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 frc^ did not fully sustain this proposition, for although the sud-
den destruction of the brain and spinal cord was followed by a temporary cessation in
the action of the heart, the organ subsequently renewed its pulsations.
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286 Experimental Illustrations of Convulsive Diseases.
Dr. A. P. Wilson Philip,* concluded from his numerous experiments upon oohl-
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 remoTed,
and that their removal is not attended by any immediate effect on its motions. It may
be urged with some degree of Justice and force, against the series of experiments iosti'
tuted by Dr. A. P Wilson Philip, to show that certain agents as solutions of Opiam
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 efiects
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 organ.
From his experiments upon warm and cold-blooded animals, Dr. Philip not only arrived
at the conclusion of Haller,.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 h«
thought that the great objections to Haller s doctrine were removed.
Mr. William Clift, shortly after Dr. Philip's researches, performed similar experiments
with similar results upon the carp. The heart was exposed, the effects of the decitroetian
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 injuiy 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 larger
vessels, and finally, the circulation is confined to thie heart and large trunks. The
energy and duration of the circulation, depends therefore, upon the, nervous system,
for in proportion as the brain and spinal cord are destroyed, the circulation is enfeebled,
and at the end of a certain time, after the destruction of the nervous syiteni, the
action of the heart and the circulation is entirely destroyed. In the second place, the
circulation 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 lalways alone in those
parts corresponding to the portion destroyed, that the circulation shows itself enfoeWed.
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 destmotion
of the nervous system, so enfeebles the entire circulation, that sometimes when the
vascular circulation still survives, the sub-cutaneous capillary circulation is almost imme-
diately stopped. This last point is worthy of attention, for it has led several others to .
regard the capillary circulation, either 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
* Experiments miule with a view to ascertain Uie principle on which the action of the heart de|mMli» u^<^*
relaUons which sabeist between that oixan and the nervous system. Philosophical Tranmctioos 1815, pp. »^
See also PhU. Trans., 1817, pp. 22-31 ; 1822, pp. 22, 23; 1827, pp. 297-300; 1829, pp. 261-278; 1«1, pp. '♦WjW; 1».
pp. 65-72. PhU. Trans., pp. 73-87; 1834, pp. 167-198; 1830, pp. 343-376. An inqairy Into the Laws oT the ^wl
Functions
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Experimental Illustrations of Convulsive Diseases. 287
at the periphery of the vascular circulation, it is most sensitive to impressions. But,
however related, the nervous and circulatory systems may be, this relation is not iustan-
tineous, 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. Da Syst^me Nerveux, Paris, 1827. More recently, M. Flou-
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 wero 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 slower ; it was lost in the capijiaries 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
luog was examined, and its circulation had ceased. The heart still beat feebly thirty-
six 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 na'tural, but in a very short time it grew 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
vigorously 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
thev led him to believe, that the action of the heart is enfeebled from the moment it
ii deprived at once of the influence of the brain and spinal marrow ; and that the con-
nexion of the heart with the nervous system, is precisely of the same nature as that of
the voluntarv muscles ; both possess a degree of irritability independent of the large
masses 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
muscular fibre, yet it may become extinct without any obvious change in that fibre ;
its oontinuanoe or renewal, depends ultimately upon the masses of the nervous system.
Pr. Hall believed that from the moment of the abstraction of the brain and spinal
marrow, the irritability of the heart begins to fail; the circulation is first enfeebled,
then lost in the most distant parts of the system, then in parts less remote ; the distance
\o 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
medulla oblongata on which respiration depends, and of the entire brain and spinal
marrow, by successive portions at distant intervals, and found that the destruction of
the medulla oblongata did not arrest the circulation, as had been asserted by M.
Flourens, and finally, that the frogs lived much longer, and the circulation continued
much more active for a greater length of time, when the brain and spinal cord were
removed by successive portions. In one instance the circulation continued, but little
altered, for about forty hoigrs after the entire destruction of the brain and spinal cord.
A repetition of the experiments of applying ^various substances, as alcohol and infusion
of opium 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 inftision of opium affect the circulation equally, whether they be applied to the
brain and spinal marrow, or to the exterior of the body and extrepiities, and that after
frogs were rendered ip9ep#W by iniinersing the extremitjies iu hud^num, alcohol ap-
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288 Experimental Illustrations of Convulsive Diseases.
plied to the suiikce of the braiti uiid ^pitial cord, as in Dr. Philip's experiii^ents, pro-
duced no stimulant effect whatever upon the circulation. Dr. Marshall Hall abu
repeated Dr. Wilson Philip's experiments, illustrating the effects upon the drcnlation,
of crushing the spinal cord and brain suddenly, and was again led to dissent fVom his
conclusions, by finding that the heart's action is equally ^rested by crushing the
stomach or even the extremities. A frog was made perfectly insensible by the a]^)lioa-
tion of laudanum or alcohol. Its respiration ceased, it did not move on the application
of any irritant. The circulation in the web was c^refolly observed. When it had
long continued iu the same enfeebled state, without change, the thigh was orusbed.
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 manj
seconds. Its beats then returned, but never r^ained its former force. The effect was
precisely such as was observed by Le Gkllois on crushing the spinal marrow. Then:
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 ed, the
circulation became at length much enfeebled in the pectoral nn. . The part one inch
and a half below the heart was crushed. The circulation in the pectoral fin now ceaaed
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. The
heart, which previously beat vigorously, sixty times in a minute, stopped suddenly, and
remained motionless for many seconds. It then conUticted again, and slowly and grid-
ually recovered an action of considerable frequency and vigor. No experiment can
more clearly demonstrate the effects of violence inflicted upon the system generallj.
The experiment is the more remarkable, because the connexion and influenoe of the
j^rain and spinal marrow were entirely removed. The physiological deduction which
Dr. Marshall Hall drew from these experiments, was that so much insisted on by Hip-
pocrates, that every oi^n or part influences, and is influenced by every other ; that
there is a pre-disposing sympathy ; the whole system may be compared, in thb point of
view, with rings entwined together, they naturally support each other, any one may be
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
frame.
Dr. Hall* does not attempt to determine the mode in which this sympathy is exerted,
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 organs indi-
cate anything of physiological importance, it is intimately associated with the action of
the heart, arteries and capillaries. In crushing an organ, no matter how remote from
the central organ of circulation, we crush the bloodvessels of the organs destroyed ;
now, as^ these blood-vessels are surrounded with the fibres of the sympathetic or vaso-
motor nerves, which form a chain of communication with the sympathetic ganglia and
nerves of the heart, it is but reasonable to suppose that their destruction should exert
an effect upon the general circulation.
Bidder removed with great care the arches of the second cervical vertebra, so that
little blood was lost during the operation, and then completely destroyed the spinal oord.f
Frogs treated in this way, often lived six weeks, sometimes ten weeks, the drcabr
tion, as seen in the web of the foot, remaining at the same time active, and not differ-
ing from that in uninjured frogs. The heart beat powerfhlly and quickly ; in a freshly
killed frog, in winter, the heart pulsated thirty-five times in the minute ; while in a
frog, the spinal cord of which had been destroyed twenty-six di^ previously, the pol-
* A Critical and Experimental Essay on the Circulation of the Blood, Espeoiallj as 01»«
served in the Minute and Capillary Vessels of the Batracbia and of Fishes. Phil., 1835^ pp,
02-125.
t Cyclopaedia of Anatomy and Physiolagy, Part xlviU M^g^ 18W> pp- 45T-458^
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Experimental Illustrations of Convulsive Diseases. 289
BAtioiiB were forty per minute. When the brain and spinal cord were destroye4, 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, according 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, stOl continued to pulsate eleven times in the minute, and retained its property of
responding to external 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 nervous system ; healthy frogs, and others which had been operated
npon, 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 even in animals whose spinal cord
had been destroyed twenty-six days previously. 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
becaune 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 destruction 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
sores 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 the 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 difficultv of sufficiently keep-
ing up reCT)iration 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 v^e-
tative organs do not require, 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-
ments in question, require such an organ, and are not produced by the mere stimulus of
the blood, fsooes, air, etc., in the same way as the twitchings of the muscles of a frog's
1^ 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-
hated ; when it affects the whole, trunk of such a nerve, many muscles are excited 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 th^sQ there 19 a c^ri^iQ unity and
37
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290 Experimental Illugtrations of Conuulsive Diseases.
plan, Id the others not ; the difference depending on the eircomstanoe that in the one
a regulating principle associates the muscular movements for the attainment of ao
organic act or purpose ; in the others this does not take place. When the r^ular 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 diaphragm
similarly circumstanced, it is hardly possible to suppose that the two kinds of movemeot
proceed from the same principle. Irritability acted on by the stimulus of the Uood 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 regolating
principle implies the existence of a regulating apparatus. While the r^ular movefflents
of the voluntary muscles suddenly cease when the brain and spinal cord arc destroyed^
those 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 ibc
sympathetie.
We have thus endeavored to examine the various experiments of Physiologists illaa-
tf^ting the relations of the action of the heart to the cerebro-spinal and sympathetic net-
tons system, and this research has only still' farther strengthened the condosion thit
oeituin poisons, as Hydrocyanic Acid, may act directly upon the muscular and nervoos
structures of the heart, and thus arrest its movements without any intervention of tbe
csrebro-spinal nervous system.
We propose^ however, still further to illustrate this proposhion by tb« following:
KXPERIMIKTB ILLV8TRATINO THE DiaBOT ACTION OF PBU88IC ACID, CYANIDE OF
)>0TAB8IUM AND BTaTCHNIA, UPON THE HEART OF . COLD-BLOODED ANIMALS,
WHEN REMOVED FROM ALL CONNECTION AND COMMUNICATION WITTI TH«
CEREBRO-SPINAL NERVOUS ST8TEM.
Experiment 30 : preliminary on a fine active corn snake (^Coluber GuttcUm — Linnttnt,)
in the month of June, illustrating the effects of rem^oving the heart entirefjf from the
influence of the cerebrospinal nervous system.
The heart of this snake was expose d, and after the excitement induced by the operation bad
subsided, the action of the heart was 76 per minute.
The trachea and oesophagus were severed just below the head, opposite the cerTical vertebn.
and all the Tiscera (lungs, heart, liver, spleen, pancreas, intestines and kidneys,) removed, tod
ihe cloaca secured just below the junction of the ureters. Previous to, and during the ope-
ration ligatnres were applied, so as to retain tbe blood, both in the blood-vessels or the tmak
and of the viscera. After the removal of the viscera,, and whilst the lungs were complete}/
collapsed, the heart beat only 30 times to the minute. Tbe action of the heart commeocedto
diminish in frequency during the removal of the viscera, owing to the complete expalsioa of
air from the lungs at the moment that the wind-pipe was secured. The whole opermtioii
occupied 10 minutes, so that in 10 minutes the heart had lost 46 beats per minute. The laags
were then inflated so as to imitate the respiration of the snake ; in a few moments the actios
of the heart was increased, both in frequency and force, and soon rose to 76 per minute. Tbe
movements of the heart appeared as usual to the naked eye, and felt as usual when the fiBg<:n
were placed around the organ and gently pressed against it.
The heart continued to beat for two hours, although the lung had been allowed to collapie.
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, tb*
heart was beating regularly 16 times per minute, and presented bath a natural appearaac^
and regular normal actions.
Experiment 31 ; Illustrating the Action of Hydrocyanic Acid upon the Heart removed
entirely from the Ckrebro- Spinal Nervous System of a large, active King Snah
{Ooronella Oetula — LinnseuSj) 6 feet in length, in the month of June,
The heart was exposed, its pulsations per minute were 66 ; the viscera were then remove^
and at the end of the operation the aotlan of the heart was 52 per minute. The pericardiom
was opened, and a solution of Prussic ^cid applied upon the external surface of the heart.
In two wiipqt^s, tb^ option of the ^eart fell tq 28 per inionte, notwithstanding, that thfr
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Experimental Illustrations of Convulsive Diseases, 291
respiration in the long was kept up, after the removal of the viscera hj artificial means. In
4 minutes the action of the heart was 18 per minute; the contractions and expansions of the
aarieles 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 Prussic 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,
acd its color both in the auricles and in the ventricles, had deepened to a dark purplish black
and 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 have
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, whicli 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 hour ; 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 the
viscera.
It might have heen said that in the previous experiments, the action of the Prussic
Acid was reflex ; that is, through the cerebro-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 cerebro-
spinal nervous system.
In order to settle this important question dafinitoly, the following experiments were
instituted with Prussic Acid and other poisons :
Experiment 32: Effects of Hydrocyanic Acid on the Ilaart of the King Snake j
{Corofiella Getula), April 6fh, 1801,
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 numbered
80 per minute ; it was then severed from its vascular attachments, and dropped immediately
io 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
•olation the auricles ceayd to beat, and there was only a spasmodic motion of the ventricle,
which was contracted and contorted in various ways, ns if the muscular fibres were tetanized ;
in three and a half minutes, one-half minute after the last observation, the motions of the
rentricie were very feeble, and the tissues of the heart began to loose the contracted, tetanized
appearance, and finally became flabby and relaxed. The flabby state was characteristic alike
of the auricles and ventricle.
Haifa minute after the last observation, and four minutes after the commencement of the
experiment, 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
Bolation of Prussic Acid was poured down its throat, and into the cavity from which the
heart had been removed. The effect of the poison was to produce contractions, contortions
sod increased motions at first, and then in the course of fifteen minutes all motion ceased.
Experiment 33 : Preliminary Experiment on tlie action of Pare Water on tlie Heart
of the VelloW' Belly Terrapin, (Emys Serrata).
The sternum of a large, female J^mys Serrata, (Vellow-Belly Terrapin), was removed
April 6th, 1861, at 4} o'clock p. m., at Montevideo, (residence of my father. Rev. C. C. Jones,
D. D.), 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, IG per minute. In the month of
A^ril,on the coast of Georgia, in the swamps and rice fields, the circulation is rather sluggish
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2d2 Experimental Illustrations of Convulsive Diseases.
in oold-blooded ftnimals, being diminished in frequency daring the cool nights, and inertawd
hj the heat of the sun in midday.
The heart of the terrapin was then cut out without injury to its muscular substance, the
large arteries and Teins being severed about two-tenths of an inch above their junction with
the heart.
The heart was immediately thrown into fresh spring water, (upon analysis I found the
water to be very |)ure ; it issued from a sand bed).
Three and a half minutes after the introduction of the heart into the spring water, its pul-
sations were 15 per minute, and were strong and regular; 11 minutes after, action of heart
accelerated, 22 per minute and regular ; 30 minutes after, heart beating 10 times per minute,
actions regular ; 65 minutes after, heart still beating with regularity and force, 4 times per
minute ; 90 minutes after its introduction into the water, heart still beating slowly, three
times per minute.
Throughout this experiment, the tissues of the heart appeared natural, and presented t
striking contrast to the contracted tissues of the heart placed in Hydrocyanic Acid.
Experiment 34; Effects of Prussic Acid on action of Heart of large Emys Ser-
rata J (^YeUow- Belly Terrapin).
Heart of fine, large, female Emys Serrata severed from the body and thrown into solution of
Hydrocyanic Acid of the same strength and temperature as that employed in experiment 32.
Montevideo, April 6th, 1861, 4:47 o'clock p. m.
Heart beating 16 times per minute before being introduced into the Hydrocyanic Acid.
The immediate effect of the Hydrocyanic Acid, was to increase the action of the heart from
16 per minute to 62 per mii^ute, during the first minute after its introduction ; after the lapse
of the first minute, however, the action of the heart fell to 22 per minute, and the fibres were
unequally contracted, and the muscular walls presented a rough, unnatural, corrugated,
appearance.
In ten minutes the heart presents a livid and wrinkled appearance, and the ventricle merely
trembles 12 times per minute. The entire shape of the ventricle is altered ; it presents t
wrinkled, contracted, contorted appearance.
The heart of the terrapin immersed in the spring water, on the other hand, just before thii
experiment, looks perfectly natural, and is beating 14 times per minute.
Seventeen minutes after being placed in the solution of Hydrocyanic Acid, there Is nothing
observable about the heart, save a slight tremulous motion, which is not excited by mechanical
stimuli. The tissues of tbe heart are also becoming more relaxed. 24 minutes after being
placed in the Hydrocyanic Acid, all signs of life are extinct in the heart, whilst the heart which
has been in pure spring water for 30 minutes, still beats 10 times per minute, regularly.
Experiment 35 ; Repetition of Experiment 33 ; Effects of pure water on action of
Heart of Emys Serrata ( Yellow- BeUy Terrapin.)
Sternum of mate Emys Serrata^ removed: heart beating regularly 16 times per minute; heart
cut out and thrown into pure spring water ; the contact of the water*excited increased action
and it rose in 7 minutes from 16 to 48 beats per miuute ; 13 minutes after, pulsations of heart
40 per minute, regular and. good ; 27 minutes after commencement of experiment, action of
heart 24 per minute; 43 minutes after, still beating slowly and regularly.
Kcperiment 36: Repetition of Experitnent .3 j^, ; Effects of PruMic Acid on Hwrl
of active male Emys Serrata, April 6th, 5.15 o'clock, P. M., 1861
This active, male Emys Serrata, appeared to be in a perfect rage during the removal of the
sternum, struggling and biting furiously ; the action of the heart appeared to have been
increased by these exertions, and the organ boat 50 times per minute. Heart removed sad
thrown immediately into solution of Hydrocyanic Acid of similar strength to that used in
Experiment 34.
The first effect of the Hydrocyanic Acid was to increase the action of the heart several
beats, from 50 to 56 per minute.
Three minutes after introduction into Hydrocyanic Acid,, action of heart 24 per minute and
spasmodic; (action Of heart placed in water, 10 minutes before {Experiment 35,) 40 per minote
and reguUir ;) 6 minutes afterwards, action of heart 14 per minute ; surface of heart presents
a wrinkled, contorted appearance; 15 minutes after immersion in the poisonous liquid, the
auricles ceased to act, whilst the ventricle beat very feebly 10 times per minute, whilst the
heart in the pure water was beating regularly and strongly 24 times per minute ; in 2S
minutes, all motion in the heart immersed in Hydrocyanic Acid, had ceased.
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Experimental Illustratiom of Convulsive Diseases. 293
Experiment 37 : Effects of solution of Cyanide of Potassium, on action of Heart
of Young Opossum^ {Didelphis Vtrginiana,) Montevideo, Oa., April, 1861.
The joang opossum was taken out of the />ot/rA of its mother ; and at the time of its removal
it was sacking vigorooslj at the teat of its mother. The thorax was opened and the heart
cut oat, and dropped into a solution of Cyanide of Potassium, of the strength of 10 grains,
dissolved in one fluidounce of water. After falling into the solution the heart beat rapidly,
for a few moments, and then ceased in one minute, after its first introduction, and could not
be eicited to any farther action.
Experiment 88 : Effects of solution of Cyanide of Potassium on action of Heart of
Pided Viper, (Heterodon Platirhinos)
Heart cut out and thrown into solution of Cyanide of Potassium, 10 grains to fluidounce
of water.
ActioQ of heart, after being cut out and before being thrown into the solution of Cyanide
of Potassium, 48 per minute. After its immersion in the solution of Cyanide of Potassium, in
one quarter of a minute its beat had fallen to 40 per minute, and in half a minute, the ventricle
and auricles contracted spasmodically, and the ventricle was corrugated, as if portions of the
muscular fibres were more contracted than others. In three minutes, all action in the heart had
ceased entirely, and it eould not be excited to contraction even by mechanical stimuli.
Experiment SO ; Effects of solution of Cyanide of Potassium on action of Heart of
female Emys Serrata.
Montevideo, Ga., April, 18G1. Sternum of large female Kmys Serrata removed, and heart
exposed ; action of heart before being cut out, 70 per minute ; after it was severed and removed
from the body, 64 per minute. Immediately after thi*owing the heart into the solution of
Cyanide of Potassium, 10 grains to fluidounce, the action was slightly increased from 64 to
70 beats per minute. In half a minute, however, its action began to decline in fre.quency, and
in 3 minntes it beat 40 times per minute. The effect of the poison was very marked in des-
troying the symmetry of the actions of the heart.
The heart in its natural state, in Chelonians beats thus : the auricles contract, and then the
ventricle in regular order. The Cyanide of Potassium destroyed this relation of the action of
the auricles and ventricles; under its poisonous influence the two auricles could be seen con-
tracting separately ; the auricles and ventricle simultaneously ; and one auricle and the com-
mon ventricle simultaneously. After this irregular action had been established for a few
moments, the muscular bundles of the ventricle then became corrugated, and irregularly
contracted. Nine minutes after placing the heart iu the solution of Cyanide of Potassium, it
beats 36 times per minute, the ventricle spasmodically, with contortion of the muscular fibres ;
whilst the auricles give but little indication of any actton whatever; 15 minutes after immer-
sioQ in solution of Cyanide of Potassium, action of heart 21, spasmodic and wholly unlike
the natural action; in 20 minutes, all signs of action had ceased, the ventricle still presenting
t corrugated, contorted outline, with a very slight spasmodic twitching in a few of the fibres ;
a few moments after this, all signs of motion ceased.
lo the preceding experiment (39,) the poison (Cyanide of Potassium,) appeared to
act upon the sympathetic ganglia of the heart, as well as upon the muscular fibres, dis-
associating their mutual and rythmical impulses ; and the rapidity of its action appeared
to be universally proportioned to the amount of muscular fibre and number of ganglia.
Experiment 40 ; Effects of a solution of StrycJmia on Heart of Alligator, April, 186 L
Sternum of Alligator Mississippiensis, 2 J feet in length, opened, and heart exposed,*- action
of heart after exposure and before removal 60 per minute. The heart was then cut out and
thrown immediately into a solution of Strychnia, of the strength of 20 grains of Strychnia
and 20 grains of Citric Acid, dissolved in four fluidounces of water.
The action of the heart became slower and slower, as soon as it was immersed in the solu-
tion of Strychnia, and ceased altogether in three minutes after its immersion, and presented
a corrugated wrinkled appearance.
The effects of the Strychnia, were even more rapid than those of the Cyanide of Potassium.
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294 Experimental Illustrations of Convulsive Diseases.
Experiment ^1 ; Effects of Strychnia on Emys Serrata.
Sternum of yeIIow«bellj terrapin (Emys Serrata), removed, heart cut out and thrown
immediately into solution of Strychnia, (Strychnia, grs., xx ; Citric Acid, grs., xx ; Water,
fluidounces, iv) ; the ^st and immediate effect appeared to increase the rapidity of the action
of the heart, and the rorce also appeared to be increased, and the actions to be rendered
more spasmodic : in three minutes, the surface of both the auriclea and Ttntricles, 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 minate, 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^ Aprils 1861,
Sternum of Emys Reticulata (Chicken Terrapin) removed; heart exposed. Action of
heart, 34 per minute. Applied solution of Prussic Acid, (Cyanide of Potassium, grains, xl.
Tartaric Acid, grains, xl, 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 linbi.
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 poison,
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 minnte,
mucles of limbs strongly spasmed ; 8C 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
mass of blood, and thus the immediate action on the structures of the heart is roodiOed and
weakened.
Experiment 43; Effects of Prussic Acul on action of Heart of Emys Serrata
Yellow-Betty Terrapin. April, 1861,
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 surface of
the heart ; the effects were visible in 20 seconds — the motions became spasmodic, and in 30
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. Ten 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-
dic. The voluntary muscles are still active, the terrapin stretches out his neck and endeavours
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) all
motions in the voluntary muscles have ceased, but the heart still acts 9 times per minute. All
voluntary and reflex muscular movements have ceased, and cannot be excited by stimuli.
In the preceding experiment (43), we see that the action of the heart continued
longer under the action of Prussic Acid, than the excitability of the voluntary muscles.
The results of this experiment seem to indicate, that Prussic Acid acta with more vio-
lence upon the cerebrospinal nervous system than upon the sympathetic.
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Experimental Illustrations of Convulsive Diseases. 295
ExpenmetU 44 ' Effects of Prussic Acid on Alligator Gooter, ( Chelonura Ser-
pentina),
Poured & qnantitj of the Prussic Acid solution down the throat of a powerful and fierce
Alligator Cooter, which was about 12 inches in diameter across the carapace. Although the
poisoDoas dose was twice repeated in the course of one hour and a half, no appreciable effect
was manifest, and the animal remained active and powerful, and appeared to be well 24 hours
after the experiment. From this experiment we gather, that certain animals are Jess suscep-
tible than others to the action of Prussic Acid, and also that the effects are more marked
wbeo the poison is applied directly to the structures of the heart.
Experiment 4^i Effect of Strychnia on the heart of Musk Cooter {Sternothserus
Odoratus,)
Sternum of actWe Husk 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
pnlsations 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,
Steraam of large Emys Serrata removed, and heart exposed ; strong solution of strychnia
(grains 10 in flnidounce of water, with sufficient Citric Acid,) applied to surface of heart in
sito ; in 7 minutes tetanic spasms of voluntary muscles action of heart spasmodic and slight,
16 times per minute. la 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 ; Iffects of the direct application of a solution of Strychnia to the
surface of the Heart oJ Chiclcen 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 the voluntary muscles at a later period, in three minutes. One minute after the application of
the strychnia, the action of the heart had been diminished near one-third, in two minutes
one-half, 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 48; Repetition of 'preceding Experiment^ (47)-
Strychnia solution applied to heart of Emys Serrata ; results similar, with the exception,
that the heart did not cease to beat quite so rapidly as in the preceding experiment.
Experiment 49 : 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
application 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
venous hue, a dark, purplish black. It is easy to distinguish the color of the blood in the
cavities of the heart of the toad, on account of the thinness of the walls. The heart ceased to
beat, because it was paralyzed by the retention of carbonic acid. When cut out and thrown
into pure, 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
•l9Q tQ tk© absorption and removal of the carbonic acid gas by the surrounding water.
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296 Experimental Illustrations of Convtdsive Diseases.
Experiments 50, 51, 52, 58, 5 4,, 55, 56, 57, 58, 59, 60; Repetition of the precediMg
experiments.
On the direct action of Prussic Acid, Cyanide of Potassium and Strychnia, od
the hearts of various cold-blooded animals ; results similar to those previouslj
recorded.
Experiments 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 78, 74, 75, 76, 77, 78,
79 and 80:
Dlustrating 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 concentration ; when ooncentrated.
they coagulated the blood, acted chemically upon the structures of the heart, and npidlj
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 instances
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 <^
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 (Amphiuma Means), 10 inches in length, was chosen as the
subject of this experiment, which was performed in the month of June, 1862. The weather
was warm and the animal was active. The Amphiuma was immersed in a solution of Chlo-
rine in pure water. The effects of the Chlorine were immediate and powerful, producing the
most rapid and continuous motions.
Experiment 82 : Illustrating Effects of Prussic Acid,
Another Amphiuma, immersed in a solution of Prussio Acid, presented the peculiar effecti
of this poison as already described, and was rapidly rendered insensible, and finally destrojed.
Experiment 83 ; Effects of Cyanide 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 band,
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 StrjohoiA
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, eiu j and anat*
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 ^ass veaseb,
so that all the varied motions and effects induced by these aeents, vie : Chkriae,
Hydrocyanic Acid, Cyanide of Potassium and Strychnia, could be careiuUy noted and
compared.
In the experiment with Chlorine. (81), in a few moments the surface of tJiebody of
the Amphiuma Means became viscid, and was covered with » whitiBh, abuudant, muoom
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Experimental Illustrations of Convulsive Diseases. 297
secretion, presenting an appearance of partial coagulation. The whitish mucus was
detached from the body 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, and 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 water had taken place, and the whole body of the
Amphiuma Means was distended. The heart was exposed several minutes afl«i? all
sigDS of movement had ceased, and aftx^r it was impossible to excite movements by either
mechanical or electrical /stimuli ; the heart was still acting regularly and with 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.
Eaeperiment 85 : 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 have 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
minutes 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 powet 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 well and as active as ever. The heart was beating regularly 62
times 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 wns then injected directly into the cavities of the heart until they were
distended 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
ceased to beat, and could not be excited to action even by stronj? magneto-electric and elec-
tro-magnetic currents.
The reptile, however, continued to move about for some time after the cessation of the
actioo of the heart, and even attempted to strike.
In tliis experiment, the almost immediate cessation of the action of the heart, when the
Chlorine was injected into its cavities, appeared to have been due to the almost total abstrac-
tion of blood, (the blood having been driven entirely out of the blood-vessels, and even out
of the capillaries of the heart, by the action of the Chlorine upon the syippathetic ganglia
tod cardiac and vascular muscular fibres), and to the complete (;hemical alteration of the
Email quantity of blood which remained in the capillaries of the heart.
Small quantities of Chlorine, on the other hand, if they be too small to produce any marked
chemical 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
action 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 virtfUe of this stimulant effect
is capable of countorstctipg, to a certain ejctent, t^ie effects of Prussic Acid,
^
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298 Experimental Illustrations cf Convulsive Diseases.
EXPERIMENTS TO DETERMINE WHETHER OTHER SUBSTANCES OR AGENTS BESIDES
CHLORINE, ARE CAPABLE OF EXCITING THE ACTION OP THE HEART A5D
CEREBRO-SPINAL NERVOUS SYSTEM.
ExperimeiU 86. : Action of Binoxide and Peroxide of Nitrogen on Emy9 Serrata,
This experiment was performed in the month of January, 1862, when the weather wai
quite cool ; the temperature of the room was 50^ F., and the Cbelonian 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 effects. At the expiration of sixty hours, although all signs of
life had ceased, the heart still pulsated — the caTities of the heart contained fibrinous coDcre-
lions 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. All the large blood-Tessels contained clots, and the Tessels, and erea
the cayities of the heart contained a colorless gas in great abundance.
That the heart ehould $tiU have kept pulsating amidtt thoee marked changet^ and after tMe cesMti»«
of the action of the Cerebro- Spinal Nervous System^ appears to be coneluiive evidence thai them guaa
are stimulant in their action upon the heart:
Experiment 87 : Repetition of Experiment 86 on Music Cooler (Slernothmrus Odorciiutf
The results were the same, and indicated that these gases acted as excitants to the actios
of the heart : and that their destructive effects were clearly and chiefly due to the chemical
changes induced in the blood.
The foUowing comparative experiment were instituted to test still farther the £ict.
whether the action of Prossic Acid on the heart is peculiar, or is shared by other sub-
stances.
Experiment 88 : Action of Strychnia on Siren Laeertina,
The Siren Laeertina, on account of its naked skin, as well as on account of its amphibioas
habits and marked vitality, is especially adapted to such experiments.
A large, active Siren Laeertina, (eighteen inches in length), was placed in ajar, contaiaisg
about one quart of water, and six grains of Strychnine were placed upon its head, ia its
month, and over its back, and mingled freely with the water.
The day was warm, and the animal endowed with all the activity usually inspired io tbii
class of reptiles, by the heat of summer.
In twenty minutes, tetanic spasms could be excited by merely touching the animal, ted
these spasms gradually increased in frequency and force for more than half an hour, and tbei
gradually declined io force, and in one hour and a half after the reptile was subjected to the
action of the poison, all external signs of life were extinct — the limbs aud muscles wert
rigid, and did not respond to mechanical stimuli. When the thorax was opened at thb
time, the heart was still beating slowly and feebly, twelve times to the minute. The inter-
rupted electrical current produced but slight contractions of the muscles.
In this experiment, the heart appeared to survive the death of the cerebro-spinal systes :
as the action of the heart was without doubt dependent upon the sympathetic ganglia within
its structures, it is evident that the poison exerted its most powerful effects upon the cerebro-
spinal system.
Experiment 89 : IHrect Action of Strychnia on Heart of Goronella Getuta (Kin$
Snake).
The heart was exposed, and Its action, after the excitement of its exposure had passed
away, was seventy- two per minute. A strong solution of the Acetate of Strychnia was tbca
injected into the peri-cardium — in four mloutes the action of the heart fell to forty-eigbt
beats per minute, showing the loss of twenty four beat^ per minute in this short period; tod
the respiration became spasmodic and violent, and the muscles were thrown into tetaoic
spasms. The action of the ventricle wa^ sharp, strong, and well defined, whilst that of the
auricles was scarcely perceptible.
Some minutes after the application oC the Acetate of Strychnia to it's exterior surface, the
pulsations of the heart were only twenty-six to the minute, showing a loss during the Us^
tbre? Wiput?9 of twentyrtwo be^t^: the actioa of the x^otricle, ia sharp, spasmodic snd
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Experimental Illustrations qf Convulsive Diseases. 299
qaick, eoramanicatin^^ to the fingers which grasp it, a strong resistance, and sl^arp spasmodic
feeling.
The effects of Strychnine upon the muscular fibre of the heart appear to be similar to those
opoD the muscles generally.
Iq poisoning by Prussic Acid on the other hand, the heart feels flaccid, when pressed beneath
the fingers. The Tentricle, especially, partakes of this relaxed flacpid condition.
la poisoning by Prussic Acid, the auricles appear to act longer than the Tentricle, whilst
io poisoning by Strychnine the ventricle appears to act longer than the auricles.
ten minutes 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 ezperimeDts 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 Cmgo Snake (Amphiumi. Means) ,
June, 1862.
This reptile was immersed in a solution of Cyanide of Potassium, 6 grains to \ pint of
Wjiter; no special effects were observed for 3 hours; at the end of this time, the muscular
ijstem was thrown into violent spasms, and the muscles of the throat appeared to be perma-
Deolly 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 hand, responded
riS^rously and readily to the interrupted magneto-electric current, thut thowing that oUhough the
powtn of the heart were destroyed^ still the voluntary muscles retained their power of reloading to
stimuli.
The intestinal canal was congested with blood, and the abdominal cavity contained effused
blood, which coagulated, upon exposure to the atmosphere.
Under the microscope, the blood corpuscles from the blood of the heart presented in many
eases perfect forms, whilst in some cases they presented an elongated spindle-shaped appear-
SDce, instead of the usual oval form
These experiments therefore confirm those previously rocorded, and clearly establish
tbe important physiological and therapeutic principle, that whilst two poisons may
both act upoD 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 experimenta were devised for the solution of these qu3Stion8 :
IXPIRIMENTS ILLUSTRATING THE DIRECT ACTION OF HYDROCYANIC ACID ON THE
MEDULLA OBLONGATA.
The 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. S. P.
For these experiments I selected ten young alligators ( Alligator Mississlppiensis ) of the
asme age, and from the same nest.
Efeets of Prussic Acid administered by the Mouth. Experiment 91. — Poured a solution of Prussic
^id, in amount about f 3 ss., down the mouth and throat of a small young alligator. The
reptile was only six inches in length, and had not left the eggshell more than a week or ten
dajs.
In three and a half minutes the alligator manifested signs of the action of the poison, in its
staggering gait and convulsive movements ; in twelre minutes, gaping and struggling vio-
leoUy, with spasmodic movements of the muscles ; in fifteen minutes, breathes only occasion-
ally (once every two or .three minutes ), and then in a spasmodic manner, lies indifferently
upon the back and belly, and cannot walk ; sixteen minutes after the first application of the
poison, and one minute after the last observation, all motions appear to have ceased; when
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300 Experimental Illustrations of Convulsive Diseases.
thrown into eold water, however, it appears to be aroused by the shock, and makes leTmi
attempts to swim and turn on its side ; these motions ceased in a few minutes, and when
turned over on its back in the water, it remaioei so, whilst an alligator whose cerebrum had
been exposed, and touched with the same solution of Prussic acid, remained vigorons and
strong.
Twentj-six minutes ( ten minutes after the preceding observation ), lies as if dead, with-
out an J 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 vanished, and the animal appears to be dead.
Thirty minutes after the application of the poison, the thorax was opened and the heart
exposed^;, liuricles and ventricles greatly distended with blood, beating slowly and spasmodic-
ally forty times per minute ; fifty-two minutes (twenty-lwo minutes after the last observatioo),
action of heart twenty-six per minute ; one hundred and twelve minutes (sixty minaies after
the last observation), action of heart twenty-six per minute ; one hundred and eighty minotes
(sixty-eight minutes after the last observation), no signs of life in the muscular system;
mechanical stimuli fail to produce contractions ; heart 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 minutes after the last observation),
pulsations of the heart still continue, fhey are, however, slower and more irregnlar and
spasmodic, the rhythm of its action has been destroyed ; the auricles act continuously abont
ten tim^s per minute, the ventricle not so often. The action of the heart continued to grow
slower and slower nntil it finally ceased. The exact time was not not«d.
Frutiie Acid applied to Brain of Alligator. Experiment 92 : Removed the superior plate of the
cranium of a small alligator (six inches in length), and exposed the superior sniface of the
cerebrum without wounding the large veins and arteries. The membranes were carefallj
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 Prnssic acid.
Four minutes after the direct application of the poison to the surface of the cerebrum, lo
signs of the action of the Hydrocyanic acid; the surface of the brain was woanded, 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 muscular
motions : the reptile is still able to crawl about, and to make the sounds usually emitted bj
young alligators. The blood oozing from the wounded surface of the brain presents a brilliant
crimson color.
In fifteen minutes (four minutes after the last observation,) motions spasmodic, gasps for
breath, and emits quick, spasmodic sounds, like an imperfect bark ; these spasmodic motionj
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 nerroes
structures constituting the cerebrum.
The poison was again applied to the exposed surface of the cerebrum, and its structoret
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, bnt evidently losing
power: the respiration is slow, spasmodic and irregular. In the last application, the ner-
vous structures were more extensively injured, and the poison more effectually applied.
The forces gradually declined, and thirty-six^ minutes after the first application (twelve
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 precediofr
experiment, auricles and ventricle filled with crimson blood ; forty-two minutes, action of
heart thirty-eight.
One hundred and six;ty-eight minutes after first application of poison to cerebrom (one
hundred and twenty-six minutes after last observation), the reptile has greatly recovered, and
is attempting ta 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 hemispheres,
and between the cerebrum and cerebellum, were removed. Considerable hsemorrhage ensned
from the large blood-vessels ; this was wiped carefully away, and the Prussic acid again
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Experimental Illustrations of Convulsive Diseases, 301
applied to the surface of the brain, reaching the cerebellam (necessarily from the anatomical
relatioos of the membranes removed and the large blood-ressels cut), and perhaps also in small
quantities the medulla oblongata and spinal cord.
The poison acted almost immediatcl}', producing tetanic spasms; followed by cessation of
re^piratioQ and loss of muscular power.
One hqndred and seventy-eight minutes after the 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 stimuli ; 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 not noted.
Prustie Acid applied to Spinal Marrow. Experiment 93 : Kxposed the spinal cord iu the tail of
ayonng alligator for half an inch, commencing ju^t below the juncture of the hind legs, and
applied the solution of Prussic acid used iu 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
the 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 coM water, the reptile swims; ten mmutes after
(tvro minutes after last observation), spasmodic attempts at respiration, gapings of the
month 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.
Prustic Acid applied to Spinal Marrow. Experiment 94: Exposed the spinal cord of a young
alligator midway between the anterior and posterior extremities, and applied Prussic acid of
the same strength as in the preceding experiments ; spasmodic contractions and motions of
the muscles and limbs were almost immediately excited. The respiration stiU 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.
Prustie Acid applied 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
minutes 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.
Pnutic Add applied to Brain and Medulla Oblongata. Experiment 9G : 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 vertebra*, 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
or 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
the precaution 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
awim with precision and vigor when thrown into water. After removing the animal from the
water, 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-
catioD 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-
CHtion, 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 back or
^ilj. In a few minutes more, all voluntary i^uscular motions ceased entirely. When the
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302 Experimental Illustrations qf Convulsive Diseases,
heart was exposed it was beating regularly, and 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 re«-
piratorj 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 extinction of the powers of the heart, in this experimeat than in the first, was
due in great measure to the loss of blood.
Pruuic Acid applied to Medulla Oblongata. Experhneni 97 : Exposed the brain and medalla
oblongata of a young alligator, and after wiping off the blood carefully applied the solntioo
of Prussic acid to these parts— in less than a minute, in fact almost immediately, violent con-
vulsive 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 adminiatration
of the poison.
Thorax opened one hundred and twenty minutes after the application of the poison; heart
had ceased to pulsate. Inflation of thjB lungs was followed by a renewal of the action of the
heart. The cessation of the action of the heart, in the two last experiments, sooner than in
the two first experiments, was due to the collapsed state of the Lungs, and the greater loss 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 first 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 miaatefl,
all action in the heart had ceased. On account of the Joss of blood, the heart presented a
pale appearance, contracted, and with but little blood in its cavities.
Pnuiie Acid applied to Medulla Oblongata. Experiment 98 : Exposed the medulla oblongata
of a small alligator, and applied directly to the nervous structures the solution of Prussic
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 musclei
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 poison, bad
ceased to beat; it contained little or no blood, and was pale and contracted. Inflation of the
lungs restored its action. Two hundred and ten minutes after the application of the poison,
the action of the heart had ceased.
Frumc Acid appUtd to Medulla Oblongata. Experiment 99 : Exposed the medulla oblongata of
a young alligator and applied Prussic Acid — the effect was almost immediate ; in one mlnate
the respiration was arrested, and the respiratory muscles permanently contracted. The eyes^
winked, and the mouth gaped for some eight minutes, and even long after the eyes and mouth
ceased to move of themselves, the eyes would wink, and the muscles of the jaw would 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 permanently contracted only when the poison was applied to the medulla
oblongata.
Pnusic Acid 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 used in the preceding experiment. At the end of seven minutes the reptile still shows
signs of great activity, being able both to swim and walk; at the end of eighteen minutei
after the application of the poison, although manifesting its effects in loss of power and irre-
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 jthere were no well marked tetanic
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 nervous and
muscular irritability.
Heart exposed ninety-five minutes afterwards ; 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 mnscnlar
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Experimental Illustrations of Convulsive Diseases. 303
fjttem generally, and especiallj to the respiratory system, are the first phenomena manifested
in the action of Prussic Acid.
When absorbed from a raw surface, or from the stomach and bowels, these phenomena are
manifested, as well as upon the direct application of the poison to the medulla oblongata, but
more slowly. In warm-blooded animals death takes place almost immediately after the
administration 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 nervous
centres. As soon as the poison in the blood reaches the medulla oblongata and spinal cord,
conTnlsiTe 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 yonng 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 npon that portion of the cerebro-spinal nervous system which presides over respiration
. and the reflex actions.
Pmssic 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 been conclusiTely demonstrated by the experiments just recorded, the most marked pheno-
mena, and those disturbances of the respiration which induce death, are due to the direct
action of the poison on the medulla oblongata.
BXPERIMENTS ILLUSTRATING THB ACTION OF PRUSSIC ACID ON BIRDS.
Experiment lOI. 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
in 10 seconds ; trembling of all the muscles ; puffing up of the feathers ; irregular action of
the heart, and iniensibility, and finally death in 75 seconds after the application of the
poison.
EfeeAt of thepoieon upon the Animal Temperature: Temperature of the atmosphere, 13°.3 C,
56** F. Temperature of rectum of pigeon, 40® C, 104° F.
The temperature 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, 14o.4 F.; loss of temperature each
minnte after death, 0^.123 C, 0o.221 F.
PoH^mortem Examination^ 30 minutes after death. Haemorrhage had taken place from all
those portions of the mucous membrane of the mouth and threat, 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 npon 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. Blood-ves-
sels of brain and spinal cord, not specially congested with blood. Muscles presented a darker
color than nsnal 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
coagnlated readily. Veins of intestines and liver distended with blood.
Experiments 102, lOS, 104, ^Oo.
Repetitions of preceding Experiment, (101) on the action of Prussic Acid on birds,
results similar to those jnst recorded.
Experiment 106: to determine whethei- any agent acts rapidly as a stimulant to the
Heart and Nervous System in Birds. Action of Chlorine on Pigeons.
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 4l<>.9 C, 107°.4 F. to 420.5 C, 108°.5 F.
The inhalation of the gas occupied only a few seconds, the mouth of the bird, was simply
held over the mouth 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
snbsided with the fall of the temperature, immediately increased with renewed force and the
temper«^ur« ?Q^pme^ced ^l§o to rise, and in 3 minutes rose from 41^9 C, 107°,4 F,, to 42°.2
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304 Experimental Illustrations of Convulsive Diseases.
C, 108^ F.; at the end of this time which was just 9 minutes from the first action of the gas,
the bird gave a violent struggle and died. The intelligence of the bird did not appear to be
affected, until 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,
S6°.8 F. Loss of temperature, in 50 minutes alter death, 6°.2 C, 11°.2 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, fir
different from the bright scarlet color characteristic of the lungs of birds.
The blood in the vessels of the brain, and in all parts of the body presented similar
alterations.
The preceding ExperimcDt dctnunstratcs that Chlorine acts as a stimolaDt upon the
l)cart of Birds.
Fxperimaiis 107, 108, 109, 110,
Repetitions of the preceding cxperimcDt (lOG,) illustrating the action of Chlorine
upon birds : results similar.
The truth of the preceding conclusions with reference to the action of Prussic Add
and of its antagonist or antidote, Chlorine, upon cold-blooded animals, is thus cfitaUished
for birds.
EXPERIMENTS ILLUSTRATING THE ACTION OF HYDROCYANIC ACID AND CYANIDE
OF POTASSIUM ON WARM-BLOODED ANIMALS — MAMMALIA.
Experiment 111 : Action of Hydrocyanic Acid an Dog,
Haifa fluidounce of the officinal solution of Prussic Acid was poured upon the tongue aod
lips of an active cur dog.
In thirty seconds, slight effects upon the respiration were perceived, and in tha coarse of
five minutes, the respiration became labored, the thorax was dilated to a much greater exteat
during inspiration than in health, whilst at the same time the action of the heart was ren-
d'ered slower, and the tongue and mucous membrane of the mouth assumed a bright red,
highly congested appearance. Half a fluiddrachm of the officinal solution of Prasde Add
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 — the
action of the heart diminished in frequency, and became more and more irregolar and spas-
modic, giving sharp, quick impulses to the hand placed against the thorax — the nnsclts
became spasmodically convulsed — during inspiration, there was a spasmodic contraction of
the muscles of the neck and face.
Fifteen minutes after the administration of the poison, the heart beat twenty -four timet
per minute — the respiration was very slow, labored and spasmodic — pupils dilated — the intel-
lectual actions of the brain appeared to be suspended : strong spasmodic contractions of the
muscles, as strong as those produced by Strychnine. The saliva continued to flow in Urg«
quantities from the mouth. The increased secretion of saliva bad commenced immediately
after the administration of the poison, and it is important that we should note in passiag,
that a similar result was produced upon the skin of the Siren Lacertina, by the local action
of Prussic Acid.
At this stage of the experiment, strong aqua ammonia and chlorine gas were passed alter-
nately under the 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, stiU the
respiration and the action of the heart were both increased and life was prolonged.
Twenty-five minutes after the first administration of the poison, the heart was still beatiag
very slowly, and the respiration was still slow and spasmodic.
The respiration and the action of the heart ceased, thirty-six minutes after the administra-
tion of the poison. The respiration ceased before the action of the heart.
Effects upon the Animal Temperature : Temperature of the atmosphere 12®.7 C, 55® F. Teai*
perature of the rectum of the dog, before the administration of the Prussic Acid, 38®.8 C.
101^85 F.
This dog was rather thin, and was not very vigorous, apd its condition maj accgant for %
diminution in the bodily temperature, .
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Experimental Illustrations of Convulsive Diseases. 305
The temperature of the rectum remained stationary for ten minutes after the administration
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 1°.3 C, 2°.35 F. After death the temperature of the rectum continued
to descend, and in twenty-eight minutes, stood at 3G° C, 96^.8 F. ; loss of temperature
daring 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 d^ath, 0^.05 C, 0.0903^ F.; loss
of beat each minute after death, 0.0535<> C, 0.0964® F.
Po4t-mortem Examination : Thirty minutes after death, blood-vessels of the dura-mater,
arachoid membrane, pia-mater and brain filled with dark, purplish, black blood. Blood-res-
seU of tb^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
this 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
nor 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 in a case of poisoning by
Cjanide 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
mipnte 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 wore
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 no 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 stomach was, in some portions, con-
gested with blood, and there were several dark purplish spots more strongly congested. The
stomach 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 small intestines presented a normal, healthy appearance, and
«ras 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, almtst black blood.
When cut, the dark blood streamed from the surfaces. The kidneys presented a daric 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
the 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
coagulum was soft, and there was a tendency in the colored blood corpuscles to separate
from the fibrin, and to fall to the bottom of the vessel, and thus color the serum.
Under the microscope, many of the colored blood-corpuscles presented stellate forms.
Cadaveric rigidity bad not taken place two hours after death.
In the preceding experiment (111), the congestion was venous. The accumulation
of the blood in the large venous trunks appears to be due to several causes, as the loss of
power in the muscular structures of the heart, and especially in the right ventricle and
right and led auricles, ajid the spasmodic tetanic contractions of the muscles.
The appearance of congestion in the veins of the brain, spinal cord and membranes,
WIS due to the same causes which produced veqous congestion in the liver, stomach
and organs, it being evident that the venous congestion 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 ^niflial to the congestion of the cerebrQ-j^pinal p.eryo\i8 system. Death
5P /
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306 Experimental Illustrations qf Convulsive Diseases.
appeared to have been caused by the action of the poison upon the ganglionic odU of
the cerebro-spinal and sympathetic system, and especially upon the potential d^nents of
the medulla oblongata, and of those ganglia regulating the vaao-motor system of nenrcs
and the rythmical action of the heart.
Experiment 112 : Action of Prussic Acid on powerful and fierce Bull Dog.
A strong solution of Prussic Acid was placed upon tlie eyes, lips and nose of a powerful
bull dog. In a few minutes (he dog struggled violently, acted as if in a great rage, attempttd
to rush at those around, bis tongue appeared to become rapidly of a brilliant scarlet hue,
and presented a swollen appearance ; then succeeded piercing cries, and yiolent spasms, and
finally death in fire minutes after the first application of the poison.
Post-mortem examination 17 hours after death : Cadaveric rigidity well maAed.
The blood-vessels of the brain and its membranes were not congested with blood. Spinal
cord examined throughout its entire length ; structures and blood-vessels 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 execated, of the
nervous structures and organs of various animals destroyed by mechanical means and by
various poisons.
A careful and laborious 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 gai
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 Tessels of the small and large intestines and stomach were distended with dark
blood, and the whole exterior surface of the stomach and intestines presented a dark red and
purplfc 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 con-
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 large^ malt Hound Dog.
This dog, although active and endowed with a ravenous appetite, was lean, and conld not
be fattened even by the most generous diet. This dog also emitted an unpleasant smell, cht-
racteristic of that of dogs, suffering with worms in the cavities of the heart. I have found
worms in the hearts of several dogs, who presented similar symptoms, and emitted sioiiUr
odors ; and in the present case, I was led to predict the presence of worms in the heart befor*
death.
An incision was made into the skin of the hind leg, in the region of the knee, and aboal
two fluiddrachms of a strong solution of Hydrocyanic Acid were injected into the subca-
taneous cellular tissue. After the removal of the nozzle of the syringe, a considerable portioa
of the solution of Prussic Acid poured out. About one to two drops of the Anhydrous Acid
(that is an amount of the solution corresponding to this quantity) were retained.
The dog was standing when the poison was injected ; in one minute there were evident
signs of its action ; in two minutes there was trembling and twitching of all the mascler
spasms, then inability to stand up, and in a few moments more, loud howling followed by
pUeous whining ; during the tjenibling tii^itchings and spasms of the muscles, the thermometer
«« th^ T?^^WW TQS^ <)®,05 C. The spQ^sms and hQwHi^ and whining, were succeeded in &
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Experimental Illustrations of Convulsive Diseases. 307
mioQles by profound coma ; 15 minutes after the injection of the poison, the dog gtill lies in
a profound coma, respiration labored (inspirations rerj full, thorax dilated to its utmost
io a spasmodic manner, expiration yiolent, forcing out almost all the air; and attended by a
peculiar spasmodic motion of the diaphragm and abdominal muscles, giving a flattened
appearance to the abdomen, and only two per minute; pulsations of heart 120 to 160 per
minate, quick and spasmodic; action of large arteries beating with a quick spasmodic motion,
a3 if they would leap out of the surrounding flesh. The temperature remains stationary.
One minute after the close of this observation, mud 16 minutes 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
minutes.
EffeOt on the 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 G. 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
minutes, after the cessation of the action of the heart, moment of death ; and in 20 minutes,
35 after death, indicated 38°.75 C. 10I°.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,
94°.8 F.; 140 minutes after death, 34.66^ C, 94°.4 F.; 240 minutes after death, 3P.8 C, 89^.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 following 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.
Po$t-moTiem Examination: 240 minutes after death, rijicor-mortis well marked. Powerful
interrupted magneto-electric and electro-magnetic currents produced no effect whatever upon
the muscles.
Dura-mater, adherent to cranium. Brain not congested with blood, and it presented a pale
aniemic appearance. Spinal cord in like manner not congested with blood, but pale and
ansmic. 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 auricle 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 carneae columnse and chordae
tendines, and which from its structure was without doubt, formed before death. Lungs not
congested. The intestines and stomach both upon the exterior and upon the internal mucous
surface, presented a normal non-congesled appearance, which was in striking contrast to
the appearance 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,
and 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 larvae 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
animal — the effects were manifest in a few moments, and at the expiration of 3 minutes, the
respiration and action of the heart had ceased. After death, the cardiac rigidity was slow
and imperfect, forming a striking contrast to cats killed at the same time with Strychnia. The
Mood 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 some of
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308 Experimental Illustrations of Convulsive Diseases.
the colored blood corpuscles presented altered appearances, assuming stellate formi ; tbU
change however in the colored corpuscles is not characteristic of the action of Prossic Acid,
as I have seen it in the blood of healthy cats as well as in the blood of animals destroyed bjr
Tarious poisons.
This experiment was performed in winter, and the blood remained without any signi of
putrefaction, 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-vessels 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.
Blood-vessels upon the exterior of the stomach and intestines engorged with blood ; mncooi
surface not specially discolored. Blood-vessels of liver filled with dark blood.
Experiment 116 : Repetition of preceding Experiments on severed CaU. Pnissic Acid
administered hy the Mouth and by Sub-ciUaneous Injections.
The results corresponded in the main, with those just detailed; no uniform effects were
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 coa-
gested with blood. Both the external and internal surfaces of the intestines were exaBined
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, 12 J^, 125 : RepetUion of preced-
ing Experiments with Prussic Acid upon various warm-blooded animals — ( CnU.
Dogs, Rats, Rabbits, Guinea Pigs, etc.) with similar results.
The points which we wished especially to establish at this stage of the inqoiry, 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 Pnissic Acid arrests the action of the heart, is there any agent, or renwdy,
capable of counteracting the direct action of Prussic Acid on the heart
We have before demonstrated that Prussic Acid acts directly on the heart in cM-
blooded animals, independently altogether, of any influence transmitted through the
cerebro-spinal nervous system ; and that Chlorine acts as a stimulant to the heart and
tends to oounteraot the action of the Prussic Acid on the heart, and also that (%k)riM
acts as a stimulant to the cerebro-spinal and sympathetic nervous and muscular systems,
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 cold-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, as in tbe
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 arrests the
functions of the brain and spinal cord, and, if the action of the heart is at the ssm
time arrested, it b highly important to determine which was affected first? wheUier
one was affected and not the other ; whether the death of the brain and spinml-mairov
was caused by the death of the heart ; or whether the death of the heart was caused bj
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Experimental Illustrations of Convulsive Diseases, 309
the death of the oerebro-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
poison 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 S3'stem. 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 THE HEART IN WARM-BLOODED ANIMALS TO THE
CEREBR0-8PINAL AND SYMPATHETIC NERVOIS 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 cerebro-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, of the action of the heart,
and even of the voluntary muscles in warm-blooded animals, have been accumulating
for centuries 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 prevedt the birds from running as before, and they only
stopped at the end of the course. Lametrie, and other physiologists, obtained similar
results, with decapitating various birds. Franciscus Antonius Cattus affirmed in 1557,
that he 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 afler
Cattus, states that after 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-
tion or other signs of life. Peyron, Petit, Boningerus, Borelli, Morgagni, and others
have recorded observations of severe injuries of the brain in man, which were not imme-
diately fatal. Morgagni afler exposing the brains of two cats, removed the cerebrunr
by successive slices. The destruction ^f the cerebrum did not destroy the motion and
sensation. 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 after the complete removal of the
head, and even pulsated several times after its complete removal from the body. Mor-
gagni 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. After describing the muscles and mechanical
actions of the heart, Haller affirms that the muscular fibres of the heart, like other
muscles, 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 the living animal after excessive irritation of the nerves, because the action of the
heart continues after the most extensive wounds of the head, and even of the cerebellum
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310 Experimental Illustratiohs of Convulsive Diseases.
and medulla spinalis, because the action of the heart continues even when it is torn cot
of the body, and can be excited in moribund, and even in apparently dead animals, 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 stimiili,
and that the irritability of the fibres of the heart was similar to that of dl the mosdes.
differing only in degree, and remaining longer in the heart than in any other part of Uie
body, so that by stimulating it, the motions of the heart may be renewed at a time
when that of no other muscle can. This mobility then is inherent in the heart, and is
neither derived ^m 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 volitioD.
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 the ribs, I got at the
axillary plexus of nerves on both sides, from behind. I separated the arteries and veins froo
the neryes, and passed a ligature under the nerves close to the spine. I thought I could dis-
cover the phrenic nerves, and instantly divided two considerable nerves going off from each
plexus. The action of the diaphragm seemed to cease, and the abdominal muscles became
fixed, as if they had been arrested in expiration, the belly appearing contracted. His respira-
tions were now 25 in a minute, the pulse beating 120. As I was not willing to trust the
experiment to the possibility of having divided only one of the phrenics, which I afierwarda
found was really the case, and some different nerve, instead of the other, after carefuUj
attending to the present symptoms, T 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 respira-
tion went on very easily without the diaphragm, in about one-quarter of an hour afUr
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 Oexor
muscles of the body seemed to contract, and instantly to relax again ; he died as suddenly 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 motion ; I immediately introduced a large blow-pipe
into the trachea, below the cricord cartilage, and inflating the lungs, imitated respiration.
The heart began to move again, and in about three minutes was beating 70 in a minote. I
recollected that there was still a communication between the brain and the thoracic tod
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 before ; the heart, which bad
stopped, began to move again, beat 70 in a minute, and continued so for nearly half aa hoar
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 easilj
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 externa] surface
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 nerres
were irritated. I irritated the stomach and intestines, which also renewed their peristaltic
motions. I then irritated the par vagum and the intercostals, about an inch above the lower
cervical ganglion of the intercostal ; the cesophagus contracted strongly through its whole
length, but the heart continued perfectly motionless." — Phil. Trans., vol. Ixxxv, p. 177.
This experiment by William Cruikshank, confirmed those previously made by John
Hunter, (Phil. Trans., vol. Ixvi, read March 21st, 1776), in which he recovered ani-
mals by inflating the lungs, and on which his method of recovering drowned people
principally rests, and it removed the objections which might be raised that the aninttb
on which Hunter experimented, had the connection with the brain entire, as the par-
vagum and intercostals were not divided.
John Hunter was led by his profound and extensive investigations in oompanitire
anatomy, to the important observation, that in certain animals the heart is not neoeB*
sary to the circulation of the blood, and that it is even absent in many animalfl
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which possess organs of generation. Hunter regarded the heart as a truly mechanical
eagine:
"For altboagh muscles are the powers in an animal, yet these powers are themselves often
converted into a machine, of which the heart is a strong instance ; for, from the disposition
of its muscular fibres, tendons, ligaments and valves, it is adapted to mechanical purposes,
and this construction 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 by 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 ol'
animal life, but no such effect upon the muscles of organic life *, 2d, all compression of
the cerebral mass has ordinarily the effect of paralyzing the voluntary muscles, but so
long as the affection 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 irregular movements of the heart, it is not observable that the principle of
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:
Ist. If the brain of au animal be exposed and irritated, either with mechanical or chemi-
cal agents, a varietj of alterations vfi\\ indeed be produced in the organs of the animal life,
bat none ia the heart so long as the muscles of the breast continue to perform their func-
tions.
2d. Experiments made in the same manner upon the spinal marrow of the neck, present
the same results.
If the eighth pair of nerves be irritated, the movements of the heart will not be accelerated ;
thej will not be arrested if these two nerves be divided. In all these experiments, however,
we must be careful to make a proper distinction between the emotions and passions of the
animal, and what it really suffers from the experiment.
4th. The nature of the great sympathetic nerve is supposed to be known ; now, if the
lame 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 Uie influence of the brain is necessary to the action of the heart, found that when
an animal was pithed, by dividing the spinal marrow in the upper part of the neck,
respiradon was immediately destroyed, but the heart still continued to contract, circu-
lating dark colored blood, and in some instances, ^m ten to fifteen minutes elapsed
hefore it« action had entirely ceased ; when the head was removed, the divided blood-
vessels being secured by a ligature, the circulation still continued, apparently unaffected
by the entire separation of the brain ; when artificial respiration was instituted in the
beheaded animals, the heart continued in some instances to contract for two hours,
with apparently as much strength and frequency as in a living animal. From these
experiments, 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 removed,
the action of the heart ceases only because respiration is under its influence, and if,
VinAer iheoe circumstances, respiration is artificially produced, the circulation will still
continue."— Phil. Trans., 1811, pp. 36-48.
^ix Benjamia B^-odie, from his experiments upon the action of Alcohol, concluded
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that the symptoms produced by a large quantity of spirits taken into the stomach,
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, ^hich is under its
influence, is ill-performed, and at last altogether ceases ; while the heart, to the action
of which the brain is not directly necessary, continues to contract, circulating daHc
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 Vpt^
Antiar, the oil of Tobacco, Arsenic, Muriate of Barytes, Tartar Emetic and Woorarm,
iu like manner convinced him that poisons might act directly upon the cerebro-spiml
system, destroying all' its functions, 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 thej not
only 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
Galiois maintained the action of the heart and "life," for upwards of three-quarters of
nil hour, in the detached and isolated breast of a rabbit thirty days old. In uiis 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 vena-oava near the
liver : a simple knot was tied in each of these ligatures. This being done, the t^w^ea
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 laogs;
the spinal marrow was then divided with a needle, near the oooiput, and artificial re^i-
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-
brsB of the neck, with a pair of scissors ; and immediately resuming the inflatioo,
which is to be continued for three or four minutes, after which the knots are to be
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 ofl* the hind parts, which is performed by taking away the intestinal
tube from the beginning of the duodenum, then by dividing with scissors the soft parts
surrounding the vertebral column, and then the column itself, immediately below the
ligatures made on the aorta and the vena-cava. In this manner, there remains only tbe
breast, the stomach and the liver, which might also be removed if care he ti^en to
prevent haemorrhage. The operation being finished, all that remains is to oontiDM
inflation of the lungs, as long as the breast has any signs of life. The most appareot
of these signs, are the motions and the sensations preserved in the fore feet, and the
small writhing motions observed in the thorax, when the skin is severely pinched, uA
when the posterior extremity of the dorsal portion of the medulla spinalis is Umdied-
In some cases aft>er carrying the experiment thus far, the remainder of the cerrictl
portion of the medulla spinalis and part of the dorsal were destroyed, uid although
life existed only in the two posteiior thirds of the breast it could still be prolonged.
Expermients on the Principle of Li/c^ etc.
Dr. A. P. Wilson Philip, whose experiments upon ^Id-blooded animals we have
already considered, also examined the relations of the heart to the cerebro-spinal nervous
system, and demonstrated the iudcpendence of the actiop of the heart by such experi*
Uients as the following ;
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Experimental Illustrations, of Convulsive Diseases. ' 313
Dr. Philip deprived a rabbit of sensation and voluntary power, by a stroke on the occiput
and supported the circulation by artificial respiration. The spinal marrow was then laid bare
from the occiput to the beginning of the dorsal vertebrae, the chest was opened and the heart
found beating regularly, and with considerable force. The spinal marrow, as far as it had
been 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
heart 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
vertebne, 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 remoyal of the brain. On renewing the respiration, howevel^, the action of the
ventricles was restored. The respiration was again discontinued and renewed with the same
effects. In another rabbit rendered insensible, and the circulation supported by artificial
respiration, 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 resnlt was the same ; no special effect
was produced upon the heart; and f)r. Philip satisfied himself that the circulation was coji«
tinned in the usual way, and with sufficient force in the distant part. Philosophical Trans-
actions, 1815, pp. 65-00 ; Phil. Tran?., 1815, pp. 424-44G.
Br. Philip, in his last paper published iu the l*hil8uphicul Trausactious of 183G,
which he states, comprehends the results of the investigations of his life, expresses his
belief, that neither the brain nor spinal marrow bestows any power on the heart or ves-
sels; but that on the other hand, each of these organs is equally capable of directly
influencing both, (the vassels even to their utmost extremities,) and that not only by
exciting their powers, but also by impairing and even wholly destroying them, according
to the nature and power of the jigent operating on the brain 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.
Trans., 1836, pp. H4(>-848.
Sir Charles Bell held that the ordinary action of the heart is dependent upon the
ganglionic system, but that its connexion with the respiratory and sensorial functions
was derived through the cerebro-spinal nerves or par-vagum. Thus, after demonstrating
the extensive coimections and offices of the respiratory nerves, he thus proceeds to
illustrate the mode in which the mind influences the body during emotion or passion :
*' Id tenor, we can readily conceive why a man stands with eyes intently fixed on the object
of bia fears; the eyebrows elevated, and the eye balls largely uncovered ; or why, with hesi-
tating and bewildered steps, his ey^s are rapidly and wildly in search of something. In this
ive only perceive <the intent application of his mind to the objects of his apprehensions, and its
direct influence on the outward organs. But when we observe him farther there is a spasm
on his breast; he cannot breathe freely: the chest remains elevated, and his respiration is
short and rapid ; there is a gasping and convulsive motion of his lips ; a tremor on his hollow
cheeks; a gulping and catching of his throat; his heart knocks at his ribs, while yet there is
no force in the circulation, the lips and cheeks being ashy pale.
It is obvious that there is here a reflected influence in operation. The language and senti-
ments of every people have pointed to the heart as the seat of passion, and every individual
most have felt its truth. For though the heart be not in the proper sense the seat of passion.
it 16 inflaenc«d by the conditions of the mind, and from thence its influence is extended
throngh the respiratory organs, so as to roonnt to the throat and lips and cheeks, and account
for every movement in passion which is not explained by the direct influence of the mind on
the features." Phil. Trans., 1822, pp. 30T, 308.
Prior to Scarpa, many eminent anatomists, as Haller, Wisberg, Soemmering and
others, appeared from their descriptionii to hold the view, that -no nerves are distributed
to the miuicular substance of the heart, and that its contractions were independent of
nervous influence. James Beuignus Winslow, in his Anatomical Explanation of the
Strticture of the Human Body, (which appears from the author's preface to have been
composed in 1722, but not published until some ten years after,) describes the '^ Ple^m
40
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314 Experimental Illustrations of Convulsive Diseases.
CardiacuSy'' as being formed by communicating branches of the Eighth Fair, and the
Intercostal or Great Sympathetic Nerve. According to this eminent anatomist,
"The Plexus CardiacnSf is formed above the lung, on the fore side of the Bronchia, and
produces a great number of filaments ; some of which go to the Pericardium, and the rest fo
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 after being divided into a
ffreat 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-
stance.
William Cheselden, in hb Anatomy of the Human Body, gives no descriptioD
of the nerves of the heart ; he appeared however to be aware of their relations to it^
actions, 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 from Mr.
Munro. Anatomy of the Hum^an Body ; ix Ed., London, 1768, pp. 197, 199.
B. J. BehrQuds (a pupil of Soemmering,) who whilst admitting in his Distertatio tpta
demon$tratur Cor Nervis Carrere, 1792 j that nerA^es accompany the Coronary Arteries,
distinctly asserted that the muscular structure is entirely destitute of nerves.
Soarpa, clearly delineated and described nerves running on the heart independtntJ}
of, ana distinct from the Coronary Arteries, and in his elaborate work ( Tabulx A«f-
rohgictt, 1794,) has given fine views of the nerves of the human heart, in some 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 herbiverous
Mammalia, however, Scarpa describes and delineates both ganglia and fusiform enlarge-
ments of the nerves, which he called corpora olivaria, and these not only upon the nerves
at the base of the heart, but upon those that are spread over the superficies of the
ventriclei Scarpa also describes and figures several nerves independent of, and not accom-
panying the blood-vessels of the heart, and avails himself of the fact to refute the
conclusions to which Behrends had arrrivcd.
In Mr. Swan's splendid plates, the nerves are represented as accompanying the
Coronary Arteries, and but few are dbtributed to the muscular tissue, and M. Chassiugnac
who translated in 1838, Mr. Swan's "Demonstration of the Nerves of the Humio
Body,'* denies that any nerves besides those which accompany the Coronary Arteria
have ever been discovered in the heart.
Mr. Robert Lee, in an important paper published in the Philosophical Tranaadtont
of the Royal Society, 1849, pp. 43, 47, has demonstrated by careful directions and dnw-
ings, that the nerves and ganglia of the heart are far more numerous than those
described and delineated by Scarpa. The series of dissections performed by Mr. Lee,
show that the nerves of the heart which are distributed over its surface and throughoot
its walls to the lining membrane and columnie carncte, enlaige with the natural giowth
of the he^, before birth, and during childhood and youth, until the heart has atduBcd
its full sixe in the adult, that the nervous supply of the left ventricle is greater tbw
that of the right; and that when the walls of the auricles and ventricles are affected
with hypertrophy, the ganglia and nerves of the heart are enlarged, like those of the
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 ca
the nerves whioh pass obliquely across the arteries and the muscular fibres of the ten
trides from their base to the apex. XJ»ese ganglionic enlargements arc observed on the
nerves, not only where they cross t^ arteries, but where they ramify on the mnflcuhr
SUb^t^i^ce^ without the blgpc(-V€88els, ' Qn the posterior surface, the principal bnacbw
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. Experimental Illustrations of Convulsive Diseases. 315
of the Coronary Arteries plange into the muscular substance of the heart near the base,
and many nerves with ganglia accompany them throughout the walls to the lining mem-
brane and columnae carnese. 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 on these, numerous ganglionic enlargements are likewise observed, but smaller in
size 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
V n ler consideration .
From the preceding inquiry, and from on extended examination of the views of many
writers, besides those quoted, and from actual experiments and dissections, the following
conclusions 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 cerebro-spinal
nervous system, because it continues its pulsations after the brain and spinal cord nave
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
cease 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 cerebro-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
Uie several ganglia ; therefore the movements exhibited by the heart after the central
masses of the nervous systemliave 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 muscular
irritaMlily^ (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 both
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
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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 theory an explanation of the efiects
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 acttoD
on this or<;an, 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
siiuated in the heart itself, and which act independently of the cerebro-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, modiiy both
the rythm and force of its contractions, and on the other, communicate to the brain and
spind cord a scries of sensations and impressions corresponding to the character of its
movements.
6th. l^isons may act directly upon the ganglionic centres of the heart, on which its
movements depend, deranging that concert of nervous impulses upon which the regular
succeasion of the contractions of the auricles and ventricles depend, and even des^ying
totally the nervous power and muscular irritability of the heart ; poisonous agenta may
also influence the action of the heart by their effects on the cerebro-spinal nervons
system ; but the derangements thus produced by reflex action, are comparatively insig-
nificant and unimpoi-taut.
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 :
EXPERIMENTS TO DETERMINE AVIIETHER PRUSSlC ACID, CYANIDE OP POTASSIUM AND
STRYCHNIA, EXERT ANY DIRECT AND SPECIAL ACTION ON TUE HEART, INDE-
PENDENT ALTOGETHER OF THE ACTION OF THESE AGENTS ON THE CEREBRO-
SPINAL NERVOUS SYSTEM.
Experiment 126 : Preliminary^ to determine tfie relations of the Heart to the Certhro-
Spinal Nervous System^ to the Lungs ^ and to the Sympathetic Nervous Systfm ;
Effects on th^ action of the Hearty of division of tlie Medulla Oblongata,
A knife blade wns passed tbroagb tbe vital point, severing the meduHa oblongata and also
the vertebral arteries of a large Pointer dog. The respiration ceased immediatelj ; the h»inor-
rhage was profuse, and in a few moments all signs of life were eztioct. The thorax was
opened' by the removal of tbe 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
immediately pulsated. ArtiBcial respiration was instituted, and the cavities of the heart
contracted and expanded as in living, healthy animals. When the intestines were pricked
by the end of the scalpel, the peristaltic motions were excited vigorously. The interrupted
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 tbe
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, f^om
the table. The heart and intestines also responded to the electricalVnrrents readily and vigor-
ously. Tbe he irt continued to beat with vigor and regularity for more than one hour, doriof
which time, the artificial respiration was carefully performed. This experiment, which has
been performed before by numerous observers, with the same result, demonstrates that tbe
action of the heart is indispensably connected with respiration, and may be maintained after
the nervous centre which presides over respiration has been entirely destroyed and severed
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Experimental Illustrations of Convulsive Diseases, 317
from the respiratory apparatus, if the respiratory acts of the alternate inflation and expira-
tion of the langs be mechanically performed.
Exprrimentn 127, 128, 129, ISO, 131, 1S2 : RepetUiom of preceding experiment
( 126), tcith similar residta.
Experiment. IS3 : Illmtrating action of FruHftic Acid on Warm-Blooded Animal.
Aagnsta, Ga., January 30th, 1861. Fine, large, Pointer dog. Temperature of atmosphere,
60*' P.; temperature of rectum of dog, 40° C.,'104° F.
Four fluiddrachms of the officinal solution of Prussic Acid were injected into the sub-cuta-
oeoQS tissue of the right thigh. As soon as the nozzle of the svringe 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
uneasiness ; the respiration became Inller, and the action of the heart slower. These phe-
nomena were succeeded by violent struggles and piercing cries, as if the dog was suffering
intense agony. During 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 fluidonnce 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
conld 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 motion whatever excited in the muscular structures. When
grasped 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
stimuli, and contracted vigorously. The intestines appeared to have lost, in great measure,
their power of peristaltic motion, and responded but feebly to mechanical irritation. Artifi-
cial respiration was immedia'tely instituted ; the opening of the 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 tUghteit
motion of the heart was produced. The heart was carefully and firmly grasped in the hand, but
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
electrical 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
such 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
ejes 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
Tcry feebly, by the electrical current.
Temperature of the rectum, 16 minutes after death,* 40**.25 C, 104°.4 F.; the temperature
fell 0*^.05 C. during this time, as it stood at 40*^.3 C. at the moment of death. The large
venous trunks and the blood-vessels of the liver and intestines were distended with dark,
venous 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 cavities, 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*^ C; 45 minutes after death, 37*^ C.
The rapid cooling was due to the artificial respiration, loss of blood, and exposure of the
mternal organs. The muscles were dark colored and bloodless; the whole mass of blood'
appeared to* have accumulated in the large venous trunks and capillaries of the internal organs.'
Reaction of blood of heart sli^tly alkaline.
The preceding experiment demonstrated conclusively that Prussic Acid acts directly
upon the heart, arresting its action, and also to a certain degree upon the sympathetic
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318 Experimental Illustrations of Convulsive Diseases.
nervous system. The muscles connected with the oerebro-spinal system were affscted
to a much less degree than those related more especially to the sympathetic system.
Experiments 134, -?^<^j -?'^^j ^-^7', 138 ^ 139 : Repetitions of preceding expenmentj with
similar results.
Experiment IJfi : Illustrating the action of Cyanide o/ Potassium on Warm-Blooded
Animals,
Augusta, Ga., April 1st, 1860. Fine, large cur dog, very fat, 6erce and powerful.
Temperature of rectum, 103°.59 F.
The attempt was first made to pass a strong interrupted current through the mosclesof 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, however it fell to 103®.79 F.
After the application of the electricity for a few seconds, his struggles were so violent, and
his strength so great, (the muzzle was torn off and the dog bit the four jouog mea who were
assisting me in the experiment), that it was found to be impossible to continae 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, (be barked and gnashed bis teeth,
and struggled in the roost violent manner to break loose), and the dog died in six minutes
after the solution of Cyanide of Potassium had been introduced into the eyes and mooth.
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, the breathing became spas-
modic; and at the moment of death, the muscles were violently convulsed, and the body ana
extremities were stretched backwards. The force of the death spasm was so great that the
shaft of the. glass thermometer, with its porcelain scale, in the recium of the dog, was broken
into small fragments.
Temperature of the rectum at the time of death, 41° C, 105°.8 F. During the violent
Fpasms excited by the Cyanide of Potassium, the temperature had risen 1°01 F. Temperttare
of rectum 15 minutes after death, 41° C, lOS^.S F.; 88 minutes after death, 40*» C, 104° P.;
09 minutes after death, 39°. 33 C; 209 minutes after death, 34°.5 C; 234 minutes after death,
33°.75 C, 92°7 F.; 234 minutes after death, rigor-mortis well marked.
Fosi-morlem Examination, 20 hours after death : When the skull-cap was removed, the
blood-vessels of the membranes and of the substance of the cerebrum and cerebellam were
distended with dark blood. Blood-vessels of membranes and structures of medulla oblongata
and spinal cord greatly congested with blood. As usual, the spinal cord was exposed through-
out its entire length. Lungs and liver, stomach and intestines congested with blood.
Experiment 1^1 : Illustrating the effects of Cyanide of Potassium on Warm- Blooded
Animal.
Augusta, Georgia, January 23d, 1861. Thirty grains of Cyanide of Potassium were dis-
solved in two fluidounces of water, and half a fluiddrachm was injected sub-cotaoeoasly
beneath the skin of the left fore-leg of a cur dog. The poison excited violent atrugglei, load
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 10
minutes, to 40 beats to the minute. Then followed along piercing cry; tetanic spasms, loaf
drawn and loud breathing, coma, and finally death in 20 minutes after the injection of the
poison. The animal in this experiment, unlike the one in the preceding experiment, died
without a struggle.
Temperature of the rectum before the injection of the poison, 39°.46C., 103° F.; ofaHaos-
' phere, 50° F., during the period of excitement; during the first 10 minutes after the injectioi
of the poison, the thermometer rose 0°.08 C, and stood at 39°.54 C. Temperature of rectaa
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 roioates
after death, 37°.05 ; 75 minutes, 36° C. *
Post-mortem^ 24 hours after death. Veins of the brain distended with 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, Mesenteric and intestinal veins
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Experimental Illustrations of Convulsive Diseases, 319
distended with dark fluid blood, as was the case also with the yena-cara. Arteries emptj.
Iiirer of a dark purplish, greatlj congested appearance. Kidneys of a dark purplish slate
<olor, and greatly congested with blood. Spleen dark colored and congested.
Langs somewhat congested. Veins of stomach distended with blood ; mucous surface
ptach corragated, contained thick ropj mucus, and was of a deep pink and purplish color.
Veins of small intestines much congested with blood ; mucous membrane pale and not con-
gested, except in the duodenum, near its junction with the stomach. The congestion of the
nacous membrane of the stomach appeared to hare been due to the local action of the poison.
Under the microscope the colored blood corpuscles, in some cases appeared to be smaller
than normal, and in others, presented a stellate appearance. When abstracted from the bodj,
the blood coagnlated imperfectly.
Bxperimenis 1^2^ I4S, 144^ 14^j, HO, HI : RcpetUioii of precciiuig KqKriments
(^HO and 14^)1 general results similar.
Experiment I48 : Action of Acetate of Strychnia on large, active Dog,
Augusta, Georgia, May 14th, 1860. Fine, large, well conditioned, active dog. Temperature
of atmosphere 24** C, t5°.2 P.; 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^.5 F.
Immediately after the sub-cutaneous injection of the Acetate of Strychnia solution, into the
cellular 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 no disturbance of the muscular or nervous system. In two minutes after the injection
of the solution of the Acetate of Strychnia, violent convulsive movements of the muscles
were excited, and the pupils of the eyes were dilated. During these convulsions the thermo-
meter in the rectum slowly 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*'.2.'>
C, during 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, 100°.6 F.; showing a rise of 0°.GH 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 heart ceased to
beat.
If we consider the cessation of the heari's action, as the moment of death, then the Acetate of
Strychnia (about one and a half grains), produced death in six 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 muscles of the loins had fallen l°.I2 C; whilst that of the rectum had fallen only O^.o.*)
C. This difference was manifestly due to the relative loss of heat from the exterior and
interior of a body by conduction and radiation. Temperature of rectum 10 minutes after
death, 40^ G.
A strong interrupted electro-magnetic current was then passed in various directions from
the grcAt oerTous centres to the periphery and vice versa; contractions were produced in all
the Tolnntarj muscles ; contortions of the muscles of the face, were in like manner produced.
The contractions, thus excited, appeared however to be much more feeble than those produced
in the muscles of animals killed by mechanical means.
Temperature of rectum 22 minutes after death, 39^ C: of surface of muscjes of loinj;,
36M6 C.
Thirty-two minutes after the cessation of the action of the heart, ngor-mortis had not taken
place, ftod the dog presented no such contractions and contortions of the muscles, as have
been said by some writers to be invariably characteristic of the bodies of animals and men,
poisoned by strychnine.
Rigor-mortis commenced 7 minutes after this observation ; that is 39 minutes after cessa-
tion of the action of the heart. Forty-two minutes after cessation of action of heart, tenlpc-
ratnre of rectum, 39°.2 C; of surface of muscles of loins, 35°.33 (;.; 72 minutes after cessation
of action of heart, temperature of rectum, 37° C: of muscles of loins, 34°. 5 C At this time
the rigor-mortis is well marked, and the limbs are strongly contracted and rigid. A strong
interrupted magneto-electric current, passed as before in various directions, produced no
movements manifest to the eye; when, however, the skin was removed, contractions were
visible in the muscular fibres, under the direct application of the interrupted currents. One
hundred and ten minutes after death, temperature of rectum 36°.2 C; temperature of surface
Qf Qiqs^l?9 of l^ins, 34°.55 C.; loss of temperature in rectupn during HO ininutcs after death,
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320 Experimental Illustrations of Convulsive Diseases.
4^.05 C, loss each minute, 0°.036; loss of temperature iu muscles of loins duriog 110 minutes
after death, 3^.58 C; loss of temperature each minute, 0^.032 C.
Autopsy^ 110 minutes after death.
The blood from the carotid arteries, from the vena cava, and from the cavities 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-vessels of the membranes and structures of the brain and spinal cord, presented
no marked congestion. The nerve cells of the gray matter of the brain and spinal cord,
j>resented under the microscope the usual healthy appearance. Lungs of a light pinkisii
color and not congested with blood. ' Heart contracted and normal in appearance. Lifer
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
raucous 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 cherry red and par-
jilish 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.
Exj^erimetU 14^: Action of Acetate of Strychnia on Female Dog.
Augusta, Georgia, May 14th, 1960. 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,
ior.9 F.
Injected about two grains of Acetate of Strychnia, in solution, into the tub-cutaneous tiMue
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 convulsions of all the
inuscles ensued ; 6 minutes after the injection of the Acetate of Strychnia, temperatare of rec-
tum, 40®. 55 C, 105° F., showing a rise of 0°.22 C. in 4 minutes. Temperatue of sarCieeof
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 t minutes after the injection of the Acetate of
Strychnia into the sub-cutaneous tissue. There was a still further rise of 0°.05 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°.l 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 muscles com-
menced to sink immediately after the cessation of the respiration and of the pulsations of the
heart. 20 minutes after the cessation of the action of respiration and circulation, tempera-
ture of rectum, 40°.56 C; slight fall of 0°.04 C; temperature of surface of muscles of loias,
35°.4 C, loss of 1°.4 C.
A powerful interrupted electro-magnetic current was then applied, 28 minutes after death,
in various directions along the nervous centres ; rigor-mortis had not as yet commenced.
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 throagb
the entire length of the spinal cord, without any rise in the temperature of the rectum, or of
the surface of the muscles. . Th^ 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 tbs
action of the heart, temperature of rectum, 39°.75 C; of surface of muscles, 3G°.; 173 miaotes
after cessation of heart, and 130 minutes after last observation, temperature of rectum, 46°.6
C-; of surface of muscles, 33°.7 C; 19G, (23 after last observation), temperature of rectan, 36®
C; muscles, 33°.4 C; temperature of atmosphere, 27° C; 282 minutes, (186 after last obser-
vation), temperature of atmosphere, 26°. 5 C: of rectum, 34°.33 C; of muscles, 32°.2 C.
AtUopsi/.y 293 minutes after cessation of respiration and the action of the heart.
Iligor-mortis well marked. The blood corpuscles presented similar appearances as in the
preceding case, so^e 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 microscopical ^exav-
ination of the structures of the brain, spinal cord and sympathetic, did not reveal any recof*
nizable alterations or lesions. I could detect no alterations in the nerve cells or comaiif*
sures of the cerebrum, cerebellum, pons varolii, medulla oblongata, or spinal cord and syaapt*
thctic, which would distinguish the action of strychnia from that of Prussia Acid. Lnnp
greatly congested ; the liver, on the other band, pale and bloodless. Stomach filled with
digested matters, aud presented a much redder appearance upon the exterior and interior
than in the preceding experiment. Intestines, spleed, bladder and pancreas normaU
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Experimental Illustrations of Convulsive Diseases. 321
Bj a comparison of the preceding experiments, 148 and 149, it is evident tliat in one case
the longs 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 150: Action of Acetate of Strychnia on Dog.
Augusta, Qa., March, 18G0. Large dog (cross, between Setter and Cur). 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
vcre injected into the sub-cutaneous tissue of the hin4 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
ibowed a very slight fall, and stood at 103°.65 F.; six minutes after death, temperatnre of.
rectum 103°*5 F.; 19 minutes, 103°.5 F.; 21 minutes, 103°.5 F.; 28 minutes, 103°.5 F.; 42
minutes, 103°.33 F.; 52 minutes, 103° F.; 142 minutes, 99° F.; 202 minutes, 97<* P.; 222
minutes, 95° P.; 248 minutes, 94° P. 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 ail
conduction of beat, and to allow the body to cool as in the preceding experiments by radiatidn ;•
in all cases the animals being suspended horizontally, zo as to occupy a standing position.'
The urine passed during the last period of life, contained no traces of grape sugar.
Autopty fivt hours after death. 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 Strychniar;'
and after death ; but nothing worthy of note was observed.
Membranes and structures of brain and spinal cord congested with blood to » greater extent
than in the preceding experiment^.
Experiment 151 : Effects of Strychnia on large mxde Cat,
Solution of Acetate of Strychnin, 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
iteel." One and a half minutes after death, the magneto-electric current, passed in every
direction, produced no effects whatever on the muscular system. Blood drawn after death
coagnlated in 10 minutes.
Blood-vessels of brain filled with dark blood.
Experiments 152, 153 y 154, 155 , 150 , 157 y 158, 15Uy 160: Repetition of preceding
Experiments with Strychnia on Mammalia. Results similar.
In these experiments the heart was exposed, and artificial respiration instituted,
immediately upon the cessation of 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
mecbaaical and electrical stimuli afler death from Strychnia. In all cases the cavities
of the heart were distended with black blood, when the thorax was opened and the organ
exposed. This fact I have repeatedly demonstrated to my medical classes, viz : that
Styrchnia acts 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 by any known means. The fact that interrupted electrical currents
excited powerful spasmodic actions in the musoles supplied exclusively by the cerebro-
spinal system, whilst they failed to stimulate the muscular structures of the heart, would
seem to show that the nerves connecting the heart directly with the cerebro-spinal system
are related to the ganglionic system proper of the heart, rather than to the mus-
cular structures of the heart itself. \x\ Strychnia poisoning th^ cessation of the
41
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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 ooo-
siderable time af\er the cessation of its action, and when all its cavities are distended
with black, venous blood, deficient in oxygen, and loaded with carbonic acid.
Br. Charles Bland Radcliffe, in his " Lectures on Epilepsy Pain, Paralyns, and ctr-
tain other disorders of the Nervous System'^
Affirms that there is reasqn to believe that ODe way in which Strychnia or Bracia, tends
to bring about spasmodic muacnlar contraction, is by producing a change io the blood, which
it equivalent to loss of arterial blood, p. 87.
Dr. Radcliffe supports this proposition by the following facts :
It has been shown by Dr. Harley (Lancet, 7th and 14th June, and 12th July, 1856,)
that air which has remained for some time in contact with blood, to which Strychnia or
Bmcia has been added, contains more oxygen and lees carbonic acid than air, which has
been lefb in contact with simple blood, for the same length of time. It has been showa
that blood poisoned in thb manner respires lees freely than pure blood. In one of
the experiments by which this demonstration is effected, two tubes, similar in siic 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 fresh air, both tubes are corked up and set aade,
with this corks downwards. During the next twenty-four hours the blood and air tbtu
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 Bunsen's method ;
and it is found as is shown in the following table, that the air which has been in contact
with the poisoned blood, contains more oxygen, and less carbonic acid than the air which
has been in contaclr with simple blood.
GA9K8. • ! COMPOSITION
ConporiUoa of air CempmMm ttiit
Iter barinsbeea In after Iwrtac ^h* *•
contact with •inple eootact vltk Mai
coMiiON AIR. iS^Tl™ '**»^- !??*^*!*JJ5J;
Oxygen | 20.96 n.33 ' 17.83
Carbonic Acid | .002
Nitrogen ' 79.038
5.96 2 73
82.71 79.45
I 100.000 I 100,000 I 100^000
Dr. Badcliffe, from the results of these experiments, views the change wrought by
Strychnia upon the blood, as equivalent to loss of blood ;
«< For blood which cannot become arterial is as good as lost to all purposes of life. Nij,
this change may be looked npon as equivalent to copious loss of blood ; for In the experinfiit
of which the results are given in the preceding table, a very minnte quantity of the poison
has had the effect of depriving the blood of full two-thirds of its natural power of beconitfr
arterial. When Brucia was used in the place of Strychnia, the only difference was one of
d^rte, the power of preventing the arterialization of the blood being somewhat less cocrgctie
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 results, with astonishing rapidity.
•Thus Dr. Warner, set. 39, took by mistake, half a grain of sulphate of Strythnii:
the symptoms began in less than five minutes, by constriction of the throat, tightness of
the chest, and rigidity of the muscles, on attempting to move. He first complained of
want of air, and requested the windows to be open. He died in from fourteen to twenty
minutes, his mind remaining dear until the last. In the case of Mrs. S. Smyth, of
RpWPey^ three graipa of Strychnia were tAken by mfeteke for SaJaqioe. This lady wia
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Experimental Illustrations of Convulsive Diseases. 323
in violent spasms, in from five to ten minutes afterwards, and she died in one hour and a
quarter. A girl, set. 13, took one grain and a half of Strychnia in solution on an empty
stomach ; the symptoms began by twitchings of the muscles, rather more than an hour
after the poison was taken ; and she died in a violent 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 oases that ordinary medicinal doses
can scarcely be borne. Symptoms of its poisonous action have been frequently
unexpectedly produced.
It is not necessary to assume any such explanation as that given by Dr. Radcliffe in
the caae 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,
not only during the actual spasms, and nlso during the intervals between them. There
are however, marked differences between the two states ; ordinary tetanus commencing
silently and progressing gradually as various segments of the spinal axis become
involved, the expression of the countenance at the same time, being peculiar and
characteristic ; Strychnia Tetanus, on the other hand, is announced by violent general
spasms, loud screams and meanings, and progresses rapidly to recovery or a fatal result.
In both conditions there is exalted activity of the ganglionic colls 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,
the 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
induc6Kl 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 fiict that whilst
it increases the irritability of the spinal cord, it does not materially affect the fiinctions
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 Strychqine, the Q)dy and limbs
will renudn 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,
9S for example, the contact of a hair, or of a feather, or even the jarring of the table
on which the animal is placed. The following fact first noticed by Bernard, has been
adduced to show that the convulsions in cases of poisoning by Strychnia, are always of
a refiex character and never spontaneous, viz : that if a frog be poisoned after division
of the posterior roots of 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 division of
the poBterior roots, external irritations cannot be communicated to the cord. That
strychnine 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
observed 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,
to which I have referred in the first chapter of these Medical Memoirs, on the contrary,
^ipear to establish the fact that Strychnia may cause congestions of certain portions of
the spinal cord. Thus he says :
*' There has been a great deal of controversy, as to whether the gray matter of the antero-
lateral or posterior columns are at all sensitive or not, and on this subject the most conflicting
opinions have been broached, which are stated by Yolkmann in a short review. Xerven
Phys. 1. c. p. 548.
" In my 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
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324 Experimental Illustrations of Convulsive Diseases.
npwards exclusively through the posterior and lateral medullary columns. That such is the
case, I inferred especially from the phenomena produced by strychnia in a dog: in slighter
attacks the hind feet acted first, and subsequently continued more rigid, the animal slanding
upon them with the body inclined obliquely forward. Not only during these convulsions, hot
even when t^e animal lay more than once upon the ground, with its feet stretched oot 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 excessive doses of strychnia the
patients, without feeling anything, are suddenly seized with abnormal movements and codvqI-
sions. After the death of the dog, I examined the spinal cord and brain chiefly with the view
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 effasions of
blood, (See also Ecker^ Diss, land, pp. 110, 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 consetjuerKe on the verge of bi^rsting. Perhaps similar effusions had taken place, bnt in
the sections I prepared I* had not met with them. In both cases, however, the two horns of
gray matter were most beautifully injected with blood, as was evident after the sections were
dried and placed in Canada balsam* * * ¥i
''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 follj
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 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 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 asceot
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 Stntcture tuui Ftme-
Uotu of the Spinal Oordj pp. 77-79.
The accuracy of the observalions of Professor Schroeder Van Der Kolk, caDnotbe
questioned, especially too as his observations are accompanied by a drawing of the
section of the spinal cord of one of the dogs poisoned by strychnia, diaplayiDg 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
fiivor and promote convulsive action ; but rarely produce such violent tetanic spasmfl t«
result in death in the course of a few minutes.
Dr. Todd has recorded the observation, that opium hofl the effect of causing i
similar state of polarity of the cord, which is most conspicuous in cold-blooded animab;
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 tkis
drug when administered in large quantities.
A similar objection may be urged against Hydrocyanic Acid in the treatment of
Traumatic Tetanus, for it not only in large doses excites the reflex power of the spinal
cord and produces violent spasms, especially of the respiratory muscles, but it alters
injuriously the blood and destroys the power of the heart. In such cases of ^Msmodic
disease, Conium and Belladonna have been found to exercise beneficial eflfects as seda-
tives.
Dr. R. B. Todd ascertained by several experiments, such as the following, that the
inhalation of Ether, has considerable effect in controlling the natural polar state of the
cord, as well as that which may be produced by Strychnine. A pigeon deprived of its
cerebral hemispheres, lives in a state of sleep for a considerable time ; it flies when
thrown into the air, spreading and flapping its wings ; standing when placed on its feet.
A bird thus mutilated, was made to inhale Ether ; it could not stand, and when thrown
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Experimental Illustrations of Convulsive Diseases. 326
into the air, it fell to the ground like a heavy log, its wings remaining applied to the
sides of its body, or if the wings were 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
before. 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 influence of Ether, the spasms ceased immediately, and the animal became
perfectly relaxed ; but as soon as the effects of the Ether 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 t^) 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
most be looked on as the most valuable agents in the treatment of poisoning by
Strychnia, as well as of Traumati« Tetanus,
COMPARATIVE EXPERIMENTS ON THE ACTION OF POISONS, AND THE DIVISION
OF THE MEDULLA OBLONGATA, 1860, 1861.
Experiment 161 : Action of Stryehiine on Warm-Blooded AnimaU.
Large, powerful, female Bull Dog. 4 grains of Acetate of Strychnia in sol u lion of excess
of Acetic Acid, were injected beneath the skin of the thigh ; symptoms of poisoning were
manifested in tiiree 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
exceedingly violent, and when the thorax was struck, it sounded like a wooden cylinder, and
the muscles felt as hard as steel : at snch times it was impossible to feel the vibrations of tlic
heart.
The pupils were at one time much dilatea and then became contracted. Death took place
in seven and a half minutes. The respiration ceased before the action of 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
minutes 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
effect 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.
Interrupted 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-
tricles remained entirely unmoved ; no contractions were observed in the muscular fibres.
The 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 curient pro-
duced 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
he.^rt ; either upon the sympathetic system, or upon the nnstriped muscular fibres.
It is evident that the Strychnine acted directly on the gray matter of the spinal cord,
becaii9e the tetanic spasms were simultaneous and universal in all the voluntary muscles,
and a single touch was sufficient to excite tetanic spasms in all the muscles.
Effects on the temperature. — Temperature of rectum previous to the injection of Acetate of
Strychnia, 39o.9 C, 103°.8 P.; during the violent spasms excited by the Strychnine, the tem-
peratnre rose slightly, and stood at 40*^ C, 104° F. at the moment of death. Temperature of
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326 Experimental Illustrationa of Convulsive Diseases.
rectum 80 miDutes after death, 38°. 5 C; 3 hours after death, 34°.3 C; 5 hoars after death,
290.8 0. Temperature of atmosphere, 58° F.
The artificial respiration was attended with cooling of the bodj, which took place more
rapidly than in those animals thus poisoned, in whom no artificial respiration had been per-
formed.
Experiment 162 : Action of Prussw Acid on Warm- Blooded AnimaU^ performed
pari passu with the preceding.
Three fiuiddrachms of officinal solution of Hydrocyanic Acid were injected into the sab-
cutaneous tissue of the back of a large, strong dog.
Three minutes elapsed before any symptoms of poisoning wore manifested ; then followed
convulsions, 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 aboat
the ventricles and auricles, which were distended with black, venous blood.
Artificial respiration was instituted; the action of the heart was very slightly iocreaaed,
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 " motioai.
The diaphragm and respiratory muscles contracted under the action of the electrical ttiaialat.
Although the heart continued to tremble or contract feebly under the artificial respiration, sUII
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 dogit
no action whatever was observed in the heart or intestines, and coold not be excited by
mechanical or electrical stimuli.
Experiment IGS : Division of the Medulla Oblongata near the base of the FoMfdi
Ventricle : Large, powerful Bull Dog^
When the blade of the scalpel swept through the medulla oblongata, respiration ceased
fmmediately ; the intervertebral arteries were cut, and profuse haemorrhage 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 fall and strung
pulsation. The electrical excitement produced strong and full contractions of the anridcs
and ventricles. The heart continued to beat with regularity and vigor for near one hour,
during the continuance of the artificial respiration.
When the intestines were touched with the point of a scalpel, the peristaltic motion was
excited vigorously ; the electro-magnetic currents accomplished the same effects.
The interrupted electric currents produced powerful effects upon the voluntary masclei.
The diaphragm and respiratory muscles, and in^fact, all the muscles, contracted with the
greatest violence ; the limbs were thrown into the most violent contractions, also tlie mis-
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 vigorous action of the hearty and the violent miucular motions, were in moet etriking cotUrttt rCli
those of the dogs poisoned with Strychnine and Prussic Add,
Effects on Temperature. — Temperature of rectum previous to destruction of mednlla obloi-
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, 30°.55 G.
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 exteat;
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 aid
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 Add
and Strychnine was grelitly congested. The blood-vessels of the iptestines were also con-
gested and distended with dark blood, whilst they were not congested in the dog destroyed
by pithing.
Experiments 16j, 165, 166, 167, 168, 169, 170, 171, 172, 173, 174, ^75, 176, 177,
178 : Repetition of preceding Experiments (^161, 162, 163)^ with similar rtst^
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Experimental lUugtrations of Conuuhive Diseases. 327
£xperment9 179^ 180, 181, 182, 183, 184, ^^^ -' Repetitions of the experiments
on the actum of Binoxide. Peroxide of Nitrogen and Chlorine Gas, on Mam^
malia, illustrating the stimulant iffect of these gases, and espedallg of the latter,
and estahlishing the great value of Chlorine as an Antidote to tJie poisonous effects
of Hydrocyanic Acid,
The symptoms of poisoning by Pnissic Acid, described in the preceding experiments,
on animals, are similar to those which have been observed in human beings. Bocker
considers that there are three stages in the symptoms of poisoning by Prussic Acid,
If hen the dose of the diluted acid is small, but at the same time sufficient to destroy
Mfe : First, a sense of constriction in the chest— convulsive breathing, with distortion
Off t)ie features, giddiness, the eyes fixed, projecting and starting, oppression at the
beart ; second, convulsions, with opisthotonos, spasm of the larynx, of the urinary blad-
der, load cries, involuntary discharge of urine and fseces, loss of consciousness ; third,
l^enend paralysis, pulselessness, coma, relaxation of the miiscles, general cessation of respi-
ration and pulsation of the heart, greatly dilated pupils, flow of frothy saliva, and death
in from half an hour to one hour. In man, the symptoms follow each other with great
nudity, or the third stage rapidly supervenes upon the first.
Aooording to Taylor, when a large dose has been taken, as from lialf an ounce to an
ounce Soheele's Acid, the symptoms 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 eyee fixed, prominent and glistening, the pupils dilated and unafiected by light, the
limb§ flaodd, 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-
.eoations are 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 confiision of intellect, giddiness, nausea, a quick pulse, loss of muscular power,
shortness 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 sufliision, or bloated appearance of the face, prominence of the eyes.
If death results, this may be preceded by tetanic spasms, opisthotonos, and involuntary
eyacoatioDS. 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
on the heurt, 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.
OBNKBAIi CONCLUSIONS AS TO THE NATURE OF THE EFFECTS OF CERTAIN POISONS,
AS HYDROCYANIC ACID, CYANIDE OP POTASSIUM AND STRYCHNINE.
I. After the introduction of these poisons into the sub-cutaneous tissue, or after
their application to the tongue and mucous membrane of the stomach, a certain period
of time elapses before the manifestation of the svmptoms of poisoning ; and during
this period the poison is absorbed, mingles with the blood, and is distributed to the various
organs and tissues, and is thus brought into contact with the ganglionic cells of thb
eerebro*spinal system.
Various statements have been made as to the rapidity of the effects of Prussic Acid
in piodueiug poisonous symptoms and destroying life, which have not been sustained by
the preQC^i.Dg experinpi^Qts, In the most, suddenly fatal cascs^ thQ action has beea
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328 ExperimenM Illustrations qf 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 introdooed
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 entirdj
out of view, the fact that Hydrocyanic Acid is highly vobtilc, and that if a drop of the
pure acid be approached towards the tongue of a living animal, the acid evaporates and
reaches the lungs by inhalation, and is immediately diffused over an immeDse
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 vi^;
and I have been myself upon more than one occasion most seriously affected by the
vapors of the acid during my experiments. The time of the action of the poison shomld
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 brondiiil
tubes, and air cells ; now it is well established that the poison may reach the heart and
ccrebro-spinal and sympathetic systems in an almost inconceivable short space of tine
from the lungs. That a sufficient interval elapses between the application of the acid
and the moment when its first effects are proauoed, to allow of its being brought iato
contact with the central ganglionic masses, will be evident from the oonsidcratioQ of the
following facts :
Haller and Sauvages were the first who tried to ascertain bv experiment, with what
Velocity the blood is carried through the vascular system ; their calculationa 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 oonclusions reapeotia^
the velocity of the circulation in frogs and small fish, are more correct, as they wen
confirmed by autopsies ; but his observations were confined to bold-blooded animals, aad
it is scarcely necessary to mention how hazardous 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 subject, the oeoi-
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 oonsideied
sufficient to determine the relative velocity of the blood ; a method, the unoertaintj 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 capacitv of the ventridei
differ very considerably in different individuals. Mr. Hering of Stitt^^, 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 lead to more accurate results. He
mixed a solution of the Cyanide of Potassium with the blood ; he then took at certaia
intervals, small quantities of blood from various parts of the body ; and fVom the
chemical examination of these different portions of blood, and from the comparison of
the time which the substance required to arrive from one vessel into another, endeavoi^d
tfo ascertain the relative velocity of the blood. The experiments were performed upon
horses, and the following are the conclusions arrived at by Mr. Hering.
1st. 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 fVom twenty to
thirty seconds ; from the jugular vein into the thoracica externa, twenty-three to thiiij
seconds ; into the saphen magna, twenty seconds ; into the arteria mesenterioa, fifteea
to thirty seconds ; into the arteria maxilla externa of the opposite side, from tea to
twenty-five seconds ; and into the arteria metatarsi, from twenty to forty seconds.
2. The Cyanide of Potassium, withiu a, very short time after its introduction iuto
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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
all experiments, within one minute after the introduction into the blood, the Cyanide of
Potassium 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. Prussic Acid produces no absolutely uniform alterations in the circulation of the
cerebro-spinal system, recognizable after death ; and the cerebral and reflex symptoms
are /lot aue to the engorgement of the blood-vessels. In some cases, the brain was not
at all congested, in others the veins were distended with blood; and the blood after 16
hours showed a great tendency to transude through the coats of the vessels from its dis-
organisation, 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 marked in the eases in which the brain was not specially congested, as in the
eases 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
ft 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
action 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-
vessels of the spinal cord and it^ membranes. Independently of the faet 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 nervous elements.
III. The peculiar phenomena manifested by the cerebro-spinal nervous system, in
poisoning by Hydrocyanic Acid, are due to the action of the poison on the nervous
elements 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 cerebro-spinal
nerves, in consequence of the action of the poison on the sympathetic nervous system,
and muscles 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
system are not less marked than those of the cerebro-spinal nervous system. The slow,
mil respiration, 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
tempwature in the trunk during the first stages of the action of the poison — the subse-
quent fell in the temperature of the trunk before death in some cases — the accumulation
of the blood in the large veins of all the organs and tissues, in most eases of ppisoning
by Hydrocyanic Acid — the engorgement of the veins of the stomach, small intestines,
spleen, liver ajid kidneys ; — the suppression of urine in some cases, all point to aberrated
nervous action of the sympathetic system.
The. mere, congestion of the blood-vessels of the sympathetic nervous system, could
not account for iany 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 cerebro-spinal nervous system,
and of all the organs and tissues, is evidently the effect, rather than the cause of the
aberrated sympathetic nervous phenomena.
From these facts it appears to be proper, to ooncludcj that th^ aberrated uervQUS
a
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330 Experimental IHustrations of Convulsive Diseases.
phenomena of the sympathetic system, are due to the direct action of the poison, ood-
veyed in the blood on the ganglionic cells of the sympathetic ; to the action of the
altered blood on the same elements, to the congestion of the blood-yessels 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 cerehro-spinal system ; and are in both sys-
tems manifested precisely at the moment, when the blood contdning the Pmssic Aod,
reaches the nervous elements. The arrest of the action of the heart, and of the peri-
staltic motions of the intestmes, must be referred to the direct action of the poison od
the sympathetic ganglia, and to the action of the poison on the unstriped muscular
fibre.
v. Prussic Acid acts on both the voluntary and involuntary muscles, and decreases
or arrests entirely their property of contractility ; and after death from Prussic Add,
in many cases it is impossible to excite contraction of the muscular fibres of the hetit,
by medianical or electrical stimuli.
YI. The blood is altered — its color is changed as if the Prussic Acid had ent^ed
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 whidi
it is brought into contact ; hence, we cannot affirm, that its action is confined exdusivdy
to the nervous system ; and more especially would it be impossible to affirm that its
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 throogfa tbii
medium affects all the organs and tissues. We have also established that Prussic Add
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.
Vm. The effects of Cyanide of Potassium on warm-blooded animals, are similar to
those of Prussic Acid.
IX. The lesions produced by Strychnine are not uniform.
X. Strychnine acts directiy 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 action
of Prussic Acid.
XI. The blood is much less altered in Strychnine ppisoning than in Hydrocyanic
Acid poisoning ; the latter agent appears to act directiy on the colored blood corpusdos
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 respect
strychnine tetanus closely resembles traumatic tetanus ; in both there is an exakadon
of the reflex function of the spinal cord. But strychnine tetanus, differs ih)m ordinanr
tetanuB, in that the sympathetic system \b involved equally with the spinal axis, and the
heart is poisoned and rapidly loses its power of action.
XIII. Prussic Acid Tetanus differs from ordinary Tetanus and Strychnine TetaDtt8>
in that the entire cerebro-spinal system, and especially the medulla oblongata, as well
as the sympathetic system, and the Heart and Blood are involved.
XIV. A carefnl comparison of the phenomena of Traumatic Tetanus, wiUi the
symptoms of poisoning by such powerful agents as Strychnine, Prussic Add, and
Cyanide of Potassium and Woqrara, leads to the conclusion, that this diseue arises
frQlR th^ tr^nsmissioQ of the ir^^^tion \\k t^he wounded surface 9Qd i^erve^tp the c^tril
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Experimental Illustrations of Convulsive Diseases. 331
ganglionic cells of the spinal 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 by exter-
nal circumstances, and the state of the system at the time of the reception of the
injury, is not caused by the generation witlAn the system of a poison, which acts like
Strydinine, or Prussio Acid, or Woorara.
This conclusion will be still farther illustrated by the following tabular comparison
of the symptoms of Tetanus, Hydrophobia, Woorara, Strychnine and Prussic Acid
Poisonioj!:.
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332
Experimental Illustrations of Convulsive Diseases.
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334 Experimental Illustrations of Convulsive Diseases.
XYI. Iq the experiments on the action of Priissic Acid and Strychnine, no post-
mortem elevations of temperature were observed. This point is of interest, io its
bearing on the action of certain poisons.
The interesting and singular fact discovered by Da 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 distiogQidbed
Physiologist of New Orleans, Louisiana, and carefully investigated by Wandwlidi.
Adolph Valentine has recently endeavored to show, that the oeowrrenDe of post-mortea
heat is common to all dead bodies, the difference being only in degree. As fiir as this
subject has been investigated, it appears that the heat is most quickly and determiiuitdy
developed afler death, from rapid injuries and lesions of the nervous centres, and
especially of the brain. Thus, in Gerebro-Spinal Meningitis, the tempamtare after
death, has risen from 104'' to 111^ F. In Cholera, Huckkenet observed the ther-
mometer to rise from 79^ to 92^ F. afler death ; in Variola, attended with modi 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, b
near three hundred animals which I have destroyed in various ways, but diielly bj
violent poisons.
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'*v^.
CHAPTER V.
TBEATMENT OF TBAUMATIC TETANUS.
Treatment uf Traumatic Tetanus. Historical Notes on the Treatment, illustrating tbe
methods adTocated by Hippocrates, Aretsus, Galen, Celsus, Pelops, Paulus ^gineta, and
maoj ancient find modern writers. Tabulated cases illustrating the results of treatment with
Tarioat remedies. Discussion of the relative yalue of tbe different remedies. Blood-letting.
Section of Nerres. Amputation of affected limbs. Local applications. Mercury. Anti-
mony. Tobacco. Opium. Indian Hemp, (Cannabis Indica). Woorara. Sulphuric Ether.
Chloroform. Alcohol. Chloral Hydrate. Cold Bath. Warm Bath. Nutritious Diet. Rela-
tire Mortality from Traumatic Tetanus in Civil and Military HospiUls, and in Private Practice.
Relative Mortality in Traumatic Tetanus, under the different modes of treatment and in tbe
employment of various agents. Discussion of the modes of action of the various agents
employed in the treatment of Traumatic Tetanus.
It 18 important in Traumatic Tetanus, 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, uninfluenoed by drugs, would furnish the proper data, for
the determination of the effects of remedial agents on its progress, duration and termib-
ation. Suchy however, is the violence of the 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 bv drugs. The records of medicine, nevertheless, contain a few observations,
which snow tibat when the respiratory muscles are unaffected, patients have sometimes
passed through an attack of even acute tetanus, without medical treatment. Thus, Dr.
Morrison, Mr. Hennen, Mr. Morgan, Sir Astley Cooper, and others, have alluded to
cases of Tetanus, in which, although the patients were left entirely to nature, without
remedies, diey recovered.
As Tetanus is of comparatively rare occurrence, the most distinguished physicians
and surgeons rarely witnessing and recording during their entire professional lite, 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 ca§e^
actually observed and treated, with the teachings of distinguished authorities, as to the
best methods of treating the disease. This was especially desirable in the histofy of a
disease, which renders the human system capabie of resisting the action of the mo$e
violent poisons in fatal doses ; for bv such an impartial comparison of actual observa-
vations and theoretical opinions, and empirical practice, we are enabled on the one h^nd
to emancipate our judgment to a great extent from the influence of mere authority, and
OQ the other hand, to establish many important facts as to the laws which govern the
lioman system, when subjected to that peculiar excitement of the ganglionic cells of
the spinal axis, which has been denominated Traumatic Tetanus.
We have therefore endeavored not only to consolidate and give the outlines of more
than four hundred cases of Traumatic Tetanus, but also to embody the observations of
many of the most eminent physicians -and surgeons, with the hopC) that the results of
Wl^bgw W C5am\ping many stwdard work^ aud journals, and in aoalyzing and con-
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336 Experimental Illustrations of Convulsive Diseases.
densing and coDBolidatiDg a vast amouDt of practical obeervation sod experimental
experience, may prove of lasting value to those who may desire to arrive wiUioat a
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, eadi
of which terminated fatally. In the second chapter of these Medical Memoirt^ in the
observations on the Natural History of Tetanus, I have ^ven these cases in full »
recorded by Hippocrates. (See Cases 4, 5, 6, 7 and 8): in only one case, vi» : that of
Scamandrus, has Hippocrates specified the treatment. In the appendix to his Treatise
on Begimen in Acute Diseases, directions are given for the treatment of TetaDos.
That Hippocrates was well acquainted with the fatal nature of T^nus, and the
unsatisfactory rcsuHs, if not. absolute futility of treatment in this disease, is evident
from his axiom, that : '^ a convulsion coming on a wovnd is mortal^ Hippocrates
appears to have employed in the treatment of Tetanus, the warm bath, fomeotatioiis,
venesection, glysters, purgatives, nutritious diet and wine.
Aretsevs, the Cappadocian^ correctly refers the origin W 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 OpistbotoiioB and
Emprosthotonos, ^^ are apt to supervene upon the wound of a membrane or of musdet,
or of punctured nerves, when for the most part, the patients die, for ipajm frcm a
wound isfataV^
The following are the directions of Aretseus for the cure of Tetanus :
'* Now, indeed, a soft, comfortable, smooth, commodioug and warm bed ig reauired ; for the
nerves become unyielding, hard and distended. * * Let the house also be m a tepid con-
dition; but if in the summer season, not to the extent of inducing sweats or faintaesa, for
the disease has a tendency to syncope. We must also not hesitate in having recourse to tbe
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 from
abortion in a woman, we roust open the vein at the elbow, taking special care, with respect
to tbe binding of the arm, that it be rather loose ; and as to the incision, that it be perfomed
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 patieat
must not be kept in a state of total abstinence from food, for famine is frigid and arid.
Wherefore, we must administer thick honeyed water, without dilution and strained ptisaa
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 mad)
calculf^ted 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 b^eo boiled.
All the articles are to be possessed of beating properties, and hot to tbe touch. We mutt
rub with a liniment composed of lemoestris eupborbium, natron, and pillitorj, and to these
a good deal of castor is to be added. The tendons also are to be well wrapped in wool, and
tbe parts about the ears and chin rubbed with liniment; for these parts in partienlar, soirr
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 bladden
bf cattle, half filled with warm oil, so that they may lay broad on the fomented parts.. Neces-
sity sometimes compels us to foment the head, a practice not agreeable to the sanses, bat
good for the nerves : for by raising vapors, it fills the senses with /ume, but relaxes the
nervous parts. It is proper then,, to use a mode of fomentation, the safest possible, and
materials not of n very heavy smell ; and the materials should consist of oil devoid of sasell,
boiled in a double vessel, and applied in bladders ; or of fine salts in a bag ; for millet and
linseed are pleasant, indeed, to the touch, but gaseous and ofan offensive smell. • • «
Aftei^ the cataplasms, it is a good thing to apply the cupping instrument to the occiput oo
both sides of the spine, but one must 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 sotk
slowly and softly, rather than suddenly in a short time, for thu^, the part in which you wish
to make the incision, will be swelled up without pain. Your rule in re^rd to thepraper
amount of blood, must be the strength.
These are the remedies of Tetanus without wouad9%
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Treatment of Traumatic Tetanus. 337
But if tho spasm be connected with a wound, it is danjgerous, and little is to be hoped. We
must try to remedy it, however, for some persons have been saved, even in such cases. In
addition to the other remedies, we must also treat the wounds with the calefacient things
formerlj described by roe, by fomentations, cataplasms, and such other medicines as excite
gentle beat, 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 levigating others beforehand with oil ; but the mallow having been
ponnded, is to be boiled beforehand in honeyed water. We are to sprinkle also some castor
on the nicer, for no little warmth is thereby communicated to the whole body, because the
rigors proceeding from the sores are of a 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
oboli. But if the stomach reject this, give immediately of the root of silphium an equal dose
to the castor, or of myrrh, the half of the silphium ; all these things are to be drunk with honied
water. But if there be a good supply of juice of the Silphium from Gyrene, wrap it to tho
amount of a tare in boiled honey, and give to swallow. It is best given this way, as it slips,
nnperceived through the palate ; for it is acrid, and occasions disagreeable eructations, being a
sobstance 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
anus Is to be annointed with oil or honey. With this also we are to annoint the fundament,
along 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
evacuating flatulence and fasces,, we are to inject two drachms of the purgative hiera along
with the honeyed water and oil, since along with the expulsion of these it warms the lower
belly; for hiera is both a compound and heating medicine." The Extant Works of Aretmut^
the Cappadocian, London, 187)6, pp. 400 to 404.
The Cyreniae Silphium, employed by Aretaeus, was a superior kind of Assafoetida,
which at one time grew copiously in the region of Cyrene. See Paulus iEgineta, t. iii,
p. 337.
Pelops recommends dry, and not moist fomentations, in the treatment of Tetanus ;
and afl^rms that the most potent cure for emprosthotonos and opisthotonos, is a fever
supervening when there was none at the commencement. — The Seven Books of
Paulus ..^^neta, vol. i, p. 403.
Ctelius Aurelianus enumerates nearly the same causes as Aret^eus, and ddscribes all
the symptoms of Tetanus with the greatest precision. His treatment also is very
similar to that of Aretaeus, namely, emollient applications to the neck, venesection, and
oily clysters. He enjoins the bath of oil, which has fallen into disuse in modern prac-
tice, most probably on account of the expense. He also permits sometimes the use of
eouamon 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
this 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 the
cold afifiision in Traumatic Tetanus.
Paulus ^gineta afiirmed that Tetanus is to be cured, like convulsions, by depletion.
In reference to the " Cure of the Varieties of Tetanus," Paulus ^^gineta says :
In treating tetanic spasms, we roust begin with phlebotomy, and wrapping the parts in
wool which has been dipped in oil, namely, the Sicyonian and Castor, with 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 neok, both sides of the spine, the muscular parts
of the breast, the hypochondria, and the region of the bladder, or kidneys, should be cupped.
We must not be sparing of the detraction of blood, nor yet take away too much at a time,
but at intervals. The sweats sj^oi^ld be ab|Sorbed by wool dipped iq Q.il, lest tM patient hap-
pen to catch cold<
43
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838 Treatment of Traumatic Tetanus.
If the attack of tetanus coDtinue long, the patient must be put into a hip-bath of oil twice
a day, but not allowed to remain long in it, for of all applications, the bath of oil is the most
debilitating. Let him drink tepid hydromel, boiled to the one-half; and the robust maj 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 stomach. We must also give gum Ammoniac; or Gyrenaic juice
to the size of a tare, made up with well-boiled honej, may be swallowed. Two spoonfals 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, in the decoction of hj'ssop. But the least dangerous
and most effective remedy, is Castor, to the extent of two or three spoonfuls in divided doaes.
And it will do no harm if yon give it after a meal ; 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 afl'usion of cold water being as Hippocrates says, exceedingly hazardous, and for that
reason I snppose, rejected by succeeding authorities, we too are disposed to condemn. A
lAnment of bard (Valerian), one scxtarius : of wax, oz ii : of malabathrum of amomum, of
Btorax, and of mastich, of each oz i : of castor, of adarcc, of euphorbium, of pepper, of each
oz i : of spikenard, of opobalsaro, of each oz i.
A Potion for Opitthotonos — 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 ortbopnoea. Let the diet be attenuant, of easy diff'usion, and by all means not
excitant. The Seven Bookt of J^ineta^ Vol. /, paget 404-405.
Octavius Horatianus, recommends bleeding, emollient applications, purgative dysten,
t^o tepid bath, antispasmodics, and sudorifics. The use of the hist 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 Meuse
join the preceding authorities in recommending strongly the use of castor and tsedot-
tida as antispasmodics. Avicenna, in common with many other ancient phyisidaie,
praises the bath of oil ; Serapion speaks of a bath prepared with emollient herbs.
Ualy 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, of
rubbing the part affected with hot oils, and of using the warm bath, with frictioDS ^Sixx
it ; he also approves of castor : for the other variety, he praises the affusions of plain
water in which lettuces, barley, etc., have been boiled. He recommends the intemtl
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' proposd 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 the part affected, purging with aloes, etc, the ad-
ministration of antispasmodics, such as castor, assafiBtida and the like. Faaltu ^&mHa^
Vol I page 407,
A, Cornelxvs Ce/«i/«, says :
"That the varieties of Tetanus are cured by the same method; so fkr physicians agree.
Bat Asclepiades believed that blood should be let; some again affirmed that ought by all
means to be avoided ; for this reason, that the body then stood most in need of heat ; and
that this resides in the blood of the veins. This indeed is false. For it is not the nature of
the blood to be peculiarly hot ; but amongst the several things which compose the human
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. But it is
evidently proper to glv© castor, and with it pepper or laser. Then a moist and hot fomenta-
tion is needful, Therefore, most physicians, pour warm water frequently upon the neck.
That relieres for the present, but renders the nerves more liable to cold, which is to be parti-
cularly avoided.
It is more proper then, first to anoint the neck over with liquid cerate; next to applj
oz bladders or bottles filled with hot oil, or a hot cataplasm made of meal, or pepper, bruised
with a fig. Bat it is most suitable to foment with hot salt. When any of these has beee
done, it is fit to bring the patient to the fire, or if it be summer time to the sun ; and to rab
his neck and shonlders, and apine with old oil, which is fittest for thitt purpose ; if that caa-
^qt li^ bad witl^ Syrian Oil i \( that cannot be ^qt, w\tl\ the oldest fat. As friction is service
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Treatment of Traumatic Tetanus. 339
able to all the vertebraae, so it is particularly to those of the neck. Wherefore, day and night
but at proper interyals, this remedy must be used. When it is intermitted some healing
malagma 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
in 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 Gyprine, and
to keep it covered with 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
saperior parts. But if notwithstanding the pain has grown more severe, cucurbltals are to
be applied to the neck, and an incision made in the skin. Eschars are to be made either by
irons or mustards. When the pain is abated, and the neck has begun to move, we m.iy know
that the disease yields to the remedies. But all food that requires chewing must be avoided.
Gruels 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 this is very dangerous, and therefore to be deferred for a longer
time.
A. Cornelius Gelsus, Medicine, in eight books. Translated with notes, by James Greive, M.
D., Third Ed.; London, 1838, pp. 166, 168.
As far as my information extends, Dr. William Callen was one of the first to advo-
Yote 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 cut oflf that part from all communication with the sensoriura, either by cut-
ting through the nerves in their course, or perhaps by destroying to a certain length the^r
affected parts or extremity."
With reference to the value of Opium, Dr. CuUen 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 has 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."
Br. Cullen not only advocates the use of Opium in large doses in tetanic affections,
but he also 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 temporarv manner in which it
had been employed by' practitioners. Dr. Cullen, also recommends pur«jatives, and the
frequent exhibition of glysters when the power of deglutition fails. He suggests that
Musk and Camphor might be employed with benefit in 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. * *
Blistering also has been formerly employed in this disease; but several practitioners assert
tbat blisters are constantly hurtful, and they are now generally omitted." First linet of the
PraHice of Phytic,
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
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340 Treatment of Traumatic Tetanus.
treatment is based upon the view that Tetanus depends upon debility, thus hesajrs: 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 cure of
diseases of less debility, nor any sense in using them ; we must therefore immediately hare
recourse to the most powerful and the most diffusible stimuli 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.
Neither Cullen nor Brown report any cases of Tetanus, in support of their views.
Benjamin Rush, of Philadelphia, affirms that Tetanus may sometimes be arrested
after the appearance of the first symptoms, by an emetic, a large dose of kadanam,
the warm bath, and Peruvian Bark. He also states, that in " many hundred instancf*^'
the most salutary effects had arisen during the first appearance of the symptoms, bj
opening and dilating the wound, and by the application of such irritant substances, as
Spanish flies, Corrosive Sublimate and oil of Turpentine. Dr. Rush recomm^ided
Opium in large and freauent doses, and wine in quarts and gallons daily. Dr. Ro^
says that the cold bath had 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. Girdlestone, to
the effect that in the East 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 have been given, but without apparent success; Opium basJcept
its ground longest, but with little reason, as it only quiets ; but from some patients haTine
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 without they pro-
duce some visible eflfect : Opium never removes the cause, though it will prevent the effecu:
it cures spasms and removes pain, but it does not remove the cause. It often does good, by
not allowing the symptoms to do harm to the constitution. The first appearance of a cure,
is a recovery of strength, as weakness is a pre-disposing cause ; and the first iodicatlon
should be to strengthen the system. 1 should recommend everything to produce external
cold, as cold applications, consisting of snow with salt, to the part, and that the patieat
should be put into an ice house, or sent to a cold climate, as soon as possible. I know^of do
internal medicine. * * Electricity has a temporary effect in relaxing the muscles, aod is
partial affections has cured by rendering the contractions less violent." Works of Jobs
Hunter, edited by James F. Palmer, Lpndon, 1837, vol. i, p. 588.
John Hunter records four castas of Traumatic Tetanus; 1st, treated with Opium, aod
Blood-letting ; 2d, with Opium ] 3d, Acetate of Lead ; 4th, Assafoetida and Opium ;
each case terminated fatally.
Baron Larrey, who, without doubt, had a greater experience in the observation and
treatment of Traumatic Tetanus in different countries and climates, than any other
military medical officer and surgeon, in direct opposition to the skeptical views of John
Hunter, and others, as to the value of remedies in thb disease, lays great stress upon
the value of certain measures. Thus Baron Larrey says, with reference to the local
treatment :
'< Experience proves that when tetanus is abandoned to the resources of nature, the patieat
soon dies. The physician should hasten to counteract the symptoms presented by the disease.
The first object is to remove the causes of irritation, and to re-establish the suppressed
excretions. This is to be effected by suitable incisions in the wound made before inflamma-
tion takes place ; for should this be much advanced, incisions are useless and even daogeroas;
when necessary, we should incl\ide as much as possible of the wounded nervous cords aad
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 wonsd,
may be made with advantage, on the first appearance of the symptoms, provicfed the saae
rule be observed as in the case of incisions. To these operations should succeed bleeding if
necessary, and the use of anodyne and emollient local applications, though these effects are
geaerally feeble.
Internal remedies, whatever may be their properties, are almost always useless, bceaaie
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Treatment of Traumatic Tetanus, 341
the pAtient in a short tinfe after the appearance of tetanus, falls into a state of strangulation ;
bat should this not take place in the early stages of the disease, such remedies may be
employed as physicians most confide in ; for instance, Opium, Camphor, Musk, Castor, and
other antispasmodics, given in large and gradual doses." Memoirs of Military Surgery, vol.
i, pp. 138-9.
According to Baron Larrey, mercurial frictions aggravated th3 disaase it 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 by the same results.
Baron Larrey not only proposed, but practicoJ amputation for the relief of Traumatic
Tetanus, believing as he did that, it is better to amputate the loouaded limb as soon as
the symptoms of tetanus appear^ thin to rely on the uncertain resources of nature and
art to effect a cure. From his fir^t series of cases, recorded in his Memoir on Trua-
matte TetanuSy contained in the fir^t volumj of his Memoirs on Military Surgery ^
Baron Larrey concludes:
1st, **That of all the remedies proposed by skilful pruclitiouers, 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 tbey take this liquid with pleasure ; and that its effects may be seconded with venesec-
tion if necessary, and by vesicatories under such circumstances as I hare before mentioned.
2nd. " That amputation performed at a proper time, is the most certain means of arresting
tctanas, when it is produced by a wound in the extremities.'' p. 153.
In the second volume of his Memoirs on Military Surgery, Baron Larrey records
additional observations on Traumatic Tetanus, thus he says ,
" I have often removed the symptoms of incipient tetanus, by adopting sucli means as are
suited to remove its causes, viz : by cutting the ligature of an artery in which a nerve is
tDclnded, and to which the patient refers all his pain, and where the nervous irritation takes
its rise. This division of the ligature arrested the disease in its forming stage, aud expedited
the care of the wounds. There is no danger of haemorrhage if the vital powers be not debili-
tated, and there be no predisposition to adynamia. A few hours of direct compression, which
brings the walls of the arteries into contact, are sufficient to induce adhesive inflammation,
as explained in the Memoir on Hsemorrhage. 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
cat the ligature. I have succeeded in this operation live times, • « *
Epispastics 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 nerve, 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 inspect 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
1 reach the points of the divided nerve, and sometimes I carry the cautery even to a greater
depth. This application justly recommended by the physicians of antiquity, has produced
most surprising eflfects. By destroying adhesions and preventing tlie twitchings of the nerves,
it removes spasm and irritation." Vol. II, pp. 300-301.
Id his Surgical Memoirs, on the Campaign of Kussia, Germany and France, Baron
Larrey, states that after the battle of Dresden, (August 27th, 1813) :
^*- Wounds of the joints, and those complicated with fractures were thwarted shortly after*
wards by that sad aflfection tetanus, which we have so often observed, and almost always in
moist 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
wounds. This agent and the amputation of the injured limb, saved the lives of some patients,
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342 Treatment of Traumatic Tetanus.
the history of which cases I was not able to collect ia consequence of mjr being obliged to
follow the moTements 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 t9 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 was
tried in 1797.
Case 60 : Traumatic Tetanus cured hy section of tlie nerve, hy Mr. G. Hick*, 1797,
A cooper was attacked with trismus 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 him about three
weeks after the injury, at which time the jaws had been completely locked for fpur days.
Observing at the seat of injury a tumor in a state of suppuration, he made an incision tbrongh
it, cutting down between the metacarpal bones with a view of relieving the nerTons systea,
by a division of the nerves affected. Opium was afterwards given in large doses, and tiie
next day the patient could open his mouth and swallow fluids with ease, the rigidity of the
muscles of the throat and face, being in a great measure relieved. London Med. and Pbyi.
Jour. Vol. XVII, p. 277.
Mr. John Henuen declares in his MUUary Sargery, (London, 1829, 3d Ed. p. 249)?
that he had never been fortunate enough to cure a case of Symptomatic Tetanus ; ia
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 Marasmus : 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. It
Mr. Hennen's last case, venesection and the use of tobacco injection, (which brought
away enormous quantities of hardened faeces), after five days perseverance 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 carefiilly
watched. The disease lasted for seven weeks. But in another case precisely similar,
treated in the sanje ward, at the same time, on the same plan, and by the same medical
assistant, the usual fatal termination occurred on the 15th day.
Whilst Sir James Macgrigor, was unable to say precisely the number of cases of
tetanus treated \inder the head of toounds, he states that there were some hundred
cases in the British armies, during the campaigns in the Peninsula of Spain and Por-
tugal, which offered room for extensive trials of remedies. He gives brief histories of
only six cases of tetanus which recovered, and after general observations upon Uie dif-
ferent reniedies employed, concludes thus :
'' I am however, obliged to confess that little or no dependence is to be placed io aoy
of the remedies, and I hare to regret that the method of cnre 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 free
sweating, in some of the few successful cases, Dover's powders may be useful, and the vegrl-
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 dis-
ease : it was tried in many cases at Toulouse. Indeed I believe this gentleman's opinioo is
altered since he published the result of his experience in Egypt. I had some conversatio*
with him on the subject, but I have been recently informed by Mr. Guthrie, that the Baroa
distinctly acknowledged to him, that the loss of the French army after the battle near Drejden.
was principally from Tetanus, when of conrse, this practice must have been fairly tried. "
Medico Ghirurgical Transactions, 1815. Vol. VI, p. 449-469.
Dr. J. H. Dickson, M. D., Physician to his Majesty's Fleet, after presenting
observations on several very severe cases of Tetanus, which occurred in the wounded of
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Treatment of Traumatic Tetanus. 343
the British Forces, iu the expeditioD against New Orleans, affirms that he was justified
in inferring :
"That to the improvements in the medical and surgical treatment of wounds ; in cleanli-
ness and Tentiiation, avoiding at the same time exposure to currents of cold air, or sudden
changes of temperature ; in fine, to superior comforts, diet and accommodation ; but particu-
larljr, to the greater attention paid to the state of the bowels, may be attributed the greater
infireqaence of tetanus of late in the West Indies, when compared with former wars." Medico
Cbimrgical Trans. VIII, p. 465.
Sir Gilbert Blane, says, that only three wounded men recovered in the whole fleet,
after the action of April, 1732. X^^ wounded amounted to eight hundred and ten,
and sixteen of this number weVe 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.
Dr. James Currie, 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-
tioD. In the use of the cold bath. Dr. Currie, appears to have been more successful in
IdioMthic 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 cold 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
induces a state resembling drunkenness, or congestive apoplexy. Antimony induces
nausea and vomiting, purging and perspiration, and thus relaxes muscular power ; but
its effect 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 continued use of the infusion of Tobacco, in the following manner :
"The infnsion of tobacco injected per 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. U may be used twice or thrice daily with perfect
safety in the onset of the disease. It produces nausea, perspiration, and sleep, often of
hoars continuance; but abore 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
coaoteract 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 hold to be a not less important indication of treat-
ment. Patients have been lost in Tetanus from want of proper nourishment and cordials, oftener
than from want of proper medicine, pp. 301, 306.'*
Mr. Thomas Blizard Curling, afler the examination of the records of 128 cases of
TraumaUc Tetanus, arrived at the following conclusions as to the treatment of this
disease which I have condensed and consolidated from his Treatise on Tetanus,
Local Treatment, — Mr. Curling dismisses at once from the inquiry, the propriety si^'
isiug the actual cautery, and other stimulating local means, to restore the suppurative
process 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
of the disease, two plans have been adopted. 1st, Amputation or excision of the
wounded 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 sequel of its perfoi^manoe.
Mr. Cunlng considers amputation as altogether so severe and serious a mode of
trwiting the disease, that \Te can scarcely ever be warranted in resortipg to it, wheu the
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344 Treatment of Traumatic Tetanus.
original wound is slight, especially as if employed under the most favorable circumstanoes
a successful issue can never be depended on . In chronic tetanus as patients usually recover,
it is certainly inadmissible, even when the wound is severe and in an uDfavorable state,
unless its oonditionr be sufficiently bad to demand the operation independently of the
spasms. Amputation can only be regarded as a justifiable proceeding after a severe injurr
of the extremities, as a compound fracture or an extensive laceration, immediately that
there is the slightest indication of spasms, for if delayed until the disease is more advanced
instead of proving beneficial, it will tend rather to aggravate the symptoms and to rcDder
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 poesibie
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 operation far
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-
nient of purgatives. A brisk Cathartic, by causing the expulsion of worms or unhealthy
fiaeces, has produced almost immediate relief in the idiopathic form. One of the most
important consequences of the free operation of purgatives, arises from their fiivoriog
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
ibedicines. Those purgatives should be selected, which being nearly soluble, act
quickly and powerfully on the intestinal canal, as oil of turpentine, and croton oil,
especially the latter, since in addition to its active and rapid operation in cases of difi-
cult deglutition, a few drops upon the tongue, will generally be sufficient 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, 9o
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 throngfaoot
the disease.
Mercury. — Although Mercury has gained some repute, as a remedy in tetanus, the
evidence of latter practitioners, in regard to its influence in controlling the progress of
the symptoms is far from favorable. The constitutional effects of Mercury will not
arrest the disease, for patients have been known to expire with a stceam of lalivi
flowing from their mouths. Mr. Curling and others, have recorded caaos, in which
cxtreibe suffering was occasioned by the increased secretion of saliva. Of 53 cases in
the table of Mr. Curling, where Mercury was employed, 31 proved fktal. Of the 2i
cases which rec(ivered, 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 alone, or
employed in conjuuetion with some trival remedy, as the warm hBm or blistere, ^
were fatal except one. Twelve cases of tetanus, consequent upon severe injuries, are
rfelated by Mr. Howship, in all of which Mercury was ftilly exhibited. Two only
recovered, and in both of them it was given in conjunction with Opium. As tk
symptoms may make considerable progress before the system is brought under its
influence — as it can possess no specific power over the disease — and as debilitjis
increased, the sufferings of the patient are seriously aggravated by the produetion of
ptyalism ; in the pure traumatic form of the disease, the free use of Mercury must be
regarded as not only useless, but exceedingly injurious.
Blood' Lettihg. — By cautiously analysing the pathological characters of Tetanus, it
has been attempted to establish a proposition of the highest import, in r^ard to
the treatment of this disease, viz : that tt is not essentially an infiammaiory diseoKy
most cases of the traumatic form being unaccompaui^ with f<?bple disturbaooe, or will
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Treatment of Traumatic Tetanus. 345
aoj symptoms indicating the fiocessity for active depletion. Autophlogistic treatment
therefore, b generally unnecssary for its removal ; but iii these cases, where inflamma-
tion is the canEc 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 meduUa-spinalis, Mr. Swann,
and other practitioners, recommended the abstraction of blood in the course of the
^inc. Numerous experiments and observations have shown that this state, not of con-
gestioD, 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 bo 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 ¥rith-
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 tho 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.— Kithcr over the affected muscles, or in the course of the spine,
is of no service.
Various remedies, as Camphor, Musk, Digitalis^ Stramonium, Conium, Hyosciamus,
Belladonna and Lead, have proved utterly inadequate to allay the excitement in the
nervous system, giving rise to undue muscular action.
Opium. — Of 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 ths
spasms ; but as it is resorted to, in, by far the greater number of tetanic cases which
occur, too much importance must not be 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. Curlii>g's table, being more than two-thirds of the whole uum-
ber. Of these forty-five recovered, of which ten were females.
Id 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
doses in many cases exert not the slightest effects upon the system. Although in
Tetanus, the cerebral functions arc undisturbed, yet Opium not only fails in allaying
spasms, but is generally, equally 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 cotistipating qualities of Opium ; and
in cases attended with difficulty of deglutition, its effects may be obtained by applioa-
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
symptoms occasioned by the influence of Tobaoco on the system, are ejctrome 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
bears some analogy to the state of extreme depression to which the spasms give place
just previous to death, af\^r t^e more violent paroxysnfta of Tetauus, But th^re w this
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346 Treatment of Traumatic Tetanus.
essential and important distinction ; in the one case, prostration is occasioned bj a sod-
den and powerful impression on the nervous system, which, if not carried too far, is
only temporary, the vital powers not being permanently impaired. In the ether, how-
ever, the powers of the system are ?o 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 ninctoeD
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 wu
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 renedy
yet resorted to. He even goes so far, as to ^ffirm, that he had not succeeded in
finding a single case, in which, being fully tried before the powers of the constituiion
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 kttcr being a
remedy that can never be relied on, having failed far oftcner than it has cured. Whilst
admitting that in its worst forms, Tetanus is a disease of too destructive a nature to be
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 whicb
will generally be found capable of diminishing the severity of the acute disease, and
oflen 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 noarishing
diet, tonics, wine and other stimulants. The carbonate of ammonia in particular, b well
adapted to counteract the extreme prostration sometimes induced. At the commence-
ment, a scruple of the tobacco leaf infused in eight ounces of water, will be enough
for an injection, which must afterwards be increased in strength, in proportion to its
effects. 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, arc
j[)ot only inefficient, but objectionable.
Antimony — Antimony being a remedy which diminishes the heart's action, and de-
presses the vital powers, has sometimes been employed for the relief of TeUnus. 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 remedy
is best adapted to the more chronic forms of the disease, for although it has a decided
influence in lessening muscular energy, its depressing effects are too uncertain, and arc
generally insuffcient in power t« arrest the course of the acute disease.
Cold Affmion — It must be acknowledged that the evidence in favor of cold affusioD.
chiefly refers to cases of the idiopathic form of tetanus. With the exception of tobacco,
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 ct>Id affosiiHi.
And he believed in the most aggravated cases, by perseverving in the application of it
until syncope or extreme depression of the vital powers is produced, the spasms may be
completely removed, l^nlcss however, a powerful impression is made and kept up fi^
some time, and the remedy repeated as soon ns the spasms recur, it will prove ineflfcct-
ual. The utmost care is necessary not to cart-y it so far as to take away all power vi
reaction, and it may be desirable to administer brandy, or a difliisable stimulant duriog
the application. The remedv possesses this advantage, that other means fitted to cav»
the same effects, m^y be combined with it. Of twelve cases in the table of Mr. Curling,
in which cold affusion and other means were adopted, seven terminated favorably.
Ireatise on Tetanus: FhiL, 1837, pp. Od-lOo.
The three objects of treatment upon which Mr. Lawrence placed reliance, were:
first, venesection in the early stage, until the symptoms of general fulness of the \Ttfco
lar system are removed ; second, the free exhibition of aperients, so as to remove costive-
ness : and third, the cmployTueix^ of opium for IcstHjning or controlling the very painful
spasmp, l4ancet, January SOth, 1830, p. 38fK
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Treatment of Traumatic Tetanus. 347
Mr. O'Brien, has used the extract of. hemp, (Hemp Resin), in seven cases of Tetanus,
of which four were admitted in a hopeless state. He employed the remedy in ten grain
doses dissolved in spirit. The effect which he describes is almost immediate relaxation
of the muscles, and interruption of the convulsive tendency. Of Mr. O'Brien *s seven
cases, four 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 unequivocally to show, that when
p: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. Lancetj ISIfi, pp, 539-640.
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,
» that produced by disease within the spinal canal itself; eccentric tetanus arises prin-
cipally ^om 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 muscles of the upper extremity as
well as of the lower are forcibly contracted. This according to Dr. Marshall HaJl, is
the very type of Tetanus. The treatment proposed by Dr. Marshall Hall however, con-
tained nothing new. Thus he says :
'*Tbe principles of treatment wopld appear to be; I, lo divide the injured nerve; 2, to
subdue the spasmodic affections by such remedies as the Hydrocyanic Acid ; 3, to prevent
organic changes in the nervous system by depletion, general and local ; 4, to remove all
sonrces of irritation as scybalae in the bowels, etc., and 5, to avoid all sources of augmented
spasna, such as shocks, noises, etc." Lectures on the Theory and Practice of Medicine.
Jjancet^ February 14th, 1833, p. 69.
M. Matteucci, 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 limbs of a frog, muat have remarked that the animal is seized
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
tetanus, and to discover how far the direction of the current, and the mode of intro-
ducing it might influence the muscular contractions. His first experiments were made
upon frogs, and from these, he concluded that the most advantageous method was that
of introducing the current in such a way as 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
length 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
exciting cause of the tetanus being thus constantly in operation ; the remedy besides,
was not applied until ten days after the reception of the wound, and at the very height of
the disease. The machine employed contained from 25 to 35 plates ; the electric current
was passed along the spinal marrow, from below upwards, for half an hour, without
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348 Treatment of Traumatic Tetanus.
interruptioD ; 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 skio was
covered with moisture, and the circulation became tranquil. Such indeed was the efieefc
produced that the patient constantly cried out for the electric pile. Unfortunat^j M.
Matteucci was confined to bed by a broken leg, and unable to direct the necessary obier-
vations; the persons to whom they were entrusted could not keep up the eleotric
current, even though the pile was renewed. Although the case finally termioated
fatally, the good effects produced were so manifest, that M. Matteucci looked fonrard
with confidence to favorable results, in future applications of the Continued Electrk
Current in the treatment of Tetanus. Lancet^ 1838, p. 350.
In his Keport of seventy-two cases of Tetanus, occurring in Guy's Hospital, since the
year 1825, Mr. Alfred Poland has given some interesting statistics, to which we have
before alluded. I will now record such facts as bear especially upon the prognosis and
treatment of the disease.
In thirty-two full years, there occurred seventy-two cases of Tetanus, in Guy's 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 [previous lesion of
surface. The severity of the symptoms bore no relation to the d^ree of local iiyuiy.
In 86.56 per cent, tetanus occurred after 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 tea
days has elapsed. On the other hand, when the disease follows close upon the injaiy.
it is for the most part uncontrollably rapid and fatal. As respects the mode of dying,
nineteen died during a paroxysm, with spasms and convulsions ; thirteen from asphyxia,
and suffocation, and ten from exhaustion. In one case the hearth 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 certain, was found to be incorrect; two of the cases at Guy a
were fatal, over this period, one on the twenty-eighth, the other on the thirty-eeeoiMi
day. Ten died on the seventh, and eleven on the fourth day, while on no odier
day did more than five die, and then it was on the third and sixth, or the dayslmmedi-
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 division of the nerves near the seat 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 cose, 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 disease,
seem to have been most efficaceous. At all eventa, in the ten cases of recovery, qainine
was givjBU in seven, and in the others, wine, mush and tonics. Of the twenty-five cases
in which quinine was given, seven recovered ; the doses were about one grain per hour,
given every third or fourth hour. Cannabis Indica and chloroform, remedies whidi are
in vogue in the treatment of tetanus in this country were of no service ; in most of the
cases in which chloroform was given, the disease was aggravated.
Dr. Jackson, (Indian Annals, October, 1858), has drawn up a careful paper on the
treatment of tetanus in the Native Hospital, at Calcutta, with a view of showing thai
great relief is afforded in that disease by the repeated inhalation of chloroform, added
to the internal administration of hemp and aloes ; and in the latter stages, of quioia,
and generous diet ; and that many more cases of recovery have resulted from this pba
than ftrom any other. It is worthy of remark however, that the same beneficial infli*
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Treatment of Traumatic Tetanus. 349
ence 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 yrerc Jive out of seven admissions.
On the other hand. Professor Laurie, (Glasgow 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 yet tried has done good, and many more have done harm, how are wo to
treat tetanus? 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
Dourisbment as he can swallow, and trust the result to the power of his constitution. And
iltke $pa*nu are severe alleviaie them by chloroform.^''
Dr. Brctton, (Philadelphia Medical Examiner), relatss 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.
Dr. Symes, (Dublin Hospital Gazette^, details the particulars of a caso of traumatic
tetanus, in which chloroform inhalations wore U33d with gr^at su3C3Sj. Rankin's
Abstract, 1854, p. 59.
In 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
tned 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,
1st. " 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,
4lh. ** That 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.
Id some 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 cases, 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
remedies, and may possibly be actively injurious itself."
The late Dr. Robert Bentley Todd* held, that the pathology and clinical history of
tetanus, point out three objects, which the practitioner ought constantly to keep in
view in its 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
sources 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 assimilating powers of the patient, administered in small quantities, and at short
intervals, and also to wine or other alcoholic stimulants, the practitioner ought not to
*Medical Gazette, 1849, p. 7G6, Rankin's Abstract, 1849, [p. 41. Clinical Lectures, on
Affections of the Nervous System, 1855, p. 276.
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350 Treatment of Traumatic Tetanus.
withhold the liberal use of quinine^ ammonia, iron, or other drugs, which exert a tonic
power over the system in general.
In fulfilling the second indication, whilst the bowels are kept open, drastic purgatives
should be avoided ; too profuse sweating or diuresis should be guarded against.
*'To obtain the third object, namely : to reduce the polarity or the spinal cord, is at once
the most important and the most difficult. The various sedative remedies, opiara, bydrocjaaic
acid, belladonna, conium, tobacco, have been fairly tried and failed. Opium is not a sed-
ative to the spinal cord; its use in tetanus may be laid aside, except in small doses as 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 the 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
fearfu] depression. It is likewise an unsafe and not a manageable remedy. I have seen arare
than one patient die, cured of tetanus, under this remedy.
'^ There*are two agents which certainly exert a considerable power over the polarity of the
spinal cord, which have no> 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 fairly
reaches the cord, its influence is shown by a marked depression of the action of the heart,
which leads to general depression and debility. During the application of the bladders is
this way, increased vigilance will be necessary in the administration frequently and at short
intervals, of nutritious and stimulant substances."
. Of the value of Chloroform and Ether, in the treatment of Tetanus and Tetanoid
affections. Dr. Todd confessed that he had had no experience, but he strongly advised
thier use from the resulte of experiments, which showed that these agents were capable of
exercising a most powerfiil 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 thb disease ; only Ave cases occurred during the years
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 bad
been a month and a half under treatment for dysentery, complicated with frost-bite of
the grejat toe, and ended fatally on the 20th February, 1855 — while during the year
1855-56, only 24 cases occurred, viz : 23 in the Crimea, and one at home. One of these
Crimean cases followed frost bite, another was thought to be idiopathic and due ta
exposure to cold, but this was questionable, as the symptoms were consequent on ao
injury of the foot; and the case which occurred in England, followed amputation for
diseased bone, consequent on frost-bite.
This number is very far under what is believed to have occurred in any former cam-
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 percent, and in the Peninsula, the loss is known to have been yery large from
this cause, although the exact proportion cannot be ascertained. The causes of this
immunity, notwithstanding the vast variety of wounds inflicted, the hardships aad
fatigue endured by the troops, and the defective and improper kind of food so long sap-
plied to them, are not clear. The very simple mode of dressing wounds, universally
adopted by British Surgeons, may not have been without its influence ; and possibly
also the universal practice of bringing the sides of the wounds in opposition by sotaiv,
position, etc., and not stuffing them with charpie, or other irritating substances, uoder
the idea of favoring granulation, absorbing discharges, etc. The nearly total absence of
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Treatment qf Traumaiie Tetanus. 351
marali malaria, ia the district occupied by the British troops is noteworthy in conjunc-
tion with this immunity ; and it may be a question to what extent the employment of
cbloroform in operations has acted. Of the 23 Crimean cases, 21 terminated fatally ;
the mortality being 91 per cent. One of the recoveries took place under the exhibition
of 1 mixture containing Chloroform, and of that drug by inhalation. He was oflen
kept for hours more or less completely under its influence, and on one occasion for more
than nine hours at a stretch.
Morphia was tried at the general Hospital, and as much as 10 grains given within
24 hours in 2 grain doses, in two cases which each lived long enough to allow the
drag a fair trial; but only once, and then only in a very slight degree, did either of them
exhibit any signs of narcotism, and both were fatal.
The only other recovery, was treated with Calomel and Opium to salivation ; but the
removal of the source of irritation from the sheath of the nerve, was more probably the
cause of the abatement of the symptoms. Non-suppuration of the wound would not
appear to have been a cause of the disease ; indeed in some of the cases suppuration
was remarkably profuse, and in many, even after the advent of the disease, the wounds
looked healthy. The practice of large bleedings as a means of cure is, so far as they
go, negatived by these cases. In no less than three the disease followed haemorrhage,
and in one of these, the bleeding had been very profuse. The average period in the
Crimean cases, before tetanic symptom* was 8i days from the date of the receipt of the
injury, and the average duration of these symptoms before death closed the scene, 3^
days. — Medical and Surgical History of the British Army^ which served in Turkey
and the Crimea^ during the war against Ritssia, in the years 185^-55-56, Vol. ii,
pp. 279-285.
Tetanus was of comparatively rare occurrence during the recent American Civil War,
1861-65, in the Confederate Army. Thus in the Field and Hospital Reports for 1861,
in 1750 cases of wounds of difierent characters, there were 13 cases of tetanus — 0.75
per cent., or one of tetanus in 134 cases of wounds. Of these only three are reportied
as having ended fatally, giving a ratio of 23 per cent, mortally ; or one death in four
cases ; — a result which clearly proves the inaccuracy of the earlier'reports. In 1862, the
consolidated reports from hospitals, presented 45,974 cases of wounds, and only 53
cases of tetanus — 0.11% or one case of tetanus in 867 cases of wouuds. Of these 53
cases, 28 terminated fatally — 52.8 per cent. ; about one death in two cases: — a much
larger percentage of mortality than in 1861, but still, there is reason to believe much
below the truth. Tetanus was doubtless of more frequent occurrence in the Confederate
hospitals than would appear from the reports, as it is well known, that cases were genc-
ndly reported under the term Vulnus Sclopeticum. No provision for the accurate report
of Supervening diseases was made upon the official Field and Hospital Reports,
until near the close of the war In the Special Reports of gun-shot injuries, involving
tetanus, covering the whole period of the war, up to the end of 1868, and which were evi-
dently drawn up with great care, only Q(5 cases were recorded ; and of these, six only
recovered, giving in the Confederate Array, a mortality of nearly 91 per cent. The
relative mortality of the cases of Tetanus occurring amongst the Confederate Sol-
diers, appears therefore to have been almost precisely that of the British during
the Crimean war. Assuming then, that these constitute the entire number of undoubted
cases of tetanus, which occurred in the whole number of gun-shot wounds, up to the
end of 1863 (56,775) ; we have the proportion of one case of Tetanus, to every 860
cases of gun shot wounds.
In the United States service, during the Civil War of 1861-1865, 363 cases of Trau-
matic Tetanus were recorded. The proportion to the total number of wounds does no*^
appear to be larger than in the Confederate service. It must be borne in mind, however,
that the Confederate statistics given above relate only to 1861, 1862 and 1863, and do
not In^dudo those of 1864 and 1865, which appear to have been either captured or
destroyed a^ tho time of the fall of the Confederate government,
Qf the total TOPa^^? Qf Q^69 of Tnmmatio Tetanus reported in the Federal service,
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352 Treatment of Traumatic Tetanus.
336 terminated fatally ; of the 27 recoveries reported, the disease is said to bare bees
of the so-caUed " chronic form/' in 23 ; in the remaining four cases, the symptoms were
very grave. In two, recovery took place under the use of opiates and stimalants ; in
two, after amputation of the wounded part. In the Federal service there was ooly one
recovery in every 14.2 cases ; and 92 per cent, of the cases terminated fatally, which i*
very nearly equal to the mortality in the Confederate aimics, viz: 91 percent.
It is very evident, that during (he Civil War of 1861-1865, in both ibe South-
ern and Northern Armies, treatment had little or no influence in lessening the rate
of mortality.
In the Federal service, the great majority of cases were treated by the free use of
Opium combined with stimulants, and concentrated nourishment. Chlorofoim inhala-
tions were very generally employed during the paroxysms of spasmodic contractioD.
Sub-cutaneous injections of the salts of morphia and atropia were frequently lucd.
Cathartics, Quinine, Camphor, Cannabis Indica, Bromide of Potassium, Strychnine,
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 seme cases applied to the wound. AmpotatioD,
the division of nerves and the extirpation of neuromata in stumps, were the surgical
measures sometimes employed. The value of Nicotine of the Cakbar bean, and of
Curare, as curative agents in Tetanus, was not tested. According to H. Demise oi
twenty-two cases of Traumatic Tetanus treated with Curare, eight recovered, Ctrailar
Ko. 6', War Department^ Surgeon generals Office^ pp. 4^, 4^*
No light appears to have been thrown upon the patnology or treatment of Tranmatic
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 trial, as a remedy in Traumatic Tetaani
and convulsive diseases generally, and thus far, the results of its employment have on
the whole been favorable.
^r. 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 other
forms of Insanity, that the facts which he had observed forced him to condude :
l8t. That in Paralysis of the Insane, when the patients are destructWe and Tioleot, the
judicious administration of Chloral acts as an excellent hypnotic by ntgbt, and soothing agvut
by day.
2d. That under its action the patients have been free from destructive habits, and bare
gained in weight and strength.
3d. That in one case as much as 2,810 grains were taken during ninety*fire dajs, tbe
average taken being 30 grains, with no bad symptoms. In a second case, as much as 3,43S
grains, were taken during 122 days, being at the rate of 22 grains daily; when tbe patieiti
gave evidence of prostration. A third patient took 2,380 grains during eighty days, the dail;
average being 20 grains, with no bad symptoms. A fourth patient took 1,362 grains diriag
sixty-seven days, the average being 20 grains daily, with no bad symptoms. A fifth ptlicat
took 510 grains in twenty-lour days, giving a daily average of 25 grains, with no bad symp-
toms.
4th. That under it the action of the bowels and bladder have^improved.
5tb. That in no case has there been a refusal of food ; on the contrary, the appetite of titt
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, itbu
cut short the hallucinations.
8th. That in patients liable to hallucinations of hearing, and under their influence becoailsf
noisy and excited, it has produced calm.
9th. That in patients with a propensity periodically to maim and hurt tbemsekct, tb«
disease has passed away under the influence of Chloral. * *
10th. In certain cases of melancholia, beneflt was derived from its administration, iDf)
convalescence advanced. * •
11th. That the greater the disorganization of the brain and cord, (as judged by the lyiap-
toms, and especially by thermometric observations) tbe SQOper dpes the system coate dd^
the Chloral action. Practitioner^ Aug., 1870,
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Treatment of Traumatic Tetanus. 353
Dt. John B. Tuke, has used Chloral very frequently of late in chronic cases of
Insanity, in which violent outbursts of excitement occur, and invariably with good
resalts. The insomnia of climacteric insomnia melancholy, is much relieved by a half
drachm to a two scruple dose at bedtime. According to Dr. Tuke, the advantages of
Chloral over all other hypnotics are : Ist. That it is more uniformly certain in if 8 action.
2d. That it has no depressing influence. 3d. That it does not cause constipation. 4th.
That it does not produce nausea. 5th. That its effects are more lasting. Dr. Tuke
believes it to be the most valuable means of producing sleep, which has yet been intro-
duced into the pharmacopia of the asylum physician. The only difficulty is to ascertain
the exact dose for each case ; but this is obviated by beginning with half drachm doses,
and increasing them bv ten grains, until the limit is found. Lancet, 1870, p. 443.
The preceding results are of great interest in their bearing on the use of this drug
in Traumatic Tetanus, especially as they demonstrate that it may be used, continuously
during considerable periods of time, without serious injury to the digestive or nervous
jstems.
Dr. A. Ballantyne, (Lancet, October, 1870, p.* 545\ reports a case of Traumatic
Tetanus, in a male nged 34 years, which supervened a lortnight after an injury of the
left thumb at the base of the nail, by a thorn ; and which recovered under the use of
large and repeated doses of Chloral. This, although the ninth, was the only case of
Traumatic Tetanus which Dr. Ballantyne had seen recover, although the temperature
was 103®, upon the third day, and the extent, frequency and severity of the spasms,
and the intensity and length of the diaphragmatic spasm, and the persistent rigidity of
the thoracic and abdominal muscles, were as great as in his fatal cases. In giving the
Chloral in this case. Dr. Ballantyne observed that the patient was less rapidly affected
by it, as the doses were repeated, and that the first dose of one drachm had the most
marked effect, reminding one very much of the rapid effect of chloroform in cases of
severe and protracted labor, when the patient is much exhausted. The congcBtion of
the conjunctiva was very great during the exhibition of the remedy, and continued
some days aft^r the doses were much lessened. In all, the patient had six ounces and
a quarter of Chloral, during the three weeks, on an (iverage of two to two and a half
drachms per diem. - After the eighth day, the Chloral was sometimes intermitted for
Beveral hours; but when more than six hours elapsed, the symptoms invariably became
more intense, and the patient required a larger dose, more frequently repeated, during the
next eight or twelve hours. Not unfrec[uently an extra half drachm of Chloral was
given in addittion to those noted in the report for some specially severe time of suffering.
Mr. Berkett, (Lancet, September 24th, 1870, p. 434), reports a case of Traumatic
Tetanus, cured in ten days, treated with Chloral Hydrate. Mr. Eager, (Lancet, March,
1871, p. 157), reports a case of Traumatic Tetanus, in which, although the Chloral
hydrate was not ultimately successful, it undoubtedly afforded the patient great relief
and comfort by procuring sleep, and for a time it certainly reduced the severity of the
tetanic spasms. In anomer fatal case of Traumatic Tetanus, reported by Mr. Tyrrell,
(Lancet, May, 1871, p. 265), although as in the case of Mr. Eager, the administration
of the Chloral Hydrate did not save the patient's life, it oertainly rendered the progress
of the disease lees painful by procuring sleep. This patient took 770 grains of Chloral
in eleven days. In a case of Idiopatic Tetanus, reported by Mr. Hany Leach, of the
Dreadnaught Hospital, (Lancet, September 24th, 1870, p. 435), the Chloral Hydrate
was administered m drachm doses every three hours, and chloroform administered by
inhalation during the same space. Although this case terminated fatally as is com-
monly the case, the chloral and chloroform greatly mitigated the severity of the spasms,'
and induced quiet, genuine sleep, A case of Idiopathic Tetanus has been successfully
treated with chloral hydrate, by Mr. George Thompson, (Lancet, April, 1871, p. 19),
In this case the drug was used in gradually increasing dos^, from thirty to sixty grains.
The effect of the Chloral in giving comfort and relief to the patient was very noticeable
in this case, and the patient frequently begged for his draught.
Mr. C. Macnamarft (The Practitioqer, September, 187l)j st^tes^ th8,t he Im tyq^tod
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354 Treatment of Traumatic Tetanus.
since September Ist, 1870, teii consecutive cases of tetanus, in the Chandine Ho^td,
with the Hydrate of Chloral, alone. The quantity administered, varied from forty to
one hundred and sixty grains per diem, according to the severity of the symptonis aod
aee of the patient ; but after a little experience of the effects of Chloral| it seemed to Mr.
Macnama^, that it had no specific influence over the tetanic spasms ; nevertheless, he
believes that there can be no doubt, that even in the most severe cases of tetanus, this
drug has the power of sending the patient off into a deep sleep, and thus for the time
being, of preventing tetanic spasms ; but in several instances it appeared as if the
Hydrate of Chloral, by thus keeping back the tetanic energy, rendered it more conoen-
trated; after deep deep from chloral, the spasms, sometuues returning with such
violence as speedily to destroy the patient. Of the ten cases treated exdusivdy with
chloral, seven were instances of Traumatic Tetanus, and only one of them recovered ;
two cases of Idiopathic Tetanus, were thus treated, one of them recovered, as also did i
case of the disease, occurring fifteen days afler child-birth. Dr. Macnamara, says:
" My experience thus far, has led me therefore, to conclude that I was hardly jasUfied in
trusting to the chloral alone, in the treatment of some cases of this disease ; as an hypDotic
it seemed invaluable, but we must, if possible, do something more than put our patieDU to
sleep in the management of bad cases of tetanus; and although the calabar bean possesses
an influence, infinitely short of being a specific in this disease, nevertheless, the extract of
Pbjsostigma, if judiciously employed, has, I think, a salutary influence on some cases of
tetanus.'*'
Ilie conclusions which Mr. Macnamara, has formed as to the general progoons, arc
that:
'* We should be mainly guided by the temperature of the patient's body ; so long (I •■
referring to the natives of India), as the temperature of the body is below lOO*'.?. I wo«M
give a favorable prognosis; and I would treat such a patient, by giving him as moch ailk
and arrow-root as he could take, with a little wine and soup from time to time ; and for u
adult, forty grains of hydrate of chloral at bed-time. If the temperature of the patieal's
body however, (especially in the morning), rises to 101®, there is danger to be apprehended.
Should the temperature rise suddenly from 99® or 100®, to 102®, the patient is in immiseot
danger, and I have seen few cases of tetanus recover after the temperature of the body bts
risen to 103®. In these cases however, we should resort to the extract of calabar bean, and
hydrate of chloral at bed-time, and we may do so with some hope of success, provided tbe
temperature keeps under 103®, and the muscles supplied from the spinal nerves are cbieflr
implicated ; but if the muscles directly under the influence of the medulla are involved, tod
the temperature of the patient's body reaches 103® and upwards, we should relieve his ter-
rible agony with hydrate of chloral, but can have but faint hopes of 4iis recovery. Aft^r
death from tetanus, the temperature from the body rises rapidly to about 107® F.''
Dr. J. A. Beck, (St. Louis Medical Jounial, June 18th, 1872), gives a summary of
tlirty cares of tetr nus treated with the Hydrate of Chloral, in which the results are hr
more favorable than those obtained by Mr. Macnamara ; viz : sixteen were cured sad
fourteen died. Successful results in tetanus, with the Hydrate of Chloral have abo
been recorded by Dr. Thomas, (Richmond and Louisville Medical Journal, November.
1872), Dr. A. G. Lawrence, (Lancet, March 4th, 1871), Dr. S. Baruch, (Richmond
and Louisville Medical Journal, January, 1873, p. 1), Dr. Lavo, (Annali Univeretlidi.
February, 1872), and others. Successful cases have been reported by several pbpi-
cians, in which the Chloral Hydrate was given in conjunction with lai^ doses of
Bromide of Potassium.
In the following table I have consolidated from various sources, the reports of cases
illu^tn^tJH^ the r^xsitfi of the yftTOU^ methods of treating TetanuSs ♦
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wine per day. In twenty-eight days, the patient took
one hundred and forty bottles of wine, several gallons
of Brandy, and five and a half fluidounces of Tincture
of Opium. During the same period twenty seven
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cations.
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fore-arm.
Division of Integuments, and evacuation of matter.
Extract of Belladonna, one to three grains every four
hours. Calomel as purgatives ; and Clysters.
Purgatives, Mercurial Ointment.
Belladonna, Wine of Colchicnm and Purgatives freely
administered.
On examination after death, it was found that a spicula
of bone had transfixed the vastus externus.
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Treatment of Traumatic Tetanus.
383
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384 Treatment of Traumatic Tetanus.
ANALYSIS OF THE RESULTS OF TREATMENT IN FOUR HUNDRED AND TWENTY
CASES OF TRAUMATIC TETANUS.
In the preceding tabulated statement of 420 cases of Traumatic Tetanus, treated by
various methods and remedies, 207 terminated fatally, and 213 recovered ; giving a
mortality of 49.2 per cent. ; or one death in 2.02 cases. This result is perhaps, more
favorable than is actually the case in Traumatic Tetanus, as it occurs generally in civil
and military practice ; and the supposition is perhaps just, that in such a fatal form of
disease, the tendency would be to record the successful, rather than the fatal cases, the
reporters being actuated by a laudable desire to throw light upon its method of cure.
By a comparison of the ratio of deaths to cases in the table, with the records of military
and hospital practice recorded in the Historical Notes on the Treatment of Tetanus, it
will be seen that the result was far less favorable than 49.2 per cent, of deaths, or ooc
death in 2.02 cases. Thus the per cent, of deaths in the cases of Traumatic Tetanus
which occurred in the British Army, in the Crimean War, was 91 : in the Confederate
(Southern) Army, 1861-1865, 91 per cent. ; in the Federal (Northern) Army, 1861
to 1865, 92 per cent. ; in Guy's Hospital, during a period of 32 years, 86.1 per cent
I have been unable to ascertain frtm the writings of Baron Larrey, the exact number
of cases of Traumatic Tetanus, which came under his observation, but from all his
statements, it would appear that the mortality. of this disease in the French Anniei,
during the memorable and bloody wars of the great Napoleon, did not differ materially
from that of British, Confederate and Federal Armies.
In instituting comparisons as to the rates of mortality in this disease in difiereot
countries, and under different circumstances, it should however, be remembered, that
in military and naval service, we have in many cases, a much more serious and danger-
ous class of injuries, than those ordinarily met with in civil practice, and at the sane
time, the wounded are necessarily subjected to greater vicissitudes of temperature, and
are oflen deprived of many of the appliancps and remedies at the command of the civil
surgeon and physician. Neither is it altogether just, to compare the results of Ho^tal
service with those of private practice, because there are oftimes important differences ia
the patients treated, the hospital being supplied with subjects from the poorer and more
abandoned classes. It will be observ^ however, that many of the oases recorded in the
table, are drawn from hospital reports and military service.
From the preceding table we gather, that whilst tetanus may arise from almost erery
conceivable kind of injury, as contusions, fVactures, abrasions of the surface, blisteiv,
bums, frost-bite, ulcers, ligature of piles, caries of bones, gangrene, incised, punctured,
lacerated and gun-shot wounds and amputation ; at the same time, the rapidity of the
supervention and the severity of the symptoms, bear no relation to the degree of the
local injury. Thus out of 420 cases of Traumatic Tetanus, recorded in the table, 189
were caused by injuries of the feet and hands ; that is, nearly one-half, or more aodh
rately, 45 per cent, were due to comparatively slight injuries. The following cases il-
lustrate the important fact, that comparatively slight injuries, may not only exdte
tetanus, but that the disease when thus induced is violent in its nature and rapid in its
progress : Case 117,* Amputation of middle finger, followed by tetanus in 24 boon,
and death on the 4th day after the appearance of tetanus ; 121,' wound of sole of foot
by rusty nail, tetanus 7th day, death 9th day after ; 112,' fracture of little finger, teta-
nus 9th day, death 2d day ; 124, ^ foot punctured by rusty nail, tetanus 7th day, death
3d day ; 128,^ laceration of hand, tetanus 13th day, death 15th day ; 130,* lacerated
wound of little toe, tetanus 10th day, death 14th day; 131,^ lacerated wound sole of
foot, tetanus 10th day, death 2d day ; 132,' wound of fore finger, tetanus in 12 hoon;
136," contusion and fracture of metacarpal bones, tetanus 10th day, death 2d daj;
138,*® wound of foot by rusty nail, tetanus in 12 hours; 156," sole of foot wonoM
with rusty nail, tetanus 5th day, death 4th day; 163;*' lacerated wound of foot, tetaow
8th day, death 2d day ; 166,** slight contusion of toe, tetanus 10th day, death 3d day;
169 " wound of thumb with splinter, tetauus 9th day, death ^t\\. day j 170,** great toe
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Treatment of Traumatic Tetanus. 385
penetrated with nail, tetanus 14th day, death 40 houi-s; 179/* sole of foot wounded
with rusty nail, tetanus ISth day, death 20 hours : 189," compound fracture of hand,
tetanus 9th day, death 3d day; 195,*® contusion of thumb of right hand, tetanus 9th
day, death 2d day ; 196,*^ sole of foot wounded with rusty nail, tetanus 8th day, death
5th day ; 199," laceration of little finger, tetanus 10th day, death second day ; 206,"
sole of foot wounded with rusty nail, tetanus fifth day, death second day; 211," com-
pound fracture of fingers, tetanus 10th day, death 24 hours; 216,^ finger of left hand
cut off by hatchet, tetanus in 2 hours, death in 12 hours; 218,** compound fracture of
bones of thumb, tetanus 6th day, death 2d day ; 220,** lacerated wound of thumb,
tetanus 8th day, death 3d day ; 230,* frost bite of toes, death 2d day ; 233," foot
wounded by glass, tetanus 8th day, death 5th day ; 243,'® compound dislocation of
astraglus and os naviculare, tetanus 7th day, death 2d day ; 249,^ little finger crushed,
tetanus 8th day, death 3d day ^ 255,*^ laceration of index finger, tetanus 4th day, death
2d day; 256," wound of sole of foot by rusty nail, tetanus 3d day, death. 8th day;
257,'* index finger crushed, tetanus 9th day, death 3d day ; 261,** punctured wound of
hollow of sole of right foot, tetanus 9th day, death 5th day ; 262,^ compound disloca-
tion and fracture of fingers of right hand, tetanus 8th day, death 2d day ; 268,** severe
contusion and abrasion of back of hand, death from tetanus in 30 hours ; 274,"* index
finger of right hand shattered, tetanus appeared immediately, and proved fatal in 32
hours; 290,*' foot crushed by wheel of wagon, tetanus 6tn day, death in 24 hours;
297,* puncture of sole of foot, tetanus 3d day, death 6th day ; 298,^ puncture of sole
of foot, death 3d day ; 299,*® puncture of sole of foot, tetanus 7th day, death 3d day ;
222,** splinter of wood m thumb of left hand, tetanus 12th day, death 3d day ; 340,*'
wound of foot by splinter, tetanus 6th day, death 4th day ; 342,** wound of ball of
great toe with rusty nail, tetanus appeared in two hours; 343,** death in 24 hours
after appeabance of tetanus ; wound of plantar surface of left foot by nail, tetanus 7th
day, death 4th day ; 381,*^ injury of nail of thumb, tetanus 7th day, death 3d day ;
382,** wound of hand by splinter, tetanus 14th day, death in 24 hours ; 384,*' wound
of palm of hand with spiculaa of bone, tetanus 2l8t day, death 4th day; 390,*® com-
pound dislocation of thumb, tetanus 5th day, death in 32 hours ; 391,*" amputation of toe?,
tetanus 10th dav, death in 48 hours; 431,*** injury of fingers, tetanus 13th day, death
4lh day. In the preceding 50 cases, in which traumatic tetanus was caused by com-
paratively slight injuries of the extremities, 48 proved rapidly fatal, or 96 per cent;
and of the wholo nuiilbor of deaths (207), recorded, 24.14 per cent, of the entire num-
ber were caused by tetanus, which ran a rapid course after slight injuries ; whilst of
tbo entire number of cases, 420, this special class of oases formed only 11.9 per cent.
Case 348 illustrates the fact that even so slight an operation as vaccination may give
rise to tetanus ; case 355 demonstrates that the sub-cutaneous injection of Quinine may
prove fatal from traumatic tetanus in 30 hours ; and in case 373 it is shown that the
operation of ligation of the piles may be followed by tetanus and terminate fatally on
the 2d day.
It will also be seen that the time at which the symptoms of tetanus supervened after
the reception of the injury, varied within wide limits ; in some cases the disease was
developed almost immediately after the reception of the injury, whilst in others, weeks
elapsed before the appearance of trismus and tetanic spasms ; and as a general rule, the
more sudden and rapid the onset of the disease after the receipt of the injury, the more
fatal was the result. Thus in the five cases reported by Hippocrates, two appeared to
have been attacked with the disease within 24 hours after tne reception of the injury,
and one proved fatal on the 2d day, and the other on the 3d day ; a case reported in
the Medical Gazette, as occurring on the day following the injury, proved fatol on the
2d day ; a case reported by Dazelle as occurring on the 3d day, terminated fatally on the
Bame day ; in a case reported in the Die. des Scienc : Medicales, the symptoms appeared
in two hours, and the patient died in twelve hours ; in a case reported by J. B. Thomp-
son, tetanic symptoms appeared immediately after the shattering of the index finger, by
the felling of a bwrel, and the patient died iu thirty-two hours; vx tte qase reported
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386 Treatment of Traumatic Tetanus.
by Dr. Brady, the symptoius appeared in tweuty hours, and death followed in tieveoty
hours, and in another case reported by the same observer, the symptoms appeared on
the following day, and the patient died in twenty-four hours.
At the same time, some of the severest and most rapid cases 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, 146, 147, 148, 149, 158 159, 166, 170,
179, 193, 199, 211, 237, 244, 245, 282, 308, 355, 373, 382, 385, 386, 391, 392, 397.
404, 424, 431, 437, 438, 443, 446, 456, 458.
After a careftil examination and comparison of the different methods of treatment,
recorded in the preceding table, whilst it will be found to be impossible from the heruif
use of the most powerful remedies and poisons, as well as from the constant interchan|:e
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 tbc
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 physicians.
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 for the
reason just assigned, this is to a great extent impossible ; but we may express the hope,
that the medical officers of armies and navies, and civil and military hospitals, will u
far as possible, institute definite plans of treatment, and test thoroughly by carefully
recorded observations, the relative value of those remedies which are employed with
most confidence and frequency in the treatment of this disease. If such practical in-
vestigations be at the same time combined with careful obser\'ations on the symptoms
and pathology, it is but reasonable to believe that the doubt and uncertainty which ha^
throughout the entire history of Medicine, involved the therapeutics of this dreadful
disease, will be gradually, but surely dissipated, and physicians will be enabled to adopt,
with some approach to certainty, that plan of treatment which will promise the hi};heht
and best results to the patient.
The following practical conclusions may be drawn from the preceding facts :
1. An important advance in the treatment of Traumatic Tetanus would be made if
it were possible to institute efficient measures for the arrest of the disease in its earliest
stages. Lassitude, restlessness, great depression of spirits, an uneasy sensation aboat
the prsecordia, cold chills, and an uneasiness about the throat, leading the patient to
imagine that he had caught cold, slight stiffness of the muscles of the jaw, and twiu-h-
ings of the muscles of the injured limb, have justly been regarded as premonitory syojp-
toms of this disease, and it is important that decided and efficient measures should be
devised for the aversion or arrest of the attack.
Recently the following case came under my treatment in private practice, in which
an opportunity was afforded for the inatitution of measures designed to arrest the int
symptoms of Traumatic Totaous,
Cask 481. — A geDtleman, age 30, wblUt stooping down in his yard with a hen in his baoJ
which he had just caught, was attacked by a spirited game cock, which drove one of hi«loag»
sharp spnrs into the posterior surfaco of the fore-arm, in the muscular space between tbc
ulnar and radius, just below the elbow-^jiaint, Tiie arm commenced to swell immcdialclv.
«nd in tweWe hours the patient suflferQ^ severe pain in the injured arm, with twiicbinffs of
the muscles. Upon the following day ^^e nervous symptoms increased, with lassitude, rest-
lessness and great depression of spirits. Upon the evening of the second day the paUent
complained of uneasy sensations iiK the throat, with Iwitchiuga of the muscles of the jtv.
arm and leg of the side upon wbi<^ the injury hfvd b.eei?^ ij^ceived. la attempting to wilk tbt
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Treatment of Traumatie Tetanus. 387
tptfmi were so severe as to torn the patient violently around, and almost to throw him
down.
The local application of the Tincture of Iodine, and the introduction of a tent smeared with
Iodine ointment into the wound, (during this operation the patient fainted), established f^ee
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 foar 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 often
days, all symptoms of Tetanus disappeared.
• A similar plan of treatment was successftilly pursued by the author in the case Of
his own child, Fannie Polk Jones, SBt. four years, who was bitten June 10th, 1875, by
a pet 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 limbs 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 also adminis-
tered internally after the bowels were evacuated. The poultices were large and renewed
eveiy 4 or 6 hours. Under this treatment the spasms entirely disappeared in the course
of 5 days.
The local measures which appear to be most suitable for the arrest of Tetanus in
the earliest stages, are :
a. Counter irritation, with the Tincture of Iodine and Ointment of Iodine applied
within and around the wound. This application should be followed by warm
poultices of flaxseed or bread and sweet milk, to which Tincture of Opium should
be 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
Iodine as a local application to such wounds of the extremities as are known to be most
frequently followed by Traumatic Tetanus, as penetrating wounds of the hands and
feet inflicted by splinters, glass and rusty nails. When poured directly into the wound,
even within a few moments after its reception, it produces no increase, but rather a
diminution of pain. The application should be repeated every day, or every other day,
as long as the wounds are painful and inflamed. In dissecting wounds vAbo I have
fbund no agent superior to the Tincture of Iodine for the arrest of the poisonous action.
In some cases a saturated solution of Carbolic Acid in Alcohol may be used as a local
application immediately to the wounded surfaces. An ointment composed of two
drachms each of the Tincture of Iodine, saturated solution of Carbolic Acid in Alcohol,
and Tincture of Opium, mixed thoroughly with from one to two ounces of Simple
(Vrate, has proved in my hands a useful application to wounds of this description.
An efficient sedative application to the surface of the injured extremity and to the
back over the r^on of the spine, will be found in a liniment composed of equal parts
of Chloroform, Uum Camphor and Tincture of Opium, mixed with from two to four
parts of Olive Oil. The Camphor should first be dissolved in the Chloroform and this
solution mixed with the Tincture of Opium and Olive OU. The injured limb may be
rubbed with this, and also enveloped in a piece of soft lint saturated with it.
L The Careful Removal of all Foreign Bodies from the Wound. — The
importance of a thorough examination of the wound and the removal of all foreign
bodies, was forcibly illustrated during the recent civil war, by the following cases, which
were treated in the General Hospital, at Charlottesville, Virginia:
In t^e first case, aft«r 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-
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388 Treatment of Traumatic Tetanus,
ner passed readily through from the point of entrance to that of exit, and henoe the
extraneous body was not discovered during life. In this case the spasms 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 spasms being oonfined
to the wounded limb. After the removal of a piece of cloth from the wound of the
leg, the patient recovered. It appears to be a fair inference that if, in the first esse,
the piece of leather had been removed from the arm before the spasms became genen),
the patient would, in like manner have recovered. Such cases support, in the clearest «
and strongest manner, the theoi^y 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 firon
thence propagated to the ganglionic cells of the entire spinal axis.
c. Actual Cautery. — The application of the actual cautery to the wonnded sur-
face appeared to be attended with beneficial results in certain cases of traumatic tetanus,
and Baron Larrey was the most strenuous advocate for its use. Cases 95, 96, 97, 98
and 99 illustrate the beneficial effects of the actual cautery. It is probable, howefer,
that the Tincture of Iodine, and the saturated solution of Carbolic Acid in Alcohol will
accomplish as efficient and satisfactory results, and with less pain and incoovenieiiee to
the patient. In case 342, the application of the actual cautery (a heated poker pressed
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 m the
earliest stages, before the spinal axis has been seriously involved, been attended with
apparent benefit in arresting the farther progress of the disease.
8uch 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 doabtfal
whether amputation, section of the nerve and the actual cautery will materially alter
the progress of the disease. We have carefully recorded the historical fiicts relating to
section of the nerves and amputation, as proposed by William Cullen and practiced by
G. Hicks, Baron Larrey and others. (See cases 60, 91, 93, 94, 112, 118, 132, 137,
172, 178, 181, 228, 257, 266, 329, 338, 343, 345, 356, 361, 367, 370, 371,372,385,
402, 447, 470). In the employment of such measures, the physician must be got-
erned by the general symptoms, as well as by the nature and position of the wouikL
2. Absolute rest of the injured part; and quiet rest of the patient in a dark
room of regulated temperature. All draughts of cold air, and all extremes of beat ind
cold, as well atf sudden changes should be avoided. The strictest quietude should be
insisted upon. If the patient has been accustomed to the use of tobacco in any form
or mode, it should not be discontinued. It is evident that in certain cases the severity
and violence of the tetanic spasms and contractions, will preclude the use of Tobacco i«
chewing or smoking.
3. The bowels should be kept open by eflficient purgatives, as Croton Oil, Caloniel,
Castor Oil, Epsom Salts, and the compound Cathartic pill of the United States Ph•^
macopoeia. The action of the purgatives may be promoted by the use of Enenw.
Infusion of Tobacco may with benefit be combined with the clyster. A simple, bat
efficient enema may be quickly and extemporaneously prepared, by mixing one fluidoonee
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 infiwoa
of Tobacco be employed as the vehicle for the purgatives administered by the recton,
half a drachm of the dried leaf, should be boiled in a pint of water and strained. The
purgatives above indicated may be added to the infusion of Tobacco, or it may be
administered alone. The infusion of Tobacco may be employed twice or three times.
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Treatment of Traumatic Tetanus. 389
daily, but iu effects should be carefully watched ; and its depressing action upon the
heart and circulation generally, counteracted by stimulants and nutritious diet.
4. The strength of the patient should be sustained throughout the disease, by simple
but nutritious diet, consisting chiefly of milk, milk punch, beef tea, egg-nog, boiled
nulk and rice, arrow root and thick corn and rice gruel.
When Traumatic Tetanus is fully developed, the physician should ever bear in mind
the important, facts, that the greatest sources of danger are from sudden arrest of respi-
ration from spasm of the respiratory muscles and epiglottis, and from the continuous and
progressive exhaustion of the powers, consequent upon the continuous expenditure of
•the nervous and muscular forces, the loss of refreshing sleep, and the imperfect nutrition
of the body, consequent upon the great difliculty in many cases, of taking nourishment.
In those rapid cases which prove fatal, in the course of from one to four days after the
onset of the disease, the caiuso of death is most generally asphyxia; 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 powers 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
alcoholic stimulants ; when asphyxia occurs, artificial raspiration after the method of
Marshall Hall, should be instituted.
5. In the constitutional treatment of Traumatic Tetanus, those remedies should be
employed, which exert the most decided sedative effects upon the spinal 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, Extiact of Indian Hemp, (Extractum
Cannabis Indicae), Calabar Bean, Sulphuric Ether, Chloroform and Hydrate of Chloral
and Bron)ide 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
absolutely impossible to estimate fully its value in the treatment of Tetanus. It cer-
tainly fails in many cases to alleviate or to arrest the disease, and it may be a ((uestion
whether the enormous doses in which it has been used in the treatment of this disease,
may not have increased the rate of mortality. Opium may be administered with good
effects in conjunction with the Hydrate of Chloral, in doses vairing from half to one
grain, every two, three or four 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
over a longer period of time. The dose of the Hydrate of Chloral should be carefully
n^ulated in accordance with its effects, and the peculiarities of the constitution of the
patient. In most cases from 10 to GO grains, at regular intervals of one, two, three or
four hours, according to the urgency of the symptoms, will be found to produce efficient
results. Bromide of Potassium has been combined with the Chloral Hydrate, with
apparent benefit. Alcoholic Stimulants may be employed in conjunction with Opium,
Hydrate of Chloral, Chloroform and other remedies, with benefit, especially if given in
sufficient quantity to produce sleep. Pure Alcohol, properly diluted, is perhaps, prefer-
able to the more common liquors vended in immense quantities and largely adulterated
with highly injurious and even pobonous 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 chronologically,
nffords conclusive evidence that important advances have been made in the treatment of
Traumatic Tetanus ; thus, if the table be divided into two ecjual portions in the first
210 cases recorded, the recoveries numbered 91 and the deaths 119, giving a per cent,
of 59.0 deaths, or one death in 1.77 cases : in the second series of 210 cases, the recoveries
numbered 122 and the deaths 88, giving a per cent, of 41.9 deaths, or one death in
2.38 cases.
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390 Treatment of Traumatie Tetanus.
Iq the first series of 210 cases which* brought the clinical history of Trannutie
Tetanus down to or about the close of the year 1840, the chief remedies employed were,
Blood-letting, Mercury, Opium, Tobacco, Belladonna, Turpentine, Croton CHI, Tarttr
Emetic, Camphor, Musk, Assafootida, amputation, section of nerves, irritant and caustic
amplications, blisters, actual cautery and cold affusion. The most valuable remedy io
this series appears to have been Tobacco administered in the form of infusioa 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 cases, when thus
administered.
In the second scries, 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 diiefly
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 nahrttioas
diat and alsolo'ic stimulants.
4. The free use, at regular intervals and in accordance with the nature and severitj
of the symptoms, of such remedies as Cannabis Indica, Calabar Bean, Chlorofbrm and
Hydrate of Chloral.
Chloroform. — In the first case reported, we were led -to attribute the fi=iVorable issoe
chiefly to the Chloroform administered internalljf. The Sulphuric Ether and Opion
were, without doubt, beneficial, especially as the strength of the patient was sapported
by nutritious diet and stimulants. It would appear that Opium and Chlorofonn
mutually aid each other when given in conjunction in traumatic tetanus. The researches
of Professor Claude Barnard, at the College de France, have shown that Morphia and
Chloroform may be administered with benefit in combination or alternately. As it is
of the utmost importance that the strength of the tetanic patient should be maintaioed
by every means, and especially by refreshing sleep, the physician should be careful to
devise the most efficient means for the furtherance of this end. According to Profeesor
Claude Bernard, Morphia produces sleep, but at the same time it brings on a pecnlar
state of excitement. If Chloroform is inhaled by an animal previously narcotised by
the alkaloid, only an extremely small dose is necessary to produce anaesthesia. On the
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 to
explain this theoretically. Professor Bernard admits that the sensitive cellule most be
in contact with blood mixed with a certain quantity of Chloroform, in order that anaes-
thesia may take place. As the anaesthetic substance is being constantly eliminated,
sensibility shows a tendency to recur, but Morphia prevents sensibility, ju^ in the
degree necessary for the production of anaosthesia by the Chloroform which is left. Oj
the other hand, if Chloroform protracts and re-establishes the somniferous action of
Mqrphia, at the time when it ought normally to cease, it is because the sensitive irrita-
bility, which is the source of reflex action, being heightened by Morphia, places the
animals in a condition of impressionability peculiar to Chloroform. The action, at once
somniferous and exciting in Morphia, does not appear to Claude Bernard to justify the
view of a double substance contained in the alkaloid, and producing this two-fold effect:
he believes in the chemical unity of Morphia, and explains this double effect by two
stages of the same physiological action, which may vary in duration or inten.sity, totJ
thus produce certain differences.
It will be found, upon examination of the preceding table, that Chloroform was used
in the following cases: 293, 294, 295, 305, 308, 309, 311, 314, 317, 325, 331, 33:?,
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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, io which Chloroform was employed chiefly by inhalation, and in con-
jaDction 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 occurred in military practice ; but notwithstanding this, the rate of mortality under
the use of Chloroform was lesi than 50 per cent., or more exactly, 46.6 per cent.
After a care^l examination of the eflFects 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 admiobtered by inhalation, and that this e£Fect is produced more rapidly than by
sab-cutaueous injection, was illustrated by a series of experiments which I instituted on
various animals, and from which I extract the following :
Experiment 186: Illustrating tlie Action of Chloroform on Warm-blooded A ninial^ by
Stib' Cutaneous Injection and Inhalation.
Angosta, Ga., June 16, 1860 : Large, well conditioaed cur dog. Temperature of Atmosphere,
79^ F.; temperature of rectum of dog, 40^.66 C. Action of heart in a state of rest, 66 per
minute; respiration, 20 per minute. When first tied and secured for the experiment the dog
made violent struggles; the thermometer was introduced into the rectum just after these
itruggles, 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
10 40^.62 C, and remained stationary at this point.
Two and a half iinidounces of Chloroform were injected into the sub-cutnneous tissue of
the right thigh and fore leg of the same side. Simultaneously with the injection of the
Chloroform the dog commeneed to struggle. During these struggles there was a rise in the
thermometer, and 25 minutes after the injection of the chloroform, the temperature of the
rectum was 41** C, showing a rise'of 0°.38 C. after the injection of the Chloroform. 40 min-
utes after the injection of the Chloroform, the dog was restless, barked and prowled. Action
of heart increased, 120 beats per minute; respiration 12 per minute, full and labored, and
occasioDally stertorous. Temperature of rectum, 41^.1 C. Chloroform to the amount of one
and a half fluidounces was again injected into the sub-cutaneous cellular tissue of the legs,
without 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 fluidounces of
Chloroform had been injected into the cellular tissue of the right thigh and leg.
One fluidounce 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
weak, bat not at all insensible, and could not be induced to lie down. Occasionally there
was a sudden 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,
75 miQQtes after the first injection of the Chloroform, a sponge saturated with Chloroform
was held before his mouth ; the effects were almost instantaneous ; in less than one minute
he 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
heart was 112 per minute and very feeble ; respiration 50 per minute, quick and short; in 10
minates after the commencement of the inhalation of the chloroform, the action of the he^rt
and the respiration had ceased; the temperature of the rectnih had remained stationary
during the short period of coma, and at the moment of death stood at 40^.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
minutes after death, stood at 40°. 6 C; 75 minutes after death, temperature of rectum, 39**.l)
C; 195 minutes after death, 38°.4 C.
Autopsy 195 minutet after death. — The blood, -after death, presented a cherry red color, and
coagulated perfectly after its abstraction, in two minutes, and the coagulum was firm. On
exposure to the atmosphere the blood rapidly changed to a bright arterial hue ; under the
microscope the blood Qorpuscles presented a normal appearance ; in some instances they
assumed a stellate] shape^ Rigor mortis complete. Interrupted magacjtQ-clcctric currents
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392 Treatment of Traumatic Tetanus.
had no effect upon the voluntary and involuntary muscles. Muscles of all parts of ihc body
of a deep red, purple and crimson color, and filled with blood ; when cut the blood poured
from the cut muscles. Blood-vessels of brain filled with blood. No coagula were found ia
the blood-vessels of.the brain. Blood-vessels of messentery filled with dark blood. Bladder
distended with urine. Mucus membrane of stomach and intestines redder than usual.
Lungs considerably engorged with blood, but much less so than the lungs of a dog killed at
the same time by a rattlesnake. The appearance of the muscles 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-
ever issued from the muscles of the latter.
Expenmait 187 : Illustrating Action of Cfdoro/orm,
Augusta, Gn., June IGth, 18C0. Subject of experiment, small kitten, two months old. Tern*
pcraturc of atmosphere, 81° F.; of rectum of animal, 39°.4 C. Administered chloroform bj
inhalation. The kitten became insensible in a few seconds. The temperature of the recton
began to descend immediately after the establishment of the coma, and in 4 minutes after the
first inhalation, stood at 39° C. The action of the heart and the respiration ceased 4 minatti
alter the inhalation of the chloroform.
53 minutes after death, temperature of rectum, 35°,2 C; 183 minutes, 31® C.
The microscopical examination of the blood after death, revealed no distinct alteratiooi in
I he blood corpuscles. The colored blood corpuscles in this young animal were distiectly
nucleated.
Expp'imentB 188, 189, 190, 191, 192, 193, 194, 195, 196, 197, 198, 199,200:
repetition of preceding experiments, with similar results.
When administered by inhalation^ Chloroform is rapidly absorbed by the pnlmoaarj
surface, enters the blood, and is conveyed in a very few moments to the central nervoBs
ganglia, and exerts an almost immediate effect upon the ganglionic celb. In mo8t cases,
when the inhalation ceases, the effects, when fresh air is freely supplied, pass off ia t
comparatively short space of time. In some cases, hpwever, obstinate vomiting, with
complete loss of digestive power, and great prostration of the muscular and nerrous
systems, continue ibr periods of time varying from a few hours to thirty-six hours. Ia
experiments which I have instituted upon myself, with the inhalation of Cbloroibna,
the nausea, vomiting, and nervous prostration, has fVequently oontinaed for more tbta
twenty-four hours. In my own case. Chloroform, when inhaled, appears to prodaoe
great irritation of the mucus membrane of the stomach, attended with the most dis-
tressing nausea, and th3 vomited matter consists of a clear aoid mucoid fluid, oflea
discolored by bile.
When Chloroform on the other hand is administered internally, it is slowly absorbed,
and its depressing effects upon the cerebro-spinal nervous system, are leas violent and at
the same time more lasting.
As Chloroform exeres a powerful sedative effect upon the brain, inducoe auaasthcsta
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 adapted to oovn-
teract the state of ganglionic excitement of the spinal system with the grottly exagger-
ated reflex actions, characteristic of Traumatic Tetanus. And it would appear that ia
this disease, much larger doscQ may be borne with impunity than in any other malady,
with the exception, perhaps, of Hydrophobia and certain forms of Neuralgia, attended
with incessant pain. In a case at Guy's Hospital, of painful neuralgia, more than ooe
pint of Chloroform was used in twenty-four hours. It should, however, be borne in
mind, that this remedial agent sometimes arrests the action of the heart, or in snne
other manner suddenly destroys life; and also, that when used freely by inhalatioo,
without propcf attention to the admission of air into the lungs, it may accumulate ia
the blood, and ako 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 tlie mosdes*
we must administer it with due caution. It is desirabjQ iu T^t^UU3, to preserve the
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Treatment of Traumatic Tetanus. 393
strcDgth by the most efl&cicnt and judicious means, on the ground, that every day of
prolonged life gives 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
sedative to the nervous 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 ooma — the pupils
were dilated, the breathing stertorous, the skin cold, the pulse imperceptible, and there
were general convulsions. He recovered in five days. (Med. Gaz., vol. xlvii, p. 675).
>I. Aran, has recorded a case in which a quantity, supposed to be from eight to ten
drachms, was swallowed in mistake by a man ; the first symptoms were a burning sen-
sation, with ineffectual 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
insensible 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 Th<5rap., xlii, 290). A private in a Cavalry r^mcnt
in the United States Army, swallowed nearly two ounces of Chloroform. He was seen
ten or fifteen minutes afterwards ; 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
for a! time he continued to get woi*se, the face becoming purple, while the pulse was
intermittent and hardly discernible. Two hours and a half after taking the poison,
however, a gradual improvement commenced, but sensibility did not return until four
hours later. For several day^ he continued to suffer from great irritability of the
stomach, and eventually he had an attack of jaundice. (Am. Jour. Med. Sci., October
1857, p. 365).
Alarming symptoms and even death have been produced by much smaller doses. A
lady swallowed half an ounce of pure Chloroform ; in five minutes she was quite insen-
sible, generally convulsed, the jaws clinched, the face slightly flushed, the pulse ftiU 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
short 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
io the case of a child only four years of age, it is evident that it is much less potent in
its effects when administered internally ; for in one instance, the patient dicKl in one
minute, in which only SO drops had been inhaled in vapor, and in another, so small a
quantity as fift^n or twenty drops, proved speedily fatal. These quantities are relatively
small, when it is remembered that the cohesion between the particles of Chloroform is
so feeble, that it yields a greater number of drops from a certain measure, than any
other medicinal liquid ; one fluid drachm yielding on an average 240 drops. With the
exception, perhaps of Prussic Acid, Cliloroform operating through the lungs, has
destroyed life more rapidly and in smaller dose than any poison known ; and from the
fact just recorded it appears to be at least ten times more potent^ when administered by
inhalation than by the stomach. According to Dr. B. W, Richardson, of London, the
proportion of deaths from Chloroform will be about one in 1500 to 2000 cases of its
administration by inhalation. Dr. Richardson recognizes only one bodily condition ^ as
fiO
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394 Treatment of Traumatic Tetanus.
a distinct source of increased risk in the administration of Chloroform bj inhalaiioD ;
and that is, a heart with its right ventricle dilated, and attended with bronchial oon^h
and dilatation of veins. Experiments have shown that the anaDsthetic left the ma8cles»
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
make a decided impression upon the cerebro-spinal system, but also to sustain that
impression for days, and even weeks, it is best to employ Chloroform by internal admin-
istration. At the same time we have recorded facts to show that it must be employed
with caution, even in this comparatively harmless mode. It is now fortunate that a
comparatively soluble and tasteless substance, capable of yielding Chloroform by \u
decomposition in the blood, is within the reach of every physician for the effective
treatment of Traumatic Tetanus. In the employment of Chloroform and Chloral
Hydrate in Traumatic Tetanus, it should be borne in mind, that in the primary impres-
sions upon the nervous centres of animal life, sensibility to pain is abolished before
consciousness, and a decided effect upon the ganglionic cells of the spinal cord may bu
produced without any suspension of consciousness.
The vehicle in whic|i Chloroform is administered in Tetanus should be carcfullj
selected, for if it be given in simple water, a portion sinks to the bottom of the Yesseh
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 iu
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
mucilage of gum Arabic and sugar or syrup, in the ordinary form. Chloroform maj
also be suspended in water, by means of the yolk of egg, and syrup of Orgeat. (Syrupiis
Amygdalss).
When one part by weight of Chloroform is mixed with eight parts of Alcohol, the
resulting solution forms stable solutions with water, wines or syrup ; and this mixture i»
specially useful in Tetanus, as the alcohol is not contra-indicated. I have thus emplojcd
Chloroform in the treatment of this disease. Glycerine also forms an admirable vehicle
for the administration of Chloroform ; a mixture composed of equal parts of cacb,
readily dissolves in water.
When used hypodermically. Chloroform quickly allays pain, quiets spasms, awl
induces sleep ; but the objection to this mode of medication is, that it tends to give rise
to local inflammations, attended with pain, redness, swelling, and tenderness on presrarf.
As a local application, and counter-irritant, applied freely along the spine, Chloroform
has proved efficacious in Traumatic Tetanus, and also in the Tetanus of new-born
children (Trismns Nascentium.) In the cases demanding frequent local applicatioiis,
and especially in the Trismus of infants, it may be used advantageously in combinatioo
with Camphor and Olive Oil, thus: R. Chloroformi fgi; Pulv. Camphorao ^: Olei
01iv8B fgiii : dissolve the Camphor in the Chloroform, and mix with the Olive Oil ; use
as a local application to spine and injured extremity, repeating at short intervals, and
also applying by means of lint and flannel saturated with the mixture.
Sulphuric Lther, — The tendency of Chloroform to depress the vital powei^, may in a
measure be counteracted, by combining it with Sulphuric Ether, for whilst this agent ads
in moderate doses as a diffusible stimulant, at the same time it has a similar effect to
Chloroform, in producing Anaesthesia, and relaxation of muscular spasm, and dcpnwion .
of the reflex function of the spinal cord.
Sulphuric Ether in conjunction with other remedies was employed (chiefly by inkah-
Hon,) in cases 87 and 88, 844, 248, 291, 292, 295, 299, 300, 301, 302, 303, 308, 309,
330, 836, 453. Of thesie 17 cases, 10 were cured and 7 died, giving a mortality of
fortyTone per cent, or one death in 2.4? oases.
Sulphuric Ethey may be administered in Traumatic Tetanus, either internally or bj
inhalation. It is well known that tkis agent is capable of producing complete jiraljsL*
of the nerves of a^uaatxQp. ; and t^his result is especially valuable in tl^e treatm^t of
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Treatment of Traumatic Tetanias. 395
Tetanus, in which disease, the slightest impression upon the nervous 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 fa^uces, to adminbter these remedies internally ; and in such cases
fjood <»n 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
such 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 aeration 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
system, 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 : lUmtrating the effects of Sulphuric Ether hy InJialation.
Aagusta, Ga., January 28th, 1861. Large car dog, subjected to inhalation of Sulphuric
Ether. The effects resembled those often observed in human beings. At one time tlie dog
growled, and barked, and endeavored to bite ; then he whined, and moaned, and struggled
Tiolentljr. 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 by the Ether.
After subjecting the dog to the action of the Ether for one hour, he was released, and placed
upon the floor; be was unable to stand ; endeavored to rise, and fell heavily upon his side ;
&H the muscles were in a tremulous motion, and when he would 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,
&nd down would fall the dog, as if struck by lightning. These effects gradually disappeared,
aod 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 moscular motions,
indicated clearly the action of the Ether on the motor cells and reflex function of the spinal
cord.
EfeeU on the Temperature. — Temperature of atmosphere 46** F. Temperature of rectum of
•log, before the inhalation of the Ether, 39*^.6 C. The temperature of the rectum remained
stationary 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
minutes more lost 0®.2 C.
Notwithstanding the struggles of the dog, the temperature still continued steadily to descend,
^Qd at the end of one hour after the first inhalation, stood at 38^.6 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
six minutes stood at 39^ C, and in 19 minutes more, (25 minutes after the cessation of the
inhalation), the temperature of the rectum was 39°. 4 C, and remained stationary at this
point until the dog completely recovered his strength.
It is worthy of note, that in the preceding experiment, Sulphuric Ether depressed
the animal temperature ; and hence this agent may prove of value in the treatment of
^li«)8e cases of Traumatic Tetanus in which there is a marked elevation of temperature.
Experiment 202 : Illustrating the Effects of Sulphuric Ether^ when injected into the
Blood
Aognsta, Oa., January 28th, 186l! Injected into the jugular vein of a young, active, female
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396 Treatment of Traumatic Tetanus,
fToat, six flniddrachms of Sulphuric Ether. In a few moments after the injection of the
Ether, the goat struggled violently, and bleated, as if in great distress ; these struggles con-
tinued for three minutes, gradually becoming more feeble, until 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.
Effecta on the Temperature. — Temperature of atmosphere, 46° F.; temperature of rectum of
goat, 39«.5 C.
The temperature of the rectum remained stationary during the strug'gles 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 mUotes
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 fnllj
established. 135 minutes after this observation, and 270 minutes after death, temperature of
rectum 31°.25 0.
Effecta 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 simultaneous at
least, if not anterior to the dilatation of the pupils and the shivering of the muscles.
Autopsy 4} h(mri after death. — Blood-vessels of dura-mater and pia-mater of brain filled wiib
blood. Blood-vessels of brain and the prolongations of the pia-roater into the ventricles of
the brain greatly congested with blood. Blood in the veins of the brain presented a cbeny
red, rather than a dark venous hue. The ventricles of the brain, as well as its substaacf,
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 longs
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 stronfr
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 coagulum, which was
about the size of a pigeon's egg, in its largest portion, was found in the right auricle, aoJ
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 coagu-
lum was also found in the aorta. These coagula all 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 trunks. In
these respects, as well as in several others, the effects of Ether were far different from ihwe
of Prussic Acid. In poisoning by this acid, the large veins are, as far as my experiencf
extends, loaded with dark, almost black, uncoagulated blood.
The blood corpuscles of this goat, killed with Sulphuric Ether, presented, in many cas^^^
marked alterations ; they were shrivelled in some cases, and in others stellate. Ether exhale<l
from the blood in all parts, and from all the organs and tissues. The color of the mosclcs
was natnral, 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 iBto
the blood caused a descent of the animal temperature.
The marked powers of Ether and Chloroform as solvents of fats, without doubt, ire
active in the production of the peculiar phenomena induced by their introduction into
the circulation and distribution to the nervous elements. As the cerebro-spinal vA
sympathetic nervous systems are largely composed of fats, and of a peculiar phosphoriied
fat, it is possible that a portion of the peculiar phenomena resulting from the actioe of
Chloroform and Ether may be due to the direct solution or disturbance of the phjskal
constitution and chemical relations of the fats, and especially of the phosphoriied fiitof
the ganglionic cells and commissures. As in the case of Chloroform, so also in the
action of Sulphuric Ether, it is far more potent when employed by inhalation. Half «n
ounce of Ether, or even less, inhaled in the form of vapor, is capable of producing i
more powerful eflfect on the nervous system than one or two ounces taken into tk
stomach. The difference appears to be due to the greater absorbing surface exposed by
the lungs.
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Treatmeni of Traumatic Tetanus. 397
As far as my experience extends, no better combination for internal administration
bas 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 ejrjr, or in brandy or milk, or in any form of alcoholic stimulants, at regular
intervals, according; 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 aa 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, 408, 405, 406, 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 Calabar 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 arc, in effect, employing Chloroform in a
pleasant and efficient form ; for M. Pcrsoune 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
Chloroform, 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
inferioT 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 oflen prolonged, is light and refreshing, and no
unpleasant after 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 case
we should administer it cautiously at first, beginning with not larger doses than from 20
to 60 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 cerebro-spinal meningitis : R Chloral Hydrate, .^iv ; Potassii Bromidi, Ji ; Syrupi
Simplicis, f Jvi ; mix ; tablespoonful every one, two, three or four hours, according to
the nature and intensity of the symptoms.
Oroton Chloral Hydrate^ as far as my knowledge extends, has not yet been
employed in the treatment of tetanus, but its physiological effects would indicate that
it may prove equally as effective as Chloral Hydrate. The relatively small dose of the
Croton Chloral Hydrate may also be regarded as favorable te its use in tetanus.
Chloral 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
local irritation, gangrene, and more or less purulent infiltration.
Alcohol^ in large doses, (cases 109, 110, 111, 283, 472), produced effects in some
respects similar to those which characterize the action of Chloroform, Hydrate of
Chloral and Sulphuric Ether, viz : relaxation of the^muscles and profound sleep. In
these 5 cases, 4 recovered and one terminated fatally, giving a mortality of 20 per cent,
or one death in 5 cases. There appears to be no question as to the value of alcoholic
stimulants in the treatment of this disease, as has been shown by the observations of
Carrie 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
conjunction with such remedies as Opium, Chloroform, Sulphuric Ether and Chloral
Hydrate. Alcohol, in large doses, reduces the animal temperature, arrests to a certain
extent the changes of the tissues, diminishes the motor and reflex powers of the Spinal
cord, promotes sleep, and acts as a nutriment.
Opium. — No remedy has been employed more frequently than Opium in the treat-
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398 Treatment of Traumatic Tetanus.
meQt of Traumatic Tetanus. An examination of the table will show, that in one form
or another, and in various modes, it was employed in a majority of cases, even wkeo
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 impoflsi-
ble to demonstrate, by actual statistics, the value of this drug. And it is a qnestioD
whether the immense doses in which it has been so often administered, may not have
been absolutely injurious ; and whether much better results would have been obtained
by a more moderate use of this powerful and valuable agent. It would appear from
the insensibility of many tetanic patients to the action of Opium in immense doses, that
a peculiar condition must characterize the cerebral nervous elements, as well as those of
the spinal axis ; for 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 strongly
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 cerebro-
spinal nervous system, and at the same time to militate against the theoiy that tetanus
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, be inevitably
led to ascribe the symptoms of rabies also to this mysterious but convenient irritation,
but the one preceding fact of a virus introduced does away with all difficulty towards
seeing in the strange nervous symptoms, not an irritation merely, but 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 raWd
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 glaiidB laid
on the wounded surface, but the blood itself, venous and arterial, are capable of com-
municating the infection. Dr. Thomson still further endeavors to establish the
ha3matic pathology of tetanus by the well known fact, that we can produce somethini:
very much like tetanus, at will, by charging the blood with a ready made poison, as
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 must be conceded, tliat a
mere analo<!y 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 aooooot
for the arrest of tetanus in certain stages, by the application of the actual cautery to the
injured nerve and surrounding parts, by amputation and by section of the injured
nerve, op the theory that the disease originates in the injured nerve or nerves, and is
propagated along the nervous tracts centriftigally to the spinal axis. And the aecuncy
of this view has been sustained by the pathological changes which have been frequently
witnessed in the injured nerves, and in the spinal cord itself. If the disease be mani-
festly due to the existence of a Materies Morbi, existing in the blood, and generated
in the diseased part, or in the system, under certain circumstances, the duty of th«
physician should be to seek some remedy which would displace and expel the poison of
tetanus from the blood, and he could b^t explain the curative effects of such an a«»eiit
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 patient,
and the phenomena of the disease, as well as the characteristic alterations are bwt
explained without any such hypothesis, the physician acts most rationally and philo-
sophically in the employment of those remedies and measures which are capable of
arresting, controlling and subduing the state of increased and exalted activity of the
nervous elements primarily involved.
While on the one hand. Opium is valuable in the treatment of Traumatic Tetanus, bj
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Treatment of Traumatie Tetanus. 399
its power of diminishing muscular force, and the susceptibility of the cerebro-spinal
system to external impressions, and of rendering the nervous 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
derangdment and irritation of the cord, analogous to that characteristic of TetanuF.
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
iu Europe after its introduction from America, about the year 1559, was only surpassed
by 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. IJscd externally, it was the great remedy resorted to
by the nations of the Spanish Main for Tetanus, and in the Transactions of the Medico-
Chirurgical Society of Edinburg, two cases of trismus 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 imprecate the water of a tepid bath.
In the " Trial of Tobacco,^^ written by Edmund Gardiner, about 1648, it is said that
'* the suffiimigation of tobacco being takpn, is a good medicine for starkness or stiffness
of neck called tetanus, and for any pains or aches in the body, 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
disease it has been employed as an injection and highly extolled. Mr. Duncan, of
Grenada, publbhed a successful case, thus treated, which was detailed in the 42d num-
ber of the Edinburgh Medical and Surgical Journal, which excited considerable inter-
est at the time. In 1807, Dr. Huggan suggested Tobacco as 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 of cases (125, 126, 132, 146, 153, 157,
166,167,169,170,173,182,219, 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 recovered and 11 died, giving a mortality of 47.82 per
cent, or 1 death in 2M cases.
According to Mr. Travcrs, the infusion of tobacco, injected per 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 onset of the disease. It
produces nausea, perspiration and sleep, often 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 depres-
sing 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
of brandy 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 nourish-
ment and cordials, oftener than from want of proper medicines.
The testimony of Mr. Curling as to the value of Tobacco in the treatment of Tetanus,
is equally ql^r ^i^d (Jecidcd, Of nineteen cases, in the Table of 5lr. Curling, in which
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400 Treatment of Traumatic Tetanus.
Tobacco was employed, nine recovered. Mr Curling concludes his obscr\'ations upon tbi>
agent, in the following manner :
'< I conceive that more has now been advanced in proof of the efficacy of tobacco, than caa
be adduced in favor of any remedy yet resorted to. I have not, indeed, succeeded in finding a
single case, in which, being fully and fairly tried, before the powers of the constttution bad
given way, it has been known to fail. Many more cases have been cured by the use of opian,
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 oftener 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 an
argument, 'Melius anceps reroedium, quam muUum,' it may be justly. alleged that only tbr
rash abuse, and not the judicious exhibition of tobacco, can aflbrd ground for apprehension.
1 would not say that tobacco is a remedy, which, even resorted to at an earlj period, and
employed with judgment, will always avail ; for I believe that in its worst forms, Tetanus 15
a disease of too destructive a nature to be arrested by any treatment whatever ; but I hoU
it to be the best remedy that we at present possess, and one which will generally be fonod
capable of diminishing the severity of the acute disease, and often of subduing it altogether.
** The doses should be regulated by the tige^ habits and constitution of the patient, who,
during its use, must be supported by a nourishing diet, tonics, wines and other sUmulaou.
The Carbonate of Ammonia, in particular, is well adapted to counteract the extreme prostra-
tion sometimes 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 increased
in strength, in proportion to its effects. A stronger infusion will be necessary for those who
arc accustomed to the use of this plant as a luxury. Unless in Chronic Tetanas, baths is-
prcgnated with it are not only insufficient, but objeetionable." — Treatise on Tetanus, p. 91.
Mr. 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 v^etable oiK
the operation of which on the nervous system is unknown. He relates, (Dublia
Quart. Jour., Vol. 34, p. 172), two cases of traumatic, and one of idiopathic tetanas
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, ceesatioQ of ddi-
rium, and feeling of relief from agonizing pain, and a lowering of the pulse from 130
to 88. This case received 3 doses of one minim of Nicotine at intervals of two houn^
The second was the case of idiopathic tetauus ; it recovered. The dose was from half to
two-thirds of a drop, repeated several times a day, so that in 11 days 44 drops were t^ken.
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 oircn-
lation, the pulse being quickened 1 0 beats per minute ; profuse sweating, which exhaled
an intolerable odor of snuff, not of tobacco ; a t3ndency to deep sleep. The adductor
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 case recovered ; the
Nicotine was given in doses of 1, 2 and 2 J drops, according to the urgency of the tetanic
spasms. Ailer the administration of the dose, in 3 minutes the spasm was gone, and
the muscles relaxed and profuse sweating accompanied by a smell 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 32^ grains.
Mr. Tyrrell, as quoted by C. Handfield Joues, in his " Studies on Functional Nervous
Disorders," p. 253, records two well marked cases of Traumatic Tetanus, which be
treated by the local application of Tobacco. (Med. Times and (jlaz., 1864, Sept 24th).
Both terminated successfully. Mr. Tyrrell argues that as Tobacco is of service when
given internally, it should be more so in eccentric Tetanus, if applied locally, by para.
lyzing the nerves of the effected parts from which the irritation proceeds, and thiL
removing the cause of the spasms. In the idiopathic form, Mr. Tyrrell propose ^
remove the cuticle of the skin by a blister, and to apply a strong solution of Toba.^
to the denuded surface, and thinks that in this way, the co^ would more quickly ^
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Treatment of Traumatic Tetanus. 401
brought under the influence 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 stjuare at the back of the neck, as well as to the noso
which had been injured, and the patient was supported by clysters of Brandy, Ether,
Quinine and strong Beef Tea, given every four hours. The treatment was begun on
the 22d ; on the 24th, he 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 effect of Mr. Tyrrell's plan in a very interesting
case, which be has published in the Ed. Med. Jour., Feb. 1867. He used at first a
solution of Cavendish Tobacco of the strength of ^iv ad Oj ; at a late dat« the strength
was doubled. The case was one of great severity, and the sufferings were extreme.
Within two or thr^a hours aftjr 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 less severe and frequent, 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.
Blood-letting y Calomel and Antimony, are doubtful remedies in the treatment of
Traumatic Tetanus. The disease has been known to supervene 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 circumstances, 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
specially applicable to idiopathic tetanus. It is difficult however to form a just estimate
of this measure, as it appears to have been almost always used in conjunction with other
powerful assents, 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
eoiployment 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
quantity of Opium was augmented ; in another case. Mercury was not resorted to until
the disease had been established seventeen days ; and in still another case, 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
alone, or employed in conjunction with some trivial remedy, as the warm bath, or blis-
ters, all were 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 McGragor, in numerous trials of Mer-
cury 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 a cutaneous
eruption.
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402 Treatment of Traumatic Tetanus.
Mr. Mosely mentions that many people have been attacked in the West Indies under
a coarse of Mercury, and expresses the opinion that it has killed more than it has cored
(Treatise on Tropical Diseases, p. 478.)
Dr. Wells has related three instances of the occurrence of Tetanus, during Salivation
from the use of Mercury.
Sir Anthony Carlisle, informed Mr. Curling of two iostancjs 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 effect of Mercury had
been produced; he observes that he has 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 aft<?r
the production of ptyalism.
Mr. Curling witnessed two traumatic cases, in which some ptyalism was produced
without being followed by the slightest mitigation of symptoms. In both of them
extreme suffering was occasioned by the increased secretion of saliva. The mouth being
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 their
fingers. Treatise on Tetanus, pp. 74j 7*5,
The effects of Antimony, when introduced directly into the blood, are shown in a
striking manneo 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 majority of the cases, in which it has been
employed terminated fatally. Its power of diminishing and relaxing the muscular
force, appears to be dependent upon the nausea, vomiting, purging, and perspiration,
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 upon
the nervous system, and is liable when employed in sufficient doses in Traumatic Tetanus
to induce &tal prostration. In most of the cases in which it has acted beneficially, it has
been combined with Opium and Morphine, and it is but fair to attribute the good
results chiefly to the latter remedies.
Quinine has been employed with a fair degree of success, more especially by American
physicians, (see oases 347, 349, 351, 357, 384,) and of these 5 cases, only one proved
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 are
needed.
Woorara, The experiments of Sir Benjamin Brodie, in X811, demonstrating the
action of Woorara upon the motor nerves, the application of the resulta of Professor
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 physiologist?,
but also led finally to the actual trial of this powerful agent in Traumatic Tetanus. The
application of Woorara to the treatment of this disease was based, not only upon a
knowledge of its physiological action, but also upon its antagonistic effects to the artifi^
cial Tetanus of Strychnine, and upon the results of its use in the idiopathic tetanus of
the horse and ass. The superior value of Woorara to other narcotics, appears to consi^i
in its peculiar power of paraly^ng the motor and not the sensory nerves, and it appw^r*
that it might be so administered, as to destroy entirely the power of voluntary motioa
without imping cooscioMsness. In administering Woorara to animals laboring under
Tetanus indu<^ by Strj^phuine, Dr. Harley gave sufficient to paralyze all the urasde^.
except those of respiration. In this way he was able to, allay the tetanic spasms without
destroying the intelligence, or arresting the performance of the organic functions. And
by continuing the thus moderated action of Woorara, until the kidneys had time to
eliminate the Stijchnine from the system he had been able to save the life of the animal.
According to Dx. Harley, th^ theory of its action in tetanus is much the same. That
is to say, yon txj to keep t^e spasms from killing the paitien^ by their violence, until the
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Treatment of Traumatic Tetanus. 40i
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
. naturally much 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
counteract 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
be satisfactory, because it is based upon the supposition that a morbific material is the
cause of Traumatic Tetanus, the riolence and nature of the symptoms depending upon
the amount of the poisonous matter which acts antagonistically 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. Harley, to demonstrate its existence by noting the
effects produced upon animals by inoculating the secretions of the wound, or of the
blood or juioc 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
iU uncertainty when administered by the mouth, to its violent effects when inoculated,
and more especially to the fact, that in order to overcome tetanus it is necessary to give
an adequate dose, and an adequate dose in severe cases would be such as absolutely to
arrest respiration.
Without the greatest precaution, the remedy loill prove more dangerous than the disease.
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
of 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
case the disease was chronic, and recovery ensued. If these be added to the preceding
eight 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
employed this agent in a certain proportion of the cases occurring afker the battle of
Koniggratz ; the disease did not appear until the second week afler the engagement ; —
before Curare 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
cases which were treated with Curare five died, one, however, of pyaemia ; 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 injuriously on the spinal cord, intensifying its reflex excitability, and to the
avoidance of the excessive increase of temperature resulting from the powerful action
of 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 ■^.
Woorara was employed in cases 315, 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
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404 Treatment of Traumatic Tetanus.
on the Woorali poison, (Am. Jour. Med. Sci., July, 1859, p. 13), found that in-afew
minutes after the introduction of the poison through a wound, paralytic phenomena floon
became obvious, and the animal died without preliminary spasm or convulsion, but the
heart, instead of continuing to act after apparent death, had entirely ceased to beat, so
that it could not be excited by galvanism. They inferred that the action of the poison
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 actiona,
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.
Extract of Indian Hemp, {Cannabis Indka), Wiis employed in cases 269, 270, 271,
278, 279, 280, 282, 313, 319, 327, 346, 360, 361, 379, 386,431, 473,475,476, 477 ;
and ofthe.se 20 cases, 12 were cured and 8 terminated fatally, giving a mortality of 40
per cent., or one death in 2.5 cases. Mr. O'Brian used the resin of Indian Hemp in
seven cases, with the effect of producing almost immediate relaxation of the masdcs'
and interruption of the convulsive tendency. More than on 3 half, or four of Mr
0' Brian's cases recovered. The late Dr. Baine used the remedy in three cases, two of
which recovered. Dr. Lewis, (Edin. Med. Jour., Aug., 1859), reports a case of Trwi-
matic Tetanus in a lad, act. 13, which terminated favorably under 4 grains of Indiin
Hemp every three houra, the first being prsceded by a full, free bleeding. No toxic
effects were produced, notwithstanding that the Extract of Cannabis Indica was cob-
tinned at the same rate for three days. Skues treated a girl aet. 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 1). Allen, of Glenarm, has recently reported a case of Traumatic Tetano?,
(British Med. Jour., April 4th, 1874, p. 450), which occurred in a lad aet, 11, whose
left hand had been crushed and lacerated by cogged-wheels. Tetanus appeared on the
18th day after the injury and the amputation of the second, third and fourth fingws.
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 hours), the
violence of the symptoms gradually abated, and convalescence was established in two
weeks.
Extract of Calabar Bean 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 tennio-
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 ca.ses.
In case 398, reported by Mr. E. Watson, (Pratcitioner, 1870, p. 207), 2 grains of the
alcoholic extract were administered at one dose, and at varying intervals, and 10-6
grains were given during 46 days.
In case 399, reported by Dr. W. Harning, (Lancet, 1869, p. 834), the Extr«< of
Calabar Bean was administered by sub-cutaneous injection. In 30 day^, about tea
drachms of the Extract of Calabar Bean were injected, generally in quantities of w^
half grain. The antagonistic effect of the remedy upon the well marked trismus awl
opisthotonos was immediate and well marked. The arched back, painfully ten«
abdomen, quivering limbs, and anxious countenance, were generally relieved in fr«D
five to ten minutes after each injection, by comfortsible decubitus, a feeling of drows?
ease, and during the night by short snatches of sleep. In ca.se 402, the extract of
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Treatment of Traumatic Tetanus. 405
Csikbar Bean was administerecl, both by the mouth and by injection. The extract was
jrivcn every two hours alternately, by the skin and mouth, so that in every four hours
one jj:rain 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 40J
grains by the skin, and 49} jrrains by the mouth, making, in all, 90 J grains given in
1(» days. The reporter of this case. Dr. A. Boutfiower, (Manchester Med. and Surg.
Reports, 1870, p. 52), was led to use this remedy from the eflfeet which it possesses of
paralyzing the spinal cord, without at the sanie timo depressing the action of the heart-
to any great degree.
In case 471, reported by Mr. Ashdown, (Brit. Med. Jour., 1863, March 21st):
Calabar Bean was administered both internally and by sub-cutaneous injection. The
patient was bled to a pint on tho 2d day after the supervention of Lock -Jaw ; on the
following day he began to take i of a grain of the extract of Calabar Bean in one
flaiddraehm of water every half hour, and was supported with strong Beef Tea, Milk,
and t*ort 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 eflfeet 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 becaine less tense, and the aching of
the spine disappeared.
The pupils also contracted, and thQ pulse sank to 82. The eflPects lasted two or three
hours, and all the symptoms then reappeared. The injections were again continued
every two hours with similar eflfects. 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 Potassse were added to it. This corrected the above-mentioned ill eflfects.
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, t 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.
Dn 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
laceration of the foot, which was cured by Calabar Bean. Dr. Cunningham adminis-
tered the Extract of Calabar Bean in solution, in aq^ounts ranging from ^4th to ^th of
a grain every hour.
Dr. Fraser has shown by valuable and elaborate investigations, that the active prin-
ciple of Calabar Bean quickly 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, after the motor nerves have quite 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 concious-
ness 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 paralysis is pro-
duced, and even after death, they conduct the motor impressions to the muscles ;
Onally the paralysis deponds alone upon the spinal cord, and is due to changes aflfected
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.
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406 Treatment of Traumatic Tetanus.
From its physiological action on the cord, Dr. Fraser recom meads the Calabv
(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 Beao. 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 fittal ewes,
in one the remedy was given in insufficient quantities. This drug should, according to
Dc. Fraser, be given at the very beginning of the attjick, fur when musclee oontract
they beget a substance which excites muscular contractions, and at the beginniog 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 pow4cr, as
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. Crr. 0.920 (thirty-two grains to the fluidoooce).
The first and last of the two forms are to be preferred, as that with water deoomposei
in a few days. The Extract may be administered by the mouth, anus, or sab-cutaDecnislj,
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-cotaneoM
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-cutaneoos injec-
tion the dose of the extract should be carefully mixed with ten or fifteen minims of
water; this mixture has always an acid reaction, which is sometimes so decided as to
produce slight irritation of the cellular tissue ; but this can be avoided by carefully
neutralizing the mixture with a solution of Carbonate of Soda. When admioistntion
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 288, 289, 318, 389, and of these four
cases, three recovered and one died ; a very favorable result. The physician in empty-
ing this valuable but potent agent, should remember that its success depends upoo 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, fron
which irritation is conveyed to the nervous centres, including a state of hyperaesthesii
or exalted polarity of these centres (the brain excluded,) derangement of nervous fi|n^
tion, increase of irritability, and contracted and torn muscular fibre, the conseoueot
crushing of the sensitive nerves, and obstruction of the capillary circulatioo m the
affected parts ; followed by the consequent exhaustion ; death occurring by a^yxia-
by spasm, or by asthenia from exhaustion, or by syncope, from sudden eessatioo of the
heart's action. Aconite on the other hand, according to Dr. G. Smith of HyderaM
alters the character of the local irritation, then abolishes it, the tingling being followed
by numbness ; it acts as a sedative of the nervous centres, (cerebrum excluded,)
diminishing their polarity, and inducing a state of anassthesia, impairing the excito-
motor, vaso-motor, and voluntary systems of nerves, causing miwcular weakness, pardyw
of the diaphragm, suspension of spasm, paralysis of the capillaries, and general exbtie-
tion, eventuating in death by asphyxia, from paralysis, or by syncope, from shock. As
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 more tho-
roughly antagonistic than those induced by Tetanus and Aconite.
Belladonna^ according to Brown-S^quard, diminishes the reflex activity of the spinal
cord, by contracting its blood-vessels ; but whether or not this be its modm operoMdi.
it appears to exert a direct sedative effect Upon the nerVe cells. In case 281, the
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Treatment of Traumatic Tetanus. 407
Extract of Belladonna certainly exerted beneficial effects. And it appears from the
obflervations of Mr. Hutchinson, that in Tetanus, large doses of this potent agent may
be administered without the manifestation of dangerous symptoms, the enormous dose
of 5 grains of the extract being susccssfully administered ; and still farther that the
system appears to acquire a tolerance for the remedy, which necessitates its progressive
increase.
Farther observations, are necessary for the establishment of the relative value of
Atropia and Strychnia.
The application of ice to the spine^ afler the method recommended by Dr. Todd,
promises to be of some use in the treatment of this disease ; we arc however, without
the necessary facts to show the relative value of this measure.
Owing to the almost invariable presence of obstinate constipation in teUnuSj purgatives
have been recommended and employed by almost every physician 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 its action, but also on account of the
facUity 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.
Aua/cBtulaj Camphor and Musk, are of doubtful utility in the treatment of Trau-
matic Tetanus ; and this observation applies also fo the application of blisters over the
region of the spine.
In conclusion, in the present state 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.
Calabar Bean.
Chloroform.
Sulphuric Ether.
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;
fession is concentrated upon two or more remedies, as Chloral Hydrate, Calabar Bean
and Bromide of Potassium.
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OBSERVATIONS
ON
Gerebro-Spinal Meningitis
AND MORE ESPECIALLY AS IT APPEARED AMOMGST THE
SOLDIERS OF THE CONFEDERATE STATES ARMY
DURING THE
CIVIL TT^H OF 1861-1865.
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_J
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OBSERVATIONS ON CEREBRO-SPINAL MENINGITIS; AND MORE
ESPECIALLY AS IT APPEARED AMONGST THE SOL-
DIERS OF THE CONFEDERATE STATES ARMY
DURING THE CIVIL WAR OF 186M865.
CHAPTER VI.
<»BSEBVATI0N8 ON THE HISTORY OF CEREBRO-*?PINAL MENINGITIS IN FORMER PERIODS.
HISTORICAL NOTES ON CEREBRO-SPINAL MENINGITIS AS IT OCCURRED IN THE ARMIES OF THE
StUTTHERN CONFEDERACY DURING THE WAR OF 1861-186r>.
RESULTS OF THE EXAMINATION AND CLASSIFICATION OF THE SICK AND WOUNDED, AND MORTU-
ART RECORDS OF THE CONFEDERATE 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 CEREBROSPINAL MENINGITIS.
"REIH>RT OF SICK AND WOUNDED IN TEN COMPANIES, TWENTY-SECOND NORTH CAROLINA
REGIMENT, STATIONED AT CAMP GREG(J, NEAR FREDERICKSBURG, APRIL, 1863, BY P. GERVAIS
ROBINSON, SURGEON P. A. C. S."
"REPORT OF W. D. MITCHELL, M. D., SENIOR SURGEON RHODES' BRIGADE, ARMY OF NORTHERN
VIRGINIA."
•REPORT OF J. T. BANKS, M. D., SURGEON THIRTEENTH REGIMENT GEORGIA VOLUNTEERS,
ARMY OF NORTHERN VIRGINIA."
-REPORT ON THE PRECEDING PAPERS BY SURGEON R. J. RRECKENRIDGE, M. D., INSPECTOR OF
CAMPS AND HOSPITALS. ARMY OF NORTHERN VIRGINIA."
-EPIDEMIC OF CEREBRO-SPINAL MENINGITIS BY SURGEON G. A. MOSES, OF MOBILE, ALABAMA."
EPrDEMIC OF CEREBRO-SPINAL MENINGITIS IN NEW ORLEANS, IH72, 1873.
Lord Bacon characterized Medicine as a Science which had been more professed th-Aw
laboured, and yet more laboured than advanced, the labour having been rather in circle
than in progression. With much repetition there was but small addition. Bacon very
justly complained of the discontinuance of the ancient and serious diligence of Hippo-
crates, which used to set down a narrative of the special cases of his patients, and how
they proceeded and how they were judged by recovery 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
.scieDce, and that as a general rule, the conclusions reached by any investigation will be
trust-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 complicated pheno-
mena of health and disease, cannot be discovered by observation alone. To the estab-
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, &cts and phenomena, and the exercise 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 tho pathological phenomena.
In the investigation of the complicated chain of pathological actions, experiments
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412 History of Cerebrospinal Meningitis.
upon living animals, are of undoubted importance, in that they afford a oompaiisoB
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 tbej
may be conclusions established by the higher powers of the understanding dealing with
data, previously acquired by the senses and perceptive faculties.
The differences of opinion amongst medical men, are due more to the extent ukj
character of their observations and studies, than to any real differences existing io 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 humanitr,
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 are 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 distres,
with violent pain and numbness in the head and limbs, convulsions, delirium, coma md
purple spots, upon the surface, and causing death within a few hours after the fin*
appearance of disordered action.
In attempting to determine the precise period of the appearance of Cerebfo-Spioal
Meningitis in the history of mankind, we are however met with numerous and iiwir-
mountable diflSculties.
Whilst there are passages in the writings of the Hebrews, and of some of the ol<lcr
writers, as Homer, Herodotus, Ovid, Plutarch, Pliny and others, showing that pestiteoce
was both common and fatal in ancient times, and that the diseases which afilict modern
armies, were not unknown to the ancients ; on the other hand^ the earliest and mow
celebrated writers, although embracing vast periods of time in their historical accouBt?,
give but few and imperfect notices of the diseases which scourged populous kiogdoms.
and decimated immense armies and navies. The absence fVom the writings of the
ancients, of such minute descriptions of disease, as would enable the physidaD of
modem times to determine with some approach to accuracy the nature and relatioDS of
different diseases, is referable to several causes. In most cases their works were com-
pends of the knowledge of their times, and embraced vast periods, and covered such to
innumerable number of civil, religious and warlike revolutions, that only the most
prominent events were reccorded. Such writings were wanting in that personal tad
actual observation, which could alone secure accurate descriptions of disease. .\nd
further, as such writers were busied, chiefly with the origin, progress and decline </
states, with the civil and military achievements and intrigues of kings, princes, states-
men and generals, the diseases and wounds of the common people passed tlmi>^
unnoticed. The ancient kings, princes, statesmen and nobles, were continually haunted
with the terrors of poison, and the object of medicine wjis rather to discover antid»>tes
than remedies; the different classes of mankind, were more widely separated, and* the
higher ranks took comparatively little notice of the destruction by pestilence of
thousands of slaves, or of the plebeian race.
Many populous nations of antiquity, were for ages, without any methodical reconis
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 Pompeio.^.
describes the Scythians, who were always regarded as very ancient, or of equal, if not
greater antiquity than the Egyptians, as a people without landmarks, neither cultivatinj:
the soil, nor having any house, dwelling or settled place of abode, but being alwij?
engaged in feedingherds and flocks, and wandering through uncultivated deserts. Their
wives and children were carried with them in wagons, which as they were covered with
hideSj ^^ i^sed instead of houses, and protected them against the rain and cold ; thCT
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History cf Cerehro^ Spinal Meningitis^ 413
were dad in the skins of wild animals, 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 observed among them, more from the temper of the
people, than from the influence of the laws. They were a nation hardy in toils and
warfare; their strength of body was extraordinary; they took ixiSHcssion of nothing
which they feared to lose, and coveted when conquerors nothing but glory.
Many powerful kingdoms have been utterly destroyed without leaving any record
whatever of their literature and science, and their advancement in the art^s may be
inferred only from the monuments which have resisted the ravages of time. Wc cer-
tainly have but meagre accounts of the history of the " antediluvian.«," 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, at
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 oflF by disease and battle, without leaving any trace behind them but their bones,
rude earth monuments and stone implements, in the aborigines of North and South
America. The red men as a race, are characterized 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 wonderful character. And yet whole tribes and nations have been swept off
by Small Pox, Syphilis, Whisky and the cruelties of their conquerors, without leaving
a single written line to record their origin, religion, arts, wars or diseases.
Justin in his history of the world, although embracing a period of at least two
thousand years, mentions only casually the diseases which had distressed 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
roads were filled with dead bodies, and birds and beasts 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 afker its foundation, notwithstanding that it was
so terrible as to lead to the establishment of the cniel religious custom of immolating
human beings ; in like manner, the pestilence which destroyed the army of the Cartha-
genian 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 Leprosy,
as the cause of the expulsion of the Jews from Egypt, and the stringent laws of the
Hebrews against intercourse with the surrounding nations, is attributed to their remem-
brance 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-
stances attending the diseases, wounds and mode of death of Alexander and other
distinguished personages. .
Cornelius Nepos, in his Lives of Eminent Commanders, makes mention of disease
but in 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 which afflicted Hannibal during
his march over the chain of the Appenines, and which cost him the use of his right
eye.
Eutropius in his abridgement of Roman History, alludes to diseases and pestilence
only in the fifth chapter of the ninth book, where he states that the reign of Hostilianus
and Volusianus was remarkable only for a pestilence and for other diseases and afflictions.
We s^rch ifl vai^), i^ the Historical works of Sallust, Florus and Vellerius Paluculus,
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414 History of Cerebro^ Spinal Memngitis.
for any information concerning the diseases and pestilence of the times of which they
wrote.
Tacitus, in his Historical works, wliilst describing minutely the mode of death, the
intrigues and the poisoning of noted personages, gives nothing of the symptoms hv
which we might recognize the terrible pestilence which devastated Remc, in the time of
Nero. Tacitus describes this pestilence as sweeping away every living thing, without
any discernible derangement of the atmosphere, though the houses were filled with dead
and the streets with funerals. Neither sex nor age were spared ; bond and free, wen-
snatched off indiscriminately, amidst the wailing of wives and children, who. whilst
they were yet attending and lamenting the dead, were themselves stricken down and
frequently burnt on the same funeral pile.
Titus Livius, the most elegant of Roman Historians, whilst recording in his Historr
of Rome, the numerous and severe afflictions of this great city by pestilenc;*, at the siiut;
time gives no such minute and accurate descriptions, as would enable the physicLi:! of
modern times to recognize the true nature of the diseases. Rome, situated in a low
malarious region, in the neighborhood of extensive marshes, was afflicted with pestilence
of a most malignant character as early as the 16th year from its foundation, and 738
years before the Christian era. Plutarch, in his life of Romulus says, that this pla^c
killed instantly, without any previous sickness, and that even trees and cattle were not
exempt from the malignity of its influence.
Thirty years after, in the 46th year of Rome, Italy was afflicted with severe pesliicnee.
of the nature of which we have no account, although Plutarch describes the institutitHi
of the Salii by Numa on this occasion.
During a period of five hundred and fourteen years, extending from B. C. 61) tn U
0. 126, Livy records no less than fifteen plagues, which afflicted Ronr\ mid oihtr
writers have still farther extended this number.
Whilst from some facts, mentioned incidentally, in the descriptions of Livy aD-l
other historians, considered in connection with the topography and warm eliuiato o^
Rome, and the season of the year in which the diseases arose, we arc led to iviMrd
some of these plagues as of malarious origin, resembling in their symptoms and pniirress.
Billions, Congestive and Yellow Fevers, at the same time, the descriptions j:re s«i •.tn-
cral and indefinite in their character, that nothing more than mere conjectures can b.*
formed as to the true nature of the diseases.
Herodotus whilst giving casual but valuable observations with reference to the art of*
Medicine amongst the Egyptians and other nations, furnishes no detailed description^
uf either the nature or the origin of specific diseases ; and in like manner, the work-*
of Strabo throw but little light on the history of diseases.
When we turn to the writings of those who have confined themselves siricily to
Medicine, and attempt to determine the date of the origin of any special disease, we Hre
met with difficulties as great as those encountered in the examination of the description
of diseases by purely historical writers. Many of the most ancient and oelebktcd
medical writers did not busy themselves at all with inquiries into the histories of dis-
eases ; some simply recorded the facts and phenomena which passed directly under their
own observation, whilst others simply reproduced, in new forms and in more ^iieral
terms, the works of their predecessors, and immense chasms of time exist, in which nu
record whatever has been preserved of the diseases which afflicted mankind. The first
body of doctrine in the history of medicine, is the collection of writings known under
the name of the Works of Hippocrates ; from the loss of the records -of the earlier cul-
tivators, the science of medicine mounts up directly to this source. In like manner
there exists a great gap aft;er the writings of Hippocrates ; the works from hi.** time to
the establishment of the school of Alexardria, and those of that school itself, haviujr
been completely lost, with the exception of some quotations and passages preserved b
the latter writings. It appears, however, that the Greeks received surgery, together
with the other branches of medicine, from the Egyptians ; and from some observatioos
made by the learned men of the French Expedition to Egypt, in 1798, it is evident
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History of Cerebrospinal Meningitis, 415
that in rery remote times, this extraordinary people had made a great degree of pro-
gress in the art of surgery ; upon the ceilino; and walls of the temples of Tentyra, Kar-
oack and Luxor, ba^so-relievos are seen, representing limbs that have been cut off with
instruments very analogous to those which are employed at the present day for ampu-
tation. The same instruments are said to be again observed in the hieroglyphics, and
vestiges of other surgical operations may be traced, which afford convincing proofs of
the skill of the ancient physicians in this branch of medical science.
We are not to regard Greece as the birthplace of 3Icdiciuc — wc arc to look, rather, to
the early Egyptians as the first and most successful cultivators of Medicine. The
priests of this ancient country were a numerous and influential body, receiving for their
support about one-third of the whole income of the nation. Most of the Egyptian
prieste were skilled in medicine, and, as some suppose, practiced gratuitously among the
people. " Here," says Herodotus, *• each physician applies himself to one disease only,
and not more — all places abound in physicians ; some for the eyes, others for the head,
others 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, before assuming the
business 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
some of the most distinguished physicians of that time, as Empedocles, Alcmaeon,
Democedes and Acron, who flourished near a century before Hippocrates. Aristotle,
though not a practitioner of medicine, was of the family of ^Esclepiadae, 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 father of medicine, was born as late as
the year 460 before the birth of Christ, and was, therefore, a cotemporary of Plato and
Socrates, and lived more than a century after the establishment of the celebrated school
of Pythagoras, and long after the foundation of the Temples of the .Esdlepiadae, devoted
to the sick, and containing numerous votive tablets, in which their diseases were
recorded. 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 Grecian 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 nfear one thousand
years ago, affirmed that the extent of medical science at his day far exceeded the bounds
of human life ; and he goes on to say : " The authors who have improved this art arc
not a few, but they are not to be comprehended within the compass of a few years ; a
fhousand writers, perhaps for a thousand years, have been improvijig 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
grounded 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, have 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 antiquity it was impossible that any accu-
rate history of diseases could have been written, because of the absence of both medical
science and of physicians devoted to the treatment of diseases. Thus, Herodotus
affirms that the Assyrians, even at the time of the greatest splendor and power of the
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416 History of Cerebro^ Spinal MeningtUs,
Babylonish Empire, had no physicians, but were in the habit of ezpoeing the fidbk !■
the market place, that they might confer about their diseases with the passiiig mahi'
tude. If tlie passers by had themselves been afflicted with the saiae diaetseB as the
sick persons, or had seen others so afflicted, they advised him to have recoarse to the
same treatment as that by which they escaped a similar disease, or as they had known
to cure others. Herodotus also relates, that amongst that nation of the Indiaos called
Padaeans, who were Cannibals, it was the custom when any one of the commanity was
taken sick, whether man or woman, for the nearest connections to put the sick peison
to death ; and they justified this barbarous treatment on the ground, that if the sick
person wasted with disease, his flesh would 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 consequence of some distemper.
The writings of Hippocrates, demand the first and most careful examination in all in-
inquiries relating to the history of particular 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, after a cold wet
autumn, duriog 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 prevailing
as an epidemic, whilst the people remained free from other diseases.
Galen in his Commentary remarks, that those attacks of apoplexy were caused 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
^^ phrenitis'\ (delirium and coma), described by Hippocrates, and illustrated by nume-
rous cases. Hippocri^tes described the ardent fevers, which prevailed during the
autumn and early part of the winter, as characterized by acute fever, small, irre^ulir.
rigors, insomnolence, aberration of the intellect, thirst, nausea, circumscribed sweats
about the fore-head and clavicles, but no general perspiration ; much delirious talkiog,
despondency, great coldness of the extremities. Paroxysms occurring on even days:
and in most cases, on the fourth day, violent pains set in with cold sweats, the extrem-
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-called
Malignant, Remittent, Pernicious and Congestive Fevers. This view is still fiirther
confirmed by a critical examination of the individual cases. Those who have prw-
ticed in malarious, hot, moist districts, similar to certain portions of Greece, will hare
no difficulty in recognizing the nature of the following case as describod by Hippo-
crates.
Case J!fS2 : Pernicious Malarial Fever.
Ti^rasimus, who lived near the Canal of Bootes, was attacked with fever after sapper, and
passed a bad night. The first day He was easy, but in pain ia the night. Worse in all its-
pects on the second, and at night delirious. On the third day, restless and very delirtoos. Oa
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, came per-
fectly to himself, and was composed, but before noon, became so raving mad, that he co»W
not contain himself. His extremities were cold and somewhat livid ; urine suppressed; and
about sunset he died. This patient's fever was continual, with sweats; belly tumified, distended
and painful ; urine black and cloudy ; bowels not bound ; thirst perpetual ; and before h*
died, was strongly convulsed and sweated.
Hippocrates also described cases of febrile disease, characterized by the sudden oo«^
coma, delirium, and rapid fatal termination, which from the presence of gUndilir
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History of Cerebro-Spinal Meningitis. 417
swellings, and tendency to putrefaction wore evidently referable to the true Plaguey
the Glandular Plague of the East. . *
This groat 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 ^leningitis than any other
form of disease :
Gasb 483. Asandras was chillj, bad pain in his side and in his knees and thighs ; after
eatiog, grew delirious, and died in a short time.
Ca81 484. Polyphantus in Abdera, had a pain in his head, accompanied with violent fever.
Ilii 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 convnlsions.
Gasb 485. The domestic, Eualcides, was affected in much the same manner. After pasaing
thick urine and suffering with pain in the head, she became phrenitio and died in strong con-
vulsions.
Cask 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 precision and
fulness, in the record of special cases, and their descriptions of disease, although often
elegant and highly finished, were wanting in those bold outlines and in those striking
illostrations, which would enable the student to recognize such a disease as Cerebro-
spinal] Meningitis, which possesses many symptoms in common with certain affections
of the Brain and Spinal Cord.
If such elegant and renowned writers as Aretaeus, and Paulus uEgineta, were
acquainted 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
compendious 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
patechiae, 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
Typhus fevers, Measles and Scarlet fever. Erysipelas, Malignant Malarial fever, and
Cerebro-Spinal Meningitis; all of which were frequently confounded in a general
description of Putrid and Maligpant fever and Pestilence ; and it is incorrect to assume
as 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
*The 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.
By Nicholas Culpeper, Physician and Astrologer, Abdiah Cole, Doctor of Physic, and William
Rowland, Physician. Being chiefly a translation of the works of that learned and renowned
Doctor, Lazarus Riverius, sometimes Chancellor and physician to the King of France, etc.
London^ 1668, pp. 611, 613.
53
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418 History of Cerebro^ Spinal Meningitis.
the results of liis own extensive experience, but also the views of the best physicians of
the middle ages, we will find that Purpura, Spots and Petechiae, were characteristic of
the continued fevers of those times.
The Malignant and Pestilential fevers, described by lliverius, include both Typhui<
and Typhoid fevers, as may be clearly discovered by a critical study of the individoal
cases recorded in his work.
During the middle ages, the characters of the epidemic fevers, were modified, and
their destructive tendencies intensified, and their external manifestations rendered more
marked by the neglect of all sanitary regulations in cities and private houses, and by the
filthy habits and salt diet of the people. Every town was a fortress, and every house
a castle, and the inhabitants, like the soldiers of a garrison, worked and slept with their
arms, and always held themselves ready to resist attacks. Bands of robbers, defied
the power of the rulers, openly encamped upon the public roads, and plundered and mur-
dered all who were not able to protect themselves by the force of arms. The country wai*
covered with forests and undrained swamps and marshes, and the best lands were uncul-
tivated. The wall-towns were encompassed by large stagnant ditches, which were the
receptacles for refuse, and all sorts of decomposing filth ; the streets were narrow, unpaved,
undrained, uncleaned, and unlighted ; there was no provision for the removal of the town-
refuse, which was thrown into the gutters and streets, forming in dry weather, a semi-flaid
mass of corrupting anin^al and vegetable matter ; and in wet weather, noxious bogs of ftkh.
The houses were described as mean and squalid, without chimnies, the windows without
glass, and the floors without boards. The floors, says Erasmus, '-generally are made of
nothing but loam, and are strewed with rushes, which being constantly put on fresh,
without the removal of the old, remain lying there, in some cases for twenty yean*,
with fish bones, broken victuals, the dregs of tankards, and impregnated with other
filth underneath from dogs and men."
From the absence of cotton and linen goods, and the scarcity of woolen garment*,
resulting from the slow production of oK)th, by the hand looms, the personal habits of
the people were filthy in the extreme. Combined with this, there existed ignorance t:^
to the mode of raising and preserving vegetables, and improvidence and intemperaoo?
of living. No attention was paid to the collection and preservation of fodder, and the
animals for the winter food, were slaughtered in autumn, and their flesh preserved by
salting and smoking. Fresh animal ibod could be obtained only during the warm
months of the year, and during the greater portion of the time, the common people sub-
sisted chiefly on salted beef, veal or pork. The cultivation of the potato, and of gardei>,
is of comparatively recent datie, and fresh vegetables could be obtained only with diffi-
culty, and in small quantities. For many centuries, no more subsistence was produced
in Europe, than was barely sufficient for the necessities of the people, consequently every
year of scarcity, became a year of famine. The malarious undrained state of the
country, the crowded, filthy condition of the towns, and the filthy, degraded habits of
the people, formed the most favorable conditions for the origin and spread of epidemic
and contagious diseases, whilst the scorbutic state of the blood induced by the protracted
use of salt meat, aggravated eveiy disease, and tended to the formation of spots and pete-
chisB and exudation of altered blood, in all fevers. It is no easy task to unravel this
complicated chain, and at thi^ late day, decide dogmatically, the nature and relatioit^ of
diseases, the descriptions of which, are given in loose and general terms, unsupported
by post-mortem examinations. The difliculty is still farther increased, by the great
revolution, which changes of diet, dress and habits, and the great advance of the arts
of civilization, and the application in public and private buildings, and in cities and
towns of correct sanitary regulations, have wrought in the character of diseases.
The plague which ravaged Europe, tor more than two thousand years, disappeared
near two centuries ago, and now only lingers iu the more ancient and filthy Eastern
cities ; the labors of the Agriculturalist have banished Malarial fever from large portions
of the European and American continents ; Typhus or Jail Fever, the fatal scourge of
the unfortunate prisoner, of the sailor and soldier, and of the ipmates of the crowded
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History of Cerebrospinal Meningitis, 419
hoepital, and which in many of its visitations, was scarcely less terrible than the plague,
is now confined to the hovels of the poor, in certain oppressed and suflfering countries,
and is almost unknown amongst the better classes ; many painful and fatal forms of
disease, which formerly swelled the bills of mortality, in the large European cities, have
so completely disappeared, that the names even, are no longer in use ; and small-pox,
which before the discovery of vaccination by Jenner, was infinitely more destructive of
life than the plague itself, sweeping off whole tribes of savages and half-civilized people,
and destroying not less than fifteen millions of human beings, every twenty-five years,
exists only because of our neglect and folly.
Several modem writers, who have traced the progress, ttnd described the symptoms
of Cerebro-Spinal Meningitis, have attempted to show, that an analogous disease, under
the names of Spotted fever. Petechial fever, Cerebral fever, Phrenzy, Cephalalgia, Cold
Plague, and Black Death, prevailed in different countries, from 1310 to 1830, when
post-mortem examinations, more freely indicated its seat and nature, and led to a dis-
troctive appellation, founded upon the characteristic anatomical lesions. In considering
these statements, it is important however, to remember, that the terms Spotted fever,
and Petechial fever, were frequently applied to severe forms of disease, as Typhoid and
Typhus fever, which often in the severity of the nervous symptoms, and the rapidity
of their progress, stimulated the disease under consideration, and it is difficult if not
impossible to disentangle those epidemics which were beyond controversy Epidemic
Meningitis. The confusion is rendered still more profound, by the view held by certain
authors, that the disease is essentially a form of Typhus fever. And we are to look
rather to future investigations, founded upon careful studies, and post-mortem examina-
tions, for the establishment of the correct relations of epidemic Meningitis, to the
malignant forms of continued and malarial fevers.
A disease resembling Cerebro-Spinal Meningitis, is said to have appeared in France,
as early as 1310.
The Putrid fever, accompanied with Phrenitis, which prevailed in "Westphalia Hesse,
and Friesland, in 1480 aud 1481, was most probably a continued fever of a severe
grade.
In 1503, an epidemic prevailed in Europe, which was characterized by violent delirium,
convulsions, contractions of the limbs, prostration and coma, and speedy death, some-
times in a few hours, but more often during the third or fourth day.
The epidemic Petechial fever of a i^alignant character, attended with extreme pros-
tration of the powers, heaviness, alvine dejections, suppression of urin3, spots about thn
fourth or seventh day, coma or complete insomnia, and finally haemorrhages, which
diminished the powers, and announced the approach of death, which prevailed all over
Europe in 1505, and carried off an infinite number of sick, partook rather of the nature
of malignant Typhoid fever, manifesting itself in Scorbutic patients.
Epidemic Encephalitis, and Malignant Pneumonia afflicted Germany in 1508.
The accounts of the Spotted fever, which prevailed in different countries of Europe,
(and which was in several epidemics followed by the plague,) in 1510, 1516, 1517,
1556, 1557, 1564, 1569—1574, 1571, 1582, 1501 and 1592, are not sufficiently full
or accurate to warrant the statement, that the disease was essentially epidemic Meningitisi
although those epidemics may have included many genuine cases.
In 1553, after a very severe winter, a disease resembling Epidemic Meningitis carried
off large numbers of the population in Silesia; and in 1580, associated with Catarrhal
Affections, it is said to have killed no less than ten thousand persons in Rome, twelve
thousand in Venice, and two thousand in Madrid.
During the Civil Wars in France, 1616, the Catholic and Protestant Armies, were
decimated by a disease, which attacked by sudden and furious pain in the head, and
destroyed almost all the victims.
The precise relationships of the punticular fever, spotted fever and petechial fever,
^hich prevailed in different countries of Europe, during the seventeenth century, (1604,
1624, 1661-1664, 1601, 1693 and 1698,) have not been fully established; and it is
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420 History of Cerebrospinal Meningitis,
not clear, that the disease described by Sydenham, as ^^fehrU nova,^* was epidemic
Meningitis. The same obscurity hangs over the epidemics of spotted fever which pre-
vailed in Prussia, 1704, in England, 1710-1741, in Piedmont, 1720, in Edinburgh,
1733, in France, 1746, 1756, 1757 and 1758, in Vienna, 1758, in Naples, 1764, io
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-mater being chiefly involved. A
disease appeared at Geneva, in 1805, which resembled Cerebro-Spinal Meningitis, in ita
sudden invasion, severe pain in the head, rigidity of the spine, occasional petechia,
engoj^ement of the brain, and heavy mortality. In this epidemic one quarter of thoee
attacked died. The case which occurred at Strasburg the same year, appears from the
results of the post-mortem examination to have been an example of inflammation of the
brain and its membranes.
It is impossible to determine the date of the first appearance of this disease amongst
the European settlers of North America. Noah Webster, in his IlUtory of Epidemic
and Pestilential Diseases, alludes to several severe epidemics which were sudden in their
appearance and rapidly fatal in their cffiects, the nature of which cannot now be d^cr-
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 weD
persons could scarcely be found to tend the sick and bury the dead. Seventy persons
were buried in three mouths, in this town, which contained less than 1000 inhabitants.
Webster states, that in the same winter a deadly fever raged in the town of Dover, in
New Hampshire; and he affirms, 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
last and of other epidemics in the country. We shall hear of it in the following oesh
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 inflammatory /ei;er with symptoms of typhus, which in the course of the
following winter carried off about 40 of the inhabitants. " The disease was extremdj
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 occurs
in pestilential periods mentioned under the year 1698." According to Dr. TrnmlmlL
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 deliriam.
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 physicians were
afraid to bleed, the patients all died. This malady prevailed from November, 1760, to
March, 1761.
Spotted Fever , first excited attention and alarm in America, in 1806, at Medfidd,
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 several towns in Massachusetts, New York, New
Hampshire and Vermont ; and in the latter State it continued during the winker of
1810 and 1811. The disease extended also to Canada, Pennsylvania, Kentucky, North-
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 described
by Jackson, Warren, North, Hale, Fish, Miner and Gallup, demonstrate in the clearest
light that this disease was epidemic Meningitis, and not a continued fever. The value
of this demonstration is not at all invalidated by the fact, that some of these obserreis
recorded amongst their cases, examples of Typhus and Typhoid fever,
Brs. Thomas Welch, James Jackson and John C. Warren, in their reports to the
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Sistory of Cerebrospinal Meningitis. 42i
Massachusetts Medical Society, io 1810, upon this epidemic, describe the invasions of
the disease as sudden and violent.
The following was given as a description of the disease as it occurred during this
epidemic :
'* Uousual deadljr coldneBs ; skin white as polished marble, and smooth ; counteDaQce per-
fectly placid, not one distorted mascle ; pulse at the wrist imperceptible ; motion of the heart
soircelj 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
opaque 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-
timas adhesion of the hemispheres of the brain to the dura-mater and to each other. In
every 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 pleurse. No marked, or characteristic, or uniform morbid changes were
discerned in the abdominal viscera.
Dr. Elisha North, in his " Treatise on a Malignant Epidemic commonli/ 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 fever attendant on Scarlatina; no petechiae, but a red, fiery erup-
tion, or what is perhaps more common, no eruption at all ; pain in the head and limbs is less
severe ; less universal 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. Gallup, in his ^^ Sketches of Epidemical Diseases in tlie State of Ver-
montf from its first settlement to the year 1815^ has given an excellent description of
*' Spotted 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
cranium ; 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
m irks of violence, and everywhere a remarkable pressure in the veins."
Dr.' Thomas Minor, in the " Essays on Fevers and other Medical Subjects, ^^ pub-
lished at Middleton, Conn., 1823, has giveu illustrations of Spotted Fever, which he
eaUs also (Phrenitis Typhoides), and says that
"Spotted Fever appears to have its seat and throne in the brain, to belong nosologically to
the passive phlegmasias. It is attended with no spontaneous reaction, but has the forming
nnd suppurating 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
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422 History of Cerebrospinal Meningitis.
authors, as Dr. James Mann, who has recorded observations upon thie disease, as it
manifested itself amongst the American Soldiers during the campaigns of 1812, 1813
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 the
United States, by quotations from the accounts of Dr. South wick, of Albany, Dr.
Hunt, of the United States Navy, Dr. Robert Dunbar, of Winchester, Va., Dr. John
Wilson, Dr. Utley, of Connecticut, Dr. Kercheval, of Bardstown, Kentucky, Dr. Ira
Bascom. of Grenville, New York, Dr. B. Vaughn, of Hallowell, Me., E. MartiD. of
Maryland, Dr. Joseph Trent, of Richmond, Dr. P. Ilerford, of Middleburg, Va., Dr
E. S. Davis, of IMilledgeville Ga., Dr. John Kerr, of Mississippi, Dr. James Davis, of
Colnmbia, S. C, Dr. (^omstock and Dr. Hunting Sherrill.
Cerebro-Spinal Meningitis appeared 181()-17 in South Carolina and Massachusetts;
1818-1822, in Virginia, North Carolina and somsof the Western States, Pennsylvania,
Maine, Connecticut and Ohio; 1823, 1824, 1825, 1826, Connecticut; 1826, in New
Orleans and Fort Adams; 1827, Ohio; 1832, Connecticut; 1845, 1 846, lUinoi^ :
1847, Mississippi, Tennessee, Missouri and Arkansas ; 1847, 1848, Washington, D. C:
1848, Montgomery, Alabama ; 184J), Mi.ssissippi; 1850, New Orleans; 1857, New
York ; 1859, Virginia ; 18t)l-18(i5, Northern and Southern armies, Indiana, Tennessee,
North Carolina, Rhode Island, l^hiladelphia, 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 Unite4 States in the
years not mentioned above ; for such a view could only be founded upon a knowledge
of the cases treated by the various practitioners of the entire country ; and it is well
known that the vast majority never report their cases to the public prints. It wouM
appear that cases occur every year in one part or another of the country, and as a gen-
eral rule these have been reported to the medical journals only when several have
occurred in the same locality.
During this period, from 1806 to 1866, including the American history of the
disease, it appeared at various times, in different parts of Europe ; 1807, in Blackestoo.
near Ashburton, England, and in Brianoou, Grenoble and Mayence; 1814, GrenoWe;
1814, Metz and University of Cambridge ; 1813-1815, Dublin, Ireland ; 1817, Ger-
many and Italy ; 1815, 1828, Millbank- Penitentiary, near I^ndon ; 1329-30, Toulon ;
1837, Bayonne.
M. Casimir Broussais has given a statement of the different accounts of the disease
as it has appeared in France, which have been drawn up chiefly by the army surgeons
and physicians.
First appearing at Bayonne, Bordeaux and Rochelle, in 1837, and afcerwards at Ver-
sailles and St. Cloud in 1 839, it seemed to be fixed in these two latter towns up Ut
1842. From Versailles it launched off in one direction to Caen and Cherbourg, in
1840 and 1841, and in 1839 and 1842. In a different direction it was met with *t
Laval, Mans, Chateau, (lontliier. Tours, Blois, and Joignv, in 1840-1841. Fioallj it
gained the neighborhood of Hambouillet. During all this time, the disease, with few
exceptions, as in Landos and Laval, Hambouillet and Strasbourg, was confined to the
soldiers. In another quarter of the kingdom, but still in the South, the disea-se bejpin
at Narboune and Foix, in the year 1.837, and thence, in 1838, broke out in Toulon,
but in the beginning of 1839, it showed itself at Nemis, where its attacks weraconfinetl
to the garrison. In the winter of 1839-40, it appeared at Avignon, and again in the
following winter. In this town* the soldiers were first attacked, but subsequently some
of the civil population were sufferers from the disease. In 1840 it broke out at Month
risen, and at Lyons in the wint^^r of 1841-42. Finally it branched off in another direc^
tion to l^upigan in the winter of 1840-11, and seemingly retraced its course to appeir
at Aigues-Mortes the following winter. In this last town, no part of the civil populi
tion was exempt, children suffering e(jually with the military.
Epidemic Meningitis has appeared in other countries besides France ; it has been
noticed in different cities of Italy, during the winters of 1837, 1839, 1840 and 1841,
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History of Cerebrospinal Meningitis, -123
and more particularly in the kingdom of Naples, wfeere the physician designated it by
the term Convulsive, or Apoplectico, Tetanic Typhus, etc.; in Gibraltar, the disease
prevailed in the early part of the year 1844, but almost entirely among the civil popu-
lation ; 1840-1849, Algiers, from whence it extended towards the (Jrcat Sahara
Desert; 1843-1849, various portions of France; 1845, 1846, Dublin, Ireland; 1849,
Spain; 1846, 1847, Ireland; 1857, Sweeden ; 1845-1848, it prevailed with great
malignancy in Denmark ; 1845-1861, Sweeden and Norway; 1860-1861, 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 writers who make no distinction
between Typhus and Typhoid fevers, and use the term Cerebro-Spinal Meningitis as
synonymous with Spotted Fever, must be received with great caution ; and it should be
bdme in mind, in such inquiries in the histories of these and related diseases, that it is
only since 1836, that pathologists have distinguished the characteristic lesions of
Typhoid fever, and established absolute and recognizable differences between this disease
and Typhus fever, and that the nature and pathology of Cerebro-Spinal Meningitis arc
still matters of dispute with many pathologists.
We conclude from this very general outline of the history of Cerebro-Spinal Menin-
gitis:
Ist. Cases of Cerebro-Spinal Meningitis, appear to have been observed by Hippo-
crates.
2d. Cerebro-Spinal Meningitis has prevailed at various times, and in all countries,
and it appears to nave been governed by no fixed laws as to duration, origin, locality
and climate ; its outbreaks have occurred simultaneously in the most widely separated
countries presenting the most diversified conditions of soil and climate, and it has
attacked alike the most salubrious and healthy towns.
3d. Cerebro-Spinal Meningitis originates de novo, at the same time in widely sepa-
rated 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-Pox, Measles and Scarlatina.
4th. The most fatal and wide-spread epidemics of Cerebro-Spinal Meningitis have
occurred in mid-winter, and no relationship can be traced between its origin and spread,
and miasmatic 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, Cerebro-Spinal
Meningitis resembles more nearly the Phlegmasise, as Pneumonia and Pleuritis, and it
appears 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 poison.
Cerebro-Spinal Meningitis, (Myelitis Petechials, Cerebral or Cerebro-Spinal Typhus,
M^negite C^r<^bro-Spinal, Fi^vre C^r^bro- Spinal, Typhus Ci'^r^^bro-Spinal,) attracted my
attention at an early period of the recent civil war, and I sought opportunities for
observing its symptoms, and of gathering its history in various portions of the Con-
federacy, by an examination of the field and hospital reports of different departments,
and of the records of the Surgeon Genei-al's Office at Richmond, Virginia, and by per-
sonal conference with surgeons in the field and hospital. The sudden termination of
the war, found my labors upon this disease, in an unfinished state : the value of all
facts however incomplete, which bear at all upon the nature of this obscure and almost
universally fatal disease, rather than the expenditure of health and strength necessarily
required in these investigations, have induced the record of the following observations.
Whilst I have made some research into the literature of Cerebro-Spinal Meningitis,
iu the Southern States, it is not my intention to do inore than call attention to the first
author (as far as my information extends) who noticed this disease in the Southern
Atlantic and Gulf States,
Bernard RomanSy an enlightened observer, who spent several years in Florida,
published in 1776, a work, entitled "^ Concise Natural Histoiy of East and Went
Florida, containing <?» mccouxit of the Natural Produce of all the Southern /Vir/s oj
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424
History of CerebrO' Spinal Meningitis.
BHtish America, in the Three kingdoms of Nature, parttcniarly (he Animul and
Vegetable, etc.,^^ in which occurs the following allusion to a disease rescmbliDg in its
seat, symptoms and rapid termination, Cercbro-Spinal Meningitis :
" In Georgia I saw one or two instances 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 od ; 1 mm
told they have a pleurisy for every part of the head. It is violently 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 obeervations,
recorded in his exceedingly rare work, ninety-nine years ago, the term Ilead PleurUtf,
is sometimes at the present day, applied by unprofessional people, black and white, to
Ccrebro-Spin&l Meningitis.
During the months of August and September, 1863, 1 examined all the sick, wouoded,
sanitary and mortuary reports on file, in the Surgeon General's Office in BichmoDd,
Virginia.
Up to the time of this examination, Cerebro-Spinal Meningitis had not bean entered
upon the reports of the sick and wounded as a distinct disease. The omission of thip
disease from the official classification of diseases, issued from the Surgeon General's
Office, and according to which all returns from Medical Officers were made, was onfor*
tunate, as it was hence impossible to determine from these records, the relative flpequency
of this disease in comparison with other nervous affections, the rate of mortality, or ike
effects of locality, season and climate. I classified and consolidated the following taMea
of Nervous Diseases from the Official Reports of Medical Directors, on file in the Sur-
geon General's Office, Richmond, Virginia, August 1863.
TABLE.
Diseases of the Brain and Nervous System, recorded in the Field Reports of the Army of the Omftier^
ate States of America ^ during nineteen months, January, 1863 to July^ 1863. CUumfidni
Consolidated from Official Reports on file in the Surgeon GeneraVa Office, War Departmad,
Richmond^ Virginia, August, 1863, by Joseph Jones^ M, D. Surgeon, Provitionul Army, (>*•
federate States.
,
MEAN BTBnCTH AK» IW
DISEASES OF BRAIN AND NERVOUS SYSTEM.
i
TAL CASES PUSAnS
AND WOCVM.
1
\ E A k
AND
W 0 N T JI .
>
1
1
9
9\
f i
i
r
14
1
B
H
3
i
3
X
34
»
»3
I
r
11
OB
F
11
f 1
s
F
2
5' ■
1 •
:
:
B
V;
:
1?
1
e
:
8
>
c :=
1
114
Mean strengUi,
Officora and Mt*u
rii
11
.Tanuaiy, l?r2
16
352
36
87
T'oi 5
..
- 1 '
133 22
232,138
90,757' 1U«*
Fel.maiy, "
7
3.",4' 22 I 3
36 ::9
3
30 0 5
29 ]
177 13 9
59
219,069
71.672 9M5
3Inrrh,
»
2391 17 4
18 ' 3o
2
44 0 6
9 1
871 "0 10
34
165,047
30.385 e^
April,
(i
2U1. 13 ...
12 1 10
,*,
42 2 2
14
381 14
4
17
58.304
23^3: e:,w
May,'
2
24G 13 2
4 , 15
13
16 7 3
6
261 6
1
29
58,«90
2*^^ ?£
June, "
7
481 19 5
, 4 44
14
t3 6 21
21
757 42
2
40
130,362
78,5«3! H*:
July,
10
347; 2 1
4 ; 29
16
48 2 12
17
(49 16
2
59
79,999
41,700* »^
AupuHt, '•
1«
253, 9 1
• 4
33
tiO
;!3 1 10
3
442 36
6
32
113,407
50,9^; €4.^
^'eptcmlcr, "
1
2()ti 7 ; 2
6
28
10
14 1 2
8
300 15
1
11
125,408
42,45U 5L<K
October, "
11
323 12 ' 2
' 13
49
5
56 2| 5
0
506 48
...
40
166,734
48.605, SlKfl
November, "
7
342, 16 5
18
o2
12
72 6' 22
32
950 39
1
32
270.480
71,328! W.2
Dec<inber, "
25
2€C 34 4
4
47
18
78 2 13
31
f89| 40
4
28
172,800
67.4«1< ».T»
January, 1>C3
3
233 16
6
6
51
5
f.y 7' 15
30 ]
1118 53
5
28
192,776
76,620: 9^
Februaiy, "
14
3(2 11
3
2
67
(>
.-■Oi 4 11
36
822 62
2
35
216,468
€0,135; ^
March, "
14
4.V>
2H
2
10
75
4
7911 4
r4
184 121
8
56
313,848
92,788 117,n
April, "
15
375
24
4
^
62
4
154 12 10
! SI
658 137
6
40
190,518
CO.407 :«^
May, "
10
315
14 ; 3
CO
7
41 3' 26
1 30
519 101
4
36
163,711
48,589 2fJ
June, '•
.•i
222
4 ' 2
2 :'0
24
18 1! 6
27
154 44
2t)
107.153
33,«ft AlH
July, "
3
li^O
2
r>3
1 ^P'5
14
182
14,2
1013 86
7
, 12
254 11
8
72,396
20,?49 HMi^
Total
182
5732 1 299
194
8:
J4_
193
476 |]2
,785 849
72
718
i
1.056.349
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History of Cerebro- Spinal Meningitis,
425
iHteate* of the Brain and Xervout Sygtem, recorded in the Hospital Reports of the Army of the Con-
federate States of America j during nineteen months^ January^ 18G2, to Julyy 1803, Classified and
QmsoUdated from Official Reports on file in the Surgeon General's Office ^ War Department ^
Richmond^ Virginia, August, 18G3, by Joseph Jones^ M. D. Surgt^on, Provisional Army, Con-
federate States.
DISEASES OP TUE BRAIN AND NERVOUS SYSTKM.
I"?
YKAB AND MONTB.
JaDoary, 18G2 ,
Febniary, 1862
JIarch,l862
April, 1862
Maj. 1862
June, 1862
JbIj, 1862
AufiMt, 1862
September, 1862»..
October, 1862
Norember, 1862....
December, 1862....
January, 1863
February, 1863
March, 1863
April, 1863
May. 1863
June, 1863
July, 1863
4; A
, 2H
Total..
li
:v 47
5 37
4' :^
si<;::i s
1- : r
o =1
TOTAL SICK
AND
MOUSDBU.
D D — a aw
I
ll
1
4
2' 2
1, G
2] r.
1, 10
2117
1 3«
;i :J(5
8' JJ6
71 M)
1
2
1 ,
:i •
a
7
... 22
1 4 13
1 10- 1.-)
I '» 124 .
1 .'.9
...' »2
...■ 'IT* I
... 12
; (i 10
... %\
I ■* '^^
1 7' 40
U)' 4l»
3 13
1 ■
r
... 2j 7
3! 4 44
3 ...I 10
A 22 6
r. l; C
»' i»; lf»
0, 41 ii
.V...I 2
n: 21 :•
3... 12
A 1 14
l.'»
1
3 ...!
la
3 ...
18
4 ...
2f»
1 ...
3
3
4
3 i 571
lo^j!
.320.3
2472
•21
1
6
20
21 '...,
2:i I 1
V,\)\
56 21'
20 '...,
32 ...'
12 ...
2.-^ 1'
30 , 2'
KJ 13
! 51 t 1
5727
475W
2:U1 3W«»
2.'>43' 6784
""TX)! 14,0»>7
[>5i 20,120
18' 28,4:^7
Ki, 31,662
56,726
53,970
50,164
.44,282
42 1 27,784
78; 28,652
■ 24,812
20,628
57,822
46,702
55,708
84
90'4157 4;W |57 .'i71 i7o!56il56 121:^51539 47 184 I' 398,641
As Cerebro-SpiDal Meningitis did not appear in the classification of the Medical
Department of the Confederate States, the cases of this disease were most probably
entered upon the field reports and hospital registei's, under several heads, but chiefly
under the head of Meningitis. Some cases may have been recorded under the heads of
Apoplexia, Cephalalgia and Cerebritis, but certain considerations, render it probable that
the largest, numbers were recorded under the head of Meningitis.
Out of more than one million cases of sickness and wounds entered upon the field
reports daring nineteen months, January 1862, July, 1863, only 476 cases of Menin-
gitis were recorded ; and in nearly four-hundred thousand cases of disease and wounds,
entered upon the hospital reports, during the same period, only 156 cases of Meningitis
appeared ; from these facts, therefore, as well as from extensive personal observation and
inquiry, I conclude that Cerebro-Spinal Meningitis did not prevail to any great extent
amongst the Confederate soldiers. In its appearance among the armies serving in
different portions of the Southern States, its victims did not amount to such a number,
in any one district, as to at all countenance the view that the disease possessed any of
the characteristics of a contagious fever ; and the disease during the recent war, appeared
to obey no well defined laws of climate, season, or of geological and physical conditions.
The mortality records of the Confederate Army, were carefully examined with the
design of determining the mortality produced by Cerebru-Spinal Meningitis. During
the period of nineteen months, I found only one death recorded as due to this disease,
and this occurred in the month of March, 1862, and in the District of Aquia, com-
manded by Major General Q. W. Smith. The following table presents the number of
deaths from Meningitis, recorded upon the Field and Hospital Beports duripg this
period.
o4
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426
History of Cerebrospinal Meningitis.
TABLE.
Deaths from MmingUis in the Confederate Army ^ during nineteen months, January ^ 18<12, to July.
18(53. Field and Hospital Reports, Consolidated from the Official Reports on file in the Surgtvn
General's Office, War Department, Richmond, Va., August, 1863, by Joseph Jones, M. D. Sur-
geon, Provisional Army, Confederate States.
\ W H
YBAE AND ^ >
MONTH
REMARKS,
Jan'rj, 1862..
Febr'y, 1862..
March, 1862..
April, 1862...
May, 1862
June, 1862
Juljr, 1862
August, 1862 1
Sept. 1862....;
October, 1862
16 I
I
4 *-
41
3 I
3 I
Nov'ber, 1862 6
Dcc'bcr, 1862 10 i
Jau'ry, 1863..|
Febr'y, 1863..
M{
March, 1863.,| 23
April, 1863,..
May, 1863
June, 1868...
July, 1863....
15
Total.
10
2
194
fb deaths in Army of Potomac, Gen. Joseph K. Johnston.
8 deaths in Department of North Carolina.
I death in Military Dist. of Ga. 1 death in Military Dist. of So. I'a.
[ 1 death in Military District of Florida.
; deaths in Army of Potomac.
!1 death from Cerebro-Spinal Meningitis in Dept. of Aquia.
1 death. Meningitis, in General Hospital, Va.
1 death, Field Reports, So. Ca. 3 deaths, Hospital Reports, So. Ca.
; deaths. Mil. Dist., N. C. 3 deaths, Mil. Dist., Ga., So. Ca. and Via.
f 1 death. General Hosp., Va. 1 death, Mil. Dist.. N. C.
[ 3 deaths, Mil. Dist., So. Ca., Ga. and Fla.,
{32 deaths from Meningitis in General Hospitals of Virginia.
5 deaths. Mil. Dist. of So. Ca., Ga. and Fla.
1 death. Army of the West. 2 deaths, Mil. Dept. of the Gulf.
f 3 deaths. General Hospitals, Va. 1 death, Dept. So. Ca., Ga. aiiJ Fla
\ 3 deaths, Army of the. West, Gen. Brajrg.
death. Army N. Va., Gen. R. K. Lee. 2 deaths, General Hosp. Va.
death. General Hosp. Va. 2 deaths, Dept. of the Gulf.
1 death, Gen'l Hosp., Va. 1 death, Mil. Dept. S. Ca., Gu. and Fla. !
death. Army of Tenessee.
3 deaths. Mil. Dept. of the Gulf.
1 death, Gen'l Hosp., Ga. 1 death, GenU Hosp., So. Cn., Ga- aud FU.
1 death. Army of Tennessee, Gen. Bragg.
2 deaths in army, serving in and around Vicksburg,
5 deaths. Army of Tennessee.
4 deaths in Va.; 6 deaths in army, in and around Vicksburg. 1 ilwib,
Army of Tennessee.
2 deaths, Dept. N. C. 2 deaths. Army of Tennessee.
7 deaths, Va. 4 deaths amongst forces serving in and around Vicksbarg
f 6 deaths, Army of N. Va. 4 deaths, Gen'l Hospital, Va. I death, Mil.
-Dist. S. W, Va. 2 deaths. Army of the Gulf. 7 deaths, Array of Tena.
I 1 death, Army at Mobile. 1 death, Vicksburg. 3 deaths, So. Ca., t^*-
I and Fla.
f 7 deaths, Va. 3 deaths, Army of Tenn. 2 deaths, E. Tenn. 1 tlwiii.
I Vicksburg. 2 deaths. So. Ca., Ga. and Fla.
f 1 death, Va. 2 deaths, Army of Tenn. 3 deaths, Vicksburg.
I I death, N. C. 1 death. So. Ca., Ga. and Fla.
r 1 death, Va. 5 deaths, Army in and around Vicksburg.
( 1 death, N. C. 2 deaths, So. Ca. I death. Army of the Gulf,
death, N. C. 1 death. Army of the Gulf.
From the preceding table, it will be seen, that 194 deaths were reeonied upoD tic
Field and Hospital Reports, as due to Meningitis. The largest number of deaAs fro«
this disease occurred in the month of July, 1862, and 32 of the 41 deaths, recorded «?
due to Meningitis during this month, occurred in the General Hospitals of Vii^gin*
The number of deaths from this disease in the General Hospitals of Virginia, dnnnc
July, 1862, very nearly ecjualled th<^ number of cases repqi:ted.
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History of Cerebrospinal Memngitis. 427
The large armies operating within and around Yicksburg, lost 23 men of Meningitis,
in 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 conclude therefore that only a portion of the cases of Menin-
gitis, 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
chiefly 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
in the number of officers and men upon the field reports ; nevertheless the statistics are
accurate as far as the numbers, viz ; the maan strength of officers and men, and the
diseases 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
Cerebro-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 Kichmond, Virginia,
August, 1863.
RBPORTS RELATING TO A VERY FATAL MALADY WHICH OCCITRRED AMONGST SOME OP
THE TROOPS OF THE ARMY OF NORTHERN VIRGINIA, SUPPOSED TO HAVE BEEN
CEREBRO-SPINAL MENINGITIS.
/. Report of ^Slck and Wounded in 10 Companies 22d North Carolina Regiment^
stationed at Camp Gregg^ near Fredericksburg^ Virginia^ April, 1863, by F.
Gervais Robinson, Surgeon P. A. C, S.
Attention is respectfully called to four case8 of Meningitis which occurred in this command
during the month of April. They were all members of the same company, (G).
Of the three who died, J. P. Faison and Haywood Paison were brothers, and of these H.
Williams was a brother-in-law. These were conscripts, having been in camp about one
month previous to the appearance of this disease, and occupied the same tent ; the fourth
case, Hardee, who recovered, was an old soldier, having been in service since the commence-
inent of the war.
It is diflBcult to assign any special circumstance, or combination of circumstances, as caus-
ing this fearful malady. The troops were at this time exposed to no influences other than
those ordinarily incident to camp life, yet it is somewhat remarkable, that of the four cases,
three should haVe been of the same family.
Ca8i 487. J. P. Faison was taken sick on the 1 1th day of April. He complained of slight
headache, but persistent, with a general indisposition to muscular exertion. Tongue rather
pale, but otherwise normal in appearance. Pulse 90 to 100, but not abnormal in force or
relume. Bowels somewhat constipated. Skin natural. H- ^^i^i 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 14th, as there has been no abatement of the pain in the head, applied a blister to the
nape 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,
or, indeed, 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-
mortem examination.
I 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
expression of such suspicion, though another surgeon in the brigade, on whose judgment I
relied, concurred in my view of the case.
As the headache was the only persistent symptom, it was not unreasonable to look to the
brain as the seat 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 pla-mater, which, on examination, appeared to be coagulable
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428 History of Cerebrospinal Meningitis.
lymph. Oa puncturiag through the arachnoid into these patches, there escaped a thii,
serous looking fluid, the larger part of the coUectloa remaiaing adherent to the iaclosUig
membranes, but could be easily removed with the end of the scalpel ; at some few points, the
arachnoid and pijt-mater were firmly adherent. The latter membrane was more or less
injected throughout its extent. The ventricles coutaioed no abnormal amount of flaid. The
thoracic and abdominal organs were healthy, with exception of the summit of the rig^i lang,
which was found to have been disorganized by old tuberculous disease.
As Watson remarks, such cases teach us that serious lesions of the brain can exist, and
even terminate fatally with scarcely a symptom of sufficient gravity to warrant even a sus-
picion of disease.
Cases 488, 489, 490. — Of the other three cases 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 Faison, 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, (medalU
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 disorganization, which was
in accordance with the greater protraction of the disease.
The usual antiphlogistic remedies, such as purgatives, counter-stimulants to back of neck
and spine, cold to head, stimulant injections, were applied in the early stage, and stimnlants is
the latter, or that of collapse, but with very discouraging results, having lost three out ©f
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 thtt
character which would justifv the abstraction of blood.
P. GERVATS ROBINSO.V,
Surffeon P. A. C. S.
.2, Report of W. D. Mitchell^ M. Z>., Sen. Surgeon Rhodes Brigade.
Headquarters Third Alabama RiaimxT,)
February 2l8t, 1863. /
Surgeon Hunter Mc Gmre, Medical Director :
Sir : — I feel it a duty that I owe to those under my charge, as well as to my professioail
reputation, when a disease of unusual fatality has made its appearance in camp, resiitiof
all those remedial agents dictated both by theory and what little practical experience I baft
had, not only to report the existence of such, but to make such efforts as would natarallj
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 sioi-
Inr in the symptoms, with a few trifling and nnimportant variations.
It is well to remark, that in every instance the subjects have been robust, healthy men, aid
in the prime of life.
Cask 491. — Sergeant A. Gemeany, Third Alabama Regiment, aged 28 years, tall and robstt;
had been unusually healthy since his enlistment, nearly two years. On the morning of the
5th of January, he was taken with a severe chill, attended with vomiting; pains in the abdo-
men; the bowels were constipated; he suffered during the day with severe headache aid
pains in the back and neck, the feeling of chilliness continued; he was perfectly seanble
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., whei
a convulsion caused his mess-mates to call me to see him ; they had, up to this time coesid-
ered his case as one of chill and fever, and paid but little attention to the matter; this coo-
vulsion, which they described as exceedingly violent, and of nearly an half hour's dsratioD,
were the first symptoms to excite their fears.
I did not see the case until after the termination of the first convulsion, but upon arrivii;
at his tent, found him in a condition very much resembling the state of collapse of Cholert
Asiatica, (stupid, could be aroused when spoken to in a loud voice, or when shaken, botbii
answers to questions when propounded, not very intelligible), surface of body cold, and eor-
ered with bluish red particles, such as are seen in Hsemorrhagica Purpura.
There were not at this time any symptoms of either paralysis or tetanus ; the pulse Mts
full, but very slow, the pupil contracted, but responding readily to the action of light; tbc
respiration was labored, and there was a constant flow from the nostrils of a yellowiik,
slightly fcBtid fluid. This condition continued without the appearance of other synptovft
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History of Cerebrospinal Meningitis, 429
UBiil about 1 a. m., when a species of reactioa ensued, severe and entirely uncontrolable.
(Bxpectiog this, from the condition of the pulse upon my first examination, I had made the
attempt, notwithstanding the appearance of collapse, thinking that the condition of the pulse
warraated 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).
ConTulsion, 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
hoor'a duration of this condition ; the intestines had remained cold during the whole of this
time ; respiration became less labored, the pulse was jiow fast and thready. At 8 o'clock the
next morning, I found the patient fast sinking, the mutterings had ceased, respiration was
slov bat not labored, the pulse very fast, but scarcely perceptible, the pupil preternaturally
dilated, and not responding to the action of light, sphincters rela.\ed, the entire surface of
the body cold, and the spots before spoken of very much increased. With these symptoms
gradoally increasing, the patient died at 9 o'clock.
In reviewing these symptoms, to find cither a name for the disease, or to draw some analogy
with some disease already named, I must confess that my efforts have been rewarded by no
conclusion at all satisfactory to myself.
Two diseases, Cerebro-Spinal Meningitis and Typhoid Fever have elicited ray attention, to
either of which I find many points of resemblance, though I must 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 prc-disposing and exciting causes, or rather such as in my opinion
would be so considered, has caused me lately to lean very much towards the Typhus nature
of the disease, lu 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 Small-Pox come
under this head), resembling the symptoms which 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 you 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. I). MITCHELL,
Sen. Surff.j Rhodes^ Brigade,
P. 8. I have seen in my Regiment, the 3rd Alabama, 8 cases perfectly well marked; six
(6) were fatal.
S. Report of •/. T, Banks j M. D., Sar^eon IJth Reginmnt, Ga. Vols,
Camp Near Fridbricksburg, )
Med. Dep., 13th Ga. Reg., March 28th, 18G3. I
Near Hamilton's Crossing. j
Surgeon JIunier McOuire^ Medical Director :
8iR. — 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
stout, healthy soldiers, three or four of them careless of protection, confident in their physical
endarance, and all inured to camp life; ages from 19 to 27 years.
Cask 492. Thompson, 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 his brother prepared his pallet, and he retired as he thought to sleep it off, but in place
of sleep, continued to complain until he was attacked with a chill, which lasted several hours.
His 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 passed
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 mucus; 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. Bowels acted well on pre-
vious day. Pain very severe in both legs, and in them alone would he acknowledge to any
pain, but 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 iii.
Called again at 6 o'clock, a. m. Condition same. I applied cups to nape of neck and drew
2 ozs. of blood, bnt 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, arouse his liver to action and facilitate the subsequent
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430 History of Cerebrospinal Meningitis.
absorption of medicine. Tiie matter ejected was the fluid which the patient bad Jast dmak,
with a little glairy mucus — no appearance of any bile.
Seven o'clock, a. m. A little change in the blush of his face, the purple tinge has increaaed
slightly with a little more depression in his circulation. (Quinine, grs. iv ; Camphor, grs. fi :
Capsicum, grs. vi ; Calomel, grs. iii ; mix administer at once, and repeat every hour ; Mustard
Plaster over the entire length of the spine).
Ten o'clock, a. ic. Circulation has failed; rapid pulse at wrist, can only be felt every 4th or
5th beat. Cardiac impulse quite feebla. Continue treatment.
Noon. No pulsation at wrist; purple tinge of face increasing. Pain continues unabated.
Though pulseless, the patient is able to rise from his pallet, and with the aid of two comrades
walk out of his but and evacuate his bowels. (Continue medicine ; repeat Mustard to spiae,
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 froa
.Mustard; paiu in legs intense. No effect 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. Flufch of face changed to a mottled, purplish hue. (Camphor and Ammonia
Julep, continue Qninine and Capsicum).
The patient continued to sink, and died at 1 1 o'clock p. u. His mind continued clear, and
he complained of the same pain as long as he could speak. Had two actions on his bowels
during his illness.
Post'Mortem 12 Hours after Death — Ejcternal Appearance. — Features very little changed, limb?
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 Viscera. — No change in the peritonaeum. Small intestines a little injected. No
change in the appearance of the large intestines. Coecum, ascending and transverse, colon
contained some foccal matter. Bladder full of urine.
Spleen almost twice its normal size. The compftrative increase of weight of this organ mast
have been greater than the increase of size, judging from its weight in handling it; dark
rolor, friable, and bleeding very freely when torn.
Gall-bladder distended to a great size by yellow, healthy-looking bile — no Obstmctioo to
its exit.
Viscera of Chest. — Right lung, lower lobe, very much engorged, with some semi-organiied.
plastic lymph over lower border, also some engorgement of posterior middle lobe; upper lobf
and left lung healthy.
Pericardium natural. No effusion in cavity. Heart 'increased in size about one-siith.
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 emptjinji
into heart full of fluid blood.
Brain and Membranes. — A slight cloudiness of the arachnoid, with three small, opaque spots,
well defined, of the same membrane, on the upper portion of the left cerebral hemisphere. Id
the removal of the brain, about three ounces of blood escaped. No effusion in the veotriclef,
(yohesive power of tissue natural ; color natural. Blood congested in the veins.
Remarks. — The information obtained in the examination of Thompson is both positire and
negative. Negative, in that no organic lesion was detected that can account satisfactorilr
for the destruction of life. But slight information based upon positive phenomena were
detected, and they produced no symptoms during life to diagnose their existence. We have
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 freelj of
dark, venous blood, indicating excessive engorgement in connection with its increased size:
and the corresponding augmentation of the spleen may account for the deficient capillary cir-
culation, as well as the systemic circ\}latioo. The heart thus robbed- of a portion of iti
accustomed stimulant, must be correspondingly weakened in its action, which, in its torn of
cause and effect, must add negatively to the coldness of the surface and defective circnUtiofl
in the extremities. In the congested condition of the liver and spleen, they act as a reserroir
for the circulation, which, peuned np in the carbonized state, must, (if the theory of reflex
nervous action be^rue), 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 motn-
ing and irregular breathing, and in some cases the congestion of the lungs, the result of the
impaired action of the pneumogastric nerve in the carbonized state of the brain.
This condition lasting any considerable length of time, the nervous system is necessariW
overpowered, and as power fails, co-existing with the congested state producing it, destruc-
tion of life must be the result, notwithstanding no organic lesion maybe detected sufficient to
account for it. One of the functions of the liver, the secretion of bile, was still in action, ti
shown by the full gall-bladder — no organic lesion existing, though greatly conge.^ted, suffi-
cient to prevent it from performing its highest function.
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History of CerebrO" Spinal Meningitis, 431
What agency, if any, did the heart clots have in this 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, even before the strength of the muscular system had failed enough to prevent
rising and walking: about in their huts. One of the cases 1 found pulseless when I first 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 inflammation,
the slight, opacity of the arachnoid being its only indication, and it gave rise to no symptoms
of its existence.
Sargeon 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, and treated by Prof. Byrd, of Savannah, Ga., who assisted in the examination of the
case placed under bis 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
50 diagnosed, the first by Surgeon Jelks, the second by Surgeon Byrd. In the examination,
less morbid action of the brain existed than in the caseof 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 naturcof 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 are the symptoms of its existence constant, in some cases no evidence
uf undue 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,' the course which one of
them ran, the association of the disease, and the result of the examination, (abundant in
itself, 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 JFevcr.
The case referred to above is the fourth case of this disease occurring in my regiment.
lUs case lasted long enough to give some idea of the type. His chill came on in the evening,
lasting forty or fifty minutes, and was followed 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 ai 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 Diarrhoea, Dysentery and Influenza.
Oar inlermittents have been well marked, generally mild, and yielding kindly to treatment.
In 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 ni<;ht time. The pain in
these cases is in many respects like that of Dengue, but dissimilar in evrvthing else. The
post-mortem appearances of the liver and spleen are not new features iu ibo course of Inter-
mittent and Remittent Fevers, and I feel quite certain that the fatality of tlse Congestive or
Pernicious Fevers, would be equally as great under similar circumstances.
Bnt a devotee to a perfect 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
modas 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,
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432 History of Cerebrospinal Meningitis.
Buveral iiours before death, in cases lasting ten or twelve hours. The purpura is CTideollj
the disorganized blood in the sub-cutaneous tissue, and it may be that this disease-prodaciog
element is a blood poison of some kind, like that of Scarlet Fever, Small-Pox, Diptberiaf
Cholera, etc., which, when imbibed sufficiently overwhelms the nervous system, chaDging
the chemical and reciprocal affiinities and tissues, and ending in the phenomena presented br
these cases.
I am, sir, very respectfully, your obedient servant,
J. T. BANKS,
Surgeon^ Thirteenth Regiment^ Georgia Volt.
Report ua (he Pn'ccdlny Papers, hy Surgeon R, «/. Breckenridge, Inspector of Gumps
and Hogpitah, Army of Northern Virginia,
Office Medical Dirkctor Army op Northern Yirgisiu,)
August Uth, 18G3. i
Surgeon L. Guild, Medical Director Army of Northern Mrginia :
Sir . — Having carefully considered the papers referred to me, from Surgeon Mitchell, Sen.
Surgeon Rhodes' Brigade, Surgeon Banks, Thirteenth Ga., Surgeon P. Q. Robinson, Twenty-
second N.tC. Regiment, bearing date, respectively, February 21st, March 28th, and April,
1863, all relative to a certain form of disease deemed worthy of special mention, — I respect-
fully return them, with the subjoined brief analysis ofj their contents, with my opinioo of
the real nature of the cases reported.
This opinion, it is proper to add, was originally written on Surgeon Mitcheirs 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 anxiously sought by me,
was unattainable, owing to the fact, 1st, namely, that none of these officers reported theie
cases, until they had nearly, if not altogether, ceased occurring; and, 2d, that the mott
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 Surgeon Robinson.
Surgeon Mitchell had 8 cases, 6 of which were fatal, but he reports only one — that astbe
type of them all. Surgeon Banks does not state the number'of his, nor their relative mor-
tality, but gives a history of Case No. 5, as typical. Surgeon Robinson bad four cases, tbm
of which were fatal. The case reported in detail was the least grave in its objective featnrei,
but furnished, upon post-mortem examination, evidences as clear, though not so great, of itf
true pathology, as the two others examined. It is greatly to be regretted, whatever may be
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 natore.
Surgeon Banks thinks his belongs to the class of " Pernicious or Congestive Fevers," thougb
I do not perceive the force of his reasoning, and cannot acknowledge that bis conclusion
are 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 sbowD
by the scalpel. My conviction, however, is that but little importance is to be attached to tbe
idea of any family tendency, 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 "Pernicious
Fever," though his own cadaveric section fully recognizes the co-existent inflammation of tke
cerebral meninges, while the condition of the spinal is not even reported examined, and tothe
close analogy of symptoms in some respects, in his cases, to those belonging to undoubted
cprehro-spinal inflammation on the one hand, and Surgeon Mitcheirs cases on the other ;^
and finally to the extraordinary corroboration of my views recorded last March, by the resoU
of Surgeon Robinson's post-mortem examinations, in all of which notable evidences of the
existence of this disease were found, I submit the following extract from my response to Sur-
geon McGuire's endorsement upon Surgeon Mitchell's report, referring it to me for ao expres-
sion of my professional opinion upon the cases therein reported, as a statement of my views
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 examii-
ation.
* * 3d. I think Dr. Mitchell is right in considering this disease either a Cerebro-^piotl
Meningitis, or, on the other hand, an essential typhus.
As it has come under his observation, it is either epidemic or contagious, or both. Soia
Typhus, It is rapid in its progress, more 90 than Typhus gep^rally is. It seems to have beei
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History of Cerebrospinal Meningitis. 433
atteoded bj more spasms and conyulsions than usually belong to Typhus. While, on the
ot&er hand, the spotted appearance of the skin, (undoubtedly I suppose the result of an effu-
sion of disorganized blood), presents a marked likeness to some cases of Typhus, 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 a new 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 :
1st. Cerebro-Spinal iMeningitis, though an active and violent inflammation (more parti-
cularly of the Arachnoid,) yet has these features in common with Dr. Mitchell's cases.
a. It is epidemic at times. No less than three epidemics are recorded in France, Ireland,
and Gibraltar.
b. It is extremely rapid in its termination, 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 that the disease rarely attacks persons after puberty.
Vet Dr. Gilkrist in bis 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 France, attacked mainly
"Conscripts who had lately joined their Regiment."
3d. Now for the symptoms. The symptoms by which the disease commences are in general
of a very formidable character, and its accession is usually sudden, and quite unexpected ;
in the majority of 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 foar of the cases in the South Dublin Union, the boys had eaten a hearty dinner, and
retired to bed in apparent health, when the disease all at once declared itself. In many
instances 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 assumes very much the tetanic expression ; twitchings
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
irritable whilst an insatiable thirst torments the sufferers, and the epigastrium evinces marked
tenderness upon pressure.
i^ymptoms of a still more serious nature quickly supervene ; the patient may be seized with
general convulsions of a frightful severity, requiring personal retainment, to prevent him
from injury,^r 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 becomes 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. Examples are on record of death from the disease in as
short a period as fifteen hours. Fatality in France, 80 per cent. The only statistics before
me give : army soldiers, 195 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 infiammation. 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, i. 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 glauds of peyer in Typhoid, or the joints and heart in Rheumatism.
I am sir, very respectfully, your obedient servant,
Il.^J. BRECKENRIDGE,
Surf/eon and Inspector of Camps and ffospUaUj
Army of Northern Virginia.
l)r Kobiusou published an account of the four cases of Cerebro-Spinal Meningitis
recorded in his report of sick and wounded in 10 Compauies^ 22d Noyth Carolina R^-
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434 History of Cerebro^Spinal Meningitis.
ment, previously given in the Confederate States Medical and Surgical Journal, Vol. ii.
No. 2, February 1865, p. 33. The published account did not differ in any essential
respect from the official report.
The following article by Surgeon Gr. A. Moses, of Mobile, Alabama, together with
the matter presented in this chapter, includes, as far as my information extends, every
thing contributed by the Confederate Surgeons, on the subject of Cerebro- Spinal Menin-
gitis, during the progress of the American Civil War.
Epidemic Cirehro- Spinal Meningitis^ hy Surgeon G. A. Moses, Mobile, Alabama.
During my connection witli the Army, my attention has been at various times, attracted by
a disease which had hitherto never come under my observation. It is that type of Oercbral
disease, known as Cerebro-Spinal Meningitis. It occurred 1 believe at Bowling Green, during
the winter of 18G1-1862.
In the succeeding winter, while the Army in the West, was at Grenada, Miss., this disease
made its appearance among the negroes employed upon the fortifications, and also among
plantation bands, in several adjoining counties. Again during the past winter, 1 bare
observed it at this place, almost entirely confined to the blacks, both those employed hr
Government, and others. Some cases have occurred amongst tlje citizens, principally in
children. The disease is marked by its rapid course, and fearfully frequent termination. 1
have heard of but few reported recoveries, and have seen none.
The first account* I find of a diseaseresembling this, but unnamed, dates in 1310, whco
it ftppcared in France ; it is not again mentioned until 1 503. A disease almost similar appeared
in 1510 and 1517; after a very severe winter, (1553) in Silesia, it carried off large nuinb«rs
of the population In 1580, associated as now with Catarrhal affections, it killed no less than
10,000 persons in Rome, 12,000 in Madrid, and proportionally large numbers in other citiw.
During the Civil Wars in France, 1616, Ozenaur says, "The armies both Catholic and Proiei-
lant, are decimated by a new disease," the subjects being attacked by *• sudden and furious
pain in the head.'' It Insied more than three months, ajid but iew were saved. Sydenbftm
reports it in 1661 and 1664, as selecting theyoung and most robust subjects and as partaking ol
the type of Typhus. In 1788, during an epidemic of Typhus in Lyle, a disease appeared
more nearly approaching to the character of the present epidemic. It was accompanied wiib
tetanic convulsions and coma, the pia-mater being chielly involved. Not until 1830, wasuij
name given to this disease, when upon closer examination, were more fully vindicated its 9«t
and nature. Of late years, it has occurred in many portions of the Confederacy. No sufficient
cause has yet been assigned for its appearance or cessation.
M. Toudes, in his valuable paper, has published statistics of attributable causes, and assipnJ
the abuse of alcoholic stimulants as the chief— but of 136 cases quoted, in 100 cases, the
cause is " unknown.^*
As it has occurred in the Army, it cannot be attributed to alcohol, as amongst its victimi
this stimulant could but rarely be obtained. It appears generally, if not universally, during
cold, wet winters, along with severe types of pulmonary complaints, and passes through tht
stages of all serous inflammations.
It is remarkable for the suddenness of its declaration, its rapid development and termination.
The subjects generally the young and most robust, are to all appearance in good health; \
chill, or pain in the head, first attract attention ; in a very few hours the patient grows stupid,
pain in the head appears to concentrate about the base, the neck becomes stiff, pains are fell
in the extremities, or in the abdomen.
These signs increase until the muscles of the neck and back become rapidly contracieJ.
giving almost opisthotonos ; the smallest movement of a finger or toe, is attended with inteo^
pain ; the pupil of one or both eyes is dilated or inactive, or their action is reversed; coroi
occurs, often trismus ; the tongue until now moist and normal in color, or, as is more usatl,
covered with a whitish fur, becomes dry, hard and swollen ; bowels obstinately constipated,
pulse small and slow, respiration labored, profuse diaphoresis, and in a short time dealii
closes the scene, or the patient may have an intermission of the severe symptoms for twel"
or twenty-four hours, the physician may hope until suddenly a relapse takes place, with faul
ending.
Treatment has been of but little benefit— everything has been recommended and tried, with
poor success.
M. Rollet advised general blood-lettiog, leeches and cups to length of spinal columo. «>r
actual* cautery, with sinapisms, and blisters of Ammonia, covering the whole body. Griswie
in addition, recommends Mercury, Ganssauch trusts to Quinine, Chauffard to Opium ialar^
doses. They all lost from sixty to eighty per cent, of the cases. After the disease has pro-
♦VId, History of Epidemic, Cerebro-Spinal Meningitis; Bibliot^que d« M^dcein Practicien, Vol. ix.
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History of Cerebro- Spinal Meningitis. 435
greased to the extent it maj in four or six hours, no medicine appears to act, Croton Oil failing
10 move the bowels to action.
The first symptom of the disease, which attracts attention, appears generally to indicate
not the commencement of disease, but its maturity, as in those cases which die in from ten to
fifteen hours, with large effusion of lymph in the pia-mater. Insidious in approach, it declares
itself at a time when interference is of no avail.
I am indebted to Dr. S. C. Young, P. A. C. S., for information regarding the course of this
disease at Grenada, Miss. Of thirty-five cases which came under his observation, he knows
of no recovery; one wa3 apparently improving, 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 difficulty 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, this epidemic appears to depend 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 flush 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
vasculosa 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.
Notes or Cases. Case 493. — 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
morning condition as follows : Pulse 64, 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
Hydrarg: Chloride: Mit: pulv. Jalapae aa grs. x., wet cups to chest; cold douche to head to
be applied continuously for half an hour, and ititermitted for some length of time, and so
alternately during day ; whiskey 1 drachm, every half hour, as long as necessary to produce
effect. 5p.m.; Pulse 80, very irregular, soft and quick; respiration 28; has been noisily
delirious and difficult to restrain in bed, since 1 p. m. pupils largely dilated and inactive;
passing urine involuntarily; spit out purgative this morning; skin of natural heat; cries as
though suffering ;■ continue whiskey and douche.
March 25th, 9 a. m. — Pulse 94, small, soft and regular; respiration quiet and easy at 28;
pupils contracted to a very small size and inactive; deep coma; left side of face warm, right
side cool. Body and extremities warm; diaphoresis ; tongue dry, continued whiskey as often
as could be administered. 4 p.m. — l^ulse 110, fuller and soft; left pupil acting a little less
promptly than normally ; right pupil still contracted and motionless ; face and skin same as
this morning — not so^much perspiration. Continued whiskey. 6 v. m. — No change except
that respiration is somewhat quicker.
March 2Cth. — Died at 6.] a. m. ; Autopi^y at 4 p. m. ; body still unusually warm, although
weather is 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 commissure, across and around the pons varolii and
medulla oblongata ; arachnoid in some places bound down by bands of lymph ; the deposit
enters the convolations, along with the pia-mater ; lateral ventricles contain turbid serum,
with flakes of lymph. Spinal cord posteriorly covered with same lymph deposit.
Case 494, March 10th. — Henry, slave, age 25 ; entered hospital March 29th, 9 p. m. Com-
plained from the first of pain in the head, so intense thai he constantly emitted cries and
groans; pulse weak, at about 90 ; tongue moist and white; pupils slow to act; had a chill
before entering hospital.
March 11th. — Pain increased, no change otherwise; is taking 5 grains Iodide of Potassium
etery hour. 12 h. — So noisy that he was moved to a detached room ; seems to be suffering
intensely ; still conscious, but no answers can be elicited. 4 p. m. Pulse somewhat increased
in frequency; tongue dry ; pupils dilated and almost inactive; coma commencing. 13th, 10
A. 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 14thv — Died at 4 a. m.; Autopsy at 10; usual appearance of congestion and lymph
deposit around aiachnoid and pia-mater; pacchionian bodies enlarged; large deposit of
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436 History of Cerebrospinal Meningitis.
lymph and pus at base of brain, especiallj over pons varolii and medulla oblongata ; Bub-
stance of cerebellum reddened and slightly softened superficially.
Case 495. — March 19th, 6 o'clock p. ic.; John, slave, age 28 ; has been sick for two daji
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 natural ; inclined to be stupid ; tongue dry and covered io
centre with a white fur ; pupils much contracted and motionless ; complains of pain in head,
and neck, and in extremities, especially in superior; ordered whiskey, J ounce every hour.
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. fl. 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 admmhn »f
light. Death occurred on the fifth day. Post-mortem examination revealed : enlargemeDt
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, after bleeding by cups to the extent of ten ounces.r-Confederate States Medical
and Surgical Journal, Richmond, August, 1864, vol. i, No. 8, pp. 113-115.
Afber the close of the war, articles and observations on Cerebro-Spinal Meningitis
were published by several Southern physicians, as Prof. E. S. Gaillard, M. D., Rich-
mond Medical Journal, Vol. 1, No. 3, pp. 204-212, March, 1866; William O'DtniA
M. D., of Marion, Ga., Atlanta Medical and Surgical Journal, Vol. 8, No. 1, pp. IT.
18, March, 1867 ; James S. Dyer, M. D., of Hart^ville, Tennessee, Nashville Jounul
of Medicine and Surgery, June, 1867, pp. 472-478 ; Prof Juriah Harris, M. D., of
Savannah, Georgia, Savannah Journal of Medicine, July, 1866, p. 219; H. M.Lawson.
M. D , of Cuthbert, Ga., Med. and Sur. Reporter, August llth, 1866, p. 141 ; W. w^.
Armstrong, M. D., of Atlanta, Ga., Atlanta Medical and Surgical Journal, June, 1866,
vol. vii. No. 4, pp. 145-151 ; W. C. Moore, M. 1)., of Atlanta, Ga., Atlanta Medical
and Surgical Journal, January, 1867, p. 491 ; W. 0. Baldwin, M. D., of Montgomeiy,
Alabama, Am. Jour. Med. Sci., Oct., 1866, pp. 321-338; J. W. Moorman, M. D.,of
Hardingsburg, Ky., Am. Jour. Med. Sci., Oct., 1866, p. 336 ; J. H. Southall, M. D.,
of Little Rock, Ark., Rich, and Louisville Medical Journal, Aug., 1872, p. 138; John
L. Cook, M. D., Elizabethtown, Ky., Rich, and Louis. Med. Jour., Nov., 1872 p. 555:
J. A. Larrabee, M. D., Louisville, Kentucky. Rich, and Louis. Med. Jour.j Dec., 1873.
p. 764.
In like manner, various Northern and Western 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. W. W. Gerhard, Am. Joar.
Med. Sci., July, 1863 ; J. B. Upham, Boston Medical and Surgical Journal, 1863,
and Sept. 3d, 1874 ; J. S. Jewell, of Chicago, Report made to the Illinois State Med-
ical Society, June, 1866 ; Chicago, 1866; S. G. Webber, Boylston Prize Essay, 1866,
reprinted from Boston Medical and Surgical Journal, 1866 ; L. Parks, Report of i
Committee of the Massachusetts Medical Society, May, 1866, Boston, 1867; J. J«
Levick, Trans. Am. Med. Ass., vol. xvii, 1866 ; Sti\\6, Philadelphia, 1867 ; Githens,
Am. Jour. Med. Sci., July, 1867.
The fects recorded by these and other observers, will be considered under the aj^ro-
priate divisions of this investigation.
Dr. S. G. Webber, in his Essay, which received the Boylston Medical Pri«e, 1ms
recorded the following facts with reference to the prevalence of Cerebro-Spinal Menin-
gitis in the Northern Army and States. The earliest records of the late epidemic are
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 who
were taken to Memphis, Tenn., by the Union army, and one or two cases were met
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History of Cerebro-Spinal Meningitis. 437
with among the Union soldiers in the vicinity of Newbern, N. C, during the winter of
1862-63, and spring of '63, it appeared in La Grange County, and other portions of
Xorthem 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
Xaval Academy •, in February and March it was seen at Philadelphia, and during thq
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 visited 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 this year, and also in
1862 and 1863 ; only a few cases occurred around New York. During January it
was in Brattleboro, Vt., during January and February in Philadelpliiii, and at Benton
Barracks, near St. Louis, Mo. During March it was seen in Brandon and St. Albans,
Vt, and Louisville, Ky., and during January, April and ]March, cases were seen in
Boston, Mass.; during May, at Chicago, at Leland, and in Williamson County, Ills.;
Darinp; 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. During the winter
of 1864-65 a few cases were seen at the City Hospital, Boston; in January, 1865, at
Greenwich, and in April at Palmer, Mass.; in the latter month at Kewana, Fulton
County, Ind., and early in the year at Palestine, near Indianapolis, Ind.; in May, at
Nittany Hall, Penn. From September, 1864, to May, 1865, this disease appeared
arnoncr the troops on Gallops Island, Boston Harbor, Miiss.; cases occurred in Boston
in 1866. — Boston Medical and Surgical Journal, vol. Ixxv, pp. 183, 184. 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 Massachusetts the disease appeared
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.
Journ., Sept. 3d, 1874, p. 222.
Daring the winter of 1872 and Spring of 1873, Cerebro-Spinal Meningitis, (Kpidemic
Meningitis), prevailed in New Orleans to such an extent as to attract some degree of
attention ; 79 whites and 41 colored (total 120), having fallen victims to this disease
in the six months ending June 1st, 1873. During this epidemic I repeated the obser-
vations which I had made upon this disease during the civil war of 1861-1 865, and
confirmed the conclusions which I had previously adopted, viz : that
1st. Cerebro-Spinal Meningitis Is characterized by true injiammatori/ symptoms,
vis : Increase of fibrin in the blood, elevation of temperature, derangement of digestion
and aberration of nervous and muscular phenomena. I'nlike the true fevers, the bli^od
is charged with fibrin, and fibrinous deposits are found within and around the inflamed
meninges of the brain.
2d. Post-mortem examinations in New Orleans confirmed my previous view, that
the disease consists essentially of an inflammation of the arachnoid and pia-mater of the
braia and spinal cord, and that in some cases the structures of the cerebro-spinal cen-
tres 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 eflfects caused by the pressure of the coagu-
lable lymph and effusion within the unresisting, bony cavity of the cranium and si)inal
cavity.
4th. The onset of the disease is in most Ciisas sudden, and characterized by chills
or chilly sensation, intense and excruciating pain in the head, and in the back and
moseles of the lower extremities; vomiting; opprcsse'l and labored respiration, irregu-
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438 History of Cerebrospinal Meningitis.
lar, feeble pulse, convulsive, muscular movements, jactitation, hyperaestbeeia, delirium
and opisthotonos.
5th. The duration of the disease is not governed by fixed laws, as in the idiopathic
fevers, as 8mall-Pox, Varioloid, Measles, Scarlet Fever, and Typhus and Typhoid
Fevers, but is governed by the nature and extent of the primary and secoDdaiy JocaJ
lesions. In cases in which the brain and spinal cord are greatly congested, the fatal
issue may occur in a few hours, from deficient and pervarted nervous supplies, and
arrest of respiration from the profound lesions of the madulla oblongata. Many case>
may continue for weeks and even months, manifesting various disturbances of the nervous
and muscular systems, attended with daily elevations and depressions of temperatnn?.
as in Typhoid Fever and Hospital (langrene, and finally terminate fatally.
Gth. It results, from the nature of the lesions in Cerebro-Spinal Meningitis, not
only that the disease may be of indefinite duration, but also that recovery in some cast's
is more to be dreaded than death itself.
The following case, illustrating the preceding statement, came under my observation
during the prosecution of my investigitions upon this disease, in 1872 Bnd 1873:
, Case Jf97 : lUastratiiig the Permanent and Disastrous Effects which may result /mm
Inflammation of the Meninges of the Brain and Spinal Cprd.
Charles Smith, age 21, native of Vicksburg, Miss, roulatto. He is said to have been i
healthy child at the time of his birth, and remained so until he had attained the age of nine
months, at which time he was seized with violent convulsions, dependent apparently npoo
intjammation of the base of the brain and spinal cord. The effects of this disease were com-
plete paralysis of the arms and legs, rigidity of the spine, paralysis of the tongue, and arrest
of mental development. The head and trunk of Charles Smith have attained the size of those
of a man, whilst Che arms and legs are withered, contracted, contorted, and utterly useless,
and powerless. Up to the present time, Charles Smith has remained utterly helpless, and
emits only weak, inarticulate sounds. During the past 20 years, he has remained more help-
less than an infant, and is one of the most afflicted and pitiable objects that I have ever
seen.
If Cerebro-Spinal Meningitis be related to the membranes of the brain, as Pleuritis is
to the investing membrane of the lungs, it should be classed with the pJdegmnsift, in
which there is an actual increase of the fibrin, and not with the pyrexiae, in which thtf
element is deficient ; and in the character of the lesions of the cerebro-spinal system,
we have an explanation of that striking and important fact, that amidst a marked
uniformity of symptoms in different cases, and in different epidemics, in various coun-
tries, and at various times, the duration of the disea.se is as indefinite as that of Fleuritt:
or Pericarditis.
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CHAPTER VTI.
NATIRAL HISTORY OF CERKBRO^««iI»INAL MKNIN(JITIS. CUANCiKS OK TRMPERATIKK, PILSE AND
BESPIRATION. PATHOLOGICAL ANATOBIY OF CEREBUO-SPINAL MENIN(;iTlS.
PULSE.
Every variety of pulse has been observed in tho same epidemic, and even in the
same patient
In cases which run a rapid course 'o a fatal issue, as a general rule, the pulse is
small, weak, thready, and intermittent, increasing in frequency until nothing but a
tremulous motion is felt.
In some cases it is full, tense and slow, and the frecjuency of the pulse is not a
prominent symptom of the disease ; in others its rate and volume are subject to repeated
variations, sometimes rising, during the course of a few hours, from 30 in a minute to
130, 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.
Any slight exertion, as rising from the recumbent to the Jritting posture in bed, may
double its frequency, and render it irregular.
It is evident, from the preceding facts and observations, that it is impossible to estab-
lish a rule for the variation of the pulse in frequency and force, as we may do in certain
diseases, as Yellow Fever ; on the other hand, the diminution of force and volume, and
the impairment of its tone to such a degree that slight causes produce extreme varia-
tions iu its rate and rythm, indicating great diminution of the powers of the heart, are
characteristic qualities of the pulse in Cerebro-Spinal IMcningitis, and distinguish this
disease from the essential fevers.
The enfeeblement and irregular action of the general capillary circulation in Cerebro-
spinal Meningitis, is directly referable, not to a poison in the blood, but to the effects
of the characteristic meningeal inflammation with its attendant congestion and effusion
upon the vaso-motor and respiratory nervous centres of the brain, medulla oblongata and
spitial cord. No extended di.scussion of this subject is needed in support of the pre-
ceding proposition, as the relations of the circulation and respiration to the cerebro-
spinal and sympathetic nervous systems have been considered in the first, third and
fourth chaptci-s of this work.
RESPIRATION.
As a general rule, the respiration is embarrassed in relation tt the gravity of iho case,
and the extent and pasition of the meningeal inflammation and fibrinous effusion. As
in the case of tho pulse, the respiration may be rapid or slow, without referonce to (he
other symptoms ■ iu general it is difficult, sighing, labored and interrupted, the insjH'ni-
tion especially bo^pg laborious and prolonged. The disturbances of respiration are to
be referred to tho^mc general causes as those of the capillary and general circulation,
viz : to the iavoJv^Vftent of the respiratory ganglionic centres, either directly or second-
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440 Natural History of Cerebro^Spinal Meningitis.
arily, by the pressure upon the base of the brain, medulla oblongata and spinal cord,
induced by congestion and effusion. There are no facts to show that the respirator}-
changes are caused by the presence of a specific poison in the blood.
TKMPEHATrRE.
In all the cases of Ccrebro-Hpinal Meningitis which I have observed, the temperatnnc
is elevated above the normal standard, and is subject to diurnal variations, and in
Home cases attained the degree Qf 107 F. In many cases, however, which recover, aod
even in fatal cases, the temperature does not attain the high degrees which are 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 :
Case 49s : CerehrO' Spinal Meningitis.
Thomas Kunan, tet. 20, native of Ireland ; entered Charity Hospital, Ward 13, Fcbruarr
I4th, 1873. Comatose; neck and back stiff; opisthotonos. Under the use of purgatirev
Quinine, Opium, Bromide of Potassium, and Chloroform applied over spine, the patient recof-
ercd sufficiently to sit up in the bed, but died suddenly in convulsions, February 26tb, on the
12th day after entering my wards.
The temperature in the axilla ranged from 100° F., to 102® P.
In the following severe case of Cerebro-Spinal Meningitis, which recovered, the high-
est temperature observed in the axilla was 105° F.
Gme Jf^OU : Cerehro- Spinal Meningitis.
Joseph White ; occupation, hotel waiter, (St Charles Hotel) ; age 19 ; native of New York.
Brought to Charity Hospital in a carriage a short time after complaining of being sick, Jan-
nary 4th. 18T3. Whilst giving his name in the clerk's office, fell upon the floor in a violeDl
convulsion. Entered Ward 13. 1 saw this patient shortly after his entrance ; the convaluofi
was followed by delirium, and continual rolling of the body from right to left, the masclrs
of the neck and baek being firmly contracted, and the head drawn backwards. PupiU greatlj
dilated. Pulse moderately accelerated. Temperature high, but subject to marked oscill*-
tions. The patient could not be kept in bed without mechanical restraint, on account of the
constant rolling and twisting of the body from right to left. I had to confine him ia bed, bj
high boards nailed to the bed-posts. A blister was applied to the back of the head, and orer
the superior portion of the spine, and the bowels, which were constipated, freely opened by
I'alomel ^ and Hydrate of Chloral, Bromide of Potassium, Quinine and Opium were freeljr
administered internally. An effort was also made to bring the patient under the inflaence of
Mercury by means of the following : IJ. Hydrargyri Subchloridi (Calomel), Qi ; Fair. Ipecac
ct Opii (Pulv. Uoveri), J)iss; Quinijc 8ulph., ^ss ; mix; divide into 10 powders; one powder
every 4 hours. The preceding prescription was repeated several times daring the active
stages of the disease. On the 18th, the violent contortions of the body were somewhat miti-
gated, and the patient, although delirious, was able to complain (when aroused) of inttase
imiu in the head.
Temperature, morning, 101°. 1 F.; evening, 105°; pulse, morning, 70; evening, 104; respi-
ration, morning 20 ; evening 32. Jan. 14th, patient more ratioaal, but still has opisibotoios
and complains of intense pain in the head, and is occasionally delirious and tarns in bed.
Temperature of axilla, morning, 100° F.; pulse, 72; respiration, 24; temperature, evening.
IOj; pulse, iOG ; respiration, 30. Continue Calomel, Dover's Powder and Quinine. 15ib.
morning, temperature, 101°. 8 ; pulse, 85; respiration, 21 ; evening, temperature, 104° F.
l(jth, morning, temperature 100°; pulse, 78; respiration, 20; evening, temperature, 103*.i;
pulse, G8 ; respiration 20. 17th, patient says that he feels better this morning, and retted
well during the night, still complains of some pain in the head. Temperature, morninfr.
f)8*'.9 ; pulse, 00; respiration, 28; evening, temperature, 104°.9; pulse, 80; respiration, 3S.
18th, continues to improve; morning,\temperature, 98°. 5 ; pulse, 80; respiration, 28; even-
ing, temperature, 98°. 5; pulse, 80; respiration, 24. 19th, patient complains of severe pain
in head, and along the spine ; there appears to have been some increase in the local inflanaa-
tion, and this has been attended with a sudden rise of temperature, from 98°.5,on theeveainf
of the 18th, to 104° F., on the morning of the 19th ; the pulse also was increased to 100, and
the respiration to 32. 1 repeated the compound of Calomel, Quinine and Dover's Powder, anJ
rubbed Croton Oil over the spine. These measures appeared to be productive of good. The
Hydrate of Chloral and Bromide of Potassium were also repeat^, ia doses varying from 20 to
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Natural History of Cerebro- Spinal Meningitis.
441
30 grains of each, at intervals of from three lo four hours. At 8 p. m., the temperature of the
azilla had fallen to 101° F.; pulse, 84 ; respiration, 28. 20th, patient continues to improve ;
morning, temperature, 98°.3 F.; pulse, 84; respiration, 24 ; evening:, temperature, 10 1<^;
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 3d. The disease continued unabated for IG days, and the patient was able to walk,
8nd was fully restored to health on the 30th day. Throughout the disease I endeavored to
maintain the strength, by milk punch and beef tea, and moderate quantities of alcoholic
stimulants, administered at short and regular intervals.
Tlie following table presents the oscillations of the temperature, and the pulse and res-
piration during 13 days—January 13lh to 25th :
D A T K .
January 13lh,
^' * 14th,
15th,
16th,
17th,
18th,
19th,
20th,
21st,
'* 22d,
'» 23d,
24th,
25lh,
DAYS TKMPKR.\TUIIE.
OF '
P U L S K .
RESPIRATION.
DISEASE.
I Morning, j Evening. Morning. Evening, j Momiog. Evening,
1873 8th.
*' 9th.
" 10th.
** lllh.
»* rjth.
" ..... 13th.
*♦ j 14th.
" I 15th.
" 16th.
" 17th.
»» J8th.-
'' 19ih.
♦• 20th.
iOl^.l F.
100°
101.8
100
98.9
98..-)
104°
98.3
99.
99.2
99.2
98.5
98.8
105°
105°
104
103.7
104.9
98.5
101°
101°
99.6
99.6
99.2
99.
98.5
70
72
85
78
90
80
100
89
84
80
80
84
88
104
106
68
80
80
84
84
80
80
88
84
80
20
I 32
24
32
21
20
20
28
28
28
28
32
28
24
24
28
24
18
20
18
19
18
18
18
18
In the following case, the highest temperature was reached on the 15th day of the
disease, when the thermometer in the axilla stood at 105.3. This marked rise in
the temperature, as in the preceding case, was preceded by a great aggravation of the
symptoms.
Case oO(f : CereLro- Signal Meidngilis.
Peter Harwasen, age 50 ; native of 'Germany ; entered Charity Hospital, Ward 13, January
20th, 1873, in a delirious state, with contraction of muscles of head and neck. Delirium,
wild, requiring mechanical restraint; bowels obstinately constipated; pupils contracted. 1
caused the bowels to be freely opened with Calomel ; applied a blister to the back of the
held and neck : and administered internally at regular intervals. Hydrate of Chloral, Bromide
of Potassium, and Quinine and Dover's Powder. The intellect was gradually restored and the
contraction of the muscles gradually disappeared under these measures, and the patient was
able to sit up in bed and converse on the 29th, 30th and 31st of January, and Ist of February,
On the second of February he was seized with a chill in the morning, during which he became
iniensible, with cold extremities, and the temperature fell to 99° F. The chill was followed
by high fever, the temperature of the axilla rising in the evening to 105.3 F. During, the
chill, and subsequent fever, the patient was entirely insensible ; neck and back stiff; opistho-
tonos; respiration labored and puffing; pulse small, thready and irregular. The patient
appeared to be in extremis. I repeated the blister to the back' of the head and neck over the
region 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 ilso gave 'freely
Carbonate of Ammonia and Alcoholic stimulants. On the 3d, the symptoms were somewhat
improved, and the patient gradually recovered consciousness, and progressed with slight
oscillations of temperature, until the llth, when there was a slight relapse, attended with a
fise of temperature. From this date, the patient gradually improved and was discharged
cured, March 10th, 1873.
The following table presents the changes qI' tcm^)crature during 21 days, January 25tU
to February 14th,
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442
Natural History of Cerebro^Spinal Meningitis.
DAY
TEMPERATUKE. |
' DAY
TBMPKRATUBE.
DATE.
OP
DATE.
OP
DISEASE.
Morning.
Evening.
DISEASE.
Morning.
ET«tog
January
25,
18Y3..
5
103.2
103.5
Febr
'y,4,
1873.
..; 15
98.5
10<».?
((
26,
((
6
102.4
103.2
t(
5,
It
..' IG
98.2
9?.:i
((
27,
((
7
102.7
101.4
((
6,
u
17
97.9
]CK».4
K
28,
ii
8
103.
102.8
i(
7,
u
18
97.8
9ti.2
((
29,
((
9
102.
103.
i(
«,
({
19
97.8
99.2
IC
30,
({
10
100.
102.
n
•♦,
it
20
97.8
99.P
l(
31,
u
11
102.4
101.5
(I
10,
It
21
98.8
I*9.H
Fcbr'y
1,
ii
12
101.
\ 101.2
((
11,
n
22
98.7
loi.:.
4»
2,
((
13
99.
105.3
i(
«2,
u
.. 23
98.4
yu.y,
((
^t
a
14
100.(3
! 102.
4(
13,
((
,.| 24
99.7
9<».2
1
((
14,
tt
..' 25
98.5
10*».
^ . _
The following cases (501 and 502,) of Cerebro- Spinal Meningitis, treated in thf
Charity Hospital, illustrate the daily oscillations of temperature.*
Cabi 501. CEaEBRO* Spinal Meningitis.
Case 502. Cerebro-Spinal Mekisgitib.
John Tompkins J Age^ 1 6 yean.
Thomas Cahil^ Age, \ 6 years.
I Day
DATE. OP
Fet
Dec.26,^72
" 27, "
" 28, *'
" 29, "
" 30, "
" 31, «'
Jan. 1,'73
** 2, '»
" 3, "
(( 4. ti
*' 5, •'
«' 6, "
u 7, "
u 8^ u
'' 9, "
" 10, "
'« 11, «'
i* 12^ It
'• 13, »'
*' 15, "
TEMPEKA.
M. I B.
PULSE. I RESP'N.
I
M. E. I M. I E. I
101.
99.
100.2
99.8
101.5
103°
102.6
103.
102.
lljlOl.S
I2I1OI.
13;i01.
101
102.
100.4
101.5
98.5
101.
98.
98.5
98.5
103.2
103.5
101.5
102.5
102.8
103.8
103.5
102.6
104.4
103.6
104.
105.
103.5
103.
100.
99.
103.
102.
99.
99.
98.5
88
62
82
101
105
102
104
104
108
94
108
95
110
' 98
66
94
102
100
82
84
84
IU\ TEMPERA.
DATE. , OP i
Fev -,
100 18 1 Dec.26,'72
64 ,
92'.,
100!.,
100'.,
96 .
100..
108;..
104J.
96'.
1041.
98 .
108 .
90..
88 .
861.
1.
.1.
I I
Jan.
28, "
29, "
30, •'
31, - I
1,'73
a;-:
4,",
5 '^ I
«; -
7, "I
8, -^
9, '' I
10, *' I
11, "I
12, " I
13, " I
14, «
10,
16, '« I
1 100.
2 101.
3 100.5
4 101.
5 101.2
G lOl.
7 101.6
8 103.
9 102.2
10 101.5
ll!l01.8
12,101.4
ISJIOI^
14:102.
15|l02.2
16,101.2
17 102.2
18 100.
19 101.8
20 101.
21 101.2
22 99.
E.
99.6
101.4
101.2
101.6
102.1
103.4
102.6
102.5
102.
103.
98.5
104.
103.
102.5
102.
103,
102.
101.2
100.4
100.4
100.
98.5
PULSE. R&PIK^
100
105
104
98
108
104
IO81
1021
104
104
102
120
110
104,
84,
98,
iioi
112
102
98
100
.|.
97 .
112 .
112 .
lOa.
li:> .
120.
118.
116.,
106,,
109 ..
120.,
no'.,
108.,
100.,
104..
84..
104..
86'..
94.,
94^..
9t>..
I.
In the following cases (503, 504,) which I have consolidated from the clinical reports
of Dr. J. A. liHrrahee of Louisville, Kentucky, (Richmond and Jiouisville MeJiol
Journal, December, 1872, p. 764, (the highest point of temperature reached vras 105° F.
*The clinical record of these cases, was furnished at my request, by Dr. Wm. Martin, *i
that time resident stijdent in the Charity Hospital. Accounts of these cases hare beespab-
lished by Dr, L. S.. JjJ.qMurtry, (New Orleans Medical and SttrgicaUqurnal, January 1874.^
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Natural History of Cerebro^Spinal Meningitis. 443
Chse SOS : Gerebro- Spinal Meningitis,
T. W., bright active boy, set. 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; anxiou's
expresaioD ; 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^bt lung ; the condition of the other lung so far as any phy-
sical sigrns of pneumonia 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 controlled, breathing hurried ; pulse 130. 3.30 p. m.; temperature in axilla 105^,
pulse 136 ; respiration 50 per minute, j^^ grain 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 1482;
respiratioD 52. Ordered Atropine in same dose at fonr-hour intervals.
March 25th, 9 a. m. Pupils considerably dilated, mouth extremely dry, tongue constantly
thrown out for water, which he 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 respiration 48*;
retains the Atropia, but vomits the water when taken in large doses.
6 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 again 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
102, 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 the last twelve hours ; he is per«
fectly 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 Slst. Rested well and awoke clear as to expression ; cannot articulate his words
well ; complains when pressure is made over cerebral vertebrae ; body covered with herpatic
vesicles, eruption and sudamina.
April 5th. Tongue appears moist, with aptha? upon surface and edges ; temperature 104°,
pulse 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 21st. 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
he was anable to swallow any nourishment, but during the past three days, has taken ^gg'i^og
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 head is raised from the pillow, the back of his neck touched, or he is turned in bed ; at
such times he makes a faint noise, and his face bears an expression of pain.
April 30th. Emaciation of trunk and lower extremities, sunken belly, herpetic vesicles
over skin. Last night irregular spasms began ; at first consisting in blight 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 size of a pea to a
nickle. He was unable to make the slightest movement with the right leg, which was stiff
and 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
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444 Natural History of Cerebrospinal Meningitis.
dilated. Has not given any sign of consciousness, but lies lilce a piece of marble stAtnaiy :
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 baa beeom^
so gentle and unobserved, that he was thought by his friends to be iead. There is eomptete
deafness and blindness.
May I5tb. 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 his own
accord. To day the right leg is stiff and motionless. A blister applied over the occiput aod
back of neck drew well, and was filled with gelatinous matter. The pupil of the right eye u
dilated ; an examination of the retina by the optbalmoscope showed that it was of a deep red
c<Hi5r, 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 face docs not shQv
much emaciation.
May 30. Tenth week of illness, and 70th day after commencement of treatment. Daring the
past week, there has been more marked rigidity of mustle, the legs and arms, are as stiff aad
immovable as marble ; trembling spells become more frequent, and always accompanied by aa
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 until now has not
p?irticipated much in the emaciation is slowly melting away. Although there is no pinched
expression or mark of pain upon hrs countenance as he lies unconscious and motionless, aod
scrupulously neat in his snowy garments, h eis not unpleasant to look upon. The eruption npos
the scalp discharges some matter; a blister has since been applied. To-day his mother gave
him a strawberry ; he ate it quickly and held open his mouth ; a piece of bread was gireo
him, and he spat it out; more strawberries were given and were eaten by him. This is the
first taste and distaste he has shown,
June 15th. No important change.
June 29th. Thirteenth week, slight diarrhoea ; same muscles contracted until their tendons
stand out upon the thin wasted limbs like strings; right arm and shoulder badly swoUcc-
Neither sees nor hears, nor is sensible to objects around him, although he is sensible to pain at
times. Eats well, even hastily of nutritious food, such as eggs, whey, sponge cake, etc., asd
appears to like certain things, rejecting others, as soon as they are put into his mouth, bai
makes no sign of disgust at what he dislikes, until it is in his mouth.
July 13th. Sixteenth ^eek; same, but more fretful from heat.
July 16th. Died this morning at 2 o'clock. Before he died he became opisthotooic; his
back was a perfect arc, and his limbs were convulsed ; the rigidity of certain muscles and »e(^
of muscles was the same in twelve hours after death as during life.
Cam 504 : Cerebro- Spinal Meningitis,
Maggie Gagan ; Irish girl, aged 13 years. Scrofulous nature, having suffered from hip-joinl
disease.
April 20th. Complained of great pain in head, limbs and chilliness. On Thursday prerioiii
to illness, she had competed with some children in jumping ropes; had reached one-hnndml
and fifty jumps without intermission, and being completely exhausted, she bathed her bead ii
cold water, and drank of the same freely. She retained the dorsal position in bed. and the
head was observed to be buried backward in the pillow; although no marked opisthotoaos :
has characteristic eruption. * Temperature of axilla 105, pulse fast and small, 140 per minatf.
April 22d. Appears easier, although in sound sleep ; answers questions very slowly: intel-
lect not clear; temperature 105^, pulse 135, little fuller.
April 23d. Temperature 103. pulse 120, 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 erideotlj
sinking.
April 25th. No sleep, constant tossing about in bed, occasionally screaming; deliriovi.
p. M. Appears to be worse ; low muttering, delirium; pulse 150 ; restlessness of limbs.
May 4th. During the past week there has been but little change in the condition of tke
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 deas ;
asked for her breakfast this morning, and ate with good appetite ; the head is still drava
back, and the hands tremble considerably.
May 12th. End of third week; still lying conscious, feverish and fretful, with head drsvn
backwards; has become extremely emaciated; the sordes about the mouth and nose renuio
and bleed considerably ; tongue perfectly clean ; appetite good and even craving ; digeftion
perfectly performed ; stool each day ; moves the right arm and leg with extreme difficolty.
May 26th. Commencement or sixth week of the disease. Tetanic spasm and opistbotoots
have entirely disappeared; abdomen sunken and fiat ; skin considerably discolored.
Digitized by LjOOQ IC
Natural History of Cerebro^Spinal Meningitis, 445
June 12tb. Has been sinking gradually, with an exacerbation of all symptoms since last
record, vomiting at frequent intervals ; 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 following cases, (505-554,) illustratiug the
changes of the pulse, respiration and temperature, from the "Notes of ninety-eight
cases of Epidemic Cerebro-Spinal Meningitis, treated in the Philadelphia Hospital,
(Blockley,) during the months of December, January, February and March, 1867, by
W. H. H. Githens, M. D., Am. Jour. Med. Science, July 18()7, pp. 17, 3D.
CAas 505. Age 47, male. Result^ death in two days. Si/mplojns^ delirium pain in head,
nausea, coma, eyes closed, pnpils 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.
Puhej Respiration and Temperature. 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. F'our hours
before death pulseless, and bronchial sounds so loud as to mask sounds of heart.
Cask 506. Age 40, female. Result, recovered in 10 days. Symptoms, semi-comatose condi-
tion, bnt 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 fseces.
PuUe^ Respiration aod Temperature, Temperature in axilla on 2d day, 103° F.; skin dry ; head
warmer than body ; extremities cool. No calor mordar, the skin feels simply warmer than
natural. 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 pulse full, 90 per minute.
Casb 507. Age 28, male. Result, recovered in 21 days. Symptoms, 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 ;
palo and tenderness in neck and along back; mind clear: corners of mouth drawn down ;
eyes widely open giving the patient a staring expression
Pulse, Respiration and Temperature, 15th day of disease, temperature,- 10 a. m., 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°. 25,
pulse 74, respiration 20; 12 M., temperature 101°, pulse 86, respiration 28; Or. m., tempera-
lure 100°.25, pulse 90, respiration 32. 18th day, 6 p. m., temperature 99°, pulse 84, respiration
28; 12 M., temperature 98°.75, pulse 84, respiration 24; 6 p. m., temperature 98°.5, pulse 76,
respiration 24. 19th day, temperature 97°, pulse 76, respiration 28 ; 12 m., temperature 96°. 75,
pulse 66, respiration 28; 20th day, 6 a. m., temperature 97°, pulse 80, respiration 28 ; 12m.,
temperature 98°, pulse 78, respiration 28 ; 6 p. m., temperature 98°. 5, pulse 86, respiration ::2.
21st day, 6 a. m., temperature 97°.5, pulse 72, respiration 32.
Case 508. Age 36, male. Result, recovered in 16 days. Symptoms, intense nervous excite-
ment, universal tremor pervading the whole body; tongue tremulous;, intense pain in head
located in occipital and temporal regions; unable to sleep by day or night; pupils small;
conjonctiva injected ; eyes prominent and staring; hypera'sthesia of skin; respiration irre-
gular; abdomen, chest and thighs, thickly covered with reddish brown petechial eruption.
Pulse, Respiration and Temperature. 7th day of disease, 10 a. m., temperature 103°, pulse 126,
respiration 36; 6 p. ii., temperature 103°, pulse 112, respiration 28. 8th day, 6 a. m., tempe-
rature 101°.5, pulse 116, respiration 24; 12 m., temperature 101°, pulse 128, respiration 28;
C p. M., temperature 103°, pulse 116, respiration 28. 9th day, temperature 102°, pulse 126,
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., temperature 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. 11th day, 6 a. m., temperature 101°. 5, pulse 140, respiration 28 ; 12 u., tempera-
ture 101°, pulse 140, respiration 32 ; 6 p. m., temperature 101°. 5, pulse 120, respiration 32.
12th day, temperature 101°.5, pulse 132, respiration 36; 12 m., temperature 102°, pulse 136,
respiration 36 ; 6 p. m., temperature 102° 74, pulse 140, respiration 36. 13th day, temperature
102°, pnlse 106, respiration 32 ; 12 ii., temperature 103°. 25, pulse 120, respiration 32 ; 6 p.
M., temperature 102°, pulse 120, respiratjon 36. 14th day, 6 a. m., temperature 100°. 25, pulse
106, respiration 32; 12 k., temperature 10l°.5, pulse 108, respiration 36; 6 p. m., temperature
101°, pulse 112, respiration 24. 15th day, 6 a. m., temperature 101°, pulse 92, respiration 24 ;
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446 ffatural History of Cerebrospinal Meningitis.
12 II., temperature 08°.5, pulse 108, respiration 28 ; 6 p. ii., temperature 99®.5, poise 92,
respiration 32.
Case 509. Age 43, male. Result^ death in seven days. Si/mptonu, Expression stupid aod
heavy, petechial mottling on abdomen and thighs, on 5th day decided opisthotonos, inro-
Inntary discharges from rectum and bladder, stupor.
FulsCj Respiration and Temperature. 3rd day of disease, 6 a. m., temperature 98^, pulse 124,
respiration 28 ; 12 m., temperature 100°, pulse 130, respiration 32 ; G p. m., temperature I0l*>.5,
pulse 132, respiration 28. 4th day, temperature 99°.5, pulse 112, respiration 24; 12 m., tem-
perature 100°. 5, pulse 120, respiration 24; 6 p. m., temperature' 99°, pulse 128, respiration 24.
5th 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°, pulse 112, respiration 24. 7th day, 6 a. m., temperature 92, pulse 102,
respiration 24.
Cass 510. Age 52, male. Result^ death in 8 days. Symptoms, diarrhoea, marked peteehlal
eruption, eyes prominent and staring, corners of mouth drawn down, active delinnm on 4th
day.
Pulse^ Respiration and Temperature. 3rd day of disease, 6 p. m., temperature 103°.5, pulse
120, respiration 40. 4th day, 6 a. m., temperature 1,01°.5, pulse 108, respiration 36; 6 p. M^
temperature 102°.5, pulse 120, respiration 40. 5th day, temperature 101°.5, pulse 104, respi-
ration 32 ; 6 p. ic., temperat.nre 101° 5, pulse 120, respiration 40. 6th day, 6 p. m., temperaUre
101°, pulse 98, respiration 48. 7th day, temperature 101°, pulse 86, respiration 28; 6 p. M.,
temperature 101°.5, pulse 142, respiration 32. 8th day, 6 a. m., temperature 100°, pulse 111,
respiration 48 ; 6 p. m., temperature 100°, pulse 152, respiration 52.
Case 511. Age 51, male. Result^ recovered in 28 days. Symptoms. Severe headache,
chill, profuse petechial eruption, coma, subsultus tendinum, opisthotonos, hyperssthesia,
sequlae, complete deafness and paralysis of left foot,
Pulse^ Respiration and Ttmperature, Pulse small and feeble, varying from 120 to 150. Tem-
perature, maximum 102°.75, minimum 97°.5, mean 100° F.
Case 512. Age 45, male. ResuU, death in 12 days. Symptoms. Severe headache, deliriaa,
constipation, vomiting, opisthotonos, hypersesthesia ; no eruption.
Palse^ Respiration and Temperatire. Pnlsd strong and irritable^ 116 to 120; temperature,
miximum 105^ F., minimum 101°.5, mjai 103° ; deith on 12th day from choking up of bron-
chial tubes with thick mucus.
Cask 513. Age 35, male. Result^ recovered in 16 days. Symptoms^ violent headache; no
delirium; constipation; severe and general muscular pains. The temperature ranged frosi
99° to 95° ; and the pulse from 96 to 62.
Case 514. Aged 30, male. Result, death on 23d day. Symptoms. For the first fortnight
had all the symptoms of well marked Typhoid Fever, with the exception of the eruption, which
was petechial in character, stupor and coma constant for several days before death. Tea-
perature, max., 104°.5; min., 97°.75 ; mean, 102°. 5; pulse, 88 to 134, barely perceptible.
Case 51. ^». Age 45, male. /?<»u^, recovered in 12 days. Symptoms, violent headache ; no
delirium ; no petechia: ; some muscular pains ; severe headache ; slight opisthotonos, with
subsultus. Temperature, 99° ; pulse, 62-80.
Case 516. Severe headache ; opisthotonos. Temperature, max., 102°.5 ; min., 98°; mna,
101°. Pulse feeble, 72-86.
Case 517. Age 22, male. Result, de&ih on 2 1st day. Temperature, max., 104°.75; oin.,
97.°5 ; mean, 102°. Pulse 86 to 120.
Case. 518. Age 20, male. Result, de&th. Moribund when brought into hospital. Tea-
perature, 101° to 103°. Pulse 110 to 120, feeble.
Case 519. Age 23, male. Death 8th day. Severe headache, opisthotonos, delirium, coo-
juDctiva congested. Temperature, 101° ; pulse, 100 to 110, feeble.
Case 520. Age 45, male. Death llih day. Severe headache, delirium, constipation,
hypersBSthesia, opisthotonos, screaming. Temperature, 101°; pulse, 110 to 130, very feeble.
Case 521. Age .^5, male. Cured in 7 days. Headache, constipation, stiffness of btck.
Temperature, 100° F.; pulse, 76 to 112.
Case 522. Age 22, male. Recovered 14 days. Severe headache, muscular pains of hes4
and back, stiffness of legs and back. Temperature, 99° ; pulse 76 to 104.
('ASB 523. Age 42, m ile. Cur jd 5 days. Constipation, headache, pain upon presinrc
over cervical vcrtebraae. Temperature, 100° ; pulse 76 to 112, feeble«
Case 524. Age .53, male. Death in 12 days. Severe headache, wild delirium, opistho-
tonos. Temperature, 101°; pulse, 74 to 130.
Case 525. Age 21, male. Recovered in 14 days. Intense headache, bowels constipaKQi
muscular pains in back, slight opisthotonos. Temperature, 98° to 103°.5 ; pulse, 93 to 14<»-
Case 526. Age 26, male. Died on 10th day. Coma, bowels constipated, opisthotonos.
Temperature, 96° to 104° ; pulse, 98 to 144.
Case 527. Age 54, male. Died 2d day. Intense headache, constipation, opisthotoBOS,
eruption. Temperature, 103°.
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Natural History of Cerebro- Spinal Meningitis. 447
Casb 528. Age 21, male. Recovered in 27 days. Slight delirium, slight headache, con-
stipation. Temperature, 97** to 104°.5 ; pulse, 72 to 112.
Casi 529. Age 20, male. Recovered 15 days. Severe headache, stiffness of back, hyper-
sesthesia, erythematous eruption. Temperature, 96° to 104° ; pulse 72 to 106.
Case 530. Age 44, male. Recovered in 8 days. Slight delirium, continued headache, con-
stipation, opisthotonos. Temperature 98° to 101° ; pulse 88 to 112.
Casb 531. Age 26, male. Recovered in 14 days. Active delirium, severe headache, con-
stipation, erythematous eruption. Temperature, 97° to 103° ; pulse, 86 to 120.
Cam 532. Age 21, male. Recovered in 17 days. iMuttering delirium, severe frontal
headache, constipation, muscular pain in neck, opisthotonos. Temperature, 97° to 104° ;
Poise, 68 to 120.
Cask 533. Age 67, male. Recovered in 10 days. Headache, constipation, erythema and
petechia, 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, hyperaesthesia, eruption, erythema and petechias. Temperature, 90° to 104°.5 ;
Pulse, 72 to 120.
Case 535. Age 16, male. Recovered 5 days. Severe headache, constipation, vomiting,
mQscnlar pains. Temperature, 97° to 103° ; pulse, 76 to 126.
Case 536. Age 30, male. Recovered 22 days. Intense headache, constipation, opistho-
tonos, hypcraesthesia, petechial eruption. Temperature 97° to 103° ; pulse 80 to 120.
Case 537. Age 36, male. Death in 11 days. Constipation, muscular pains, hypcraesthesia,
petechial eruption and erythema. Temperature, 94° to 104° ; pulse, 112 to 120.
Cass 538. Age 46, male. Recovered 8 days. Headache, constipation, muscularv pains.
Temperature, 95° to 105°.25 ; pulse 68 to 96.
Cabs 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
104°; pulse 70 to 106.
Case 540. Age 40, male. Recovered 14 days.. Active delirium, severe headache, vom-
iting, muscular pains. Temperature 99° to 104°; pulse 80 to 130.
Cask 541. Age 21, male. Recovered 20 days. Headache, diarrhoea, vomiting, muscular
pains, petechial eruption.
Case 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.
Case 543. Age 13, male. Death 10th day. Delirium, coma, injection of eye, petechial
eruption. Temperature, 104°.5 ; pulse, 120 to 140.
Cass 544. Age 27, male. Recovered 21 days. Active delirium, some frontal headache,
diarrhoea, muscular pains, petechial eruption. Temperature, 98° to 103°; pulse, 90 to 12u.
Cass 545. Age 30, male. Recovered 28 days. Delirium, severe frontal headache, opistho-
tonos, severe muscular pains, copious eruption, deafness. Temperature, 97° to 103° ; pulse.
120.
Case 546. Age 25, male. Recovered 21 days. Headache, delirium, diarrhoea, muscular
pains. Temperature, 98° to 104°. 75 ; pulse, 136.
Cask 547. Male. Recovered 21 days. Headache, delirium, 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, constipation, opisthotonos,
Uypersesthesia, petechial eruption. Pulse 112 to 120.
Cass 549. Age 36, male. Died 9th day. Severe headache, constipation, eruption of
erythema. Pulse could not be felt.
Casb 550. Age 57, male. Died in 60 hours. Severe headache, constipation, muscular
pains. Pulse 116 to 120.
Case 551. Age 32, male. Recovered 18 days. Headache, muscular pains, opisthotonos.
Pulse 68 to 130.
Casb 552. Age 25, male. Recovered 21 days. Active delirium, coma, muscular pains,
opisthotonos. Temperature, 98° to 104°; pulse, 80 to 130.
Casb 553. Age 65, male. Died 9th day. Headache, constipation, petechial eruption.
Pulse 86 to 90.
Cask 554. Age 29, male. Recovered 21 days. Intense headache, constipation, muscular
pains, hyperaesthesia. Pulse 86 to 140.
In many of the cases observed by Dr. Githens, the tempemture was lower than that re-
corded in typhoid or inflammatory diseases ; the observations were made at G a. M., 12 m.
and 6 P. H. daily ; and were taken as far as possible, in typical cases, and in those
where the temperaturQ was most elevated, and yet the average is lower by four or five
d^rees, than that of typl^us w typhoid fevers, pneumonia, etc. In two cises only did
the thermometer xxk t^e wlla^ roach 105*^. In fifteen cases it was between 104° ancl
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448 Natural History of Cerehro- 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 arc the highest point reached in each ease. The differ-
ence in the temperature at the (evening and morning observations, was not so marked
as in u'lost other fevers, a fj\ll of more than one degree being unusual, and frequentlv
there was no change. A regular and gradual descent, indicated the beginning of con-
valescence ; a rapid fall was the sure precursor of collapse.
The pulse varied from normal to 150 beats per minute in t^n uncomplicated oasee,
and ranged as high as 160 in two cases in puerperal women , it was in aJl, very weak.
with a dichrotic tendency ; sometimes entirely imperceptible in the radial arteiy, and
always interrupted by a very slight pressure. It appeared to l)e the most deceptive
symptom, as no one would have suspected an inflammation of a high grade, with a
pulse, which, although, sometimes quick, was very strong, but always gaseous and
feeble in the extreme. Am. Jour., Med. Sci., July 1867, p. 38
Dr. J. Baxter Upham, of Boston, in his " Additional Beflections upon the Late
Epidemic of Cerebro-Spinal Meuingitis," states that in the replies to the circular issaed
under the auspices of th^ Massachusetts State Board of Health, from about two hun-
drcd physicians, representing seventy-two towns and cities, and containiBg the dal«,
more or less complete, of upwards of five hundred cases of disease, " the tempenture
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, aud in one
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 wis
accelerated ; the temperature of the skin was natural, or sometimes even lowered ; snd
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 tnie
fever was lighted up which remained until convalescence or death ; this fever was of
the continued type, but presented marked and regular exacerbations, which took place
in the afternoon along wkh an aggravation of the other symptoms. According to the
writer, the force of the fever, was sometimes, although rarely, inflammatory ; more
generally it was typhoid.
J. Burdon-Sanderson, in his '' Report of the Result of an Inquiry into the Kpide-
mics of Cerebro-Spinal Meningitis, prevailing about the Lower Viatuta, London, 1865,"
states, that in adults the temperature varied from 100° to 104°, and in children was
still higher. Exacerbations of Pain, were always accompanied with an increase of heat
of the skin, amounting to 2° or 3°.
Dr. Felix A'ou Niemeyer, states, that in the first stage of the disease, up to the third
or fourth day, although the pulse may be over 120, and the respiration of 40 per
minute, the bodily temperature still remains proportionately low, or rises to 102° or
over.
According to Ziemsscn's numerous observations, the /(rver has no regular couree;
very few temperature curves resemble each other ; sudden leaps, and exaoerbatioos of
short dui-ation often occur ; but generally a remitting type, with exacerbations of half a
degree to a degree, is most frequent ; very high temperatures are almost exdosively
seen in severe cases that terminate fatally, in most cases the temperature being not
above 103°. The intermittent fever that occasionally accompanies the other symptonw
during convalescence is regarded by Ziemssen, as a re-absorhing fever ^ while he refew
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 Cerebro-Spinal Meningitis being obviously a form
of disease, which in spite of the actual identity of the anatomical lesions, may preseot
itself under apparently widely diflcrent symptoms, the tewpera^ture, may pursue varied
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History of Cerebrospinal Meningitis. 449
coarscs. From more than thirty cases obser\'ed by Wundcrlich, it appears to this
aecaratc observer, that three special varieties of the fever course, can be particularly
disitinguished.
(a). In some ver^ sere?'c, and rapidly fatal cases, the temperature displays a similar
course to that of Meningitis of the convexity. Though not invariably very high at
the beginning of the disease, it reaches very striicing heights in the briefest tiinc,
which persist continuously for some days, and rise just near death, and in the very
moment of death to quite unusual degrees, 42® C. (107°.6 F.) and more; and in one
<*ase, 43.75 C. (110.75) in dying, and may even rise some tenths higher after death
(three quarters of an hour after 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 disease.
(^). On the other hand, relatively inild 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 crisis, 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 diflferverscing, 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 cases, 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 chiefly
depends upon the varied complications which supervene in the shape of bronchial,
pulmonary, and' intestinal affections, and affections of the serous membranes. Some-
times the fever has the same duration, and the exacerbations of the temperature, the
same height as those of typhoid fever, and its curves, when projected, may greatly
resemble the latter ; but there is not the irregularity of abdominal typhus, and at the
best, the course is only that of the amphibolic period of that disease, or like that
which occurs in 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.
Defflervescence may occur rapidly, but is however, for the most part protracted by
lysis. 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
of the temperature 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, 18G5, vi, 268.
On the Temperature in Diseases, a 3Ianual 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, as in the essential fevers ; it is evident, therefore, that the febrile phenonjena
of Cerebro-Spinal Meningitis arc not to be referred to a definite poison acting primarily
upon the blood.
BL0()1>.
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, aiid by cups from the b^k pf the
^\
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450 Pathologieal 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 buiFed ; in thirty severe
cisee in which its 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 thirty-five. In the first analysis. Fibrin, 6.40 ; Corpus-
cles, 140.29. Second analysis. Fibrin, 5.20; Corpuscles, 112:79. Third analysii*.
Fibrin, 3.64 ; Corpuscles, 123.45. Fourth analysis. Fibrin, 4.56 ; Corpuscles, 129.50.
Tourdes states that blood drawn from a vein was rarely buiFed ; if a huffy coat existed,
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. SecMid
analysis. Fibrin, 3.90 ; Corpuscles, 155.54. Third analysis, Fibrin, 3.70 ; Corpus-
cles, 143. Fourth analysis, Fibrin, 5.63; Corpu-scles, 137.84. Maillot gives as the
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 Cerebro-
spinal Meningitis, represents the condition of this fluid in inflammatory diseases.
I PATHOLOGICAL ANATOMY OP CEBEBRO-SPINAL MENINGITIS,
Near the close of the recent civil war, and shortly after my return to Augusta from
the Army of Tennessee, a most favorable opportunity occurred for the careful invegii-
gation of the pathological anatomy of this disease. During the months of January
and February, 1865, Cerebro-Spinal Meningitis appeared in one regiment of a brigade
of Georgia militia, which had been summoned for the defence of the city against the
threatened attack of General Sherman. The brigade was camped on the Sand Hilk
about three miles from Augusta. The Third Regiment of Georgia militia, in which
six oases of Cerebro-Spinal Meningitis occurred, were camped in a valley between the
hills occupied by the remainder of the brigade. As far as my information extended,
the troops camped upon the dryer and warmer hills escaped this disease, Throe of
the six cases died in camp, and the remainder were sent to the general hospitaU in
Augusta, and in like manner terminated fatally. The symptoms manifest<?d by theif
cases were clearly those of Cerebro-Spinal Meningitis; the first symptoms which
attracted attention being nausea, vomiting, diarrhoea and convulsions, followed with
severe pain in the head, extending along the spine, alternate contraction and dilatation
of the pupils, deafness, low-muttering, spasms; delirium and coma,
Case 555 : Cerebro-Spinal Meningitis.
In the case of Private Goosby, of Company J,, 3d Regiment, Georgia Militia, a^zo
28 ; the first symptoms noticed by the i\Iedical Officers, were sorencj^s in the chest,
and cough, accompanied with pain in the head and back, and with nausea and slight
diarrhoea. This patient was sent to the 3d Georgia Hospital in Augusta, on the foUow-
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 Cerebro-Spinal distur-
bance, progressively increased, and upon the next day, February 14th, delirium set in,
with inoontrollable restlessness, and loud cries and shrieks. In lucid intervals, Md
when aroused from the delirium, the patient complained of violent pain in the hcid.
A large blister was applied to the back of the head and neck, and ten ounces of blood
abstracted, and quinine freely administered at intervals. These measures appeared U)
afford some temporary relief, but the disease progressed steadily, the prominent spp-
toms being characterized by muttering, delirium, contraction of the pupils, deafhes,
rigid contraction of tho muscles of tlie neck and spine, slow pulse and impeded rf«pi-
ration and torpid bowela, Death occurred on the 25th of February.
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Pathological Anatomy of Cerebro-Spinal Meningitis. 451
AUTOPSY EIGHT HOURS AFTER DEATH.
Cerebro-Spinal System. — After the removal of the Skull Cap, the dura-mater of the
brain, presented a normal appearance, there were no marks of inflammation, and no
effusion between this membrane and the arachnoid.
The arachnoid presented afn 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 with a firm,
light-greenish yellow, wax-like fibrinous exudation ; large tracts of the cerebrum and
cerebellum were also thinly coated with this effusion, which also surrounded the Cauda
Equina and most of the roots of the spinal nerves, up to their entrance within the dura-
mater of the Spinal Cord.
This exudation possessed various degrees of consistence, from that of a serous fluid
to a liewly formed membrane, and differed in thickness, in different parts of the Spinal
Axis.
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,
fn^dually diminishing in thickness, to the convolutions of the cerebrum and cerebellum.
Over 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
clcise inspection of the pia-mater for its discovery.
When 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,
semi-fluid exudation, resembling to the naked eye, pus. The optic thalami, and striated
bodies, 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 desired to settle by this examination, were :
Ist. The nature of the effusion— whether pus? Or organ iaable and ""organ iaing "
lymph ?
2d. The extent of the action of the organiaing force, in the plastic elements and
products of inflammation.
3d. What membranes of the brain and spinal cord were involved in the disease ?
4th. Whether the nervous structures, themselves, commissures, ganglionic cells, and
connective tissue of the nervous elements of the brain and spinal cord, Were involved
in the diseased action.
5th. Whether any of the effects and products of inflammation, could be detected
by the microscope, in the nervous structures proper.
The following appeared to be the most important results of these labors.
Under the microscope, the exudation presented different stages of organization and
development, from the simple granule, to the perfected fibre, and even fibrous tissue.
Ahhough resembling pus, to the naked eye, the exudation .possessed in its micros-
copical characters, and structure, a higher organization, and the more solid portions
were rapidly passing into the state of an organized fibrous tissue.
The first question was of great interest and importance, and was settled beyond all
cavil and doubt. The effusion and deposit, was organizable, and "organizing" lymph.
The eflusion resembled in its physical, chemical and miscroscopical properties, the
plastic lymph, thrown out in mechanical injuries, and in acute inflammation, pleuritis
and peritonitis.
It is therefore incorrect to speak of the effusion in Cerebro-Spinal Meningitis, as Pus,
or as Purulent matter. The effusion may in some cases degenerate, simply into puru-
lent matter ; but at first and in its essential nature, it consists of coagulable plastic
organizable lymph, capable of conversion into fibrous tissue.
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452 Pathological Anatomy of Cerebrospinal 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 careful examinations
of the brain and spinal cord in this disease, and the microscopical characters of the
deposit was in all respects similar to those now recorded. The organizable effusion
presented various stages of cell developemcut, from the simple exudation corpuscles to
organized tissue.
These facts struck me as being of importance, in that they ctmnected 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 case, had
persisted for two weeks, and the results of post-mortem examination, indicated that the
intensity of the inflammatory process had ceased, and much of the eff*u8ed material wm
becoming organized. The mere presence of the organizable and organizing material,
even after the subsidence of the active inflammation, constituting as it were, the essence
of the disease, from the very structure and functions of the cerebro-spinal ner\'ous sys-
tem, 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 aflected, 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 commoD
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 exudatiou
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 eff'used fibrous deposit covering the medulla oblongata,
pons varolii and spinal cord, were seen under the microscope, to be passing rapidly into
the condition of fibrous tissue, presenting numerous cells in various stages of develop-
ment, forming fibres and coalescing, and interlacing with each other.
In the wax-like deposit, from the surface of the anterior columns of the medolla
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 nerves,
were examined microscopically, but no exudation corpuscles were discovered within the
nerve structures proper. Exudation corpuscles were observed adherent to the neuri-
lemma of some of the spinal nerves, but ^lone were discovered between the fibres or
nervous tubes of the spinal nerves.
No exudation was observed on the external portion of the arachnoid between thb
membrane and the dura-mater.
The arachnoid could be lifted ofi" the exudation in many places, in others it Wis
adherent. Under the microscope the exudation corpuscles and elongated spindle-shaped,
and branching cells and fibrils, were seen adherent to that surface of the arachnoid,
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 ner\'ous structares, in
this case, is a fact of importance, in throwing light upon the sudden and apparently
rapid course of many cases of Cerebro-Spinal Meningitis. As long as the nervous ele-
ments themselves are unaltered, it is not reasonable to suppose that active nervous dis-
turbances would be manifested. It would appear that in these cases the effosiea
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Pathological Anatomy of Cerebrospinal Meningitis. 453
progressively increased until the pressure upon important nervous structures gave rise
to the disturbances of circulation, respiration, and muscular and mental action. The
presenoe 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 liver 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.
After death the large 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-
meot-s of ha&matin characteristic of Malarial 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 size and consistence, and when cut and exposed to the atmasphere 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 Malarial fever, of even a few days duration ; and I felt convinced from the
results of thb 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-
fying glass the blood-vessels of the highly colored and ecchymosed spots, presented a
beautiful congested arborescent appearance. The punctated congestions were most
numerous 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
result of the free use of purgatives.
The mesenteric solitary and agminated glands presented an appearance of health ; —
nothing unusual was noted in them.
Commentary. The following points were established by the investigation of this ease
of Cerebro-Spinal Meningitis.
1st. This was a typical case of Cerebro-Spinal Meningitis ; the disease was epidemic
in character, being one of a number of simultaneous ca,ses ; and the jMjriod of death
was deferred until all the phenomena had time for development ; this then muy be
accepted as a type of the epidemic form of Cerebro-Spinal Meningitis.
2d. There was no complication with malarious disease.
3d. The products of the inflammatory action resembled in all respects, those of
Fleuritis and Peritonitis.
4th. 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,) appeared to be free from
inflammatory action.
6th. If the nervous elements were primarily involved 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 lesions recognizable by microscopic investigation.
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454 Pathological Anatomy of Cerebrospinal Meningitis.
On the other hand it can be readily conceived, that the inflammation of the nutritive
membrane and the coatinl^ of the most delicate organs confined in a bony case with &
dense exudation tending to organize itself progressively into more firm and resisting
structure, might give rise to all the phenomena of Cerebro-Spinal Meningitis. An effu-
sion of coagulable lymph is just as capable of producing pressure and deranged action
in the brain and spinal cord, as an effusion or haemorrhage of blood iwitbin the bony
case of the cerebro-spinal system.
7th. This case furnishes an explanation of t^e almost universally fatal character of
Cerebro-Spinal Meningitis, as well as of the tedious nature of recoveries from this disease.
Even after the subsidence of all active inflammation in the meninges of the brain and
spinat 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 fibrinoos,
plastic, inflammatory effusion, but also on the character and rapidity of the sabsequeot
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 Pleuritic,
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 pyrexia3. If Cerebro-Spinal Meningitis
belongs to the class of febrile diseases, then Pneumonia, Pleuritis 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 Cerebro-Spinal Meningitis to the action of a specific poison, " disorganizing
the blood. It is entirely pertinent to ask : If the blood is so disorganized in this disease
as to allow of the effusions of disorganized blood into the skin, why should all niarb
of disorganized blood and bloody effusions be absent from .the structures most inflamed
and diseased, the meninges of ihe brain and spinal cord? The fact is, that these dis-
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 dependeot
upon deranged nervous action and circulation. It is unnecessary in this connection, to
do more than allude to the effects of pressure upon the medulla oblongata, upon the
functions of the circulation and respiration. And even if it be true that the blood is
disorganized in certain cases of Cerebro-Spinal Meningitis, such disorganization may be
entirely explained by the derangements of the circulation and respiration induced bv
the disturbance and perversion of the functions of the cerebro-spinal system.
10th. Cerebro-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 is
not contagious ; and therefore it may be treated in hospital wards, in contact with other
patients, and all hygienic efforts should be directed to its original ouisation.
Another case of Cerebro-Spinal Meningitis occurred shortly aft3r the preceding one,
which afforded opportunity for careful post-mortem and microscopical examination.
Case ffoG : Cerebro-Spinal Meningitis.
Private H. Powell, Company D., 3d Georgia Reserves; age 20. Patient brought iolo
Second Georgia Hospital, Augusta, Georgia, at 12 m., March 12th, 1865; inarticulate; lying
on his back; neck curved back; quiet when left alone, but crying out with agony when
moved, particularly when the neck was disturbed and moved from its curved position ; pulse
small, about 90 beats per minute, and quite quick ; eyes slightly crossed, pupils dilated, bnt
mobile and sensitive to light ; hearing impaired and mind stupefied. The patient protrudeii
his tongue, when ordered to do so. The tongue presented a healthy appearance. The
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Pathological Anatomy of Cerebro^ Spinal Meningitis. 455
attendants who accompanied the patient from camp to the Hospital, informed the attendant
medical officer, Surgeon Joseph Ganahl, that the day previous, he was to all appearanceis,
health J 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 lying 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 officers placing his hand upon the patient's head, the
latter threw his 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 ;
B. Quinae Sulph., grs. xx.; Hydrargyri sub-chloridi, grs. vi ; Potassse Nitratis, grs. xxxvi ;
Potassic et Antimonii Tartratis, grs. ii ; mix and divide into 12 powders, one powder every
hree h ours. 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 his tongue. The next morning (March 17th,) 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 articulo-mortiSj 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 lymph
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-
t us, 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 filling up the fourth ventricle, and thus pressing
upon the roots of the Pneumogastric nerves. The deposit also embraced and extended over
considerable portions of the nerves which emerge from the brain at the above mentioned points.
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 ressels 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 eiudation, 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 ^^th of an inch.
The dura-mater of the spinal marrow was greatly congested, amounting in some places even
to inflammation ; in such parts this membrane adhered slightly to the arachnoid membrane.
The vessels of the pia-mater were also distended with blood, and the membrane itself inflamed,
•A few nHintlis !>oforo tlio c](wc of the ^Vnr, ! applliHl to Surginin (ipiioral Moore, of tlio ("onnflcnilo Amiy, in
Jaonary IWVS, to relievo Apsiitant Surgoon H. 1>. Schmidt, from duty in tho ('on»cript Uurrnn, and to n«»iign him to
doty under my comnutA(t,'(Vi<^^ (^^(stant in tho i»rut<tH:ution of tho invcHtipition.s which I liad condnrtcd during tlic
entliT war.
Thta reqacet waa gmntiHl by Hurgoon Q€»neral S. P. Moore, and Dr. Sclimidt roj o.ted to me for duty, near the close
cf January, 1865. The ill-he9,lth of Assistant Surgeon Schmtdt, na well a« the sudden close of the var, precluded
extended or lystematiQ lalK)r^
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456 Pathological Anatomy of of Cerebro- Spinal Meningitis.
and adhcrinjif to the exudation. By microscopical examination, it was fooad that the exuda-
tion corpuscles were lodged between the fibrous bundles of which the pia-mater is 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 diflferent stages of development, as Ihcj
usually present themselves under like circumstances. Many of these cells were reand, or
larger, or smaller, resembling those found in liquid lymph; but the great majority of them
had already become elonjjated and spindle shaped, and were bound together by a granalar
nmorphous 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 th« 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^ Lungs and Heart. When the cavity of the chest was opened, by carefully rcmovrng
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 mediastinnm, 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 gradoally sob-
Bided into a thinner layer, to be lost at the limits of the area it occupied. The snl»ttiic«
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 tke
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 sixe
of these cells varied greatly, for while some of them were as large, or not mach larger thai
ihe normal epithelial cells of the pleura, others had attained a diameter of jj^ millemetrej,
' with a thickness of from yjjj.y to j JJ^ millimetpcs. By mutual pressure they had assumed a
somewhat polygenal form, tlius resembling hepatic cells. These elements were held together
by a viscid mucus-like fluid, which under the microscope exhibited a yellowish tint. Tpoa
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 natnral appearance.
with the exception of some portions, where the surface was elevated by emphysema.
Heart. All the cavities of the heart were filled wiiU coagula of black blood, extendisg
ihrough the pulmonary ortery and its branches.
Abdominal Cavity. The liver was considerably enlarged, and of a slate color, and the fall-
bladder filled 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 previoasly.
The geueral results of the preceding post-mortem examination (Case 556,) oorreBpond
with those of Case 555.
In the latter case there were no facts to show that the slate color of the liver and the
enlargement of the spleen, were marks of malarious disease, proceding pari^passa, whh
the Cerebro-iSpinal Meningitis. On the contrary, the thickened state of the capsiile of
the spleen indicated that the lesion was of long standing. The Georgia reserves h«d
seen considerable service, and a large proportion of the men had suflfered with paroxysBul
fever. It is probable, if not absolutely certain from the nature of the cells, that the
collection of viscid matter upon the pleura, was in no way connected with the dis^ae
which caused death.
In the preceding cases, the most prominent anatomical lesions were found in th*
cerebrospinal nervous system. In Cerebro-Spinal Meningitis, the pia-mater appearsi to
be the chief seat of the inflammatory action, and the exudation of coagolable Ijmph ;
it would appear however, from the results of post-mortem examinations, that the arach-
noid and dura-mater, and even the structures of the brain and spinal cord may be
involved. The character and extent of the inflammatory changes, will depend in great
measure upon the length of the disease. lu those who h^ve died suddenly after a short
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Pathological Anatomy of Cerebrospinal Meningitis, 457
illuess of a tew hours, we otleii discover iiothiug more thau an intense injection of the
piai-mater, and of the substance of the brain and spinal cord.
I will proceed to conipai*e tlie results of the investigations just recorded with those of
various other observers, who have endeavored to illustrate the pathological anatomy of
this diseai^e.
I shall make no spotiul selection of the cases an<l jM>st 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-mortonrexaminations 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 ISGB-Gl^. and ISiM-d.").
The symptoms which characterized the cases occurring in thisejiidemic, either in the for-
mative or advanced stage, weie of an e<iually grave import. Some patients were suddenly
attacked with coma, or stupor, so i)rofound as to he 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,
pain in the head and cervical region, extending al»)ng the sj>ine, with lassitude and apprehen-
sion of impending danger, were observed : in othei-s, again, chilly .sensations at inter\'als
of two or three hours, with cold extremities, followed by exacerbations of heat, flushed
face and increased pulse. Delirium, more or le.^s wild, with a disposition forcibly to
leave the bed or room, was, in the outset, a prominent sympttmi. The condition of the
]iulse was variable, usually nuiging 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 tifty beats per minute. Vomiting of bile and constipa-
tion were usually, in the beginning, ])romiiient symptoms ; the tongue ^as 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 close, it
passed involuntarily. Intolerance of light and sound, when ])resent, appeared at the
early part of the attack — the least ray of light being sufficient to cause spasmodic
closure of the eyes and intense suffering; walking across the floor was excessively
annoying to the sufferer ; deafness and a general indifference to surrounding objects,
was occasionally noticed.
The most prominent, and alumst univei-sal .symptoms, were pain in the head and
ueck, accompanied by a tetanic rigidity of the cervical mu.scles. and of the large exten-
Mr muscles of the back. This trouble, slight at tii'st, increased, until the head was
drawn back on the shoulders, and no ordinary degree of force used by the attendants
could overcome it. The muscles of the back and lowej* extremities were occasionally so
much involved as to produce complete opisthotonos. In connection with this condition,
paralysis of the muscles of the face was sometimes present, as exhibited in depression
of the lower jaw, and protrusion of the cheeks and lips in expiration. Involuntary
iwitchings of the muscles, and want of prehension also, often existed — the patient being
unable to drink without assistance. Strabismus, in one or both qyes, was met with in
several cases. The appearance of the pupils was not always the same, in the majority
of cases being dilated; sometimes one was contracted and the other dilated, and occa-
sionally both were contracted. Delirium was not common in the latter stages, before
c^ma set in, and was then of a low, muttering character. AVhen coma came on, which
was usually about the fourth or fif^h day, the pupils became widely dilated, the pulse
l)ecame more full, but it was never, as far as the observation of Dr. Armstrong extended,
of a bounding character, as in coma from apoplexy. After the appearance of coma,
involuntary discharges from the bowels and bladder were of frequent occurrence. Ster-
torous breathing was rarely present, and until the coma became profound, the patient
continually to.^sed from side to side in bed, canying the h^pds to tjic head as if in
great pain. .\ not her very common svmpto\n was the hyper?estlic?i^ pf {\^c vtiole
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458 Pathological Anatomy of Cerebrospinal Meningitis.
nervous system , pressure upon the extremities, slight moving of the feet, or bend-
ing the toes, causing the patient to cry out with pain. This exaltation of aeusibil-
ity 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, exalted sensi-
bility of the nervous system, delirium and coma, were the usual symptoms by which
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 Quioia.
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 men*
violent, as extreme pain in the head and neck, ri^dity 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 in 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 lart
cases having lived from ten to fifteen days. The prognosis in this epidemic was unfii-
forable — in fact it was regarded as a death warrant to the subject ; and Dr. Armstroof;,
notwithstanding that his observations were (extensive among the soldiers and negru
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, wu«
adopted : in the one where [there was much febrile excitement. anti>phlogistics were
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
}<cruple 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 performed, which revealed the
characteristic lesions of the brain and spinal cord :
Ca$e 557 : Cerehro- Spinal Meningitis, Effmion of Lymph on Cerebrum ^ and at tht
base of the Brain, Serum in lateral Ventricles.
Prirate, H. C, age about 40 years, was admitted into hospital, January 17th, 18G0. cSomt
six weeks ago, was exposed to the weather both day and night in camp ; he had three chilU,
the last of which was congestive, and fear days had elapsed before consciousness retumetl.
In a short time he was conyalesceDt. This history was obtained from a comrade. Preseot
condition : he complains of soreness from head to foot, has frequent rigors, and is unnble to
express himself clearly ; pulse 90 ; tongue moist and furred ; bowels constipated. Ordered
a Cathartic and Quinia. January IS.^Pulse 93; bowels moved five times from purgative;
skin has been warm since admission ; pain in the bead and neck. Ordered blister to back of
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 band to his head, as if in
pain. To have a blister to the head.
January 20th. — No improvement ; pulse 100 and weak. To have Cathartic and Spirits of
Wine at short intervals. January 21st. — Pulse 120, and very feeble ; skin warm and perspir-
ing ; comatose j opisthotonos, which began to develop itself yesterday, is very marked.
Died at 11 P. x.
Antopiy January 22d. — The anterior two-thirds of cerebrum superiorly, are covered wilt.
an adTentitious deposit of lymph, of a greenish color, forming adhesions between the
arachnoid and pia-mater, and following the latter, as it dips down into the convolutions of
the brain. The under surface of the anterior lobes, optic commissure, crura cerebri and pou5
varolii, are the seat of exudation also. Some pus is found at the medulla oblongata. Tbis
exudation is from one to two lines in thickness. The lateral ventricles are distended with
effusion, which being drawn off, pus is found at the bottom. The choroid plexus is injectftl.
The brain shows on section, no indications of softening, but appears healthy.
Qase 558 : Cerebro- Spinal Jifeningitis. Effusion of Serum in Arachnoid Spnct ;
deposit y lymph on Brain and Sjnnal Cord.
^riyat^^ V- 1^- Y-— ^^s atjfnjfted January lOtb, 1Bor>, at lo v.m— Pulse ho; skin ipoi^i
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Ptithologieal Anatomy of Cerebro-SpincU Meningitis* 459
and cool ; pupils natural ; restless ; stares at bis attendants ; makes no replj to questions
addressed to bim ; bis cbeeks protrude at eacb expiration. To bave Quinia, January 20tb.
—Pulse 98 ; bad several actions on bowels; pupils responded to light feebly j both wrists
swollen and painful to tbe touch ; notices what is goiug on in the tooni, but seems to be
unable to articulate. Continue treatment. January 2Ist. — His mind is clearer; answer*
some questions rationally ; for the first time he protrudes bis tongue, which is furred and red ;
look some nourishment; bowels acted freely last night ; picks at the bed clothes ; has passed
no urine since yesterday ; one pint is drawn oflf. Continue treatment.
January 23d — Has been perspiring freely for 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 off one pint of urine. Died in the early part
of the night.
Autopsy, January 23d — Effusion of serum in the arachnoid cavity ; membranes very much
injected ; light deposit of lymph between tbe pia-mater and arachnoid, on the anterior sur-
face of the cerebrum, superiorly, extensively upon and around the optic commissure, over
the entire cerebellum, crura cerebri, pons varolii, medulla oblongata, and spinal cord throtigh-
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.
Gise .550 : Cerehro- Spinal Meningitis ; Deposit of Lymph^ Superiorly and at 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 10th. — Pulse 120, and feeble ; skin cool ; coma-
tose; died at 10 ▲. m.
Autopsy; December 11th. — Effusion in the arachnoid space. On tbe 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.
Br. Armstrong also recorded a case of Cerebro-Spinal Meningitis, in which the
disease made its appearance, whilst the patient was suffering from severe ptyalysm, from
Oalomel, 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 eases of Cerebro-Spinal Meningitis,
one of which recovered, and three terminated fatally. The following is the record of
the three fatal cases.
Case 560 : Cerehro- Spinal 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 stoat mulatto man,
aged 30 ; apparently of a sanguine temperament. He died three days after, with all the
symptoms of Cerebro-Spinal Meningitis.
Autopsy two hours after death. Arachnoid congested with effusion of plastic lymph over
middle lobe, left hemisphere of the cerebrum, causing adhesions. 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. Sub-
stance of brain apparently healthy.
Case 501 : Cerehro- SpinoX Meningitis.
Admitted and treated at same hospital as the preceding case. Subject, a stout black man,
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460 Pathological Anatomy of Cerebro- Spinal Meningitis,
aged about 25, of a strumous diathesis. Six days prior to death, was admitted in hospital
with double pneumonia. He continued to grow worse for three days, when he commenced to
complain of severe pain in the K^ead, and in twelve hours was delirious, with great hrper-
lesthesia, in which condition he died.
Autopsy four hours after death. All the membranes of the brain congested with tffTasioQ of
serum in yentricles, and between folds of arachnoid. Great congestion of lateral sinuses an-i
base of brain. Both lungs in a state of red hepatization, except upper lobes, pleuritic adhe-
sions with effusion in pleural cavity.
Case 'jf^U : Ccrebro-Sin'nal Mt uuii/ifis.
Negro girl, aged 8, of strumous diathesis ; was first attacked with iutlucuzii, in three or four
days became delirious ; on the fifth day after the supervention of the head symptoms, compler<»
rigidity of cervical and dorsal muscles, pupils of both eyes diluted, eyes injected, tempcraturr
ofskinnormaK * * Died on the eleventh day, after the supervention of Cerebro-Spinal
.Meningitis. The following appearances are reported as having been disclosed by a post-
mortem examination : All the membranes of the brain congested, but no effusion of plastic
lymph. Found pus and serum in ventricles. Substance of brain softened, with partial dis-
organization about the base. (Atlanta Medical and Surjjical .lourual, January, 1><<;7, pp.
401-407.
Dr. Sanford B. Hunt, in his report on Cercbro-Spinal ^leiiingitis, publLshcil iu tk-
Sanitart/ Memoirs of th^ United St^tfcs S'lnifarf/ Commission, states as the result oi
his examination of sixti/-eight autopsies, ieeorde<i by Confederate and Federal Snr«reon-
and American Physicians, that :
" All present positive evidence, not only that the nieiiiiigcs of the brain and spinal con
were the locations of inflammatory disease, but that the sufferers died from that inflammatioa
and not from any intercurrent or other disease, which might cloud the discussion of Un
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." ( After accepting the result-
of the autopsy previously recorded, case 5.')."), as conclusive, as to the pathology of Cercbro
Spinal Meningitis, U. S*. Sanitary Commission Medical .Memoirs, pp. 303-300, I)r Huat con-
tinues) : " We are inclined, therefore, to believe that the only essential pathological condition
of epidemic Cerebro-Spinal .Meningitis, is that which its name indicates — an inflimmatioQ o'
the meninges, especially of the pia-mater, and that it does not differ iu character or tendencif-
from ordinary phlegmasia? of serous membranes. Its locality gives it a fatal tendency do'
seen in pleuritis, but not much exceeding that of peritonial inflammation.* " Snnitanf M^mw^
Medical, pp. 381-01,
Dr. J. Baxter ri)hain, in his aceount of an epitleujic of ( -erehro-Spinal MeuinpitJ^'
which occurred in the winter and sprinj; of 18()2 and 18(lo, in the camps in and arouoti
Newbern, North Carolina, describes the usual symptoms indicating les^ions of lb*'
cerebro-spinal nervous system, as sudden attacks of pain in the back part of the head,
excruciating pain in the back and limbs, sometimes accompanied with rigors, and nausea
and vomiting ; a peculiar stiffness of the muscles of the face and neck, convulsioos aod
coma. Post-mortem examinations revealed opalescence of the arachnoid, increase*!
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 floccnli
of lymph, with an abundant exudation of thick yellowish, apparently scmi-orgaDiial
lymph at the base of the brain and in the medulla oblongjit^i. Dr. Upham also record''
passive congestions of the lungs, with spots of discoloration on the lungs, resemblio?
pulmonary apoplexy ; in some cases, diffluent lymph in the pericardium, in other
instances sero-purulent fluids holding in suspension masses of flocculent lymph. 1"
some cases deposits of lymph were also noticed in the endo-cardium and the knee joints
(Boston Medical and Surgical Journal, xxxvii, April 6th, 1863, 16, 34, etc)
I have condensed the histories and post-mortem appearances of the following fift<^'"
cases of Cerebro-Spinal Meningitis, from the report of Charles M. Clarke, M. B., la»«^^
Surgeon 39th III. Vol. Infantry, and Chief Operating Surgeon 24th Army Corp*
(Chicago Medical Journal, vol. xxiv, No. 1, Jan., 1867, pp. 1-14, pp. 103-112).
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Pathological Anatomy of Cerebrospinal Meningitis, 461
Case Jfi'^ : Cerebro- Spinal Meningitis.
BeDJamin Hyiuan, private, Companr F, 11th "West Virginia Regiment; American by birth ;
a^e 20 years ; admitted to hospital February 20th, 1865. On his admission he was fiercely
delirioas. Pulse 80. Vomited a large quantity of dajk green matter. Pupils of eyea
slightly contracted ; tongue moist an3 normal ; skin dry and cold ; hands and feet of a pur-
plish color; urine scant and high colored ; bowels costive. 21st. Restless and wild ; no
sleep ; pulse 120, very small and irregular. During the day petechias of various sizes com-
meDced to appear, chiefly on fore-arms and legs. No considerable change, with the excep-
tion of increasing weakness, until February 26th, 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 the same; dimness of vi:*ion noticed ; he is also becom-
ing quite deaC
Patient gradually grew weaker, au<l died March 5ih, 0 o'clock r. m. Just previous to death,
pustules of acne broke out, most apparent about the face au«l neck, but some few crops were
Aeen on the fore-arms and legs.
Sectio Cfidav.j 17 hours after dfalh. — Rigor mortis well markcil. Body not emaciated.
Jlead. — Dura-mater greatly injected with both arterial aud venous blood, and somewhat
thickened. The arachnoid had a shiny, opalescent look, and was noticeably thickened at
about the middle and on either side of the longitudinal fissure. Pia-matcr covered with
patches of lymph and pus. On removal of brain from the skull, a large quantity of scrum,
flaky with pus, escaped from the membranes of the spinal cord, and when the brain was
placed on the table, by slight pressure, some si.\' 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 rentricle contained three drachms of flaky serum ; and in the anterior and posterior
coruna there was one drachm of thick pus. The right lateral ventricle presented the sapic
appearance. Pus was also found in the third and fourth ventricles. The brain tissue,
especially the cervical portion of ,bolh cerebrum and cerebellum, was soft and pultaceous,
and easily broken down. The medullary portion did not seem greatly altered, although the
pnncta raseulos awere more numerous than usual.
Thoracic and abdominal organs healthy. ,
Oti^e 5*1 Jf. : 0 I'ebro-Spinul Jfrnfttf/ifis.
Gaines Reynolds; private, Co. I, Si»th N. V. Vols.; American: age li years. Admitted to
hospital February 7th, 1865.
\Vas taken sick January 17th, with chill, severe pain 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 discharjied 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, lie was rational all the lime, 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 : Slight pyrexia; eyes injected, looking like
a case 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
and fully. No 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 6 o'clock
p. M., Feb. 13ih, when he died comatose.
Sectio Cadav.f 2 p. m., Feb. 14th. — Head. K.Klensive congestion of dura-mater ; some slight
adhesions between dura-roater and arachnoid. On reaching the pia-mater, there was quite a
flow of flocculent serum, and on each side of the longitudinal sinus there was an extensive
exudation 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
medulla 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 tissue
was softened throughout its whole extent. Upon examination of the cervical portion of the
cord, some pus was found, and the cord was softened.
Chest. — 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. (J real hypertrophy of the pericardium on the left
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462 . Pathological Anatomy of of Cerehro- Spinal Meningitis.
side; no effilsion within it. Tliere was an abnormal fatty deposit over the whole anterior
surface of the heart.
Abdomen. — Substance of liver engorged ; galUbladder greatly distended : spleen and kid-
neys normal.
Intestinei. — Omentum thickened and somewhat diseased ; transverse colon contracted to
one-third its normal size ; ileiim congested and coat thin, but not ulcerated. A lumbricoid
worm was found in the jejunum. Descending colon thickened and constricted : bladder dis-
tended with urine.
Cuse o(Jo : Cerebro- Spinal Meningitis.
Emory Wells; private, Company D., 39th III. Vols: American; aged 25 years. Entered
hospital at Richmond, Va., June 14th, 18G:>, at 10 o'clock a. m. Comatose; pupils largely
dilated; tongue moist, but not furred ; pulse 140 to 150; great disposition to tonic spasms :
head thrown back ; no apparent delirium; eyes congested and suflfused; respiration rery
rapid. This man was apparently-well the day before his entrance into the hospital. Xo
change occurred, and he died at 11:30 p. m., June i:)th, 13 hours and 30 minates after his
entrance.
Autopaj/y 12 M., June IGth, 1805. — Body emaciated, rigor mortis not well marked.
Head. — 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 pns. Brain
tissue.proper infiltrated, greatly congested, and very much softened — a slight stream of water
could wash it away. Pus found distributed in patches over the whole brain and in its salci,
beneath the pia-mater. The right and left ventricles were full of bloody seram, which was
Haky with pus corpuscles. The third and fourth ventricles presented the same appearance.
Medulla oblongata and cervical portion of spinal cord infiltrated with pns.
Thoracic and abdominal organs normal, with exception of kidneys, which showed a little
fatty degeneration.
Cuse '166: C^rcbro- Spinal Meningitis.
Dennis Brow ; private, Company M, 4th Mass. Cav.; age 26. Entered hospital Febmair
loth, 1865. When first seen, was suffering with severe chill; delirious; considerable
dyspnoea, tongue red, wi^h brown centre ; pupils natural ; skin dry and moist; pnlse scarcelr
perceptible at wrist, very frequent and irregular, 120 to 150 ; eyes red and highly injected ;
diarrhoea, with involuntary discharges from bowels ; [respiration short and qaick ; reapira-
tory murmur clear and distinct ; no congh ; very restless, with some tenderness over abdo-
men ; purpura hemorrhagica appeared in spots over the whole surface of the body ; indis-
posed to talk, and it is with great difficulty that he can be made to answer questions. Is
^od health up to the day before entering hospital.
February 20th, ▲. m. — Wandering of mind, and disposition to talk ; increase of purporm
over body; breathing more natural; pulse imperceptible at wrist; skin cool and moist:
pupils enlarged ; vomiting ; diarrhoea ; whole surface of skm hyperaesthetic. The patient
gradually sank, and died at 2:30 o'clock p^ m.
Autvpsy^ 11 o'clock a. m., February 2 1st, 1865. — Brain. The dura-mater presented petechial
discoloration over the whole of the superior surface, considerable effusion beneath it; arach-
noid somewhat thickened ; pia-mater extensively congested with blood, with here and there
a thick purplish streak, pus found in patches over the whole extent , lateral ventricles fnll of
bloody serum ; thick pus over optic tract; the cerebellum presented the same appearances;
there was pus in the fourth ventricle and in the spinal canal.
Chest. — Right lung closely adherent to the pleura costalis ; and the pleura of both Ung*
presents a mottled appearance; lung tissue healthy; pericardium greatly congested and"
spotted, with thick, purple streaks of congestion. Pericardium contained two ounces of
serum, largely mixed with pus. The heart itself is mottled, and is covered with large patches
of pus, especially aronud the sinuses of the aorta. The muscular tissue of the heart con-
densed, cutting like cartilage. Left ventricle contained one ounce of thin, bloody serum.
Abdomen. — The liver, both externally and internally presents patches of congestion; &
small ulcer was found in the left lobe ; substance of liver greatly softened. Spleen one-third
larger than normal. Kidneys normal.
Intestines. — The whole tract was covered with the haemorrhagic spot.^ ; otherwise healtbT.
Bladder full of urine.
' Cnse 507 : Cf^rebro- Spinal Meningitis,
William Statlen ; American ; age 21 ; private, Company C, 15th West Ya. Vols. AdmiU««l
February 26th, 1865. High fever; pulse 120; delirious and* restless j pupils contracted)
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Pathological Anatomy of Cerebrospinal Meningitis. 403
coald not be aroused or made to understand anything; petechial spots present over the
whole surface of the body, but most marked oyer the chest and abdomen ; vomiting every half
hour. Died comatose at 12 o'clock noon, February 28th, without any change in the symp-
toms.
AtUoptyj 10 o*clock p. M., Mai*ch l3t, 1865. — Body emaciated; rigor-mortis well marked.
Brain. — 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-
tmted with pus, and some two ounces were collected in a cup, on section of the cord, through
the lower cervical region.
Case i'tUS : Cerchro- Spinal Mnuugitis.
F. M. Dwyre ; American ; aged 23 ; private. Company C. 9th Maine Vols. Admitted Jan.
15ih, 1865, with hiffh fever; pulse 120; severe pain in the back; tongue brown and dry ;
5ome epistaxis; urine high colored, with thick phospbatic deposit; eyes injected ; pupils con-
tracted ; the skin has a jaundiced appearance, and is dry and harsh. Soon after admission,
lie 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.
Autopsy^ 12 o'clock m., 25th, 1865. — Body greatly emaciated, and the skin very yellow
throughout its whole extent.
Dara*mater intensely congested ; pia-mater covered with lymph, with here and there
patches of pus ; 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
•erum, with pus in cornus.
Chest. — Right lung healthy; left lung found to be undergoing hepatization ; lymph was
found suffused over its entire surface, and adhesions had commenced forming to the pleura
oostalis.
Heart. — Some effusion in the pericardium, organ otherwise normal.
Abdomen.^-'LiyeT 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 finger through it. Spleen and kidneys normal. Stomach and transverse colon
inflated. Three inches of the ileum intussusoepted in one' place, and four inches in another
The vessels of the whole intestinal tract were injected ; glands of the mesentery enlarged.
C'ii<e boo : Cerebrospinal Meningitis.
Joshua J. Drake ; private, Company H, 199th Regiment Pa. Vols.; age 2ii years ; American ;
entered hospital January 18th, 1865. Tongue dry and brown ; teeth encrusted with sordes ;
pulse full and rapid, 120 in the minute; great subsultus tendinum ; furious delirium ; nu
occasional cough ; pupils natural ; urine scant and high colored.
The subsultus increased, with tendency to opisthotonos ; some epistaxis : eyes injected :
coma-like stupor.
Died January 22d, 8 o'clock p. m.
Auiopsi/, 1 o'clock, p. M., January, 23d, 18t>5.
Bodj emaciated ; some discoloration about abdomen ; the toes of each foot look blue.
Brain. — Dura-mater highly engorged ; some effusion between pia-mater and brain; 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 ventricles ; mem-
branes of the cord distended with serum; cerebellum covered with lymph: slight exudation
of pus, over optic tract.
Chest. — Upper lobe of left lunjr consolidated; lower lobe highly conjrested. Kijrlit lmi;r
shows a highly inflamed condition, and on cutting into the tissue, pus exudes. /Mz/f— Pei i-
cordium contains eight ounoes of serum ; slight pericarditis manifest : blood in ventricles
not coagulated ; the right cvu.riclo contains a fibrinous clot.
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464 Pathological Anatomy of Cerebrospinal Meningitis.
Abdomen. — Liver enlarged one-third; gall-bladder enormously distended; substance of
liver apparently healthy; spleen weighs U lbs.; kidney, normal.
Case 570 : Ccrebro- Spinal Meningitis.
havid Small, Co. T, '.»ih Maine Vols., a^ed KJ yeai.^, American. Admitted to hospiul, Jau.
IHiii, 18():>. On admission there was well marked crupiiou of rubeola; «ldn--^oi and drr :
pulse 1 JO : some cough ; tongue red and dry, especially through the centre ; pupils natural :
no delirium ; respiration very hurried, and patient seemed stupid. The patient became dcii-
rions ; pupils contracted ; tendeney to opisthotonos. Died January 23d, at 9:30 a. M.
Scctio Cadav, 12 o'clock, m., January J23d. Body extremely emaciated^rigor mortis well
marked.
i?ram.— :Membrancs engorged with blood. Extensive deposition of lymph beneath arachnoid
membrane. Sulci of brain filled with serum. Six drachms of serum found in leftiateral
ventricle ; none found in the right. Cerebellum and pons varolii softened. Some pas foand
around optic commissure. Pons varolii softened.
Chest. — Four ounces of serum in the pleural cavity. Lower lobe of right lung bepatixed:
false membrane is forming x)ver posterior surface. On cutting into the substance of the lower
lobe, pus exudes. Left lung normal. Heart. — Pericardium contains four ounces of semm:
heart atrophied and the muscular tissue much softened.
Abdomen. — Liver one-third larger than normal, and greatly congested. IntassuscepUon of
Ileum for eifeht inches, old in character. Whole intestinal tract engorged with blood. *
(^i.<c 'n J : Cf'i'cbrO' Spinal Meningitis.
Arthur Smith, aged 2o, private. Co. (i, 7th Conn. Vols., admitted to hospital, January (>ih,
1804 ; taken with a chill followed by fever; complained of soreness tbroughoat bis whole
body; vomiting. No change in symptoms, until just prior to death, when he became deli-
rious; pupils dilated and had tonic spasm. Died comatose, 12 m., January 22d.
Scrlio Cadav, 4 p. M., January 22il. Body slightly emaciated; rigor mortis, but weli
marked.
Brain — Dura-mater distended with serum ; substance of brain greatly congested wiih
exudation of pus over its whole surface; cerebrum softened; cerebellum so Tcry soft, tbti
a stream of water disorganized it : no effusion within ventricles; spinal cord congested.
Chest. — Right lung normal ; left lung congested; and lymph in upper lobe. Pericardium
contained eight ounces of serum.
Abdomen. — Liver hypertrophied : gall-bladder distended. Small intestines congeswd;
patches of ulceration found throuirhout the whole tract of the ileum. Spleen somewhat
enlarged.
(j(s(.17.J: CtichiO' Spinal Meningitis.
John Hughes, private, Co. G.*158ih New York Vols., American, aged 24 ; admitted to hos-
pital, December 22d, 1864. Face flushed ; respiration hurried, and talks incoherently— cannot
be roused; pulse 120 and full ; skin hot and dry: tongue slightly coated; some dtspositioo
to tonic spasm.
December 23d, continues unconscious; some spasm of flexor muscles. Semi-deliriaiD<
Pupil of eye contracted. Died December 24th, 10 a. m.
Seclio Cadav. Seventeen hours after death. Body slightly emaciated, but presents gooJ
muscular development. Rigor-mortis well marked.
Head. — Membranes of Brain present a highly congested appearance ; Cerebellam intensek
congested, and at its base the sub-arachnoid cavity was covered with a soft yellow exadatios.
presenting every appearance of purulent matter. Cerebellum softened. On removal of lb«
brain, a turbid stream, to the amount of one and a half fluidounces, was found in the occi-
pital fossa, containing pus corpuscles. On the left hemisphere and near the longitodiiul
sinus, the arachnoid was raised from the brain, by a collection of turbid serum, about js*
in quantity. Each of the lateral ventricles contained one fluidrachm of milky serum
Spinal cord congested throughout its length, but no exudations were apparent.
Thoracic and abdominal organs normal.
Case 'j7J : Cen-Jn'o- Spinal Meningitis.
W. Manshur, private, Co. E, 2d N. H. Vol. Infantry. Admitted to hospital, Februaiv 6tb,
18G5. This man had been sick in the Regimental Hospital, two weeks prior to bis eotn:
had chill followed by fever ; also had diarrhoea. On day of his admission, was dclirioo?,
pupils contracted; tongue dry and discolored ; respiration hurried,, puls^ 130^
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Pathological Anatomy of Cerebro- Spinal Meningitis. 4G5
February 7th. Continues delirious; appears to be suffering greatly; had seTeral involun-
t&rv dejections from bowels during night ; some spasms of the muscles and disposition to
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-
Aoce of petechias over body ; hands and feet purplish in color, and very cold.
February 10th. Died this morning.
Avtopty 10 hours after death. — Brain. The membranes of the Brain, appeared distended and
puffed up with fluid, except the pia-mater, which was closely adherent to the brain; convo-
lutions of the cerebrum were covered with lymph, and in some places there were large
patches of pus ; f ,:^i. of flaky serum found in each of the lateral ventricles ; substance of
brain, much softened. The cerebellum presented the same appearanoefs. Membranes of the
cord, infiltrated with serum. Patches of ulceration in Ileum.
Case o/Jf : Cerebro- Spinal MenluyitU,
J. K. i>pellen. private, Co. II, lOOih Penn. Vols., American, aged 2G years ; admitted to
hospital, February 26th. High fever ; pulse 120 ; tongue furred : skin dry ^nd hot; respiration
hnrried with considerable cough ; eyes injected and watery. February 27th. Complains of
some pain and jactitation. March 1st, died.
Autopt^ 24 hourt after death. — Body emaciated. Kigor-mortis well marked.
Brain. — On removal of the brain from the skull, fgii. of serum was found in the occipital
fossa. Great effusion beneath the arachnoid, which was considerably thickened ; pia-mater
fxtenslvely congested with both arterial and venous blood ; lymph found in abnndance over
whole surface of cerebrum and cerebellum, but no pus. No serum found in the ventricles ;
l»rain tissue very much softened. Spinal cord not examined.
Ch€9t. — Lungs normal; considerable effusion found within the pericardium; right auricle
nod ventricle filled with coagulated blood ; large fibrinous clot found in left ventricle.
Liver and kidneys normal. Spleen atrophied. Intestines congested and spotted.
Case 575 : Ctrebro- Spinal MeningltU.
li. \V. Bean, private, Co. C, 9th Maine Vols.; American; age 24. Admitted January iUth,
1«65, with what was considered a well marked eruption of rubrola ; slight fever; pulse 98 ;
<$cvere cough with pneumonic expectoration ; severe pain in right side and considerable dysp-
noea ; tongue red and dry. Eruption had made its appearance three days before his
entrance. Made complaint of severe pain in his head and down his back. Pupils of eyes
natural. The man became delirious on the third day after his entrance, and continued insen-
sible until the date of death, which occurred January 31si, at 3:30 o'clock, a. m.
Autopgy, 2 o'clock, m. Body greatly emaciated ; rigor-mortis well marked.
Brain.' — Membrane greatly congested and distended with serum ; arachnoid thickened ;
pAtches of lymph over surface of cerebrum and cerebellum. No effusion found in the ven-
tricles; some little pus found over tract of optic commissure. Membranes of cord infiltrated.
Brain tissue softened.
Ohett. — Upper lobe, and portion of lower lobe hepatixed (red).
Ahdom^n. — Liver enlarged one-third, and mottled.
Case 5i(j : Cerebro- Spinal Meningitis.
James Kirkpatrick, private; Co. C. 190th Pa. Vols. Admitted to hospital January 20th,
!«65. Died February 2d, 1865.
Autopty, 12 hours after death. Brain. — Considerable effusion under the membranes, and
•iura-mater in a high state of congestion ; arachnoid thickened. Over right hemisphere of
cerebrum there was a large deposition of lymph ; pia-mater thickened, and adherent in some
places to the brain. Pns found in small quantities over optic tract. Ventricles pkrtly filled
with turbid serum ; brain tissue soft and cavity broken down ; spinal cord much congested.
Case 577 : Cerebro- Sjnnal Meningitis.
Samuel Farnsworth, private, Co. H, 10th N. H. Vols. Admitted to hospital, December
ilst, with marked fever ; pulse 120; tongue thickly coated ; skin dry and burning; difficult
respiration; diarrhoea with involuntary discbarges ; severe cough with free expectoration:
constant pain ascribed to back of head and neck ; urine voided freely, but of dark color.
December 22d, more obtuse, pupils natural ; pain in back continues; discharges from bowels
<iuite frequent ; December 24th, died comatose, at 10 p. m.
Seetio Cadav,^ twelve hours after death. ^ram.^-Dura-niater intensely congested, with
Eome effusion beneath it : some lymph deposited over the lobes Of the cerebellnm ; ventricleit
dry ; brain tissue softened : meninges of cord congested through cervical regioB.
'C^«/.— Double Pleuro-Pneumonia. ^eart noimal. Liv^r, spleev «nd l^idnevs ^e^ltb^^
^
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46G Pathological Anatomy of of Cerebrospinal Meningitis.
During the months of January. Fe))ruary and March, 18G5. a large number of
cases came under the notice of Surgeon Chas. M. Clark, at the field hospital of tiie
24th Army Corps, iB?hich at that time was located near Hutching's Run, Virginia.
The troops were comfortably quartered about three miles back from Varina Landin*:.
on the James River. The country was high and rolling, and heavily timbered, the
soil being a mixture of sand and clay. The season had been remarkably wet, and
intermittent, remittent and " fypho malarial " fevers were prevailing extensively. Tbi-
)nen were also greatly and continuously exposed to fatigue and excitement, there bang
almost constant calls upon them for duty in reconnoitering, constructing earth- worki^.
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, considenog
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 cases, recorded by Sui^eon Clark, without doubt,
should be referred to the preceding causes and not to the disease under considention
It is a matter of regret that a full record of the previous history in each of tht
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 cases, ftillji and
unequivocally sustain the view that Cerebro-Spinal Meningitis is essentially an inflani-
matory disease of the Cerebro-Spinal Nervous System, and that it may be accompanid
by inflammation of the Peri-Cardium, Pleura and Lungs.
In the epidemic of Cerebro-Spinal Meningitis, which prevailed in Philadelphia,
during the months of December, 1866, and January, February and March, 1S67.
according to Dr. W. H. H. Githens, who recorded careful observations upon the case?
treated in the Philadelphia Blockley Hospital, the post-mortem examinations revealed
similar lesions of the Cerebro-Spinal System. The membranes of the brain were con-
gested, and serum was effused in large quantity in the sub-arachnoidean spaces, at the
btise of the brain, and within the membranes of the spinal cord. Fibrin was deposited
along the margins of the longitudinal fissure of the brain, about the commissure of the
optic nerve ; in fact, freely over all the base of the brain ; and in one case, it could b<»
separated in masses weighing from three to five grains, from where it had firmly glaed
together the two surfaces of the fissure of Sylvius.
The quantity of this deposit of fibrin, its color, consist<Mice and strength of aiach
ment, were influenced chiefly by two cases observed during life. In some cases, when;
the inflammatory symptoms were of an active character, as shown by the congestion of
the face and eyes, the character of the pulse, and the violencie of the delirium, death
occurred early ; and an autopsy showed little or no deposit of solid lymph, but a large
quantity of serum, and in one case pus, in all the serous cavities connected with tlu-
brain and spinal cord, with turgescence of all the vessels of the pia-mator and nervon.s
substance. If on the other hand, death did not intervene so quickly, there wen^
deposits of fibrin, becoming larger, firmer, and more adherent, in proportion to the
grade of inflammatory action, and the time allowed for its coagulation. These depoeita
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 meio-
branes were congested, and there were several deposits of fibrin about the roots of the
spinal nerves.
The following cases with post-mortem examination.'-', are selected from the report of
Dr. GithenSj in addition \o those previously recorded.
^se 5.78 : C^rehrO'Spinal Meningitis.
Julia Dilen, aet. 21 ; wa^ delivered at full time, January 25ih, l8t3T, by means of forceps,
Janoary 30th. An eruption of an erythematous nature, appeared on chest with distioct
eruption of a darker hue on abdomen and thighs. Vomiting, no pain or tenderness in neck or
back, or stiffness of mu^les anywhere.
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Pathological Anatomy of Cerebro- Spinal Meningitis. 467
After midnight, a haemorrliage of about sixteen ounces from uterus oceurred.
January Slst, a. m Vomitinji: and continued thirst, pulse 130, quick and weak.
10 p. V. Signs of cerebral disturbance; pain in the head with general uneasiness, and
Tomiting.
February 1st, 10 a. m. Semi-comatose; evidently suffering great pain; face darkly con-
freated ; pupils contracted. Pulse quick, 150 heats per minute. Later in the morning, coma
deepened ; the eyes became dry and rolled upwards ; patieut comatose, could not be aroused.
Died at 3 p. x.
PoMl^Mortem Examination^ eighteen hours after death. Effusion of serum within the mem-
branes of the brain and spinal cord; deposit of fibrin. along longitudinal fissure; congestion
of the membranes 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 : Cerebro- Spinal Meningitis.
Mary Peterson, set. 45; temperate; first noticed in a collapse of three hours duration^
Symptoms were congestion of eyes ; the right pupil cooTtracted, 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 hour$,
PoU-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 : Cerebro- Spinal Meningitis.
Wm. McAllister, 8et. 63 ; temperate; slight headache ; alternate constipation and diarrhoea ;
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.
Case 5S1 : Cerebro- Spinal Meningitis.
Annie Fitzgerald, aet. 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 582 : Cerebro- Spinal 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 1867, pp. 17, 34.
Dr. S. J. Webber, in his Essay on Cerebro-Spinal Meningitis, which received the
BojlstOD Medical Prize, (Boston Medical and Surgical Journal, vol. xxv., pp. 59, 61,)
affirms that the results of all careful observers, have shown that the principal lemons
are found in the brain and spinal cord ; the morbid changes varying from slight
increase of the number of haemorrhagic points, to extensive softening of the brain,
with effusion of lymph and pus beneath the membranes.
*'Tbe arachnoid in some instances has lost its transparency and become opaque, especially
at the vertex. Beneath it may be seen the vessels of the pia-mater engorged with blood, that
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, pons 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
situations. 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'-liqnid substance. The veins and sinuses of the brain, are distended
with dark fluid blood. The substance of the brain may be natural in appearanoe, but it is
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468 Puthologicai Anatofny of Cerebro-* Spinal Meningitis.
often congested, the hasmorrhagic points being increased in numbers ; it maj be foftesed
almost to a pas-like liquid. * * The same congested appearance and softening are found
in the cerebellum, pons varolii, and medulla oblongata. *^ ^ In the spine, a similar condi-
tion may exist, the membranes being congested, there being an effusion of ;ierara, lymph or
pus, and the substance of the cord being congested or softened.
The following b a very brief statement of the results recorded by Professor J. S.
Jewell, of Chicago, in his report on Cerebro-Spinal Meningitis, based upon the repoiu
of 200 Autopsies which he had collected from various sources. In this disease, port-
mortem changes are almost never absent from the cerebro-spinal cavity. Both th**
cranial and spinal dura-mater, almost never present well-marked evidences of stractonil
change, or of a firm exudation, on the free or serous surface. The arachnoid also ha?
not often presented evidence of disease. The pia-mater. unlike the two oerebro-spiiiaJ
investments, just mentioned, has almost uniformly presented the appearance of disease.
Rarely cases have occurred in which no evidence of structural change or exudation hare
been observed, but not one where congestion has been absent. The rule is that it presents
the most indubitable evidences of disease. Those parts of it most frequenUj diseased,
are at the base of the brain, about the optic commissures ; the interpeduncular spaeo
behind the commissure ; the pons varolii and medulla oblongata ; under surface of thr
cerebellum, and along the fissure of Sylvius. Aft<3r this, the surface of the hemisphere-
is the most constant seat of disease. The congestion and the exudation when preseat
may occur uniformly over the surface, or, as invariably happens with the latter, is found
along the course of the sinuses and blood-vessels, and large fissures, and along the fi-i
sures between the convolutions. Next, the pia-mater of the cervical portion of the conl
is most freauently diseased, and of this part and the medulla, the posterior aspect \^
most often diseased. M. liovy found in 44 cases, the posterior part almost exclusively
affected in 27 cases.
Next in order, the lumbar and lower part of the dorsal regionis arc most often affected :
and laatly, the pia-mater of the dorsal portion seems most frequently to be free from
disease. Sometimes cases have occurred in which the spinal element has been absent,
but the converse has been exceedingly rare.
Except in some cases, where death has occurred either with extreme suddenness, or
in cases of long standing, there is found to be an increase of the subarachnoid fluid,
especially at the base of the brain. In recent cases, it consists in a simple incret?'
of the natural fluid, but in most cases, it is colored yellowish or reddish by pus or blooii.
and varies in quantity from a few drachms to several ounces. It varies in consisienc
and has been found by M. Forget almost gelatinous.
Except in those cases where aeath seems to have taken place too soon to permit of such
a result, there has been found more or less plastic exudation, most abundant, in soeh
places as have been already indicated. It may be a sofl, friable, pus-like layer, or havi-
a gelatinous consistence, or be firmer yet as coagulated fibrin ; it may be nearly tran."
parent, or have a grayish color, or may have a white or creamy appearance, or be tuige<l
various hues, by either pus or blood, or both. It may cover a large extent of surfiic.^.
or be disseminated in patches here and there. But it is always when present, fbiwl
along the course of the large vessels and the fissures, and about the roots of the nerve-^.
whether the cranial or spinal, the posterior roots of tlic latter in particular. It is, when
present, on the surface of the pia-mater, but may be infiltrated into its structure, or
beneath it into the nervous substance for a short distance. It varies in thickness, from
a mere film to a line or two, or more. Its consistence depends much on the duratioH
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 noniuil
quantity of fluid in them ; occasionally, the quantity has seemed to be normaL It ha>
been found to vary from a small increase to several ounces, and in a case reported bv
Dr. Reading, the quantity was so great the ventricles were ruptured. M. Tondes, Ba«r
in 44 cases examined at Strasbourg, 26 in which the ventricles were distended ; and in
44 cases examined by M. Levy, at Val de Grace, 18 presented distended ventricles.
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Pathelogieal Anatomy of Cerebro-Spindl Meningitis. 469
Xiemeyer mentions a case, where the ventricles contained as much as six ounces of fluid.
The Tentricular walls have been found softened, and Allen speaks of having seen ecchy-
moeed spots in them.
The Nervous substance in the majority of cases has baen reported healthy ; occa-
sionally it has been seen paler than natural, more frequently it has been seen congested
in Tarious parts and degrees. M. Levy found in 44 cases injection of the nervous sub- '
stance, 9 times. Softening has occasionally been reported in chronic cases ; Niemeyer
records it in 2 cases out of 15. One of these cases was of 40 days standing, and
exhibited cheesy metamorphosis.
The spinal cord, is sometimes congested and softened.
No characteristic or uniform lesions have been observed in the lungs, heart, and
abdominal viscera. Report on Ccrcbro -Spinal Meningitis, Chicago Medical Examiner.
October 1866, pp. 609, 617.
As early as 1806, Drs. Danielson and Mann, found adhesions of the cerebral mem-
branes, in two out of five dissections, or " a fluid resembling pus, both over the cere-
brum and cerebellum." 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^Ia^sachusetts Medical Society, recognized the important distinction between the
appearances in two classes of cases ; in those which are fatal within the space of twelve
hoars 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 arachnoides and the pia-mater are remarkably altered
in i^pearance by the eff'usion of an opaque substance between them, which may be
called coagulable lymph or semi-purulent lymph. This substance is frequently of the
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 base present the same appearances as at the vertex of the
brain. * "
Dr. Joseph A. Gallup, in his " Sketches of Epidemical Diseases in the State of
Vermont, published in Boston, 1815," gives an accurate account of Cerebro-Spinal
Meningitis under the name of Spotted Fever, and devotes an entire section to the
appearances afUr death and on dissection. Dr. Gallup appears to have been fully
acquainted with the characteristic lesions ; thus he says :
^* The blood-yessels ia 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 term of sickness
and degree of local affection in the brain. Signs of inflammation 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. An increase of serous fluid is often dis-
covered 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 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 Cerebro-Spinal System in this
disease, which at that time was called Spotted 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 effusion of the pia-mater in sev-
eral oases, and calls it pus. — Sketches of Epidemic Diseases, in the State of Vermont,
etc, pp. 236-243.
After careful examination of the work of Dr. Hale on " Spotted Fever," I find that
* This Committee was appointed by the Counsellors of the Massachusetts Medical Society,
March 27th, 1810, and their Report is given in the Massachusetts Medical Communications,
Vol. 2, Boston, 1813.
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'470 Pathological Anatomy of Cerebro^ Spinal Meningitis,
this author had made no post-mortem examiDation himself, and appears to have been
ignorant of the results obtained by other observers.
Dr. Job Wilson, in his work, published at Boston in 1815, not only describes the
nervous derangement observed during life, but also gives drawings representing the
appearances found after death, in the brain and appendages.
Drs. North,. Woodward, Fish and Miner, all directed, in their observations upon
Spotted Fever, published about this time, attention to the nervous distorbances, 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
body, shifting pains and spasms, anajsthesia and paralysis, and hyperassthesia of various
parts, blindness, deafness, loss of sense of taste, spasmodic deglutition, and paralysis of
the pharnyx. The last named author, after giving a case which he describes as stupid
as a block, unconscious of any impressions on either of the senses, and so convulsed
that it required three or four men to hold him on his bed ; with eyes open and rolled
back so as to hide the colored part, and with teeth firmly clinched as in locked-jaw, and
with face, arms and legs, and body literally covered with spots : Dr. Miner remarks.
*' Spotted fever appears to have its seat and throne in the brain, to belong nosologically
to the passive phlegmasiac.*'
Dr. S. Ames, of Montgomery, Alabama, appears to have been the first author in this
country, 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 eigh^-fi?e
cases, sixty-four of which were subjected to a regular analysis. According to Dr. Ames,
250 cases occurred during the winter and spring of 1848, in the town of Montgomery.
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, wis
almost invariably involved. He believed that there w^re good reasons for suppoang
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 hypersemia of the brain, in
every instance in which the condition of that organ is noticed. While the occa»onal
observation of one of the products of inflammation, viz : softening, and in all the fatal
cases the occurrence of symptoms, such as abnormal sensibility and muscular motions,
delirium, coma, &c., which, being observed in a disease having a constant excess of fibrin
in the blood, may be considered as unequivocal evidence of inflammation of the nervous
substance — at least, so long as there is no proof that simple meningitis can produce
them. The symptoms indicating serious and undoubted lesions of the brain and spinal
cord, as described by Dr. Ames, were of the most unequivocal character — cephalagta,
( .some described the pain in the head as a continual, painful roaring, others as a fulnecs
and tightness, as though a band were tightly drawn around the head, or as if the fore-
head, crown or sides, were being crushed inwards ; a greater number described it a*»
darting and thn)bbing, frequent shooting through the head from behind forwards, and
tVom side to side with a violence causing the patient to cry out); giddiness in the fin4
few hours of the attack ; injected conjunctivae, with glittering, watery eyes ; the pupiW
were dilated in seven out of forty-one cases, in the others they were either contracted
or natural, in three cases they were insensible to light from coma, and in two without
loss of consciousness ; double vision occurred in six cases, photophobia in six cases, in
a number of others the ordinary light was disagreeable ; in one patient, the sense of
smell was lost in one nostril, in some cases there was spontaneous deafness, and in one
case the deafness occurred three times on the second day, each time lasting about three
hours, with intermissions of about the same duration ; stupor, amounting generally to
profound coma, which did not remit in the cases which proved rapidly fiital, but which
in other cases alternated with delirium, and in favorable cases with lucid intervals ;
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Pathological Anatomy of Cerebro- Spinal Meningitis, 471
toDic contraction of the uiuo^cleh; of the back and neck, tonic spasms of the muscles?
aod in some patients tremors, twitchings and perpetual motions of the limbs, in some
cases 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
coDvulsions in a number of cases ; strabismus occurred in nine eases, an incompleti^
paralysis of the right eyelid occurred in one case, and of one entire side of the body in
another; pain in the muscles in various parts of the body along the whole length of
the 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
tench would make the patient start with a general spasm and scream out with pain ;
pressure applied to the cervical portion of the spine produbed pain in the head, frequently
darting to the forehead, eyes and temples.
Dr. Ames drew up his account of the anatomical character of this disease, from
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 cases. The
pia-mater exhibited abnormal vascularity in every case. The vessels carrying the con-
Yolutions 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
tx.'chymosis were observed on the lateral walls of the third ventricle, the anterior wall
of the fourth, and in the posterior horn of the left lateral ventricle. They were also
>*cen, 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
eases of congestion and inflammation, there was invariably found an infinite number of
red vessels containing, sometimes fluid, at others, coagulated blood. The gi-ay and
white matter had a pink color, dependent upon the presence of vessels that were sepa-
rately visible — which, although never entirely absent, occupied diflerent parts in different
subjects. In two cases, the medulla oblongata was spotted interiorly with dark, ccchy-
mosed 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 pai*ts 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
canal leading to the fourth : in another, in the corpus callosum and outer semi-circular
nm of the left 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 eff'usion of yellowish colored matter, showing, under the
microscope, an abundance ot pus and lymph globules, on some portion of the membranes
covering the exterior surface of the brain. In the greater number, enough of the
effused lymph was coagulated to give some cohesiveness to the morbid product, but not
enough 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
hemispheres ; in others, it was confined, on the convex surface of the hemispheres, to
the course 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-
ces of the convolutions being occupied by a serous fluid, containing a few pus globules.
It was found also on the corpora quadrigemina, the medulla oblongi\ta, and around the
third pair of nerves, where they penetrate the arachnoid membrane. The exterior sur-
face of the cerebellum was frequently the seat of this deposit.
In nine casQS, there was an effusion of fluid into the arachnoid cavily. With this
eflTosioD, pus globules wore mixed, \x\ various proportions, in every case \\\ which they
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472 Pathological Anatomy of Cerehro^ Spinal Meningitis.
were sought. In two cases, the eflusion cousbted chiefly of pus, mixed with Uood
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 seat of an organized false membrane.
In four cases, a morbid effusion was found in the lateral ventricles ; in one, it con-
sisted of a cream-colored layer, semi-fluid, on a part of the left corpus striatum ; iu
another, there was about a drachm of a greenish colored pus; in another, senim 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, viz : In the
internal carotids, in two ; in the basilar artery, in one, and in the longitudinal sinosaixi
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.
Sp^inal Cord. — So fiir 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 intaiee
vascularity of the pia-mater was always present, but the lympho-purulent deposit, and
the injection of the cord proper, were less common than in the brain.
In other parts of the body no lesions were observed, which seemed to be other than
accidental, or particularly worthy of note, except those found in (he digestive tube, aud
mesenteric glands.
The abdomen was opened in five cases ; in all of them the mucous membrane of the
.stomach and ileum was reddened, thickened and softened to a greater or less extent In
four cases, there were lesions of the agminated, solitaiy and mesenteric glands. The
solitary and agminated glands were enlarged, and in one case ulcerated. The mesen-
teric glands were enlarged, red, and in one case soflened.
Blood. — The blood taken fVom the arm, and, by cups, from the back of the neek,
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 serum separated from it very slowly, and in small
quantity. Its color was. generally bright — in a few cases nearly approaching to that of
arterial blood ; it was seldom buffed ; in thirty-seven cases in which its appearance ww
noted, it was buffed in only four. The blood, an analysis of which is given below, was
taken, early in the disease, from the aim, and was the first bleeding in each case. The
first was from a laboring man, thirty-five yeai-s old ; the second from a boy of twdve
years old, while comatose, and the two others from stout women, between thirty and
thirty-five.
I'UMPOJflTlUN OF THE BLUOD IN CEJIEBBO-MMNAL MENlXGlTli*.
(!•) (2.) (3.) (4.)
Specific Gravity of Defibrinated blood 1053.50 1046. 1046.50
" " Serum , 1026. 1022. 1024.
Water 767.87 813.83 796.07 787.37
Solid Contents 232.17 186.17 203.83 212,65
Fibrin 6.40 5.20 3.64, 4M
Corpuscles 140.29 112.79 123.45 129.50
Solid Residue of Serum 85.31 68.10 76.84 78.5)
Xew Orieans 3Iedical and Surgical Journal, November, 1848, Vol. v, No. iii, pp.
295-328.
In those cases of Cerebro-Spinal Meningitis in which death occurs suddenly, withio
a short period after the first manifestations of nervous derangement, no marked leaoa
of the cerebro-spinal nervous system is found, beyond congestion. The absence of the
deposit of lymph, and of the unequivocal marks of inflammation in the cerebro-spiDal
axis, led to many erroneous speculations, with reference to the nature of the disease.
Ihr. W. W. Gerhard, of Philadelphia, has recorded the following observation upon
this disease, which he teims Spotted Fever, and which be attempts to throw into tbe
class of essential fevers :
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Pathological Anatomy of Cerebrospinal Meningitis. 473
" About the middle of last February, (1863), I was called to a case of a new form of dis-
ease.
" Cask -583. — The patient, a boy of sixteen years of age, was taken suddenly with intense
paia in the head and back, with occasional doliriuih ; there was also vomiting and nausea.
la 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 ecchymoses, such as might be caused by the puncture of an insect, than a proper erup-
tion. There was no diarrhoea, moderate heat and fever; the tongue was scarcely coated.
This patient died in four days from the attack, sinking into a state of coma.
"Case 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, I was called to the Falls of Schuylkill, five miles out
of the city, to see a nnmber 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
nanaber of thirty, ten terminated fatally. Unfortunately, no examination after death was
permitted in any of these cases, notwithstanding the most urgent entreaties.
* " From an examination of the symptoms of a nnmber of these cases, and comparing them
with the one I had already seen in Philadelphia, 1 was enabled to make out the character of
this aflTection, 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 disease appeared more than half a century ago, from
the year 1807 to 1815 or 181G."
Dr. W. W. Gerhard, under the head of Anatomical Lesions^ gives the report of the
only post-mortem examination of what he calls " Spotted Fever." which hiid come
directly under his observation. Thus he says :
*' In a case in Montauk, a patient of Dr. Uhler, 1 was enabled to see the autopsy of the
whole body. The brain was found to be congested with blood, the veins containing an
unasaal 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 scrum, but there was not a
trace of any lesion produced by inflammation."
Xo lesions of note were found in the other organs.
Upon this very slender foundation, viz : one post-mortem, by l)r. Packai*d, the* sub-
ject having died in the first stages of the disease, twenty-six hours from the commence-
meDt, and one post-mortem witnessed by Dr. Gerhard himself, the subject being a
paticDt of another physician, and in a different locality, and the account, as recorded,
without any history of the cane, this distinguished pathologist boldly announoes 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 " the only account of Spotted Fever, (Cerebro-Spinal 3Ienin-
gitis), " is to be found in an imperfect description given of it by a number of physicians
in New England, where the disease appeared more than half a century ago, from the
year 1807 to 1815 or 1816."
Immediately after recording the post-mortem examination above given. Dr. Gerhard
gays :
** The anatomical lesions thus confirmed the conclusions at which I had already arrived
reipecting the pathology of the disease. That is, that it is strictly a blood disorder, uncon-
nected with any atrnctural lesion. The internal ecchymoses of blood are precisely similar
to the spots on the skin,, and are evidently depetiding on the same cause. This fact estab-
lifhei a wide distinction between them and those appearing in Typhus or Typhoid Fevers, at
well as the eruptions of the exanthemata.
GO
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474 Pathologieal Anatomy of Cerebrospinal Meningitis.
It requires nothing but actual observation to entirely dissipate all such ideas. The dis-
ease belongs to the same class as other continued fevers, or exanthemata, but is just as dis-
tinct from Typhoid, or Typhus Fever, as from Measles or Small-Pox. The two affections to
which it has the closest similarity, are the Petechial Typhus Fever, and some calignant
varieties of Scarlatina.
Dr. Gerhard even goes so far as to congratulate himself in being thus able to " estdb-
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 Ur
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 a largt
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 character? of
another variety of febrile disorder, which, although not so common as either Typhnt or
Typhoid Fever, is yet more fatal in its symptoms and course. These three varieties of fefer
I regard as more distinct than many cases of Intermittent and Remittent ; although occa-
sionally the distinctive characters may be somewhat confused one with another, yet, on the
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 than
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 diflScult.'' Spotted Fever occurring in the
vicinity of Philadelphia, in the year 1863. Quarterly Summary of the Transactions of the
College of Physicians of Philadelphia, 1862-1864, pp. 41-49.
Dr. Gerhard was evidently led into error as to the nature and characteristic ledioiu
of " Spotted Fever," by making a hasty generalization upon the results of two post-
mortem examinations ; and it is very evident that he had not critically examined the
authorities on the disease ; for if he had studied the " imperfect desa-ipHon given of it
by a number of physicians in New England," he would have found that the theory so
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, commonlj
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 Typhus to all fevers i{L which prostration aad
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 pages.
But if Typhus is to be considered as a particular disease, the fever under consideration wai
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 progress
was more rapid, its features more variable, its changes more abrupt, and its termination mor«
sudden.
"These are obviously characters of different diseases; and in practice, nothing eanbe
easier than to distinguish them. A very slight examination is sufficient to show that we hare
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 diitiAC-
tion between mere prostration of strength and debility. The fever under consideratioa
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 elasticity
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 the
two diseases resemble each other, yet there are others, equally important, in which thej eri-
dently differ. Several of these have been mentioned. There is one other circumstance of
difference, deserving of notice, which was omitted there, because its correctness may not per-
haps, be universally allowed, without further illustration. Typhus is everywhere described
as a contagions disease, while the epidemic which has so extensively ravaged our conntrr, is
igenerally believed not to be contagious.
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Pathological Anatomy of CerebrO'SpinaV Meningitis. 475
*< This is fullj mj opinioD, and bo generally is it established, that I should not think it ne-
ecssarj to saj anything in its support, were it not that the contrary opinion is held by some
gentlemen for whom I have a high respect." Chapter yi, pp. 226, 227, 240.
Dr. Jewell and Dr. W. II. H. Githens, of Philadelphia, have recorded observations,
which demonstrate 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. 333-336), to report on " Spotted Fever," so-called.
Thus, 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 fever, not essentially an inflammation ; that local inflamma-
tions, when they do occur, are consecutive to the constitutional dietarbance, are due to the
morbid condition of the blood, provoking exndation, 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 endo-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
state 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 monthsi
both of whom died in twelve and fourteen hours after tlie seizure, in the midst of health)
the cerebro-gpinal meninges were filled with black blood. The account is imperfect)
because 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
substance of the brain and medulla oblongata was natural in appearance and consis-
tence," 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 the theory that the disease is an essential fever. If patients die in the first
or congestive stage of pneumonia, before any of the products of inflammation have
been £)rmed, we are not justified by such superficial observation in classifying this
disease 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 Society, on Spotted Fever, or Cerebro-Spinal Meningitis, in
the State of Massachusetts, May, 1866, says, with reference to this disease, as observed
in the Federal armies during the civil war, 1861-1865, that
" There were at least 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 cases, no perceptible anatomical lesion in the cerebro-spinal
axis 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."
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47G Pathological Anatomy of CerebrO' Spinal Meningitis.
After an extended inveetigation of the nature of Cerobro-Spinal Meningitis, m it
prevailed in the Confederate army and after the performance of post-mortem examina-
tions, both during and subsequent to the war, in widely separated portions of th«
Southern States, and after a careful examination and comparison of the labors of
American and European physicians, and of both Federal and Confederate medical ofi-
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 protracted, " no perceptible anatomical lesion in the cerebro-
spinal axis was observable."
Until such a careful record of these cases has been furnished, as will permit of care-
ful study and comparison, the preceding stat^jment cannot be accepted as a basis for
generalization as to the nature of this disease.
Dr. Meredith Clymer, in his chapter on Epidemic Cerebro-Spinal Meningitis, pob-
lished in the Third American Edition of '' The Science and Practice of Medicine, bj
William Aitken," pp. 492-505, holds a theory similar to that originally propoanded
by Dr. Hale and others, and more recently advocated by Drs. Gerhard, Levick, Wood-
ward and others.
As a result of his inquiries, Pr. Clymor is compelled to conclude^tliat,
"The pathogeny of epidemic Cerebro-Spinal Meningitis is still unsettled. There is reason
to say that it is not a yariety of simple or idiopathic inflammation of the membrmnes of the
brain and spinal-cord, nor of typhus fever, nor of pernicious paludal fever, but a snbstADtire
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 moit
be owned that its pathogenic nature remains unknown."
Beyond the general statement of Dr. AVoodward, Dr. Clymer adduces no facts to sus-
tain his hypothesis as to the nature of Cerebro-Spinal 3Ieningitis.
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 facts and
observations, recorded by competent observers during the last half century, as will
enable me to draw conclusions as to the nature of this disease.
PRACTICAL CONCLUSIONS.
Cerebro-Spinal Meningitis should be classed with the Phlegmasiae and not with the
Pyrexiae.
The exciting causes, as far as known, the origin, progress and lesions and Mood
changes of this disease are similar to those of acute idiopathic Peritonitis, and Plevritis,
Pneumonia and Acute Rheumatism. |
In Cerebro-Spinal Meningitis, as well as in Acute Pleuritis, Peritonitis and Pneo-
monia, the first symptoms are sudden, sharp, and grave, and the inflamed membrmee
and tissues, commence in a short time to pour out fibrinous inflammatory lymph, fiBed
with living exudation, granules and corpuscles capable of higher development and
organization. The term ^^head Pleurisy,'' applied by the common people in some aectioiis
of the Southern States, to Cerebro-Spinal Meningitis, is by no- means an inappit^iriate
term, as expressing the analogy which exists between this disease and Pleuridc inflam-
mation.
Without doubt one of the most potent causes of the various forms of idiopathic
inflammations is exposure to cold and the consequent arrest or perversion of the fonctioQ
of the skin.
Inflammation of the Kidneys, Lungs and Pleura, appear to be caused not so much
by the d^ree of cold, as by sudden variations of temperature and moisture. It is wdl
known that Pneumonia often prevails as an epidemic over large tracts of country, and
varies in its type, and in the rate of mortality, and in the rapidity of its progress, with
certain atmospheric and climatic changes.
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Pathological Anatomy of Cerebrospinal Meningitis. 477
The term Epidemic^ may with equal force be applied to Poeumonia as it prevails at
certain periods in the sub-tropical and temperate zones of the earth.
All ioflammatioDS have been divided into two classes, viz ; extrinsic and intrinsic ;
the former term being applicable to all those cases in which an injury, either sustained
by the affected 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 Idimmthic. To the latter class must be referred Cerebro-Spinal ^Meningitis, Acute
Pleoritis, 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.
1st. 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 tcuiperdture and moisture, may
induce the suppression or diminution of certain important excretions as those of the
skin and lungs, and induce the accumulation of certain noxious cxcrementitious 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 circulation, 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 havo
therefore, much in common, with the so-called infective tnjlammations, arising, as in the
case with puerperal peritonitis {^^^ puerperal fever ^'' ) 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 generally of any organ or tissue, by exudation of liquor
sanguinis, and emigration of the white corpuscles (Jeucoc^teSy) from the blood through
the walls of the capillaries. 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 Midarial fever, is to degeneration and disorganization of the Mood, and of
the secreting organs, and of the secretions and products peculiar to the disease.
Thus Malarial fever is characterized by a rapid destruction of the colored blood cor-
puscles, 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, disintegrated 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 the liver, may remain for months and even years. The enlarged, softened, disor-
ganized spleen, resembling a bag of sofl mud, in malarial fever, is far different from the
hardened, inflamed spleen.
The deposit filling the glands of Peyer, and the Mesenteric Qlands, in Typhoid fever,
although containing exudation corpuscles tends to degeneration and not to the forma-
tion of distinct fibrous tissue, as in Pleuritis, Peritonitis and Cerebro-Spinal Meningitis.
In a word, Cerebro-Spinal Meningitis, like other acute inflammatory diseases, is cha-
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478 Pathological Anatomy of CerehrO' Spinal Meningitis.
racterized by an increase of fibrin in the blood, and by the formatioQ of deposits of
inflammatory lymph, capable of organization into fibro-elastic tissae; whilst on the
other hand, the true uncomplicated fevers, are characterized by a decrease of fibria,
and the tendency to passive hajmorrhages.
The very diversity of the symptoms in Cerebro-Spinal Meningitis, would indicate
that the disease, is not due to any special poison, acting upon the blood, as in certain
well known fevers. Upon the supposition of a special blood poison, we cannot accooat
at all, for the fact that in some cases, the symptoms are so obscure and light that the
nature of the disease is hardly suspected before death ; whilst in others, the disease b
announced with violent delirium and convulsions.
The diversity of the symptoms of meningitis has been well illustrated by the cas&
already presented, and especially by those recorded by Dr. P. Gervais Robinson, in the
paper given in the preceding chapter. The cases of Cerebro-Spinal Meningitis reported
by Dr. Robinson, occurred in the same Company. The phenomena of the first case
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 headache, whidi
was persistent, and from which he could obtain 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, wii
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 siae of the
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 as
to his honesty. On the morning of the fifth day, he became profoundly coinatose,
and died the same day. An autopsy, a few hours after death, revealed an extensire
efiiision 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 aboat
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 persistent
headache, and in the evening became violent and suddenly delirious, and raved ami
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 bowels
closely constipated. By the use of cold water poured over the head in considerable
quantity, the more violent paroxysms were controlled ; and by the steady application of
wet clothS; in eighteen hours his delirium subsided, and reason was restored. The
bowels were moved with Croton Oil ; and blisters applied to the nape of the neck and
spine, constituted the list of remedies used in this stage of the disease. From thi^
time, until about the end of the fifth day, the disease appeared to be quiet and inactive,
the patient being tranquil and quite rational, and partaking of such light nourishment
as could be procured in qamp. During this period of intermission, there wore no verr
remarkable symptoms of disease, the pulse being almost quite normal, the ton;^uc and
skin presenting no very peculiar or characteristic conditions, and perhaps the onlv
appreciable sign of any lesion of the brain was exhibited in the paralysis of the scnsor>
root of the fifth pair of nerves, thus destroying the sensibility of the face. Toward*
the end of the fifth day, the functions of the optic began to be interfered with, and
vision became impaired, together with dilatation of the pupils Dr. Robinson, also
observed, that during this interval, the sensibility of the portlo mollis^ was maeli
increased, the hearing unusually acute, and the patient's attention would be attraAKed
by the slightest noise, and he would even remark upon what was said in a low tone, at
some distance from the bed. A part of this time, he could not recognize a watch held
at his nose, nor feel a severe pinch of his cheek. From this he became much pros-
trated, and gank into a state of collapse, and soon profound coma supervening ; in this
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Pathological Anatomy of Cerebro- Spinal Meningitis. 479
condition he contioued 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 course
of this case was very similar to that of the preceding, with the exception of a varia-
tion ia the paralytic phenomena. In this case, the ^r^w mo^ii was affected intensely,
and the patient was quite deaf a^r 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 coma, 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 withiif a firm unyielding bony case, the
characters and diversity of these manifestations of nervous and muscular disturbances,
are 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, are
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, Small-Pox, Measles, Scarlatina, and Typhus and Typhoid Fevers, pre-
sent definite and characteristic 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 (he 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 cause of the
local inflammation.
I have observed many cases in which fever, 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 similar nature, observed
by myself, will illustrate the truth of the preceding proposition in a clear manner :
Gjue 585 : Frost Bite^ Gangrene of Both Feet; Amputation of both feet, recovery ;
the local injury and mflammation, attended mth great elevations and continual
fluctuations of temperature.
Joaquin Gonzallcs, age 42 ; native of Portugal ; entered Ward 13, Charity Hospital, Nov.
2l8t, 1873, with Frost Bite of Both Feet. Patient says, "that on the night of the lUh of
November, he was oat tmntiog in the swamp, and that his feet were immersed in the cold
mnd for several ^ours. The nigl^t was nnnsually cold for this latitude, (Louisiana), and the
surface of the ground wi^s frozen^ Or\ the next day the feet were red and painful.*'
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480
Pathological Anatomy of of CerebrO' Spinal Meningitis.
At the time of his entrance, four days lifter exposure to the cold mnd (Xot. 2l8t), 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 :
PUIilE.
REMARKS.
DATE. TEMPA.
PULSE. REMARKS.
M.
E.
1 M.
,E.
M.lE.
1873. 1
i i
I
120
108
Half of both feet including toes |
Jan. 7 100.2
1
l.o.lOi
108
blue and inclining to black.
■ 9 101.
1. 108
..I..
1
•• 10 100.
1
ij)!*...
• 11 1Q1.2
"98.3
Right foot amputated Jan. 11.
1.5
120
126
[and insomnia. 1
• 12101.2'
,
120
112
C^jinplnins of great pain in feet
•• 13 102.
1.
110
110
Feet gradually turning black, .
•• 14101.5
t.5
120
128
especially about the toee. The '
• 161 99.
.!.!!!
1
:.o 116
112
toes are becoming dry and
shrivelled.
•• 18 100.
• 19 100.
::::::
Had a chill at 12 m. on tb*
i 18th, followed by fev«.
. 112 112
Patient complainH of constant.
•• 25. 99.2
;
1 Had another chill en tU
.81112 120
tingling and pain in the feet.
•• 29 99.
99.2
1 12th.
:. 130 1 132
Sweats profusely; unable to
■• 30 99.
99.4 1
1
1.8 120,132
sleep.
• 31 101.5
101.
1.51 136 1 102
Feet emit a foul odor and have
Feb. 1100.
101.
..5'll2'll4
been dressed with carbolic j
• 2 101.4
101. 1
1 1
ointment since Nov. 25th.
• 3 101.
101.4
I
.. Il20l
Distinct line of demarcation j
• 4 101 .4 1101.81
.. 120
126
forming about middle of both j
•• 5 101.2
101.4'
;.5ll26
108
feet on the 16th day of injury.
•• 6 101.
101.2
,
1. 114
.51
Considerable discharge from '
feet. Pulse very feeble. Pa- 1
• 7 101.
•• 8 100.
101J>
90.
51
tient hhivcrs and complains
.. 9 101.
101.5
'Left leg amputated. BHiirr
, 1
i." '
of cold. Patient very weak.
•• 10 101.5
•• ii!ioo.
•• 12101.
101.
100.5
101.5
ampnution, TempeimV U«.
Under the infloeaoe af
Chloroform, tlia tempsn-
ture feU in k of an hour t»
90°. In tba evaalBf of
1. 1
•• 13 102.
101.4
.51
•• 14:102.2
101.
.8.
!
" 15 100.
104.
same day (he temperatnr*
. !
• 16»104.
104.
] waa loio.
" 17111.
104.
1
•• 18101.5
104.
1
1
Mar. 3|
105.5
Pus borrowing under textnrt
1
I
•■ 4 lOJ.
105.
1 and cansiDK pain and
1 1
1
•• 5 104.
I sloughing.
_:i-i-^ Li_
1
• 61101.
,
When this patient entered my ward, he was in such an ezhaasted and feeble state,
with rapid and feeble pulse, that it appeared almost impossible that his system could
possess sufficient strength to cast off the dead tissues. The treatment consisted of
Quinine, Tincture of the Sesquichloride of Iron, nutritious diet, (beef steak, beef tea,
soft 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 Carbolic Aeid
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 living
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 Profesaor Logao,
on the 1 1 th of January. The shock of the amputation was very great and the tempe-
rature sank down to a low figure, and the patient did not fully rally until after the
lapse of several days. The left foot was amputated on the 8th of February ; before
the operation the temperature of the axilla was 100° F.; three quarters of an hour after
the amputation, the temperature was only 90° F.; this reduction I attributed chiefly to
the efliect of the Chloroform. In the evening of the same day the temperature had
risen to 101° F., which was about his average temperature, except wben suflfering with
marked increase of the hectic fever. On the 13th, the temperature in the evening wis
104°, and this elevated temperature continued until February 22d, with slight daily
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Pathological Anatomy of Cerebro^ Spinal Meningitis. 481
oscillations. ThU rise was due to the formatioQ of an abscess in the tissues near the
ankle joint. After opening and evacuating the abscess, the temperature fell from 104*^
to IOC. 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 oif another
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 ^vations 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 subse<juent 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 inspection 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
natural processes had been almost complete before the performance of amputation. The
elevated temperature (with its marked diurnal oscillations), was attended by a rapid
palfl^, rapid respiration and profuse sweats at night ; sleeplessness and intense thirst
and great nervous prostrtftion. The recovery of this patient was satisfactory and com-
pieCe, and at the time that the stumps had completely healed, he presented the appear-
anoe 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 Iron, it
is believed that the case would have terminated fatally.
This case thus sustains the proposition, that the fever which accompanies acute
inflammation should be regarded as one of the results of the inflammatory action and
not as the cause.
3rd. In Cerebro-Spinal Meningitis the pia-mater appears to be chiefly afl'ected, 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
p^eneral rule to be free from inflammatory action. This absence of inflammatory action
from the brain and spinal marrow, aflbrds 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
cells, 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 effusion
of eoagulable lymph, is just as capable of producing pressure and deranged action in the
brain and spinal cord, as an efixision or haomorrhage of blood within the bony case of
the Cerebro-Spinal Cavity, it can be readily conceived that the inflammation of the
nutritive membrane, and the coating of the most delicate and important nervous
structures, confined in a bony case, with a dense exudation, tending to organize itself
progressively into more firm and resisting structure, might give rise to all the phenomena
of (^/crebro-Spinal Meningitis.
4th. The derangements of the circulation 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 of the meninges of the brain and spinal cord.
The theory, that the febrile phenomena, the derangements of circulation and respira-
tion, 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
snstidned by the natural history of the disease. Derangement in the action of the
medulla oblongata and of the nerves, given off from the base of the brain caused by
the meningeal inflammation, and by the pressure of the products of inflammatory action
is entirely sufficient to accotjnt for the derangement^ of circulation apd respiratioq,
01
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482 Pathological Anatomy of Cerebrospinal Meningitis.
and for the stagnation of the blood in the capillaries of the surface, and the ooDsequent
mottling of the surface, as in Malignant Malarial fever. Not only is ihe fibrin ipcraeed
in the blood in Cerebro-Spinal Meningitis, but marks of disorganized blood and of
bloody effusions, are absent as a g&neral rule from the structures most inflamed and
diseased, viz: the meninges of the brain and spinal cord, and in those eases in whieh
circumscribed discoloration of the membranes of the brain and of tlie pleura and peri-
cardium have been observed after death, such appearances were evidently caused by
local congestions and post-mortem exudations of the coloring matters of the blood. And
oven if it should be true, that the blood is disorganized in certain cases of Cerebro-
spinal ^leningitis. such disorganization may be entirely explained by the derangements
of the circulation and respiration induced by the disturbance and perversion of the
functions 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 mtgority of the
cases, and in many epidemics not more than 17 per cent, of the cases manifest any
mottling or petechial spots of the surface. In soldiers and in the poorer classes^ whose
diet has consisted largely of salt food, the presence of petechial spots during the progrees
of this severe disease, is largely due to the preceding scorbutib condition of the blood.
5th. An explanation of the almost universally fatal character of Cerebro^fHaal
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 doubtiiil and unfavorable. Even after the subsidence of
all active inflammation in the meninges of the brain and spinal cord, the most seri^nu
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 effusion. The period of convalescence from this dis-
ease will depend, not only upon the amount of fibrous inflammatory efinsion, but also
upon the character and rapidity of the subsequent changes, resulting in the fonnatioB
of fibrous tissue, and in the gradual absorption of some portion of the product! of the
diseased action.
6th. The treatment of Cerebro-Spinal Meningitis, based upon the preceding pno-
ciples, should be, in the first stages of the disease, entirely directed to the arrest or
modification of the acute inflammatory action.
As spon as the practitioner has convinced himself that the disease is Cerebro-Sphial
Meningitis, and not Pernicious Malarial Fever, the patient should be freely bled, (b
the upright posture if possible), the blood being allowed to flow in a full stream notil
the patient feels faint and exhausted ; from ten to forty ounces of blood should be
taken, the amount bebg regulated by the severity of the case, and the age, oonstitutioQ
and strength of the individual.
Cut-cups should be freely applied to the temples, to the back of the head and neck,
and along the entire region of the spine, and from four to eight ounces of blood bethm
withdrawn over the region of the brain and spinal cord.
The bowels should be freely opened with Calomel, and, if necessary, with Crotoo
Oil.
The back of the neck and head should next be shaved, and a blister applied ov^ the
region of the cerebellum and back of the neck, and down the entire length of the apinc
Over the spine, this blister should not be wider than from one inch to one and a half
inches.
After the free evacuation of the bowels, Mercury should be given in small doses,
combined with Opium, with a view to mercurialization. The Mercury may be adTui-
tageously combmed with Dover*s Powder and Quinine, as in the following foimda :
B. Hydrargyri Subchloridi (CJomel), 5 ss ; Pulv. Doveri (Pulv. Ipecac et Opii),
3 ii ; QuinisB Sulph, 3 i ;, ^pix ; divide into 30 powders ; Sig : One powder every t¥o
or three hours.
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Pathological Anatomy of CerebrO'^ Spinal Meningitis. 483
Wheo it is evident that active iuflammatorj symptoms have subsided, the strength
should be supported by nutritious diet, and alcoholic stimulants judiciously adminis-
tered in small quantities, at reji^ular 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 internally^ in conjunction with Opium
and its preparations, by Hydtate 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
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 the reparative
process.
In instituting this vigorous plan of treatment, the physician should be confident of
the correctness of his diagnosis, 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.
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C.^HAPTP.Il VIII.
OBSERVATIONS ON TilK RELATIONS OF CEREBROSPINAL MENINGITIS TO MALARIAL FEVER.
CASKS OF CERBBRO-SPINAL MENINGITIS, WHICH OCCURRED AT SAVANNAH, GEORGIA, FEBRUART
AND MARCH, 1863.
EFFECTS OF DERANGEMENTS OF THE BliOOD, ARISING FROM DEFECTIVE CIRCULATION AXD
RESPIRATION, UPON THE ORGANS AND TISSUES. THE DERANGEMENTS OF THE CIRCULATION
AND RESPIRATION, AND OF THE SECRETIONS AND EXCRETIONS, AS WELL AS OF THE NEBVOU.^
FUNCTIONS IN CERBBRO-SPINAL MENINGITIS, MAV ALL BE REFERRED TO THE LOCAL INFLAMMA-
TION, CONGESTION, AND ALTERATION OF THE MENINGES (RSPECIALLY THE PIA-MATER) AND
STRUCTURES OF THE BRAIN AND SPINAL CORD. CBREBRO-SPINAL MENINGITIS RESEMBLES IN IT9
ORIGIN AND PROGRESS, INFLAMM.VTORY DISEASES, AND HAS FREQUENTLY PREVAILED AT THE
SAME TIME, AND BEEN INTIMATELY ASSOCIATED WITH INFLUENZA, CATARRH, AND PNEUMONIA.
THE CHANGES OF TEMPERATURE DURING THE PROGRESS OF CERBBRO-SPINAL MENINGITIS, INDI-
CATE THE ACTION OF THE AGENT PRODUCING THE DISEASE, DIRECTLY ON THE CERSBRl>-
SPINAL SYSTEM, RATHER THAN ON THE BLOOD. THE CONDITION OF MANY PATIENTS DURING
CONVALESCENCE FROM CEREBRO-SPINAL 3IENINGITIS, INDICATES IN THE CLEAREST MANNEB,
THAT THE CEREBRO-SPINAL NERVOUS SYSTEM, HAS BEEN INFLAMED AND PARTS OF THE STRUC-
TURES PERMANENTLY ALTERED, RATHER THAN THAT THERE HAD BEEN NOTHING MORE THAN
THE ACTION OF A SPECIFIC FFVER POISON UPON THE BLOOD. EXPERIMENTS ILLUSTRATING THE
ACTION OF VARIOUS POISONS UPON LIVING ANIMALS AND DESIGNED TO ILLUSTRATE THE PRE-
CEDING PROPOSITIONS.
My attention was strongly directed to the important ([uestiou of the relations of
Cerebro-Spinal Meningitis to Malarial fever, by the examination of several cases of t
fatal form of disease, which occurred in the months of February and March, 186:1,
amongst the Confederate troops assembled for the defence of Savannah, G^rgia.
During the prosecution of investigations upon camp diseases, amongst the Confedente
Troops, stationed along the coast of Georgia, my friend and colleague Dr. H. V. M.
Miller, Chief Surgeon of the District of Georgia, requested me to examine some sudden
and severe cases of disease, which had occurred in the 32d Regiment of Geoi^ia Vdnn-
teers, at that time camped near the southern boundary of Savannah, at Camp William
Duncan Smith.
According to the testimony of Surgeon Hugh A. Blair, of the 32d Regiment, almost
the entire command, of an average mean strength of one thousand men, had suffered
with Malarial fever, and many of the men whom I saw upon regimental parade, showed
in their sallow anaamic faces, the effects of malaria.
In the hospital of this regiment, which was crowded with cases of Typhoid fever,
pneumonia, and malarial fever, I observed three cases, suffering with a form of disease
which bad been sudden in its inception, violent in its symptoms, and resembling in its
main features, Cerebro-Spinal Meningitis.
In the latter part of February, a few days before my visit, five of these cases had occarrcd
and two proved fatal. Three of the five cases, commenced with strong convulsions,
followed in a short time by delirium. In four of the cases, the pupils were dilated ; and
the conjunctiva was congested in all. In one case the pupil- was alternately dilated and
contracted. Pulse weak, but not specially accelerated. Respiration apparently natmal
at the commencement of the disease, but gradually became stertorous and irregular,
Coma rabidly supervened, and the patients died in from 12 to 18 hours.
The three cases which I examined, presented an an83mic and sallow hue, as if the
patients had been subjected to the prolonged action of malaria; and upon inquiry I
found that they had in each case suffered previously with chill and fever. These casei
presented somewhat the symptoms of severe concussion of the brain ; the patients hy
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Relations of CerdfrO'-Spinai Meningitis to Malarial Fever. 485
with tlie eyes open, without moyifig or noticing anything passing around them, and
when the attempt was made to arouse them they gave little or no sign of intelli-
gence. These cases terminated fatally in the course of a few days. It might with some
reason, be supposed that the continu^Ml' action of malaria, had produced changes in the
constitution of the blood and of the ccrebro-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 coses occurred about the sam3 tim3, in the General Hospital in Augusta,
Geoi^; six cases, — the entire number proved fatal. All these were soldiers who
hid be3D suffering with mjdarial fever in Savannah, ani had been transferred in the
latter 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 effects in their pale, sallow, and
anaemic hue.
In most of the cases occurring in the General Hospital of Augusta, the disease was
ushered in with an intense pain in one of the eyes, which was speedily followed by
coma and death, in from 18 to 50 hours.
Surgeon Blair, informed me that a case similar in some respects to those previously
described, occurred as early as September, 1862. The patient had had chills and fever
for some time, and looked sallow and anaemic. Had missed his chills for several days, and
had 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 in 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 dilated, pulse not specially accelerated, but weak. The patient died at mid-
night of the same day upon which he was seized.
RELATIONS OF G£RKBR6-SP1NAL MENINGITIS AND MALARIAL FEVER.
The following tables which I have consolidated from my labors 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.
TABULAR VIEW OF THE CHANGES OF THE BLOOD AND 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.
CHANGES OF THB BLOOD IN MALARIAL FRVBR.
The malarial poison is capable of altering the constitution of the solids and fluids, and of
raodifjing and altering the type, and progress, and efifects of various diseases, even when no
symptoms of aberrated physical, chemical and nervous actions have been manifested, so flB-
cient to arrest the attention of the patient.
The colored blood corjnueles are diminished during Malarial Fever ; the extent and rapidity of
the diminution 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
Ferer. The colored blood corpuscles are destroyed both in the liver and spleen. The col-
ored blood corpuscles are more uniformly and rapidly destroyed in severe cases of Malarial
Fever, than in any other acute disease, with the exception, perhaps, of Pyaemia.
The specific gravity of both the blood and serum is diminished during the active stages of
Malmrial Fever, and during the slow action of the malarial poison.
The solid matlere of the blood are more rapidly and decidedly diminished in Malarial Fever
than in any other disease. The color of the blood and serum is altered ; in severe cases, the
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486 Relations of Cerebro^ Spinal Meningitis to Malarial Fev$r,
blood, wbea first abstracted, presents a dark purple, aliaost black colori and changes sloirlj
to the arterial hue vbeq exposed to the atmosphere ; and in seyere casea It changes to a
cherry red color, and not to tbe bright red assumed by the surface of healthy, Tenons blood.
The blood of the liver and spleen, after death from Malarial FVver, presents a deep pnrple,
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 slowly, and is more
voluminous than in normal blood.
Th% fibrin is diminished greatly in severe cases of Malarial Fever; the dimlnntion 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 rnle, 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 dimloatioa
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 its
properties, and in its relations to the other elements of the blood, and to the blood-resseli ;
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 dne to any
loss of this element in the urine. As a general rule, albumen is absent from the arine is
Malarial Fever, and when present, as in Malarial Hiaematuria, it is accompanied with blood
corpuscles, and with casts of the tubuli uriniferi containing colored blood corpusclea.
CHANGES OF TUB CIUCULATION, RESPIRATION AND TEMPERATURE.
IntermiUent Fecer. — During the cold stige, (chill), there is a rapid, feeble pulse, rapid respi*
ration, and hot trunk, and cold extremities — the temperature of the extremities is redaced 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 arreated, apparently by the coo-
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 ot
the fever (animal temperature), which often reaches, in the hot stage, 107° F., is by no meau
an index of the character and severity of the subsequent effects. As a general rale, the
higher the temperature (within, of course, certain defined limits, not exceeding 102° and
107°.5 F.), the more readily does the attack yield to treatment. The changes of the tempera-
ture in Intermittent Fever, are characterized by abrupt elevations and depressions, so that
when the curves are projected upon a chart, they differ in the rapidity of the elevations and
depressions from those furnished by all other diseases.
Remittent Fever, — The phenomena of the cold stage preceding the hot stage of , Remittent
Fever, are similar to those of Intermittent Fever ; the difiference is one of degree, and not of
kind ; the phenomena of the cold stage of Remittent Fever are more protracted than those of
Intermittent Fever ; tbe 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 Remittent
as in Intermittent Fever. The alterations of the blood are more profound in Remittent thaa
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 than
Remittent Fever. Remittent Fever may be distinguished from Typhoid Fever by the greater
and more sudden elevations and depressions of temperature.
Congestive or Femicious Fever, — The complete prostration of the muscular and nervous forcet
the reduction of animal temperature, both in the trunk and extremities, the cold, damay
sweat, the .rapid, feeble pulse, the rapid, thumping action of the heart, and the sndden inter-
vention of the most alarming cerebral symptoms, may occur gradually or suddenly, in either
Intermittent or Remittent Fever, and may be induced by several distinct causes acting singly ^
or in conjunction. There is a want of coordination between the circulation, respiration and
animal temperature in Congestive Fever. The respirations are full, accelerated, and otten
panting and heaving, varying from 30 to 50 per minute ; the pulse beats from 120 to 160, and
feels like a delicate thread, and is often so small that it cannot be counted ; the heart tbunpe
irregularly and spasmodically, and rapidly against the walls of the chest, as in some cases of
narcotic poisoning ; the circulation in the capillaries is feeble ; the temperature of the traok,
notwithstanding the full, rapid respiration, sinks below the normal standard, and the surface
is covered with cold, clammy sweat.
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Relations of Cerebrospinal Meningitis to Malarial Fever, 487
CHANOBS OP TUB URINE IN MALARIAL FEVER.
Inter/mttent Fever. — The amount of urine excreted during the active stages, and during the
•arliest stage of the intermission, is less than that of health, and this dimi-nution relates to
ibe water, and not to the solid constituents. During convalescence, and especially under the
action of depurants, 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
daring 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 Quinia, during the active stages,
when the pulse is full and rapid, and the respiration full and accelerated, and the tempera-
tore 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 B'ever, is characterized by heavy yellow deposits of Urate of
i^oda and Triple Phosphates, the former in the form of granular and acicular masses, and the
latter as beautiful 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 dnring 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 hsematuria, characterized by intense jaundice, and
congestion of the kidneys, and passive 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 difl*erent in degree,
from those of Intermittent Fever. The urine is higher colored, more concentrated, and richer
in area, 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 formatfon 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 analogous periods, and is due to the same causes as in the urine of Intermittent
Fever.
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Relations of Cerebro^Spinal Meningitis to Malarial Fever,
497
TABULAR VIEW OF THE PATHOLOGICAL ANATOMY OF YELLOW FEVER AND
MALARUL FEVER.
BY JOSEPH JONES, M. D.
The following comparison of the Pathological Anatomj of Yellow and Malarial Paroxysmal
FeTers contains the general outline of the results which I have obtained by investigations
conducted in varioas parts of the Southern States, and which were commenced in 1856. I
hare, upon several occasions, embraced opportunities of examining the bodies of those who
had died A'om Yellow Fever and Malarial Fever, at the same time, as thej lay side by side in
the I>ead House, Such examinations served to establish more fully the results of numerous
post-mortem examinations of the subjects of each disease.
TBLLOW FRVBB.
J?x/«rwr.— -Generally full and not reduced in
flesh ; features may even present a swollen,
bloated aspect. Skin of face and upper por-
tions of trunk of a golden yellow color.
Dependent portions of body of a mottled pur-
plish and yellow ecchymosed appearance.
Black Tomit frequently oozes from corners of
the month, and trickles down the face and
neck. When the muscles are cut a large
quantity of dark blood escapes, which upon
exposure to the atmosphere changes to a
bright scarlet hue. Putrefactive changes take
place rapidly after death. In some cases of
Yellow Fever, especially when the functions
of the kidneys have been arrested for some
time before death, the' putrefactive changes
take place with great rapidity and energy, and
sometimes even appeal to commence before
death) the body exhaling a disagreeable odor.
Cerebrospinal Nervous System. — Sympathetic
Nervous System. — The post-mortem examina-
tions of the brain, spinal cord and sympathetic
system have thus far revealed no characteristic
lesions to which the aberrated nervous symp-
toms of Yellow Fever can be referred. Beyond
congestion of the capillaries of the cerebro-
spinal and sympathetic systems, which con-
gestion appeared to be referable to the same
cause as that producing capillary congestion
in the internal organs, I have observed no
structural lesion, as fibrinous effusion, hemor-
rhage, or softening of the eerebro-spinal and
sympathetie nervous structures. Chemical
analysis revealed the presence of urea, bile
and leucine in the brain, and to the effects of
these substances, as well as to the direct action
of the Yellow Fever poison, must be referred
the aberration of intellect, the restlessness,
convulsions and coms^^
MALAEIAL FBVER.
Exterior, ^Th^ general appearance of those
who die from the effects of malarial fever will
depend upon the nature and length of time
and the effects of the disease. When stout
healthy men are suddenly destroyed by per-
nicious malarial fever, the body may present
the fulness of health ; and in such cases the
superior portions of the body may, as in yellow
fever, present a golden yellow color, whilst the
dependent portions present a purplish and
mottled appearance. The jaundice and mot-
tling of the skin, however, is, as a general
rule, present to a less degree than in yellow
fever. In cases of protracted bilious fever,
the body is frequently emaciated. In chron-
ic malarial poisoning, attended with enlarge-
ment of the spleen and cirrhosis of the liver,
the belly and body and limbs generally are
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.
Cerebro- Spinal Nervous System— 'Sympathetic
Nervous System.-^AB far as my observations
have extended in Malarial Fever, the dura-
mater was always normal; the arachnoid
membrane pearl-colored, opalescent in some
cases, in others perfectly transparent and
normal in appearance; the blood-vessels of
the pia-mater congested with blood, but-
always without marks of inflammation. Sub-
aracbnoia fluid in almost all cases dear,
transparent, and in some eases of a golden
color; the amount varied in different cases,
sometimes exceeding, but most generally fall-
ing short of, the usual amount. Blood-vessels
of the brain generally filled with blood. The
structures of the brain appeared in acute cases,
as a general rule, to be unaltered either in
structure or appearance ; in chronic cases the
nervous structures sometimes presented a
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 conpistence nor appear-
ance, and the same is true alpa vith r^f^rei;ice
tQ t^e sjmpathetip neryoi^? s^s^^*
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Relations of CerebrC'Spinal Meningitis to Malarial Fever.
HearL'—TeAe yellow and brownish vellow,
as if undergoing fatty degeneration; structures
of heart flabby and somewhat softened; nume-
rous oil-globules deposited within and around
the muscular fibrillse of the heart. Cavities
of the heart, in many cases, filled with dark
fluid blood; yellow flbrinous clots sometimes
present. Blood contains abnormal amounts
ot urea and extractive matters and ammonia.
Fibrin of blood greatly diminished in amount.
I have determined, both by chemical analy-
sis and microscopical examination, that the
heart undergoes acute fatty degeneration in
Yellow Fever. As far as my observations have
extended, the heart undergoes more rapid and
extensive degeneration in Yellow Fever, than
in any other acute disease. The acute fatty
degeneration of the heart in Yellow Fever
should not be confounded with similar changes
observed in spirit drinkers and in certain
chronic diseases.
Lungt. — Dependent portions greatly con-
gested ; otherwise normal. In some cases
circamscribed effusions of blood in textures
of lungs.
Stomach, — Mucous membrane of stomach in
many cases intensely congested, softened and
eroded. Stomach often contains large quanti-
ties of black vomit. Reaction of black vomit
often alkaUne from the presence of ammonia^
resulting from the decomposition of urea^
eliminated by the gastro-intestinal mucous
membrane. Ammonia and urea present in the
black vomit ejected during life, and also when
examined almost immediately after death. The
presence of ammonia in the stomach and black
vomit was not the result of post-mortem putre-
# factive changes. In many cases ammonia
was present in such large amount, tbat when
a rod, dipped in hydrochloric acid, was held
over the mucous membrane of the stomach, or
over the black vomit, dense fumes of chloride
of ammonium were formed, as if the rod had
been held over a bottle containing liquor am-
moniae. Chemical analysis revealed the presr
ence of ammonia and also of >irea in the black
vomit. Under the microscope the black vomit
was seen to contain colored blood- corpuscles,
and cells of the mucous membrane of the
stomach and broken capillaries. In some
cases vibriones and fungi were numerous in
the black vomit; in others they were absent.
Inteilines, — As a general rule dark-coloxed
and distended with gas. In some cases the re-
action of the intestinal contents was strongly
alkaline from the presence of ammonia.
Heart. — Normal in color, presents the deep
purplish red muscular appearance of the
healthy heart. Muscular fibres of the heart
firm and of normal appearance under the
microscope. No deposits of oil in the mus-
cular structures.
Cavities of the heart frequently distended
with dark blood. Firm laminated, fibrinoof
concretions very common : and in some cases
of Pernicious Fever, the formation of these
heart-clots during the cold stage withoat
doubt causes death, and renders unaTadiag
the action of remedial agents.
The fibrinous concretions are not only at-
tached to the carnesd columnse and chords
tendineae, and auriculo ventricular valves, but
they also frequently send forth long branches
into the pulmonary arteries. The formatka
of these concretions is rare in Yellow Fever,
and when formed they are much smaller and
softer than in Malarial Fever. The blood of
Malarial Fever contains more fibrin, fever
colored corpuscles, and changes more slovly
to the arterial hue, upon exposure to tfav
atmosphere, than the blood of Yellow Fever.
Lungt, — Dependent portions congested with
blood ; otherwise healthy.
Stomach. — Mucous membrane often prescsti
a normal appearance ; sometimes ecchjmoie^;
rarely inflamed or softened ; sometimes dis*
colored with bile ; rarely contains black voait
(altered blood). Reaction of mncoos mem-
brane of stomach and intestines acid. Tb«
pathological alterations of the stomach, ob-
served after death, do not correspond, as t
general rule, with the severity of the symp*
toms, the vomiting and pain on pressure
during the progress of the fever. The injecttoa
of the blood-vessels, and the mottled, pnrplish
brownish red color, after death, appear to be
indicative, not of inflammation, but rather of
stagnation and accumulation of the blood ia
the capillaries, consequent upon the distar-
bance of the relations of the blood to the
CApillaries. The distressing vomiting, so oftM
a troublesome symptom in Malarial Fever,
appears to depend upon the contact of the
altered bile and the irritation of the nerroas
centres, which supply the stomach with ner<
vous force, by the altered blood and by the
malarial poison.
In cases where there has been chronic is-
flammation of the stomach before the appear-
ance of the fever, and in cases of long standiof^.
where the solids and fluids were permaneotl;
altered, decided lesions of stroctare irere
found in the stomach. It may be asserted,
however, that there is no constant or charac-
teristic lesion of the stomach in Malarial
Fever.
These remarks apply also to the small istea-
tines. The mucous membrane freqoeotlj
presented a purplish, irregularly injected,
mottled appearance, especially after iht ad«
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Relations of Cerebro^ Spinal Meningitisjo Malarial Fever.
499
Liver, — Yellow color and bloodless, resem-
bling ibis organ in fatty degeneration, but
firmer and denser in structure. Under the
microscope, textures of the liver infiltrated
with oil ; secretory cells of liver contain much
oil. The liver of uncomplicated Yellow Fever,
as far as my observations extend, and accord-
ing to the observations of Louis and many
others, is of a bright yellow color. It is pro-
bable that this color, as in the case of the
malarial liver, varies with the length of the
attack and the effects of previous diseases.
Thus, Dr. Samuel Jackson, of Philadelphia,
found the livers of those who had died in the
earljr stages engorged with blood. The decoc-
tion of the Yellow Fever liver is of a golden
yellow color, whilst that of the malarial Uver
is of a brownish yellow color. The golden
yellow color of the Yellow Fever liver can be
extracted both by Alcohol and water. The
Yellow Fever liver is firmer and harder than
that of Malarial Fever, contains much less
blood, and is much less readily acted upon by
liquor potassae and acids. Liquor potassse
readily dissolves the Malarial Fever liver, and
the decoction presents the appearance of ve-
nons blood, while no such effect is produced
by the action of this alkaline solution upon
the Yellow Fever liver.
Chemical analysis reveals the presence of
nrea and fat in abnormal amounts; animal
starch and grape sugar are also present in the
Yellow Fever liver. As a general rule grape
SQgar is absent from the malarial liver.
ministration of purgatives, and it was fre-
quently observed that the injection of the
blood-ivessels 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 injected
with blood.
Liver. — The weight of the liver is increased
in Malarial Fever above the standard of health.
This increase of weight is due in part to the
stagnation and accumulation of blood in the
capillaries and blood-vessels, and to the de-
posit of pigment matter in the structures of
the liver. This observation applies to the
liver in the acute stages.
In all the different forms of Malarial Fever,
intermittent, remittent and congestive, which
had continued longer than five days, and in
which there had been no previous alterations
of the structures, as in cirrhosis and fatty
degeneration, I found the exterior of a slate
color, and the interior of a bronze color. In
that form of cirrhosis of the liver which is
directly induced by the prolonged action of
the malarial poison, the Tver is in like manner
of a slate color upon the exterior, and olive
green within, and loaded with dark pigment
granules. The change in the color appears
to be very persistent, and in several cases I
have observed the liver to retain shades of
light slate and light bronze several weeks, and
even months, after the relief of the attack of
Malarial Fever, the patients having been de-
stroyed by other diseases or by violence. The
liver, especially in the peripheral portions of
the lobules, contains pigment granules, result-
ing from the alteration of the colored blood-
corpuscles and the hsematin. The pigment
granules are frequently distributed uniformly
through both the portal and hepatic systems
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 globules
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 hand, 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
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delations of Cerehro-Spinal Meningitis toMatatidt Pever^
QdU Bladder^^The gall bladder in Yellow
Fe?er is, as a general rule, contracted, flaccid,
small, and contains little or no bile. The
amount of bile generally does not exceed 100
grains. In Malarial Fever, on the other hand,
the gall bladder is, as a general rule, distended
with dark, greenish, black bile. In Yellow
Fe?er the Tomiting is rarely bilious, unless
in the commencement of the disease ; and the
black vomit contains little or no biliary matter.
The small intestines are rarely if ever dis-
colored by bile in Yellow Fever, whilst in
Malarial Fever it is common to find the gastro-
intestinal mucous membrane discolored by bile.
Spleen — As a general rule but slightly en-
larged. In many cases normal in size and
appearance. In many cases of Yellow Fever
the spleen is neither enlarged nor softened,
nor altered in appearance, either upon the
exterior or within. There appears to be no
special alteration or destruction of the colored
corpuscles in the spleen of Yellow Fever as
in that of Malarial Fever. The enlargement
ef 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 gpreater 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 organs, as a general rule,
present a brownish yellow color, much lighter
than that of health. They, in common with
the heart and liver, contain much free fat.
When thin sections of the kidneys are examined
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 chanj^es 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
examination, the malarial liver contains ftaiaal
starch, but no grape-sugar ; the Yellow Fever
liver contains both substances.
Oall Bladder, — In most oases distended with
more than 1000 grains of thick, greenish black
bile, having frequently a specific gravity
ranging from 1030 to 1037. The bile it more
abundant in Malarial Fever and is of a deeper
color, and frequently contains concretions of
epithelial cells, from the coats of the gall
bladder and biliary ducts, and casts of tbe
biliary tubes. In thin layers, and when added
to water, it presents a deeper shade of greei.
The Yellow Fever bile presents a golden color
in thin layers and when added to water.
5j9^«n.— Enlarged, softened and loaded with
altered blood-corpuscles and pigment gram-
les; of a dark slate color upon the exterior;
the blood of the spleen does not change to
the arterial hue upon exposure to the atsos-
phere. In many cases the spleen is so soft
that it ruptures when the attempt is made to
remove it from the cavity.
JTtcfnfys.^Kormal in appearance and struc-
ture, except in malarial baematnria, wbea tht
textures are congested, and dark colored is
some cases. Occasionally slate-colored spots
appear upon portions of the kidneys.
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delations of CerebrO'Spinal Meningitis to Malarial Fever, 601
albumen and fibrin of the blood bj tbe febrile
poison, and the congestion of the capillaries
induced by derangement of the raso-motor
sjstem of nerres and by the altered blood.
Urinary Bladder. — As a general rule the Urinary Bladder. — Oftea distended, with
bladder contains little or no nrine in Yellow high colored urine, free from albumen and
Fever. Tbe urine is of a light yellow color, casts. In malarial hsematuria tbe uriile con-
without any crystalline bodies, and loaded tains c.ists and blood-corpuscles, and des-
with albumen, granular fibroid matter, urate quamated cells of tbe tubuli uriniferi. Casts
of ammonia, casts of tbe tubuli uriniferi, high colored, and often contain colored cor-
excretory 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 recoyer, even
though black vomit may have appeared, but
if the action of the kidneys has been arrested
by stmctural changes, death is inevitable.
After the careful study and record of the phenomena and pathological anatomy of a
large number of cases of the various forms of malarial fever, I have reached the fol-
lowing general results. *
GENERAL CONCLUSIONS CONCERNING THE RELATIONS OP THE MALIGNANT FORMS
OP MALARIAL FEVER TO CEREBR0-8PINAL 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
entirely 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
cases, may be compared to that of a violent alkaloid, or even mineral poison.
It is well established that in death from various violent pobons, which produce great
disturbances 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
could at all account for the nervous manifestations during the action of the poison.
Other causes and agents are also active in producing the nervous dbturbances in
Malarial Fever, as ;
(a.) Alterations in the physical, chemical and physiological properties of the blood,
induced by the direct action of the malarial poison upon the blood. This action is
characterised 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-
ations in the nutrition of the nerve structures, 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 nerrous system. *
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50^ fietations of Cerehro^ Spinal Meningitis to Ualarial Fever.
(h,) Arrest of the functions of certain organs, as the spleen and liver.
(o.) Ketention of certain excretions, which should be separated by the liyer, oolon
and skin, in the general mass of the circulation.
(d.) Ke-absorption of the altered secretions and products of certain org ins, 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-
lanta 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 firequentlj
in the autumn and winter.
Cold appears to have much to do with the production and termination of suoh ouei,
as we shall endeavor to show.
. Individuals, who have the " seeds " of malaria in them, may even remove to healthj
regions, and pass months with only an occasional slighl chill, or headache, and then sad*
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 persist-
ent, and terminated fatally, the true causes are found in the lesions of the blood, as weO
as of the nervous structures. Even in those cases of Pernicious Malarial Fever, wbidi
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 brain aad
spinal cord ; but on the other hand, the ventricles of the brain, and the sub-arachooid
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, cause death ; and at the same
time, it is not necessary to suppose that this effusion or fluid, in and around the cer^HiI
structures, is due to the presence of inflammation. Ailer the colored blood oorposdes
have been destroyed, and the fibrin and albumen altered, and the blood thus rendaned
watery and thus altered in its most essential, physical, and chemical and physiological
properties, by the rapid, or more slow action of the Malarial poison, it is evident that
an eflusion of the watery elements of the blood is liable to occur from the blood-veasdi
of any organ and tissue, in which there is an active determination or congestion of blood.
A prolonged chillj in itself, or in conjunction with the action of cold, which still ftither
increases the internal congestion, may be attended with such efiusions of the liqior
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,) in the
case of the lungs, the irritation or inflammation of a comparatively small portion of an
organ, in the body, upon which the malarial poison has exerted its characteristic effects,
may be attended with large serous effusions, not only from the parts immedialdj
involved, by the inflammation, but from surrounding parts. We may thus explam is
certain cas^ at least, the sudden supervention of symptoms of compression of the bram,
without any apparent inflammation of that organ, in those laboring under the action of
the malarial poison.
4. The functional and structural derangements of the Cerebro-Spinal Nervous Sys-
tem in Malarial Fever, and under the a<3tion of the Malarial Poison, without thoae
symptoms characterized as fever, are referable to several causes :
(a.) The direct action of the poison upon the nervous structures.
We have r^arded the action of the malarial poison in most cases, as dq>re8BiDg
and not inflammatory, and analogous in its action and relations to certain alkaloid
Vegetable poisons. We mast admit, however, that to determine accurately, the altera-
tions of the nervous apparatus, under the action of various morbific and remedial agents,
it is absolutely necessary that the structures of the different parts of the nervoos appa-
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Sehticins of Cerehro^Spinal Meningitis to Malarial Fever. 503
ntoB, Bhonld be submitted to rigid Chemical and Microscopical Analysis. Numberless
and almost insuperable difficulties, lie in the way of complete microscopical and chemical
analysis of the Cerebro-Spinal System. It is impossible to obtain the substances for
analysia, until seyeral 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 nervous elements ; and the presence of a varying amount of blood, of
varyinfT 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 aocumulatipn of blood in the blood-vessels and capillaries of the brain, and ita
meninges, and especially the pia-mater. This accumulation of the blood in the vessels
of the cerebro-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 cerebro-spinal and
sympathetic 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
full vigor, from the most profound coma, and the most alarming cerebral symptoms vanish
unde^ the free use of the Sulphate of Quinia. When Quinia was withheld^ the efiects
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 seat 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
during the chill, and earliest period of the hot tit, the oxydation of Phosphorous in the
nervous structures, is either arrested, or is so modified, that the products of this impor-
tant change do not appear in the urine; as the hot stage however, progresses, and
during the active stages and changes of fever, the elements of the nervous system are
rapidly oxydized and Phosphoric Acid increases largely in the urine. Although the
increase of Phosphoric Acid, necessarily attends all active changes in the constitution
and structure 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 diffierent stages of malarial fever, is either due to
the direct action of the malarial poison upon the Cerebro-Spinal and Sympathetic
Nervous System ; or to the effects of the changes excited by the poison, in bringing
about 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.
(h.) The direct action of the malarial poison upon the blood.
The colored blood corpuscles are not only ^eatly and rapidly diminished iu ^falarial
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604 Relations of Cerebro* Spinal Meningitis to Malarial Fever.
Fever, but /they also often lose a portion of their mineral constitnenta. It ia probaUe
that the colored corpuscles, taken collectively, perform the offices of an immenie
gland, for the elaboration of the materials for the nutrition of the muscular 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 tbe
nervous system. The constitution of the urine is greatly altered in the severest fonns
of Malarial Fever, and some of its most important constituents, are either not fbimed
or, if formed, are not eliminated. The retention of such constituents as urea and
uric acid, as well as of the excrementitious matters in a partially oxydised form, in Hkt
manner, must disturb the normal action of the nervous system. The fibrin of tfce
blood is altered, both in quantity and quality. I have frequently found fibrinoos faevt
clots, free from colored blood corpuscles, in fatal cases of Malarial Fever ; and th«
clots often extended long branches into the pulmonary arteries. The coagulatiooof tbe
fibrin during life, signifies loss of vitality in the blood, and change of its pbjii-
cal properties and relations to the containing vessels. The presence of these bo(Uei
especially in the puknonary arteries, deranges the action of the heart, and of the geo*
eral circulation, and in like manner deranges the respiration, and the absorption anddii-
tribution of oxygen, These disturbances must necessarily be attended by similar (&>
turbances in the actions of the nervous and muscular systems. These profound ahen-
tions of' the blood must induce corresponding disturbances in the muscular and nonroos
systems, and in all the organs and tissues which derive their nutrition from the blood.
The profpund alterations in the constituents of the blood, must produce correqxmdiDg
disturbances in the general and capillary circulation, and in the ohemioal chan^ in
the capillaries and surrounding tissues, upon which depend the devalopment and maia*
tenance of the physical, muscular and nervous forces.
5. As a general rule, the general and capillary circulations are greatly disturbed io
Congestive Fever. These disturbances are manifested in the quick, thumping actioB 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 abemtioB of
the physical, chemical, muscular and nervous phenomena, and in the stagnation of tin
blood in the different organs and tissues. The stagnation of the blood in the ot^am
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 qnalitiei
of the constituents of the blood, and arrest or perversion of the chemical changes of die
capillaries. It is well established, that the circulation of the blood through the oapil-
laries, depends upon the quantitative and qualitative physical and chemical relationa of
the individual constituents of the blood to each other, and to the capillaries, and (^
surrounding tissues ; and that disturbances of these relations will be attended bj
arrest of the capillary circulation, stagnation and congestion of the blood, notwithstaad-
ing that the generaJ circulatory apparatus may receive sufficient supplies of nerFOOf
force, and perform its offices with sufficient vigor. When the general drculatioB 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 ot the nervoos fbwe,
supplied by the sympathetic nervous system, or by the cerebrospinal nervous aysUB.
through the sympathetic, consequent upon the action of the altered blood, or c^ tbe
malarial poison, or of both, it follows, as a necessary consequence, that the iotroduotioQ
and distribution of oxygen will be retarded, and the chemical changes in the eapiUaries
impeded, and the blood will stagnate and accumulate in the capillaries.
As chemical change is necessary for the development of muscular and nervous fbice.
and for the manifestation of intellectual phenomena, whenever the normal cfaemkal
actions of the blood are disturbed, aberrated nervous action, both in the cerebro^^iBal
and sympathetic nervous systems may result.
6. The treatment of the sudden and fetal form of Malarial Fever, the pathology o(
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Relations of Cerebrospinal Meningitis to Malarial Fever. 505
whioh we have endeavored to unfold in connection with that of Cerebrospinal Menin-
gitiB, 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
malarious 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*
rienoe of numerous practitioners. These remedies should be used immediately and
freely, regardless of the cerebral symptoms, and of the presence or absenoe of delirium
and fever. The greatest portion of these cases will be arrested, and the patient rescued
from the jaws of death, by the energetic use of Quinine, in doses varying from 5 to 15
grains every two or three hours, and by the free use of diffusible stimulants, as Alcohol,
Solphurio Ether, Chloroform and Ammonia. If the sudden and severe symptoms are
not arrested by the free use of Quinine and stimulants, and the patient does not die, but
remains in a feeble, semi-conscious state, anti-periodios 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
shonld be continued to ward off if possible the recurrence of the congestive stage, and
siimalantfl and nutritious diet should be given to support the strength, with the hope
that the effusion may be absorbed, and the impaired cerobro-spinal structures restored,
Ibdide of Potassium and Iodide of Quinia, together with blisters to the back of the
neok 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
pr^Mirations 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 citrates of potassa 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 cases 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, on the other hand, although many of the symp-
toms resemble those of certain 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
Gerebro-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 essentiaUy in a
violent inflammation of the meninges, and especially of the pia-mater of the entire
cerebro-spinal system.
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-
ntis, 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 aberrated nervous actions are similar in many sudden and &tal forms of disease,
involving profound lesions of the blood and cerebro-spinal and sympathetic systems.
As far as our knowledge extends, the main differences between Cerebrospinal Men^
ingitis and Malignant MsJari^. ^ever,, appear to be as follow^ :
€4
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506 Relations of Cerebrospinal Meningitis fo Malarial Fever.
DIFFERENCES BETWEEN THE SYMPTOMS AND PATHOLOGICAL LESIONS OF CEREBO-
SPINAL MENINGITIS AND MALIGNANT (CONGESTIVE PERNICIOUS) UALARLIL
FEVER.
(a.) Cerebro-Spinal Meningitis more frequently commences with coDVulsions, and
less frequently with a well marked chill, in which there is an elevation of the tanpen-
ture of the trunk, and a depression of the temperature of the extremities.
{h,) The temperature is not subject to the periodical elevations and depressiom
which characterize Malarial Fever.
(r.) Contractions of the muscles, and persistent dilatation or contraction of the
pupils of the eyes, are less frequent in Malarial Fever.
{d.) 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 is
liable to greater variations, and the difference between the temperature of the trunk
and extremities is greater, as well as the range of variations during the progress of the
disease.
(c,) The tongue is dryer, 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 anaemic in Malarial Fever. Jaun-
dice is much less frequent in Cerebro-Spinal Meningitis.
(A.) The alterations of the blood are more profound in Malarial Fever. In Cer^ro-
Spinal Meningitis the fibrin is increased, and there is no destruction of the blood cor-
puscles, nor of the ferment, by which glucogene is transformed into glucose, as in Mali-
rial Fever ; and the tendency to passive haemorrhages is much less in the former dis •
ease.
(i.) The liver and spleen are universally involved in Malarial Fever, whilst they
are frequently not at all affected in Cerebro-Spinal Meningitis. The bronzed liver and
large, softened, disorganized spleen of Malarial Fever, will serve to indicate to the
pathological observer whether or not tho epidemic of Cerebro-Spinal Meningitis be oobh
plicated with the action of malaria.
(j) Even in the most sudden, and malignant, and rapidly fatal forms of Malarial
Fever, with the greatest marks of cerebro-spinal disturbance, no organized or organiza-
ble fibrous lymph is thrown out from the membranes of the brain, and if effdsioDi
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 coagulable plastic
lymph is the characteristic lesion of Cerebro-Spinal Meningitis.
(k.) The nervous disturbances are more uniform and persistent in Cerebro-Spinal
Meningitis, and do not yield, as they do in Malarial Fever, to the free use of aloohoUe
stimulants and Quinine,
It is not to be denied, that inflammation of one or more organs may arise in ih«
progress of an essential fever. Pneumonia is freriuently excited during the progress of
Malarial Fever, just as peritonitis may arise in Typhoid Fever from perforation of the
bowels ; but we contend that when these inflammations arise during the progress of
these fevers, they do not stand in the relation of an effect to a cause ; they are in no
manner essentially and uniformly the results of the action of the Malarial and Typhoid
pQlsons.
We have also dwelt upon tho important fact, that the delirium, coma, and irregular
nervous actions which characterize the severer forms of Malarial Fever, Typhoid and
Typhus Fevers, are not due to an inflamed condition of the cerebro-spinal nervous sys-
t2m, but rather to impairment of the nutrition and action of the ganglionic cdls, and of
the nerves generally, in consequence of the disorganization of the blood and nutritive
fluids, and in consequence of the retention of noxious products resulting from the
chemical changes excited by the febrile poison, and probably also in consequeooe of
the direct action of the peculiar poisons upon tho nervous elements. The delirium of
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delations of Cerebrospinal Meningitis to Malarial Fever. 507
fevers is frequsDtly removed by the most active stimulation, and by the administration
of alkaloids, as Quinia, which excite the nerve centres, and promote also the removal
of the products of the metamorphosis of the blood and tissues.
The delirium and coma oF Cerebrospinal Meningitis cannot thus be relieved by free
stimulation, and such alkaloids as Quinia and Morphia. In a word, Cerebro-Spinal
Meningitis like other acute inflammatory diseases, is characterized by an increase of
fibrin in the blood, and by the formation of deposits of inflammatory lymph, capable of
organization into fibro-elastic tissue.
COMPARISON BETWEEN THE CIIANUES OF THE BLOOD IN CEREBRO-SPINAL MENIN-
GITIS, AND THOSE INDUCED BY TUE ACTION OF CERTAIN POISONS.
In considering the accounts which have been given by various observers, as to the
condition of the blood in this disease, it is important that we should distinguish between
t^e characters of the blood drawn by bleeding during the life of the patient, and that
observed in the vessels after death. Confusion in this matter has led to false conclu-
sions. I have adduced the testimony of competent observers, to show that the blood
is not disorganizsd in Cerebro-Spinal Meningitis, and does not present the characters
of the blood in the essential fevers. Dr. Joseph A. Gallup describes the blood as cov-
ered with an inflammatory crust or huffy coat, (Sketches of Epidemic Diseases, p. 261),
and we have seen that Dr. S. Ames, of Montgomery, Alabama, found that the blood
coagulated firmly in thirty-seven cases in which it was abstracted from the arm, and by
cut-cups from the back and neck, and in his quantitative analyses of this fluid, the col-
ored corpuscles were normal, whilst in all there was an excess of fibrin, the maximum
being double that of health, this constituent ranging from 3.46 to 6.40 in 1000. In
four cases, in which the blood was examined by Andral and Gavarret, the fibrin Was
found increased from 4.70 to 5.G3, the normal standard being about 2.20 ; and the cor-
puscles from 134 to 143 parts in 1000, the normal standard being about 131. Mens.
Maillot reports 6 cases, in which the blood was examined by Soulier, where the fibrin
rose to 6 parts in 1000. Dr. J. S. Jewell says, that in all the cases whi^jh have fallen
under his notice, the fibrin has been uniformly increased in quantity above the normal
standard, and the same was true of the corpuscles. In one case observed by Dr. Jewell,
blood was drawn the third day of the disease — it was the first bleeding; it coagulated
rapidly, and with a clot, which, for size, firmness and thickness of the huffy coat, sur-
passed anything that Dr. Jewell had ever seen.
The objection which has been made to such examples, that the blood was probably
examined after the second or third bleedings, when we would be led to expect an
increase of fibrin, if it were true, as it is not, will certainly not apply to the corpuscles,
since we should for the same reason look for a diminution of these organic elements.
But the corpuscles show no diminution, but rather an increase above the normal
standard.
M. Forget, Faure, Villaure and others, have made observations tending to establish
the same fects.
On the other hand, those writers, who by their own confessions, never bled their
patients, but who confined their inspections of the blood to that obtained from the large
vessels after death, have been led into the most erroneous statements, and have used
crude, superficial and untrastworthy observations, upon which to found theories of the
nature of the disease.
Dr. James J. Levick, of Philadelphia, who may be regarded as representing the
opinion of a considerable number of the physicians of that city, and of many com-
posing "the American Medical Association," in his report on " Spotted Fever,'' thus, in
a small foot note attempts to dispose of the observations of pathologists :
*< Dr. Ames of Montgomery, Ala., and one or two recent German writers, state that tbey
notice an excess of fibrin in the blood of spotted fever. It may be that this was in an
advanced stage of the disease, or that it was merely relatively in excess."
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508 Effects of Gases On th^ Blood of Living Anifnds.
The question may well be asked, if Cerebro-Spinal Meningitis be a blood diteate, an
essential fever in whicli ^^ the only constant pathological condition, is an altered state of
the blood/' why should the continuance of such an altered state of the blood during
"the depressing and degenerating effects of the fever, be the condition necessary to
increase the plastic element of the blood ?
In the report of the Committee of the American Medical Association, through Dr.
Levick, as chairman, we find the statement that :
'< A Bpecimen of blood, taken from a spotted ferer patient, and examined by the commiUee
presented the following appearances. The red corpuscles were shrivelled, crenated, not in
rouleaaz, and numerous white corpuscles were noticed on the field."
No history of the case from which this blood was taken is given, and we are led
from the fact that Dr. Levick was opposed to blood-letting, and also from the fact Uiat
whenever the blood is spoken of as examined by himself, it evidently was taken after
death, to conclude that the sample examined, was most probably altered by the post-
mortem changes. After a critical examination of this report, which received the sanct
tion of the American Medical Association, we have been unable to determine at what
time after death, the examination of the blood was made. Thus it is said, that :
"In two cases, each proving fatal in about twelve hours, the vessels of the dura-mater were
found fiUed with dark fluid blood. * * ^ In these cases besides uniFcrsal ecchymosea
the lungs Were found engorged with dark fluid blood. Soft coagula were found in the left
Ventricle, while in the. right ventricle the blood was thin and without coagula."
It is impossible to decide from this report, the exact number of post-mortem exami-
nations performed actually by himself or others, upon which Dr. Levidc bases his
generalizations ; but he refers substantially to only four post-mortem examinations.
And yet the assertion is made that " in every case the blood was fluid, even when dettJi
took place, in four hours was this the case."
Not a single fact is given by which any light is thrown upon the time at which tbe
post-mortem examinations of the blood were made. It is well known, that the blood
is found fluid in the blood-vessels, in those who have died from various diseases, eren
diseases of the most inflammatory character. And it is worthy of note, as shown bv
tuy own observations, that heart clots are most likely to form in the severest and most
malignant forms of malarial fever, in which there is a marked diminution of the fibria.
The condition of the blood in the vessels afler death, will depend in large measure,
upon the cause of death, and the condition of the vessels and tissues at the time of
death, and also upon the surrounding temperature, and the period after death at which
the blood was abstracted for examination.
In Cerebro-Spinal Meningitis death most frequently takes place, in consequence of
the disturbances of respiration and circulation induced by the pressure of the effbsioa
and coagulated lymph, upon the brain and especially upon the medulla oblongata; and
the final issue is frequently sudden, in spasms and convulsions. In such cases the
character of the blood, has undergone comparatively little change, except that whidi is
due to the retention and action of the Carbonic Acid Gas. If we may use the expres-
sion, the tissues and organs of those suddenly cut down, are also in a perfect state, and
do not rapidly undergo change, as in the case of the bodies of those who have died of
malignant fevers. Br. Gallup, long since observed, and his observation has been regeii-
edly confirmed, that with the resemblance to a state of mortification, there is no oflfen-
sive scent, any more than with a person killed by lightning; nor is there anj
evidence of a weakened texture of the fibres of the skin or muscles. Now these an
precisely the conditions most favorable to the preservation of the blood in a fluid state,
in the vessels afler death.
Upon such observations upon the blood in three or or four dead bodies, the Con*
toittee proceed to erect their theory.
"A careful examination of the subject has left no doubt in the mind of the OommtUtf tbat
the dma49 is ettentially a /every not essentially an inflammation ; that local inflammations when
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^eets of Oases on the Blood of Living Animatsi 509
they do occar, 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 have derived their ideaa 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 impoyerished condition ot this fluid, from innutritions or deficient food,
as none of the patients whom I saw, were in a condition of actual poverty, and a large majority
of them belonged to a class amply supplied with all the comforts of life." — Traus. 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 Quantitative 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-
titaUve Analysis of the blood during life, and based their observations upon this most
complex of all 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 ftirnish no proof that the disease is essentially
a bfood disease, and no justification for the assertion that " the only constant pathological
lenoD, 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
derangement of the nervous centres and nerves presiding over this function, either 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 is such that Carbonic Acid accu-
mulates in the blood, especially as the disease draws nearer to a close, and this poisonous
gas exerts certain effects upon the blood.
I have performed a number of experiments upon the action of various gases upon the
bk>od 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, acts 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.
EXPERIMENTS ON THE EFFECTS OF QASES ON THE BLOOD OP LIVING ANIMALS.
Carbonic Acid Gas,
Etperiment 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 expirations resembling deep sighs. The noise made by the passage
of the gas, in and out of their lungs, resembled that often made by human beings dying from
narcotic 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
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Mo Effects of Gases on the Blood of Living Animals.
of time, it became upon its exterior, of a red color. The heart, and intestines, and laofs^
were engorged with black blood. The contractility of the muscles was destroyed.
The blood corpuscles had undergone remarkable changes. They were shriTelled and
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 eflfects 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 brougitt
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 these
animals.
These effects upon the blood cells are not so manifest in warm-blooded animals, on accoas:
of the rapid manner in which they are destroyed by this gas.
Experiments iUmtrating the Action of Carbonic Acid Gas on Birds.
Experiment 204 : Augusta, Ga., February 18th, 1806. A strong, active pigeon, was subjectctl
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 ihr
respiratory muscles, became labored and spasmodic-^the mouth of the bird was thrown wide
open, and the muscles of the throat were convulsed. Immediately after the manifestatloo of
the effects upon the respiration, the action of the heart was greatly increased in fore* — the
pulsations were so powerful, that the thermometer introduced into the rectum, wa3 Tioleatlr
agitated by each impulse of the heart. The bird was killed by the Carbonic Acid Gas ia 1^
seconds.
Effects on Temperature. During the violent pulsations of the heart, the thermometer ro«
0.05° C, and after remaining stationary for a short time commenced to descend slowly , as
soon as death took place, and in five minutes after death, fell 0.55 C; temperature of atmoi-
phere, 10° C; temperature of rectum before experiment, 42°. C.,* temperature of rectum jas:
before the heart ceased its violent action, 42°.05 C; temperature of rectum 5 minutes 'after
death, 41°. 5.; 75 minutes after death, 33°.; 120 minutes after death, 20° C; 285 minutes after
death, 21° C.
Post'Mortem Examination. 24 hours after death, the blood was fluid in the blood-vessels ot
the brain, liver, intestines, and of all the organs, and presented a dark, venous hue. Wbes
exposed to the atmosphere, the blood changed to the arterial hue, and coagulated.
Experiment 205: January 19th, 1861. A strong, active Pigeon, was treated in a simiUr
manner to that described in the preceding experiment, the effects of the Carbonic Acid Ga*
were similar, with the exception that the temperature of the rectum did not rise, bat slowlv
descended during the action of the gas. Temperature of rectum before the administration o(
the gas, 42°. 5 C; during the experiment, the temperature descended 0°.05 C, and stood at
42°.45 0. at the moment of death ; temperature of atmosphere, 18°. 3C.; of rectum, one hour
after death, 34°.; 85 minutes after death, 32° C. Post-Mortem Examination. The appearances
were the same as those indicated in preceding Experiment 204 ; blood-vessels of organs aoi
tissues filled with black, fluid blood.
ExperimenU 206, 207, 208, 209, 210, 211, 212, 213, 214, 215: Repetitions of Experiments 104
and 205, with Carbonic Acid Gas, results similar. Blood-vessels after death, filled with black,
fluid blood.
Carbonic Oxide Gas.
Experiment 216: Effects of Carbonic Oxide Gas on Corn-Snake, (Coluber Guttatus.) Mar-
bank, Colonel's Island, Liberty Co., Ga., July 1855. An active Corn Snake, (Coluber Gutta-
tus,) was placed in a glass jar containing Carbonic Oxide Gas.
At first the efforts of the serpent to escape were unceasing and violent. Gradually iu
respiration became ^more laborious ; it gasped violently for breath ; its motions became spas-
modic and were succeeded by intervals of apparent exhaustion. It died forty-five mioated
after its Introduction into the gas. An examination after death, showed that the contractUiiy
of the muscular fibres had been destroyed, and that the muscles could not be excited by arti-
ficial stimuli. The heart was the last portion of the muscular system to yield to the actioo
of the poison, it continued to beat feebly for a short time after the thorax was opened. The
blood from all parts of the body was of a brilliant scarlet color, and coagulated into a dense
firm clot, which was unstable and dissolved again. After the dissolution of the fibnn, the
blood corpuscles settled to the bottom of the glass vessel, and the serum above was perfectly
clear, and without any marked color. Under the microscope, the blood corpuscles presented
no unusual appearance, when their broad surfaces were turned towards the eye ; when how-
ever they were viewed edgeways, they appeared swollen, and the central nuclei, was much less
distinct than in their normal condition, being scarcely visible. Acetic Acid exerted iti cha-
racteristic action, first rendering the blood corpuscles dumb-bell or hour-glass in shape, when
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^ects of Gases on the Blood of Living Animals. 511
Tiewed edgeways, and then rendered the exterior cell-wall transparent, and revealed clearly
the nuclei. When the Acetic Acid was neutralized with diluted liquor potassfe, the cell-walls
were again brought into yiew. Concentrated liquor potasssb 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 separate,
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-
iDf( 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 be suspended.
Experiment 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
moch 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 fibrin.
Experiment 218: Action of Carbonic Oxide Gcu on King Snake^ May 30th, 18G1. Active King
^<nake (Coronella Getula,) 3 feet in length, placed in a glass jar of Carbonic Oxide Gas, mixed
with 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 effects 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 (or more than two hours after the thorax was opened, notwithstanding that
mechanical and electrical stimuli failed to excite contractions in the voluntary muscles. The
blood in all the organs and tissues presented a brilliant scarlet color.
Experiment 219; Action of Carbonic Oxide Gas on Pigeon^ 1861. The head of a large, active
Pigeon was introduced into a receiver containing a mixture of Carbonic Oxide Gas and
atmospheric 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
rectum at the commencement of the experiment was 42°. 75 C; temperature of atmosphere,
18° 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
of death, the temperature of the rectum stood at 42°..*) C; 48 minutes after death, :J7°.33 (\;
153 minutes, 33°.; 318 minutes, 23°.5 C.
Immediately after the inhalation of the gas, and before death, the mucous membrane of the
eyes and mouth presented a beautiful scarlet hue.
Pbtt'Mortem 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. Xo other change was observed, in the form of the colored corpuscles
under the microscope, except that they were more swollen than normal. When kept for days
the blood still retained its brilliant color.
Experiment JJO : Action of Carbonic Oxide Gas.
January 1800. Strong, active Pigeon; head of bird placed in receiver, into which a stream
of Carbonic Oxide Gas was flowing. The gas was almost undiluted, and its effects were
immediately apparent, and the bird died in a few moments. The mucous membrane of the
month and eyes, were changed almost immediately to a bright crimson hue. The bird died
in less than one minnte. Temperature of atmosphere, 1«°.5 C; temperature of rectum before
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512 BffecU of Ga^es on the Blood qf living Animals,
inhalation of gas, 40^.7 C. The temperature commenced to descend, almost immediatelj after
death, and at the end of 50 minutes, stood at 33^.8 C; 75 minutes after death, 32^.33 C.
Posi'Moriem Examination. Mucous membrane of the mouth, eyes, and skin of the most
dependent portions of the body, of a beautiful, light carmine color. The blood in all the
organs and tissues presented a brilliant carmine color.
Experiment 221 : Action of Carbonic Oxide Gas on Dog, large Bitch ; strong and in good
condition. Action of heart, 100; respiration 35 ; temperature of rectum, 40^.6 G. The head
of the dog was placed in a receirer 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 m
struggles. Both the respiration and the actions of the heart were diminished. The respiri.
tion was only 2 per minute. At the end of 4 minutes, the respiration ceased entirely. Tb*
gas was then withdrawn ; the dog excited most probably by the atmospheric air, gasped
several times, stretched itself, voided faeces, and manifested signs of recovery. 10 miootei
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 temperatare
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 mncons
membrane of the mouth, tongue, and eyes, assumed a brilliant scarlet and pink color, aad
profound coma, while slow action of the respiration was produced in 3 minutes, and ia <
minutes both the respiration and the action of the heart had ceased. Temperatore of rectaa
40^.35 0. AH signs of life extinct.
The chest was opened about 5 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 stimali.
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 feeblj
to the electrical stimulus. The muscles of all the organs presented a brilliant color, ih%
blood in all parts of the body presented a brilliant scarlet color. This brilliant color pre-
sented a marked contrast to that of the blood of animals killed by varions other gases, as
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 flexiblf .
Experiments 222, 223, 224, ^^0, 226, 227, 228, 229, 230, 231, 232,
Repetitions of preceding Experiments, (216-221), illustrating the action of Carbonic
Oxide Gas on living animals. The results were similar. By numerous expmments, 1
found that Carbonic Oxide Gas produced the characteristic brilliant scarlet or canDioe
color in the blood of all vertebrate animals — Batrachians, Ophidians, Chelonians, Stm-
rians, Mammals and Birds.
£XP£RIHENTB ILLUSTRATING THE ACTION OF BIN-OXIDE OP NXTROOBN (NITEK
OXIDE NITROSYLj) AND PEROXIDE OP NITROGEN (NITRIC PER-OXIDB, OR HT-
PONITRIC ACID.) •
Expei^'ment 223. January, 1861.
A 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 (Emys Serrata), appeared
to be stimulating ; the force and rapidity of the respiratfons being increased. At the expira-
tion of 60 hours, although all signs of life had ceased, the heart still pulsated. The vesirli
leading to the heart, as well as the cavities of the heart itself, contained much gas. The
cavities of the heart contained fibrous concretions, entirely free from colored blood cor*
puscles. Clots of blood were found in all the large blood-vessels. The blood presented t
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, shriT^
elled, altered forms. All the organs presented a brownish color.
Experiment 23^: J liusf rating the action qf Bin-Oxide and Per* Oxide of Nitro^u,
1861.
Placed a Musk Tortoise (Sternothserus Odoratus), in receiver containing % mixtare of Ka-
Oxide and Per-Oxide of Nitrogen. Life was QOt destroyed ^ntil the expiration of 60 hoiff-
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Effects of Gases on the Blood of Living Animals, 513
At the end of this time, its blood, and organs, and znascles presented a similar brown and
purplish brown color, as in the preceding experiment (233). The blood corpuscles wer^
grestlj altered in form and appearance under the microscope.
Experiment 285 : Illustrating the action of Per- Oxide and Bin- Oxide of Nitrogen
on Birds,
1861. Active Pigeon ; head of bird introduced into a receiver containing a mixture of
Bin-Oxide and Per-Oxide of Nitrogen. Immediately upon the inhalation of these gases the
eflfects were evident. Death ensued in 50 seconds. During the action of the gas, the tem-
peratare 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<p
Isb yellow color.
Experiment 236 : Illustrating action of Per- Oxide and Bin- Oxida 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 0.; 84
minutes 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.
Experiment 237 : Illustrating action of Deutoxide and Per^ Oxide of Nitrogen on
Dog.
I860. 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.
In the course 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.
Autopsy 22 hours 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,
longs 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 ; coagnlum firm ; serum clear.
Under the microscope, the blood corpuscles presented a swollen, almost perfectly round
shape.
Exposure to the atmosphere did not induce any special alteration in the brown and yellow
eolor 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 Garbonic
Oxide Gas, or by Carbonic Acid Gas. When the blood was painted on stiff, white paper, it
retained its color, and at the end of 14 years it can still be distinguished from any other
dried blood.
Experiments 2SS, 239, 2^0, 2Jfl, 242 : 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 animals were theu successively subjected to atmospheres of these gas^s, in lar|;A
glass reeeirers.
»a
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514 ^ects of Gases on the Blood of Living Animals.
In each cnse the animals struggled vi'olentlj, and cried, the cries expressing great agony
and pain. Before death, they became comatose, the respiration spasmodic, and the mootk
was filled with froth. The time of death varied 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 corpuscles presented a swollen, altered appearance.
All the organs, as well as the muscular tissues, presented the usual brownish appearance.
Experiments 2Jf.S, 2^, 245, 2^6, 247, 248, 249, 250 : Repetitions of preceding Eimen-
mentg oh Various Animals, illustrating the effects of Bin- Oxide and Per- Oxide
of Nitrogen.
llesults similar to those just recorded. la all cases, uo matter what the char-
acter of the animal, profound changes were induced in the color of the Wood and
organs, and this color was similar in all the various classes of animals.
EXPERIMENTS ON THE INHALATION OP CHLORINE.
Experiment 251 : Effects of CJdorine on Birds.
January, 18dl. Large, active Pigeon. Head of bird held in mouth of glass receiTcr con-
taining Chlorine. The effects of the Chlorine gas were immediate, after the first inapiratiou .
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 0.; 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. Durisf
this rise in the thermometer, the action of the heart was greatly increased in namber aad
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 caose sev-
eral inspirations, and was then removed, and as we have said, in five minutes it bad the effect
of causing an elevation of 0^.6 C. The temperature then commenced to descend, and at \ht
end of two minutes stood at the original point, viz : 4l°.9 C. The bird was again sobje^tcd
to the action of the Chlorine gas, and the action of the heart, which had subsided with tbc
fall of the temperature, immediately became violent, and the thermometer indicated a rite of
temperature, ^nd in two minutes stood at 42^.2 C. At the end of this time, which was JQSt S
minutes from the first action of the gas, the bird gave a violent struggle and died. As sooi
as death took place, the .thermometer, after remaining stationary for a few minutes, ecufrt
roenced to descend, and in 50 minutes stood at 36® C.
This experiment confirmed the result previously stated, that Chlorine acts as a stimqlaotto
the heart, and also increases the animal temperature.
Autopsy, one hour after death. — The interrupted electrical current had no eflfect on the voUa-*
thry and involuntary muscles. The blood was fluid, and presented a purplish brown coloi,
but changed to the arterial hue when exposed to the atmosphere, Cerebro-splnul tyiten
not specially congested. Cavities of heart filled with fiuid blood, which did not coagvlate
when removed. Lungs presented a pale color, quite different from the brilliant hue of the
lungs of birds. Haemorrhage had taken place from the mucous membraqe of the month aB^
trachea. Liver congested. Under the microscope, the blood corpuscles in many initance)
presented an altered, swollen and shrivelled appearance.
Experiments 252, 253, 254, ^-^^j ^^^'j ^^^i ^^^^^ ^^^, 200 :
Repetitions of preceding experiments, with Chlorine on birds. Results similar to tboM
detailed in Experiment 251.
Experiment 261 : Illustrating the effects of Chlorine Gas on Z>oy«.— May 27th, 1861. Yoaag,
b|j)t grown hound dog. Action of heart, 100 per minute; respiration 50 per minnte ; ten*
perature of atmosphere, 25° C; of rectum, 39°.7.
The first inhalations of the Chlorine, mixed with four limes its volume of atmospheric air.
produced violent struggles and cries, and the thermometer rose almost immediately to 39®i^
C. Action of the heart 2 minutes after the inhalation, 113. Th? Chlorine excited the saliTarr
glands and mucous membrane of the mouth violently, and the saliva poured in streams froB
the mouth. This effect is characteristic of Chlorine, which acts powerfully upon the mncovs
membrane. Ten minutes after the first inhalation, the Chlorine was again administered, aad
again excited violent struggles, and the force of the impulses of the heart was still fdrtber
increased. Action of the heart 114 per minute. As in the case of the action of BromisSySo
also in that of Chlorine, the pulsations of the heart were greatly accelerated in insplralioD.
but were diminished in expiration. The respiratioi.\ v?as diminished in frequency, and l%3'-^
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Effects of Gases on the Blood of Living Animals^ 515
minates after the inhalation of the Chlorine, it was onlj 18 per minute. The respiration was,
howerer, fuller and more labored than before the administration of Chlorine.
The Chlorine was again administered by inhalation, 35 minutes after the first inhalation.
Strugn^les and loud cries were again excited. These struggles appeared to be due to the irri-
tating 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 picccding observation, during which time no Chlorine had been
administered, the action of tlie heart was 116, and the respiration 24; temperature of rectum,
390.0 C.
The dog was now removed from the operating table ; he stood up and walked with facility,
but appeared to be oppressed in his breathing ; the sounds of the lungs 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.
The next 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, ia 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 as the effects of the Chlorine, in reducing the respiration were manifest, and
now, 3 minutes after the injection, stands at 40^.5 C. A most copious flowof 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 stimulas. 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.
Experiment 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
mouth. The period of excitement lasted 10 minutes, and was followed by a comatose condi*
tioo, accompanied with spasmodic actions of the respiratory and voluntary muscles generally.
There were tremors of all the muscles. Death took place in 20 minutes.
Auiopty^ 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. Under the microscope, tome of the
eolored blood corpuscles presented an altered, swollen appearance ; others were normal.
Btpermenta 263, 264, 265, 266, 267, 268, 269, 270, 271 : Repetitions of preceding experi-
ments on warm-blooded animals^mammalia ; results similar.
Experiment 272 : Effects of Chlorine Gas on Dog. — May 8th, 1860 : Healthy, young dog. Tem-
perature of atmosphere, 26° C; of rectum, 40°.75 C. The dog was introduced into a large
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. 516 ^ects Of Gases on the Blood of Living Animals.
glass receifer, and subjected to the action of Chlorine gas ; the dog straggled Tiolently, aad
cried greatly during the action of the Chlorine. During these struggles, and dariag the
action of the gas, the thermometer rose, and at the end of 5 minutes, stood at 4P.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 0.
Autopsy, 143 minutes after death — Cadareric rigidity well marked. Powerful interrapted
magneto-electric currents passed in erery direction through the nerres of motion and sen»-
tion, and through the nerTous centres and muscles, produced no effects upon the moscQlar
system. Blood-vessels of brain filled with dark, brownish colored blood. Lungs much cob-
gested ; liver also congested in various portions. Under the microscope, the blood eorpasdes
were in many cases swollen, and in others crenated ; they were especially altered in Uit
blood-vessels of the lungs.
Experiment 273 : Injection of Atmospheric Air into the Blood, — 1860 : About one half piai
of I atmospheric air was forcibly and rapidly forced into the left Ijugular vein of an active
Scotch Terrier dog. The animal emitted piercing cries, struggled violently, andd led ia less
than one minute from the' commencement of the experiment. When the pipe was withdrawn,
air and blof^ Issued with force from the vein. Temperature of atmosphere, 15° C; of rectaii,
39.^5. The temperature remained stationary during the injection of the air, and commeaced
to fall immediately after the death of the dog, and one hour after, was 37^.1 C; 95 miaatea,
36^.^6 C; 5 hours and 45 minutes after death, 28^.8 C. Rigor-mortiB commenced one boar
and thirty-five minutes after death. 22 hours after death, temperature of rectum, 17M C;
temperature of atmosphere, 14^.4 C.
Autopsy, 22 hours after death, — Blood-vessels of the brain and spioal cord greatly congested
with blood, which contained numerous air bubbles. Lungs much congested with blood, and
blood-vessels contained air. Heart contained air in all the cavities. The liver was coagetted
and mottled, and the hepatic and portal blood-vessels contained numerous air babbles. The
stomach and intestines, both upon the exterior and iuterior, presented a deep red, congested
appearance. The large and small bood-vessels and capillaries could be seen ramifying io
every direction, as if fully injected with red coloring matter. The blood was fluid in all tht
vessels, and did not coagulate when removed from the body. When first removed firom the
vessels, and whilst in the vessels, it presented the usual venous hue ; but after removal asd
exposure to the atmosphere, it rapidly absorbed oxygen, and changed to a scarlet arterial
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 coats
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 textares
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 under
the action of such poisons as Prussic Acid and Cyanide of Potasium, which induce congestioa
of the internal organs. It is also evident that the appearances of congestion are greatir
increased by post-mortem changes. Such facts illustrate, in the clearest manner, the aeoet-
sity of caution, when we endeavor to determine accurately tlie characteristic morbific efl^ctf
of diseases and poisons.
ExperimenU 274, 275, 276, 277, 278, 279, 280 : Illustrating the effects pf the mechanical
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, with tht
amount of air injected, and the force used.
Experiment 281 : Illustrating the effects of the Continuous Inhalation of Hydrogen Ous. — Maybsak,
Colonel's Island, Liberty County, Georgia, 1855 : A yellow-bellied terrapin, which bad bcei
placed in a receiver of Hydrogen gas, died in 10 hours. The blood corpuscles from all psrtf
of the body presented an altered, shrivelled appearance, similar in all respects to that i^o*
duced by Carbonic Acid gas. The simple exclusion of the atmosphere, and the sabttitatioi
of an inert harmless gas, produced remarkable alterations in the shape of the blood eer«
puscles. The urine of this chelonian contained grape sugar.
Experiment 282 : Effects of Exclusion of Air on the j$too(f.— Maybank, Liberty Coaa^, Ga^
July, 1855 : Ligatures were passed around the trachea of yellow-bellied terrapins, (A^^
Serrata)f and salt water terrapins, (Emys Terrapin). The access of air to the lungt was thus
completely cut off. These chelonians gave signs of muscular contractility from 13 to ^
hours.
In all cases, after death, the blood presented a dark purplish, almost black color, and mu
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^eets of Gases on the Blood of Living Animals. 517
mneh darker than that of reptiles in its normal condition. The blood coagulated \?hen
abstracted.
The blood corpascles, (ander the microscope), bad undergone important modifications*
Many of them were shrunken, contorted and contracted ; others were swollen, assuming the
forms of spheroids, cubes and ovoids. The nuclei, which were rendered distinct by the action
of Acetic Acid, in many cases presented corresponding changes.
A stream of ozjgen 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
cbelonians contained grape sugar.
ExperiminU 283,284, 285, 286, 287, 288, 289, 290, 201, 292, 293, 294 : Illustrating the eflTecls
of Nitrogen Gas and Atmospheric Air on animals in closed receivers.
I hare also performed a number 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
eqaal sise, and age and activity, are placed in two glass receivers (filled with either Nitrogen
or atmospheric air), of precisely the same capacity. Hermetically 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
tlian six hours in a receiver containing less than one gallon of atmospheric air.
After death 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 ezperimeuts sustain the view which I have advanced,
that a portion at least of the phenomena of CerebronSpinal Menin<ptis are due to the
disturlmnces of respiration ; which disturbances result from derangement of the nerves
and nerve centres at the base of the brain, and are attended by the retention of a dele-
terious gas (Carbonic Acid Oas), and other poisonous matters in the blood.
The mere inflation of the pulmonary apparatus with air does not constitute respiru'
turn ; in this process there are changes involved, which are dependent on nervous
influence ; and as the integrity of the blood depends absolutely upon the proper per-
formance of the respiratory act, in all its manifold physical, chemical and physio-
logical relations, it is evident 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 maaifested 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 difficult 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 mv 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 the American Copperhead and Rattlesnake^ and Ptitrid
Organic Matter.
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518 Sffeets of Gases on the Slood of Living Animals,
Experiinent 295; lUiutrating the action of Bromine, Augusta, Ga., Februarj 4Ui, 1861.
Actire Female Scotch Terrier. Action of heart, 96 per minute ; action of heart increaied
during inspiration, and diminished during expiration. 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, llM C, of rectum of bitch, 39**.05 C.
The dog was made to inhale the fumes of Bromine. The effects upon the animal were imme-
diate, irritating the lungs, eyes, and mouth, causing labored respiration, and most rioleot
struggles, and loud cries. A profuse secretion of mucus took place from the eyes, mouth and
nose, and bronchial tubes. The dog struggled violently, and the temperature rose 0^.3 C. id
5 minutes, and stood at 39°.35 C.
15 minutes after the commencement of the inhalation of the fumes of Bromine, largely miied
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 fall aod
regular, but the action of the heart can scarcely be felt, and the temperature of the rectum ii
slowly descending. The bronchial tubes and rectum, appear to be fast filling with mucoi :
and loud rales may be heard, at a considerable distance, and the bronchial tubes appear to br
contracted, the phenomena and sound resembling those of Asthma in the human subject
40 minutes after the first inhalation of the Bromine, the temperature of the rectom vis
39® C, showing a loss of 0.35 C. in 40 minutes. The temperature continued to desceod for
several minutes, and after reaching 38^.9 C, it slowly rose during several minutes to 39^ C,
and then again in 10 minutes fell again to 38^.9 C. The filling of the bronchial tubes with
froth, and the diminution of the action of the heart, are without doubt important causes of
the fall in the temperature. The action of the heart is now so feeble that it is with difflcoltr
counted.
The dog was now loosed, one hour after the commencement of the inhalation — it wis 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 ai the
mucous membrane of the mouth and nose. The temperature of the body continued steadUv
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 full, with loud rattling sounds la
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 taUdnf.
attempted to walk, bat was unable to do so, the limbs being weak and tremulous, sat up (oo
fore legs) for a few moments, and then fell over on the side, and appeared to be compleie!/
exhausted, and almost immediately relapsed into a profound slumber, with loud, barsb,
labored breathing.
Action of heart feeble, determined with difficulty, 100 per minute. Respiratioa, 15 per
minute ; temperature of rectum, 34^.35 G. The temperature of the body has fallen 5^ C. siact
the administration of the Bromine. Half an hour after this observation, the temperatore of
the rectum was 33^.7 C, having fallen 0^.65 C. in this time. The extremities and surfiee of
the body also feel very cold. The loss of temperature appears to be due to three causes ; 1st.
the local inflammation of the pulmonary apparatus, and the filling of the bronchial tubes tad
air cells, with thick tenacious mucus ; 2d, alteration of the blood ; depressing eflfecti npoa
the action of the heart.
At each inspiration there Is a spasmodic contraction of the muscles of the neck, associated
in the act of inspiration. The contractions of the muscles of the mouth and nose, as well as
the spasmodic action of the organs of respiration, indicate derangements in the respiratorj
centres of the medulla oblongata, and evidence approaching dissolution.
The temperature continued to fall. The dog was kept under observation for about 7 honrr^
till 6 P. II.
During the remainder of the evening and night, the phenomena were not observed ,*— tbe
dog was found dead the next morning. Rigor-mortis complete. The temperature of the bodj
corresponded with that of surrounding inanimate objects, and the atmosphere. It is probable
that the dog died shortly after the last recorded observation.
Autopsy^ about 12 hours 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 filled
with blood. The muscles presented a dark purplish hue, and when cut, little or no blood
escaped from them. The coloring matter of the blood appeared to have transuded tbroogb
the minute blood-vessels. The blood in the small vessels of the dura-mater, arachnoid and
pia-mater, after exposure to the atmosphere, changed to a bright arterial hue. M icroscopicil
examination of the brain and spinal cord, revealed no lesions in the ultimate elements.
The lungs collapsed but slightly, when exposed by the removal of the anterior wait of tbt
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Effects qf Gases on the Blood of living Animals,^ 519
thorax. They presented a bigbl/ 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 caTitiei of the heart were distended with imperfectly coagulated, viscid, black, tar*
like blood.
The Vena CaTa, 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 uniform, 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
snch abundance in the blood.
Spleen presented a dark blue color, and appeared to be more distended with blood, and
softer than nsuaU The blood of the spleen contained acicular crystals of hsematin. Kidneys
congested with black blood.
The blood after its removal from the vessels coagulated imperfectly, and there was no con-
traction of the coagulum ; it had no consistency and the coagulum was ruptured with gently
shaking the vessel, and not a drop of serum was separated. Upon 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^ resen^ling tar in color and tenacity, and did not change to the
arterial hue even after 48 hours.
Under the microscope the colored blood corpuscles were swollen, and had a tendency to
ran 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 iis natural state, when first
abstracted from the vessels were acicular and colorless. The crystals of haematin 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
for comparison.
It is worthy of note that the Bromine had acted powerfully upon the blood, causing altera-
tion in the form of the colored blood corpuscles, and the formation of acicular crystals ; whieh
dilTersd materially from the crystals of haematin, which separated m great numbers, during
the slow desioation of the blood.
It is also worthy of note that these alterations of the blood, were attended by passive
haemorrhages from the intestinal mucous membrane, as in yellow fever,
EXP£ItIU£NTB ON THE .XCTIpN OF THE POISON OF CERTAIN AMERICAN OPHIDIANS.
ExperimeiiU with the Foiaon of the American Ojpperhead ( IVigonocephalas Vontor-
trix — Holbrooli) .
This reptile was first described by Linnseus, in the twelfth edition of his Systema Naturue,
under the name of Boa Contortrix. The genus Boa, of Linnaeus, included all those serpents,
venomous or not, that had plates under the tail, as well as on the abdomen.
Synonymet, — Boa Contortrix, Lin., Syst. Nat., vol. 1, p. 373. Angkistrodon Mokeson,
Bcauv., Tran. Amer. Phil. Soc, vol. IV., p. 381. Cenchris Mokeson, Baud., Hist. Nat. des
Kept., vol. V. p. 358, pi. XI., fig. 3. Scytalus Cupreus, Rafin., Am. Jour. Arts k Sci., vol. I.,
p. 85. Scytalus Cupreus, Harl., Med. k Phys. Res., p. 130. Ceuchris Mokeson, Uarl., Med. k
Phys, Res., p. 128. Trigonocephalus Contortrix, Holbrook, North Am. Herp., 1838, vol. III.,
p. 39, pL Xfv. Trigonocephalus Contortrix, DeKay, Zoolojry of New York, Part III. p. h\\
pi. IX., fig. 18. Copperhead, Vulgo, Red Adder, Dumb Rattlesnake, Red Viper, Cbunckhrad,
Copper-belly, bead Adder, Bastard Rattlesnake.
The geographical distribution of the Trigonocephalus is extended, Naliirulists having
observed it upon the eastern Atlantic slope, from the western parts ot New England to the mid-
dle of Florida. Its geographical range extends from about 45° north l.ititude to the Gulf of
Mexico, whilst upon the vest \i appcari? to be limited by the Alleghany Mountains. In the
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520 Experiments on the Action of the Poison of American Ophidians.
r
Valley of the Mississippi, its place is supposed, bj Dr Holbrook, to be sapplied bjr the Toxica
phis Atro fnscus, of Troost, which it resembles in habits. The motioni of the CopperhMd
are slng^ish ; and when approached it prepares for defence, raising its head, tbrowing oat tht
tongue, hissing and contorting, and flattening the head and body. The following is an aecii-
rate description of this reptile, as given by Dr. Holbrook in his great work on North American
Herpetology :
Characters. — Head very large, triangular, covered with plates in front and on the vertei,
with scales behind, and a pit between the eye and nostril; upper jaw with poisonons fangs:
body, thick, light hazel-nut brown, with transverse bars of dark brown, narrowest on tke
mesial line, broader and bifurcating on the flanks ; tip of the tail coriaceous. — PI. 150, CbW.,
foL 42, $e. 4.
Description. — The head 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 are
irregularly triangular, with their apices turned inwards, and their bases outwards, projecting
over the eye ; the occipital are rhomboidal, the frontal plates are large and qnadrilateral ;
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 iti
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, lon^;,
narrow, and semi-circular. There are two anterior orbitals, the upper quadrilateral; tht
lower makes the superior wall of the pit between the eye and the nostril, which is completed
below by the second labial plate, ahd by a small plate that rests on the third labial. Tb«
margin of the upper jaw is covered by semi-quadrilateral plates. The nostrils are large, late*
ral, and placed near the snout ; the eyes are large, but do not at first appear so, from Uie pro-
jection of the superior orbital plates ; the pupil is elliptical, vertical and dark ; the iris brigfat
golden with a tinge of red. The neck is greatly contracted ; the body is elongated, bot 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 homy tip.
Chlor. — The head is a delicate light hazel-nut brown above, with the labial plates whitish :
the ground of the color of the whole animal, body and tail, is of the same delicate hae, 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 spots oi the
abdominal plates, near their extremities, which then ascend, to include a scale or two on tht
flanks, and are so disposed that one spot corresponds to the point of bifurcation 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.
Dimensions. — Length of head, 1 inch 2 lines; breadth of head, 11 lines; length of body, 21
inches; length of tail, 3} inches; greatest circumference of body, 3} inches; circnmferraoe
of neck, 1 inch 10 lines. In the individual described there were 150 abdominal plates, 42
sub-caudal, and four pairs of bifid plates, or scales, near the apex. — [ ybrth Amenean Berft*
tology ,Phila., 1838, Vol. III., pp. 39-41.]
As a general rule, the Trigonocephalus Contortrix inhabits dark, damp, shady plaees,
though it is frequently found in meadows bordering upon the low lands. The specimeoi
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 marsh. The
related species, the Water Moccasin ( Trigonocephalus Piscivorus), which is very abnndaat
in the low swampy regions of Georgia and Carolina, frequents the rice dams and swamps, aid
is never seen far from water ; and in summer numbers of these reptiles may be seen resting,
in the low branches of such trees as overhang the water. The reptile is exceedingly danger-
ous to the unwary ; and is the especial terror of the negroes about the rice plantations, as it
is very sluggish in its movements, 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 its head and
opening the mouth for some seconds before striking, and from the white appearance of the
mouth, it has been called, on the rice plantations, the cotton mouthed moccasin. I once saws
stout negro man who had been bitten by a large water moccasin. The symptoms of polsonis;
were very marked. For hours the man appeared to be in extremis, notwithstanding the free,
scarification of the wound and the administration of large quantities of alcoholic stimnla&ts.
Beneficial results appeared to be derived by applying, chickens and frogs cat open alive, to
the wound. The entire leg and thigh swelled enormously, and t^e icecoyery ^nw tedioni.
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Experiments on the Action of the Poison of American Ophidians^ 521
The limb continued somewhat larger than the sound leg for several years, and the man com-
plained of pain in the region of the site of the poisoned wound during certain changes of
the weather^ and especially during damp spells. Both species of the Trigonocephalus feed
upon frogs, mice, birds and insects. As far as mv information extends, they^do not, as the
kin^ stiake, feed upon other reptiles of the same genus and species. The copperhead is
regarded by the negroes wiih as much dread as the rattlesnake. It is, however, not so
abnndnnt 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.]
BXPIRIMKNTS ON BITE OF COPPERHEAD, (tRIGONOCEPUALUS CONTORTBIX.)
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 F.
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
nlnute. H 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° F.
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 anake, temperature of rectum 104° F.; heart as yet not specially affected, although t)ie
foot is greatly swollen ; thirty minutes after stroke of snake, ( 5 minutes after last observa-
tloo ) 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 minutes after
last observation, ) action of heart 110 per minute. One hour after the bite of the snake, tem-
perature of rectum still 104° F., 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 serous fluid now issues from the wound in considerable
quantities^ and the epidermis can be readily removed from all the region around the point where the fang
entered^ presenting a red^ raw appearance. The swollen parts feel hot, and are severed 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°F.
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, o( one- tenth of a degree F. Action
of heart 150 per minutct
Daring the night the dog remained quiet, and next morning appeared much better. Swel-
ing in leg declining. Temperature of rectum next day, at 11 o'clock a.'M., still 104° F. 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, 11a. m., dog seems lively, but the leg is still much swollen, and several
degrees warmer than the sound leg ; temperature of rectum 104° F. 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 eheath 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, and the
force of the heart has greatly increased. The wounds and excoriated places on the foot pre-
sent a much lighter color, and appear to be healicg over. Mag 16th, 11a. m. — The dog still
continues to improve — swelling of leg and 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,
as upon yesterday, tremble occasionally. This dog recovered entirely from the effects of
the poison.
£3rpmnt(nt Kc, 2iiV— Subject of (xi;eiin:(nt a fine active young ccck — temperature of anus
110°.3. Augusta, Ga., Msy 12ih, 1862, 4 o'clock p. m. The copperhead used in the preceding
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522 Experiments on the Action of the Poison of American Ophidians.
experiment was aUowed to strike the cock upon the comb and bead ; tbe reptile appeared to
be somewhat exhausted bj striking the black dog in the morning. The strokes of the snake
appeared to excite violent pain in the cock ; he struggled violently, and opened his wings.
The rapidity and force of the action of the heart were increased during the strokes of the
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 poiot
whence it had started, being llO^.S 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 was
again thrown to the copperhead, and several severe blows were inflicted about the head an^
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 looked
about, and attempted to fly and run with some activity.
Thirty-five minutes after the first stroke of the snake, the temperature of tbe rectnm still
remained at 110^.3 F., whilst the head, comb, and adjoining parts, as well as the regieot
around the wounds in the breast, swelled greatly, and presented a dark purplish color, similar
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 and
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 found to
be infiltrated with bloody serum and tenacious blood, which did not appear to possess tbe
power of coagulating. The muscular fibres, in the region of the wounds, which had been sob-
jected to the direct action of the poison, were evidently in a state of softening and disorgaoi-
zation. 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 escaped
in many cases from the blood cells.
The infiltration of all parts around where the poison had been injected, and the flow of tbe
blood out of the vessels which had not been ruptured by the fangs of the snake, as well •»
the bloody color of the effused serum — all point to profound changes both in the blood and
in the capillaries and muscular tissues. A simple prick with a sharp instrument, like that ot
the fangs, certainly could not produce the pouring out of disorganized blood and bloodr
serum, through all the pectoral muscles. The blood and bloody tissues subjected to tb^
immediate action ot the puison, remained black, and did not change, even after several hoan
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 oi
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 bird!^-
The intestines, liver, stomach and spleen presented no special alterations, except that ibr
liver appeared to be somewhat more congested with dark blood than usual. The blood-cor-
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, from
the breast of the cock, killed by the stroke of the Copperhead, as related in the precedisf
experiment, was introduced beneath the skin, on the side of a young kitten, three weeks old.
and secured by a bandage. Twenty-four hours afterwards, the wound looked healthy, and
the kitten did not appear to be at all affected. During the night, the mother pulled off the
bandage and licked out the meat and blood. No injurious effects were observed from tbe
action of the flesh of the cock.
Experiment No. 299.— Augusta, Ga., May 12th, 1862. — The Copperhead appeared to be mncb
exhausted by its strokes of the dog and cock, and its poison appeared to lose its activity, for
a fine large pointer dog, which was bitten on the foot and lip by the snake, at the conclation
of the experiments, was but slightly affected. The temperature of the rectum, which stowt
before the stroke of the snake at 103°.l F., remained at the same point, and whilst there w<s
some swelling of thn'foot and lip, it was comparatively slight. The action of the poison v«s
manifested chiefly in a tendency in the dog to sleep, and also in a slight increase in the fre-
quency of the beats of the heart. The effects were only temporary, and the dog recovered
entirely in a few days.
Eicperiment No. 300. — Augusta, Ga., June 5th, 1862.^The Copperhead used in the precedinf
experiments was allowed to rest for near one month, in order that it might accnmalate a
stock of poison. The fine large black cur dog, which had been employed in the first experi-
mental an(jt yrWqh at thi? ti^pe T^a§ y^ry fat an< strong^w^s seljBQted for tbe trial. Temptrs-
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Experiments on ths Action of the Poison of American Ophidians^ 523
lure of rectum 103^.7 F. Action of heart 100 per minute in standing 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 by the snake, the
dog cried out loudly and shivered with pain. 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 faeces, and apparent loss of
consciousness. The temperature of the rectum during this period of twenty-five minutes,
remained at 103^.7 F., and then rose to 104° F. Dui-iug 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
to ibis period, after the strokes of the reptile, the action of the heart could scarcely be felt.
One nour after stroke of snake, temperature of rectum 104° F. Action of heart so rapid and
treble 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
can be felt with sufiicient distinctness to be counted, and is now 160 per minnte in the
recumbent 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
anioial raises bis head and notices when called, and the pupils are less dilated ; and when
r.ii8ed up upon the fore-legs, maintains his position and appears quite sensible.
Jtme 6. — Next morning, dog looks badly — dysenteric flux from the bowela — bloody discharges
(if altered blood-corpuscles, having a dingy, dark, purplish look. Temperature of rectum
\ }\^3 F. Extremities feel cold. Leg much swollen — the swollen leg feels warmer than the
other extremities. Animal very weak and feeble. Action of b^rt 145 ; respiration 24. With
the diminution in the frequency of the action of the heart, and the diminution in the frequency
of the respiration, the intellect appears clearer.
The evacuations of the bowels resembled in appearance tar, presenting a black color, and
consisting 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
appearance of a semi-transparent bloody jelly.
(Tnder the micnoscope but very few blood-corpuscles could be seen, and these were altered
in shape ; 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
iii'.itters.
' Whether the destruction of the cell-walls of the blood-corpuscles occurred in the intestines
after the passage of the blood out of the blood-vessels, from ruptured vessels, or whether
t'lere were but few ruptures of the capillaries of the intestinal mucous membrane, but rather
a 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 haemorrhage.
Six o'clock p. M. — Action of heart 145 ; respiration 22. Bog very lethargic and feeble in
motions, but perfectly sensible. Has discharged more of the tar-like bloody matter. Tem-
p.rature of rectum 101°.4 F. The dog drank a large quantity of cool water, and in a few
ntoments the temperature fell to 100°.4 F., and remained at this point for three-quarters of
an hour.
June 7, 2 o'clock p. m. — Action of the heart about the same in frequency as on yesterday,
but more feeble; the dog rose up to pass excrements, and the pulsations or beats of the heart
iu creased to 184 per minute. Respiration slow and regular as before. Temperature of rec-
tum I03°.l 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
color, and emits a dark colored serous fluid. The dog appears to be sensible, but is very
slufrgish and indisposed to motion ; drinks water freely, but refuses food — has refused to eat
I'vcr since the stroke of the reptile. Lips also much swollen.
During the night this dog died.
Autopsy 30 hours after death. — The fore-leg which had been struck by the copperhead was
ioiiltrated 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.
Under the microscope this presented numerous oil-globules and altered blood corpuscles,
with ragged, star-like edges; long acicular crystals were also seen floating amongst the
altered blood corpuscles. The blood from the swollen, infiltrated cellular structures of the
bead 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 htematin in all directions. The blood**
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524 Experiments on the Action of the Poison of American Ophidians.
vessels of the brain were filled with gelatinous, coagulable blood, which presented altered
blood corpascles and acicular 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 corpascles alnost
immediately commenced to assume a crystalline form. Blood vessels of brain filled with dait
blood; membranes and structures of brain presented a normal appearance ; there were so
lesions of the brain recognizable to the eye. The exterior fibrous sheath of the spinal cotd
presented a red appearance, as if the coloring matters of the blood had been effused ; strmc-
ture of spinal cord natural ; vertebral arteries filled with coagulated blood.
Stomach. — Mucous membrane of this vis'cus greatly congested — the stomach contained i
considerable quantity of bloody water.
Small Int€ftines — Congested with blood, and presenting a dark purplish appearance. Sone
portions were more congested with blood than others. The congestion was especially gnat
in the ilium, colon and rectum. The lower portions of the intestinal canal — the ilinm, coIob
and rectum resembled raw flesh, and contained the dark, tar-like, altered blood.
The peritoneum presented a purplish reddish color, as if saturated with the disorgmnized
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.
Spleen somewhat enlarged.
The fibrous tissue of the lungs 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 abont
which little or nothing was known, we conclude : —
Ist. The primary and chief action of the poison of the American copperhead (TrigOB^
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 p<f-
formance 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 bat
slightly increased, notwithstanding the profound changes inaugurated in the blood ; and after
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, under tht
influence of the poison of tlie 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 stnptd^
it may produce death without the establishment of profound coma.
7th. The profound alterations induced in the constitution of the blood by the poison of
the American copperhead give rise to passive haemorrhages into the cellular structures, and
from the intestinal mucous membrane. This phenomenon recalls strongly the passive haemor-
rha^res in certain febrile diseases, and especially of Yellow Fever. Some have supposed that
the black vomit of Yellow Fever was the resultant of the effects of the preceding intense
fever. Do not the present experiments indicate that it is rather the resultant of the action of
a poison upon the blood and gastric-mucous membrane ? We have here also an illustration of
the mode in which dysentery might be produced by a poison introduced into the blood.
Experiment 301. — Augusta, 6a., June 14th, 1860; fine fat, large cur dog. Temperatore of
rectum 40®. 2 0., temperature of atmosphere 79® F. The dog was brought near an active
Rattlesnake, (Crotalus durissus) which struck him in the right foot, at twenty minutes past
ten o'clock a. 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 swelling
rapidly ; 15 minutes after the stroke of snake temperature of rectum 40®.24 C., there has beea
a slight rise of j}^® in the last 10 minutes. Action of the heart appears to be a little fnllerr
and is now 120 per minute. The dog was again struck by the Rattlesnake on the left foot, 30
minutes after the first stroke.
Ten minutes after the last stroke, and forty minutes after the first stroke temperatnrt of
rectum 40®.6 0 ; respiration rapid and panting; action of the heart appears to be rather Ailler
than at first. Ten minutes after this observation, (20 minutes after the second stroke, and 50
minutes after the first stroke,) the temperature of the body still continues to rise, and the
thermometer in the rectum indicates 40®.8 C. The right foot and leg is now much swollen,
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Experiments an the Action of the Poison of American Ophidians. 525
and drops of bloody seram of a dark purplish color, issue from the wound, and the dog
oceasionally gi?es 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 G. 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
tUis observation and 90 minutes after first stroke, temperature of rectum 41**.23 C, tempera-
ture surface of muscles of loins 38^.20 C.
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 aboard the violent convulsions were excited, and the
temperature of the rectum rose from 40.8 to 41°. 23 G. Ten minutes after this observation,
aud 100 minutes after the first stroke of the Rattlesnake, temperature of rectum 41^.28 C,
temperature of surface of muscles of loins 38^.6. Mucous membrane of lips and mouth injected
witb blood, 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 was 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
no 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 faecal matters, and now discharges foetid bloody watery
stools. Six hours after this observation, and 9 hours and 10 minutes *after the first stroke of
tbe rattlesnake, temperature of rectum 40^.2 C; action of heart 140 per minute; respiration
gentle and natural.
June 15th, 10 o'clock a. m. — Dog appears well and hearty, with exception of swelling of
legs, temperature of. rectum 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.
Experiment 302 ; lUuetrating the action of the poison of the American Rattlesnake (Crotalue DurxM"
nu). — Augusta, Ga., June 15th, 1861 : Half grown cat was struck by a medium sized Rattle-
snake, which had been exhausted by striking several times before. Temperature of rectum
of young cat, 38^.8 C. at the time that it was struck by the snake ; 7 minutes after, tempera-
tore 38^.2 C; 9 minutes after the stroke, 37^*8 C; 30 minutes after stroke, 37^4 C.
One hour after the stroke animal apparently well, with the exception of some tremuloueness
of the muscles.
Temperature of the rectum 37^.8 0. During the first 30 minutes after the stroke the tem-
perature of the rectum descended 1^.4 C; during the next 30 minutes it rose 0^.4 C; and
continued to rise, and at the end of the next hour stood at 39° 0, or 0°.2 C. higher than
before the introduction of the animal poison.
The young cat recovered entirely.
Experiment 303: Illuttrating the action of the poison of the American Rattlesnake {Crotaltu
Dwrissus). — Small, active bull dog pup, 2 months old. Temperature of atmosphere, 26^.11 C;
temperature of rectum, 39° C.
A medium sized, dark-banded Rattle-snake, five feet in length, inflicted a wound with its
fangs in the left side 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-
gle or bark. The temperature of the rectum rose almost immediately after the injection of
the poison, and in three minutes tbe thermometer stood at 39^.4 0. Action of heart 120 per
minute. Respiration full, rather labored. The pop appeared to lose all muscular power
almost immediately after the injection of the poison, and did not once struggle or attempt to
rise, but lay quiet upon its side. 13 minutes after the stroke, respiration 24, action of heart
130, temperature of rectum 39^.28 G. At this time the pup lay in a profound coma. The
blood appears to be settling in the capillaries of the extremities, as the feet present a purplish
appearance. Respiration spasmodic. Temperature of the rectum is gradually declining, and
has fallen 0^.12 Ci during the last eight minutes.
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626 Experiments on the Action of the Poison of American Ophidians.
Nineteen minates after the injection of the poison coma profound ; papilf greatly diiaied ;
respiration 12 per minute and spasmodic ; the muscles of the mouth act spasmodicallj — the
mouth gasps conTuIsivelj at each inspiration. Action of heart 130. The temperature of the
rectum still falls gradually, and now stands at 39° C. 22 minutes alter the injection of the
poison pupils greatly expanded, and do not contract when exposed to the action of the light ;
temperature still falling, and is now 38°.8 G. Respiration slow and spasmodic, in &ct 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 C.
Twenty-eight minutes after the injection of the poison the action of the heart could not be
felt ; it had just ceased beating, having continued two minutes after the cessation of the|res-
piration. From the injection of the poison to this time, the mucous membrane of the momtb
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 C ; 167 minutes, after stroke of
reptile (139 minutes after cessation of action of heart), 31°.8 C. In the last 127 minutes (X
hours and 7 minutes), the temperature of the body has fallen 5^.8 C.
AtUopsy 167 mmttUs after the injection of the poieon, and 139 minulee after the cetuUion tftke
action of the heart. — The interrupted magneto-electric current produced slight contractiooa n
the muscles, showing that up to this time there had been some susceptibility to the electric
stimulus.
When the skin over the region of the poisoned wound was removed, the cellular tissae
was found congested with blood, and contained much dark purplish and black coagiilatcd
blood effused into the cellular tissue — the blood-vessels and capillaries of the surroanding
skin were also greatly congested with blood. This effect is evidently due to the direct action
of the poison upon the blood and capillaries. By the peculiar structure and arraogemeot of
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 all
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, bat
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 skull-cap. Tb«
sinuses of the dura-mater contained well formed, dark purplish coagula \ all the large reioi
also of the various organs contained dark purplish, coagulated blood.
Thorax. — The lungs presented a deeply congested and mottled appearance. The right auri-
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, and
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, ij
interesting, as pointing to the effects of the poison directly upon the coagulating properties
of the blood.
Abdomen. — Blood-vessels of the liver filled with dark blood. Stomach and intestines
somewhat congested with dark blood. The mucus membrane of the intestines, and more
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 appear-
ance.
Experiment 304 : Illustrating the action of the Poison of the Dark Banded Rattlesnake. — Jnac
15th, 1860: Strong, active, well conditioned Cur Dog, Terrier blood predominating.
Temperature of atmosphere, 27° C; temperature of rectum, 39°.2 C. The dog was thrown
into the box with the snake, and several strokes were inflicted by the reptile on differeai
parts of the legs. The struggles of the dog were very violent during the strokes of the snake,
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 snake occupied
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°.8 C^
showing a rise of 0°.6 C, in the short period after the introduction of the poison.
Seventeen minutes after the injection of the poison, and seven minutes after the last obser-
vation, the dog fell into a profound coma.
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Experiments on the Action of the Poison cf American Ophidians. 527
The temperature of the rectum rose during the struggles and excitement, during the injec-
tion, and just after the strokes ; and then just before the establishment of the coma, stood
Btill ; and as soon as the coma '^I'as established, commenced slowly to descend. The action of
the heart and the respiration also diminished in frequency; the action of heart 100 per
minote ; respiration 12 per minute. During the coma, or deep sleep, the thermometer de-
scended 0^.2 C. The dog then revived, and immediately the temperature of the rectum com-
menced to rise, and 12 minutes 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
eleren 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 0°.06, in
this period.
One hour and ten minutes 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 temptra-
ture 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°.\ C. One hour
and a half after this, the dog was again subjected to the attacks of the snake, 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
captured the reptile, extracted his fangs, and plunged 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 C. 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 C, having lost in four minutes 0°.2 C; and in two minutes more
descended still farther to 40°.2 C. 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 C. Dog appears
drowsy and indisposed to any exertion ; action of heart, 150 per minute; respiration 24-26;
left leg und 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
Lrine, 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 knife,
the animal does not evince pain. Temperature of rectum, 40°.2 0. Sixteen minutes after
this observation the thermometer in the rectum, indicated 39°.8 C, showing a fall during this
period of 0°.4 C. Temperature of the surface of the muscles of the loins, 35°.8 C, showing
a loss of 0°.6 C.
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 C. Action of heart 13 ; respiration II.
After considerable effort, the dog 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. Temperature of rectum, 38°.5 C. There had been a fall of
1°.0 C, 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.
Autopsy about 4 hours 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 same deep black and purplish color of the structures were
observed.
Muscles generally presented a dark purplish h^ue,, fa^^ different from the appearance in Ue9,lth^
Electric cur^evts bftd ao effect vhatev^r.
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528 Experiments on the Action of the Poison of American Ophidians.
Blood-vessels of brain not congested with blood, yenous blood-yessels rnnning along iht
sides of the spinal marrow distended with black coagula.
Both the right and left cavities of the heart were filled with dark purplish, firm eoa^la of
blood. The vena cava also was distended with firm, purplish black coagula of venous bloody
as in the previous experiment.
These facts would seem to show that the poison of the Rattlesnake promotes the coagalaiios
of the blood. Prussic Acid on the other hand, although acting in a few moments, on tke
contrary destroys to a great extent the coagulating power of the blood.
The right auricle and ventricle of the heart, contained numerous worms, several inches ia
length, and these were surrounded by a firm coagulum of blood. The lungs were greatly
congested with blood, and collapsed but to a slight degree when the thorax was opened.
Blood-vessels of stomach and intestines congested. The mucous membrane of the stomacii
and intestines, was of a purplish color.
The mucous membrane of the small intestines was coated with a reddish and porptish
bloody looking mucus ; — when this was scraped off, it did not appear to be specially congested.
This corresponded with the appearances during life.
^e rectum, both upon the exterior and interior, was of a deep purplish red and browa
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 normal.
Fore leg which was most swollen, was black as tar or pitch, and resembled in all respeet«
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 the
atmosphere.
From the preceding experiments we conclude :
1st. After the injection of the poison of the Crotalus Durissus, (Rattlesnake,) the
temperature rises for a brief period ; but as soon as the poison has induced a decide
effect upon the cerebro-spinal nervous system and heart, and coma has been established,
the temperature descends. If the animal recovers from this state of coma, the t^c-
perature will again rise slowly and descend again, upon the supervention of co'ma.
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 aimniDC
and duration.
2d. The Poison of the Crotalus Durissus (Rattlesnake,) acts as a local iiritant upon
the capillaries, and as a destructive agent on the blood and muscular structures, causing
congestions and bloody effusions, and softening, and disorganization of the ^nuscuUr
fibres.
3d. The blood does not lose its power of coagulating, in every case of poisunin*; by
the Rattlesnake, but the clot is soft and voluminous, as if the fibrinous element uf the
blood had undergone some change.
4th. The colored blood corpuscles do not lose their power of absorbing oxygen, amd
change readily to the arterial hue, when exposed to the atmosphere.
5th. Whilst the microscope fails to reveal any marked or characteristic changes in
the blood corpuscles, in the general mass of the blood, still its direct action on this fluid
is evinced not merely by changes in the coagulating power of the fibrin, but also by tht
congestions of the organs, and the passive hsemorrhage of the muoous membraneew
6th. The Poison of the Crotalus, destroys by its direct effects upon the Cer^wo-
Spinal Centres, and by its depressing effects upon the sympathetic ganglia, and moscttlir
structures of the heart ; and also by the changes which it induces in the compoeitioii of
the blood.
EXPERIMENTS ON THE EFFECTS OF PUTRID ANIMAL MATTERS.
In connection with the action of poisons, clearly of animal origin, as thoee of ^
Trigonocephalus and Crotalus, it is important to remember that one of the most rem^c-
able phenomenon presented by animals into whose veins Magendie more than tliiiij
years ago, injected putrid substances, was what is termed inflammation of the inteatiBes ;
that is to say, exhalation of a matter, having the color of UDashings of flesh.
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Experiments on Putrid Animal Matters. 529
Yarioos 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 oases 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-eio;ht 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 afier the acme had been reached ; whilst on the other hand,
after 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 pysemic and septicsemic
blood, 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 PROM THE HEART AND
THE BLACK YOMIT FROM THE STOMACH OP YELLOW FEVER C^SES.
Es^erimtni 305: With a Bmall "subcutaneous" sjriuge, I injected beneath the skin of a
healthy puppy, about thirty drops of bflood taken from the heart of a yellow fever patient three
hoars after death.
No ill effects 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
17th, the animal appears sluggish and refuses food. October 18th — Animal feeble; moves
with difficulty, and is evidently 511 from the effects of the injection. October 19th, 5 a. m. — 1
found the Guinea pig dead, cold and stiff.
Post'Mortetn 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.
Under the microscope the fluid from these portions of the cellular tissue was found to con-
tain bacteria and revolving aniroalculie. Cavities of the heart distended with dark, almost
black, loosely coagulated blood. Blood changed rapidly to the arterial hue upon exposure to
the atmosphere. Uuder the microscope the blood corpuscles presented no peculiar alteration.
Liver congested. The microscope revealed no accumulation of oil in the textures of the liver.
Liver cells distinct but pale. N-o bacteria, or animal or vegetable organisms, were observed
in 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 male guinea-
pig, I injected about thirty drops of black vomit, taken from the stomach of the yellow fever
patient three hours after death.
77ie black vomit thue carefully injected into the cellular tissue caused the death of this animal in
iiz hours.
Poat'Mortem Examination. — Diffused redness, and great capillary congestion of cellnlar tissue
beneath the skin. 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 effused, 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-
cula;, bacteria or fungi, or algae 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
shortly before death on the 9th of October, 1873, six days before the present experiment.
Death caused by the black vomit in six hours.
PoU'Mortem Examination. — Results similar in all respects to those recorded in the preceding
experiment ; intense' congestion of cellular tissue arouud locality of iDJeciiOQ of black Tomit *)
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530 Experiments on Putrid Animal Matters.
no aDimalculffi or vegetable organisms in blood ; patrefaction rapid and marked by foul odor.
Experiment 309 : I injected into the sabcutaneous tissue of a Guinea-pig about thirtj dropi
of putrid blood, which I had extracted from the cavities of the heart of a sobject vbo bad
died six days before, on the 9th of October, in a " congestive " malarial chill.
Death caused by the putrid malarial blood in eight hours.
Post-mortem changes similar to those recorded in experiments third and fourth.
The preceding experiments are of importance in establishing the fact that 6^adb vomii, takm
from the stomach immediately after death, or ejected during life in yellow fever, will, when i^fecUd lalf
the subcutaneous tissue, produce as 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 at a deadly
SEPTIC 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 vomit, especially after it has undergone putrefactive changes in the stomach, may 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 caebolatb o?
SODIUM, in doses of 20 grains, every 4 or 6 hours in the treatment of yellow fever.
I have used the sulpho 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 appeare(f 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 qk,
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 akin of
an animal's neck a single drop of putrid blood, the surrounding tissue became extensively
infiltrated, and death soon followed with symptoms of septicasmia. The blood of thta animal
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 with
the blood of the preceding one, and in this way 24 in all were experimented on. The resaltt
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 23
animals with healthy, 23 with putrid, and 73 with blood diluted by transmission. Of the first
series, 4 died. Of the second series 11 died. In experiments with diluted blood, when it had
passed through 13 different animals, 53 of the 73 aied. From this it appears that even the
very small amount of y^^ of a cubic centimeter of poisonous material could cause deatb
when injected hypodermically. Davaine's statement, that organisms form in the blood and
increase by every transmission, was not sustained by investigation. Strieker found nuraerooa
colorless bodies in the blood of these animals, but he did not regard them as organisms, but
rather as proto-plasmic bodies.
The following facts he regards as ascertained :
1. That transmission greatly increases the injurious and fatal action of the putrid matter.
2. That the original disease was infectious, but that through inoculation it became conui-v
giouB.
3. That though it be not proven, yet it is probable that the special poison is a living coi-
tagion (contagium animatum,) for such rapid proliferation is only possible in organized material.
4. That the poison is diffusible and is not destroyed by boiling {AUg. Wim. Med. Zeitumf,
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 cer-
tain conditions of the constitution, and more especially of the chemical and physical consii-
tution of the blood and of the nervous and muscular structures, when subjected to the
combined influences of heat and crowding in an impure atmosphere ; if it be still farther true
that decomposition, both before and after death, is more rapid than in any other form of
disease, and if this decomposition forms the most favorable condition for the rapid multiplica-
tion of bacteria and fungi, and other simple organisms; it is reasonable, in the light of the
preceding experiments of Davaine and Strieker, to suppose that these organisms may becoaae
carriers of the poison, and may constitute an important medium of its dissemination f^om the
original foci*
MageD<^6 has sbovn by actual experiments on living animals that an exoee of
alkalinitj in th.% Wqo4> W*^^W> 9^^ ^^^J '^^^ ^® f Veeclom of the passage of this Ikfaii
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Experiments on Putrid Animal Matters. 531
through the capillary vessels and diminishes the property of coagulation, but also, when
thus modified, the blood tends to penetrate the walls of the capillaries 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
coogulable part, in a semi-liquid state, collects in irregular misses, which appear to bo
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 same 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 of a living animal, the fibrin will loose its coagulability, and this change afiects 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 efiects 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
appeared 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 left 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 Eitsat/ of Fevers, uses this fact to
explain the changes of the blood in Scurvy and Putrid Petechial Fevers.
It is well known that volatile alkali salts mixed with the blood, when just drawn, or rather
nrter it rans from the vein, keep it from coagulating and hinder it from separating into crasa-^
mentum and serum, as usual. The experiment is easj, and every one will find it true on
trial. This very adequately resembles the blood drawn from the bleeding scorbutics, and also
fruro most persons that labor under putrid petechial fevers, when the blood is drawn very
early in the disease.
All hnmors of the 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, hath had this appearance, and been
observed actually to stink as soon as drawn, as well as the urine, as soon as made ; so far was
the patrefaction advanced, whilst even life was still subsiding. The surprisingly great and
speedy corruption of bodies dying of pestilential fevers with spots, shows this likewise ; I
have known such a corpse 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 most putrid aaniet^ from all the outlets
of the body : which, by-the-bye, is a reason why persons dying of such fevers, should be
buried very soon." — An Essay on Fevers, etc., by John Huxham, M. D., 1757, pp. 50, 51.
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 hsmor^
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 cause of the other.
In Scurvy the proportion of globules is natural, or varies within narrow limitS)
whilst the quantity of the fibrin is diminished, and its coagulative quality is at the sam^
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532 Changes of the Blood in Various Diseases,
time altered ; and thb coQditioQ is most favorable to the production of repeated and
proflise hsemorihages.
The tendency of the formation of petechial and livid spots, daring the progreas of
malignant fevers, in the middle ages, is referable chiefly to the scorbutic eondition of
most patients, at those times, when salt meat constituted the chief nutrim^it daring a
large portion of the year, and fresh vegetables were almost unknown. In this oonneo-
tion it should be remembered, that authors have declared, that they have found aa
excess of alkaline matters in the imperfectly coagulated blood of persons who have died
of low-fevers or Scurvy, attended with livid petechias and spots. An analogous rerak
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 pasare
haomorrhages, so constantly described by authors, in their hbtories of epidemic feveis,
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 wu
common to observe gangrene, hsemorrhagc from various parts, extensive ecchymoeis, or
thousands of petechisd covering the skin, whibt 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 manifestatim
of an internal 4X)ndition of the blood.
Erasmus, the philosopher, who flourished towards the close of the sixteenth centmy,
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 houses
clean. These houses are of wood, and very cold in winter, which makes it necessaij
to fill the rooms with straw. But as this cannot be oft<2n renewed, it becomes ^wikd
and very injurious."
Grant, who practiced medicine, and wrote towards the close of the last century, sug-
gested the inquiry, whether the peculiar hygienic condition of the people of Eoit^
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 rf
dissolution of the blood. It is certainly remarkable, that the observers of preceding ages,
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, illus-
trating the great tendency to Petechias and passive haemorrhages, in the fevosof
those times.
Andral in treating of the changes of the blood in Scurvy, records the disappearance
of this disease, and of the great febrile epidemics of the middle ages, and says :
^* We must therefore admit, that in coDsequence of the change in the nature of the inflo-
ences which, necessarily act upon men, the blood which receives before the solids, the impres-
sion of the greater part of these influences, must present changes in its constitution propor*
tioned to those undergone by the agents which operate upon it. It wonld appear then, th»t
there roust have been a time, when a very peculiar constitution of the blood engendered mala*
dies, which in certain respects, may have differed from those now observed, and may not
have required the same treatment. And thus it is that at diflferent periods of the ezisteooeof
our race, and the diversity of influences to which it may be subjected, diseases of very dilu-
ent types may arise, and undergo changes in their essential nature, which are revealed to is
by the specific character of their symptoms."
Andral has likewise established this invariable law, of augmentation in the fibfiii of
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Changes of the Blood in Various Diseases. 633
the blood, Id regard to every acute inflammation of the serous membranes ; and this
increase was very marked in a case of Cerejbro-Spinal Meningitis, in which ai^r death,
Andral found the Spinal Marrow surrounded in its whole extent, by a sort of purulent
sheath, the pus having infiltrated the pia-mater.
In the following case of softening of the b^^in, Andral, in like manner, discovered
an increase of fibrin.
Case 632. — A woman was brought to the liospital, 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
hsroorrbages. She soon died, and the autopsy disclosed in the right corpus striatum, and
around a clot, a red softening of the cerebral substance of small extent, but very distinct.
Inflammation had then existed around the apoplectic centre; the contraction of the paralyzed
extremities had 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 inflrtmraatory 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 remarks^ble 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.
Case 633. — A seamstress, 24 years of age, entered the hospital of La Charity, May 27th,
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 affection 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 convulsive movements
whenever the sicin 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,
t 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-
lations, similar to those which filled the pia-mater, were also found in the pleurae 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 whateyer may b& tke
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634 Petechias in Cerebrospinal Meningitii due to the Local Inflammation.
extent or the rapidity of the formation of tubercles, it does not in the b^inning, w^-
ment the fibrin in the blood.
The changes of the blood in certain oases of Cerebro-Spinal Meningitis, may hate
been the re^lt and not the cause of the aberrated nervous actions. If thu be tree,
the petechim and spots, observed in a certain proportion of the cases, should not be
Horded as true cutaneous eruptions, like the cutaneous affections characteristic of tlie
exanthemata.
It has been said, that extreme agitation of the nervous system, may deprive the blood
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, affeetinir
the nervous plexus of that region. 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 influence over the constitution of the blood, and that
consequently a lesion of innervation may deteriorate the blood, just as an alteration d
the blood may modify the nervous action. Professor Dupuy announced, that by dividiag
the pneumogastric nerves in horses, the blood of these animals lost its prop»^ of
coagulating; Dr. Mayer, on the other hand, having tied the pneumogastric nerreiiii
living animals, found that uniformly the blood had coagulated throughoat the whole
pulmonary circulation* These facts, as well as those relating to the eSoc^ of lightaiag,
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 €i tke
nervous system affected, as in section of the pneumogastric and sympathetic, it may be
inferred that the changes of the blood in Gerebro-Spinal Meningitis m^i^ vary wkhia
certain limits with the portion of the nervous system chiefly involved.
THE DERANGEMENTS OF THE CIRCULATION AND RESPIRATION, AND OF THE SECEI-
TI0N8 AND EXCRETIONS, AS VTELL AS OF THE NERVOUS FUNCTIONS IN CS&BBBO-
SPINAL MENINGITIS, MAY ALL BE REFERRED TO THE LOCAL INFLAMMATION,
CONGESTION AND ALTERATION OF THE MENINGES, (ESPECIALLY THE PIA-MATIB)
AND STRUCTURES OF THE BRAIN AND SPINAL CORD.
The theory, that the cold stage, the febrile phenomena, the derangementa of circdft*
tion and respiration, and the mottling and discoloration of the surface, are due to the
action of a distinct blood poison which so alters the constituents of the blood that it
stagnates in the capillaries, and transudes through their walls into the surroondiBg
tissues, is not necessary for the explanation of the phenomena, and is not borne out b;
the natural history of the disease.
Derangement in the action of the nerves given off from the base of the brain and of
the medulla oblongata, caused by the inflammation of the pia^mater, and disturbances ia
the nutrition of the ganglionic cells, and by the mechanical pressure of the products of
inflammatory action, are sufficient to cause the derangements of circulation and respi-
ration, and the stagnation and alteration of the blood in the capillaries of the sorfaee,
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, but all
marks of disorganized blood and of bloody effusions in consequence of disorganixatioa
of the constituents of the blood, are absent from the structure most inflamed and
diseased, viz : the pia-mater of the brain and spinal cord. The appearance of effnsioM
of blood and bloody serum, into the cavity of the cranium and spinal oanal, described
by some observers, may be referred to the rough manipulation of the post-moiteai
examination, and to post-mortem changes and exudations of the coloring matten «f
the blood.
The facta point chiefly to a want of oxygenation of the blood, and to a t^ideiM^ to
the stagnation of the venous blood in the capUlaries of the periphery, and not to a <&-
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PeteehicB in Cerebrospinal Meningitis due to the Local Inflammation. 535
UncUve eniptioD, as in Typhus Fever, Measles and Scarlet Fever, nor to actual effusions
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 petechiae 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 eruption, because they are found
in many cases in the mucous and serous membranes.
The " ivflamynatory " 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
wonld 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 efflorescence of the skin, attended with redness, heat and
itching, which was a common symptom during recovery.
<* I have hitherto said nothing of anj spots upon the skin, although their real or supposed
appearance has in many places given a name to the disease. The reason is that I have very
little to saj respecting them. In most or all the fatal cases, just before death, small patches
of a parple, or rather livid color, were irregularly dispersed over the surface of the body.
Tbey 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-
duction 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
confounded with them, and this was exceedingly dissimilar in its appearance." pp. 95, 06.
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 highly important, as indi;
eating that these spots were in no wise an eruption, but were produced 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 sise 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 asQumed much of the appearance of incipient sphacelation, for which they were often
taken by the attendants." p. 109.
Dr. Hale thus doscrib^ the eruptiou which sometimes OQCi^nced during cQAvalea^
oraoe;
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536 PeteehkB in Cerebro^Spinal Merdngitis due to the Local Infiammatim.
" After the epidemic season bad considerably advanced, an eruption on tbe skin became a
very common symptom during recovery. It did not appear in but 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. The skin was very slightly elevated and uneven, bui
commonly not pimpled. It subsided in two or three days of its own accord, leaving a braDoj
scale upon the skin from the desquamation of the cuticle.
*' This eruption seems not to have been in any degree critioal. 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 tbe
other hand, did it appear to increase the fever, or in any way add to the sufferings of the
patients, except by the external heat and irritation, which were not often severe. It roar
perhaps be a question, whether the eruption is not attributable to the treatment, rather thsa
to the disease itself." p. 81.
Dr. Hale also describes a species of boil, or carbancle, as another oommon affectioB of
the skin and cell alar membrane during convalescence.
*' It did not commence until the cure was considerably advanced, generally several dtji
after the eruption had disappeared, and sometimes not until the patieni has so far recovered
as to have left his chamber. It was an exceedingly painful swelling, beginning in the form of
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 tbe
inflammation rapidly extended itself, the centre became considerably elevated, and changed
to adeep purple, and almost black color. In a few days it ulcerated, and cast off'a gangr»-
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 tbe 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
eruptions, at about only one-sixth.
Dr. Elisha North says that petechiaB were by no means constant, and Drs. Tbomss
Welsh, James Jackson and John C. Warren describe the petechiae and vibioes as
occurring " in comparatively few cases of the disease. They are of worse portent io
proportion as they are more dark colored." According to these observers, they were
not always found in fatal cases, nor confined to such.
In fifby-seven cases, in which Dr. Ames, of Alabama, noted the state of the skin,
purple petechisd, which did not disappear upon pressure, occurred in only one case;
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 »iip-
t ions, not disappearing under pressure; thirteen had mixed petechias and erythema;
nine erythema and urticaria ; three had indistinct petechial mottlings ; and m thirty-
seven cases there was no eruption at all. If present, it usually appeared early ; it vas
in many cases the first diagnostic mark ; and although showing, perhaps the oonditioo
of the vital fluid, it did not seem to have any reference to the degree of oerebnl
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 oem
observed petechise 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 observed b
only 55 cases in 315 cases of Cerebro-Spinal Meningitis. He describes the spots b
this limited number of cases, to have been generally of a hsBmic character, and to hare
resembled those seen in the worst cases of Typhus. Boston Medical and Surgical
Journal, vol. xci ; Sept, 3d, 1874, p. 225.
We are in like manner justified in the conclusion that none of the other appeannooi
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Relations of Cerebrospinal Meningitis to Climate. 537
and eraptions of the skin are characteristic or essential elements of Cerebro-Spinal
Meningitis, for in a largo proportion of the cases, they do not appear at all, and many
other diseases present similar phenomena.
CKBEBRO-SPINAL MENINGITIS, RESEMBLES IN ITS ORIGIN AND PROGRESS INFLAM-
MATORY 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
Additions" to the ''Treatise on Febrile Diseases, Etc., by A. P. Wilson Philip, M. D.,"
pablished in Hartford, Connecticut, 1816.
Dr. Smith, in his note upon Epidemic Catarrh, says :
" In mj 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 judicious physician has observed that the spotted fever, is a particular form of catarrh.
In 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
adults 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 liiseases 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 mucous 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 Typhus, 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
chiM'acter, 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
us to believe (bat it depended on a peculiar morbid excitement of the capillary vessels in the
brain, which soon extended itself to this system of vessels throughout the body. The disease
attacks suddenly. The arteries of the neck and temples beat strongly, the head is hot while
the pnlse at the wrist is small, and the extremities cool. The functions of animal life are
soon impaired or lost.
" Several persons affected with this disease, who have recovered their health, have lost the
sense of hearing ; and others have been affected with blindness for several weeks. In one
case it affected the 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 Yale 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 hahit of the disease, called Spotted Fever, as
generally,
" The offspring of cold climates, and cold seasons of the year. With a few exceptions, it
has broken out in the coldest seasons, and spread most alarmingly at such times in the differ-
tnt places it has visited. The months of January and February have oftenest given rise to
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538 Relations of Cerebrospinal Meningitis to Climate.
it In point of seasonw hen it rages considerably ; it continues perhaps to the 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 afflicted t^
inhabitants of Vermont, the epidemic peripneumony of the autumn of 1812, and
winter of 1813, presented the general features of the disease, that had been in tb*
State for about two years, called Spotted Fever :
** The chief difference seemed to be, that now, the greatest force of local affection fell upon
the lungs. * *
*< The chief difference seems to consist in the locality of the principal affection. In the
disease of 1810, '11 and '12, it was in the bead ; in 1813, it was in the thorax. And these
circumstances go far in explaining the phenomena of the two diseases. Neither of ike
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 thonx,
some could be traced in the membranes of the head." Loc. Cit., pp. 69, 70, 283, 284.
Dt, Gtdlup also alludes to the fact, that the epidemic cause, affected both domeslk
and wild animals, and a large number of Foxes and Squirrels died suddenly.
Dr. E. Hale, in his history of the " Spotted Fever, which prevailed at <jaidiDer,
Maine, in the spring of 1814, in like manner, observed, that
t( The epidemic throughout its whole course, was remarkably affected by the state of the
weather, and especially by any sudden change in the temperature. * * A few days of
unusual col^j seemed to render all the existing cases more severe, and at the same time, pro«
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 the
ravages of 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 firrt
case in Gardiner, to which Dr. Hale was called, was on the 11th of February ; througli-
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 Gardiner, with the close of Mav. Many of the writers who have recorded
observations upon Cerebro-Spinal Meningitis, have failed to give careful records of ^
weather and accompanying diseases, but in addition to the strong and clear testimony jist
recorded, an immense mass of facts exist, to show that the disease generally, if not
invariably, appears during cold, changeable and wet weather in autumn, winter and spring
along with some pulmonary complaints. »
It appeared in the Confederate Army, at Bowling Green, during the winter of 1861,
1862 ; in the succeeding winter it attacked the troops of the army of Northern Yirgioia,
encamped upon the snow-clad hills around Fredericksburg, and about the same tone, it
appeared in the Department of South Carolina, Georgia, and Florida, on the Atla&tk
and Gulf Coasts, in the Army of the West at Grenada, Mississippi, and among^ the
negroes employed upon the fortifications, and also amongst the plantation hands, m
several adjoining counties; during the winter of 1863, 1864, it proved very htiH
amongst the blacks at Mobile, and finally, it appeared in various parts of the ConM-
erate States during the winter and spring of 1864-5. Some were disposed to coniiect
its appearance and spread, with the assembling of large armies, but its oocurrea«
^mongst the citisens, in remote and comparatively isolated villages and towns, and K^
appearance also in the sparsely settled districts, at the same period of the year, wooU
indicate that the disease was due to a general epidemic influence. The fact that Ae
number of cases was relatively greater amongst the troops and negroes in serrioe, tb
readily explained on the ground that these men were more exposed to cold and wet,aBd
at the same time subject^ to those depressing influences, as scant diet, fiidgue od
mental anxiety, which render the syst^n liable to the action of all epidemic inflnenoi.
The sick and mortuary reports of the Confederate Army, show that Pneumonia ari
Pleurisy and Catarrh, yrere fai* more prevalent apd serious in their effects amongst die
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Relations of Cerebrospinal Meningitis to Climate* 539
soldiers thaa amongst the citizens. And there is no doubt, but that the fever, which
appeared in, and spread fi'om 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 tme contagious petechial Typhus fever, and not the disease under consideration.
Cerebro-Spinal Meningitis accompanied with Malignant Pneumonia, prevailed in Ger-
many, in 1508 ; the epidemic of 1557, which prevailed in the environs of Poitiers, La
Rochelle, Angoul§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 fehriz nova, supposed by many to be
Cerebro-Spinal Meningitis, commenced in the month of February, 1685, after a severe
winter, and was at first considered by Sydenham to be the same as peripneumonia ; the
disease 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
porformed very hard service, always in the soow, and exposed day and night to great
fatigue ; 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 Pr. 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-
ruary, and as being intimately associated with an epidemic Catarrh or influenza. —
Transactions of the College of Physiciam of Philadelphia, 1862-1864, p. 79, SO.
Dr. Levick, on the 6th of April, 1864, presented a paper to the College of Physicians
t>f 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. G. Webber, in his Prize Essay on Cerebro-Spinal Meningitis, after recording
many facts from various authors illustrating the effects of the weather, and of low damp
situations upon the origin and spread of Cerebro-Spinal Meningitis arrives at the fol-
lowing general conclusions :
''The influeaces, tben, which have been recognized as causes of this disease are unasaal
fuigae, which seeraa to have a pecaliarlj powerful effect upon soldiers latelj enlisted ; all
'lebilitating influences ; over-crowding in badly ventilated apartments ; want of cleanliness ;
.•^liddea variations of temperature, especially when combined with damp and wet weather;
:i 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 which causes periodical diseases, and not a peculiar influence, tui generu upon
nbich this epidemic depends, there is no evidence of its existence.
Undoubtedly an epidemic condition of the atmosphere is the principal cause of this affec-
tion. The other causes do not all exist at the same time, and sometimes none of them can be
'liscovered ; 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
producing the disease, only in those most susceptible to its influence, or who have been most
exposed to the pre-disposing causes, and that cause has been called an epidemic condition of
the atmosphere, which will answer well enough until its true nature is discovered. Whatever
this influence 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 Meningitis, indicate the action of the agent producing the disease directly upon
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540 Irtfiammatory Nature of Cerebrospinal Meningitis shown by its Effects.
the oerebro-spinal nervous system, rather than upon the blood ; in 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 CONDITIONS OF MANY PATIENTS DURING CONVALESCENCE PROM CEREBRO-SPINAL
MENINGITIS INDICATE IN THE CLEAREST MANNER, THAT THE CBREBRO-5PIICAL
NERVOUS SYSTEM HAS BEEN INFLAMED, AND PARTS OP THE STRUCTCEB
PERMANENTLY ALTERED, RATHER THAN THAT THERE HAD BEEN NOTHING
MORE THAN THE ACTION OP A SPECIAL POISON UPON THE BLOOD.
An explanation of the almost universally fatal character of Cerebro-Spinal Meningitis,
as well as of the tedious nature of recoveries from the disease, may be found in tbe
physiological actions of the nervous structures involved, and in the nature and eflfoctB 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 celb
and commissures, it can readily be conceived, that the inflammation of the nutritiTe
membrane, and the coating of the most important and delicate organs confined in a
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-
gitis.
Even after the subsidence of all active inflammation in the meninges of the brain lod
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 eflusion, but also upon the character and rapidity of the 8ubs^
quent changes, 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. Gallup 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 los of
muscular and nervous power, pains in the head and various portions of the body and
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. Gallup, of
the " Sequelx of Spotted Fever,^^ in the sixth section of his work, will show that tbe
symptoms which he describes, were due to the lesions of the cerebro-spinal nerfois
system.
Dr. Gallup refers to an obstinate case of this kind, attended with piun in Uic ht$^
(hemicrania) and tetanus, which finally ended in a state of deafness and idiotism.
Dr. Gallup also recorded the important practical observation illustrating the inlsB*
matory nature of this disease, that:
*' Althongh there is a fi^reat degree of debility in the organs of locomotion, a small pabe,
and a deficient circulation in the extreme vessels, the subjects of this disease bear bleediaf.
puking, purging and moderate sweating to a great degree, without growing weaker or showifif
many signs of increased debility. Not only this, but it is a fact capable of demonstimtioa,
that where these remedies are freely used the patient grows stronger, as soon as the fatifve
and immediate depression is over, which is only a short time.
^*The circulation becomes more perfect, as is proved by the warmth in the hands, feet, kc
The pain is mitigated, and by perseverance in the use of these means health is gradoalty
restored."
Dr. Hale says, that during the whole course of the convalescence from Spotted Fevo'j
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Inflammatory Nature of Cerehro- Spinal Meningitis shown by its ^eets. 541
unUl the care was perfectly completed, most persons were subject to occasional attacks
of pain and numbness, either together or separate.
Many other observers have recorded cases of Cerebro-Spinal Meningitis, which ended
io paralysis, deafness and loss of vision ; thus, out of ninety-seven cases reported by
Dr. Githens, deafness existed during and after convalescence to a greater or less extent
in sixteen 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 extremities ; paralysis of the bladder ; paralysis
of one or both upper extremities ; dementia, insanity, blindness and deafness, to result
from Cerebro-Spinal Meningitis.
Such results cannot be referred to the action of a distinct febrile poison.
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CHAPTER IX.
HISTORICAL KOTBS ON THE TREATMENT OF CEREBRO-SPINAL MEKINQITI8. TABLB lUUDS-
TRATING THE NATURAL HISTORY AND DURATION OF CEREBRO-SPINAL MKNINQITI8. KATIO Of
MORTALITY. RELATIVE VALUE OF DIFFERENT REMEDIAL AGENTS. TESTIMONY OF TARIOOB
PHYSICIANS AS TO THE VALUE OF BLOOD-LETTING, MERCURY, BLISTERS, CABBOHATl OF
POTA88A, HOT BATH, OPIUM, QUININE, COLD APPLICATIONS TO HEAD AND SPIKE, AND OTRO
REMEDIES.
Whilst there exists no want of theories and pkns of treatment, and coafidenoe ia
special remedies, unfortunately the attempts which have been made to urge the dauns
of conflicting systems, have availed but little in the accurate determination of thoae
practical questioRS which involve the lives of a large portion of those afflicted with this
sudden and fatal form of disease.
It is customary to dignify with the title Extensive Experience, the use of one or
more remedies for a series of years amongst a number of patients, r^ardlesa of the
fact, whether these remedies were selected as the result of education, or of aocidentand
prejudice, or as the result of careful investigation and comparison of the relative effects
and value of different 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, intended to express the pathology of disease,
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 materia-medica ;
but a vast amount of error must necessarily follow from crude and hasty pathologiciJ
speculations.
In medical science, as well as in sciences of more exact observation, no other meUiod
except that of strict induction from well observed facts, will result in the establishment
of fixed and general principles, which will express with truth the operations of nature,
and enable man to guide and direct them in fixed modes for the accomplishment of
useful ends. Hypothetical discussions of the nature of disease, and of the actioii of
remedies, apart from established facts, are worse than useless — they are poativdy
injurious, in that they divert the mind from rigid experiment and from the carefol
observation of nature. In therapeutics, we need above all things, rigid observations on
the effects of the different agents, on the duration, progress, effects and termination of
particular diseases. In every inquiry in therapeutics, the physician should endeavor to
determine.
1st. The natural progress of the disease when no remedies have been used : what is
the natural history of the disease ; what are the tendencies of the disease — to recovery
or to death ? The relative mortality to the total number of cases, and to other diseases ;
when recovery takes place, what are the antecedents and the immediate causes ? The
effects of variations of climate, of previous habits, of diet, of age, as well as the extent
and severity of the inflammation or disease should be accurately noted ; also the effects
of various modes of diet and stimulation. The results of such investigations, will form
a standard, by which the value of different remedies may be <letermined. Every con-
scientious physician desires to dispense with all needless remedies: and if it were possi-
ble to treat certain diseases by aliment alone, with more success than with drags, it
would be the manifest duty of the medical attendant to conform the treatment to the
established course of nature.
2d. Whether the remedies used, diminish the rate of mortality in particular diseases,
and thus contribute to the safety of the patient.
3d. Whether the remedies abridge the course of the disease.
4th. Whether they lessen the sii^erings.
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Treatmeni of Cerebrospinal Meningiti$^
543
5di. Whether they leave any injarious results.
6th. The modes in which tne 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
favorite one, it will be possible in the course of time, to determine with an approach
to accuracy, the most efficacious remedies and modes of treatment.
In Cerebro-Spinal Meningitis we have to deal with a violent form of epidemic disease
appearing suddenly, and affecting immense districts of country, the natural progress of
which, especially in 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, less than one sixth
having died after that time. The following tables illustrating the duration of disease,
were drawn up by Dr. S. G. Webber, from the records of 164 cases published in various
Medical Journals :
TABLE I.
DUBATIOSr OF FATAL GASES.
DUVATIOV.
No. of
Cases.
Less than 1 day 9
1 day 6
2 days ! 18
3 days..
4 days..
5 days..
6 days...
7 days..
8 days»
10 days..
11 days..
14 days..
18 days..
20 days..
22 days..
24 days.
30 days.
34 days.
17
16
10
4
1
4
2
1
1
1
1
2
1
1
1
36 days | 1
56 weeks « I 1
Sereral days | 1
Not mentioned , 12
TABLE II.
DURATION OF BECOVERIES.
DlTRATiOX.
3 days
4 days
5 days
7 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 montbs
Not mentioned..
No. of
Cases.
TABLE III.
AGE AND POSITION.
1
2
2
3
1
1
3
1
1
1
3
2
1
2
1
1
1
1
1
1
1
1
2
1
2
2
1
13
: Military
1 year..
I J year..
2 years
3 years
4J years
5J years
6 years
7 years
8 years
9 years
10 years
11 years
12 years
14 years
15 years
I 16 years
17 years
I 18 years
i 19 years
20 years
: 21 years
I 22 years
, 23 years
' 25 years
I 26 years
I 27 years
' 28 years
29 years
30 years
31 years
32 years
34-40 ys
42 years
46 years
68 years
not staM
. T0UI..I 68
1
4
3
4
8
11
3
5
3
2
2
i
2
1
1
1
1
3
11
Clvi'n.
2
1
2
2
1
1
4
3
2
2
4
4
1
2
3
3
1
2
6
2
2
1
2
1
2
1
37
Total.
2
1
2
2
1
1
4
3
2
2
4
4
1
3
7
6
5
10
17
5
5
.3
a
2
2
• 1
2
1
3
2
1
5
1
3
1
48
96 164
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544 Treatment of Cerebro-Spinai Meningitis.
In regard to the period of recovery, it is not possible to give so precise bformfttioD
as in the case of death. It will be seen from the 2d table, that health maybe r^ained
at any period from the third to the tenth week.
Many of these cdses from which these tables were constructed, were not reported up
to the full restoration of health. Convalescence is usually slow and tedious, and as
soon as that was fairly established, the record ends. This may perhaps account for the
great difference in the length of the cases, some being recorded until health was entirelj
re^tablished, and others only until convalescence. Table 3d gives a comparative viev
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 were 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 lattev only 36 ; sex not mentiooed,
14 ; 67 cases, however, were soldiers and midshipmen in the academy at Newport ;
deducting these, we have only 47 males, and the disproportion 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, ?ii;
five years old and under, one ; between five and ten, tioo ; between ten and twenty.
eight; between twenty and thirty, ^Arcc ; between forty and %ftj^tux>; over fif^,
three. Of the whites, ten were males and twelve females.
The blacks were sixty-three, viz : Under five years, one ; between five and ten, ux ;
between ten and twenty, fifteen ; between twenty and thirty, tvoenty-four ; betweoi
thirty and forty, ten ; between forty and fifty, five ; over fifty, two. Of the bUcks,
thirty-six were males, and twenty-seven Jemales. In the cases observed by Dr. Ames,
the mortality was confined to the malignant forms, and was about sixty (60) per eeot.
In an epidemic observed by Lef6vre, ^ur-fifths died at the commeucement, and two-
thirds towards the end of the epidemic. Of 366 cases analyzed by Dr. S. B. Haot,
the deaths were 243, and the recoveries 123, making the per oentage of fatal cases TO
per cent.
.The following mortality table was drawn up by Dr. J. S. Jewell from the monograph
of Mr. Broussais :
Nancy 8 deaths in 28 cases = 1 in 3.W
Le Mans 3 >' " 9 " =lio3.00
Ancenis 4 '' " 12 ** =rliii3.00
Mont Brison 16 ** " 47 ** = 1 in 1.W
Caen... 4 ** " 10 " =1 in 1.25
Poitiers « ; 8 " *< 20 " =1 in J.M
Versailles Ill ** " 227 »* = I in 104
Mets 22 '* " 40 " = 1 in 1.81
Perpignan « 28 " " 50 " = 1 in 1.78
Strasbourg (Mil. Hosp.) « 108 " " 184 " = 1 in l.TO
Strasbourg (Inhabitants) 90 " " 160 " = 1 in l.«
Laval 44 '* " 69 »« = 1 in 1.5«
Colmar ^... 5 " "7 « = 1 in 1.40
Bayonne « 21 « " 28 " =1 in 1.33
Aigues Mort 120 " " 160 " = 1 in 1.33
Thus, in 1035 cases, 592 terminated fatally, or 1 in 1.76.
Out of a toUl of 249 cases analyzed by Dr. S. G. Webber, death occurred in 147,
and only 102 recovered. In the Sweedish epidemic, of 3051 persons attacked, 1387
died. Out of 161 cases treated in the Philadephia Bloekley Hospital, during Ae
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Treatment of Cerebrospinal Meningitis. 545
months of December, 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 ; in 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 5O0 cases, by Dr. J. Baxter Upham, 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 Still6, 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 far 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
natural history and patholdgical anatomy of the disease, should, in the first stages, bo
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.
JBlood' Letting, — As soon 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 blister applied over the region of the cerebellum, and back of the neck, and down the
entire length of the spine. Over the spine 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 Meningitis, or Cerebro-Spinal Memngitis, by Alfred Stills, M, D., etc. Phila,^
1867, p. 72.
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546 Treatment of Cerelro-^Spinal Meningitis.
bonate of Potassa has been dissolved, in the proportion of one drachm to the put of
tea.
Cold cloths, wet with ice water, or bladders filled with ice, should be applied to tlie
head.
When it is evident that the active iofiammatory symptoms have subsided, the mcHe
energetic measures should be abandoned, and the strength supported by nutritious diet
and stimulants judiciously employed. The contractions of the muscles of the neck and
back, and the spasms may be moderated, and sleep promoted, by such remedies as Cala-
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.
After the subsidence of the inflammatory symptoms, the convalescence will, in all cases
be more or less tedious, in which there has been an extensive effusion of fibrinous or
plastic lymph. During the transformation of portions of the deposit into fibrous tissue,
and the absorption of other portions, the strength must be supported, and the more
active depletory measures must be avoided altogether, or employed with caution, as they
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 pounds 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 d^ree of excitement snceeded,
blood-letting was practiced with good effect."
Dr. Joseph A. (xallup 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 paUic
The entire observations of this intelligent phvsioian " on the Treatment or Methodut
JHedendi of Spotted Fever y' are worthy of careful study, at the present time, when the
mass of the profession condemn blood-letting, without themselves having gi?en the
remedy a fair trial.
Some writers of considerable pretensions, who condemn bleeding in to/o, in Cerebro-
spinal Meningitis, do so entirely upon theoretical grounds, as by their own confession,
they have never used the remedy in a single case.
Aft^r illustrating his method of practice by cases. Dr. Gallup'*' proceeds thus to dis>
cuss the value of blood-letting :
<< It will not be maintained that blood-letting is always necessary or safe. It will only be
insisted on tliat it is often necessary and sometimes indispensable. * * Support and eqaal>
ize action when low, or depress and equalize action when bigh. Some cases I have met.
w})ere the most assiduous use has been made, from the beginning, of brandy, wine, essences
and essential oils, cayenne, camphor, ether, etc., internally, to support, and to equalize action
externally, warm bathing, blistering, frictions with red pepper and rum, moderate and lon^r
continued sweating, etc. By equalizing^ it may be understood to divert the morbid aclioa
from the internal parts and important organs oppressed and agitated with pressure of blcx»d
and membranous inflammation, to the surface and extremities of the body. If excitement it
kept up on the surface of the body, morbid action will spend itself partly there, and sare tbe
more noble internal parts from destruction. It is presumable that the pressure of the blood
and peculiar inflammation of the membranes of the brain, diminish the nervous energy, and
* Sk^Ul^fs of Epidemical Piseases, pp. 2^^^71.
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Treatment of Cerebrospinal Meningitis. 547
maj be a cause of weakening the heart, and the rest of the system. So, taking some blood
oftimes actually gives strength to the action of the heart and system generally.''
Dr. Gallup states, that in the 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. Gallup 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,
aod 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
stead, hot infusions of aromatic herbs, seeds and roots. With reference to Blisters, Dr.
Gallup says : ^^ blisterino; 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 surface ;
the absorption of a safe stimulus from the flies, is supposed useful, as also the mechanical
irritation upon the skin, helps to increase sensibility m lethargic cases.**
Dr. (jallup disapproves of the indiscriminate use of emetics, and directs that cathar-
tics be used cautiously, as soon as the circunistanoes of the case will admit, as the
evacuation they produce, and the translation of excitement from the head they effect,
is oflen 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 181 2,-' 14, in his "Medical Sketches of 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
i»anie causes, and was characterized by symptoms which in their sudden appearance, rapid
)>rogre8S, and fatal character, resembled those of the "Spotted fever,** which it had
succeeded.
The peri-pneumonia notha 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
of torpor, an oppressed respiration with pain in the side supervened ; the first stage of
coi]g3Stion and depression was followed by reaction, and in the stage of febrile excite*
ment, the heat of the body was never much above the standard of health. The pulse
during the cold stage was very small, and somewhat fuller than natural during the hot
sta^, 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,
after the first symptoms of indisposition supervened. Dr. Mann relates the case of a
holdier, 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, apparently in a state of suffocation. There were other
instances of death almost as sudden. Upon inquiry, the patients said that they did not
suffer irom 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. Post-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.
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548 Treatment of Cerebrospinal Meningitis.
The bronchisB 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 glutinoos,
extravasated fluid, which adhered with some force to its surface. Dr. Mann deBcribes
a remarkable, pale, pink colored suffusion 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, after having been exposed to cold. Thb appearance was
most conspicuous on persons having fair and light complexions. A cough superv^ed
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 iDStances, this epidemic made its assault upon the head, which bleed-
ing immediately relieyed ; upon inquiry I found there was here no complaint wbatever witbia
the chest. It was then prognosticated that in twenty-four hours, more or less, disease woald
exhibit itself on the lungs. This prediction was fulfilled in every instance when made. * *
In the campaign of 18J4, 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 derangemeat
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 hours, two of the number within six hours.
Dr. Mann has left most clear and decided testimony to the inflammatory nature of
the " Pneumonia Nbtha^ Pneumonia Typhoides, Malignant Pleurisy^ Bilious Pneumo-
wui," which he considered in all respects similar to the Peri-pneumania Nothon, des-
cribed by John Bell and other old writers ; and he has farther shown, that blood-letdng
was the most efficient and valuable remedy.
In his remarks upon the treatment of the disease, as it prevailed during the campaiga
of 1812, he says :
" Without the employment of the lancet, other auxiliary remedies proved ineffectual. The
bleediug 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 quantity.
The patient sometimes fainted with the loss of eight ounces of blood at the first, who tabae-
quently was bled sixteen ounces, without auy collapse of the vessels. A fortunate 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 in every form of these
pulmonic affections. Prior to these potent stimulants, emetics, cathartics and blisters 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, doubted the
propriety of bleeding. Their doubts were removed by the superior success which followed
the use of the lancet, 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 be consid-
ered typhus, when the patient is able to walk the room, and continue this exercise evea a
few minutes previous to death ? Is that disease typhus, which is relieved by bleeding? This
form of the disease, in some cases demanded as many ounces of blood in the course 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. Yet, in this disease, it was inexpedieit
to take more than two, four, six or eight ounces at once. The above quantities were takca
away every two, four 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 orfonrtfc
bleeding."
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Treatment of Cerebrospinal Meningitis, 549
Dr. Mann, in his account of the 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 congestive, as well as the
inflaunmatory 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 ^ssea^ 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 the 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 the hands of Dr. Ames, employed 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 pood 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.
Blister$ 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 Fotassa was employed by Dr. Ames, with apparent benefit, in several
eases, 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 fifteen 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 enei^tic 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.
Quinine was employed by Dr. Ames frequently in the grave variety, to which it
seemed most applicable, and sometimes with partial success. When the disease was
attended with a fever, which was regarded remittent, the meningitis appearing as if it
were engrafted 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 aa Appendix, by James Mann, A. A. S., Hospital Surgeon of the Army. 1816.
pp. ix, 16, 17, 34, 125, 127, 305-317.
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650 Treatment of Cerebrospinal Meningitis.
Cerebro-Spiaal MeniDgitis^ Dr. Ames could not recommend this remedy ; in saefa cues
its use, if not hazardous, never afforded much encouragement.
Dr. Ames used Emetics but little, but frequently employed Oatharties as adjonets,
and to effect particular indications, but he did not rely upon them as curatiTe reme-
dies. In two instances, a free catharsis, induced by drastic medicine, was evideatij
prejudicial.
Opium was not considered by Ames as a safe remedy in the inflammatory maligmit
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 imp
Jour., November, 1848, vol. v. No. iii, pp. 295-328 ; Am. Jour. Med. Sci., Apil,
1849, pp. 451-462.
Dr. Ames employed blood-letting much more freely than Dr. Gallup, and his soooes
was not so marked. By a careful comparison of the testimony of these two obserren,
it would appear that comparatively small bleedings, repeated at short intervals, if neees-
sary, are more beneficial than these large evacuations which may in the congestive cases,
depress the forces below the point of reaction.
Dr. Toudes, who advocated blood-letting, says, that to deny absolutely the atiHtj of
bleeding, would be to fall into an exaggeration as false, as the unlimited oonfidenee in
the employment of that remedy ; and notwithstanding the frequent inefficaey of bleed-
ings in the epidemic which he witnessed, he nevertheless concludes, that they raidered
more real service than other medicaments. In' the observation of this physidaii, tk
local abstraction of blood in the early stages of the disease, was in a number of etsee
attended with good results, and followed by the happiest cures.
Casimir Broussais, considered bleeding as the only means of treatment during tbe
early stages, likely to be attended with success ; and Professor Forget strongly fiTored
general and local depletion, considering the latter preferable ; Matlot, Basseron, Corbiiit
Maillot and many otner European physicians, have advocated and practiced free Ueeding
from the arm, and locally by leeches and cups.
Dr. Robert Bums, of Philadelphia, who employed both local and general blood-lettisf,
reports most favorable results, viz: nine recoveries out of 12 cases. The following is
his method of treatment.
*' Tbe treatment pursued was the early abstraction of blood generally or locally, accor^
to circumstances, to relieye tbe brain and spine. Stimulating frictions to the whole spiBtl
column and extremities. Warmth to the feet, with sinapisms to different parts, to cane
counter-irritation. Blisters sometimes, but seldom necessary stimulants. Dispboretict wben
feyerish. The liver and bowels steadily acted on by mercurial purgatives at night, and Csstor
Oil next morning, and as soon as tbe Tiolence of the symptoms abated, Quinia f)reely adBioii-
tered to the amount of eight or ten grains per day, for the first three or four dajs; tbii
however, to be varied according to circumstances. The nutriment, chiefly beef tea or esMscf.
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. E. Oreeie,
of Bellefonte, Pa., has illustrated the value of blood-letting in a successful case reported
in the Philadelphia Medical Reporter, May 7th, 1864, pp. 277, 278.
We will examine briefly, in the next place, the testimony of some of the priodpil
American authors, who have opposed blood-letting in Cerebro-Spinal Meningitis.
Dr. Hale considered the disease as a fever, adynamic in its character, ohanotertaed bj
great debility and prostration of strength :
" The strength was not only oppressed by the impulse of disease, but it was nfi^}
exhausted ; to adopt the comparison of Fordyce, the spring was not only overpowered, so ii
to prevent its action, but its elasticity speedily vanished under the weight which pressed ipo
it."
Acting on this hypothesis. Dr. Hale did not employ venesection in a single casa^ wff '
did he see any case in which it had been employed. He says :
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Treatment of Cerebrospinal Meningitis. 551
" I WM deterred from publishing it, bj the great tendency to debilitj which I witnessed in the
disease, as well as bj the reports which I hare heard of the disastrous effects, which were
said to haTe followed its use in other places/' And strangely enough, he adds : '* The fonnda-
Uon of these reports, or the accuracy with which they were related, it does not come within
mj plan to examine here."
Dr. Hale, thus 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 cases. 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
stimnlants, 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>220.
The epidemic treated by Dr. Hale, was comparatively mild, and we are unable to
determine with precision the ratio of mortality, but from the statement of the author
the results of his treatment were favorable, 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 an
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." — Essat/s on Fevert^ p.
119.
i According to Dr. Miner, ** Spotted Fever " has " its seat and throne in the brain,"
and belongs " nosologically to the passive phl^masiae ;" and ^' no foreign author,'* he
confidently believed bad " ever described this disease." The work of Dr. Miner is
abfldately 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
" authority " 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 treatmetit
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. Gerhard,* 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 ha)f a
century ago, viz : 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 blood-letting in any case^
Dr. Gerhard's plan of treatment was evidently founded upon his preconceived hypothesis
•Trang, Col ?hy8, PhiUd., 1864, pp, 48, 49,
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552 Treatment of Cerebro-Syindl Meningitis.
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 treal-
ment of the epidemic, he states, ^' that at least 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-lt^xing
exclusively upon hypothetical reasoning, and not upon actual experience with the relative
value of this remedy.
Dr. Wood divides the disease into two varieties, which he affirms are distinguishable
by the predominance respectively of the features which have, in different places, giveo
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 petechise, and in the other, of
the symptoms of inflammation of the investing membranes of the brain and spinal
marrow. He admits that the two varieties are separated by no precise line, as thej
run together by insensible shades ; but in their extremes they are strikingly different.
After careful examination of the entire article upon Petechial 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 truth,
be styled the expectant plan of treating Cerebro-Spinal Meningitis.
The experience of certain European physicians, with reference to the value of bluod-
lotting, is more decided, and apparently based upon more reliable data ; and it most be
confessed that the weight of this testimony is adverse to the indiscriminate employment
of this remedy. De Kenzi, Tourdes, Mottet, Lef6vre, Faure, Besseron, Corbin, MaiUol,
and Laveran, have recorded observations illustrating the uncertainty of this as well as
of all other remedies in the treatment of this disease. Dr. N. S. Davis, of Chicago,
claims to have had good succesSj in the epidemic which prevailed in Chicago, in 187-.
by the employment of Calabar Bean and Ergot. A teaspoonful of a mixture composed
of one and a half fluidounces of Tincture of Calabar Bean, and two and a half fluid-
ounces of the fluid Extract of Ei^ot, were given every two hours, by Professor Davis.
Cantharides^ in the hands of Professor Allen, of the Hush Medi^ Collie of Chi-
cago, is said to have yielded good results in the early stages, and in cases exhibiting
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 Hydrate have
found advocates.
Dr. Alfred Stilly, has well said, that the difficulties involved in the questions whi^
have hitherto been discussed, and which refer exclusively to the history, phenomena,
and nature of epidemic meningitis, are trifling in comparison with those that relate tu
the cure of the disease ; these are partly inherent in the general subject of thers^uties,
in which no problem whatever is susceptible of a categorical and permanent sulutioo ;
they depend still more upon the epidemic nature of the disease which gives a greu
diversity of type.
" These difficulties are further multiplied by occurring in a disease which stands alone is
all other respects ; whose causes, phenomena and lesions, in a word, whose laws are specific.
and whose varieties of type are as infinite as can be formed by the combination, in constaatlj
varying proportion, of a special disease of the blood deranging the molecular actions of tke
economy, nnd an inflammation of the Cerebro-Spinal Meninges, and even of the substance
itself ot the great nervous centres. These reasons are sufficient to account for the difergent,
and often opposite methods of treatment which have been adopted and recommended by phy-
sicians of equal sagacity, at different limes and places." — Epidemic Meningitis, etc., p. 134.
Dr. J. Baxter Upham, in bia recent paper on the late epidemic of Cerebro-Spinal
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Treatment of Cerebrospinal Meningitis. 553
Meniii<^iti8, read before the MiisHiichuscttij Medical Society, June 2d, 1874, ha« forcibly
illustrated the state of doubt, hesitation and absolute obscurity, which characterizes the
ti-ciitucnt of the present day.
Dr. Upham, however, notwithstanding the doubt and uncertainty, disclosed in the
replies to the Massachusetts Board of Health, from two hundred physicians, represent-
ini; seventy-seven towns and cities, and containing the data, more or less complete, of
upwards of five hundred cases of the disease, and giving a mortality of nearly onc-
lijilf of all the cases reported, concludes that " something can be accomplished in the
icity of treatment^ Thus he concludes his article with the following practical observa-
tions, the spirit of which is similar to that of the views of Drs. Wood and Gerhard :
**BcAriDj^ in roiiid the essential element of the disease, a morbid poison, acting i«rimarily
iiMon the vital fluid and affecting; secondarily and rapidly the meninges of the brain and spinal
cord, mort especially giving rise to symptoms and phenomena which simulate while they are
not identical with inflammatory action in these parts, and consequent exhaustion of the vital
liunrers and great perversion of the nerve force, as manifested in the irregular action of the
heart, the labored breathing, the restlessness and jactitation and extreme sensitiveness of the
:;iirf>ice ; remembering also the material lesions which are so generally revealed on poat-mortcni
in5pection, the indications for a rational treatment, should be these: —
"I. To husband the strength.
•'2. To combat the tendency to congestion of the brain and spiual cord.
'* 3. To mitigate the intense pain.
•' 4. To calm the nervous excitement
'' 5. To nourish and support the system till the exuded morbid products can be removed
iiy the kindly ofiBces of nature, and to minister, in the meanwhile, by all the ways at hand,
to the comfort and relief of the patient." — Boston Medical and Surgical Journal, September
:id, 1874, p. 228.
I have thus endeavored to present a general view of the various modes of treatment,
which have been proposed and practiced with the hope, that the record will prove of
[lennancnt value ; and that whilst serving to direct the attention of physicians to the diflfi-
tultics 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
investigation.
The therapeutics of Cerebro-Spinal Meningitis will be advanced in the future, by
.•<uch accurate investigations of the symptoms, (pulse, respiration, Temperature, nervous
and muscular phenomena, etc.,) Chemistry, (composition and changes at various stages
<»r the disease, of the Blood, Urine and various secretions and excretions). Pathology
and Therapeutics, in various countries and under various conditions of climate, soil and
tjccupation, as will permit of careful comparison and analysts.
TO
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CLINICAL OBSERVATK
ON
Mji\\ DlSEjlSES OF THE L
AND
CIRCULATORY SYSTI
AND OP THE
Liver and KID^
tLLURTBATINa THK
RELATIONS OF DROPSY TO YARIOVS Dli
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CLINICAL OBSERVATIONS ON CERTAIN DISEASES OF THE
LYMPHATHIC AND CIRCULATORY SYSTEMS, AND OF THE
LIVER AND KIDNEYS, ILLUSTRATING THE
RELATIONS OF DROPSY TO VARIOUS
DISEASES.
CHAPTER X.
ODSKRVATIONS ON OSMOSIS. PRELIMINARY REMARKS CONCERNING THE OBJECTS OP THE
INVESTIGATI<»N. PEKINITION OP THE TERM DROPSY. OSMOSIS, EN D08M081S, EX08M081S. IMBI-
BITION, CAPILLARY ATTRACTION, ABSORPTION, DIPFCSION. EXPERIMENTS ON LIVING ANtMALS,
ILLlhTRATING THE PHENOMENA OF OSMOSIS AND THE ABSORPTION ANI» ACTION OP SALINE
PfBGATlVES.
PRELIAIINARY REMARKS CONCERNING THE OBJECTS OF THE INVESTIGATION.
Useful results in clinical instruction, may sometimes be obtained, by grouping
together the more important facts relating to some grave and striking symptom, and
by investigating the relations of this symptom to a large number of diseases. No
symptom is more striking or more uniformly grave, than dropsy, and as the practitioner
Is oilen 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 its
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 facts and
commentaries will serve to illustrate many points in special diseases : and whilst we are
thus taught by experience, that oflimes no small difficulty is encountered, in determining
to which of its many sources, a particular symptom, common to many diseases, should
b€ 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 most distressing symptoms,
eousing, in some cases, extensive destruction of tissue, and in others, embarrassing by
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558 Osmosis, and the Absorption and Action of Purgatives.
its presBure, important fuactions, and even extinguishing life ; and finally becanse tiie
removal of the dropsy, even when the original cause remains, may restore the patient
to a state of comparative comfort and health.
We do not propose to enter into an exhaustive consideration of aQ the causes of
dropsy, but desire chiefly to examine the causes which have been illustrated by cases
actually observed and recorded in the practice of the author.
It may perhaps add something to the accuracy of the succeeding descriptions tod
discussions, to recall the attention to the definition of certain terms employed by wp-
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, arisiog
either from increased exhalation, or from diminished absorption, each of which ooodi*
tions depend upon antecedent states of di&ease. When limited to one part, the teno
oedema is employed, denoting swelling produced by the accumulation of serous fluid in
the intersti<^ of the areolar texture, which swelling is soft, yields under the finger,
preserves the impression for some time, and is pale and without pain. When tk
aropsy is extensive, the term anasarca is employed, and by some writers as synonvmoai
with general dropsy. When limited to the peritoneum, it is called abdominal arafiy,
or ascites. Specific names are also applied, as descriptive of the sack, tissue or oipa
involved ; as when it affects the pleura, hydrothorax, or dropsy of the chefit ; vbet the
pericardium, hydropericarditis^ or dropsy of the hearty when the arachnoid, hydff^
cephalusj or dropsy of the brain ; when the spine, hydrorachttis ; when tbe tesdde,
hydrocele ; when the uterus, hydrom^ra; dropsy dependent upon disease of the IiTer,
hydrops hepaticus; dropsy dependent upon disease of the kidney, hydrops renaUs,
During life, there is a continuous circulation of the fluids and el^aieats of nutrition,
not only by means of the heart and blood-vessels, but interstitiaUy by a slower prooes
of osmosis through the walls of the blood-vessels and absorbent, and through tlU iod}-
vidua! constituents, the cells and fibres of the various organs and tissues. Although
not so rapid nor so manifest to the senses as the greater cifeulation, 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 constantlj
re-absorbed into the circulation : when, therefore, the serous fluid accumulates in th«
(issues or cavities, without active inflammation, either the quantity of fluid secreted
has been abnormally increased, without a corresponding increase in the process of
absorption, or it may be with an actual diminution of absorption, — or else the secretiuo
has continued the same as in health, whilst the absorption has been diminished.
OSMOSIS, (END08M0SIS, EXOSMOSI8, IMBIBITION, CAPILLARY ATTRACTION, ABSORP-
TION, DIFFUSION).
It has been held by physiologists, that the lymphatic as well as the blood-veaae)
system, never terminate by independent extremities, but everywhere present a eoa-
tinuous network ; and the teachings of both anatomy and physiology, up to a eomptr-
atively recent period, appeared to establish the conclusion, that absorption is primarily
effected by the capillary attraction dependent upon porosity, which characterizes liviajs
as well as inanimate matter. If it be granted that the whole vascular system, with the
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 enter
the blood-vessel^, excepting in a state of solution, and that the process of veooo*
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 probable
that venous absorption is something more than mere filtration. The researdicsof
Strieker and others have shown that capillary vessels are composed of a delicate donble-
contoured, dull membrane, in which oval nuclei are imbedded, at tolerably regular inter-
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Osmosis, and the Absorption and Action of 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
(Siomata of Conheim). In order to understand the passage of the colorless corpuscles
through the vascular walls, in the process of inflammation y it is not necessary to admit
the existence of coarse spacies or openings (jtomata)^ provided the capillary walls be
regarded as composed of a soft material having the properties of protoplasm, and form-
ing an elastic and permeable membrane. If the openings in the capillary wall, were
really coarae, coloring particles of large size would pass through the vascular wall in
varions 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 them -
pelves 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
posseted by certain animals of a simple construction. The escape of the colorless
corpuscle in inflammation must not therefore be regarded as a simply passive process,
like the filtration of a colloid substance, to which it was likened in the first instance by
llering ; for this phenomenon can be influenced in the most various modes hj t^e 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 around 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 irom 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 origin 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 diflerence 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
tiystem 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 accessory closed system to, the blood vascular apparatus. It is no longer a
matter of doubt, that the capittary lymphatits are lined by a single layer of flattened
epithelium, and that they also possess a special membrane, though not completely
homogenous and structureless 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 stomata in the lymphatics, were first demonstrated by Professor F. V. Reckling-
hausen, 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
beautiful injection of the network of lymphatics of the central tendon of the diaphragm
may b^ obtained. It haa b^n shoii^n by various experiments, that the opemngsby
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560 Osmosis, and the Absorption and Action of Purgatives.
which solid matters gain entrance into the lymphatics are roundish, sometimes even
quite round, and represent, as is clearly shown by subsequent staining with Nitrate of
Silver, spaces between the epithelial cells.
They usually lead perpendicularly into the lymphatic vessels, over which they ait
immediately placed, but sometimes they are situated somewhat obliquely towards the
margin of the vessel, or they may even be as far distant as a semi-diameter of the ves-
sel, in which case there is an oblique canal leading to the latter. The openings (stotnata^
never exceed the size of an epithelial cell. From the experiments of Recklinghansco.
Schwigger-Seidel, Dogiel, and Dybskowsky, it is rendered probable, that analogous
formations, will be found in the pericardium and in the arachnoid membrane of tbc
brain, and all serous cavities possess a very intimate and direct connection with tbc
lymphatic system.
From such facts, the inference has been drawn, that whereas it is the function of the
blood-vessels to absorb substances which are soluble and diffusible, those which arc
incapable of diffusion are taken up by the lymphatics.
It is evident, also, that capillary action is not the sole cause of absorption in living
tissues ; it simply causes or permits the entrance of fluids through the interstices of the
tissues, and cannot produce motion beyond the limits of the solid body, with which it
is conne(ited, and the phenomenon of Osmosis, (Endosmosis, Exosmosb, Absorption ),
is dependent also upon certain conditions, as the physical and chemical rebtions of the
fluids to the interposed membrane, and to each other. This increased flow in o«c
direction or the other, is determined not alone by the differences of densities in tht
opposite fluids, but also by their chemical relations to the interposed membrane, and by
the relative diffusive powers of the salts which they respectively contain. Upon sotb
facts rest the power of the physiologist and physician, to increase or diminish Osmosis
in living tissues, by the employment of certain remedial agents.
The phenomenon of Osmosis, forms as it were, an essential and primary act or coth
dition of all vegetable and animal existence, for it is coeval with all vital manifestation*,
and endures throughout the existence and action of all the component parts of each
living structure, and is absolutely essential to the acts of nutrition, secretion and growth.
And it may be shown by actual experiment and calculation, that the circulation of the
fluids, through the various organs and tissues, by the comparatively slow procefls of
OsmosiSj is as essential to the manifestation of vital phenomena, as the more evident
and rapid circulation of the blood in the higher animals. The life of the more simple
H^imals, like that of the individual cells and morphological elements, composing dtc
higher animals, is maintained, and the distribution of the elements of structure, accom*
plihhed by the physical process of Osmosis.
It is not my purpose to enter into an elaborate consideration of this subject, nor to
dwell upon the valuable observations and experiments of the Abbe Nollet, who, in
1748, directed attention to the passage of various liquids through animal membranes.
of H. Dutrochet,^, Carlo Matteucci,^ Justus Liebig,* Julius Vogel,** Professor Thomas
Graham,^ and others : I desire simply to record the results 6f some experiments which
I devised and executed with the design of illustrating certain physiological and thera-
peutical principles.®
1 Dfr I'Gndosmose des Acides, Memoire la a rAcaderoie des Sciences le 19 Octobr«, 163J.
Kncyclopaedia of Anatomj and Physiology, by R. B. Todd, M. D., London, 1837.
* Lectures on the Physical Phenomena of Living Beings: Trans, under the Superintendence
of Jonathan Pareira, M. D. etc.
3 Researches on the Chemistry pf Food, and the motion of the Juices in the Animal Bodr.
♦ Chemical Reports and Memoirs of the Cavendish Society, London, 1848.
^ Phil. Trans., 1850-1861. Elements of Inorganic Chemistry.
** Abstract of Experiments on the Physical Influences exerted by Living Organic and Inor-
ganic Membranes, upon Chemical Substances in Solution passing through them by findoimoie*
by Joseph Jones, A. B., Student of Medicine in the University of Pennsylvania, n»i
before the Academy of Natural Sciences, Philadelphia, October, 1854. Am, Jour. Mci
Sciences, April, 1855. Experimental Investigation^, instituted wUh a ticw to ascertain iM
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Osmosis, and the Absorption and Action of Purgatives. 561
£xperiment$ on Living Animals, showing that their Membranes eocert a Physical JpJIu-
ence capable of changing the molecular arrangement q/ Chemical Substances in
soluHoHf passing through them bi/ Endosmosc.
!,':> p<n'tn(n(t 310-318: 1 iniDci^td ilic lilly fii:d Icwer exticiuitics of a large Fpring-ficg,
in a stroDg solution of the chloride of culiiLin, nr.d allowed it to remain for an hour; then
washing it carefully with water, inrocrscd hs lower extremities in a strong solution of tbe
oxalate of ammonia. It rtmained in this roluticn for one hour, when it was again carefully
washed and placed in the Eoluticn of the ehloride of ealciiim, where it remained for a similar
length of time. Finally it was removed fiem thiB, back to the solution of the oxalate of
ammonia.
Daring the course of the experiment, \ihich lasted four hours, the frog gradually became
\reaker and more inactive, and finally died in the solution of the oxalate of ammonia in which
it was last placed. The specific gravity of the solution of the oxalate of ammonia was much
less than that of the chloride of calcium, consequently the object in moving the frog from one
Bolution to another, was to obtain as large a deposit of the oxalate of lime within its blood-
reaselB and tissues as possible, by promoting the actions of imbibition, endosmose, and
ex osmose.
As a general rule, the rapidity of the action of cndosmose is proportional to the difference
of the densities of the exterior and interior fluids. The effects of this action, or rather of
the membranes, upon the chemical substances passing through, will be manifested by tbe
change of physical form exhibited by (he precipitate of the oxalate of lime.
Immediately after the frog had been removed from the solution of the oxalate of ammonia
an incision was made below and to the sides of its sternum, into the cavity of the thorax and
abdomen. Tbe heart was found still pulsating. The blood-vessels beneath tbe skin, upon the
surface of tbe stomach and intestines, in the muscular fold of the peritoneum, and between
the kidneys, appeared thoroughly injected with blood, as if the animal bad died of violent
inflammation of all these parts.
The blood from the heart and lungs was first examined under the microscope, in which,
with a magnifying power of 210 diameters, were seen innumerable minute cubical particles,
floating amongst the large elliptical blood corpuscles. In the fibrous tissue between the epi«
dermis and pectoralis major muscle, square plates, cubical crystals, and parallelograms were
seen, together with minute particles, the largest of which appeared to be cubes.
The mesenteric fold of the peritoneum contained tbe same equilateral, equiangular plates,
and cnbical crystals. In the fascia of the thigh, besides numbers of these, there appeared,
also, beautiful octohedral crystals of the oxalate of lime, similar ip all respects to those formed
when the intestines of a raccoon (Procyon loior) were filled with a solution of the chloride of
calcium, and immersed in a solution of the oxalate of ammonia.
When the eggs of the frog were mashed, and their contents spread out on a glass slide and
examined under the microscope, they contained multitudes of equiangular plates, and cubical
crystals of the oxalate of lime. It is probable that the exterior fluids passed through the
anus and cloaca into the oviducts and ovaries, and finally by endosmose into the eggs them-
selves.
In the fibrous tissue of the walls of the abdomen, in addition to the cubes and octohedra,
and equilateral plates, there appeared, also, delicately formed dumb-bell and ellipsoidal
crystals.
When the plantar fascia of tbe foot was cut through, from the incision flowed a fluid resem-
bling the liquor sanguinis mixed with a little blood, which, under a magnifying power of 210
diameters, contained beautiful octohedral and dumb-bell crystals of the oxalate of lime.
This experiment wag repeated, with slight variations as to the length of the time and the
density of the fluids, and in every instance, without any exception, the results were the same.
In one instance, the deposit formed within the blood and tissues of the frog assumed the
form of delicate dumb-bell and cruciform crystals of the oxalate of lime. In another experi-
ment the blood from the ventricle of the heart contained large and perfectly formed octohedra,
with a few dumb-bell crystals, while the various tissues and muscles contained chiefly
delicately formed dumb-bell crystals, and the aqueous humour of the eye contained octo-
hedral, and comparatively large acicular crystals.
We see, then, by these microscopical examinations, that the oxalate of lime has assumed
forms different in all respects from those of the precipitate thrown down, when solutions of
the chloride of calcium and oxalate of ammonia are brought into immediate contact. The
Action of Saline Solutions of different densities upon Living Animals, and also the Reciprocal
Action, through Dead Animal Membranes of Serum, Water and Saline Solutions, by Joseph
Jones, Student of Medicine, Univerpity of PennFvlvania. Am. Jour., Med, Sciences, Jan,
1856.
71
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562 Osmosis, and the Absorption and Action of Purgatives.
precipitate thus formed consists of minute irregular granules. What has changed the pbjsictl
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 on the Physical Influence exerted hy Mucous Membranes^ removed from all
vitality^ on chemical substances in solution passing through them.
Experiments 319-372 : I filled the intestine of a raccoon (Procyon loior) with a Bolation of the
chloride of calcium, whose specific gravity was 1031, and immersed in it a solution of the
oxalate of ammonia, having a specific gravity of 1007. In ihe 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 magnifyiog
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.
SpeciOc gravity of exterior fluid 1005.
The interior fluid was next examined, the intestine having 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 have taken place. The slight change in the exterior fluid, of 1007 to IOOj,
is readily explained, when we consider the fact, that the exterior measured 12, whilst tbe
interior was only 4 fluidounces.
Within the intestines but a small deposit had taken place, in comparison with that of the
exterior fluid. Under the microscope this presented a magnificent crystalline appearaocc,
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 octohedral and dumb-bell crystals, as the forms in which the oxalate of liiae
nlniost 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, oocornDf
in urine, may be the result of the physical action of the basement membrane of the tqbiji
uriniferi 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, trkile
in others there was a very abundant deposit.
In all places the mucous membrane appeared free from any deposit of the oxalate of lint^.
It was found diflScult, however, to decide this question by the microscope, on account of ihe
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 {Procyon 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 biniodide 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. Iq
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 beautiful,
stellate crystals.
When a sheep's bladder was filled with a solution of the oxalate of ammonia, and immeraed
in a solution of the Chloride .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 same
appearance. The fact that solutions of certain chemical substances will pass tbrongh a
membrane in one direction, |)ut 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 iti
natural color and appearance. The results were in all respects the same when the intestines
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 [Crotalus Aelamantent)^ y^ns ireAitd m a iiwiUi
way, only a small deposit occurred in the exterior fluid.
I filled the stomach of a t^qcoou, and a portion of the intestines of a large rattlesnake with
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Osmosis, and the Absorption and Action of Purgatives, 563
a tolation of the iodide of potassium, and immersed them In a solation oi the bichloride of
mercarj ; in both cases, a copious deposit occurred upoa 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 influence 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 upon their
physical constitution, allowing one fluid to pass through in one direction, but not another
fluid, holding a difl^erent 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 difl'erent sizes, also a few dumb-bell crystals.
In the exterior deposit the octohedra were about one hundred times more numeroas 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 orer a hun-
dred dumb-bell crystals to one octohedral crystal. Minute octohedra, and delicately formed
dumb-bells 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 difiisrent 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 exos-
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 sev-
eral different ways, and under different circumstances.; sometimes the density of the solutions
of the chloride of calcium and oxalate of ammonia were varied, 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 have been produced by the action of the membrane, and in every case the
precipitate of the oxalate of lime thrown down consisted of irregular granules 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
millions of irregular particles.
All our experiments thus far prove that dry membranes exert little or no physical influence
upon chemical substances in solution passing through them.
Our 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
solation 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.
la no instance did we obtain a regular crystalline deposit. So far, then, as our experi-
ments 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
molecules.
Experiment upon the Physical Influence exerted upon Chemical Substances in solution^ <u they pass
through the cell walls of vegetables.— ^l immersed the cut end of a stalk of Indian corn in a solution
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
similar 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 taken
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564 OsMosisj and the Absorption and Aetion of Purgatives^
place within tbb hexagoaal cells of the vegetable, differiDg widely from the deposit formed when
soluiions of the oxalate of ammonia and chloride of calcium are brought into immediate
contact. The precipitate thus formed consisted of irregular granules.
The crystals deposited within the cells of the corn, diflfered widely also from those formei
when the intestines of a raccoon or a sheep were filled with solutions of the oxalate of
ammonia, and immersed in solutions of the chloride of calcium.
I immersed sections of different lengths of the stem of a young and rerdaat bene plant, id
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, beautifal sqaare
and lozenge-shaped plates had crystallized in all the hexagonal cells.
When the broad thick leaf of an endogenous plant was placed alternately in solatioDS 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 ib
different chemical solutions, which, when mingled, produced a deposit of irregular grannies,
and in every instance a regularly crystalline deposit took place within their cells.
It is unnecessary to do more than recapitulate the following results :
1. Cell- walls, like animal membranes, exert a physical influence upon the chemical sob-
stances held in solution passing through them. This physical influence is capable of alteriig
the arrangement of the molecules of the precipitate formed within the cells, so thai tbe
precipitate which under ordinary circumstances consists of irregular grannies, 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
roann^ri the arrangement of the molecules of the same substance.
It may yet be demonstrated, by experiment, that cells in the same plant, baviog different
offices, elaborating different products, exert a different physical influence upon the same che-
mical substance. Or, in other words, the crystalline deposit of the same substance, will vtry
in physical properties with different cells.
Experiments determining the action of the Sulphate of Magnesia, in sohUwn, upw
Living Animals.
Experiments loiih a solution made of the strength of the ordinary purging dose, one ounce of the
salt to eight fluidounees of water. Experiment 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 »
ligature around the oesophagus, just above its junction with the stomach ; punctured the
duodenum; introduced the nozzle of a syringe, and threw into the stomach one flaidoonceof
the solution of the Sulphate of Magnesia. The duodenum was then tied between the inctnen
and the stomach, thus inclosing completely the saline solution. The stomach and intestines
were carefully returned, and the edges of the incision so closely sewed together that little or
no atmospheric air could enter. Previous to the experiment, the cat had been starred for
more than thirty hours ; the stomach and intestinal canal were therefore completely empty.
Specific gravity of saline solution, 1055. The next morning the cat appeared remarkably
strong. Upon pressing the abdomen, the bladder was felt, greatly distended with urine, 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 vert
voided.
Sept. 7. The cat appeared strong and active, and passed about one fluidounce of clew
yellow urine. It continued alive and strong, being able to walk about without any apparent
difficulty, until 1 o'clock p. m., of Sept. 8, when its throat was cut. The experiment lasted
sixty-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 examination. The
stomach contained one fluidounce and 2^ drachms, of a fluid almost transparent, haviof*
slightly turbid aspect. It was to a small degree ropy, from the admixture of mucas, the
presence of which was further determined by the detection, under the microscope, of nniae*
rous mucous corpuscles. Reaction decidedly acid, turning thick litmus blue promptly red.
Specific gravity, 1014. Compare this with the original specific gravity of the saline solutwi
1055, and we see at once that the greatest portion of the solution had been absorbed. The
contents of the stomach were next evaporated lo dryness, dissolved in water, filtered and
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 carbonate of
lead and all organic matter. It was next evaporated to complete dryness upon 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 solutioB, ip-
gr. 1055, was also treated with the acetate of lead until a precipitate of the sulphate of lesd
ceased to fall. This was dried and weighed in like manner. Knowing the amonnt of the
Sulphate of Magnesia contained in each fluidounce of the original solution, we are able, bf
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Osmosis, and the Absorption and Action of Purgatives. 665
the application of the rule of three, to ascertain the amount of the Sulphate of Mai^nesia
corresponding 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 ^ f Its corresponding weight of the
one fluidounce of original saline solution. / ' ( sulphate of magnesia.
{Weight of the precipitate of the sulphate of lead i 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, under 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-
cited that a purgative effect 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, raptdly, 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 of coins. 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 7.06. 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.
jStperiment 374. — 10 o'clock a. m., Sept. 4, 1855. Made 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 fluidounce 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 arouud the oesophagus where it joins the stomach. Specific gravity of saline solution
1055. 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 fluidounce 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 sulphate 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-
ounces of clear urine. At 9 o'clock p. u., 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 the 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
sulphate of magnesia. Although the dog vomited one-half fluidounce of mucus with the
solution^ 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 {Sciunu Carolinenm)^ cut into
small pieces. At 9 o'clock p. u., 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 substance 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
nourishment, 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-
ticles of meat undergoing partial fermentation after death. The blood-vessels upon its
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666 Osmosis, and the Absorption and Action of Purgatives.
exteriorKrere filled with blood. Its internal mucous coat was of a light purplish pink color.
The intestines were distended with gas, and contained a red, bloody viscid fluid, which, under
the microscope contained blood-corpuscles altered in shape, epithelial cells, mucous corpuscles,
large ellipsoidal cells containing granules, and irregular cells containing orange-yellow matter.
Crystals, resembling the prismatic crystals of triple phosphate which occur in urine, were aUo
present, in small numbers, in the contents of the intestines. The internal mucous coat wai
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 coa-
tained numerous minute worms, the larvae of larger ones, several inches in length, whidi
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 vm
liberally supplied with vegetable and animal food. And it is remarkable that the dociUty,
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 aad
blood-vessels.
Experimmi 375. — In an experiment upon the absorption of fatty matters, I operated upon a
remarkably large, powerful and intellectual pointer dog, which possessed the characterittict
of the preceding dog, a voracious appetite, without any lasting benefit resulting from Um
consumption of enormous quantities of animal and vegetable food. His heart contaioed
numerous worms, several inches'in length, and exactly resembling those of this dog, (Bx. 374.)
With reference to the action of the gastric juice upon meat, we are aware that it conflicti
with the theories of certain physiologists. We have, however, enjoyed many opportnnitief
of demoristrating the fact that meat is digested in the stomach, and not in the small intestines.
We have found in the stomach of an alligator, the bones and hair of an entire pig, withoota
particle of meat upon them. In the stomachs of others we have found fish, snakes, crabs,
&c., in different stages of digestion; some, like the meat in the dog's stomach, slightly 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 we
will therefore be unable to ascertain the exact amount of the medicine absorbed.
Bj comparing 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, they 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 constitaeots
of the urine.
Several other conclusions are ibrced upon our minds, but we will reser\'e their expres-
sion until after the completion of this series of experiments upon saline solations of
high specific gravities.
Experiment 37G; Ten minutes before 12 o'clock. May 25, 1865. — Opened the abdomiaal
cavity of a cat by an incision along the linea alba, passed a ligature around the cesophagus
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 magnesM
into the stomach. A ligature was then applied to the duodenum, between the puncture and
the stomach.
A ligature was next passed around the colon, just above its junction with the rectum ; tb«
nozzle of the syringe was introduced into the puncture in the duodenum, and one fluidonocc
of the saline solution thrown into the intestines. Lastly, a ligature was applied around tbe
intestine, a short distance below the incision, through which the solution of the sulphate of
magnesia was injected into the stomach and intestines. The saline solutions were thns sepa-
rately and completely inclosed in the stomach and intestines, without any possibility of their
passage upwards or downwards. The stomach and intestines were returned to their natural
positions in the abdominal cavity, and the incisiou 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 accurately
determined upon a delicate balance capable of indicating the weight of -n^ part of a grain.
The iengtii of the intestine inclosed between the two ligatures was three feet.
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Osmosis, and the Absprption and Action of Purgatives, 5j67
As nsaal, the cat, before the operation, was kept without food or drink for twentj-four
hours. During the operation, which occupied ten minutes, one of the small arteries which
supply the intrttines were cut, and speedily tied, with little loss of blood.
The bladder was completlj 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. ic., 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 Inrf^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 floatinpr about.
Under the microscope, with a magnifying power of 210 diameters, it contained mucous 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 flocculi, 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 ofmagnesia con-
tained in it, as ascertained 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
Huidddrnchro of the original solution held grains 6.94 of the sulphate ofmagnesia 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.
£xamination of the Intestines. — The blood-vessels on the exterior of the intestines were filled
with blood, and the whole surface was reddened. This was not the case with the surface and
blood-yessels of the adjoining intestine which was not filled with saline solution ; they pre-
sented a natural appearance. The internal mucus surface wns 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
surface 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.
Heat and nitric acid revealed the presence of albumen in minute quantity.
After standing for several hours, a light colored sediment settled at the bottom of the ves-
self which, under a magnifying power of 210 diameters, consisted of epithelial cells from the
mucous 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.
Amount of the sulphate of msgnesia which had passed out of the stomach, grains 14.27.
Each 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
amount of the saline solution was equal at the commencement and end of the experiment,
whilst the absorption had been twice as great in the intestines.
Experiment 377; Repetition of Erperiment 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 usual manner and secured with ligatures.
Specific gravity of saline solution 1055.
Operation performed at 12 oVIock at night. The cat appealed to Eufl'er considerably
during the operation, but as soon as the wound was sewed up, it gave no indications of paiii,
but eommenced, when stroked upon the head, a vigorous purring. The operation was col-
ducted without accident, and only a few drops of blood from the cutaneous veins and arteries
were lost.
Previous to the experiment, the cat was kept without food and drink for thirty-six hours,
the stomach and intestines, therefore, were completely empty when the fluids were introduced.
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568 Osmosis, and the Absorption and Action of Purgatives.
The cat w&s found dead at 9 o'clock a. m. next morning.
The blood-vessels 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. SeTeral
small spots were visible of a deep purine.
The stoinach contained one fluidounce, three'draclims, of a light pinkish colored floid cen-
taining much mucus. Specific gravity 1035.8. Heat and nitric acid produced only a slight
precipitate. Albumen was present in an amount just sufficient to manifest Itself in t feeble
manner, and was, no doubt derived from a drop or two of blood accidentally introduced dnncg
the experiment. Under the microscope, the fluid contained nucleated epithelial cells frcn
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 magDesia,
consequently one fluiddrachm and forty minims of the original solution, or three and a hilf
fluiddrachms of the fluid in its present state of dilution, passed out.
Examination of the Intestines. — The blood-vessels on the external surface of the intestinti
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. Wbei
this was gently scraped ofiT, the mucous coat was found congested with blood, being of a pir-
•plish-pink color, very deep in some parts, and in others lighter.
Amount of fluid in the intestines two fluidonnces, four drachms. The fluid was of a jellov*
ish red color, and contained a large amount of thick mucus, epithelial cells, also gramltr
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 the presence of albumen was promptly indicated.
It was present in considerable quantities. In addition to the cells above mentioned, the
microscope revealed the presence of innumerable crystals which pervaded the whole mm,
and were visible to the naked eye as minute silvery particles. In form, the majority of then
were prisms, exactly resembling the prismatic crystals of the triple phosphate of lime,
ammonia, and magnesia, found in the urine of man and all animals. They were insolable
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 in (orv
or numbers.
They were insoluble in aqua ammoniee and liquor potassse, and completely soluble in nitric,
hydrochloric, and acetic acids. These, and other chemical test6,prove these crystals to be
triple phosphate.
Amount of the sulphate of magnesia remaining in the fluid of the intestines, grains 25.48.
Amount of sulphate of magnesia which was absorbed, grains 30.04.
If the original solution was absorbed without dilution, more than four fluiddrachms pasted
out of the intestines ; if, however, it was not absorbed until its present state of dilution, 30.04
grains of the sulphate of magnesia would have required an amount of fluid g^reater than tkit
existing in the intestine. By comparing the effects produced by saline purgatives on the
stomach and intestines, wc see that, in equal lengths of time, the intestines absorb much more
rapidly than the stomach.
In the stomach, 11.31, grains whilst in the intestines, in the same length of time, 30.04 grain
of the sulphate of magnesia were absorbed.
The increment of the fluid in Ihe stcmaeh was three fluiddraclms, whilst that of the istrF-
tine was twelve fluiddrachms. The effort to relieve the blood-vessels of their congestion, to
dilute the saline fluid, und icr.der its properties less irritating by the admixture of mnoif,
was four times greater in tie intestines than in the stomach.
By carefully ccnsidering crd ccropaiiug these experimentp, we arrive at the followng
conclosioDS :
1 . The primary action of a solution of the sulphate of magnesia, of high spec^
gravity, is that of an irritant. The impression is transmitted to the nerves. Throoj^
their influence, blood is determined to the stomach and intestines. The blood-vo
are congested, absorption is consequently almost entirely arrested. The mncous
brane is excited to increased and rapid secretion of a watery macous fluid. The objects
of this secretion are to unload the blood-vessels and dilute the internal saline sohitioB,
and thus mitigate its irritant properties.
The saline solution is not immediately absorbed ; it must be first prepared, and fcr
' this, time 5s required. This first stage of the action of a saline purgative is analogc^ffi
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Osmosis, and the Absorption and Action of Purgatives* 569
to that of a blister, with this difference, that mucus and excrementitious matters, instead
of serum, arc poured out.
2. Absorption of the saline solution, in an appreciable degree, does not take place
until the blood-yessels are partially relieved, and the fluid sufficiently 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 dbtended 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 deflnite materials.
The active agents in this process are the living cells, which exert a controlling
influence 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 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, watory, 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 solution 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 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 those
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 flnal 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, 13 much more rapid in the ^tqiaaqh^ whilst
11
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572 Osmosis, and the Absorption and Action of Purgatives.
Uoperiment 382. — The same length of sheep's colon, and a saline solatioa of the same
strength were used, as in the preoedisg experiment ; the relatire position of fluidSi however,
was reversed, the saline solution being in contact with the internal mucous coat. Amoant 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 fluiddrachms, having lost
two fluiddrachms. The action of nitric acid and heat showed the presence of albumen. Tbe
exterior serous fluid gave indications, with the appropriate chemical tests, of the presence of
the sulphate of magnesia.
Experiment 383. — Repetition of experiment 381, using the same length of intestine and the
same relative position of the fluids ; speciflc gravity of the saline solution, 1053. Specific
gravity of serum, 1020. Examined after 17 hours. The interior serum measured seven floid-
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.
Experiment 384. — Secured in 3(i 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 solatioa of
the sulphate of magnesia. Speciflc gravity, 1053. Examined 17 hours afterwards. Amoaotof
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 endosmose and eioi-
mose bad been equal.
Experiment 385 : The same length of intestine, and the same fluids were used, bat their
relative positions were reversed ; the solution of the sulphate of magnesia, instead of tbe
serum, being inclosed in the intestine. This then may be called tbe reverse of the last experi-
ment (384). Examined 17 hours afterwards. Amount of interior saline solution, seven flaid-
drachms. The greatest flow was from the saline solution to the serum, one fluiddmchm of the
interior having passed out.
By carefully comparing these experiments, we see that in four out of six, the grettat
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 experiments, the
cndosmotic 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 stated
by numerous observers, that the flow is always from the less dense to the denser Uqnid.
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 exerts a controlling influence upon the p«»-
aage through of fluids. This fact has been almost entirely overlooked by observers.
In experiments 380, 381, 383 and 384, the serum was placed in contact with the intonal
mucous membrane, whilst the saline solution was in contact with the exterior serous
eoat 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 int^raal
mucous membrane, and the serum in contact with the external serous eoat of the
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 sola-
tion towards the serum was retarded, and that of the serum increased.
When the mucous coat was in contact with the saline solution, its passage throii^
the membrane was greatly accelerated, whilst that of the serum was diminished.
The fact that solutions pass much more readily out of dead animal membranes, fioa
the interior to the exterior, might be illustrated by numerous examples. The resuH of
these experiments demonstrated conclusively that the laws regulating the action of saline
purgatives upon living animals, cannot bq determined by experiments performed with
dead animal membranes. In living animals their primary impression is always attended
with a rapid flow from the blood to the saline solution, whilst the reverse takes p^oeia
dead animal membranes. \
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Osmosis, and the Absorption and Action of Purgatives. 573
Experiments on the reaprocal Action of Serum and weak Saline Solutions through Dead
Animal Membranes,
Experiment 386 : Introduced one and a half flaidounces of t];ie serous fluid from the hydrocele
of the tunica vaginalis testis, into 9 inches of pig's intestines and immersed it in a solution of
the sulphate of magnesia, having a specific gravity of lOlO. Amount of saline solution, four
flnidoances. Specific gravity of serous fluid, 1021.
Examined three hours afterwards :
Specific gravity of exterior saline solution 1010.
Specific gravity of interior serous fluid, 1019.
Amount of interior serous fluid, one and a half fluidounces and forty minims.
The serous fluid had 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 magnesfa. 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.
Amount of interior saline solution, one fluidounce, and three fluiddrachmg. It had lost
one flniddrachm.
The appropriate chemical tests showed that there had been an interchange of the fluids.
Experiment 388 : Introduced one fluidounce of serum of pig's blood, into the intestine of
this 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
salphate of magnesia in the serum.
By comparing these last experiments, the facts are demonstrated that the greatest
flow wa^ from the saline solution to the serum.
The rapidity 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.
When, 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 internal
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
in 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 different 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 serum 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,
regardless 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 used, 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, oH the other hand, a weak saline solution is used in
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674 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 RECIPIO9CAL ACTION THROUGH DEAD ANIMAL MEMBRANES,
OF WATER AND SALINE SOLUTIONS OP DIFFERENT DENSITIES.
Experiments on the reciprocal action through dead Animal MemhraneSy of Wattr and
dense Saline Solutions,
Experiment 389 : Introduced into eighteen inches of pig's intestine, baTing the pftritoneimi
on, two and a half fluidounces of a solution of the sulphate of magnesia, and immersed it io
pure water.
Strength of saline solution one fluidonnce of salt to eight fluidounces of water, specific
gravity, 1056.
Four hours afterwards the amount of the saline solution was found, by measarement, to be
three fluidounces and forty-eight minims. It had gained four fluiddrachms and tortj-eight
minims, specific gravity, 1040.
Specific gravity of the exterior fluid, which was originally pure water, 1009.
The presence of the sulphate of magnesia was also indicated by all the appropriate cbemictl
tests.
Experiment 390 : The same length of intestine, the same strength and relative position of the
fluids were used in this as in the last experiment. The only difference was that the peritoneun
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. Specifc
gravity of the exterior fluid, I014.
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, introdaced
six fluidounces of pure water, and immersed it in a solution of the sulphate of magnesia.
Specific gravity, 1056. Four hours afterwards the interior solution measured five fluidounces
and fifty-three minims, having lost seven fluiddrachms and seven minims. Specific graviif,
1016. The appropriate tests showed the presence of the sulphate of magnesia. Specilc
gravity of exterior saline solution, 1045.
Experiment 392 : Similar in all respects to the preceding experiment, except that the intei-
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, inttoduced
one fluidounce of a solution of the sulphate of magnesia, having the usual 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 was
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 gravity,
1056. 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. Specific
gravity, 1033. Specific gravity of exterior solution. 1030.
Experiment 396 : Repetition of last experiment without the peritoneal coat, — After the same length
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 thaw
above, and supported the following conclusions :
A mutual interchange of the fluids always took place, and the greatest flow was from
the water to the saline solution. The rapidity of the flow depended upon the posittoa
of the membrane. The flow was greatest from the internal mucous coat to the exterior
The presence or absence of the peritoneal coat also modified the rapidity of the flow.
The endosmotic and exosmotic actions were most vigorous when the peritoneal coat was
absent. The rapidity of the interchange of the fluids varied with the employment of
the intestines of different animals. As a general rule, it was more rapid in the intes-
tines of the pig than in those of the sheep or cow.
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Ainoant of flaid
Length of intestine.
Time.
intniduccd.
3} flnidouDces.
18 inches.
4 hours.
1 "
8 »*
7 "
* Osmosis, and the Absorption and Action of Purgatives, 575
The following tables will illustrate these points :
Saline solution inclosed ia intestines having the peritoneal coat on.
Amount of fluid Length of intestine. Time. •Amount gained. Sp. gr. of
introduced. exterior fluid.
3 fluidounces. Sheep's 36 inches. SJ hours. 2 fluiddrachms.
4 " Cow's 12 »' 4 " 2 **
2J " Pig's 18 " 4 '' 4 " and 48 minims. 1009
1 " Pig's 8 " 7 " IJ " 1008
Water inclosed in the intestine having the peritoneum on.
Amount of fluid Length of intestine. Time. Amount lost. 8p. gr. of
Introduced. interior fluid .
2 fluidounces Sheep's 24 inches. 3^ hours. 3 fluiddrachms and 12 minims. 1010
2 »* Pig's 8 " 7 " 2 '* 12 " 1033
G " Pig's 18 " 4 «t 7 » 7 " lOlG
Saline substances inclosed in intestines deprived of the peritoneum.
A mount gained. 8p. Gr . of
cjitvrior fluid.
1 fluidounce. 1014
1 fluiddrachm. 1033
Water introduced into intestines deprived of peritoneal coat.
Amount of fluid Length of intestine. Time. Amount lost. Sp. gr. of
introduced. interior fluid.
6 fluidounces. Pig's 18 inches. 4 hours. 1} fluidounces. 1019
2 •» Pig's 8 '• 7 " 4 ♦* 1033
iJxperiments on the reciprocal Action through Dead Animal Membranes, of Water and
weak Saline Solutions.
Expcrimenl 397 : Into eight inches of pig's intestine, having the peritoneum on, introduced
one fluidounce of common salt (chloride of sodium, made in the strength of one fluiddrachm
of salt, to four fluidounces of water, and immersed it in pure water. Examined 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
exosmose 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
exterior 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-
irards. Specific gravity, of interior fluid 1007. Specific gravity of exteriof^ fluid, 1001. .5.
Amount of internal fluid one fluidounce, seven fluiddrachms. It had gained three fluiddrachms.
Experiment 400 : The same length of intestine and strength of saline solution were used,
but the relative position of the fluids was reversed, the water being inclosed iu 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
1003. The internal water had gained five fluiddrachms.
Experiment 401 ; Introduced into twelve inches of pig's intestine, three fluidounces of a
solution of the acetate of lead, and immersed it in pure water. The intestine was deprived
of its 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 fluiddrachms, twelve minims. It had diminished
fortj-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,) was attended with a distinct orange yellow precipitate of the iodide of lead, indicating
the presence of the acctc^te of lead^
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576 Osmosis, and the Absorption and Action of Purgatives.
By oomparing these experiments, the fact is confirmed that in every 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 sdations
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 bj
the same fixed laws as the interchange of water and dense saline solutions.
When compared with the experiments upon living animals, the fact is conclusivdj
demonstrated that the laws which regulate the action of saline solutions upon living
animals, cannot be demonstrated or illustrated by experiments performed with dead
animal membranes.
The truth of this proposition is still farther 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 Lehmann, as
one-tenth part of the weight of the body. The latter ratio would give 14 fte. in a
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 gas-
tric fistula, in a woman, the estimated daily quantity was 30i fts. av.; the wei^t 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 lbs. According to EoUiker, H. Miiller,
and other physiologists, the quantity of bile secreted daily in dogs with artificial biliaiy
fistulas, is about i oz. to every pound weight of the animal, or ^ part of its weight
This estimate if applied to a man weighing 140 lbs. would give 70 ozs. or 4 flbs. 6 oi.
avoirdupois in a day, of which about Xth, or nearly 3 oz. would be solid matter. This
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 33i ozs.; whilst others
again have estimated it at only from 17 to 24 ozs. The quantity of pancreatic jmoe
secreted daily in animals, varies according to different observers, firom 15 to 35 giaiat
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. toll oz. per hour. The Pancreatic Secretion, as
well as the Gastric Secretion is probably not continuous, but related to the prooe® of
digestion. From these fluctuations, it is impossible to estimate correctly the quantity
formed daily ; which has been differently estimated at from 7 ozs. to 16i lbs.
Whilst, therefore, discrepancies exist in the statements of different physiologists ooih
ccrning the actual amounts of gastric juice, bile and pancreatic juice secreted during
specific periods ; and whilst the collection of these fluids by the aid of artificial fistn-
lae in animals, is open to the objection, that the conditions, especially of the n«ves
which govern the quantity of the secretion are not healthy ; and whilst objections may
be raised against those estimates based upon calculations of the probable quantity, by
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 intennittency
of the secretions ; at the same time it is evident that the total quantity of the digeadfe
fluids poured into the alimentary canal after taking food, is much greater than wa«
formerly supposed, and in comparison with the blood circulating in the body m veiy
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 absolnteiy
impossible to fulfill the conditions perfoimcd by the constantly moving currents cf
blood, and by the nervous and muscular forces, and by the development, nutriticm aid
constant metamorphoses of the individual morphological elements. The importaat
phenomenon, first fully illustrated by Graham, under the term diafysiSj vii : that
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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 language 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.*
* U is well known that in the living animal, there is a preponderance of the so-called
mdosmotic current, whilst there is little or no transudation, or ezosmotit of albumen, the chief
nutritive constituent of the blood, except into the lymphatic system, which, as we have 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. Albuminose on the other hand, is constantly absorbed in the ali-
mentary canal, and transformed into the albumen of the blood. Mialhe has giveu an expla-
nation of this remarkable phenomenon, by establishing the different endosmotic properties of
albamen and albuminose. 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 exosmotic current :
hot 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 bodies based entirely upon their osmotic properties, as slight physical and chemical
changes may render the colloid as readily osmotic and diffusable as the crystalloid.
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 in 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/ully explained by physical experiments, although much light has been undoubtedly
thrown upon such phenomena, by the investigations of Nollet, Lebktichner, Magendie,
Dutrochet, Parrot, Porrett, Fischer, Liebig, Mialhe, Graham, and others. Some of the
modifications which absorption undergoes in the living economy, evidently, can only be
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 —
1st. 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 obstruction
and congestion, increased serous effusion from the distended blood-vessels, and dimi-
nished absorption.
4th. Derangement of the functions of those oi*gans, 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 ezcrementitious materisds.
It is important that the student should bear in mind the distinction between transu-
dattom and exudations :
Transudations are not, properly, liquor sanguinis, although derived from 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-
nlable 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 walW of tliQ blood-vessels \
73
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578 Osmosis, and the Absorption and Action of Purgatives.
and transudatioQ is usually the result either of a diminution of the albuminoid elemeotg
and salts of the serum of blood, or of undue hydraulic pressure, or of both causes
combined. Effusions, or exudations, devoid of fibrin and cytoblasts, and incapable of
organization, when retained, are characteristic of dropsy. Occurring upon mneoos
surfaces which communicate with the exterior, they constitute Jluxes,
Exudations contain, on the other hand, fibrin and cytoblasts or germ cells, and are
capable of coagulation and organization. Exudations are the result of inflamaiatioo,
whilst in true dropsy this morbid process is wanting.
Inflammation of serous membranes may be attended with more or less effusioD, bat
the liquid is turbid from the admixture of coagulable lymph, and in this respect differs
from the clear serous liquid of true dropsy.
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CHAPTER XI.
DROPSY ARISING FROM DERANGEMENTS IN THE NUTRITION OF THE TISSUES, LEADING EITHER
TO AN INCREASE OF SFXJRETION, OR DIMINUTION OF ABSORPTION.
SUDDEN ACCUMULATION OF FLUID IN THE PERITONEUM. RESEARCHES OF ANDRAL, BECQUERBL
AND RODIER, ON THE CAUSES OF ACUTE DROPSY. CONSTITUTION OF THE BLOOD IN ACUTE
DRi>PSY. TREATMENT OF ACUTE DROPSY.
This division is placed first, not only because it should include the most simple and
uncomplicated cases of dropsy, but also because the progress of pathol — '"^^ — * — "
and chemistry during the past thirty years, has greatly modified the
entertained respecting dropsy, and the class of dropsies long regarded i
essential, has become so restricted, as almost to have disappeared JProm n(
fications. Some pathologists have so far restricted the causes, as to >
species of dropsy, viz : the so-called mechanical dropsies, the result of i
sen ted to the flow of blood, whether in the central organ of the circ
vascnlar trunk of a certain size ; and dropsies symptomatic of a special '
the blood, consisting exclusively in a decrease in the proportion of the albumen to the
serum.
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 privat« practice,
which are for the most part acute, and in which no trace of albumen is found in the
urine, 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 ca »,
where fluid is rapidly thrown out into the peritoneum and cellular tissue i-
ties, after exposure to cold and wet, without fever, or any sign of ii d
independent of any disease of the heart, liver or kidneys ; and where, a 3,
the fluid is again absorbed. And he gives the following as a typical ca8< i-
ena of active dropsy ; a laborer is engaged in some employment. It
requires considerable bodily exertion, and causes copious perepirai y
ex{K)se8 him also to the influence of external cold and moisture *, he 1 g
(perhaps) in a wet ditch, in winter time, and he pauses to take his 8
been unloading his wagon, and rides home, some miles, in a heavj s
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 d^ree, is very apt to rise. The aqueous liquid thus detained in the
blood-vessels, seeks, and at length finds some unnatund and inward vent, and is poured
forth into the areolar tissue, or into the cavities bounded by the serous membranes.
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580 Dropsy arising from Derangements of Nutrition and Absorption.
Dr. Charles Murchison, in his Clinical Lectures on Diseases of the Liver, Janndice
and Abdominal Dropsy, has recorded the following interesting case of what might be
termed acute dropsy.
Case 634 : Symptoms of Colic, followed by signs of Fluid in the Peritoneum. — Edward, J.,
aged twenty-one, who bad formerly been a printer, but had been working for six weeki
at a carver 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 constant 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 boveU
had acted on the 8th and 10th, after castor oil and laudanum. Shortly before his attack, the
patient had been suffering from gonorrhoea, and stated that some years before he bad a simiUr,
though much less severe attack of abdominal pain.
On admission, the patient complained of constant pain in the abdomen, with frequent acaie
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 and
tympanitic, and the breathing was entirely thoracic. There was frequent retching of scanty,
bijions matter. There was a dark red (not blue) line along the margin of the gnms. The
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 the
tongue 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 assafoetida, and a grain of opinm crerj
four hours.
The enema brought away two copious motions, but with no relief to the pain. On April
13th, a third of a grain of extract of belladonna was ordered every three hours, but next dtr
the pain, tenderness and tension of the abdomen had increased, although the pulse was obIt
72, and the temperature 97°. He was again ordered a grain of opium every four hoars^* .
draught of castor oil and laudanum, and frequent enemata. He also continued taking sii
grains of opium a day, until April 17tb, and then three grains until April 23d. Under this
treatment the bowels were freely moved, and the paroxysms of pain became less severe; bat
«tili he had occasional vomiting, the abdomen grew larger and more tense, and on April Idth.
there was unmistakeable evidence of fluid in the peritoneum. A thrill could be propagated
from one side to the other, on tapping, and where the patient was supine, there was dullness
on either fl^nk, which varied with his position. He still had occasional paroxysms of pais,
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 slight
paroxysms of pain continued until May 4th. After this, the abdomen gradually hecane
smaller, and on May 18th, it had regained its nor;nal size, and presented no sign of fluid, and
the patient left the hospital free from pain.
The researches of Andral, Becquerel and Rodier, render it probable that in these
cases of acute dropsy, there is oftimes, if not always, in the early stages, a oongestiooof
the kidneys, with the appearance of albumen in the urine.
Andral, after noticing the fact that sometimes individuals, who, after exposure to
some sudden cause of cold, arc attacked a few hours after with anasarca, states tint
after accounting for the dropsy, by supposing that the sudden suppression of the cnt»-
neous function of transpiration rapidly produced a superabundant exhalation of serua
into the areola of the cellular tissue and the serous cavities, he was led to conclude tint
this kind of dropsy was dependent upon derangement of the kidneys.
A young man, previously in good health, and strongly constituted, entered the hos-
pital of La Charit^, with considerable anasarca and commencing ascites. He related to
Andral, that a few days before, being abed and asleep, some of his comrades poured
upon him a pot of cold urine, while he was in a state of perspiration. He got «p
naked in order to pursue them, and was very much chilled ; he remained, said he, as though
frozen. From the day following this occurrence, he began to perceive a slight d^re«
of swelling, which rapidly augmented. The urine of* this patient was examined, vad
found to be albuminous. Andral concluded from this, that the blood had been depn^e'l
by the kidneys of a certain amount of it^ albumen, and in this way accounted for the
formation of the dropsy. It is then upon the iddnei/a that the action of the cold had
/alien. This dropsy was not, moreover, of long duration ; at the end of a fortnight^ the
cure was complete^
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Dropsy arising from Derangements of Nutrition and Absorption. 581
Beoquerel and Rodier, in their pathological chemigtry, have given the results of the
analjsb of the blood in eleven cases of aciUe dropsi/.
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 month 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-
ore 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 suffering 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
aaiount of fever, with vomiting and diarrhoea ; 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 diff'use puffiness 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 affiected 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 as regards quantity and chemical composition. In two cases, however, the following
phenomena were observed : In one man, who was admitted on the fourth day of the disease,
a considerable amount of albumen was found in the urine on that and the succeeding day ;
OQ the sixth and seventh day it bad 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 nntil 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.
" An analysis of the blood was made in each of these cases, and the mean results thus
obtained, will be found in the subjoined table :
Analysis of 1000 Grammes of Blood,
Mean. Maxim'a. Minlm^a.
Specific gravity 1045.84 1053.20 1037.55
Water 830.78
Globules 104.58 134.88 70.10
Solid matters of the serum 61.87 65.62 57.24
Fibrin 2.C7 4.10 1.25
Analysis of 1000 Grammes of Serum.
Mean. Maxim^a. MinimV
Specific gravity 1022.61 1024.28 1020.05
Water 928.47
Albumen 58.52 63.18 61.12
Extractive matters and salts 13.01 17.14 7.74
•* The globules 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.
« The albumen of the serum was always diminished, and in some instances this diminution was
considerable ; it ranged from 60 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 is almost needless to add that the specific gravity of both the blood and serum was
always found to have fallen below the standard of health.
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582 Dropsy arising from Derangements of Nutrition and Absorption.
" Snch, then, is the history of acute dropsj. We have now to interpret and explaio its
attendant phenomena.
'* At first, two prominent facts present themselves to our notice ; the one being the dropij,
and the other a modification of the blood, consisting in a decrease of the albamen, and of the
specific gravity of the circulating fluid itseU.
'' What is, then, the correlation of these two facts ? Upon which of the two does the other
depend, or are they independent of each other? To answer such questions, is somewhat more
difficult than might be a priori imagined. If, in fact, we admit that the alteration of the
blood precedes the dropsy, how are we to explain the decrease of the albamen in those caies
where there has not existed (as in cachetic dropsy) any material appreciable cause, toaccoait
for the impoverishment of the vital fluid ? This difficulty, however, is not insurmountable,
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 found is
the urine, its decrease is watched, and about the eighth day it is found to disappear entirelj.
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-
uals, whether under the influence of cold, or some other cause, were attacked with a certiia
amount of congestion of the kidney. This congestion was manifested by the escape of albu-
men along with the urine, which lusted as loug as the congestion itself, viz : seven or eigbt
days, and then ceased. Under the influence of this escape of the albumen, the proportion
of that element naturally existing in the blood became diminished, the density of the senia
fell, and dropsy was produced. But the change in the composition of the blood, when odcc
eflected, lasts for some time after the disappearance of the albumen from the urine, aad as
long as this change exists, so long will the dropsy likewise exist. Had these two patieotf
not been seen until the eighth day of the disease, no albumen would have been fonnd in the
urine *, the diminished amount of that constituent existing iu the blood, together with tb«
dropsy, could alone have been discovered, and their correlation would have been lost.
" In these two oases 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 aiae
cases? We think it will ; and we admit the same, by induction it is true, but yet upon cer-
tain plausible reasons, which are the following :
1. As these nine cases were not admitted into the hospital until after the seventh dij of
the disease, we may readily conceive the albumen to have disappeared from the urine pre-
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
ucute congestion of the kidney (active hyperaemia).
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 raiioaal
and satisfactory, it is still but a theory :
" Under the influence of some cause or other, congestion of the kidney is produced. The
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 the
albumen of the blood, and the latter condition in its turn gives rise to a greater or les§
degree of dropsy. We may here observe that, when this decrease of the albamen takes
place rapidly, dropsy is produced with greater facility and with less diminution on the part
of this constituent of the blood, than when it occurs in a chronic form. But the coogestioB
of the kidney is generally of much shorter duration than the modification of the blood aad
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 alooe
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 seem advisable to
designate the disease -in question, as congestion or active hyperaemia of the kidney, rather
than as acute dropsy from decrease of the albumen of the blood. We do not, however, deen
ourselves authorized to make such a change, being unable, as yet, to elevate our hypothesU
to the rank of a positive fact, at least in the majority of cases."
These investigations of Becquerel and Rodier, conducted in the spirit of Philosophw*
inquiry, are of great value, in establishing the connection of acute dropsy with conges-
tion of the kidneys. It would be more reasonable to suppose that the accompanjing
dropsical effusion was as much the result of the non-elimination of the elements of tka
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Dropsy arising from Derangements of Nutrition and Absorption. 583
urine, and the retention of the watery element, as the mere loss of albumen. I have
witnessed the supervention of acute dropsy in patients who were exposed to cold,
during convalescence from chicken pox, measles and scarlatina, within two days after
the cause which produced congestion of the kidney, with almost complete cessation of
its action. In such cases, the two or three ounces of urine excreted during the twenty-
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 urine, as the
result of exposure to cold during convalescence from variola ; and uremic convulsions
of the most violent character supervened.
The retention of the urea, and water normally excreted by the kidneys, appears to
be connected with the dropsical effusion, even more intimately than the loss of a small
amount of albumen.
The treatment of acute dropsy should be based upon an accurate knowledge of
the previous 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 suffers with fever, general uneasiness and gastric derangement, 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 congestion. After the albumen has disappeared from the urine, and in those cases
in which its presence has been never detected, blood-letting is not indicated.
The diet should be light but nutritious, and composed largely of vegetable and farina-
ceous artides.
Various measures may betnstituted to procure the removal of the effused fluid ; as
purgatives, hot air baths, diuretics and stimulating frictions.
When the kidneys are congested, stimulating diuretics should be avoided, and the
saline diuretics should be employed. The bitatrate of potassa ( cream of tartar ),
employed in the proportion of one ounce dissolved, or rather suspended in one pint of the
infusion of juniper berries ( juniperi fructus ), may be administered during the twenty-
four hours. If the gentle stimulant 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 glassful of this mixture may be taken every two or three hours. After the
relief of the kidneys, and the establbhment of the excretion of the urea in its normal
amount, good diet, together with tonics, especially cinchona and the v^etable bitters,
may be employed to restore the blood to the normal standard.
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CHAPTER XII.
DROPSY ARISING FROM DERANGEMENTS OR ALTERATIONS OF THE BLOOD, LKADIXG Tl>
DERANGEMENT OF THE NUTRITION OF THE TISSUES, WITH AN INCREASE OF SKCRETIOX (»« A
DIMINUTION OF ABSORPTION. EFFECTS OF THE PROLONGED ACTION OF THE MALARIAL POIflUS
IN DERANGING THE CONSTITUTION ;0F THE BLOOD, AND IN INDUCING DROPSY. CONSTITVTIOX
OF THE BLOOD IN MALARIAL FEVER. CONSTITUTION OF THE BLOOD IN MARSH CACHEXU.
TREATMENT OF DROPSY ARISING FROM THE ACTION OF THE MALARIAL P0I80N.
The prolonged action of the malarial poison , not unfrequently induces such changes
in the composition of the blood and such derangements of the liver and spleen, as to
lead to the effusion of serous fluid into the areolar tissue and peritoneum. The changes
of the blood induced by Malarial Fever, appear to be the chief cause of the diopsMil
effusions, although in some cases this symptom may be attributed to the meduiiiicd
obstacle, offered by the enlarged spleen and liver. Several well marked cases of dropsy
resulting from the prolonged action of the malarial poison have been firom time to time
presented to the Medical Class of the University of Louisiana, in whidi no albomeB
could be detected in the urine, nor any diminution of this tecretion, nor any werj great
enlargement of the liver and spleen. Such cases were uniformly characteriied byi
sallow, anaemic complexion, and watery blood, poor in solid constituents. The eSetto
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 eon-
parison with the following typical formula of the constitution of the blood.
Physiological limits of the variations of the constituents of the blood as establidied
by the researches of MM. Becquerel and Rodier :
IN 1000 PARTS OP BLOOD
The water, may varj...... ..„from 760.00 to 800.00.
The specific gravity may vary " 1055.00 to 1063.00.
The globules may rary " 120.00 to 150.00.
The fibrin may vary.... " 2.00 to 3.50.
The solid matters of seram may vary <' 90.00 to 105.00.
The saline constituents may vary ^^ 4.00 to 10.00.
I.X 1000 PARTS OF SERUM.
The specific gravity of serum may vary from 1027.00 to 1032.00-
The water of serum may vary " 880.00 to 900.00.
The solid matters may vary " 100.00 to 120.00.
The albumen may vary » " 70.00 to 90.00-
The following is the typical formula of the constitution of the Blood in health,
adopted by MM. Becquerel and Rodier.
ANALYSIS OF 1000 PARTS OP BLOOD
Specific gravity of blood, , .......1060.0$
Water , 781.»
Globules , 135.00
Albumen 70.00
Fibrin « 150
Fatty Matters, Extractive Matters and free Salts 10.00
Phosphates , 0.50
^ron ,,...M.M.M.... 0.35
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Dropsy arising from Alterations of the Blood.
585
74
.5^
>
*5J
CongcBtivo Fevor.
Male.
Congofltive Fever.
3Iale.
Remittent Fever of
2 weeks* duration.
Male.
00 GO >* »0 "-J <o f-^ t-. -^ij
cooorj»o<Oi#'*»Or4
^ lO 00 lO t«- *•
CO C^ CD 40
r*-oo«ocoe^e^coc<io
i-H CO t* 00 o *^
CO C^ C© CO
• C>1 >-«
Cicicocoot-coroc^
O CO t- d <0 t^
CO C^ CO CD
Csj ^ CO ^ W C? '
M CO r-J "^ C^ C^ I
o t-^ ci c> t«^ d
O CO »-« CO 00 00
• N •-<
I
Remittent and Ty-
phoid Fever of U
days* duration at
timeof apalyris. M.
Remittent Fever of
10 days* duration
at time of analysis.
Male.
Remittent Fever of
16 days* duration
at time of analysis.
Male.
Intermittent Fev*r
of 6 weeks* dura-
tion. Male.
d oi d C6 CO ^
»0 CO i-i fo *- t-
»0 CO
»^C0t-O00"t0&C0i-'
CO CM O CO o »o
^ CO »-« lO »o
O O '^ Oi CO 00
O *• ^ O CD 1-^
d 00 •-* c<i ^ M
lO -^ t«- t«- CO
i'COOi-lC'liOr-lC'ICM
O O O O C^ CO
-I* CO •-' »0 lO
Od 00 00 •
t-^io.-Ioc*i^»ocOf-i
o lO in o 03 CO
Intermittent Fev'r
of 2 weeks* dura-
tional time of aaa-
lysis. Male.
Intermittent Fever
of 12 days' duration
at time of analysis.
Blalo.
COOOCilCOOOD'^CM
OS C<l 1— O CO CO
« CM t- CO
COOOCOCOOOOtI*.-'
^ ^ O 00 c4 »o
■^ CO •-• UO O
cj esi t- Ci o "^
^ •««• CO r- CO
09 09
hi hi
o o
S o o
3.2 .2
0 00 o .2 "
SSoSS
a 0
hobo
e 6
OS «
(3 O o
2^^
2tS5 &2§- !«•§
o
o
§
o
2 S 5*
o © o.
CQCQo
^5 o o
4.* ^ U«
O O 9
O O fc;
<=>«)«
rl r-i GO
:3 09 fl fl a
—J 1^ ..•«—< —
OB ti hi hi fci
o « V
g J5 JS
OS eS OS
'o'o'o
^s 5ss
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586 Dropsy arising from Alterations of the Blood.
ANALYSIS OP 1000 PARTS OP SERUM.
Specific gravity of serum 1028.00
Wftter - %8.00
Albumen 80.00
Extractive Matters and free Salts 12.00
The following results are established by this comparison :
1. Tn Malarial Fever the specific gravity of the blood and serum is diminbhed.
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 moiat
blood-corpuscles from 207.92 to 323.63.
The careful comparisop of these analyses of malarial blood with each other, reveils
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 dimion-
tion of the colored blood-corpuscles, as a long attack of intermittent fever, or the
prolongejl action of the malarial poison.
3. In Malarial Fever the relation between the colored corpuscles and liquor sanguinis
is deranged.
I^hus in healthy blood the relative proportions of moist blood-corpusdes in the 1000
parts and liquor sanguinis, may vary from 480.00 to 600.00 of the former, and &oa
520.Q0 to 400.00 of the latter ; whilst in Malarial Fever, the globules vary from 207.92
to 323.63, and the liquor sanguinis from 792.08 to 676.37.
4. The Fibrin of the Blood is diminished to a marked extent, in some cases of Malarial
Fever, and is altered in its properties and in its relations to the other elements of the
blood, and to the blood-vessels.
5. The Organic matters of the Liquor Sanguinis, and especially the Albumen, k
diminished in MaUirial Fever.
Thus the solid matters of the serum may vary in health, from 90.00 to 105.00;
whilst in Malarial Fever, they vary from 62.78 to 80.22 parts, m the 1000 parts rf
blood.
It is chiefly to this latter change, viz : the diminution of the albumen of the bk)od
in Malarial Fever, that the dropsical effusions are to be traced. The other changes d
the blood, without doubt, lead to congestions of the liver and spleen, and to dei^ge^
ments of the capillary circulation and nutrition of the organs and tissues, but a carefol
examination of those diseases as anaemia, chorea and pyaemia, in which the oobnd
l)lood-corpuscles are greatly diminished, will show that this cause alone will not induce
dropsy. In the watery state of the blood induced by the action of the paludal poisom
comparativdy slight obstruction^ of the circulation in the spleen and liver might lead to
dropsical effusion,
It would appear ^go, that from the djgrs^ngement of nutrition caused by the a<^on of
the malarial poison upon the blood and nervous system, that certain effete products ait
not sufficiently and properly eliminated, and then as in the case of urea, may be acdre
in the production of dropsy.
MM. Becquerel and Rodier have demonstrated that in that peculiar condition of the
system (mllea marsh cachexia, accompanied by a remarkable decloration of the dda,
and not unfrequently by (J^^psy, and produced by the long influence of malaria, there
is the greatest decrease o^ both the albumen and tlie globiJes ; as is well shown by thft
fbUowing analysis of Hlprsh cachexia.
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Dropsy arising from Alterations of the Blood.
687
Analytis of 1000 parU of Blood in Jtfarsh Cachexia.
A man, aged
50. suffering ftom
Marsh Cachexia
and Oen'l Dropsy.
A man. aged A man, aged
48, suffering froml«. suffering from
Marsh Cachexia Marsh OaohexU
and Oen'l Dropsy, and Oen'l Drotisy.
1040.00 1034.06
853.75 869.71
407.48 269.12
101.87 67.28
305.61 201.84
41.84 59.88
2.54 3.13
A man. aged
». suffering fIrom
Marsh Cachexia
and Oen'l Dropsy.
1033.85
875.67
224.88
56.22
168.66
63.83
4.27
A man, aged
18. suffering ftam
Marsh Cachexia
and Oen'l Dropsy.
Specific Gravity
1035.40
869.34
268.40
67.10
201.30
61.10
2.36
1040.57
Water
846.31
Moist Globules
378.88
Solid Matters of Moist Globules
Water of Moist Globules
Solid Matters of Serum
Fibrin
87.22
251.66
62.32
4.15
Analym of 1000 ParU of Serum in Marsh Cachexia.
The mean composition of the blood in marsh cachexia may be represen
Analysis of 1000 parts of blood (mean composition of in five cases of Marsh C
Specific gravity
Water
Moist globules
Dried residue of globules
Water of globules ....,
Solid matters of serum
Fibrin
Mean composition of 1000 parts serum.
Specific gravity » ,
Water
Albumen
Extractive matters and salts i
The following interesting remarks with reference to the cause of the dro
by MM. Becc[uerel and Rodier :
"The dropsy has been attributed to the mechanical obstacle afforded by the
dition of the spleen, so common in these cases. We do not deny the possibi
sequence ; but it is certain that in many instances, we fail to discover such
splenic enlargement, as would suffice to explain the occurrence of an increasir
anasarca. In only one of the preceding analysis of the blood, in marsh cacl
notice a marked degree of splenic enlargement ; it was, however, insufficient
the serous infiltration. « « «
" It is in this disease, therefore, that we meet with the greatest decrease of I
men and globules. It may be taken as the type of cachectic dropsy.
"How now, are we to account for so great a change in the composition of th
are driven to admit a poisoned condition of this fluid, produced either by t
of the marsh miasm, or by repeated attacks of the peculiar fevers to which thii
rise ? "
The indications in the treatment of dropsy arising from the action of
poison, are:
1 st The removal of the cause, giving rise to the phenomena of malai
causing a simultaneous decrease of the globules and albumen, with cong
liver and spleen. The patient must be removed from the influence ol
poison. In many cases, even afler the removal of the patients to elevated,
miasmatic regions, the attacks of ague wiil recur again and again with obs
Specific Gravity
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
t nn*% K n
Water
Albumen
Extractive Matters and Salts...
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688 Dropsy arising from Alterations of the Blood.
2d. • The prevention of the recurrence of the malarial paroxysms, and the removi^
neutralization or elimination of the cause. Thb indication may be fulfilled by the per-
sistent use of cinchona, in various forms, and especially sulphate of quinia. To prevent
the recurrence of the paroxysm, quinine should be given in doses varying from five to
ten grains every two or three hours, until from twenty to thirty grains have been taken
before the time of the expected paroxysm. In the intermission, and in fact througli-
out the continuance of the dropsy, the patient should be kept gently under the influ-
ence of quinine, from two to four grains being administered three times a day. T!tf
iodide of quinia (from one to three grains dissolved in a wineglass of water,) bas proved
highly beneficial m my hands in such cases. As the blood is impoverished, good results
are obtained by giving iron in combination with the sulphate of quinia.
3d. The removal of the dropsical effusion. This will best be accomplbhed by the
judicious use of purgatives, diuretics, the hot air bath, and stimulant frictions of every
kind, as dry friction, and aromatic, alcoholic and ammoniacal frictions.
Purgatives judiciously used not only cause absorption of the serous effusion, but they
also diminish the congestion of the liver and spleen. The blue pill (pilulse hydrargyii)
in doses of from five to ten grains, occasionally may be administered with marked
benefit The cream of tartar and juniper berry infusion is one of the best diuretics in
such cases.
In the employment of purgatives and diuretics, great care should be exercised not to
exhaust the patient, nor to weaken and derange the digestive function.
If possible, we should avoid impoverishing the blood further by the n^ of these
remedies.
In many cases, the free perspiration induced by the hot air bath will prove of essen-
tial benefit.
4th. The improvement of the blood. Nitrogenized food, especially good beefsteak,
if the digestive powers are sufficiently strong, fresh milk, and soft boiled ^gs, with a
moderate quantity of generous wine, will tend, not only to improve the digestire
powers, but also to fumbh the materials for healthy, rich blood.
The digestive powers and the nervous system may, in like manner, be iDvigorated.
by the use of the vegetable bitters, and especially of gentian, and strychnine. It i»
best to administer the strychnine in doses of one twentieth of a grain dissolved in
water acidulated with citric acid. In many cases it is found, that the dropsical effuaoo
diminishes just as the blood recovers its normal composition.
Iron is almost universally indicated, by the marked decrease of the blood globules,
and on account of its valuable effects in restoring the digestive function. One of tiie
best combinations in such cases, is a pill composed of three grains of precipitated Ira.
(iron by hydrogen,) two grains of sulphate of quinia, and one grain of the extract ni
rhubarb. The extract of rhubarb is used in proportions just sufficient to overcome tiw
astringent effects of the iron. This pill may be taken three times a day and perseverel
in for weeks and months. In this combination, we likewise obtain the prophylaetic
action of quinia.
The cure of this form of dropsy is tedious and prolonged in most cases, and iiie iron
and bitter tonics should be used with perseverance.
5. Hygienic Measures. A healthy, well ventilated residence in an elevated noa*
malarious rc^on, gentle but regular exercise in the open air, and the wearing of wins
clothing, as flannel next to the skin, are valuable adjuvants to treatment
Dropsy may also arise from the changes of the blood, induced by insufficient and salt
food (as in scurvy,) by repeated haemorrhages (as the haemorrhoidal flux ;) by chroak
diarrhoea, and by the effects of the absorption of cancerous matter.
In the great Valley of the Mississippi, a large proportion of the cases of dnqisy
which occur, both in Hospital and Private Practice, are directly traceable to Uie pro-
longed action of Malaria, which induces profound alterations in the blood, destroyiBS
the colored corpuscles and fibrin, thus deranging the normal relations between the sohds
and fluids ; ana at the same time producing important and serious lesions of the lirer
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Dropsy arising from Alterations of the Blood. 589
and spleen, attended with obstructions in the portal, splenic and intestinal circulation.
The extent to which malaria prevails in the Mississippi Valley, is clearly shown by
the mortuary statistics of New Orleans, and by the annual reports of the Charity Hos-
pital, which receives vast numbers of patients from all the States tributary to the Mis-
siasippi River, and to New Orleans fu^ a great commercial centre, and shipping port.
The relation of paroxysmal, paludal malarious disease, to the other forms of disease,
is well shown by the following statistics :
During a period of 45 months active service in the Charity Hospital, of New Orleans,
(distributed as follows: January 1st, 1869, to April 1st, 1870; October 1st, 1870, to
April Ist, 1871 ; October 1st, 1871, to April 1st, 1872 ; October 1st, 1872, to April
1st, 1873; October 1st, 1873, to April 1st, 1874; October 1st, 1874 to April Ist,
1875,) I treated two thousand three hundred and eighty^ (2,380) cases of various
diseases, with a total mortality of 235 deaths from all causes.
During the period specified, the mortality in the cases of various diseases treated by
me in the wards of the Charity Hospital amounted to 9.83 per cent, or in the ratio of
one death in 10.12 cases.
Of the total number of cases treated. Intermittent Fever numbered 725 cases, all of
which were relieved and discharged without a single death ; Paroxysmal Fever of long
standing, in which such profound lesions had been produced in the blood, liver and
spleen, as to induce ascites and anasarca numbered 54 cases, with 6 deaths ; Pernicious
or Congestive Malarial Fever, numbered 31 cases, with 17 deaths ; (the fatal cases
without an exception, having entered the hospital insensible and comatose, and often in
articulo mortis, the character of the disease being verified in such cases by post-mortem
examinations;) Remittent Faver 82 cases, with 1 death ; Malarial Hsematuria, 4 cases,
with 2 deaths. Total cases of undoubted paroxysmal malarious paludal diseases directly
traceable to malaria, 896 : total deaths, 26.
Per cent of deaths in cases of malarious diseases, 2.9.
Ratio of deaths to cases of malarious disease, one death in 34.46 cases.
A large number of the remaining diseases, 1484, were more or less under the influ-
ence of malaria, and were to a greater or less extent complicated by it. This was
especially true of such diseases as Pneumonia, Pleuritis, Rheumatism and Organic
Diseases of the circulatory apparatus, of the digestive apparatus, and of the liver, spleen
and kidneys.
Whilst therefore the mortality attributable to the direct action of the malarial poison
was comparatively slight, owing most probably to the efficient and persistent use of
Quinine, Bark, Iron and Bitter Tonics, combined with supporting treatment and nutri-
tious diet, it appears that the progress of other diseases was influenced by the pre-
existing and accompanying action of malaria.
During the fall of 1870-71, I treated in my wards in the Charity Hospital, a larger
namber of dropsical cases than usual ; a considerable proportion of the patients who
entered with the various forms of malarial fever, and more especially with obstinate
Intermittents, and with chronic malarial poisoning, were suffering with more or less
anasarca and oedema. When there was no serious or malignant disease of the liver, kid-
neys or heart, these cases of dropsy recovered under the use of Quinine, Iron, Arsenic,
Cream of Tartar, and Blue Mass. Great benefit was derived in some of these cases,
afler the bowels had been properly regulated, by a combination of Quinine, Tincture
Sesqui-Chloride of Iron, and Chlorate of Potassa: thus, R. Sulphate of Quinia, two
drachms ; Chlorate of Potassa, three drachms ; Tincture of Sesqui-Chloride of Iron,
one fluidounce ; Hydrochloric Acid, one fluiddrachm ; Distilled water, six fluidounces ;
mingle the Hydrochloric Acid and water, and dissolve the Quinine in this acid solution,
and add the Tincture Muriate of Iron, and Chlorate of Potassa ; dose teaspoonful, (60
drops,) in wine glassfull of water, sucked through a quill, one hour before each meal.
The following cases will illustrate the general characters and progress of the anasarca
which complicated these cases of malarial disease.
Cask 035. — Anasarca following protracted IntermUlent fever ; relieved by the use of Iron, Quinine ^
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590 Dropsy arising from Alterations of the Blood.
and diuretics. Gustavo Brok, native of FinlaDd, age 57 ; sea-fariDg man, has always eojojtd
good health up to the time of his residence in Louisiana, six months ago. Commenced work on
the Railroad at Bloomficld, in a sickly malarious locality, and was seized with chills in the Utter
part of July, 1870; and suflfered with a paroxysm (cbill and fever) every other day, until he
entered the Charity Hospital, (ward 25, bed 368,) November 24th, 1870. Swelling commeneed in
lower limbs a short time before entering the Hospital, and increased rapidly until the abdonen
became distended with fluid, and the features of the face were bloated. The complexion wu
sallow and jaundiced. It was observed that the swelling was always greatest ia the right lef.
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 Potasst,
and Iron, and the mixture of Quinine, Chlorate of Potassa, Hydrochloric Acid and Tincture
Muriate of Iron, this case progressed slowly but favorably; and on the 23d of Febmary,
1871, every vestige of the ascites, anasarca and oedema had disappeared, and the complexion
had assumed a clear and healthy appearance. Throughout the attack the urine was fi^fron
albumen, although at times, and especially during the paroxysms of the chill and fever, wbiek
recurred several times, containing biliary matters and presenting the nsnal changes charac-
teristic of malarial fever.
We observed that the absence of albumen from those cases of dropsy which were cletrh
referable to the action of malaria, was a most favorable symptom.
During the months of November, December 1870, and January, February and March 18T1,
I treated in wards 24 and 25, Charity Hospital, 180 cases of disease, and of this number, more
than one-half, or 114, were suflfering with the various forms of malarial fever, (PemicioBs,
Remittent, Intermittent, and Chronic Malarial poisoning.) Of these one hundred and four-
teen cases of malarial fever, one tenth were suffering with anasarca. Treated upon the
principles just. indicated, the entire number, including the fourteen cases complicated witb
anasarca, ascites and oedema, were relieved and were discharged cured — no death occarred.
We attributed this favorable result to the persistent use of purgatives, diuretics, Iron aod
Quinine : as well as to the fact that in this series of cases, tjie liver, and kidneys were aot
seriously involved. We have from time to time, in both civil and military practice obsemd
a number of cases of anasarca acccompanying the prolonged action of the malarial poifioo,
and apparently dependent upon the alterations which it induced in the liver and spleeiu
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 kidneys were involved.
^Casb 636 : Chronic Malarial Poisoning^ with Ascites and General Anasarca. — Victor Sievaox,
nge 52, native of France ; admitted ward 13th, bed 189, Charity Hospital, December llth.
1872. Patient gives the following history: about nine months ago. May 1872, in Illiaols
was attacked with Intermittent fever (chills and fever,) which continued about six mooths.
Three months (October 15th,) before entering the Charity Hospital, he left Illinois and ctn*
down the Mississippi River to New Orleans, and while on the boat, was again attacked bf
chills and fever, and he observed that the chills were accompanied and followed by swelUaf
of the abdomen and lower extremities. Was also greatly exposed on the deck of the steaottr
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 tad
legs began to swell ; the swelling gradually progressed upwards, until the abdomen becaae
involved. After his arrival in New Orleans, on the 30th of October, there was no rcguUritr
in the attacks of fever, which assumed in turn, the quotidian, tertian and quartan type;.
Entered the Charity Hospital, and was so much relieved by the treatment with Quinine, Iroe,
and Bitartrate of Potassa, that at the end of three weeks, he left and endeavored to follow bis
occupation (Veterinary Surgery.)
At the end of twelve or fifteen days, the chills and tever returned, and the swelling of tb«
abdomen and lower extremities appeared again, and increased rapidly.
Entered Ward 13th, December llth, 1872; pale, sallow, anaemic; face presents a swoUet
bloated appearance ; abdomen greatly distended with fluid ; veins upon the walls of U**
abdomen, present a full distended and arborescent appearance ; lower extremities swollen afid
distended to such an extent, that the patient walks with great difficulty, and in fact is com-
pelled to lie in bed. Pulse accelerated and feeble. No appetite. Great depression and pros-
tration. At tiines the patient cries, and says that there is no hope for his recovery.
Ten grains of Sulphate of Quinia, and twenty minims of Tincture of Opium, (LaadsDan,;
were administered this day, and repeated again on the 12th. On the next day, December 131b,
I administered 5 grains of Sulphate of Quinia, every two hours, until the patient had taken 2*
grains. These measures arrested the chills for a short period. As the dropsical effusion wis
increasing, I determined to employ a combination of diuretics and purgatives. A powder
composed of forty grains of flowers of Sulphur, one ounce of Bitartrate of Potassa, a»d
twenty grains of pulverized Jallap, was mixed with half a pint of water, and administered
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Dropsy arising from Alterations of the Blood. 591
momiDg and evening. 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
fluidoonces of Syrup of Squill, and two fluidounces of Syrup of Wild Cherry Bark, (Prunus
YirgiQiana ,* ) 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 he is much better. R. Quinise et Ferri Citratis, four drachms ; Acidi Citrici, one drachm ,\
Aqaae, Menth, Pip, six fluidounces ; mix, teaspoonful three times a day.
December 20th, m., temperature axilla 100° F.; b. 100°.; 2l8t m., 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 F.; 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.
Be- Quinie Sulph, one and a half drachms; Ferri Sesqui Chloridi, one fluidounce ; Aquae
DistillatA, eleven fluidounces ; mix ; tablespoonful in wineglassful of water every four hours ;
sack through glass tube.
December 23d m., temperature 100°.5 ; 24th m., 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 If., 98° ;
27th M., 97° ; 28th, 98°. December 28th, had a chill at 8 a. m., followed by fever. Repeated
the Qainine, 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. Daring 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 2l8t. 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
bad disappeared, and the complexion presented the clear, rosy tint of health. This patient
has 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.
Case 637 : Intermittmt Fever; General Anasarca^ Resulting from the Prolonged Action of Malaria. —
Patrick Flavin, age 46, native of Ireland. Entered ward 13, Charity Hospital, February
I2tb, 1873. Has been working in swamps and been exposed to cold and wet. Sallow, jaun-
diced, anaemical 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 14lh, 16th, I7th, 18th and 19th, the temperature oscillated between 99° and 100°. 8
F.; and on the 20th, rose after a chill to 102° F.
J attributed the ascites and anasarca in this case, {especially as in the preceding case, the hearths
action was normal, and the urine entirely free from albumem,) to the effects of the malarial poison
ID 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.)
Case 638 : Intermittent Fever ; Chronic Malarial Poisoning ; enlargement of lAver and Spleen ;
Anaemia; Anasarca. — Noah Wilkinson, age 13, native of Georgia ; laborer. Entered ward 13,
bed 189, Charity Hospital, December 31st, 1874. Had suffered with chills and fever, for more
than 12 months. Whilst passing through New Orleans 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, anaemic 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 oede-
matous. Says that he lived in a low, damp, malarious locality in Georgia, and suffered with
chiils und fever for more than twelve months.
Quinine with severt^l of tl^^. ^ti^^dard preparations of Iron, as the Citrate of Iron and
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Dropsy arising from Alterations of the Blood. 51^3
itirra. — G. M., age 23, native of Germany ; entered ward 21), Charity Hospital, November :JOtli,
1874. Has been working in swamps and marshes, and has suffered with chills and fever for
two months. Spleen greatly enlarged ; pale, sallow complexion ; anicmic ; lower extremities
and scrotum codematous. Improved under a treatment similar to that instituted in the pre-
ceding case ; discharged December 2l8t.
Case 642 : Intermittent Fever ; Chronic Malarial Poisoninf/ ; Enlarged Spleen ; Aniemia ; (Edema
iff Scrotum and Lower Extremities. — 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 ; a'dema of scrotum and lower extremities ; urine slightly albuminous.
Tndcr the treatment specified iu the preceding cases, restored to health and discharged Dec.
32d.
Cask 643 : Intermittent Fev»ir ; Chronic Malarial Poisoning ; Enlarged Spleen ; Amemia ; Ana-
^irca. — Daniel Gary, age 31, naiive of Kentucky, laborer. Has suffered with chill and fever
for three months, whilst working in malarious swampy region, and durinfir this time has had
little or no treatment. Entered ward 29, Charity Hospital, Dv.c. lOtl
slightly jaundiced complexion. Ana)mia; spleen enlarged; lower exti
csderaatous; belly distended; countenance presents a swollen, bloated a|
no albumen in urine. Improved under treatment, and was discharged Ji
Casr 644: Intermittent Fever; Chronic Malarial Poisoning; Anmmia ; At
a^ 30, native of Ireland, laborer ; entered ward 30, Charity Hospital, Dc
enlarged; anssmia; anasarca; no albumen in urine. Improved under tr
Iron and Bitartrate of Potassa, and Tiuc. Quassia and Cinchona. Disci
1875.
Casbs 045-655. — Similar to preceding, and relieved by similar measun
Case 656 : Persistant Intermittent Fever : Antemia and Anasarca.^J oh
native of Germany ; contracted malarial fever in the swamps of Louisiant
G. H., October 8th, 1874, with fever and anasarca.
3^ albumen in urine. Heart and lungs normal. Treated with Quinine
of Potassa. Recovered.
Cask 657 : Intermittent Fever^ and Chronic Malarial Poisoning. — Frank
Pennsylvania; laborer; has suffered with intermittent fever for about (
Ward 30, C. H., Nov. 10th. Lower extremities, scrotum, and penis distc
effusion. Pale, sallow-auasmic ; great deficiency of red corpuscles. No ai
normal.
Recovered under the usual treatment with Quinine, Iron and Hitartn
charged November 25th.
Case 658 : Intermittent Fever ; Chronic MaUirial Poisoning ; An-isarca. — Ci
of yellow pigment in skin. Anaemia.
Thomas McElroy, age 30 ; native of Ireland. Brown hair, brown eyej
B. 446, C. H., Nov. 15th, 1874. Has had chills and fever, with little
nine weeks. Features swollen ; pale, sallow and swollen, with several b
These spots, which vary in size, from half an inch to three inches in diai
various portions of the body. Some effusion iu abdominal cavity. Lo'
matous. Heart normal. No albumen in urine. Recovery under Iron, (
of Potassa, and nutritious diet, slow, but complete. Discharged Dec. 24
Ca.se 659 : Intermittent Fever of Two Months ; Anvemia ; Anasarca ; En<
Brown, age 25 ; laborer ; native of Ireland. Contracted malarial feve
swamps and low grounds on Mississippi River, iu the month of August
422, C. H., Nov. 17th, 1874. Pale anaemic, with loss of muscular and nc
fcdema of lower extremities. Xo albumen in urine. Heart normal. Uud(
with Quinine, Iron and Bitartrate of Potassa, recovered, and was discha
Case 660 : Intermittent Fever ; Anmmia ; (Edema of Lower Extremities
Thomas Reid, age 30 ; native of Ireland ; laborer. Entered Ward 30, C
Has suffered with intermittent fever for " several weeks," during which
no treatment. Pale, sallow complexion ; anaemic ; lower extremities
albumen in urine. The usual treatment with Quinine, Iron and Bitatrat
in the removal of the effused liquid, and the improvement of the blood, s
of health, and the patient was discharged Dec. 3d, 1874.
Cask 661 : Intermittent Fever ; Chronic Malarial Poisoning ; Enlargement
Aniemia; Diarrhoea; (Edema of Lower Extremities. — J. M. Budge, age 39
pcdler. Has suffered with malarial fever 5 months. Entered Ward
1874. Pale, sallow hue ; anaemic; liver and spleen both enlarged; low
swollen; pitting deeply upon pressure. No albumen in urine. The pen
Iron and Bitartrate of Potassa removed the malarial disease, restored tl
blood, and relieved the dropsical effusion ; patient discharged, Dec. 30t
Case 662 : Intermittent Fever ; Chronic Mnlaial Poisoning ; Enlarged Live)
75.
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Dropsy arising from Alterations of the Blood. 597
aal cavity. The mucous membrane of the stomach and of the small intestine, as far as the
ilio-caecal valve was pale. The ctecum over its greater extent was firmly adherent to the
fodsa iliaca, and its mucous membrane was partially converted into an ulcerated surface of a
dirty-gray, ragged character j 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
aggregated masses of cylindrical epithelium of a gray color. The liver contained no sugar,
but large quantities of leucine and tyrosine.
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Dropsy arising from Alterations of the Blood. 599
the left, as well as of the right lobe, was opaqae, from recent exudation, and covered with
pale red, newly formed vessels. The hepatic tissue was of a dark, grayish-brown color, and
of soft consistence. Here, as well as in the spleen, there were large masses of pigment.
Bile, thin, pale and albuminous.
Kidneys anaemic.
Urinary bladder and prostate, normal, pp. 250-352.
(A Clinical Treatise on Diseases of the Liver, by Dr, Fried. Theod. Frerichs. Trans, by
Charles Murchison, M. D., London, 1860, Vol. I.)
Several cases, similar in all respects to those just recorded, have come under our
observation, following protracted intermittents, and consequent upon the prolonged
action of the malarial poison.
These cases were characterized by a pale, sallow, anaomic, unhealthy, jaundiced hue.
The lips and mucous membrane of the mouth and tongue 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 Leukocythaemia. 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
pnneatly 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
patientfi were afflicted with a continuous and uncontrollable diarrhoea, which could not
be reached by remedies. Notwithstanding the continuous diarrhoea, the extremities
became oedematous, 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
eases 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 such cases, the enlarged spleen resembles a sofl 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
decomposing blood corpuscles, and resulting pigmentary matter, be correct, we must
look to the changes of the blood in the spleen as the primary cause of this form of
malarial dropsy.
Frerichs assumes that the capillaries of the splenic artery pour their blood into a
system of large sinuses, whence it passes into the efferent veins ; even in the normal
state, the blood which has flowed rapidly through the narrow capillaries, would patrs
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 be
formed, which gradually might be transformed into pigment. In the intense conges-
tion, 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 sinuses of the spleen; the club and spindle shaped pigment
cells arc 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 other congestions of the spleen, in Typhus, Pyicmia,
and simple Intermittent Fever ; and why it is that the metamorphosis of the blood pig-
5[ieqt into melanotic matter, app^ently t^l^es pla^e ^luch more rapidly here than at other
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Dropsy arising from Alterations of the Blood. 601
ADj remarkable change of Btructure, or derangement of function bo observed. 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
melansemia 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
the skin suffices to show numerous particles of pigment under the microsc
Treatise on Diseases of the Liver, by Dr. Fried. Theod. Frerichs, New Syd. Sc
pp. 322-332.)
The most striking objection which meets us, in attempting to account ;
in the liver and the dropsical effusions in certain cases of Malarial F
theory of Frerichs, that the pigment granules are the active agents in cai
of the smaller capillaries, and local congestions and structural alteration
the spleen and liver may be loaded with pigment granules, without any d
hardening of these organs, and without even any marked derangement o\
Two oases have come under my observation, where death was produce
full healthy by causes other than those producing the accumulation of pig
in these organs, and in which there was no relation between the fatal
pre-existing action of malaria, to which the patients had been subjects
periods.
The following are the cases :
Case 671 : Augusta, Ga., July 1862. An active, strong, athletic, well form
mechanic, was assaulted by two ruffians, as he was peacefully going to his woi
ruffians presented a double-barrelled shot gun, which the mechanic seized w
and attempted to wrest from his antagonist ; one barrel of the gun was disi
four inches of the left thigh. The discharge of the gun was not attended by
of power in the limb, and the mechanic struggled tor a few moments and th
examination it was found that the linen pants were not destroyed over the re(
charge ; whilst the cotton drawers were burned ; a circular wound was discov
inches below Ponpart's ligament, on the anterior surface of the thigh. Bio
this wound, and the skin was extensively ruffed up towards the abdomini
probe failed to pass into the wound for any distance — no shot or^balls were fc
was no' well defined track indicating the passage of any hard body through the
thigh. Upon examination of the gun it was found that only one barrel had b<
and that the other barrel contained two loads of shot. The condition of th(
fore, as well as the fact, that two loads of buck-shot were found in the other
that the injury to the thigh and surrounding parts were due to the explosi^
gunpowder alone, discharged within a few inches of the thigh.
The patient remained insensible a few moments after his fall, but soon recovi
After reaction took place, the patient appeared to be doing well, but in th<
succeeding night (the deed was perpetrated at 1 p. u., in the day,] he manlfcsU
great uneasiness and prostration.
The next morning his countenance was pale and sunken — pulse small and
complete suppression of the urinary secretion. At 1 1 o'clock p. m., the patient
calm, mind clear, with the exception of a slight failure of memory with re
length of time which had elapsed since the infliction of the injury. Express
nance calm ; features sunken, face deathly pale and fore-head bathed with cold
pulse could scarcely be felt, — a mere thread, beating 160 times in the mi
moments the pulse disappeared from the wrist, whilst my hands rested o\
Extremities cold, and the cold creeping up slowly but steadily, towards the tri
labored ; action of heart rapid and thumping. He was at ibis time under the a
Oil administered a few hours previously ; had an action from the bowels duri
nation, but passed no urine. The kidneys appear to have been torpid since t
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 driven in amongst the muscles. Abdomen
distended to a small extent, especially in the region of the bladder. Percussion showed th%\
7Q
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Dropsy arising from Alterations of the Blood.
almost immediately. These facts were communicated to me bj my coUeagu
who wa9 called in at the Coroner's inquest. At the post-mortem, no spe
was made of the' brain and spinal cord. No definite information was given i
to the appearance presented by the alimentary canal.
The liver presented, upon the exterior, a dark slate, and bronze, and pur
interior presented a dark, olive, bronze color, and the blood presented ver
of the liver, and also represented the color of the blood of malarial fever.
liver presented a mottled appearance — a mixture of the bronze, olive, Sp
purplish color of the liver of health. The appearance of this liver is interest!
closely the darker shades presented by the liver in malarial fever. I was un
deAnitely whether the patient had at any time suffered with malarial fi
ever, highly probable that he had so suffered, for his bouse was in a malar
within a half square of the graveyard. Being a barber by trade, and hav
one-half mile distant, he must have been much exposed at night. This con(
does not appear to have affected his health, as he was of a full habit, and
sides, death occurred i n the winter season, and if this state of the liver \
malarious influence, the effects must have been of long standing.
It is evident, therefore, from the preceding cases, that the slate \
mentary liver of malarial fever may be present, without being attende
turbances of health, such as those described by Frerichs, and refcrre
the injurious action of the pigment matter.
The dropsy of the malarial fever is, without doubt, connected witl
the blood induced by the malarial poison, and also with the structural a
spleen and liver ; but that the alterations of the liver depend primarily, o
in great part upon the mere stasis and alteration of the blood in the s]
fully established, and it is very evident that the malarial poison exerts
tive action upon the colored corpuscles both in the spleen and in the lii
In attempting to determine the effects of malarial fever in
of hardening and cirrhosis of the liver, we must, in every case
effects of intemperate habits, in altering the structures of the liver,
during the existence of malarial disease. By careful histories of cas
enabled to show that a large proportion of the cases of malarial feve
induration of the liver, occurred in those addicted to the inordinal
spirits.
Ths effects of hsemorrhage, in producing dropsy, were well illusti
lowing case, which recovered under my treatment, in Ward 24, Cha
Casb 673. — John M. Rose, age 32 ; native of Maryland. Admitted into
Ward 24, bed 369, January I9th, 1871. Belly greatly distended by effusioi
cavity. General anasarca, greatest in lower extremities. Sallow, malarioi
abdomen turgid and arborescent. Portal circulation evidently embarrassc
built; weight 170 pounds ; dark hair, dark eyes and dark complexion. Has (
good health, with the exception of occasional attacks of chills and fever. Si
federate army during the American Civil War, and, with the exception of d
weeks' duration, was never sick.
During 1866 and 1867, lived in Arkansas, upon the Arkansas River, and
suffered severely with chills and fever. Has been running upon Mississippi
past four years. Twelve months atro was attacked with a severe htem
stomach ; vomited blood and passed blood by the bowels ; could not accou
as he felt perfectly well, and was engaged in chopping wood with an axe
not lose his appetite, and did not quit his work, but for the space of o
account of the general debility caused by the haemorrhage.
Patient says that he lost at this haemorrhage " about one gallon of blood
was bright red, and other portions appeared black. Had no dropsical s
attack. The complexion became sallow after this haemorrhage, and remai
present time. At the time of this haemorrhage, was not, (and had not bee
suffering 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) upon one of the Mississippi steamboats, was 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.
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CHAPTER XIII.
DBOPSY ARISING FBOM DERANOEMKNTS OF THE CIRCULATORY APPARATUS, ATTENDED WITH
VENOUS OBSTRUCTIONS AND CONGESTIONS, INCREASED SEROUS EFFUSION FROM THE DISTENDED
BLOOD-VESSELS AND DIMINISHED ABSORPTION.
i'ARDIAC DROPSY RESULTING FROM STRUCTURAL ALTERATIONS OF THE HEART AND LARGE
BLOOD-VESSEIiS. CARDIAC DROPSY ; DILATATION OF HEART; DEATH. CARDIAC DROPSY. DILATA-
TlilN OF HEART; GENERAL ANASARCA; DEATH. DILATATION OF CAVITII-S OF HEART; UNIVER-
SAL DROPSY. ARTICULAR RHEUMATISM; VALVULAR DISEASE. ANEURISM OF INTERNAL ILIAC.
ANEURISM OF DESCENDING AORTA. ANEURISM OF ASCENDING AORTA. ANEURISM OF ARCH OP
AORTA. ANEURISM OF ARCH OF AORTA AND ASCENDING AORTA; DILATATION OF HEART.
TREATMENT OF CARDIAC DROPSY. *
Under this head may be classed Cardiac dropsy, resulting from 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 dyspnoea and palpita*
tion, the general health appears good.
Owing to the continuous disturbance, however slight, at first, of the circulation and
respiration, the dyspnoea and palpitation increase, the nutrition of the body is impaired)
the general health progressively deteriorates, and a slight amount of oedema appears in
the lower 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 becomes 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 appears
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 cardiac disease is usually, therefore, of late occurrence, making its
appearance almost invariably about the ankles and feet, as slight oedema, and by slow
d^rees ascending towards the trunk, and ultimately involving the upper extremitiei^
and face. 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.
According to Dr. Walshe, dropsy, sequential to heart disease, occurs in the following
situations, enumerated in the order of frequency with which they severally suffer ; the
Bub<cutaneous cellular tissue ; the pulmonary parenchyma ; the peritoneal and pleural
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Dropsy arising from Derangements of the Circulatory Apparatus, 607
Jugular yeinSi which fill from below and as shown after death by actaal examination, does not
necetsarily 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
aflfections 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 difficulty in the systemic circulation ; what influence actually and directly leads to the
dropsical exosmosis ?
Tills 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.
Firstf 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 effusion. The cedema
and sometimes extensive anasarca of spansmia ; the slight oedema attending the hypnosis of
protracted convalescence from various acute diseases ; the various dropsy of uremfa — 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 lungs, 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-
tion. Thirdly, cases occasionally present themselves, in which dropsy supervening from
diseased heart, fails to affect portions of the body, noted under ordinary circumstances, as the
earliest and readiest sufferers— for instance the lower extremities. I have observed this where
the legs had been the seat 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
case 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, jnst contended for. It may be urged that when the heart is so affected, the
necessary vis a tergo in the circulation is wanting, and capillary stagnation must ensue — and
that this very stagnation, becoming habitual may modify the qualities of the blood, and im-
pair the nntrition of the walls of these vessels through the strain they suffer. But plausible
though 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. Bnt 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
difficulty 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, the capillaries of the base of the neck may dilate in such
maooer as to produce notable general swelling ^t the spot, yet not a particle of oedema bo
discernible.
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Dropsy arising from Derangements of the Circulatory Apparatus, 609
the impedimoDt to the circulation, and tho diminution of the solid matters of the
seram.
The following cases of cardiac dropsy, have been selected fVom those observed io our
wards in the Charity Hospital.
Organic diseases of the heart and great vessels, although constituting, relatively, a
small proportion of the diseases treated in military, civil and hospital practice, at ihe
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, during a period of 45 months, the total deaths were 235. During thiis
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 ratio of one death in 2.95 cases.
The following are the cases and results, as entered upon the Case Book : Organic Dis-
eaie 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 cases,
1 death ; Dilatation and Fatty Degeneration, 3 cases, 1 death ; Fibrous Concretion,
right side, attached to Chordae Tendince, and Cameae Columnar, and Tricuspid Valve, 1
case, death 1 ; Palpitation and Irregular Intermittent 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
Degeneration of Coats of Aorta and Semilunar Valves, with Dilatation of Lefl Ventri-
cle and Auricle, 1 case, death 1 ; Insufficiency of Mitral Valve, with Dilatation of Letl
Anriole and Ventricle, cases 6, deaths 2 ; Insufficiency of Aortic Valves, 3 cases, 1
death.
Casb 675: Cardiac Dropsy ; Uypertropky of Heart i First stages of Cirrhosis of Liver. — In this
case, the stodents 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.
Bighteen months ago, the patient says, that he was working in the hot sun, and drank large
quantities 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, nsed alcoholic stimulants freely to relieve the pain in the region of the heart. At first,
the stimulants 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 the
hospital.
Admitted into the Charity Hospital, ward 18, bed 267, March 9tb, 1869. At this time, the
patient was suff'ering 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 suffiers debility from muscular exertion ; came under my treatment at this time
and the following results of physical exploration were then recorded :
Anscnltation 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, l^he first sound of the b^eart is entirely altered,
n
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Id \Dropsy arising fromrDerangements of the Circulatory Apparatus.
being coDverted into a loud, blowing sound, much more distinct upon the left side, and orer
the region of the left Huriculo-Tentricular valve, near the junction of the cartilage of tlie
fourth left rib with the sternum. This loud cardiac murmur was heard at the apex of the
henrt and along its body, becoming most distinct over the region of the auriculo-ventricolar
valves, in the middle of the sternum, in a line with the articulation of the cartilages of tbe
fourth ribs with the sternum, and gradually diminishing towards the base, and becoming quite
indistinct over the position of the semilunar valves of tbe aorta and pulmonary arteries near
the junction of the third ribs with the sternum. At the apex of the heart, tbe second somid
was heard with difficulty. At tbe base of tbe heart, or rather about the region of the arch of tbe
aorta and the arch of tbe pulmonary artery, above the line joining the cartilages of the third
ribs with the sternum, the first sound was heard with difficulty, or rather it became indistinct.
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 longs. Xo
physical signs of either tuberculosis, or pneumonia, or of pleurisy, were detected. The coi*
gestion of the lungs was referred to mitral regurgitation. The veins of the neck (exterwl
jugulars), gave a distinct Tenons pulse.
The liver was enlarged, and tender to the touch. Slight effusion into the abdominal cavit;,
and oedema of face and extremities, especially marked in the feet and ankles, complexion sal-
low, wax-like, with slightly jaundiced hue. Tbe yellow, jaundiced hue was especially di>-
tinct in the eyes. Urine scanty, high colored, high specific gravity, and loaded with bilitrj
acids. The urine contained no albumen or urinary casts.
Bowels irregular, most generally constipated. Appetite poor ; tongue coated with whitish
colored for. Pulse feeble, 80 per minute ; respiration 22 ; temperature under axilla in tbe mora*
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 tbe Lungs and Venous Pulse, in consequence of Regurgitation of Blooil
through both Left and Right Aoricolo-Ventricolar openings.
Absence of Active Inflammation or Tubercles from Lungs.
Cirrhosis of the Liver in the early stage, in which the organ is increased in size.
The patient was treated with small doses of Calomel and Sulphate of Quinia, with occa-
sional saline purgative, with no perceptible benefit. The heart trouble increased, tbe
spitting of blood became quite common^ and the oedema of the extremities, and dropsical
effusion steadily increased. Tincture of Wild Jessamine (Gelseminom Sempervirens), was
also effectually tried, ag 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 depressia;
effects opon the action of the heart, and its debilitating effects upon the nervooB^ system.
Nitro-Muriatic 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 nacfa
swollen, the effusion in the abdominal cavity increased, the venous congestion becaoi mon
marked, with distinct pulsations of the jugular veins and blue lips ; the difficolty of ripira-
tion became so great, and the action of the heart so irregolar, tha\ the patient coal<*ot
rest at night, and was compelled to sit up in bed. The forces failed progressivelj, at.,^
died on tbQ i5th of Jqne. The following is a tabular statement of the more important s^^
toms;
1
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Dropsy arising from Derangements of the Circulatory Apparatus. 613
htriag its maximum intensity at the position of cardiac impulse. The anasarca has been greatly
reduced bj the persistent use of diuretics, and especiallj by the cream of tartar and Juniper
berry infusion and mixture. Tincture of bark and preparations of iron, and especially the
tincture of the sesquichloride, appear to have been most beneficial in maintaining the strength
of the patient. The following obserrations give a correct view of some of the leading symp-
toms in this case. April 7tb, 9 a. m., respiration 20; temperature of axilla 98°; tongue
clean, bowels regular, complexion sallow, anaemic, urine abundant, cedema of extremities and
of face ; spirits good, assists in nursing the patients. April 8th, 9 a. 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
sabstances were detected. April 10th, 9 a. m., pulse 92; respiration 21; temperature of
axilla 99° ; urine excreted during twenty-four hours 100 fluidounceg, sp. gr. 1010 ; no grape
sugar nor albumen. April 11th, 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 eutrance of this patieut iato the hospital, the anasarca was
very 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 drojysy in this case appeared to be the result of the cardiac disease, and the
anaemic state of the blood.
Case 677: Dilatation of Heart ; General Anatarea ; 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-
cussion over region of heart; and the area of dullness at least four times as great as that
usual 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 ihe thorax as to indicate pleuritic effusion. 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 2lBt, two days after her admission into the ward.
Autopty twelve hours after Death,
Exterior. — Trunk, abdomen and extremities greatly swollen. Areolar tissu
infiltrated with serous fluid. On opening the cavity of the thorax, a large amo
fluid filled the pleura, and occupied a large portion of the space usually filled
The right lung was compressed into a mass not larger than a man's hand, ar
hepatized appearance, and apparently had lost the power of dilatation. The
also compressed into a comparatively small space, but was readily dilatable ^
from the pleural cavity. The heart was enormously enlarged, measuring sevc
tenths inches in length, and fifteen and a half inches in circumference, as it lay
with the auricles and ventricles immensely distended with black blood. The bl
tially coagulated, and the coagula were readily divisible into two portions, the
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 chordae tendinae. The walls of the heart were thin and not hyper-
trophied.
The edges of the mittal valve were thickened and from the deposits of calcareous or osseous
matter ; or rather ft-om 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-
neum ; and a small patch of fibrinous exudation was observed on the surface of the descending
colon, in the lumbar region*
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614 dropsy arising from terangmenis of the Circulatory Apparatus.
The origin of the cardiac disease and the supervening dropsy appears to have been
the deposit of fibrinous matter upon the auriculo-yentricular valves in some fonxua
attack of rheumatism, thus causing auriculo-ventricular regurgitation.
Case 678: Dilatation of Cavities of Heart; Universal Dropsy; Death, — John Wilson, negro
man, aged 57, stout, well-built man, native of Virginia. Admitted to Cbaritj Hospital, ward
No. 32, September 2d, 1868.
Patient says that he has always enjoyed good health up to December, 1868, when he wmi
seized suddenly with palpitation of heart, and great difficulty of breathing. Has been ad-
mitted several times into the Charity Hospital, since this date, suffering with palpitatioa of
the heart and dyspbcea. As soon as some slight improvement took place, under rest aad
diuretics and ionics, the patient would ask to be discharged.
At the present time, September 2d, the patient suffers with great dyspnoea, pain in the regioi
of the heart, dry hacking cough, general anasarca, which however is less in the right arm aad
head.
The apex beat of the heat't is just below the itlpple ; space of percussion dallnaas 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 conteqoest
upon heart disease. No albumen or bile was found in the urine. Diuretics and toaics
were administered, with only temporary benefit, however, as the anasarca increased as w^
as the oppression of breathing; the lower extremities became immensely distended; the
patient was unable to lio down, and finally died twelve days after his admission, on the 14tfa
of September.
The post-mortem examination revealed a similar condition to that described in the prec^*
ing case No. 677. Universal anasarca — liver and kidneys and intestinal canal bealUij. Heart
greatly dilated and distended with black blood. The dimensions of the organ were telly
equal to those given in the preceding case. The mitral valve was thickened with osaeoas
deposit.
The auricles and ventricles were greatly dilated, and the auricular ventricular opening so
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 evidence of insnfi*
ciency of the aortic valves, without dropsical effusion.
Case 679 : Articular Rheumatism^ with derangement of Second Sound of Heart, — Wm. Rofers<
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 the upper
extremities. Patient states that seven years previous to the present attack, he was coafiaed
to his bed six or eight weeks by rheumatism, which affected chiefly the upper extresitics.
The attack was brought on by exposure. Two years afterwards he had a second attack, whick
was confined to the parts and joints of the lower extremities ; and at this time be svflarad
severe pain in the. left side, which his attending physician pronounced to be due to pks-
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 the shoulder joints. On perciidsioe
the heart appears to be hypertrophied ; and upon auscultation the second sound is eotireij
altered, being converted into a prolonged, blowing sound, heard loudest at the base of the
heart over the aortic and pulmonary valves, and is transmitted up as high as the point af
bifurcation of the common carotid artery. The sound is loud and distinct. The patient was
placed on a mixture of Wine of Colchicum, and Solution of Iodide of Potassiam, ao cow-
pounded that eight drops of the Wine of Colchicum and five grains of the Iodide of PotsiasitiB
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, and was
discharged from the ward on the 26th of February, 1870.
It is worthy of note in this connection, that the most extensive aneurism maj exist
without the production of any dropsical effusion. If the aneurism presses upon one or
more of the large veins, it may, by its mere mechanical pressure, cause such a oooges-
tion as to lead to oedema of those parts from whence the obstructed vein should reiaort
the blood.
It is also worthy of note that in the cases of aneurism, which I have examined k
the Charity Hospital, there was most generally more or less fatty degdneration of At
arterial coats, in various portions of the circulatory system*
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Dropsy arising from Derangements of the Circulatory Apparatus. 615
Case 680 : Aneurism of Internal Jliac.
Thus in the case of a large aneurism of the internal iliac, which filled the entire
pdTic fossa on the lefl side, measuring eleven inches in the longest diameter, and six
and a half inches in the short diameter, the heart is partially degenerated into fat and
the entire aorta is dilated, with thickened, degenerated, roughened walls.
Cass 681 : Aneurism of Descending Aorta; Absence of (Edema ; Great Emaciation ;
Death
The hody of this man, aged sixty, af^er death, presented no marks of dropsical
effusioD, 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
aneurismal 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 efiiision was discovered in the areolar tissue and
serous oavities after death, and none had beep observed during his residence during the
past three months. ,
Case 682 : Aneurism of Ascending Aorta ; sudden rupture of Aneurismal Sac
within the Pericardium ; Hxmorrhage — 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 after 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 eflfiised exterior to the
pericardium, and there were no marks of dropsical e£fusion 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 blood lost. As is well known that portion of the
aortA which arises from the left ventricle, behind the sternum, opposite the third inter-
oogtal 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 ^orta together with that 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
aneurismal dilatation was sent off, downwards from the arch of the aorta, and rested
against the auricle. The rupture took plaoe at the most dependent portion of this
division or diverticulum from the dilated aorta, just where it rested upon the auricle.
In the case of aneurism of the femoral artery operated on by Dr. Warren Stone, Jr,
and which terminated fatally from haemorrhage and pyaemia, I found the artery for
some distance above the seat of the aneurism in a state of fatty degeneration. Wo
can see in such a case, the cause of failure in the operation of ligation of the artery
for aneurism. The ligatures out through the softened and degenerated arterial coats,
and haemorrhage occurred ; compression had been previously tried without success. It
is probable that in such cases, the results of compression would be rendered unsatisfac-
tory from the degeneration of the coats of the artery.
In the three following cases, no dropsy and no tendency to it was at any time
observed,
Ga8B 683 ! Aneurisw^ of Arch of Aorta^ involving aho the Ascending Aorta ; Absence of Dropsi-
cal SweWng ; Death. — Michael McCaoD, male, age 35 years ; height 5 feet 6 inches : weight 120
pounds; dark brown hair, grey ejes, dark florid complexion, sharp features; native of Ire-
land ; has been twenty years in New Orle<ins; occupation, day laborer ; had syphilis ten years
ago, which the patient says affected (lirn for several months ; had yellow fever fifteen year^
ftf^o ; and chills and fey^r in tl^e snmi79,9r mont^^^ of 186$.
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616 Dropsy arising from Derangements of the Circulatory Affxiratus.
Admitted into the Charity Hospital November 14, 1868, sufferiog with pain ia right ant,
extending up along the Bide of the neck and head, and attended with difficulty of deglutitioa.
Patient says 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 applica-
tions and liniments, without any perceptible benefit. For four or five weeks after enteriog tin
hospital, the patient could not lie down by day nor by night, on account of the great oppret*
sion of breathing, and a most troublesome cough, and sensation of choking, in the recambeni
posture. Ho lost flesh, his weight being reduced from 155 in health, to 130 pounds. The
treatment has consisted chiefly of anodyne, sub-cutaneous injections of Morphia and Atropla.
at night; Iodide of Potassium, as an alterative, and Tincture of Sesqui-Chloride of Iroo, as
a tonic. The pains are relieved by the sub-cutaneous injection of Morphia and Atropia. and tht
patient is unable to sleep without them.
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 his 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, tbngiie 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 chest,
over the intercostals of the first and second ribs, immediately to the right of the stemara,
where the sounds are loudest. There is also flatness, on percussion, over the infra-clariciilar
region, on right side of chest, where the sounds of the heart are heard with the greatest inten-
sity. Temperature of axilla variable, ranging from 98^.5 to 100^.5 F. The respiration varies
from 18 to 22, and is natural, with the exception of some prolongation of expiratioo and
inspiration, and a peculiar sound, as if the bronchial tube was pressed by a tumor. The eos-
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 aneurism 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 distieet
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 tendeBcv
to faint.
May 6th : There appears to have been a gradual change in the position of the supposed
aneurismal tumor in the chest ; careful and prolonged examination revealing a more turanl-
tuous and powerful impulse against the supra-clavioular regi3n of the left side. The sab-
clavian artery of the left side appears to have suffered dilatation, as it is of great size, and ths
column of blood is thrown with great power and a marked thrill through its dilated walk,
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 outline andfeebit
in beat. In fact, it is almost impossible to feel the beat of the carotid, without the mo«t 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 aloag
the walls of the aneurism, or the tumor presses upon it in some manner, so as to diminish iu
column of blood, or the aneurism does not extend much beyond the junction of the left sab-
clavian. The third supposition is excluded by the previous history of the case. It wonU
appear that this tumor was slowly shifting its position to the left of the vertebral colnssa.
It is well known that the soft parts become incorporated with the aneurismal tumor, and
even the vertebrse are absorbed by the constant pressure, as was seen in the case of the
aneurism of the descending aorta, previously described. The diagnosis of aneurism of the
arch of the aorta, appears by these signs, and especially by the movable nature of the tumor.
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 condition of
this patient has somewhat improved ; at least he has certainly '^ held his own.''
Patient does not suffer any pain of consequence ; heart is not so forcible in its action ; the
left radial pulse is still stronger than the right, whilst the beat of the right carotid is mnch
more powerful than that of the left, which can scarcely be felt. Dullness upon percosaioa,
with bronchophony extending from the left border of the steijnum, to the middle of nght
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Dropsy arising from Derangejnents of the Circulatory Apparatus. 617
claricle, thence downwards, to midway batween clavicle and nipple, thence inwards to left
border of sternnm, thence upwards to starting point, making an area of marked dullness and
bronchophony, of about four inches in diameter.
Jane 9th : Patient is suffering more than usual pain in head ; and neck and supra-clavicular
■paces 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
BeDsation in the throat.
Jane 21st : Condition of the patient good ; complexion that of health ; appetite good. Im-
pulse of heart quick and powerful, two and a half inches below left nipple. The apex of the
heart acts as if it was thrust directly forwards against the walls of the thorax, making a
deAaed 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.
Lieft supra-clavicular 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
Boonds 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 leil; ventricle. The arch of the aorta
was dilated into a large aneurismal tumor, thirteen inches in circumference, and contained a
large laminated fibrinous 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, viz :
Aneorism 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.
Cass 684 : Aneurism of Arch of Aorta ; Great Oppression of Respiration ; Absence of Dropsical
SwelUng ; DecUh. — William Willougbby, aged36 ; height 5 feet3 inches ; weight 14*7 in health ;
auburn hair, gray eyes, fair complexion; native of Canada; seaman by occupation. At
eleven years of age sdfered 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 consid-
erable 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, 1869, 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 tumor or
swelling, with a livid surface 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 his 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 Sulphate of Morphia and
Atropia. Rest at night could be procured only by these injcQtiQns. The effects of th^
75
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618 Dropsy arising from Derangements of the Circulatory Apparatus.
Atropia were almost immediatelj maDifest, in the rapid dilatation of the pupils of botk
eyes.
April Ist : The patient came under mj treatment and observation at this time. Sayi that
he does not suffer so much pain. General appearance that of health, with clear, florid cobi-
))lexion ; no oedema or dropsical effusion in any part of the body ; his countenance, howerer,
wears an anxious, and, at times, distressed and oppressed look ; weight 125 pounds, appetitt
fair ; bowels regular ; skin soft and natural ; tongue clean ; pulse 88 ; suffers with congliaDd
oppression in breathing. Apex of heart displaced, two inches below, and to the left of tl»
nipple ; action of heart strong ; pulsations very marked over the sternum, and visible at the
apex. Great difficulty in the deglutition of solid food, from the pressure of the anenrtsmal
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 GOQfh
when lying upon back. The cough and clearing of the throat is peculiar in its character,
li^iving the impression of great constriction of the wind-pipe and the bronchial tubes, and
the sounds are heard as if they proceeded directly from tho upper third ot the stemiiiB.
Pulse feebler in the right, than in the left arm.
DiagnotU. — Aneurism of Arch of Aorta.
May 12th : Complains of pain in side of neck and head, and over the sternum ; diflBculty in
respiration very marked, and amounting to decided dyspnoea, especially when attempting ta
assume the erect position. The least particle of phlegm in the trachea, gives much troubia
and distress until removed. Clears his throat in a peculiar manner, as if the bronchial tubes
were 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 injection
of Morphine and Atropia administered last evening, and the patient is this morning in a ner-
vous state ; pulse 96 ; temperature of axilla 101°.Y5 ; 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 tubes.
The sternum appears to be more prominent upon the right side ; apex of heart still further
displaced to left of nipple ; sounds at this point apparently normal, though with less forca
than 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 mucas
is with great difficulty expectorated through the compressed bronchial tubes.
Juno 10th : Symptoms greatly aggravated ; great difficulty of deglutition ; great oppression
in breathing, with prolonged, wheezing inspiration and expiration, as if the air passed through
tho compressed bronchial tubes and trachea with great difficulty. The patient, altboufh
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 resia*
ration appear to issue directly out over the space of at least five inches in diameter, as it the
sonorous vibrations were transmitted directly through a tumor. Percussion revealed dull-
ness over the sternum, and over the greater portion of the clavicular and infra-daTicnlar
spaces. The form of a tumor and its position, may be made out with great clearness, by
combining percussion and auscultation. The diagnosis is especially aided by caasing the
patient to speak when the ear is applied to different portions of the thorax. The positioa of
the tumor may be made out by auscultation and percussion on the back, as well as upon tb«
front of the chest.
When the 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 roift,
heard most distinctly over all the upper portion of the lungs, appeared to be due solely to the
pressure exerted by the tumor.
The patient is evidently near his end, and at this examination the Opinion was expressed
that his life would terminate suddenly from suffocation in the course of a few days.
During the night of the 13th of June, the patient was seized with great difficulty of respi*
ration, became black in the face, struggled violently for breath, and died suddenly from the
effects of the compression of the bronchial tubes, or arrest of respiration.
This patient had friends, who carried off his body before a post-mortem examination could
be made. This was greatly to be regretted.
It was clearly abotwn in the peceding cases also^ tbat the most extensive aneonsms
are not necessarily^ attended with dropsy.
Cask 686 : An^rism of Ascending Aorta and Arch of Aorta ; Dilatation of left Ventricle ; *Sbd-
dcn Death f Ah^nce of Dropsical Effusion or (Eldema. — Moone^, ^e ^6, naUT«. of Ireland, tall.
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Dropsy arising from Derangements of the Circulatory Apparatus, Cl§
well formed mftn, entered the Charity Hospital, ward 16, bed 150, January 16th, 1870. Has
been in this hospital several times before.
At the time of my examination, January 18th, 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 he 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 space normally occupied by the heart, for an area, the diameter of which was at least
scTen inches transversely, and eight inches laterally ; the apex beat of the heart was at least
\sro inches below its normal position ; great oppression in breathing, inspiration and expira-
Uon prolonged, with a wheezing sound, as if the air was passing through a greatly constricted
trachea. It was necessary to prop the patient up in the sitting posture before an open window.
The symptoms oi enlargement of the heart and aneurism of the aorta were well marked.
This patient died suddenly 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 enlarj
cavities distended to their utmost capacity with dark fluid blood. The ascc
greatly dilated, the dilatation commencing at the heart, and increasing rapid
JQSt after emerging from the pericardium, the arch of the aorta expanded in
rismal sac, six inches in diameter. The arteries given off from the arch ol
greatly dilated, and the innonimate artery, was, at its junction with the aneu
large as a healthy aorta. The pericardium was adherent to the heart, this a(
to have been of long standing, and was probably coincident with the changes
valves. The heart measured in its longest diameter, seven inches, and in its si
inches. The semilunar valves of the aorta were thickened, adherent at ce
insufficient. The aortic regurgitation accounts for the great dilatation of tl
As far as we could learn, this patient had suffered with deranged action o
oppression of breathing for more than six months, and he referred the first d
toms, to the lifting of a great weight.
We shall consider in the next place, briefly the treatment of cardiac (
TREATMENT OP CARDIAC DROPSY.
When dropsy depends upon serious organic lesions of the heart a
vefisels, treatment should be regarded as chiefly palliative ; the physioi
certain symptoms of the most grave and distressing character, and
saffering and thus prolong life, for a considerable length of time ; but 1
disease, is in many cases out of the question, as it is impossible either b;
mechanical means to restore the enlarged, dilated, degenerated heart
valves, to the normal state.
Cardiac dropsy supervenes in most cases, afker the forces have been
the blood rendered watery ; venesection therefore as well as drastic purgj
used with great caution. Local blood-letting (cut cups over the regie
and kidneys) may accomplish good results by relieving congestion and
diuresis.
It is well known that diminished fullness of the vascular system prom
tioD of serous effusions ; when therefore obstruction to the circulatio
through the heart, co-exists with pulmonary congestion and anasarca, a
time> the general Vigot is as yet unimpaired, the abstraction of a moder
blood, affords relief to the over-loaded blood-vessels, and congested lungs
the action of hydragogue remedies.
Bitartrate of Potassa, the Compound Jalap Powder, Gamboge and
peculiarly valuable, from their certainty of action as hydragogue purgati
From one ounce to one ounce and a half of the bitartrate of potassa,
of water, taken in two doses, at an interval of two or three hours, forms i
effective and safe purgatives.
The extract of Elaterium may be administered in doses of from one-s
of a grain. Caution, however, must be employed in the use of the Ej
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620 Dropsy arising from Derangements of the Cireulatory Apparaius.
rium, on account of its intense activity, and occasionally depressing effects. A bolus of
the following composition has been recommended and employed with success by Tarions
physicians : B. Pulveru Jalapse^ Pulveris Bhei., Pulveris Scammonii al^ gr. t; KU-
terii, gr. ss ; Bitartratis PotassaB; Sulphatis Potassae, a^, 3SS ; Syrupi Zingeberis;
quantum mfficet utjiat bolus. It is an observation of long standing, that in the exhi-
bition of remedies, more decided and beneficial effects may be obtained by combining
several analogous remedies in small quantities, than by giving a single one in a lir^
dose.
In cardijjc as in 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 kidnejs, 11
affording the most probable channel for the relief of the disease.
Although sometimes uncertain in their action, diuretics upon the whole prove noet
effective in the control, moderation and even complete removal of dropsiod effusions.
As far as my experience extends, the Bitartrate of Potassa or Cream of Tartar, is
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 soi-
pended in a pint of water, and the mixture should be taken in wineglassful doses every
two or three hours so that the whole may be administered during the twenty-foir
hours. The bottle containing the mixture should be always most carefully agitated, at
the cream of tartar is almost insoluble, and falls 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 jumper
berries or wild carrot seed, and some aromatic, cardamom, fennel or ginger may be
added.
It would be foreign to our purpose to enter into any recapitulation of the observations
made at the bedside with reference to the various diuretics, and we shall simply oane
those of the most undoubted efl&ciency ; such as :
Acetate, Nitrate and Citrate of Potassa ; Acetate of Ammonia ; Iodide and Bromide
of Potassium ; Nitric Ether ; Squills ; Digitalis ; Veratrum ; Colchicum ; Tobacco ;
decoction of Scoparium and of Chimaphila.
Squill as an active diuretic has enjoyed a hi^h reputation with the profession, and it
appears to be peculiarly useful in dropsy of the chest, with scanty high colored and
uncoagulable 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 subaequentlr
kept just within the nauseating point. In cases which demand the mercurial influence,
the squill may be advantageously combined with calomel. Small doses of Blue J^
occasionally at bed time, will frequently promote the action of diuretics.
Diaphoretics are much less efficient than diuretics, and cathartics; beneficial remits,
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 necessary for eon-
trolling its influence ; such as tapping, puncture with a sharp lancet and acapaoctwe.
Owing to the danger of the supervention of erysipelas, incisions should be made with
great caution, and whenever practicable, puncturing with the needle should be preferred,
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 the
effusion, and they should be at least half an inch asunder.
When the blood is anaBmic, Iron and the bitter tonics, and nutritious diet should be
employed.
Experience has established the tact, that no advantage arises from the denial of wat^
to dropsical patients.
In some cases attended with great debility, spirituous liquors, in moderate amonnt
are indicated ; hard cider and gin, are amongst the best forms of alcoholic stimulants.
Of course, the results of treatment will depend, in a great measure, upon the extent
and character of the organic lesions.
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CHAPTER XIV.
HEPATIC DROPSY, ARISING FROM SOME OBSTRUCTION TO THE CIRCULATION OP THE BLOOD
THB0U6H THE LIVER. CIRRHOSIS, FATTY DEGENERATION, AND ATROPHY OF THE LIVER.
DRfiPSY RESULTING FROM OBSTRUCTION OF THE PORTAL CIRCULATION IN CIRRHOSIS OF THE
LIVER.
DBOP8T RESULTING FROM CIRRHOSIS OF THE LIVER AND CARDIAC DISEASE.
TREATMENT OF HEPATIC DROPSY.
HEPATIC DROPSY, ARISING FROM SOME OBSTRUCTION TO THE CIRCULATION OF THE
BLOOD THROUGH THE LIVER.
The distinguishing oharaoters 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 be 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 1^ 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
io dropsy arising from obstruction of the portal system ; whilst in that form of the
disease which is dependent upon structural alterations of the kidneys, oedema 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
serous 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
dyspnoea precedes the ascites, and is distressing out of all proportion to its eittent. 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-
quenoe 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
further distinguish hepatic dropsy, from that dependent upon alteration and degene-
ration of the kidneys.
5th. The ascites occasioned by portal constriction, is still further distinguished, by
enlargement of the spleen, enlargement of and tortuosity of the superficial veins of the
abdomen, hcemorrhoids, gastro^enteritb and hsomorrhages from the stomach and bowels.
Enlargement of the superficial veins of the abdomen, however, is not in all cases a cer^
tidn 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
veins of the legs.
It is important that we should consider briefly those morbid conditions of the M^ef)
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622 dropsy from obstruetton of Circulation of Blood thfOUgh Liv^f.
which give rise to dropsical effusions, in connection with those diseased states of thk
organ, which seldom or never gives rise to this symptom.
In waxy, lardaceous or amyloid degeneration, the liver undergoes greater enlaigemeDt
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 betug
uniform in every direction, the form of the organ is not essentially altered, the outer
surface is smooth, and the lower margin more rounded than natural, r^alar 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, dropsj
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 obsenrttioo
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 obstractiM
of the portal circulation ; and consequently ascites, and enlargement of the sabcati-
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 fact, Uut the
branches of the hepatic artery, and not of the portal vein, are implicated in tiie disease.
In some rare cases of waxy liver, ascites results from the pressure of enlarged wizj
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 be^ «^
shown in the post-mortem examinations, and in the specimens of &tty liver mouoted in
alcohol. In fatty liver, as in the waxy disease, the enlargement is uniform io every
direction, and without tumors or nodules upon the surface, and the natural form ci
the liver is but little altered ; there is no ascites or enlargement of the saperfioial veins
of the abdomen, the secretion of bile is not arrested or impeded, and jaandice b 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 degeneration of the heart is eri-
denced by the feeble cardiac impulse, faint cardiac sounds, slow or quick, fedt>le and
irregular radial pulse, attacks of vertigo, syncope or pseudo-apoplexy, and dyspoiM ob
slight exertion. When fatty degeneration of the liver, is attended by fat^ degenera-
tion of the kidney, there will be a tendency to general anasarca ; the urine is dimia-
ished in quantity, oftimes turbid, and contains albumen and casts of the tubali uriniferi
containing oil globules.
In simple hypertrophy of the liver, attended by an increased' size of the lobnles.
and by an increased size or number of the secreting cells, without any alteration of
atructure, the enlargement is uniform, and rarely great, and is not attended by aaj
prominent symptoms nor by dropsical effusion.
Whilst the enlargement may be very great in hydatid tumor of the liver, ascitM,
oedema of the lower extremities, enlargement of superficial veins of the abdomen, and
hsemorrhoids are not distinguishing characters ; and as the hydatid tumor rarely inte^
feres with the functions of the kidneys, those of the urine so common in waxy and
fatty enlargements, are absent ; in rare cases, however, the kidneys also may be the teat
of hydatids, and dropsy may arise from this cause, or from the pressure of the hydatid
tumors upon the portal trunk ; or from the bursting of the cyst, or through the super-
vention of peritonitis.
Ascites rarely results fVom mere congestion of the liver, unless this dqiend ob
inechanical obstruction of the circulation in the heart and lungs.
In the venous engorgement of the liver resulting from mechanical obstnu^on of the
cardiac circulation from valvular disease of the heart, the primary enlargement of tke
liver gives place after a time to an opposite condition of contraction, atrophy of die
central portion of the lobulesy being induced by the pressure of the constantly diatewied
veins. The congestion of the liver dependent upon cardiac disease, ioduoes a form ni
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Dropsy from obstruction of Circulation of Blood through Liver. 623
granular liver very different from true cirrhosis, where the atrophy commences at the
circumference of the lobules.
The diseases of the liver which most commonly give rise to portal obstruction, 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, peri-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' b 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 MUller, and in the Ootodon 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 Glis-
son^s capsule between them or in their interior. Vogel, Henle, Bowman, and Beale
have failed 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
fibrons 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
cirrhosed liver, may be manifest to the eye, and especially when slices of the organ are
Bubjected 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.
Cirrhosb of the liver is of slow* development and progress. The whole structure of the
liver is not pervaded with fibrous tissue in a few days. It is reasonable to conclude
with Dr. Endd, that the remarkable changes in cirrhosis, are mainly the consequence
of adhesive inflammation in the areolar tissue about the small twigs of the portal vein,
and in the areolar tissue of the portal canals, by which serous fluid and coagulable
lymph are poured out
In 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 oi^an. Finally, this fibrous tissue compresses the small twigs of the
portal 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 organ in the latter stages, the outer surface presents
a granular or nodulated character, which has given rise to the designation, " hoh nail
Hver." The yellow color of the organ is also due to the hrge amount of yellow pig-
ment contained in the secreting cells, and hence the term cirrhosis. The capsule is also
sometimes thickened and adherent to the surrounding parts.
In the firm, tenaceous, granular liver, ^suiting from the congestion caused by
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624 Dropsy from obstruction of Circulation of Blood through Uver.
obstructed cardiac circulation, and which hag frequently been mistaken for cirrhosis^ the
^ depressions, however, correspond to the centre of the lobules, whereas, in true drrboos,
they are at the circumference.
Ascites, resulting ftom portal obstruction, is met with oftener in cirrhosis than in tnj
other disease of the liver. The fluid in the peritoneum, is a dear yellow, serum, rich b
albumen, and without any blood or inflammatory products. In consequence of tba
congestion and distention of the veins that return the blood from the intestines and
peritoneum, the serous portion of the blood transudes through the walls of the vesseb
into the peritoneal cavity, and when once ascites appears, it persists and gradoaHj
increases ; and when the amount of the effused fluid is large, it may compress the
inferior vena cava and iliac veins, and thus produce secondary oedema of the legs, Irat
it is a peculiarity of dropsy from uncomplicated portal obstruction, that the asdtei
precedes and preponderates over dropsy elsewhere. A laree 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 fVom the ascites caused by cardiac
disease, by the fact that the dyspnota 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 nrat,
independently of any disease of those organs, the albumen disappearing from the uriae,
after the removal of the pressure by the operation of paracentisis.
The following cases will illustrate the characters of dropsy resulting from poital
obstruction:
Gasb 686 : Dropty resulting from obstruction of the portal circulation in Cirrhotu of the Uver.^
This case illastrates in a striking manner, the effects of obstri^ction of the portal circalatioB,
in the production of ascites, and of serous effusion into the cellular tissue of the lover
extremities.
S. McL , native of Rapides Parish, Louisiana; latelja resident of Catahoula Parish: bu
been engaged in farming during the past two years ; age 35 ; height six feet ; blue ejet, dark
hair, dark complexion, thin beard ; no heriditarj tendencies ; up to the present attack b&i
enjoyed good health with the exception of occasional attacks of chills and fever. Patieat
says that he has used ardent spirits in moderation, and never to excess, except upon one oeca*
sion when he had an index finget shot off.
Patient states that three months since, was seized with violent abdominal pains, exteadiif
from the umbilicus to the pubis, and attended with griping. A few days afterwards was seised
with violent vomiting and ejected a large quantity of blood (**an ordinary blue backet full";)
the vomiting and loss of blood was attended with great exhaustion ; four days aftervards.
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 wilk
swelling of the lower extremities. Purgatives and diuretics were administered ; the paticst
remembers that F4leterium was used which appeared to be productive of no benefloial eActt-
Three weeks since his lower extremities began to ulcerate, and the ulcerations 'nvolved tb*
subcutaneous areola tissue, and ragged indolent ulcers appeared.
This patient was admitted into the Charity Hospital, ward 19, bed 284, on the I3th of Apr£
1869, in.an exhausted, restless state; abdomen greatly distended; lower extremities OBdeas-
tons and ulcerated. Auscultation and percussion revealed no disease of the heart and Isift.
The lungs and diaphragm were forced upwards by the effusion in the cavity of the abdoaet,
the heart also appeared to be pressed upwards and forwards.
The sounds of the heart were unusually distinct and abrupt, and sharply defined, but m
enlargement, dilatation, degeneration or valvular disease could be discovered. The Imp
were resonant; the respiration was more frequent than usual, from the abdominal prewire,
but there were no signs of obstruction in the pulmonary circulation; no pleuritic efniiei,
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 distinct arborescett
appearance upon the abdominal parites. The lower extremities were greatly swollen, and tk«
legs ulcerated, with thickened, indurated discolored integument. The general comple^
was sallow and anatmic. Tfie urine was scant, high-colored, and loaded with biliary acids.
The swelling was circumscribed by the superior wall of the abdominal cavity, and in fSi^by
the diaphragm. All above this was of the normal appearance, and the face, and arms, s^
thorax, were thin and wasted, almost skelelou-Uke, whiUt 9iU Uelow tl?e diaphra^ WS8 «w«l'
len and infiltrated with serous fluid.
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Dropsy from obstruction of Circulation of Blood through Liver. 625
The tallow^ jaundiced hue ; the presence of the constituents of bile in the urine ; the limitation of the
iweUing to the abdominal cavity and lower extremities ; the absence of all organic disease of the heart
and lungs ; the absence of albumen and of fibrinous casts from the urine ; the abdominal dropsy y and the -
fongettion of the venous system of the abdomen and lower extremities^ all sustained the diagnosis^ that
this was a case of Cirrhosis of the Liver, in the latter stage of contraction^ unattended by disease of
the hearty lungs or kidneys.
The bowels were opeDed with two Compound Cathartic Pills, and the patient was placed
apon the diuretic mixture composed of Cream of Tartar oz. i, Juniper Berrj Tea (Juniper
Berries oz. 1, boiling water f. oz. xvi ; after cooling strain) f. oz. xvi; to be taken in wine-
glassful doses during the twentj-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
urates, which disappeared when the urine was heated, aad 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 fluid distending the abdomen, and also to the small amount of nourishment taken, the
ansmic 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.
In two hours the nausea returned, and the patient vomited a similar amount. The matter
was so 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 : bnvrc^la
free. Appetite poor.
April 17th. — The nausea, with occasional efforts at vomiting, continuing, tl
Potassa and Infusion of Juniper Berries were discontinued. No appetite.
Seven and a half fluidounces of urine collected ; high colored and loaded wi
and urates. Ulcerations of the lower extremities improving under the use of
ointment. Patient restless and unhappy. It has been necessary to administer
evening to produce rest. Tincture of Cinchona, of Gentian, and of Rhubarb
of two parts of the former to one of the latter, have been given, properly di
glassful doses, as a tonic and gentle laxative.
April 18th. — Symptoms the same ; the distention of the abdomen has
increased. Only four fluidounces of urine collected during twenty-four hours
April 19th. — No change; distention of the abdomen so great as to embarrn
distressing manner the action of the heart and lungs.
it was determined to tap the patient upon the following rooming. Sixt<
oances of urine were collected; upon careful^esting no albumen was discover
colored and loaded with urates and biliary acids; specific gravity, 1030.
April 20th. — Operation of paracentisis performed midway between the ar
spinoQs process of ilium and umbilicus; three and a half gallons of serous fli
off, which presented a light golden yellow color. Specific gravity of serous
npon the application of heat, the coagulated albumen filled about one-fifth ol
The patient expressed great relief. Percussion revealed no enlargement of tl
actual diminution in the volume of this organ. After the application of the b
the abdomen, the patient was put on stimulants and nutritious diet.
Seventeen ounces of urine collected, high colored, loaded with urates and biliary acids j
free from albumen ; specific gravity 1027.
April 21st. — Condition of the patient apparently improved by the tapping; appetite good ;
swelling rapidly subsiding from the lower extremiiies, and ulcers healing. Twenty-four fluid-
ounces of urine collected ; high colored ; specific gravity 1027 ; no albumen.
April 22d. — Patient perspiring freely ; previously the skin had been dry and hnrsh. Serous
fluid gradually accumulating in the abdomen. Appetite good, spirits cheerful, bowels regu-
lar. Urine presented similar character.
The patient was placed upon a gentle course of mercury, one grain every four hours and
on the 27th his gums were slightly touched ; the abdominal swelling, however, went on
steadily increasing. The patient continued to lose strength, and the accumulation o^f serou,?;
78
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626 Dropsy from obstruction of Circulation of Blood through Liver.
fluid in the abdominal cavity continued until the distention was as great as before the firs^
tapping, bedsores began to form on the 29th, and a persistent diarrhoea set in, which wti not
arrested by astringents.
The patient became delirious on the night of the 30th, and lay in a semi-comatose statf,
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 actstl
death, and finally died at 4 o'clock, p. m., May 3d.
The poat-mortem 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 disteodfd.
The abdominal cavity contained near four gallons of serous fluid.
The lungs were hcHlthy ; without tubercles, or adhesions, or any marks of inflammitorr
change.
The heart was normal in size, with no lesions of the valves ; the pericardium, bowerer,
was adherent, and this adhesion of the serous membrane of the heart, tbronghoat its entirt
extent, accounted for the more distinct sounds of the heart.
The liver was greatly contracted, hardened, and of a slate color; and the spleen also was
enlarged and hardened, and of a similar color with the liver. The kidneys were congesteil
but healthy. No derangement beyond congestion of the blood-vessels was discovered in tbe
kidneys.
The liver was cirrhosed, hardened and greatly diminished in size ; the weight beiog only
twenty-four ounces ; the length ten inches, and breadth four and a half inches, and greatcsi
thickness two and a half inches. The liver bad lost the appearance of divisions into lobnles
upon the exterior, and resembled an elongated flattened spleen.
The color of the liver was slate on the exterior, and a mottled olive green yelloT and
bronze within.
The peculiar color of the liver appeared to be the result of the previous attacks of mtlariil
fever, and the slow action of the malarial poison. Under the microscope, the fibrooi tissae
was found to be greatly increased, and the dark masses of altered hsmatin were scattered
throughout the structures, giving to the organ, its peculiar malarial hue. The liver cot like
leather and was firm and bard.
The spleen was enlarged and indurated and had lost the natural splenic mad Weight of
spleen; nine ounces; length, six inches; breadth, three and a half inches; thickness, od«
inch. Spleen cirrhosed like the liver, and cut like leather. Contained nameroqs m^seiof
bsmatin and altered blood corpuscles.
This then was a case of undoubted induration and contraction of the liver, unaecom
panied by disease of the heart or kidneys ; but attended with the marks of pre-extst-
ing malarial disease.
The relations of the action of the malarial poison, to the induration and coDtnctitiQ
of the liver, are of the most important character, and demand further investigation.
The question is, whether the effects of the malarial poison were merely concurreat
^ith, 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 subsemient
contraction and induration of the organ.
This case resembles the chronic atrophy of Frerichs, or the red atrophy of Bokitanskj,
in which there is no nodulation or granulation of the outer surface, and not necessariij
any thickening or adhesions of the capsule, The liver affected with the chronic atropby
of Frerichs, like that of the oase now under consideration, presents a dark-brown, or
bluisb^red color, firm consistence and homogeneous appearance, with litUe or no iadi-
cation of a division into lobules ; the secreting cells being smaller than natural iB<i
loaded with dark-brown pigment granules. In like manner, the atrophy of the otjm
is general, and as in the present case it has been known to weigh only twenty-four
ounces. But the most important anatomical character of chronic atrophy, is said to be.
the destmctioQ of the ramifications of the portal vein, the branches of which temuBite
in club-shaped extremities, so that the organ cannot be minutely injected from the por-
tal vein.
Pathologists describe this comparatiyely rare form of liver disease, as being occaaioB-
ally seen in connection with simple and cancerous ulcerations of the stomach and iiit&-
tines, or with a deposit of blood pigment in the minute vessels of the liver, in the bodi«
of persons, who have suffer2<|^ long or often from intermittent or remittent fevers.
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Dropsy from obstruction of Circulation of Blood through Liver. 627
It is well known tbat both the liver and spleen are conge3ted during; the cold stages
of intermittent and remittent fever, and during the action of the malarial Doison, either
in its most active manifestation, or in the state of chronic malarial pois
blood corpuscles are destroyed in large numbers both in the liver and
It is reasonable therefore to refer the induration and atrophy of the
in its first origin, to the action of the malaria.
In five cases observed by Frcrichs, cirrhosis of the liver was prece(
intermittent fever, a coincidence which has been repeatedly mentione
vers. Frerichs states however, that on the whole, granular infiltrati<
a rare lesion in individuals who have died from the cachexia of interi
he had more frequently found either simple chronic atrophy or fatty,
colloid infiltration. It would appear therefore, that other agencies m
(he development of cirrhosis in intermittent fever, and the precise nati
cies is obscure. In an extensive series of observations on malarial f^^
to connect cirrhosis of the liver directly with the action and effects of tb
for many stout, athletic men, who were suddenly stricken down after a sh
one to four days, a few weeks after entering for the first time in thei
region, presented marked cirrhosis of the liver. For in such cases, the <
referable to some antecedent cause. And in such investigations it si
mind that a certain amount of cirrhosis may exist for a length of time,
ceptible impairment of health ; and without incapacitating stout labori
daily performance of their arduous duties.
The three following cases of cirrhosis of the liver, recorded by Fr<
of notice, inasmuch as they were preceded by obstinate intermittent
them not one of the causes existed which are wont to give rise to cirr
others, the abuse of spirituous licjuors, etc., could not with certainty 1
Casb 687 : Persistent Intermittent Fever ; Irregular Ilahits of Life ; Gastric Ca
dice ; Cachexia ; Ascites ; Paraccntisis ; Collapse. — Death, Autopsy. — Finely-
of Liver ; Splenic Tumor witli slight pigment deposit ; Catarrhal Tumefac
Membrane of the stomach ; Cicatrices in the Duodenum ; Typhus (sic)
Ileum.
Cask 688 : Rosina Fritze, aged 28, was a patient in the Clinical Departn:
Hospital, from the 14lh of April lo the 20th of May, 1857.
rp to the beginning of 18r)7, she had been at service in the country, wo
ing in the house, and in the afternoon, out of doors, and she had then b
drinking from one lo two glasses of brandy daily. During the previous sui
she had suffered first for six weeks, and afterwards for four, from a tertian
for which she had been treated in the Ohlau Infirmary. During January
seemed to have led a very irregular course of life. The patient stated t
before admission, her appetite had failed, and she had been troubled with \
in the right hypochondrium and epigastrium, and during the same period \
swelling of the abdomen, and a pale, yellow tinge of the skin. Three we<
had become swollen.
The patient was jaundiced, and remarkably emaciated ; the skin was c
sured, and covered with branny scales; there were extensive ascites, i
enlargement of the veins upon the abdomen. The lower extremities wer
matous ; the upper were free from oedema.
Percussion of the chest presented nothing abnormal ; loud, sibilant, ai
Hudible over the back part of both lungs ; the patient complained of a troub
Heart normal.
The hepatic dullness was completely absent at the epigastrium ; in the r
it commenced at the sixth rib, and extended downwards about 4 centime
inch); but the percussion tone was nowhere completely dull. The spl
raenced at the eighth rib, but its lower margin could not be defined, owing
the (Edematous condition of the integuments. The abdomen was greatly d
quantity of liquid and gas, but was nowhere tender. The tongue was coat
After the administration of Tincture of Colocynth, the bowels were freely
were of a brown color. Urine scanty, scarcely 300 cubic centimetres, (1
the day, dark, reddish-brown^ dense, with a reddish sediment of urates, ai
of bile pigment,* It was free from albumen. Pulse 80.
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628 dropsy front obstruction of Circulation of Blood through liver »
On the 19£b, pulse 84 ; respiration 22. The ascites and dyspnoea were rapidly iocreABin^;
less jaundice ; urine more scanty, only about 200 cubic centimetres, (about 7 flatdounces), ie
24 hours, turbid, neutral and rapidly decomposing. The sediment contained a large qaantity
of globular lithates, also triple phosphates, and a few small octohedres of oxalate of lime.
The patient complained of pricking pains in the liver, and was very morose. Was order«4
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 dyspncra was more
urgent, the secretion of urine bad almost entirely ceased.
On the 5th of May, paracentisis was performed, and about five pounds of a bright yellow,
perfectly clear fluid were drawn off from the abdomen.
On the 6th, pulse 90; respiration 26; had slept well. A large quantity of serum was
flowing from the punctured wound. The region of the liver was tender when toachei.
Stools very 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 I7th, 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, on the
following morning, the patient died rather suddenly.
Autopsy, — Body extremely emaciated ; no jaundice ; no cedema of feet. ♦ *
Fodr pounds of yellow, tolerably clear fluid in the abdominal cavity. Spleen 5J inches
long, 3} inches broad, 1 inch thick, flabby, reddish-brown, and infiltrated with bloish-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 C0D8isteDc«.
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.
Case 689: IntermiUent Fever of teven monM duration ; Aictics ; Hydrsemia ; Anasarca; Death
from (Edema of the Lungs, Autopsy. — A moderately enlarged pigment-spleen. Cirrhosis of tli«
liver. Mucous membrane of the stomach and intestines, and likewise the kidneys, normal.
Casb 690 : Old Pleuritic Exudation ; Persistent Intermittent Fetyer ; Tubercle of both Lmngs :
Ascites ; Bronzed Skin ; SmaU Liver ; Dyspeptic Symptoms. Autc^sy. — Firm adhesions of Pleur*.
Tubercle of the lungs. Cirrhosis of the liver. Snper-rennl capsules normal.
Spleen of moderate siee, tolerably firm, and dark brown. Liver very small, anifonnlj
granular, firm, tenacious, and of a yellowish brown color. Two concretions of a mnlbcrrr
form in the gall-bladder. Supra-renal capsules in every respect normal. The cortical sub-
stance of the kidneys presented several cicatrix-like depressions, but in other respects
these organs were healthy. (Clinical Treatise on Diseases of the Liver, Vol. ii. pp. 63-69).
Cask 691 : Dropsy resulting 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 nj
treatment, presents several points of interest, and the dropsical effusion in the cavitj of tht
abdomen, and into the cellular tissue of the face, and upper and lower extremities, were dnc
to both cardiac disease and cirrhosis of the liver. The following outline of this case will serrt
for comparative dedactions :
William Woods, aged 47 ; dark hair, dark complexion ; in health, a large, powerful, stout
athletic man ; ship carpenter by trade ; has been sick about two years ; says that his disease
commenced whilst working in the water; has always used ardent spirits daily, in larger or
rather pretty free quantities.
Entered the Charity Hospital November 9th, 1868. At that time the abdomen was miKk
distended with serous effusion, and it has been necessary to tap the abdomen upon seven]
occasions, and several gallons of water have been drawn off.
When this patient came under my treatment, in the month of March, 1869, the complexies
was of a wax-like, unhealthy, jaundiced hue ; the features of the face were swollen and UriJ
from venous congestion ; the abdomen was distended with dropsical effusion, and the extremi-
ties were oedematous. Patient feeble, but able to sit up and walk about a little. Great
obstruction of venous circulation ; veins of neck distended with black blood. Lips livid.
Arteries in all parts of the body, where they could be carefully examined, greatly enlarftd
and tortuous, with a powerful beat. The column of blood is sent out with great force froa
the heart, giving a powerful beat to the arteries, which appeared to be nniversally enlar^
and degenerated. This degeneration of the arterial system is still farther shown by the orvr
senilis. Great oppression in breathing. At times the restlessness and oppression very greai
Patient cannot lie down with comfort) but requires to be propped up in bed. Percnssiofl
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Dropsy from obstruction of Circulation of Blood through Liver, 6^9
and aascultation revealed dallness in the lower dependent portions of the lungs, and greater
flatness over the chest than in health ; there were no symptoms of pneumonia, or pleurisy, or
of phthisis, and the dullness was referred wholly to the obstruction of the circolation. Heart
greatly enlarged, with a powerful beat. The dullness, upon percussion, extends from the
jaoction 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:
TU-u-CHUCK. The sounds of the heart resemble those made by an ordinary steam tug. The
sounds of the heart are heard with great distiuctncss along the track of the large arteries,
and especially of the carotids.
Abdomen greatly distended with serous effusion. Liver apparently diminish^'i »" «'«*» «n'^
hardened.
Derangement of the liver is evidenced aside from the ascites, by the yellow j
of the complexion, and the great amount of bile in the urine. (Kdema of extremi
constipated. Appetite poor. No marked febrile phenomena. Patient dull and
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 cuntmued to grow worse ; treatment was only palliative, and h
27th of March, 1869.
Th^ Post-nwrtem Examination^ performed six hours after death, revealed enormou
of the heart; this organ was eight inches in the longest diameter, and six and
in transverse diameter, after being emptied of the dark venous blood which
cavities, and after being preserved in alcohol. During life, when distended ¥
dimensions were much greater. All the cavities of the heart, but more espe
ventricle, were dilated, and the auriculo-ventricular openings were greatly
thickening of the auriculo-ventricular valves was observed.
The valves of the aorta and pulmonary arteries were somewhat enlarged and
nerated, but no deficiency or adhesions or calcarious degeneration were observe
Aorta and pulmonary artery ; but especially the former, degenerated, roughenc
The dilatation of the aorta amounted in the ascending portion and ftrch almost
The arteries were universally dilated and degenerated in their structure, and
great measure to have lost their elasticity. Microscopical examination showed
tation and loss of elasticity was due to the conversion of the unstriped musci
fat. The liver presented a rough hob-nail appearance upon its exterior; it w
diminished in size ; the capsule was greatly thickened, and could be pealed off,
tures were cirrhosed.
Kidneys congested, but healthy in structure — no degeneration or alteratio
textures.
Spleen somewhat enlarged.
This liver, as in all the other patients who had been exposed to the malari
the Mississippi valley, presented a darker color than usual in cirrhosis, and i
dence in the dark granular masses of the preceding destruction of the color
pascles.
The dropsy ia the preceding case was clearly referable to cirrhosis of
cardiac disease.
Casb 692: Cirrhom of Liner ; Chronic Dy^entmf i Atcites. — John L K wing, q{
Mississippi, Brakesman on Railroad.
Entered Charity Hospital, ward 13, bed 198, August 17th, 1872; died Febrt
Cause of disease, exposure to wet and cold, especially at night, combined wit
and excessive use of alcoholic liquors. Father and mother of patient healthy,
of their deat)i, from Typhoid Fever, in 1869. Light blue eyes ; light brown an<
hair and beard ; florid complexion ; height 6 feet, 9 inches ; weight in health 1 1
good health np to January, 1872. The only serious disease with which he h
the Small-Pox. In January, 1872, suffered with severe pain in region of the 1
the abdomen and diarrhcea ; continued working however, until the lat of Ju
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639 Dropsy from obstrueiion of Circulation of Blood through Liver.
swelling commenced about the 1st of July, and the patient entered the Charity HoBpital of
Nevf Orleans, on the 1 7th of August. Has been in the habit of drinking strong ardent spirits,
(Whiskey and Brandy); his custom for several years, has been to take from one to three
drinks of (raw undiluted) Whiskey in the morning, before breakfast. The dropsical effusioo
into the abdomen rapidly increased after his entrance into the hospital. Was tapped, SepL
26th, October 8th and October 15th. Abdomen distended with dropsical effusion. Veins of
abdomen distinct and arborescent in appearance. Lower extremities distended with fluid.
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 aoy
oedema, but thin and wasted. Action of heart feeble, but regular: no cardiac derangemeuL
Upon percussion and auscultation, the lungs also are found to be healthy. Respiration some-
what embarrassed, and diflBculty 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. Careful che-
mical and microscopical examination of the urine, demonstrated the absence ot both albamea
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 mucou
discharges streaked with blood.
The results of the preceding examination lead me to exclude the heart, kidneys and langs,
from any connection with the dropsical effusion, and accordingly the following dia^nom:
cirrhosis of the liver and chronic dysentery ; anasarca of lower extremities and ascites of
abdominal cavity, caused by the portal obstruction ; prognosis 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 seroos
fluid from cavity of the abdomen 1007.5. Microscopic examination revealed the presence of
numerous colorless blood-corpuscles and exudation spindle-shaped corpuscles. The serous
fluid from the abdomen was coagulated, both by heat and the mineral acids. Upon analysis
1000 parts of this serous fluid yielded 19.5 parts solid residue, of which 9.9 parts were dried
albumen, and 8.7 parts salts and extractive matters. Each pint of the dropsical fluid yielded
63.6 grains of dried albumen ; each gallon 508.8 grains, and the entire quantity of flaid con-
tained in the cavity of the abdomen (4 gallons,) yielded 2035.2 grains of dried albameo.
Reaction of serous dropsical fluid, alkaline. Upon standing, a few small fibrous floccuH sepa-
rated. The putrefactive process was slowly set up, and a number of vibros and fungi were
developed.
The 2035.2 grains of albumen contained in the whole amount of dropsical effusion, correi-
ponded to the serum of 28,899.84 grains of blood, which 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 the
dropsical effusion ; the tension being thus removed, and the lungs and heart being relicTed of
the pressure. A tight bandage was applied around the abdomen.
After the tapping, the dropsical effusion rapidly disappeared from the lower extremities, and
the abdominal cavity commenced to fill up rapidly, and in 24 hours a perceptible accumuUtion
of fluid had taken place.
The pulse ranged from 100 lo 110, and the temperature oscillated daily, between 100° F,
and 101«> F.
The dropsical effusion accumulated so rapidly, that it was necessary to tap the (latieDt again
on the 26th of October, 9 days after the last tapping.
October 26th, a. m., abdomen enormously distended; diaphragm pushed upwards ; brcatbiof
embarrassed, action of heart feeble and irregular, mind wandering. I introduced the trocb&r
(paracentisis,) and drew off 5 gallons of light yellow serous fluid. The walls of the abdomen
were somewhat thickened, especially the peritoneal coat ; and there had been some tenderneii
of the abdomen, after the last tapping.
Specific gravity of dropsical fluid lOOT.C; reaction alkaline. Under the microscope the
fluid contained colorless blood-corpuscles ; 1000 parts contained dried solid residue 17.6 paru:
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 dried
albumen.
The relief from the tapping was only temporary ; the effusion disappeared from the lower
extremities, and increased rapidly in the abdomen. The application of a tight bandage aroaod
the belly, appeared to exert but slight influence in preventing the return of the dropsical
effusion.
I determined to attempt the reduction of the dropsical effusion, by exciting the'kidneys to
increased action ; and accordingly on the 27th of October, commenced the admlnistratioB ai
regular intervals of 4 hours, of a powder composed of eight grains of powdered Squill, oo«
and a half grains of poWdered Digitalis and three And a half grains of Nitrate of Potash.
The sixth of a grain of Sulphate of Morphia, was also administered at bed time*
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Dropsy from obstruction of Circulation of Blood through Liver. 631
October 30lh. Patient very weak ; delirious; dropsical effusion 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 bus slowly decreased, and it has not been necessary again to
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
medtcihe 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
and upon careful analysis, I found that this amount of serous fluid contained
albumen, which was equal to that contained in the serum of about 17 pounds (
the whole amount of blood contained in the body of a man of this size, might
at about 24 pounds, it is evident that from the 26th of September, to the 26t1
(one month,) the greater portion of the albumen of the blood, that is an amoui
nearly equal to that contained at any one time, in the whole mass of blood, hac
into the cavity of the abdomen.
Under the systematic employment of the Bitartrate of Potassa, Sulphur ai
dropsical effusion, was not only kept from accumulating, but was entirely rem
such an extent that the lower limbs presented a shrivelled- appearance, and
reduced very nearly to the normal size in health.
When necessary, opiates were given to induce sleep, and the diet was nutrition
^SS^t mutton and beef, milk, rice and bread.
The Chronic Dysentery however, and the constant pain attending the action o
slowly reduced the strength of the patient, whilst at the same time, the digestio
lation of food, were imperfectly performed, and the patient died December 30th,
Autopsy 12 hours after death.
Exterior, — Face, neck, arms and thorax greatly emaciated. Abdomen, flaccid
reduced in size in comparison with its former dropsical condition. Lower extn
normal in size and but slightly swollen.
Thorax. — Muscles normal in color ; adipose tissue completely absorbed ; peri
heart, normal in size and position ; heart normal in all its parts. Pleura and 1
Lnngs without structural alteration or congestion.
Abdominal Cavity. — When the abdomen was opened, about thirty fluidounces of
fluid poured out. Surface of the peritoneum, rough and nodulated from the eff
gulable lymph. The fibrous nodules of the peritoneum varied in size from J to
in diameter. Sub-acute inflammation had evidently been excited in the p(
tapping.
Alimentary Canal. — Stomach, normal. Jejunum and Ileum, somewhat co
healthy. Mucous membrane of large intestine studded with the cicatrices o
Some of them appeared to have completely healed ; in the rectum however, some
ated surfaces presented a bright congested appearance and appeared to be in a s
inflammation.
Ztper.T— Color of liver yellow ; surface nodulated and irregularly contracted
liver, 2 pounds and eleven ounces. Liver contracted and cirrhosed, the hardenii
marked in the Portal system of Capillaries bordering the individual lobuli. Wh
periphery of each lobulus was hardened, the interior was softened, and contain
within and around the hepatic cells. Under the microscope the excretory cell
were filled with oil globules, and the oil was greatest in the centre of the lobuli
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 : Cin
and Chronic Dysentery.
Case 693: Enlarged nodulated Liver; Cirrhosis and Tubercular Deposit; Ascites
Ah Choo, Chinaman. Admitted to ward 30, bed 449, Charity Hospital, Novemb(
Died December 10th, 1874. Diagnosis: Cirrhosis, and Tuberculosis of Live
unfavorable.
Patient says that he has been sick for several months. At the period of entran(
presented a golden hue, the sclerotic coats of the eyes bein^ tinged of ^ deep ye
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632 dropsy from obstruction of Circulation of Blood through Liver.
men digtended with dropsical effusioD. Li?er greatly enlarged, extending some 3 inches
below tbe border of the false ribs. Urine loaded with bile and urates. The urates were ia
such abundance, that upon the addition of Nitric Acid, a heavy deposit resembling that caojtd
by albumen, took place, but this was cleared up by heat.
When pressure was made over the region of the enlarged liver, the 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 J of an inch to IJ inches. Under the microscope the nodolar
masses consisted of granular matter, small cells like those characteristic of tubercle, liver
cells filled with oil, oil globules, and fibrous tissue.
Cask 694 : Congenital Enlargement and Cirrhosis of Liver ; Ascites ; Fever ^ and persistent Jaundice :
Passive Htemorrhages into Cellular Tissue ; fatal result. — Infant daughter of Doctor of New
Orleans, born January 6th, 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 birth, but it was not previously noticed because light had been
excluded from the room. A few small doses of calomel were administered, but no apprehen-
sion was felt by the parents, as the infant appeared to be healthy in all respects, with the
exception of the universal jaundice.
I was called in consultation about the middle of March, and upon careful examioatioc, found
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 effused into the abdominal cavity. The liver extended across the epigastriam
and encroached upon the left hypochondriac region ; and on the right side it projected about
three inches below the border of the 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 could
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 paroxysms
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 agonizing; the littk
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 discharges from the bowels
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 as Tincture 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 necessary
to induce short periods of rest. The intellect of the child, however, continued bright, and
the appetite good, and the digestion apparently unimpaired. Liquid continued to accumulate
in the 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 res-
piration. However, by the persistent and free use of the Bitartrate of Potash, in purgative
and diurectic doses, the effusion was so fur reduced and controlled, as to obviate the neces-
sity of the tapping.
About the beginning of the 9ih month, haem'jrrhage occurred from a slight abrasion or
ulcer on the franum of the tongue, which continued at intervals of a week, and was res-
trained by the local and internal use of the Tincture of the Sesquichloride of Iron. There
supervened a general haemorrhagic condition. Hsmorrhages took place in the cellular tissae
beneath the skin, in the legs, arras, body, head and face. The position of the local haemor-
rhages were indicated by circumscribed, hard, dark colored, elevated tumors of various sizes,
from one-half un inch to three inches 'in diameter. A free hemorrhage into the cellular
tissue occurred suddenly in the left cheek. Blood was poured out into the tissues, until the
whole side of the face and the mouth was distorted. The whole cheek, both within (mucous
surface) and without, presented a purplish, almost black color. The diameter of this ckrt
appeared to be about three inches. The haemorrhage into the cellular tissue of the left check
occurred seven days before death. A haemorrhage of about equal amount occurred in tbt
cellular tissue of the right side of the head, above the temple.
Kighteen hours before death, a violent fever supeir^enedj attended with cough, and great
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Dropsy from obstruction of Circulation of Blood throu
oppression of breathing, and finally, with stupor. Before death, the <
and large quantities of bloody mucus issued from the mouth and nostri
The preceding case is of interest, as illustrating the effects of the
ID inducing passive hasmorrhages in the cellular and muscular tis
mucous membrane of the mouth and stomach.
The effects which were slowly induced in this case, are rapidly i
eases of yellow-fever, in which, in addition to the action of a specie
the rapid and marked elevation of temperature, there is also indue
We vill consider briefly in the next place :
THE TREATMENT OF HEPATIC DROPSY.
The treatment of dropsy arising from portal obstruction, mufi
upon the cause of this condition, but also upon the various comp
aod renal disease. The preceding cases illustrate in a clear mai
dtropsy may be referred in the same case, to several causes, as cirrho
cardiac disease ; it is therefore absolutely essential that the physici
possible, clearly recognise in each case the cause or prominent can
effusion. It would be foreign to our purpose, to discuss the mode
cable to all the diseases of the liver, which may give rise to ascites ;
be to indicate briefly the mode of treatment of that form of dropsj
preceding cases, viz : ascites arising from cirrhosis of the liver.
Cirrhosis of the liver is at the outset obscure and insidious, and is i
oilen extending over several years: the physician therefore rarely hi
treating the disease at its commencement. When, however, the exis
is indicated by the symptoms of disordered digestion, loss of appeti
ular action of the bowels, pain after food, dull pain, with slight ten(
hypochondrium, and slight enlargement of the liver, occurring in a
spirit drinking, attention should at once be directed to the habi
patient. Alcoholic stimulants, and rich, indigestible, stimulating fo
should be interdicted, and the patient confined to spare, but nutriti
of such articles as milk, eggs, and farinaceous substances, with a m(
meat and fish. In order to avoid the occurrence of delirium treme
sary in some cases in which the habit of taking large quantities of
has been fully established, to reduce the amount gradually. The b(
freely open, by saline purgatives, and occasional doses of blue mag
the general h^th preserved by regular exercise in the open air.
If the pain and uneasiness, in the region of the liver, is well
leeches, dry cups and cut cups may be used over the affected organ.
If the liver still remains enlarged, after the subsidence of pain, t
of Iodine — either locally, in the form of the tincture or ointment,
the liver, or internally, in the form of the Iodides of Potassium anc
Solution should be carefully tried. If these measures fail in
recourse may be had to the mineral acids, the Hydrochloric, Nitric
Acid, internally, and to the Nitro-muriatic acid bath*.
When the stage of contraction of theMiver sets in, as evinced b
area of hepatic dullness, jaundice and ascites, there appears to be i
which will restore (he liver to its noinial condition, or remove th(
*The Nitro-muriatic Acid Bath is prepared by adding two ounces of
Acid, and one ounce of strong Nitric Acid to two gallons of water, at
earthen or wooden vessels should he used, and the feet and legs are ii
whilst the thighs and right side are spooged with the acid solution. T
main in the bath from half an hour to one hour. The bfitb thus prepnr
at least every third or fourth daj-.
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634 Dropsy from obstruction of Circulation of Blood through Liver ,
portal circulation. In this stage the efforts of the physician are direoted 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 be nutritious but not stimulant, alcoholic stimulants should be
entirely prohibited, or used only in cases of emergency and with ^nreat caution ; tiie
digestion should be improved by such tonics as Quinine, Gentian, Nitro-mnriatie 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 hdf
a grain of powdered digitalis, one grain and a half of powdered squill and two 'graiiis
of blue pill, has been administered with benefit in cases of ascites, dependent upon
hepatic disease, two or three time daily.
The diuretics and purgatives previously recommended in the treatment of cardiac
disease may be employed. As a rule, however, the ascites slowly increases, and aoontx
or later it is necessary to resort to the operation of paracentisis ; tlus should be ddayed
as long as possible, for notwithstanding the temporary relief afforded, and the indexed
action of the kidneys, the fluid usually collects again rapidly, and the patient is
exhausted by the great drain of albumen from the blood.
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CHAPTER XV.
DBOPST ARISING FROM DERANGEMENT OR LESION OF THOSE ORGANS WHICH REGULATE THE
AMOUNT OF THE BLOOD, AS WELL AS ITS CONSTITUTION, BY REGULATING THE AMOUNT OF THE
WATBRT ELEMENT, AND BY THE ELIMINATION OF EXCREMENTITI0U8 MATERIAL. DROPSY
A8I8ING FROM DISEASES OF THE KIDNEY. DROPSY RESULTING FROM BRIGHTS DISEASE OF
THE KIDNEY. BRIGHT'S DISEASE OF KIDNEY. ANASARCA. TREATMENT OF DROPSY ARISING
FROM DISEASE OF KIDNEYS.
The kidneys not only regulate the amount of the watery element of the blood, but
they also eliminate certain noxious substances, resulting from the metamorphosis 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 accumulation of the watery element, and certain excremen-
titioos matters in the blood, derangement in the processes of absorption and exhalation,
and disturbance of the sympathetic and cerebro-spinal nervous syjBtem.
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 one-half a fluidounce, to six-tenths
or seven-tenths of an ounce for each pound avoir, of body weight ; a man averaging
140 pounds, will therefore take about seventy to ninety fluidounoes 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 kind.
But the amount taken, varies within wide limits, in different circumstances, and
from individual peculiarities ; some men take only sixty ounces — others as much as
one hundred and twenty, or even more ; more water is consumed in a dry than in a
moist climate, and during great exertion, than during a period of rest. The mean
amount of water excreted through the kidneys by different male adults, varies from
thirty-five to eighty-one fluidounces a day. The variations in the amount of water
excreted by the kidneys, will depend upon the varying quantity introduced into the
system; and upon the varying 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 to eighteen hundred pounds
of water. This great and continuous circulation of water through the living being is
essential to the existence of life, and the performance of the various functions. Thus
during 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-health, and finally death, will result. To accomplish the con-
tinuous removal of the various useless ahd noxious substances, there is first, the almost
universal solvent, water ; second the circulatory apparatus, in which these substances
are received, and by which they are 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. We are thus enabled to understand the reason why general dropsy
so rapidly and so surely supervenes, when the function of the kidneys is arrested or
materially impaired.
An additional cause of dropsy is also known to exist in certain dissjwea of the kid-
neys, via : The constant loss of albumen by transudation through the capillaries and
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636 Dropsy arising from Lesions of the Kidneys.
excretory tubes of these organs, and the consequent derangement of the eomposttioB erf
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 caiuKe
of Bright's Disease, are, cold ; incautious exhibition of certain irritating diuretics, as
cubebs, copaiba and oil of turpentin3; the abuse of ardent spirits; the alcohol elimin-
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 suppa-
ration accompanying caries and necrosis of the bones ; the conditions of dyscrasia*
occasioned by gout, rachitis, scrofula and malarial cachexia.
In the so-^xiUed large white kidney, the cortex is pale and hypertrophied, and the
uriniferous tubes crammed with granular epithelium. The large white kidney is oflea
merely an advanced stage of acute nephritis, but it may also be developed independently,
as the result of chronic inflammation.
In the fatty kidney, the organ is large and pale, and the secreting cells loaded with
oil ; and the observationi 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 most
generally noticed first in the face ; fluid is also almost always effused into the plear»,
pericardium and peritoneum. The urine is scant, turbid or smoky, containing laige
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 appea^
ance. There is a tendency to nervous disturbances, convulsions, loss of memory, rest-
lessness, delirium and coma. The digestion is deranged, with dry tongue, foetid breath.
and obstinate vomiting.
In the production of the anasarca, which accompanies and forms a prominent symp-
tom in certain diseases of the kidney, several causes are in operation.
1st. In the acute aflfections; when dropsy comes on rapidly in a few hours, and is
almost the first indication of the disease, this symptom is most probably produoed by
the retention in the blood-vessel system, of the water, urea and salts, which should be
eliminated in the form of urine. The anasarca comes on before any great amoant of
albumen has been thrown off" from the blood by the kidneys ; the blood is still riA in
this constituent, and the change in the blood results rather from a relative increase ta
the watery element, and the retention of those noxious compounds, as urea, wbidi
should be continuously eliminated. The circulation of the blood through the capiik-
ries, depends, not alone upon the continuous action of the heart, but also npOQ tbe
relations of the blood to the capillaries and to the organs and tissues through wbicb h
circulates ; whatever, therefore, alters the constitution of the blood, deranges tbe cap3-
lary circulation, by deranging the chemical affinities of the blood and tissueB, and by
deranging the action of those portions of the nervous system which preside over and
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Dropsy arising from Lesions of the Kidneys* 63t
regulate the amount and character 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 into a more active
subetanoe, 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-
menfitious 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 Grregory, Bostock, Christison,
Andral and Qavarret, 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 1060 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 dimmished, 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.
Cask G95 : BrigUCs Disease ; Anasarca ; Ascites ; Exciting Cause of Disease^ Cold and Exposure.
— Clemens Schwcrcr, age 48 ; native of Germany ; occapation, seaman. Has always enjoyed
good health up to his present illness. Entered Ward 25, Charity Hospital, January 11th,
1871. About the 1st of December, 1871, took cold on ship-board, after being wet by a cold,
driving rain. Suffered with diarrhcca at this time, and two weeks after taking cold from the
wetting and exposure, noticed that his extremities, especially his legs, were swollen. Suf-
fered with dull pains in the head and in the small of the back, and observed that the urine
became rery scant and high colored.
At the time of his entrance into the Charity Hospital, the face was puffed and swollen ; the
extremities, especially the legs, were oedematous and greatly distended with serous eff^asion.
The urine was scant, high colored, and loaded with casts of the urinary tubes, and albumen.
Under the use of Cream of Tartar, Juniper berry tea, and Extract of Squill, the dropsical
effasion was completely removed ; the limbs and face returned to their normal size, and the
urine became abundant and light colored, and the amount of albumen diminished greatly.
During the night of the 5th of February, however, the patient slept with the window at the
head of his bed raised ; a sudden cold change occurred during the night, and upon the next
day I found the urine 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 farinaceous articles ; the patient was rigidly confined to bed ; the function of
the jBkin was promoted by the hot air bath ; and the function of the kidneys was excited
frently by Cream of Tartar, administered in flaxseed tea, conjoined with the Extract of Squill.
The effects of the congestion of the kidneys, consequent upon the actiou of cold, was almost
immediately evident, in the return of the oedema.
Under 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 1st of April was discharged at his own request.
Case 696 : Dropsy Arising from Exposure, Cold and Alcoholic />rmAr«.— Henry Nelmer, Butcher,
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638 Dropsy arising from Lesions of the Kidneys.
age 32 ; native of Germanj. Has lived in Louisiana 17 jears, and followed the occnpatioB of
butcher. Has never had malarial fever. Has been in the habit of rising at 2 o'clock in tkt
morning, and has been much exposed to wet and cold. Has been in the habit of drinki&g
alcoholic stimulants freelj. Had an attack of anasarca with ascites, in November, 1870, aad
after remaining in ward 22, Charity Hospital, for 1 month, was relieved to a considermble
extent, and went out and renewed his old occupation; but the dropsy returned ag^in upon
exposure, and he re-entered the Charity Hospital, ward 24, on the 14th of February, 1871.
The bowels were regulated by gentle purgatives, and the kidneys excited by Squill aad
Cream of Tartar, and the condition of the blood was improved by Quinine an4 Jforiated
Tincture of Iron ; and this patient was discharged from the Hospital on the 13th of AprU.
Case 697 : Anasarca; Ascites; resulting from Cold and Abuse of AlcohoUe StimulanU, — Tbomts
Moran, age 38 ; height, 6 feet; native of Ireland ; has lived in Louisiana during the last 26
years, running on steamboats on Mississippi and its tributaries. Had chilla and fever in 1851,
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 hours." Hti
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 suddailj
to the North, and the temperature becoming suddenly cold, he was thoroughly chilled.
(Edema followed by general anasarca and ascites, commenced a few days after the expoiore to
the cold rain, and continued five weeks. Patient says that during this attack he had no regt-
lar medical attendance, but took on bis own account salt and oil; and under this regular
purgative, th£ dropsical swelling progressively declined and disappeared. During this attack
he did not intermit daily work. The second attack occurred six months after, in the moath
of July, 1869; cold was in like manner the exciting cause; was acting as a batcher, aod
carried his meat around to the markets at night, and took cold after being exposed to a cool
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 honse;
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 cos-
menced to swell two or three days afterwards.
Entered ward 25, bed 374, Charity Hospital, February 1st, 1871 ; abdomen greatly distended
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 upper
extremities emaciated as well as the thorax ; lower extremities and scrotum, and penis, dis*
tended with the aropsical effusion. Urine high colored and loaded with biliary matters and
albumen. No disease of heart or lungs.
Diagnosis : Cirrhosis of Liver ; Bright's Disease of Kidney. Dropsical effusion clearly refer-
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 unsatisfactory effects of
both purgatives and diuretics in the treatment of the case. These*agents hardly restrained the
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 reliei". When 1
resigned the ward, at the close of my regular annual term of service, on the 16th April, thif
patient was in pretty much the same condition.
Case 698 : Dropsy resulting from BrighVs Disease of the Kidneys. — Frederick Mayer ; f ged 30
years ; height 5 feet 7 inches; weight 160 pounds; light, sandy colored hair; blue eyes, fair
complexion; native of Sweden ; laborer by occupation ; has generally enjoyed good health,
with the exception of chills and fever in the last two years.
Admitted March 21st, 1869, to Charity Hospital, ward 29, bed 422; oedema of the lower
extremities ; scrotum and penis greatly distended with serous effusion ; some effosioo ta
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, referred
to the praecordial region ; cough most troublesome during the night; very slight expectora-
tion ; percussion sounds over lungs duller than in health, indicating oedema of those orgaas,
with some pleuritic effusion. Patient has a large and well formed chest and there are lo
symptoms of tuberculosis. No enlargement of the heart was detected, and the cardiac mir-
mur was referred chiefly to the anaemic state of the blood. Bowels regular. The diaptomt
that this was a case of Bright's Disease, was still further confirmed by an examination of Ike
urine. Heat and nitric acid showed the presence of albumen in the qrine and casts of tbc
urinary tubes of the kidneys were detected in moderate abundance under the microscope.
The bowels were opened freely with Compound Cathartic Pills, and the attempt was made
to excite and increase the action of the kidneys, by the Cream of Tartar and Juniper Berry
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DrQfsy arising from Lesions of the Kidneys. 639
mixtar« 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 ; specific 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-
tions diet, slowly improved, and left the hospital at the end of April ; the swelling had 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 effusion. The scrotum was so greatly distended that
the skin bursi, 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 his 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: Dropsy resulting from BrigMs Disease of the Kidneys. — John Shone. The patient
gave the following history: Was admitted to Charity Hospital in 1858, with what he 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 he enjoyed good health for the space of two years ; at the end of which time he
began to be aflSicted 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 cedematous, 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 cedematous 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
contains 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; suffers'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 dyspnoea ; 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 first sound, whils.t the second sound is prolonged. Serous effusion in abdominal cavity,
with tenderness in epigastric and hypochondriac regions.
The following table will present in a condensed fprpi soine of t^e chief symptoms ;
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640
Dropsy arising from Lesions of the Kidneys.
I
r
V^
CHAKACTERS OF URINE,
~ - -
PATE.
9
1
11
REMARKS.
Am't in
I
;
5*
FS
ti hn.
Sp. Gr.
Color. lAlbu-
:
3
tnoH.
men.
April l8t, 1869, 9 a.m.
72
18
F.
98.6
68 ^ 1010
reddish
« 2d, "
72
18
98.5
110 1010
yellow
: ■
In bed and suffering with
" 3d, 1869, 5 p. 11.
72
18
99.5
110 1010
amber
"
headache.
" 4lh,1869,9A. M.
70
18
98.
150 1010
pale
Headache.
" 5th, "
70
18
99.5
45 , 1014
yellow
" 6th, "
80
99.
72 1013
...
l
" 7th, "
82
...
99.2
75 1012
\
" 8lh, *'
82
...
98.5
75 1012
i
** 8th, 1869, 6 p. M.
86
...
100.5
100 1 1010
\
" 9th, 1869,9 a.m.
83
100.
100 1 1010
i
" 10th, "
88 22
99.5
83 1010
1
<« 12-13
88
99.
80 1010
85 1010
i
Daring night headache.
»' 14th, 9 A. M
9o:;;;
on.
«' 15-16
901...
99.
75-85 1010
65 1010
50 1014
« 17-20
80'
99-100
*** 1 1
*' 2l8t, 9 a. M
9o;:::
99.2
... 1 t
On 20th, headache aid
*» 22d, "
96'...
100.7
60 1010
+
Tomiting.
" 34-25, "
80 ...
100.5
60 1010
Do. do.
" 26th, '*
82...
100.5
80 1009
...
Do. do.
" 27th->rfly l8t
80...
100.5
100 1009
Headache-
May 2d-9th
82 ...
100.
70 1010
▼
»» 11-15
82!...
82
99.5-10
99.
35-75 1010
40-50 1010
35-65 1010-1012
1 X
TTpAflAr^hA »nA fIrannrfkA
" 16-24
" 25-30.. J
80..:
99.
June 6th ,
80 ...
99.5
40-65 101?>
... i-il
.-^j
» _i a
- - - - - -
In conjunction with Dr. B. A. Pope, this patient, together with several other cases of Brigbt's
Disease, under my treatment, were subjected to a careful examination with the ophtbalmo-
scope; the characteristic alterations of the retina indicative of Bright's Disease, were dis-
covered, although they were absent in other cases of this disease ; thus showing that the
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 aid
treatment.
I was informed that after the transfer, the diuretics and purgatives were discontiDued, tod
the dropsy rapidly increased, and the patient died about the middle of July.
In this case, the dropsical effusion was restrained within certain limits by the judicious
use of diuretics and purgatives, and as soon as they were discontinued, death speedily ea-
sued.
Case 700 : Dropsy Resulting from Bright's Disease of Kidneg. —Chsirles Daley, age 60, height 5
feet 5 inches, weight in health 140 lbs.; left leg shorter than right, from having had compoud
fracture of both tibia and fibula; the patella is now quite prominent ; black hair, hazel eje«.
florid complexion in health ; native of Ireland, laborer ; no constitutional tendencies as fir ts
could be gathered from statements concerning the health and diseases of his relatives; bts
never had syphilis or scrofula ; has been in the habit of drinking whisky freely, at times to
excess, for forty years ; has enjoyed pretty good health, with the exception of a spell of chill
and fever about five years ago.
Was admitted to the Charity Hospital on the 15th March, 1869, ward 29, bed 429, wiU
general anasarca and with albuminous urine. The anasarca appears to have come on gra-
dually.
Complexion sallow, and of a waxy appearance. Features swollen. Trunk and extremities
oedematous ; pressure causes pits which disappear very slowly. Appetite and spirits very
good, but muscular and nervous forces depressed. Diagnosis; Bright's Disease of the kid-
neys.
The patient was placed upon the Cream of Tartar and Juniper-Berry Tea, Tincture of tk«
Sesquichloride of Iron and nutritious diet, and the bowels were kept gently open by salioe
purgatives.
March 30th. — Patient appears to be improving; the amount of urine has increased; the
complexion is somewhat clearer, and the anasarca has disappeared to a considerable exteit.
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Dropsy arising from Lesions qf the Kidney s^
641
Wtight at the present time about one hundred and twenty pounds. Patient oheerfol, with
a good czpreiiion of eyes, but is very weak and confined to bed most of the time. Bowels
r«galar; skin softer and more moist. Tongue natural. Urine loaded with albumen and
•MtS.
The following table will exhibit some of the more prominent symptoms :
*^
P
H
H
?
y
•
:
J
S,g
^§
1
CHABACTKR8 OF UBINE.
P ATE
1
II
(**§
•2.
^
Jtg t 2
Am-t ofi
i
•
3
'i, F
f
^i boun. Gnvltr Vrtne.
APNOIMIAI. Ck)M8TITCKN-Tt.
April Ut, 1860, 9 A. If
75
18
U
Sallow.
Confln'd
52 1008
Palo
Albumen.
" 2d7 «*
75
18
98.
Waxy
to bed.
34 1010
Yellow
C*«t0 of Tubull Uriiilfcri.
•* 3d, •♦
75
18
8305:97.6
features
Lies on
30 1010
...
l^ albumen.
« 8d,isee.6P.M
" ♦lll,18eb,9A.M...
75
18
99jb
iwollen.
back.
30 1010
...
98
25
98.
...
32 1 1010 ... y. "
40 t mo 1 ... ^4 "
- 5th, •♦
97.6
...
- eth,
...
'97.5
38 I 1008 1 ... % "
- 7th,
...
...
•
35 1010 1 ... 3j ♦'
" 8th,J869,eP.M
•..
1005 ,..
...
35 ... ]^ "
8 1010 ... ;5^ "
•• 9th, 1869,9 A. M
...
...
98.5
,,.
H loth.
UB
26
98.6 1 ...
...
. 11 ! 1025 , ... i
April 10th.— Lungs dull upon percussion, and there is a decided increase of heat every day
towards night. The urinary secretion progressively decreased, and with Jthis decrease the
swelling increased in the cellular tissue and abdominal cavity;
On 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 severe bronchitis, which seemed to prostrate him greatly, and he gradu*
illj grew worse, and died on the 5th of May. Death was preceded by convulsions and coma.
The post-mortem examination revealed adhesions of the liver, stomach, heart and lungs to
their respective serous cavities and membranes ; the liver was congested j spleen normal ;
longs contained miliary tubercles ; kidneys in a state of fatty degeneration.
Cask 701 : Dropsy remtUng from Bright' 8 Disease of the Kidneys, —John Crowley, seaman ;
native of Pennsylvania ; age 27. No hereditary tendencies can be traced. Had syphilis
twelve years ago ; the disease is said to have yielded readily to treatment, and disappeared in
three weeks. Well made, muscular man, with full, well developed chest ; blue eyes, light
yellow hair. During his sea-faring life has been in the habit of using strong alcoholic stimu-
lants freely. During a portion of bis life has acted as fireman on board steamship, and whilst
performing his duty, would frequentlv be exposed to sudden changes of temperature, and to
wet and cold, and at such times would indulge freely in alcoholic stimulants. Enjoyed good
health up to the last twelve months, when be was shipwrecked, and remained in the water
some nine hours, and contracted a severe cold, from the effects of which the patient has suf-
fered, in the way of a slight cough, up to the present time.
Entered Charity Hospital, ward No. 13, bed 199, December 8th, 1869. Features of face
swollen ; slight serous effusion in abdominal cavity ; lower extremities oe^dematous, pitting
on pressure ; scrotum swollen ; complexion has a sallow, wax-like appearance ; urine albu-
minous, and, under the microscope, loaded with casts of the tubuli uriniferi. Upon ausculta-
tion, sub-crepitant rales are heard in the anterior portion of the right lung, referred to chronic
irritation of the bronchial tubes ; no signs of tubercular deposit were discovered, i^ The heart
sounds are not altogether normal, and the soft murmur was referred to the anemic condition
of the blood. Liver slightly enlarged. Excretion of kidneys augmented ; the amount of urine
passed daily ranging from eighty-eight to one hundred and eleven fluidounces. of low specific
gravity, ranging from 1008 to 1009. Patient says that during the last three weeks he has been
easily fatigued, and during the last twelve months, has suffered with pain in his back, in the
region of the kidneys, but has been following his usual occupation to within the last month,
Temperature of axilla 98^.8 F.; pulse 72 ; respiration 18. Amount of urine passed during
the last 24 hours 88 fluidounces,* sp. gr. 1009. When the urine was subjected to the action
of beat and nitric acid, the moist, coagulated albumen filled one-fifth of the test-tube. The
patient was placed upon the Cream of Tartar, and Juniper berry tea, Tincture of Sesqni-
chloride of Iron and simple but nutritious diet.
December 18th.— The apex beat of the heart is most forcible to the left of nipple ; percus-
sion also renders it probable that the left ventricle is bypertrophied to some extent. Auscul-
tation over region of teart reveals a soft murmur, heard loudest over base of the heart during
second sound ; it is also heard at apex, with loss of murmur over body of heart, the sound
being transmitted along arch of aorta, but not from apex towards spinal column. The veins
of the upper portion of the cbest are sopiewbat enlarged apd congested. Fstient svffers tH¥
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642 Dnq^y arising from Lesions qf the Kidneys.
cough ftnd oppression of breathing after exertion, The respiration it prolongMl with (
erable ronchus, tvith a few sibilant rales. The lun^^s are duller upon peroatiioa Uma i&
health, and there is some effusion in both pleura. The dullness upon percastion appears to
be due in part, also especially in the infra-claricular and clavicular regions, to osdenaa of the
]>ulroonary tissue. The cardiac murmur is probably due, not only to the an»mie f tata of the
blood, but also to fatty or calcareous degeneration of the aortic valyes, permitting somt
regurgitation of the blood into the left ventricle. The urine contains albumen in abundaaoe,
with casts of the tubuli uriniferi. The amount of urine passed during the twenty-four boars
has ranged from sixty to one hundred fluidounces. The temperature of the axilla ranged, in
the morning, from 99® to 100® F., and in the evening, from 99°.5 to 101®.
Under the use of the diuretics and gentle purgatives, the anasarca has slowly diminisbed,
and the patient oppears to be more comfortable. There are times, however, when the nerroai
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 heating a brick and pouring water over it while under the bed
clothes), were ordered ; and as a tonic and gentle stimulant, a tablespoonfol of Hozhaa'i
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 SqQiUs aad
Syrup of Ipecac were ordered in doses just sufficient to induce naueea, but not Tomiting.
Dec. 3l8t. — During the past twenty-four hours has been affected with vomiting ; papili
greatly dilated, with dull pain in head, lethargy of intellect and imperfect visioB. At tuaa
one pupil is dilated and the other contracted.
January 3d.-- Vomiting and dilatation of pupils continue.
January lOtb.-^Patient feels much better than he did a week ago, has ceased to vomit, and
the pupils are not dilated.
January 13th. — Condition appears to be improved, the oedema has almost entirelj disap*
peared ; the lungs also are much less doll upon percussion. The same treatment baa beet
continned up to the present time.
January 24th. — Patient has not been doing so well during the past five days. The Crea» of
Tartar mixture has disagreed with his stomach, and it has been necessary to intermit the
diuretic. Pupils dilated. (Edema of extremities increasing. The cessation of the diarctii
medicine has been attended with a marked diminution of urine, only twenty-nine flaidonncct.
of low sp. gr. (1010) were excreted during the past twenty-four hours. The amount of alba-
meh in the urine has also increased, and it now reaches one-fourth of the volume in the teft-
tube, when heat is applied. The bowels were opened by ten grains of the Extract of Rhubarb,
and on the following morning the patient appeared to be less lethargic and more cheerfaU
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 breatbt
log ; stomach very irritable, obstinate vomiting whenever the Cream of Tartar mixture it
administered. Four grains of Iodide Potassium were substituted, three times a daj.
January 28th. — Patient rested badly and was disturbed by frightful dreams. Pupils stlQ
more dilated ; stomach irritable. (Edema increasing.
January a9th. — Rest imperfect and troubled ; pupils dilated ; patient feels very wea^ |a4
dfpressed.
February 1st. — Cough and oppression of breathing increasing; patient wei^k, and depresaei,
and nervous ; can retain but little upon bis stomach, from the nausea and vomiting. Itfs
Impossible to administer sufficient medicine to act upon the kidneys which secrete not oae*
half the former amount of urine. The urine is not only diminished in amount, but it isef
low sp. gr„ (1010), and loaded with albumen and casts. It is evident that the conitltueBts e(
the urine are but partially eliminated. The warm bath and the hot air bath fulfil the oSee
of the diuretic mixture but imperfectly.
February 8th. — The condition of the patient has continued steadily to grow worse, the
i)^rvous symptoms increasing, and the anasarca in like manner au^enting. Patieot tey
iReak, unable to get ant of bed, and passes his urine in small quantities and involuMsfily.
The patient lies in a dull, lethargic state, with pupils widely dilated, as if under the iaAi-
ence of some powerful narcotic poison. Urine scant, and loaded with albumen and nriasiy
casts.
February 9th.— Continues to grow worse, and more feeble ; is notable to move in bed witb-
out suffering great pain ; has been vomiting almost incessantly during the past twenty-l^r
hours ; the ^uid ejected resembles mil^l^. Urinary excretion suppressed, bowels constipated,
constant hiccough.
February lOth. — Vomiting continues, but the matters ejected have changed color, helif
Sr^en instead of white. Pupils greatly dilated, muscles of extremities trembling, inteSect
nil and letbftrg^c ; wlien ar9U8ed, appears to be under the influence of 8om^po.icei%lpo!inu
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Dropsy arising from Lesions of the Kidneys. 64S
The slightest touch upon the surface causes pain. The patient continued in Hub state, with
▼omiting, and hiccough, and suppression of urine, and died Fehmarj 11th.
The following table (page 644) presents tiie changes of the puls«, respiration, and temper-
ature, and the amounts of urine.
A number of other cases of Bright's Disease have been under observation during our
medical service in the Charity Hospital, and careful post-mortem examinatbns were
made in the presence 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 occur most commonly in the ill-fed and ill-conditioned laborers
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, appear 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
yarious 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
TREATMENT OF DROPSY ARISING FROM BRIGHT^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-
quired 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 dearly in view. The student should ever remember
that no description, however minute, will relieve him of the duty of studying each case
carefuUy 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 b almost always necessary to continue the plan
of treatment persistently for a length of time ; and without general principles, only
disappointment will result from the frequent change of remedies. In this class of
diseases, it is especially necessary that we should not only remove the secondary
effects 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 physician should be careful last 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 efiusions in diseases 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
shoidd be applied with caution or wholly abandoned, as tending to throw the effusion
upon important internal organs; and for the same reason, th3 recumbent position
should 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, to a certain
extent, from the dropsical effusion.
As the skin and even the lungs may act as supplemental^ organs to the kidneys,
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644
Dropsy arising from Lesions of the Kidneys.
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Drqfsy arising from lesions qf the Kidneys^ 64S
special attention should be paid to the clothing and to the surronndiDg temperatore and
bjgrometric condition of the atmosphere.
The amount and character of the urinary secretion may also be greatly influenced by .
diet. It is well established that an exclusive diet of meat greatly increases the nitrogen*
iied elements, (urea and uric acid, etc.) of the urine, whilst an exclusive fiurinaoeous
diet greatly diminishes these constituents of the urinary excretion. The importance of
attention to the diet is placed in a dear light, when the relations of the reUuncd urea
to the nervous phenomena and convulsions characteristic of Bright's Disease are con*
sidered.
Alcoholic stimulants, and stimuladng diuretics not only induce the disease, but when
persirted 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 the kidneys relieved as far as possible, by cut cups and leeches over the,
region of the kidneys, and the function of the skin should be fVeely excited by the
warm bath, hot bath, vapor bath, and warm clothing. As purgatives, the compound
jalap powder, or epsom salts, or a combinatioA.of carbonate of magnesia and epsom salts
(magnes. carb. gr. vi ; maenes. sulph. one drachm to one and a half drachms ; aquao 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 should be of the severest antiphlogistic character, composed chiefly of fari*
naceous substances ; for in the acute form, the blood is not sufficiently deteriorated to
demand rich nitrogenized food, and but little 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 effusion, such diuretics as the
Acetate of Ammonia, and Bitartrate and Tartrate of Potassa, and the Seltzer and Vichy
waters may be employed.
When convulsions and coma superv^c in consequence of the retention of the urea in
the blood, local depletion by leeches and cupping to the temples, and in some cases gen*
eral blood-letting, and blisters to the shaven scalp, are in conjunction with the hot bath
and brisk purgation with elaterium and brisk hydragogue 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 flannel 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 oold, damp weather. When the circumstances will permit of it) the patient should
remove to a warm, moist climate, for by this change, not only is 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 physicians have claimed important results in the treatment of chronici
Brifi^t's 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 good wxdiluUd
cow's milk were administered daily ; and some of the patients, who prior to the treats
ment, had been in the most wretcned condition, got rid of their dropsy) recotered an
app^ranoe of healthy and regained so much of their strength, as to be able to resume
their business and even to perform hard labor.
From the active measures should be excluded blood-letting and mercurials; and
reliance, for the relief of dropsy especially, and the elimination of the deleterious
materials from the blood) should be placed on the judicious establishment of diaphoresis^
diuresis and purgation.
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646 Dropsy arising /torn LesUms of the Kidnegs.
Odo 0^ the most efficient modes of establishing aotite dtaphoreRS as prerioiislj is£*
cated, is by the daily use of the hot bath, followed by sweating hr one or two boon ib
woollen blankets.
Stimulating diuretics should be avoided on account of their irritating action on the
kidneys; such diuretics as the Tartrate and Bitartrate of Potassa, siay be employed
persistently for a great length of time, and as far as my experience extends, if amnmis-
tered in a manner previously recommended, their action is always attended with beoeit
and relief of the dropsical symptoms.
Of course, in those cases where the stomach is so irritable that neither the Cre«n of
Tartar nor any other diuretic is borne, there is little or no chance of recovery.
The dropsy may also be controlled, and to a certain extent, relieved, by the jodieiow
employment of such purgatives as Elaterium, Golocynth, Compound Powder of Jalap,
Oream of Tartar and Sulphur, Epsom Salts and Glauber Salts.
It should be borne in mind that the duration and results of Bright's Diseaae, ^epead
upon the extent to which the kidneys have been altered ; the most frequent temiiiatioe
being death, caused either directly by the affection of the kidney, or by interounaik
inflammation ; complete recovery may take place, but it is very rare ; some cases nm
their entire course 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 efieeted, the
physician may aeebmplish much good by relieving the symptoms and prolonging life.
It is importantr therefore in a disease of such a chronic nature, that the comaBoal
tendency to the deterioration of the blood, should be counteracted by the use of Iroo
and Quinine, and nutritious diet.
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OBSERVj^TIOISrS
ON
DISEASES OF THE RESPIRATORY ^
INVESTIGATIONS
ON THE PREVALENCE AND FATi!
or
PNEUMONIA
IN THE CONFEDERATE ARMY, DURING THE AMER]
WAR-1861-18e5:
WITH PSAono&L obsesVatiovs ov the
HELATIYE TALUE OF THE TABIOVS MODES OF
PNEUMONIA.
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INVESTIGATIONS ON THE PREVALENCE AND FAT^
MONIA IN THE CONFEDERATE ARMY DURING '
CAN CIVIL WAR OF 1861-1865: WITH PRACT
SERVATIONS ON THE RELATIVE VALl
THE DIFFERENT MODES OF TREATIN
PNEUMONIA,
CHAPTER XVI,
• ON THE PREVALENCE AND FATALITY OF PNEl'MOMA AND 1>F TYrilOID 1
KRATE ABMY DUKING THE WAR OF 1801^1 Stio.
Importance of Pneumonia in view of its Prevalence and Fatality. Table
the Total of Sick and Wounded, the Cases of Pneumonia, and the Pei
in Mean Strength, etc., in the Confederate Army during Nineteei
Analysis of this Table. Cases most Numerous in the Winter and S
illustrating the Prevalence of Pneumonia in the Armies serving in Di
Confederate States. Cases in Virginia; in the Army of the West
Deaths from, Pneumonia, Typhoid Fever, and other Diseases in the G
Army of the Potomac, Northern Virginia and other Hospitals, durii
1862-1863. Common Continued and Typhoid Fever identical. Perc
Pnenmonia. Fatality from Pneumonia and Typhoid Fever. Fatalit
Cases of, and Deaths from. Typhoid Fever. Pneumonia, and some
General Hospitals in and around Richmond, during Seven Months,
and Deaths from, Pneumonia, Typhoid Fever and several other D'l
Hospitals in Virginia. Cases of, and Deaths from. Pneumonia and sc
the General Hospital at Charlottesville, Va., during Twenty-six Moni
Angnst, 1863. Fatality in Hospitals at Savannah, of Pnenmonia and '
showing the Numerical Relations of. Cases of, and Deaths from, Ty[
monia, in the General Hospitals in Virginia and Georgia. Progress!
Prevalence of Typhoid Fever during the War. Table illustrating th
of Pnenmonia and Typhoid Fever in the Confederate Armies during N
63. Cases and Deaths from all Causes, and Cases of, and Deaths
Typhoid Fever in the General Hospitals of Charlottesville and Stauni
The prevalence of Pneumonia in the Confederate Army, and tl
ta]itj amongst the cases treated in the field and in the general he
disease with peculiar interest and importance ; and the writer urge
General the importance of a thorough examination of the relative
modes of treatment employed by the Confederate Surgeons. '
contain facts relating to Pneumonia, which were contained in a n
General during the progress of the recent civil war ;
»-4
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650
Pneumonia in Confederate Army.
TabU giving the Mean Strength, Officers and Men, the Total Sick and Wounded, and the Total Guao
Pneumonia, and the Percentage of Pneumonia in Mean Strength, and in Sick and WouMded « tt'
Confederate Army during Nineteen Months, January, 1862, to July, 1863, Consolidated from fUU
and Hospital Reports, by Joseph Jones, M. D., Surgeon Provisional Army C. S. A,
siontm axd
Yeas.
|2
1862.
January
February
March
April
Mftj
June
July
August ,
September ..
October
November. ..
December....
1863.
January
February
March
April
May
June
July
15
FIELD REPORTS.
Si
o e
S5
HOSPITAL 1EPORT8.
232,138
219,069
•165,047
58,304
58,690
, 136,362
I 79,999
113,407
125,408'
156,734
270,480'
^ 172,800
I
192,776
,215,458
I 313,848,
190,518
1163,711
107,153
I 72,396;
90,757
71,6721
50,3851
23,243
25.985
78,583;
41,700i
50,987l
42,450
48,605
71,328
67,461
i
u
a B'o
til
gg
^1
.1
Is.
--1
m
I
I
115,416
96,463
63,387
27,559
30,491
94,487
55,997
64,436
51,432
59,841
90,472
85,769
!
96,053
.| 80,889|
76,620
60,135
92,788 117,1711
60,407 1 74,806!
49,589 63,211 1
33,805 43,1141
20,849, 24,807'
Total I 160,23l| 1,057,349
3,960
2,041'
1,849'
891
36o!
881
826;
430
179
384
2,282
2,985|
I
2,676
1,997,
2,816
1,779'
1,593
267;
77|
128,2731
1.70 ,
0.93 :
1.12
0.06 :
0.61
0.65
1.03 I
0.379
0.142'
0.245
0.84 ,
1.72 ^
1.38
0.92 .
0.89 j
0.93
0.97 '
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
3,292
2,472!
2,341
2,543
9.700I
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 l« -^
365 10.'2
44)8 I'.*'
540.21.^
6561
812
491
303
473
465
2,587
1,811
0.249 0.79
0.106; 0.37
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.T«>
2.5i*
l.4«:
l.ol
l.ls
5.70
6.23
S.tKJ
7.1&
B.4P
8.41
\M
O.W
I 397,406|
,155421
From this table it appears that in the Confederate Army, with a mean nioathlj
strength of 160,231 officers and men, 1,057,349 cases of disease and woandti weit
entered upon the field reports during a period of nineteen months, (January, 1863 to
July, 1863, inclusive); and of this number Pneumonia constituted 28,273.
Seventeen and six tenths per cent, of the mean strength of the army, on an avera^,
Buffered with Pneumonia during a period of nineteen months; and this disease consti-
tuted two and seven tenths per cent, of all cases of disease and wounds entered upon
the field reports.
During thb period of nineteen months, 397,406 cases of disease and wounds were
entered upon the Hospital Reports, and of this number 15,542 were recorded as Pneu-
monia; and this disease, therefore, constituted 3.15 per cent, of all the cases of disease
and wounds entered upon the Hospital Reports.
The cases of Pneumonia entered upon the Field and Hospital Reports were relatively
most numerous as compared to the mean strength and the total sick and wounded durii^
the months of December, 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 rule
the c^ey of Pneunionia diminished^ as the temperature became more elevated, and the
vicissitudes of the season less m^^ked. The month of July, 1862, is an apparent
exception, but it will be observed tW the number transferred to the general hospitals
was very sm?ill, only 491, or 2.59 per cent, of all diseases and wounds ; and during the
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Pneumonia in Confederati
daine mouth, in 1863, the number of cases of Pneu
any other month, being only 0.106 per cent, of the
of the sick and wounded transferred to the general l
The disease, therefore, would appear to depend in
other words, upon the effects of exposure to cold and
heat and moisture. The following tables present dati
of elevation, geographical position and temperature u
TabUt iUiulraUng the Prevalence of Pueumonia in the Am
Confederate States^ giving Mean Strength^ Cases of Wounds
and Cases and Deaths of Pneumonia^ (the Deaths given on
validated from Field and Hospital Records on File in the Si
Joseph Jones^ M. />., Surgeon P. A. C. S.
CONFKDERATE FORCES SERVING IN VIRGINIA
Field Reports.
Month and Vkar.
' Total Sick ani
Meon Strength, | Wounded en-
(.iftteorH nnd Men. | tered during
Month.
1862.
January
February
March
April
May
June
July
August
September^
October
November
December
1863.
January
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
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
79,396
443,167
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652 Pneumonia, in Confederate Army.
Confederate Forces Serving in South Carolina, Georgia and Florida.
1862.
January
February'....
March
April
May
June
July
August
September..
October
November...
December ...
1863.
January
February. ...
March
April
May
June
July
Total
19,148
25,262
25,730
28,986
26,313
28,620
22,608
23,784
24,266
25,007
24,710
20,570
19,701)
31,880
38,901
33,363
26,307
23,100
19,478
25,670
8,627
6,746
7,305
11,109
11,148
10,487
9,495
10,091
9,807
0,404
7,202
5,742
4,455
7,005
10,157
0,402
7,641
6,372
5,748
157,313
<D
82
78
78
55
104
70
62
62
57
27
14
10
22
28
20
31
23
28
924
326
272
281
407
116
50
57
24
23
24
47
85
118
151
02
46
22
4
2,120
10
27
25
14
2
10
1
1
3
3
7
8
6
5
3
1
1
127
1,400
1,309
1,758
2,041
1,932
1,634
3,598
39,750
70
24
145
3«
221
5^
287
43
164
5?
111
4<»
61
n
18
1
23
'
10
\ —
37
1 4
38
. |j
127
.,
S3
:♦
146
K<
173
2:^
T9
1-*
28
#
16
,862
37*
Confederate Forces serving in and around Mobile , on Gulf of Mexico.
FiET.D ANn Hospital Rrpobts.
MoNth am> Vrar. ;
Moan strength Offi.
cern and Men.
Total Sick and Total l>oathsi.
Wounded entered |
during Month. |
]
(iaw«.
1862.
January. ..»*»« ...............
8,178
;^,43I
2,018 1)6
1,048 28
224
37
I 3»
February
4
March.
April.* ».i..
May
June
July
August
September
October
Xovember
December
1863.
January
February
March
April
May
June
July.*.
Total
2,511
4,955
7,025
3,625
0,208
0,425
9,126
9,571
8,923
9,213
9,231
0,417
.-.,121
4,366
4,683
3,539
6,752
1,715
27
3,444
146
4,971
135
3,146
127
5,296 ;
158
4,929
72
4,536
3,899
55
67
3.610
74
3,708
2,845
3,233
39
41
36
1,815
40
2,063
58
2,006
3,291
42
59
58,453
1,201
1* I
3
39 {
I
123
38
9
31 }
«
^^
3
40 !
t
121
10
114
23
89
7
94
10
84
6
43
4
40
12
14
4
7
#
1,163
151
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Pneumonia in Confederate Army. 653
Army of the West and <ff Tenneaee serving in Tenneuefj Kentucky, Alabama, and MuMiippi.
MOJfTB AND YkaR.
1862.
January. ,
February.
March
April
May
June
July
Aagast
September ,
October
November.......
December
1863.
January
February
March
April
May
Jane
July
Total
40,675
10,658
30,025
9.311
15,082
33,791
48,958
50,604
63,494
61,226
64,441
55,121
40,273
34,114
11,197
18,251
2,677
5,379
9,720
19,747
27,066
20,800
27,728
28,169
21,873
226,711
1,435
799
455
29
127
145
1,190
434
520
600
648
481
6,963
462
469
267
53
96
498
518
917
1,001
1,056
977
660
6,974
158
87
49
0
7
51
123
108
150
144
141
67
1,090
2,010
1,484
4,151
4,980
1,258
10,902
7,347
12*527
1,160
5,993
1,437
1,423
54,672
116
253
24
121
116
14
219
326
13
252
241
10
65
42
...
586
280
62
276
202
37
859
1,124
285
136
114
44
209
i'g's
44
55
37
7
31
27
2
,916
2,957
542
Army of the Vallfy of Virginia, General T. J. Jackson.
Field and Hospital Biports.
SIOKTU AKD Yp.An.
Mean Strength Offl-
I cere and Men.
1862.
January
February
Harch
April
May
June.
July
August
September
October
NoTember
December
1863.
January
February
March
April
May
/aue
July ,.,
Total
9,278
8,193
7,418
9,554
16,731
18,099
15,589
15,643
21,123
34,200
15,682
Total Sick and
Wounded entered
during Month.
Total Deaths.
Pneumonia
Ouien.
Pnenmonia
Deaths.
4,956
63 '
284
26
2,594
22
241
0
1,389
75
38
3
2,014
6
37
...
4,856
100
81
2
8,741
216
83
6
7,613
119
156
4
6,423
237
31
...
5,949
298
10
...
8,663
•
31
84
...
63,198
1,16'7
1,034
50
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t>54 Pneumonia in Confederate 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 this
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 diaeasf
constituted 2,48 per cent, of all cases entered upon the field reports. During the sane
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 case*
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, on
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 1st to October 31st ; May 1st to July 3l8t,) in th«
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,) serving!
along the low hot coast of South Carolina, Georgia, and Florida, during a period of
nineteen months, only 8.25 per cent, of the entire command (mean strength) wertr
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 upon the Gulf coast, was somewhit
higher even than in the army of Tennessee ; the ratio of the cases of pneumonia beio?
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, bebg
only 6752 officers and men, and the statistics embrace both the field and hospital
reports. This confusion, therefore, of the field and general hospital reports renders it
impossible to institute a just comparison with the armies of Virginia, Tennessee, and
South Carolina, and Georgia. It appears also that the troops of the Golf ooa^t
were subjected to a more moist and malarious climate than the mass of the troops
serving in South Carolina, Georgia and Florida. A large portion of the troops servia^
along the Atlantic coast, in the latter department, were encamped in dry, sandy, pine-
barren, healthy locations, which, although elevated but a few feet above the level of
the ocean, are, nevertheless, remarkably free from diseases of the pulmonary organs of i
serious character.
It appears, therefore, from these statistics, that pneumonia prevailed to the greater
extent in the more elevated and northern r^ons of the Southern Confederacy, and ia
the armies which were subjected to the severest labors, privations, and exposures.
Pneumonia not only prevailed to a considerable extent amongst the Confederate
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 th«
department of South Carolina, Georgia and Florida, during a period of nineteen
months (January, 1862, July 1863,) 2220 cases of pneumonia, with 127 deaths, weft
entered upon the field reports, and 1786 cases, with 370 deaths upon the hospital
reports. As the cases were in most instances, first entered upon the field reports, and
then transferred to the general hospitals, we will approximate more neariy to the truth.
by assuming that the 2220 cases of pneumonia entered upon the field reports, indodc
those also transferred to the general hospitals, and the mortality of the cases treated in
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Pneumonia in Confederate Army. 655
general hospitals, should be added to the mortality of the cases treated in the field ;
thus 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, tKe 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 short period 6.6 per cent, of the mean strength were affected with this disease.
The number of deaths entered upon the field reports of General "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 chiefiy to the large genend
Ijo&pital 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 Viiginia, throughout the war, under Generals Jackson and Early.
During a period of forty-four months, July, 1861 to February, 1865, in the General
Hospital at Staunton, Virginia, 833 cases of pneumonia were treated, with 191 deaths.
In this large and well-conducted hospital22.9 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 large 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.
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656
Pneumonia in Confederate Army,
Deaths.
Cases.
Doatlis.
Caties.
Deaths.
Caaos.
Deaths.
Casos.
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Pneumonia in Confederate Army 657
From the preoediog table we gather that during this period of fifteen months, one
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 Richmond ; out of this number of cases, ^ve thousand ^\e
hundred and sixteen (5516) proved fatal.
The ratio of deaths from all causes to the entire number of cases 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 carefol examination of many cases registered as common continued
fever, and after conferences upon this subject with numerous surgeons in Virginia, I
have been convinced that the great majority of the eases reported as common continued
fever are nothing more than cases of typhoid fever. As the cases recorded as common
eontinaed 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 oases. The ratio o^ deaths from typhoid and
common continued fever, to the entire number of deaths from all causes, is Z9.35 per
cent., or one death from these diseases in 3.4 deaths from all causes. Whilst on the
otber hand the ratio of cases of typhoid and common continued fever to the entire
number of cases treated is 5.48 per cent., or one case of these diseases in 18.25 cases of
all diseases.
A fraction more than one fourth the oases of pneumonia terminated fatally, or more
exactly 22.86 per cent., 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
cases of pneumonia amounted to only 4.16 per cent, of the entire number of oases.
Typhoid fever, common continued fever, and pneumonia together, caused two thou-
saud eight hundred and eighty deaths, out of five thousand five hundred and sixteen
deaths fVom 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 oases were classed under the head of chronic and acute diar«
rhoea and dysentery, whilst the mortality from these diseases was 4.05 per oent. 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 was 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 in the hos-
pitals 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 cases.
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) eases
were recorded of typhoid and common continued fever, and during the same period
seven hundred and twenty^hree deaths from these diseases. Therefore mox^ thap oncv
'«a
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658
Pneumonia in Confederate Army.
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Pneumonia in Confederate Armi'. 659
foartb, or 26.31 per cent, of the cases of typhoid fever, terminated fatally ; that is, one
case 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 Tvere caused by 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.
Daring 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 thsso four months
were only 3.54 per cent, of the entire number of cases treated during this period.
Daring 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 id 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 hospitab 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
namher 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 General Hospital at Charlottesville, because they
date from an early period of the war, and have been accumulated under the able admin-
istration of intelligent surgeons, and this hospital has drawn its patients directly from
the largest army in the Confederacy.
In the General Hospital of Charlottesville, Va., 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 causes,
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 giving
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
death in 27.24 cases of all diseases treated.
Nearly one-third, or, more exactly, 31.9 per csnt. of the ea.«es of Pneumonia termi-
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660
Pneumonia in Confederate Army.
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Pneumonia in Confederate Army. 661
nated fatallj, that is, one death occurred in 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 froin 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 cent.,) or, more plainly, one case of Pneumonia
in 23.13 cases of all diseases, Pneumonia included.
Typhoid Fever and Pneumonia, together, caused 519 deaths out of 868 deaths from
all causes, these diseases included. That is. Typhoid Fever and Pneumonia caused
more than one-half, or 59.9 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 5.79 per cent., or one death in 17.24 cases of all diseases '
treated.
The largest number of cases of Typhoid Fever occurred in July, August, September
and OctoW, 1861, and during the first thirteen months (July, 1861 to July, 1863,
inclusive), 1094 cases of Typhoid Fever entered the hospital, whilst during the last
thirteen months (August, 1862 to August, 1863, inclusive), only about one-fifth the
number of cases of T^hoid 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 afilicted 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 that incident to the hardening and strengthening
of the troops under exposure and fatigue.
The cases of gunshot wounds were 18.99 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-
lottesville, 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 facts, that all thmgs being equal, as to treatment, nourishment, and
hygiene, the mortality in a hospital thus situated and supplied with patients must neces-
sarily be heavier than in 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 we are at a loss to account for this high
death-rate, from the fact 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., daring a period of twenty-fire months.
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662
Pneumonia in Confederate Army,
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Pneumonia in CoT\federate Army, 663
(December, 1861 to December, 1863, indosive,) 178 cases of typhoid feyer 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 cases. 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 pnjeumonia, 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 fVom 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, Ga., 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, to the deaths from 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 oases of pneumonia to the entire number from all diseases,
was only 3.174 per cent.
Pneumonia and ^phoid 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, Ga. From June,
1862, to December, 1862 (six months,) 13 deaths from remittent fever were recorded,
out of only 141 cases treated ; tliat is, nearly one-tenth of the cases of remittent fever
during this period proved fatal. In view of the present enlightened and successful
mode of treatment in this disease, this b certainly a remarkable ratio of mortality.
The statistics might be greatly extended, but they are sufficient for comparative pur-
poses. The following tables will furnish the necessary data for comparison with the
records uf other hospitals ;
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664
Pneumonia in Confederate Army,
Tables ihomng the Nwnerical RelaiioM of the Cases and Deaths by Typhoid and Common OontinMed
Fever and Pneumonia ^ in the General Hospitals in Virginia, and in several Hospitals in Georyia,
during a portion ofthe'war of 1861-1865. Consolidated and Calculated from the official recordi
on file in the office of Surgeon^ General S. P. Moore, by Joseph Jones, M. Z>., Surgeon, P. A. C. 5.
CASES AND DEATHS FROM ALL DISBASKS AND CAUSES.
Naub of
Hospital.
DATES AND LENGTH
OF TIME
OF STATISTICS.
^3
m
General Hospitals in Vir- Jan. 1862— Feb. 1863, > ; ..^ ^..
ginia, oat of Richmond i (15 months) \ '
General Hospitals in Vir- : Sept. 1862— Apr. 1863, \
ginia, in Richmond ' (7 months) /
General Hospitals in Vir- Apr. 1863— Aug. 1863, S
ginia (4 months) /
General Hospital of July 1861— Sept. 1863, ^
CharlottesTille, Va (26 months) /
General Hospital No. 1, Dec. 1861— Jan. 1864,1
Savannah, Ga i (25 months)... /
General Hospital No. 2, June, 1862— Jan. 1864, ^
Savannah, Ga , (18 months) /
Guyton Hospital, near ! May, 1862— Jan. 1864, ^
Savannah, Ga \ (20 mouths) i
113,914
5,51H
4.84
20.05
93,832
3,849
4.11
24.37
108,165
2,705
2.5
39.98
14,966
868
5.7
17.19
7,149
333
4 65
21.46
3,402
125
3.67
27.21
2,695
46
1.70
58.58
CASES AND DEATHS FROM TYPHOID FEVER AND COMMON CONTINUED FilTBR.
Name of
Hospital.
DATES AND LEN«TH
of time
OF statistics.
»^? H
Cl'S.H
c 5 o
3 sr©
'i9%
Ifl
: » 2
?l^
11*
ill
^ g-
i ?H
: 2.5:
1 I
SSl !l B.I I
l:i lis?:?
General Hospitals
in Virginia, outi
of Richmond...!
General Hospitals'
in Virginia, in'
Richmond i
General Hospitals,
in Virginia
General Hospital!
of Charlottes-'
ville, Va I
General Hospital
No. 1, Savan-i
nah, Ga i
General Hospital
No. 2, Savan-
nah, Ga ....!
Guyton Hospital
near Savannah, i
Ga I
January, 1862 —
February, 1863
(15 months)....
Septe'ber, 1862—
April, 1863, (7
months)
April, 1863— 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, 1864, (20
months)
t, i 6,245
■}; ■•
1 1 2,863
p- I
!3, I'
l
1;
1,312
204
239
105
1,019 , 25.92 3.85 5.48 18.25 29.35 j 3.4
26.31 ; 3.8 3.50 27.27 24.94 , 8.
509 ! 17.77 5.62 i 2.64 37.9 18.82 J 5.31
I
313,23.8 4.19 18.77 11.4 36.05 2.7:
93 45.58 1 2.19 2.85 35.0 27.62
3.5:
42 , 17.57 5.66 7.02 14.23 33.6 , t-'^'
11
10.47 9.54 , 3.89 25.66 23.69 i 4.lf
! I i , I
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cm
Pneumonia in Confederate Army.
Table illustrating the Numerical Relations of Pneumonia and Typhoid Fever, in the Confederate Ar
during Nineteen Montht, from January y 1862 to July, 1863. Calculated from Official ReporU,
by Joseph Jones ^ M. /)., Surgeon P. A. C. S.
FIELD REPORTS.
Pneumonia.
MONTH AXD YEAR.
tPer cent, of
cases of Pnou*
monia in
Mean
Strength.
Per cent, of
cas68 of Pneu-
monia in total
Sick and
Wonnded.
Typhoid Fever.
Per cent, of
Cases of Ty-
phoid Fever
in Mean
Strength.
Per cent, of
Cases of Ty-
phoid Fever
in Total Sick
and
Wounded.
HOSPITAL BIPOBTS.
Pneumonia. Ferlur:
Per cent, of
Cases of Pneu-
monia in total
Sick and
Wounded.
Per oeot. of
Coses of Ty-
phoid Fever
in Total Sek
and
Wonaded.
1862.
January
February
March
April
May
June
July
August
September
October
November
December
1863.
January
February
March
April
May
June
July
l.YO
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
o.ro6
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
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
4.36
3.59
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
10.24
10.72
17.00
21.23
6.76
4.89
2.59
1.46
l.Ol
1.18
5.76
6.23
8.90
7.19
8.48
8.41
2.69
1.76
o:98
9.6
10.8
8.1
14.5
7.1
8.6
10.3
6.1
6.5
4.8
3.9
2.9
4.7
4.9
5.7
4-9
2.6
4.4
2.8
The foMowrag Ubles ffluslrate, still tnore clearly, the progressive decroasQ of typfaotd
f^er, and the (^^^*(?ctioii of T)ti<euiiroiia wjt^. tbq g^asons ;
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Pneumonia in Cor\federate Army,
ml
Cases and Deaths from all CauseSy and Cases and Deaths from Pneumonia and Typhoid Fever in the
General Ilospitals of Charlottesville and Staunton ^ Virginia j from Official Reports ^ by Joteph
Jones J M, D,j Surgeon Provisional Army C S.
;■ ■ ■.■■..==
^ — ;_: : ^^.i^. — .^^i^.i_^_ -.^__^ — , — 1^
Qexeral Hospital, Cbabiottu*
viLL£, Virgin t A.
Genkral Hospital, Stacxtok,
Virginia.
MosiTH AND Tear.
ni
fir
4
ii
r!
ii
i
it
Ill
• si
-1
1
1
i!
JnnSUkTj 1861
2,608
a29
511
656
448
329
147
87
32
33
31
12
48
6
12
14
41
22
1*8
10
2
2
7
3
2»i
74
150
195
100
63
76
46
24
27
15
6
1 1,430
938
615
734
1
30
19
11
69
17
3
19
37
::: :::
...
3 1 151
:
255
... 269
22 103
Fftbrnaiy
Maroh
AprIL
M»y
JuDe...i
Jnlj
Aug^ost.
20
t»ept«mber.
October
6
November ~
December
7
14
Totalt, 1861
4,781
226
300
290
639
429
764
337
682
886
340
016
903
342
21
8
67
63
26
35
23
11
32
64
143
24
21
21
80
35
20
9
2
1
1
38
118
42
15
"i
25
36
12
3
i
15
27
866
30
34
14
60
32
23
33
19
7
6
21
21
193
4
6
1
8
20
13
11
10
2
3
7
7
2,417
126
264
614
705
2,272
1,229
892
805
1,435
4,549
3,923
361
119 1
17
6
10
27
83
36
42
78
29
95
151 1
69
76
4
12
78
66
63
2:J
3
27
80
19
25 1 i
8
2
2
7
28
6
5
3 1
3
4 S
24
12
i68
30
64
66
45
48
34
56
(Si
20
522
96
5
47
Januiiry, 1862.....
1
Febraarr
1
Harch
3
April
7
Jf*y
June
26
8
July
25
Aagust.....
6
O^ber.
42
KoTember
66
December -
15
Totelft, 1862
6,698
11,473
601
312
198
124
672
417
H21
449
271
397
301
469
381
723
41
26
17
14
11
8
7
11
'?
10
27
370
513
49
23
15
6
14
13
6
8
2
9
16
29
138
180
11
7
6
8
2
2
"i
"i
2
6
299
1,166
16
12
6
3
11-
65
20
18
5
16
91
284
2
3
3
17,165
19,582
102
96
483
165
639
1,642
8,428
1,209
406
308
127
228
642 4
761 I
15
8
13
37
15
14
25
37
16
12
12
1
154
»30
1
6
76
14
23
16
25
12
3
4
3
6
103 ■
128 1,
6
4
4
]
79
647
5
6
32
6
24
48
23
65
21
23
10
6
239
TotalA) 1861-1862
286
jfumni^ 1863
1
Tebruaiy
1
March
2
April «.
ffWy -- -, T--r-r
5
3
^^J ••••• • •
jaiT...V.V..V......... ...."..!!.*......!!.
6
.11
Angnst
18
September
3
October. «
Kovember
3
5
December
(1
■
Totalf. 1863 ,.
4,932
401
145
249
481
1,152
1;H4
490
321
267
189
35
9
6
11
68
50
is
7
9
190
80
11
13
30
27
8
:::
.3
11
10
46
8
3
2
I
2
!."
"i
190
1
2
7
4
15
6
10
3
43
13
1
1
2
3
6
3
2
• 13,723
2-25
108
177
138
1,475
826
1,.'>98
1,304
1,693
1,531
611
606
206 1
3
3
1
4
47
29
19
21
13
30
25
14
67
10
16
9
7
7
3
9
2
1
4
10
30
61 ?
1 1
;;■
...
3
Z
...
1
4
(68
4
3
5
3
18
14
41
21
30
24
11
18
68
-l^titt^yy 1864 «
1
Febnuuy
March -
^S?:::z::::::;::::;::;:::::::;:;:::
June.
I
1
Angost.
8
7
September.
2
October
Norember
3
1
Totals, 1864
4.850
0,782
21,265
208
497
1,120
143
333
846
28
74
254
71
161
1,426
30
73
367
10,001
23,814
41,306
209 1
414 S
1,176 I
03
570
100
11 1
72 t
190 2,
92
►60
207
29
Totalii. 1 863-1 8A4r,-
87
Tntalji. 1861-1864 r,r.,.,r
393
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668 Pneumonia in Confederate Army.
In the proceding tables we observe a progressive atid marked diminutdon of ihe \
of typhoid fever, whilst the yearly fluctnations of pneumonia are not referable to any
such law.
Thus, in the General Hospital of Charlottesville, during the year 1861, the cases of
disease and wounds numbei^ 4781, with 342 deaths: of this number, pneamonia
constituted 143 oases and 42 deaths, and typhoid fever 866 cases and 193 deaths. Baring
the year 1862, the total cases entered upon the hospital records, numbered 6692, with
381 deaths ; of these, there were of pneumonia, 370 cases and 138 deaths ; typbmd
fever, 299 cases and 91 deaths. During 1863, total cases, 4932, and deaths, 189 ;
pneumonia, 190 cases, 46 deaths ; typhoid fever, 190 cases, 43 deaths. During 1864,
total cases, 4850, deaths 208; pneumonia, 143 cases, 28 deaths; typhoid fever, 71
cases and 30 deaths.
In the General Hospital of Charlottesville, during the first twenty-six 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, boch
months inclusive,) 1094 cases of typhoid fever entered the hospital ; whilst daring the
last thirteen months, (August, 1862 to August, 1863 inclusive,) only about one-fifUi
the number of cases of typhoid fever entered, or, more exactly, 203 cases. During the
first period of thirteen months, 253 deaths from typhoid fever occurred ; whilst daring
the last thirteen months there wore only CO deaths, or not quite one-fifth the nombo'
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 during
either 1861 and 1862, notwithstanding that the total oases of diseases roistered was
greater in 1863 and 1864.
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CHAPTER XVII.
OAMINATION OF TITE DIFFERENT MODES QF TREATING PNECMONIA.
Objects and Importance of the Investigation, Dietetic System, which consists in allowing the
Disease to run its coarse, 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.
Antiphlogistic System of Treatment. The lancet abandoned by Southern physicians in the
treatment of Pneumonia. The statistics to prove the wisdom of this step, wanting. Ex*
amination of the data by which the relative merits of the Antiphlogistic System of the treat-
ment 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. Jaibes 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.
EXAMIXATION OF THE DIFFERENT MODES OF TREATING PNECMONIA.
After a careful examiaation of the official reports, od file ia the Surgeon Generars
Office at Bichmood, Virginia, I established the important fact, that up to the time of
my examination, and consolidation of the sick reports and mortuary records (September,
1863), Pneumonia and Typhoid fever, had caused one half the deaths from all causes,
gun-shot wounds included, in the field and general hospitals. I was led to draw up
extended reports, presenting the results of my investigations on the causes and treat-
ment of the most fatal diseases. The manuscript volumes thus prepared, were captured
or burned at the time of the evacuation of Bichmond.
In the official 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 made to the science of medicine. The plan of investigating the phenomena
of Typhoid fever {Camp /ever), addressed to the Surgeon General and the Medical
Officers of the Confederate Army, was also applied to Pneumonia.
It remained that an effort should be made to point out the line of inquiry to be pur-
sued in the investigation of the relative value of the different modes of 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 ot unbounded confidence, in
special remedies in the treatment of Pneumonia : but unfortunately however, the bo
called experience J avails but little in the accurate determination of questions involving
the lives of a large proportion of those afflicted. It is customary to dignify with the
title of extensive experience, the use of one or more remedies, for a series of yearSj
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 tesult of
education, or of accident or prejudice, or as the result of careful and conscientious inves^
ligation and comparison of the relative effects and value of the different modes of treat*
ment. It was urged, that under all circumstances, of peac3 or of war, and especially io
a contest in which the entire community was emptied of its male population 5 from boy-
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6Y0 Dietetie System of Treating Pneumonia.
hood to old age, and from the statesman to the day-laborer, snch iovestigations should
be considered as of the greatest moment, and should be conducted with the most scnpo-
lous accuracy and honesty ; and the belief was expressed that with concert of actMn,
amongst conscientious and competent obaervem, results of great value would be adiieved.
In the report referred to, the various modes of treating Pneumonia, were dassed
under the following heads :
1st. Dietetic System ; 2nd. Rational Treatment designed to further the natural pro>
gress of Pneumonia towards recovery ; 3rd. Antiphlogbtic System of Treatment ; 4tL
Antiperiodic, or Abortive Treatment of Pneumonia.
I. DIBTBTIC SYSTEM OP TREATING PNEUMONIA.
It is now established that Pneumonic inflammation is dependent upon definite otm-
ditions, and will without any assistance from the physician, run a definite course thioii^
sucoessive 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 invol?ed,
whether one or both, and whether the whole lung, or only a small portion, and upoo
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.
Que 702. Circumteribed Pnaumnia, attended with high fever, arruted or retolvtd in seamd ttaft.
Andrew Jackson Sharpe, Confederate soldier ; Private ,* age, 25 ; height, 5 feet, seTCfl
inches; weight, 150 lbs. ; black hair, dark eyes.
Had measles in the month of June 1862, in this hospital, and regained his usual health.
General Oonfederate Hospital, AugusU, Georgia, July l7th, 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 ; pabe
and respiration accelerated ; dullness upon percussion over right lung. I ordered nothinf
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 verr
restless.
July 19tb, 12 M. Pulse 100; respiration 24; temperature of hand 4loC (105*. 8 F) ; of
axilla 41*. 85 C. ( 107*. 4 F). Right lung dull on percussion; auscultation rerealed raionu
crackling crepitation, with some increase of vocal fremitus. The natural resoaance of tke
lung was more diminished, and the sense of resistance increased, more especially over the
lower lobe of the right lung. At first the expectoration consisted only of glairy mocos, but
it now presents the rustj color, and viscid tenacious characters of the characteristic pnennuK
nic sputa. Patient restless and depressed, and the hot *<6urmny" fever causes him to t«3!
incessantly from side to side in the bed. Breathing oppressed, and painful and honied.
Tongue drj and red. Severe pain in head.
ft. Tinct. Opii, two fluiddrachms; Pulv. Ipecac, ten grains; Sodae, ProtQ Carh., two
drachms ; Flaxseed tea, ten fluidounpes. Wineglassfnl every two hours, or at shorter ipiter-
v^ls, 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. Cold water as a drink, ad Hbituoi.
Examination of Urine: — Amount of Urine passed during the preceding twenty-four hoon.
July 18th, 12 M. to July 19th, 12 M., Grains 15,^)96.56. Specific Gravity 1016.3. Golden-jd-
low cojor. Reaction acid.
No. 87. Analf/m of Urine Passed daring iwenlg-four hours :
Urine
I>«'«°^Twentar.f<mr ^2S SST
Grains: Gnlu:
Amount of Urine 15,996.56 666.53
Urea 432.32 18.00
Uric Acid 5.00 0.20
Free Acid 60.48 2.89
Phosphoric Acid 60.56 2.52
Sulphuric Acid..» 37.73 1.57
Chlorine 13.11 0.54
Equivalent Chloride of Sodium 21.58 0.89
Phosphates of Lime and Magnesia 17.00 0.70
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Dieittie Sfstem qf Treating FneumotUn. 671
Evtmng, The mixtnre cftuled the patient to vomit freely, and '< much bile was thtown 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. B< Continue Ipecac and Soda
mixture.
July 20th, 12 M. Pulse TO. After the relief Of the stpmach by the emetic, the severe head-
ache disappeared, and has not returned, and the patient appears tu be better. Skin moist, and
the temperature is not so elevated. Respiration more regular and less painfull. Expeetora*
tion still rusty-colored, tenacious and gelatinous.
Continue turpentine stupes to the chest, and also the Ipecac and Soda mixture.
July 21st, 2 P. M. Patient continues to improve ; temperature of hand, 36^. I ( 9*7.^ F) ;
of axilla 38^, C. (100*'. 4 F) ; pulse 52 ; respiration 20 ; skin feels cool and moist— in a pro-
fuse perspiration : pulmonary symptoms improved ; the rusty colored sputa has disappeared
aod been superceded by clear, viscid sputa. The right lung is less dull on percussion,
although the crepitant rales continue.
Ezamimation of Urine: Amount of Urine passed during forty-eight hours, July 19th, 12 M.,
to July 21st> 12 M. Grains, 28,980.48; Specific Gravity, 1022.6j orange colored. Upon
standing, the urine emits a putrid smell, and throws down a heavy^deposit of urates and
phosphates.
No. 88. — Analyna of Urine ptuaed during forty-eight koure:
TJrine, Forty- tWae, Twenty. UritteSkcb
eight Bonn. four Houn. Hour.
Graint: Gimlns: GnUnf;
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 2.26
Sulphuric Add 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 2.70
July 22d, 9 P. M. The left lung appears to be involved to a certain extent. The eoilgfa is
more troublesome than yesterday, and the rusty colored pneumonic sputa has retutned. 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,
Toogue cleau.
Notwithstanding some apparent increase in the pneumonic symptons, the patient says that
he feels much better. The patient was placed upon a mixture composed af Camphorated
Tincture of Opium, one fluidounce; Syrup of Ipecac, three fluidounces; Honey, four fluid*
ounces. Teaspoonful every two hours.
July 23d. Continues to improve.
July 24th, 12 M. Pulse 76; respiration 16; Temperature of hand 88^ 4 C ( lOl®. I F)j
of axilla 38®. 5 C ( 101°. 3 F ); tongue clear ; patient much better.
Examination of Urine: — 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
condition and emitted a putrid odor.
Xo, 89. Analgtie of Urine parsed during eeventg-Hoo houre^July 21»<, 12 M.^ to July MM, 12 M^
Urine, Sereoty- Urine, Twenty- Urine, 15hd»
twa Hours. ftmr Bonn. Hoar.
exalAs: Grains: ^rtik^x
AltoMt...'..v ....M..ov,».>..#..i ^ >...•* 45,004.07 15,001.55 6i5i05
tTrea 2,134.52 711.50 29.64
Phosphoric Acid 105.02 35.00 1.45
Sulphuric Add 180.86 60.28 2.51
Chlorine &4.90 18.30 0.76
Equivalent Chloride of Sodium 93.32 31.10 1.21
The patient continued to improve rapidly, and, in fact, on this day (July 24th), was dressed
fLQd walking about the ward^ although the temperature was about three and a half degrees
above the normal standard.
In tie preceding Caee, 702, although bvt little mtdidoe was employed, find that (^f
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W2 Dietetic System of Treating Pneumonia.
the laiideBt oharaoter, the pneumonic inflammation resolved spontaneously, and did not
pass into the stage of hepatization and suppuration. There was no subsiequent pitni-
fent expectoration, and the recovery of the patient was rapid and complete. The &TOf-
able result in this case could scarcely have been predicted or hoped for, on the 19th of
July, third day of disease, when the temperature of the axilla was 107^.4 F., and of
the palm of the hand, grasping the thermometer, 105^.8 F. The temperature of tbe
internal organs was, without doubt, at least from two to three degrees higher, and pro-
bably reached 110^ F. ,
That high degrees of febrile heat are not necessarily fatal in Pneumonia, will be
clearly shown by an examination of the outlines of the histories of the two foUowii^
eases, 703 and 704, which I treated successfully in the Charity Hospital of New
Orleans ;
Cask 703 : Double Pneinnonia ; Great EUvation of Temperature; Recovery.
John Venwiek, age 23; laborer; stout, muscular, well built mau. Admitted into Cbtrit;
Hospital, ward 13, bed 195, December 9tb, 1873', in the evening. I saw this patient for tbe
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
left side; bowels constipated ; restless; considerable thirst: dullness oyer lower lobe of left
lung, which is most marked posteriorly.
Breathing weak in the lower lobo and lower portion of the middle lobe of right long, b&t
exaggerated in the superior portions. Vocal fremitus increased ; bronchial breathing and
bronchophony, with feeble crepitation heard over those portions of the right long which
were especially dull upon percussion. Expectoration scanty ; the sputa consisting of thick,
gelatinous, rusty colored, fibroid exudation. Urine devoid of chlorides ; no albamen : nrca
and nrio acid. Phosphoric and Sulphuric acids increased; coloring matter of bile and bilt
acids present. I ordered the following : K* Emplastri Cantharidis, 6 by 8 inches, over lower
portions of right chest. R. Quinias Sulph., half drachm ; Pulv. Doveri, half drachm; mii,
divide into 10 powders ; one powder every three hours. K* ^W > Ammoniac Acetatis, (Spts-
Mindereri), half a fluidounce every two or three hours. Diet, Milk Punch and Beef Tea.
Eight o'clock p. M. — Patient sufiering much pain, .with great oppression of respintios.
Skin hot and dry. Temperature of axilla, ]06°.2 F. Continue treatment. The blister hsi
hot had the usual effect.
December 11th, 8 a. m. — The palleut wns delirious during the night. This morning t^
skin is hot, but bathed in perspiration. Features haggard and pinched. Cheeks much fln2iel
Pulse 116, full and bounding. Respiration 54, panting, oppressed and painful. Temperatan
of axilla 104^.8 F. Pneumonic inflammation 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 percnssm,
and emits crepitant rales. Expectoration has ceased.
R. Tinct. Veratri Viridi, 5 drops every three hours. Continue Solution of Acetate 6f
Ammonia, and Quinine and Dover's powders. Dress blister with Simple Cerate. Milk Paotb
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 full andrapR
With the invasion of the left lung by the pneumonic inflammation, there has been a progressiTt
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 111° and 1 13° F. No trace of
chlorides in the urine, which is of a brownish red color, and entirely free from albamen. >'a
expectoration from lungs.
December 12th, 8 a. if.^Polse 108 ; respiration 26. The fever subsided gradaally d^riAf
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, 10^.5 F
Careful examination of both lungs, by auscultation and percussion, reveals the fact that
there has been no fresh portion of lung invaded, and that crepitation is now heard in por-
tions of the lungs which were devoid of all respiratory sounds, except bronchial breathisf.
The expectoration has reappeared, and the sputa presents the appearance of thick, vtm-
transparent jelly, which adheres fiimly to tho bottom of the vessels in which it is recetved.
Chlorides still absent from urine. No altbumen in urine. I regarded the arrest of the paco-
monic inflammation in both lungs, and the reappearance of the expectoration, and the
marked diminution of the temperature, and the absence of delirium, as most favorable sigui&
this apparently hopeless case.
Eight o'clock p. M. — Patient continues in much the same state, althongb, as was to ^vi
beei^ expected, under any circumstances, there has been a slight rise of temperaturSi tht
^t^w^w^ in^catiBg 164° in ths axilla. There has been no iacress* of the pnev^Mvi*
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Dietetic System of Treating Pneumonia, «;73
loflammation during this day, aod there ig just grounds for a favorable prognosis. I attrib-
uted the arrest of the pneumonic inflammation to the combined effects of theVeratria, 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-
quency of the pulse and respiration.
December 13th, 8 o'clock a. m. — Continues to improve ; expectoration more abundant ; air
penetrating gradually the solidifled portions of lungs, crepitant and sub-crepitant rales being
beard in the solidifled portions of both lungs. Chlorides have reappeared in small quantities
in Urine. Pulse 100; respiration 24 ; Temperature of axilla 104®.4 F.
Bight 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 14th, 8 o'clock a. m. — Continues to improve. Pulse 84 ; respiration 28 ; tempera-
ture of axilla 101<*.4 P. 8 o'clock p. m.— Temperature of axilla 99^8 F.
Ou the following day, the temperature rose to 101^.5 P., and for several days oscillated
between 99^5 F. and 101** F. The recovery of this patient was complete, without any abscess
of lang, or purulent expectoration, and he was discharged from my service in good health.
Cass 704 : Double Pneumonia ; Temper aiwe of Axilla reacfted 109* /'.; Abeeest of I^nff ; Tedi"
0U8 Chnvalescencf ; Recovery.
August Raville; 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
ID the head, 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 flushed, 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 56 ; temperature of axilla 104'* F. Great
dyspncea, 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
luDg dull over region of middle and lower lobe.
Auscultation reveals crepitation, in inspiration, with bronchial respiration and increased
vocal fremitus over the lower and middle lobes of right lung. R. Quinias Sulph., Pulv.
Doveri (Ipecac et Opii), of each, one scruple; mix; divide into four powders. Sig: One
powder every 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
continued. The temperature, also, of the axilla, has fallen one and a half degrees, and is
103®.6 F.
Shortly after this observation, the patient expressed a desire to receive '< extreme unction"
from the Catholic Priest. He was accordingly, (withottt 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 ; lips and hands congested. Respiration rapid and panting. Expectora-
tion almost entirely suppressed. Respiration rapid, embarrassed and painful. Lower lobe of
left Inng dull upon percussion, with crepitant rales and tubular breathing. Pneumonic symp«
toms of right lung aggravated.
False 130 ; respiration 56 ; temperature of axilla 102°.5. The exposure of yesterday has
evidently excited fresh inflammatory actions in the lun^s, both of which are now involved
%h
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674 Dietetic System of Treating Pneumonia.
aud the remarkable rise of temperature to 109<» F., daring the evening, was evidently dae to
the sudden spread of the pneumonic 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. Uq;
AmmoniflB Acetatis, half a fluidounce every two hours. R. Tinct. Jelseminum Sempervireni
(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 in
the middle lobe of the right lung.
In this case, during the changes of the pulmonary textures resulting from the pneu-
monic 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 PhthiMS Pul-
monalis. Under the continuous employment of Quinine, Iron, bitter tonics, gentle
expectorants and Cod Liver Oil and nutritious diet, I had the satisfaction of seeing
this patient restored to health after an illness extending over four months. Daily
observations were taken of the pulse, i*espiration and temperature, with observatioos
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, occurring in the same individual.
Cask 705 : InlermiUent Fever foUawing Pneumonia in the Same Indwidual.
Andrew Jackson Sharpe, Confederate soldier ; had an attack of Pneumonia, which we bavt
recorded (Case 702).
August 21st. — Had a chill this morning, about 8 o'clock, and at the present time, 11 o^olock
A. M , has fever. Pulse 94, respiration 28, temperature of hand 41^.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, even
after standing several days ; reaction strongly acid ; specific gravity 1011. Amoant of qriiif
passed during 10 hours of the commencement and height of the fever, 7794 grains.
yo, 90, AnalyM of Urine pa^tti iiVfing Ten ffoure of the commencement qnd hfi^hi of ajxtrox^Mm
of Paludal fever,
Urin* pMnd
duiinc 10 boon.
GnixML
Amount of Trine.,, ,,,.,.,,,,,,,,. umi......*..!...,.., 7794.81
Phosphoric Acid..,.,,, , ,i«...,i,mi»..., , 2.96
Sulphuric Acid,.,,,,.,,.., , ,,,.,„.., , ,, 10.08
Chlorine,,,, ,.,,,,, , „ 42.75
Fixed Saline ") Equivalent Chloride of Sodium 70.56
Constituents, v Phosphates of Lime and Magnesia 0.23
74.23, J Phosphates, Sulphates and Carbonates of Soda, and Potassa.. 3.34
The saline constituents consisted almost entirely of Chloride of Sodium, whilst the Potassa
salts appeared to be, in a great measure, absent. The presence of Chloride of Sodiam, and
the absence of the Phosphates and Potassa salts in the urine during the active stages of ma-
larial fever, correspond with the patholbgical changes which we have demonstrated by the
analysis of the blood and urine, and organs, in a large number of cases. Daring the chill of
Paludal fever, the spleen and liver, and, in fact, all the central organs, but more especially
the spleen and liver, are congested with blood. The changes of the blood in the lirer and
spleen, are of a peculiar nature : there is not a mere congestion and stagnation of the blood:
important changes take place in the blood of these engorged organs. I have determined by
numerous microscopical observations, as well as by chemical analysis, that the mud of the
enlarged and softened malarial spleen consists almost entirely of dead and altered colored
blood corpuscles. So also the liver contains vast numbers of pigmentary fragments deposited
chiefly in the periphery of the lobuli, and which have resulted from the destruction and
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 sknd B«th9l9fl7 of this disease, and ta gross,
incompetency in ths i\«(^ of the micij^scope. *
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Dietetic System of Treating Pneumonia. 675
It is impossible that the pigment particles of the liver and the spleen of malarial fever,
which consist chiefly of altered bsmaiin, should escape the attention of any competent
microscopist.
After the active congestion of the liver and spleen during the cold stage, the blood corpus-
cles which have been withdrawn from the circulatory 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 tlie
liquor sanguinis ; and, hence, it appears that the urine excreted during the first stages of the
paludal paroxysm presents corresponding characteVs: — 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 P.);
of axilht 3S^. 3 C. (101** F.) Patient in a good perspiration; fever appears to be declining,
which change commenced about 7 a. m., when sweating commenced.
Ezamination of Urine: — The urine 4)assed 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 21st, 10 p. m.
to August 22d, 12 m. : Grains 9601.20; specific gravity 1016. The phosphoric acid appeared
xo 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 small 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 suit, but not to so large an extent as during the fevtr.
No. 91 : — Analysis of Urine passed durinff fourteen hours — Atiffusi 21, 10 P. if. <o Auffusl 22, 12 M;
Urine Patsod During
Fourteen Hours.
Grains:
Amount of Urine 9601.20
Phosphoric Acid 29.07
Sulphuric Acid 19.20
Chlorine 36.30
Fixed Saline 1 Equivalent Chloride \ 59 g^
Constituents V " of Sodium )
76.50 J Phosphates and Sulphates of Lime, Soda and Potassa.. 16.66
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 paroxysms characterize the phenomena
of malarial fever, so do marked changes, at difterent periods of the disease, characterize the
urine
August 23d, 12 M.—Pulse 80; respiration 24 ; temperature of axilla 38®. 5 C. (101°. 3 F.)
£3Utmination of Urine: — Heavy crystalline deposit in urine, of 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. ^2:— Analysis of Urine passed during tweniy-f our hours y Aujust 22</, 12 J/., to Awpist23djl2 M,
Urine Passed Durirg
Twenty -four Hourb.
Gralni:
Amount of Urine ,...%» 12,927.60
Phosphoric Acid 52.93
Sulphuric Acid 43.54
Chlorine 64.90
Entire Saline 1 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 eomparlson of the rarious analyses of the urine in this case, we observe a progres-
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676 Dietetic System of Treating Pneumonia,
siye increase in the saline constitnents, and especially of the phosphates of lime Md
magnesia.
Absolutely no medication was employed in the preceding case, so that it famishes daU
for the comparison of the phenomena of Pneumonia and Paroxysmal fever, occnrriagat dif-
ferent times in the same indiTidnal.
That cases of fever should arise in a hospital, or in camp at any time, indepeodentlj
of the eflPects of exposure or fatigue, or the supervention of any recognizable ioflamna-
tory lesion, may be accounted for in a measure by the fact, that tents and hospitab are
often 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 bdiere,
from an impression upon the sensitive nerves of the surface transmitted throogb the
central spinal ganglia, and reflected upon the sympathetic and vaso-motor nenres, 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.
It 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 ph^
nomena of the nerves and muscles, and of the secretions, should also be considered io
the discussion of the origin of Irritative fever and inflammations. I select the
following case of Irritative fever, arising spontaneously in my hospital practice dariK
the civil war, as affording materials for comparison with the case of Pneumonia (702 <
' previously recorded, in that it was treated strictly upon the so called expertant plan,
without drugs.
Case 706 : Fetter originating in Military Hospital^ without any assignable cause, and without aay &♦
cernible local inflammation ; treated upon the Expectant plan, without drugs.
Powers, Confederate soldier; age 18 ; height 5 feet 7 inches; weight 115 pounds; iigb:
hair, fair complexion. Has been in the General Hospital, 0. S. A., Augusta, Georgia, for 4
weeks. Entered with bronchitis, and in an anaemic condition. Native of Marion District.
Sonth Carolina. Says that he had chills and fever last year ; and has had pneomonia thrte
times in his life. Daring his stay in this hospital, hns been treated with Qainine, Iron, ui
bitter tonics, and supplied with nutritious diet. Under this treatment the patient his ia-
proved rapidly, gaining both in flesh and strength, and presenting a clear, healthy complexiot^
The patient was in apparent good health, and fit for active service in the field, when on tin
night of July 18th, 1862, he was seized with severe pain in his head, followed by high ftrer
the pulse beating 120 per minute and the temperature of the axilla reaching 106^ F.
July 10th, 12 M., pulse 120; skin hot and dry; tongue moist, but red. Ordered his onK
saved from this moment. I prescribed nothing, but directed that the patient should be np-
plied with cold water, ad libitum.
July 20tb, 11 A. M. Much better; skin cooler; pulse 112: skin warm but moist; tosfie
red but moist. Bowels have been moved four times and are inclined to diarrhaea. Urisf
orange colored. Nothing ordered beyond cold water and simple nutritious diet.
July 21st, 2 o'clock p. If. Pulse 92 ; respiration 22; temperature of hand 36® C, (98* F.
of axilla 380.4 C, (lOlM F.)
Exdmination of Urine. Amount of urine passed during the last 48 hours ; grains, 31,890. £
specific gravity, 1012. 4. Urine rapidly underwent putrefaction, and emitted an offeoii"
smell, as in that of the case of Pneumonia, 702 ; while on the other hand the ariae ezcrett^
during the active stages of malarial fever, as in case 705, did not undergo a similar chaofe
and emit an offensive odor, until the febrile excitement had subsided.
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Dietetic System of Treating Pneumonia. 677
No. 93. Analytit of Urine penned during foriy'tighi kourt.
Forty-Eight Twentj-foar Ekcb honr.
hours. houn.
GroiDS. Grains. Grains.
Amount of Urine 31,890.60 15,945.30 664.38
Urea 741.12 370.56 15.44
Uric Acid 22.68 11.34 0.47
Free Acid 46.32 23.16 0.96
Phosphoric Acid 96.90 48.45 2.01
Sulphuric Acid 47.53 23.76 0.99
Chlorine 15.82 7.91 0.32
Bqniyalent Chloride of Sodium 26.05 13.02 3.13
Phosphates and Sulphates of Lime, Magnesia, and of
Potassa and Soda 150.35 75.17 0.64
July 22d p. M. Free of fever, pulse 84 ; skin cool.
July 23d, 2J p. m. Pulse 96; respiration 22; temperature of hand 360.8 C, (98<>.2 F.;) of
axilla, 38<» C, (100*».4 F.;) skin moist ; tongue red.
EzaminaHon of Urine. — Amount of urine passed during the last fortj-eight hours; grains
19,857.12; specific gravity, 1009; normal color, slight deposit.
^Vb. 94. Analysit of Urine passed during forty -eight hottrs.
Forty-Eight Twenty-four Kach hour.
hours. hours.
Grains. Grains. Grains.
Amount of Urine 19,857.12 9,928.56 413.69
Urea „ 636.90 318.45 13.26
Phosphoric Acid 22.71 11.35 0.47
Sulphuric Acid 44.10 22.50 0.93
Chlorine 3.57 1.78 0.07
Equivalent Chloride of Sodium 5.48 2.94 0.12
p. M. Free of fever ; pulse 80 ; surface of body feels cool and natural.
July 24th, 1 p. M. Pulse 96 ; respiration 16 ; temperature of hand, 36*».4 (97°.5 F.;) of axilla
38<'.2 C, (100*».7 F.)
EzaminaHon of Urine. — Amount of urine passed during twenty-four hours ; grains 9,515.52 ;
specific gravity, 1008 ; straw colored ; heavy deposit of phosphates and urates. Alkaline re-
action and putrid odor.
No. 95. Analyaitof Urine passed during twenty-four hours^
Trine Twenty- Ilrlne each
four houn. hour.
Grains. Grains.
Amount of Urine 9,615.52 396.48
Urea 236.23 9.84
Phosphoric Acid 7.62 0.30
Sulphuric Acid «. 11.31 0.47
Chlorine 1.48 0.06
Equivalent 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,
aud this slight disturbance of the alimentary canal, might have been produced by the copious
draughts of cold water.
The conBideration of the spontaneous resolution of such oases of fever, which in
their onset, forbode serious consequences, is important in the warning which it gives
agunst the unconditional acceptance of the statements of those who assert, that cert-ain
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
remedy, had been used, the physician might have attributed the gradual subsidence of
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W8 Eieietie System of Treating Pneumonia.
the fever, to the so-called abortive effects of his drugs ; whilst in reality, nature needed
no assistance ; — either the poison producing the fever being so limited in amoont, as to
be readily destroyed during the changes of fever, — or dse, the disturbances in the
nervous system and blood, and organs, were so slight, as to be readily re-adjusted bj
the working of the natural and fixed laws of the economy. It would also be a salijcct
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 withdjawal of the
agent, and free supplies of f^esh air upon the progress and results of such a ewe cf
fever.
An examination of the changes of the urine in the preceding case, reveals the ^
that the chlorine was diminished to a marked degree. The diminution of this ekmeot
is characteristic not alone of pneumonia, but all those diseases, as Typhoid fever, SmaD
Pox, and Remittent fever, which continue for a considerable length of time, and u wliid
little or no nutriment is taken. We have shown that the chlorides may be dimiaisked
to a marked extent even in Traumatic Tetanus. It would expand the present idmt
to too great an extent to detail the observations which we have made upon the uine ii
Pneumonia and various other diseases in order to illustrate the chemistry, pathologT.
and treatment ; and I will content myself with an expression of such genenl coodo-
sions as will illustrate certain questions relating more especially to the method of trest-
ment.
1st. During the active stages of Pneumonia, the Urea, Uric Acid, Free Acid, Pboi-
phorio Acid and Sulphuric Acid, are present in increased quantities in the urine; isi
such increase is evidently due to the metamorphosis of tissue during the incraftd
chemical changes of the forces.
2d. During the active progress of the Pneumonic Inflammation, the chlorine r^)idlT
diminishes in amount and may entirely disappear ; and its re-appearance in the unv
and progressive increase indicates an arrest of the farther progress of the pnenmook
inflammation. The reappearance of the chlorides in the urine may indicate the owa-
mencement of convalescence, before auscultation and percussion afford any informsU*
as to the progress or arrest of the pneumonic inflammation in the sound portioffi '^
the lungs.
A similar observation is also true with reference to the indications afforded by tW
thermometer. The retention of the chlorides is connected with the morph(^ogiJ
changes of the pneumonic exudatiop, and their excretion is increased, during the ibKffp^
tion and disappearance of the exudation.
3d. In malarial fever, on the other hand, during the chill and early staj^of tia
febrile excitement, Chloride of Sodium appears in increased amounts, whilst therein
marked diminution of Uric Aeid and Phosphoric Acid.
During the cold stage, the colored blood corpuscles are accumulated and altered »
the liver and spleen ; and during the hot Stage an impoverished blood circulates vd
undergoes chemical change ; as this blood is characterized by a preponderance of tb
liquor sanguinis ; and as the chloride of sodium is the most abundant and characterau
salt of the Liquor Sanguinis, it will appear most abundantly in the urine. As a ltf9
portion of the colored blood corpuscles have been temporarily withdrawn from ti»
general mass of the circulation, the salts peculiar to them and their chemical daa?fi-
viz : the Phosphates of Iron, Lime and Potassa, will in a great measure disi4>petr fno
the Urine. Owing to the congestion of the liver, the bile also is altered in its property
and appears to be excreted in larger quantities than in health.
4th. During the continuance of the fever however, the urine becomes of ^^^
color, the Phosphoric Acids and Potash Salts, and Uric Acid gradually increase, y
increase of those constituents, in the urine during the progress of the fbver, is lea^
explained, by the fact that the altered blood corpuscles during the active changes rf w
fever, are themselves drawn into the round of chemical change, undergo decomposiw
and yield up the coloring matters and salts to the eliminating action of the kianeyi
6th. The remarkable changes of temperature, as well as the internal oongww*
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Dietetic System of Treating Ptwumoma. 679
chaiacteristio of the chill, are probably due to the action of the mahrial poison, or of
the blood altered by the paludal poison, upon the internal ganglionic centres. This
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 as 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 pheoomena 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
coutraction 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 large central organs, consequent upon the paralysis of the
ganglia of the sympathetic Cerebro-Spinal system, which preside over circulation and
animal heat. When^the chills recur frequently, these phenomena will be frequently
repeated, becomine 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 arrest of the normal and nutritive and
chemical actions of the nervous system.
7th. In Typhoid, (Enteric, Continued, Camp) fever, nniformity 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.
9th. Pneumonia is characterized by structural alterations of certain defined ana-
tomical elements of the lungs ; malarial fever b 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
pyrexiae, arising from preceding blood disease. On the other hand, it may be 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
[)f certain anatomical elements of the pulmonary tissue. I do not propose to enter into
in exhaustive discussion of these theories, which would demand even greater space than
hat 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
supervention of the local inflammation, and presents characters in accordance 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.
According to this view the fever of Pneumonia resembles the traumatic or so-called
mmcal fever attending wounds.
In the Dietetic System, which consists in allowing the disease to run its natural course
aninfluenoed by drugs y during the active stages, UiQ diet is light, with cold water for
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680 Dietetic System of Treating Pneumonia.
drink ; and subsequently when the fever and active symptoms aecline, a more genero«
diet is allowed, with alcoholic stimulants if the forces are depressed.
Dr. Dietl treated 380 cases of primary pneumonia, in the Charity Hospital of Viesna,
by Venesection, by large doses of Tartar Kmctic, and by diet alone, with the following
results:
In 85 cases of Ppeumonfa 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 Kmetic, 22 died, giving 20 per cent of
deaths ; or one death in 4.818 cases.
On the other hand, in 189 oases treated by diet alone, only 14 died, giving 7.46 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 cases treated by diet, not one of tlie
deaths was uncomplicated.
According to Dr. George Balfour, who examined the statistics of the Homoepadiic
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 ooune,
under certain regulations of diet.
In the expectant plan of treatment, adopted by Skoda, in the Charity Hoflpital of
Vienna, in which remedies were given to meet occasional symptoms, venesection beiig
practiced early if there was much dyspnoea, opium administered if there was much pan,
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 ia a
great measure proportional to the interference with the operations of nature by reoe-
section and drugs.
It is important, however, that 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 commencement 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 and chemical composition and variations of the sputa.
6th. Careful observations on the various stages of the disease, which mark tht
progress to recovery or to death. All critical discharges from the skin, lungs, kidnejif
and bowels should be carefully noted, as well as the attendant variations of tempev«tiii«,
and of the circulatory and respiratory acts.
7th. In fatal cases, careful miroscpical and chemical examinations should be madt
of the diseased structures.*
II. RATIONAL TREATMENT DESIQNBD TO FURTHER THE NATURAL PROGRESS Of
PNEUMONIA TOWARDS RECOVERr.
. This mode of treatment should evidently embrace the Dietetic System, and, althou^
resembling in some respects the Expectant plan, differs from it, in that it is an attasfl
to treat disease by fixed principles, rather than according to casual symptoms, cke
design of the remedies being to excite and aid those natural processes by which tke.
disease terminates favorably. However imperfect this system may now be, in compaitioii
* Dr. Parkes, Emeritus Professor of Clinical Medicine in UniYersity College, has gira &
valuable record of an uncomplicated case of Pneumonia, unmodiClQ^ by any other disease
OT by treatment. Med. Times and Gazette^ Feb 25th.
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Rational Treatment of Pneumonia. 681
to itfl possible improvomont, still it is not too much to affirm that the priaciple which
UDderlies 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 modem 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 tho
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 Airther the nec&^sary changes which
the exudation must undergo, in order to be ^Uy excreted from the economy. To this
end, during the period of febrile excitement, Dr. Bennett contents himself with giving
salines in small doses, with a view of diminishing the viscosity of the blood. As soon
as the pulse becomes soft, 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 ^ther, sometimes com-
biaed with ten minims of Colchicum Wine, three times daily, to favor the excretion
of urates. But if crisis occurs by sweat or stool, care is taken not to check it in any
way.
Dr. Bennett gives as the results of this practice during eight years, in the clinical
wards of the royal Infirmary :
Total number of cases treated, 78 ; average age 30| ; 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, uncomplioated
Pneumonia, 14i days. Average duration of double uncomplicated Pneumonia, 20 days.
The fatal cases were all complicated. The first with uncontrollable diarrhoQa, and on
dissection conjoined with Pneumonia, there was found extensive follicular disease of the
mneous membrane of the duodenum, jejunum, but chiefly of the ileum. The second
case was complicated with persistent albuminuria and anasarca. No post-mortem exam*
inadon could be obtained. The third case, that of s^ 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 from a
comparison of the results obtained by other practitioners. Dr. Bennett concludes : ^^ That
nncomplioated 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 eflfete 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 far more Ukely to be pror
S6
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682 Rational Treatment of Pneumonia.
duced by the practice. In fact, the only cases in which it occurs, are io aged or
enfeebled constitutions, in which nutrients, and not antiphlogisticg, are the remedies
indicated. We can, however, readily understand how blood-letting, practiced early, ind
in young and vigorous constitutions, does less harm, or, to use a common expressioD, U
borne better,' than when the disease is advanced, or the patient is weak, and tkh
because then the vital powers are less affected by it. Hence the diminished mortality
in the second series of Louis' cases, and probably in the army and navy cases. Bit
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 Lectopw
on the Principles and Practice of Medicine, by John Hughes Bennett, M. D., F. R. J^.
E., Professor of the Institutes of Medicine, and Senior Professor of Clinical Medicine in
the University of Edinburg. Third Edition ; Edinburg, 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 priucipal, and very important part of the treatment, to which, as most of you knov, 1
pay very especial attention, id that which I may call the dietetic portion. The object of tkis
is to support the vital powers of the patient, and to promote general nutrition during the tim?
when those changes are taking place, which tend to check or alter the morbid process, aadto
convert it into a healing process. When a patient suffers from Pneumonia, the tendencr is
fo*r the lung to become solid, then for pus to be generated, and at last, for the pus-infiltrat«i
lung-structure to be broken down and dissolved. Such are the changes when matters tske
an unfavorable course. On the other hand, recovery takes place, either through the non-
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 therapeaik
art, that any of the measures which are ordinarily within our reach, such as the administn-
tion of certain drugs, or the abstraction of blood, or the application of blisters, exercise adirrrf
influence in effecting these changes. Save in the case of antidotes, which directly antagoniie
the proximate cause of the morbid state, medicines promote the cure of acute disease, br
assisting and quickening some natural curative process. And he is the wisest practitioner,
and will be the most successful therapeutist, who watches carefully the natural processet •i
cure — in other words, who studies the phenomena, both anatomical and physiological, vhieb
accompany them, and of which, indeed, they consist.''
You will perceive, then, that my argument may be thus summed up : InternaMDlUBi-
mations are cured, not by the ingesta administered, nor by the egesta promoted by the drop
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 bj oar
interference, may either aid, promote, and even accelerate this natural tendency to getv^.
or it may very seriously impair and retard, and even altogether stop that salatarj process.
If then, this view of the nature of the means by which inflammation is resolved ia interaa*
organs be correct, it is not unreasonable to assume, that a very depressed state of vital
power, is unfavorfible to the healing process. Indeed, if you watch these cases in wbidi
nothing at all has been done, or in which nothing has been done to lower the vital powo^
you wiirflnd that the more inflammatory process itself, especially in an organ so importut
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 m
favor of the policy of upholding our patients, even in the earliest stages of acute disease, bj
such food as may be best suited to the digestive organs, such as is most readily assimilated
and calls for the least effort, the smallest expenditure of vital force, for its primary digestioe
Nutritive matter in a state of solution — broths, soups, farinaceous matters — ^answers t&e
purpose the best ; and, also, alcohol, which is directly absorbed, without any preTioss
change, and tends to feed the Galorifacient process, and to diminish the waste of tissae;.
which would necessarily follow in order to maintain it.
Inflammation is a deranged nutrition. Like the normal nutrition, it involves supply hsc
waste, and as the latter is considerable, the former will be proporiionally so. The tende&cr,
in inflammation, is to the more or less rapid formation of abnormal products such as lympb
and pus ; and the supplies for these formations must be drawn from the blood, or from t^
tissues, in both cases, with tbs effect of more or less exhaustion of vital force ; in the latlK^
with more less extensive organic disintegration. The active chemical procsss which accoc-
panics 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 the ex-
haustion of the yim force, aud the more Ih^ whole fraoxo will suffer; the more it feeds oi
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Rational Treatment of Pneumonia. 683
the tissues, the greater will be the difficaltj of the reparatire process. Is it not, then, im-
portant that adequate supplies should be conyeyed to this process, abnormal though it be?
And is it not likely that the most appropriate supplies maj 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 orjranic 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 au
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 ihe
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
occars, 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 tt\je
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 aflections. 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
is, 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,
daring the inflammatory process, must necessarily take place in the most important tis-
sues 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 Liquor Ammonias 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
be given in moderate quantities, but usually it is not advisable to employ opium in large
doses 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-
lants does not form a necessary 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
* Bemarlu upon the Treatment of Acnte Internal Inflammations (an extract from a Olinical Lecture delirered in
July, 1857), by B, B. Todd, M. P., F. R J8., Physician to King's rollt^e. Anhirw of Medicine, edited by Lionet
ft. Beale, M . D., No. 1, pp. 2, 4. No. 2, pp. W, 65, 57, 58 .
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H84 Antiphlogistic System of Treating Pneumonia.
depressed, with a pulse iacreasiDg in quickness, or when the patient has been previourij
accustomed to live well, or in the habit of indulging; in the use of alcoholic drinks, th^
wine or brandy, or what is really the proper way of expressiv.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 h
compelled to confess that they have given him so little satisfaction, that he his abac-
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 pUce, 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 sardj
be no more worthy of consideration than the statements of the honored writers whose
practice he condemns ; but he has furnished data by which the relative merits of his
system may in a measure be determined.
From 1840 to 1859, Dr. Todd treated 78 cases of Pneumonia at King's College
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 the period o/rtdMc-
ing^ treatment J the patients were treated very much in the manner just described. The
total number of cases was 78, and of these, 10 were fatal. Of the seventy-eight cases
twenty-five occurred in the first period, and four of these proved fatal, or about one is
every six. In the second, the number of cases was fifty-three, and in these there were
only six deaths, or about one in nine ; fairly leading. Dr. Tood thought, so far as can
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 its
results than the severer measures which are frequently had recourse to in this disease.
(Clinical Lectures on Certain Acute Diseases, by Robert Bently Todd, M. D., F. R. S.,
etc.; Phila., 1860. Lecture x, pp. 199, 212. Lecture xii, p. 261. Lecture xiii^pp.
265, 276, 277).
III. ANTIPHL0ai8TIC SYSTEM QV TREATMENT.
Volumes have been written upon the value of blood-letting in inflammation, and
physicians have attested their belief in its value, by the rivers of blood which have been
drawn in their battles with inflammation. We do not, however, intend to follow tke
plan of the vast majority of the works upon blood-letting, and the systematic treaties
on " Practice,'' and enter into any hypothetical discussion of the efiects and value of
blood-letting in pneumonia ; we shall endeavor to confinre ourselves to an examinatioa
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 grett
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 depres-
sing efiects of the climate, or from supposed changes in the characters of inflammatorr
diseases, or of the human constitution, or from a more thorough knowledge of tk
efiects of blood-letting, or because the practice has passed ''out of fashion/' or &om the
discovery of more energetic and valuable modes of treatment, or from two or more, or
all these causes combined. Whatever the reasons for the abandonment of the ancieoi
method of combatting inflammation may have been, one thing is certain, the statistics
to prove the wisdom of this step are wanting in the Southern States. They are ctr-
tainly not furnished by the medical statistics of the Confederate States Army, which
may be justly taken as representing, with tolerable accuracy, allowing for the exposuref
and hardships to which the soldiers have been subjected, the success of Confed«3t<?
physicians in the treatment of Pneumonia.
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Afl Id the case of QuiDine, 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, we
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.
C. H. A. Louis ; Boston, 1836 ; pp. 23, 48-49).
The first series of cases of Pneumonitis investigated by Louis, at the Hospital of la
Charity, numbered 78, of which 28 proved fatal, or one death in 2.78 cases, or 35.85
per cent.
All these cases 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 fifth 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
Tariance 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
those 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 large bleedings ; and this result appears to support the view,
not only tbat 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 Louis
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himself remarks, that the facts which he has collected, are neither so numerons nor iw
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 jiumber of cases of Pneumonitis which came under bis
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, oflimes to the extent of 20 to 25 ounces and more,
or even to syncope had not been more decidedly success^l, and in no 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 having
observed that in some qases, rare indeed, the bleeding is followed by a considerable
amendment in the general, and in some of the local symptoms, pain and dyspnoea. Bat
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 accurately examined, the practitioner believes that the
disease is arrested, when in fact there is only a diminution of febrile action and som3
other symptoms. Whilst stating thus decidedly his experience from memory, be ooo-
fincs his analysis of the effects of blood-letting in the second series only to 29 cases.
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 ch|iracter of the
disease which affected them, all having expetorated rusty, viscid, semi-transparent spata ;
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 d^ree 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 Uie 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
Piti6 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 Piti^, in this respect, that vesication was employed at the former and not at th?
latter hospital. At the Hospital of la Charity, blisters were not applied in all the cases
which terminated favorably but only where bleeding was so ineffectual that fears were
entertained for the result. Vesication was used, in one half of the cases, or in twenty-
five patients, whose first blood-letting was during the first four days of the disease, or
later ; and the average length of the disease in these cases was twenty-two days two
hours ; while it was fifteen days and eight hours only, in the other cases. An enor-
mous difference, which would seem to show that the unfavorable conditions under whicb
blisters were used, have not been sensibly affected by their action ; and Louis therefore
infers that the vesication was 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 Piti^ without vesication in a single instance, all recovered. The reasons
which led Louis to reject vesication from the treatment of acute thoracic inflammatioD.
are worthy of careful examination by the profession. This accurate observer, inform*
us in his second series of observations upon the effects of blood-letting, that an atten-
tive study and rigorous analysis of the facts forced him to acknowledge that acute
inflammatory affections, so far from preserving from inflammation, organs which are no4
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Antiphiogistie System of Treating Pneumonia. 687
the primitive seat of disease, are in truth, 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-
tality of 8 deaths, or one death in 6,37 cases, or 15.68 per cent. These cases were
treated strictly upon the antiphlogbtic plan, with repeated blood-letting, cathartics, tartar
emetic, and opium, in many cases, mercurials and colchicum. The mercurials were used
in small dose;, 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 Tartarized
Antimony was used after 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
bad ceased, and then recommenced in a smaller dose. The sensible effects of this medi-
cine and the colchicum were 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 oases 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
eases 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
1st, 1849, 648 cases of Pneumonia were admitted, and 222 proved fatal, or one death in
2.91 cases, or 34.26 per cent.
M. Grisolle, whose plan of treatment was similar to that of Louis, with this difference
that he advocated more nxoderate bleedings, reports 37 deaths ii^ 232 cases occurring in
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688 Antiphlogistic System of Treating Pneumonia.
his hospital practice, or one death in 6.27 oases, or 13.9 per cent. In like manner
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 adroetted
and introduced into general practice by Rasori, about seventy years ago, (although many
other physicians, as Paracelsus, Huxham, Pringle, Cullen, Mauyat and others, hid
recommended Tartar Emetic in the treatment of fevers and other diseases, still there
appeals to be no dissent from the view that it is to the Italian Physicians, and espedaDj
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 many practitioners have abandoned the use of this remedy in Pnea-
monia, especially in the large doses recommended by the Italian physicians, on accooat
of its depressing effects upon the forces, and its frequent injurious action upon the
bowels. As far as my knowledge extends, the Southern country affords 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 woM
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 more
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 daily increased until they amounted to a draehm,
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 fonrteeo
per cent, in the former and about twenty- two per cent, in the latter.
The success of Tommasini with this remedy, conjoined with bleeding, was much greater;
thus he states, that out of 115 cases of Pneumonia, only 14 died ; or one death in 8^1
cases, or 12.17 per cent.
The celebrated Laennec employed Tartar Emetic with marked success in the treat-
ment of Pneumonia. The following is his method, together with his testimony to its
therapeutic value in comparison with other modes of treatment.
*' As soon as I recognize the existence of the Pneumonia, if the patient is in a state to bear
venesection, I direct from eight to sixteen ounces of blood to be taken from the arm. I rerr
rarely repeat the bleediog, except in the case of patients afifected with disease or the heart, or
threatened with apoplexy or some other internal congestion. More than once, I bare tret
affected very rapid cures of intense peripneumonies without bleeding at all ; but in commoa,
I do not think it right to deprive myself of a means so powerful as venesection, except ia
cachectic or debilitated subjects. In this respect Rasori does the same. I regard blood-lettiait
AS a means of allaying for a time the violence of the inflammatory action, and giving tiac
for the tartar emetic to act. Immediately after bleeding, I give one grain of the tartar esietic
dissolved in two ounces and a half of cold weak Infusion of orange-leaf, sweetened with half
an ounce of syrup of marsh-mtillows or orange flower ; and this I repeat every second hoar,
for six times, after which I leave the patient quiet for seven or eight hours, if the symptovts
are not urgent, or if he experiences any inclination to sleep. But if the Pneumonia has
already made progress, or if the oppression is great, or the head affected, or if both longs or
one whole lung is attacked, I continue the medicine uninterruptedly, in the same dose, aad
after the same intervals, until there is an amendment, not only in the symptoms, bat indicatei
also in the stethoscopic signs. Sometimes even, particularly when most of the above mca-
tioned unfavorable symptoms are 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 quantity
of the vehicle. Many patients bear the medicine without being either vomited or purged.
Others, and indeed, the greater number vomit twice or thrice, and have five or six atloos the
first day ; on the following days they have only slight evacuations, and often indeed have
none at all. When once tolnance of the medicine (to use the expression of Rasori) is esta-
blished, it even frequently happens, that the patients are so much constipated as to require
clysters to open the body. When the evacuants are continued to the secon^d day, or wbea
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AntipfUogistie System of Treating Pneumonia^ 689
there is reason to fear on the first, that the medicine will be borne with dlfBcuUy, I add to the
six doses to be taken in the twenty-four hours, one or two ounces of the syrup 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 eflfect of Tartar Emetic is
never more rapid or more efficient than when it gives rise to no evacuations; sometimes,
however, its salutary operation is accompanied by a general perspiration. Although copious
purging and frequent vomiting are by no means desirable, on account of the debility and the
h artful irritation of the intestinal canal which they may occasion, I have obtained remarkable
cares in cases in which such evacuations have been very copious. I have met with very few
cases of Pneumonia, where the patient could not bear the Tartar Emetic ; and the few I have
met with occurred in my earliest trials, insomuch that this result now appears to me to be
attribntable 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 rapid and
progressiYe 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 continuation of the remedy
will effect complete resolution of the disease without any fresh relapse ; and it is in regard to
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 puU
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
sorry 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 long enough for its effects to be experienced. I
have only witnessed a few fatal terminations, when the case was slight peripneumony, 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 had 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
simple or complicated with slight pleuritic effusion. Most of these cases were very severe,
yet they were all cured, with the single exception of a cachectic old man of seventy, who took
but 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 number, two
women— one aged fifty-nine, and the other, sixty-nine — were brought to the hospital mori-
bund, and sunk before they bad taken more than two or three doses of the emetic tartar; a
third died of disease of the heart, when convalescent from the pneumonia ; and a fourth fell
a victim to chronic pleurisy, also in the period of resolution of a sub-acute pneumony. These
last two cases will be detailed hereafter. 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 ;
and the next two are proofs of its efficacy iupneumoniaj rather than the contrary.
The result, therefore, of the vl^o.le is, that of fifty-seven ewes of pneumouia tres^ted by the.
«7
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690 Antiphlogistic System of Treating Pneumonia,
tartar emetic, only two individuals, both upwards of serenty, died of this disease, conjoioed
with cerebral congestion, — that, is n little less than one in twenty-eight. In prirate practice,
during the last three or four years, I hare not been called in consultation to cases of acate poeH>
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 prored faul
under the use of the emetic tartar, except that of a plethoric subject aged seTenty-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 aascalu-
tion enables us to ascertain the existence of peripneumony 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 peripneumony, — it being impossible to discriminate these diflereit
affections from each other, without the aid of auscultation. I have already stated that vt
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 tbf
tartar emetic, during the last two years, forty cases of the pleuo-pnenmonia. Of these, six
proved fatal, three in consequence of errors of regimen during convalescence. SubstractlD^
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 Pneumoaia, aAer
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-lettio;
and diruetics, which I have stated to be one in six or eight." (A Treatise on the Diseases
of the Chest, and on Bfediate 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. Wolff, of Warsaw, Drs. Wesener, Brughart, Forbes, Grares,
Stokes, and many others, in France, Germany and England, have employed the Tartar
Emetic method, afler the method of Rasori, in the treatment of Pneumonia, with great
success. On the other hand, Wagner states, that out of 13 oases of Pneumonia treated
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 testimony of
Drs. Todd and Bennett against this remedv.
With reference to Calomel and Opium, in the treatment of Pneumonia, we are unac-
quainted with any statistics by which the value of these remedies may be determined,
comparatively at least. The game remark applies to the Veratrium, so popular as i
remedy in Pneumonia in certain portions of the South. Calomel and Opium have beet
almost utiiversally employed, in conjunction with other more energetic remedies, 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, judidoosly
used. Opium e^^erts a most salutary effect upon the progress of Pneumonia, not only in
easing pain and promoting sleep, often so essential to the comfort, and sometimes even
to the life of the patient, but also in promoting free secretion from the skin ; it may, on
the other hand, when used in large and often-repeated doses, increase the oongestioo of
the lungs. Calomel may, in certain cases, especially in those in which the liver has
been rendered torpid by the action of malaria, prove a valuable purgative ; but, on the
other hand, when used iu alterative doses, it mav produce mischief, by defibrinatingtkc
blood, and prolonging the convalesoence. If the increase of fibrin in the blood be a
salutary process in inflammation, similar to what takes place in the blood of pr^:iiant
women, and for a similar reason, of increased production and development of structare.
then, whatever tends to break down the constitution of the blood, and espeeially the
fibrinous element, weakens the reparative process.
It is well known that a cha^ge in the treatment of inflammation has been gradoaDj
progressing, with at least a poTtion of the profession. This change is said by its advo-
• Jonr. de la Sect, de Med. de la Soc. Acad, du depart, de la Loim infer. 1825,
t This Memoir hai since b^cn published by tl\o Antlior, under the UMo " Cliniqu^e Medlcale de motel DIeu, Bc-yvv
Premier^ Ann6e, Paris, 1826.
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cates to be the result of increased 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 treat-
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 profession 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 state of parts, which require a new, 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
system during inflammation, which is now engaging the attention of eminent physicians,
and which is so intimately connected with the value of blood-letting and the antiphlo-
gistic remedies, recently discussed with so much ability by Drs. Bennett, Alison. Wat-
son, 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 ;
but it appears to be certain that it is either the one or the other. There are some circum-
stances, however, 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
exertion 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 blood-letting and the administration of
antiphlogistic remedies :
''When I described inflammation, I observed there Was either an increase of life, or an increased
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disposition to use with more violence the life which the machine or part was in possession ofj
and also that there was an increased size of vessels and of course an increased circuUtion ia
the part inflamed) and in the constitution 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 cob-
sistini: 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 cflect, 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 applj
with more certainty our reasoning upon it, for reasoning from analogy will assist ns in oar
attempts. We find, fromcommon observation, that many circumstances in life, as also maij
applications to parts, will call forth the contraction of the vessels ; we are, therefore, from
the above theory, to apply such means,* and whatever will do this, without irritation, will lo
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, ther
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 oar igDormnce
of the immediate cause, it is probably only through such secondary causes that we can pro-
duce any effect; 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, incrtasiag
itself, then the modes of resolution are to be put in practice : the one by producing a contrac-
tion of the vessels, the other by soothing or lessening the irritability or the action of dilatatioB.
The first, or contraction of the vessels, is produced in two ways : one by producing weak-
ness, 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, viz : sickness. The inconvenience, however, arising from this practice is, that
the sound parts must nearly, in the same proportion, suffer with the inflamed, for bring*
ing the inflamed part upon a par with health, the sound parts must be brought much lover,
so as to be too low.
2d. The soothing may be produced by sedatives, rclax.ants, anti-stimulants, etc., such as
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. Tfae second
will act as an auxiliary, for so far as irritation is a cause this will also lessen it, and the two
should go hand in hand ; for whenever we lessen power, we should, at the same time, lesiea
the disposition to action, or else we may increase the disposition ; but neither bleeding, pnrg-
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 erysipe-
latous inflammation, although that inflammation has the very action for which we ^oald
bleed in the common inflammation, viz : dilatation of vessels. However, these means may, i>
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 belonging to
any disposition can only lessen or protract the effects, which, however, will be of singular
service, as less mischief will be done, and it will often give the disposition time to wear itself ooi.
Means employed on this principle should be such as give the feel of weakness to the constita*
tion, which will affect the part, and will make the vessels contract ; but this practice shoild
not be carried so far as to produce the sense of too much weakness, for then the heart actt
with great force and the arteries dilate.
Bleeding, then, as a general principle, is to be put in practice, but this must be done with
judgment, for I conceive the effects of bleeding to be very extensive. Besides, the loss of sir
quantity of blood being universally felt in proportion to the quantity lost, a universal alam
is experienced, and a greater contraction of the vessels ensues than simply in proportioa to
this quantity, in consequence, as it would appear, of a sympathetic affection with the part
bleeding.
Too much blood, in an inflammation, is a load upon the actions of the circulation. Too
little produces debility and irritability, because there is loss of powers, with an increased
action to keep up which is now not supported. It would seem that violent actions of a
strong arterial system required less blood than even the natural actions, and even leas stilt
than a weak or irritable system ,- from whence we must see, that bleeding can either reliere
inflammatory action or increase it, and, therefore, is not to be used at random. » * *
However, bleeding should, in all cases, be performed with g^at caution, more particoUrlr
at first, and no more taken than appears to be really necessary. It should only be done tn
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ease the constitution or the part, and rather lower it when the constitation is already 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 admit 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 first, from the idea of
bamonrs to be discharged), and such practice will answer best, when bleeding succeeds,
because i% 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*
sarj 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
Tomiting, 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 F»
Palmer, London, 1837, vol. i, p. 393; vol. iii, pp. 296, 297, 300, 357, 372, 375, 381, 382, 385.)
It is evident that Hunter recognized the fact, since demonstrated by Louis, thatblood*
letting cannot arrest inflammation ; and it is still farther evident from the confirmation
which modern discoveries, and especially the recent experiments upon the sympathetic
neryous system, are giving to his theory of inflammation, and from the philosophical
manner in which he r^ulated 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-
ficatidns of the inflammatory process in different constitutions and under difierent
circtimstances of life, that the moderns have made but little advance on his principles of
practice* Unfortunately we have no means of determining numerically the success of
Hunter's practice in different inflammations* I^rom his immense experience, and from
his still greater observation and judgment, and from the great caution, and from the
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iaductive method which ho employed in determioiag the action of remedies, and in
applying them to the relief of disease, and from his high position as a suoces^ pne-
titioaer in the estimation of the public, as well as of the profession, we are led to
believe that the most eminent success attended his practice.
The observations of Conheim and others have rendered it probable that the first and
most important changes, not only of inflammation, but also of Phthisis and Caneer are
to be fouud in the blood. The discovery of the transmigration of the colorless corpnade
in ioflammation, and the investigation of the changes which they subsequently undergo,
have not only revolutionized the theories of inflammation, but have tended to fms-
tablish upon a new basis the long neglected humoral pathology.
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mikfrn
CHAPTER XVIII.
ANTIPERlODIf OR ABORTIVE METHOD OF TREATING PNEUBfONIA.
MALARIA.
RELATIONS OF PNEUMONIA TO
Vse of Quiniue in the treatment of Pneumonia, by Southern Physicians. Obseryations of
Jean Senac, Galeatius, George Cleghorn, Morton, Lautter, Alibert, Laennec, Ramizini, Lan-
eisci, Sydenham, Hnxham, Sauvages and Broussais, upon the relations of Malaria and
Pneumonia. Inrestigations of the author on the relations of climate to Pneumonia. Mor-
tuary statistics of Savannah, Georgia ; Auguata, 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.
ANTIPERIODIC OR ABORTIVE METHOD OF TREATING PNEUMONIA.
OF PNEUMONIA TO MALARIA.
RELATIONS
These terms are used, not so much to indicate the true nature of this plan of treat-
tucnt, 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 time, appeared in the various medical journals, extolling the virtues of Quinine in
the treatment of this disease, and more especially in malarious r^ons. 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 fVom 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 remark is not unfrequently heard, that Pneumonia should
he treated as a malignant remittent. Those who adopt the view ot the identity of par*
oxysmal 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 modem 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 his 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 of Intermittent Pleurisy, cured by feb-
rifuge remedies. Galeatius, near seventy years ago, in a work on Peruvian bark,
pointed out the eflficacy of this remedy in the cure of Pneumonia, occurring in Inter-
* De Recondita Febrium Intermittentium, turn Remittentium Natnra et de caram Corf^«
tione: Variis experim^n^i^ et qb^ervationibua illustrata. 1769.
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mitteDt Fever, and which he considered as one of the manifefitations of paroxjemal
Fever.
Jean Senac* advances the theory that Intermitting fevers are due to certain noxious
and morbific matter, generated within the body, or introduced from without, which is
capable of being diffused throughout the whole system. This matter is particulazlj
hurtful to the Liver ; it is accumulated in and exerts its action on that viscos. 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 fliiid acrimonious and vitiated in its qual-
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 d^rees, may pro-
duce a recurrence of the same commotions. Sometimes the fomes 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 peca-
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, at)d possessing no affinity, whatever, to intermitting fevers. Senae
illustrates these views by numerous examples ; Sometimes, without any 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, un-
accompanied by any other symptom, the commencement of the pain being, sometiiiies,
attended with a sort of palpitation around the affected part. This author also described
a kind of periodical ophthalmia, which uniformly made its attack at stated hours ;
although an inflammation of this kind does not usUally disappear in a short spaee of
time, yet in the affection under consideration, the eye was soon restored to its natural
state. Senac met occasionally with cases of excruciating hemicrania, which he consid-
ered as the offspring of intermitting fever, or rather which were intermitting feven
converted into hemicrania. The whole head was at times attacked by a pun aridng
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 affectioD
was not discovered, but on a close examination, it was completely unveiled, for it
always made its attack towards noon, raged for a few hours, with great violence, and th«i
remitted. The febrile cause fixes itself not only in the orbit and in the eyes themselves,
but also upon the external surface of the head ; indeed, it is capable of attacking eveiy
part of the system separately. So true is this, that in some patients certain parts
seem to suffer from fever, while all the others are exempt from it ; some of these parts
are periodiciilly affected by a sense of coldness or heat, others by convulsive or tre»-
ulous motions, so various are 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 illusUated
by a case in which a very acute pain in the stomach, marked by periodical occmrenoe,
was, at length, cured entirely by febrifuge remedies. This pain was accompanied by no
change in the state of the^pulse, and no preternatural heat, and during its continuance the
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 descriptions of
the manifold effects of the febrile poison, upon other organs, as the brain, bowels, splees
aqd liver, and we will close our examination of his remarkable work, with his views
upon the relations of Periodic fever and inflammation of the lungs.
The febrile poison, continues Senac, falls not only on the brain, but ako upon the
"^De Recondita Febrium Inlermittentiam, turn Remittentiam Natara et de earum CuratioBe:
variis experimeatis et obsevationibus illustrata, 1 796, Also Translation with notes by Charles
Caldwell.— Philad, 1805.
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orgaoB of regpiratiotv It less frequeotly, however, attacks these latter parts, nor,
indeed, is the reagon of this sufficiently 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, which 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 respiratioii
ID 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 oough, 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 penpneumony. 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 intermittenta when disguised under the mask
of other diseases, he relates a case of intermittent pleurisy cured by febrifuge remedies.
George Cleghorn, 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 Clegnorn,
'^ 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 complainti were
violent, as I had always used to do in inflammatory fevers ; but the remissions in the morning
gometimes 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 expecto-
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 DuretU8,t wh^o 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 concealed
under the mask of pneumonia and pleurisy. This physician relates, among others, the
case of a man who was seized in the morning with a violent shivering, and a pain in
t^e thorax of so severe a character as to render respiration scarcely practicable. The
pulse of the patient was small and rapid, his weakness was extreme, and universal tsold-
new overspr^ all the limbs. Notwithstanding these symptoms, blood-letting from the
arm was employed as the necessary and proper remedy for this spasmodic 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 intermittents, has
recorded two similar cases in his Hist. Medic, bienn. morb. rural, etc.; Casus v. and ix.
Case 707 : A laborer of Luxembour<^, thirty years of age, of a dry temperament,
being engaged in threshing corn, was seized, first with a trembling, and then with a vio-
•BaUon. Epid. Spanim. Blanch. HUt. Hop. p, iii. $ viii. etc. Bagl. Prtx. MeO. 1, i. c. ix. Lancb Epid. Bom. c. vi.
fO homines ropnblicic calamitosos atque funestoa! ipum pleuritidem, quae sua sponte nullfun opeiii Indigent cum
taU tpnto qoieecerot, ex eveotar reddu^t qiortifenun. Puret in Praenpt. Co«lc^,
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lent coldness, to which succeeded a short hot fit, and great thirst. The principal sy*^
torn was an excessive pain in the lefl side, which consideriEd)ly impeded re^Hratioii.
Being obliged to quit his work, he took to his bed ; the fever continued nearly eighteen
hours in the same state, and then underwent a perceptible remission. On the morDuig
of the day following, the patient was still better. Although he was rather feeble, the
stitch in his side continued, and he was certainly in some degree feverish, yet be went
to work again, but all the symptoms returning toward evening, he again took to bk
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 io
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 himsdf in
moderating the violence of the symptoms. He drew from the arm of the affected side
ten ounces of blood, which was covered with an inflammatory crast, and ordered an
emollient cataplasm to be applied to the part where the pain lay, and to be freqn^itly
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 poise
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 sedimOTt ;
the symptoms were now much milder, but as they had not altogether disappeared, the
forgoing 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 undergone no change since the day before, the
skin was constantly cold, etc. Lautter discovered immediately the malignant oharaoter
of the fever. He took advantage of the remission to administer an ounce of the bark
in the spaoe ol twenty*four hours ; the next paroxysm was a very moderate one ; and
by ootitintiing the use of the same remedy, the disease was radically cured.
Case tOS : A woman, sixty vears of age, having her system greatly heated by exer-
oisc, exposed herself imprudently to the coolness of the evening. She was attaked by
a cold fit, which was followed by a fever of great intensity. A severe pain ooconed la
the right side, extending round to the spine ; a dry and frequent oough added to its
ftcuteness ; th<a respiration was short and laborious, and the succeeding night was passed
without sleep, Lautter was called in ; be fi^und the pulse greatly agitated, fhll a»d
bard, the tongue white and dry. Taking the disease for a pleurisy, he drew blood fron
the arm of the side affedted, and laid an emollient cataplasm on the part where the pab
was situated ; the blood Was covered with an inflammatory crust. The symptoBs
became mild^.
Ou thd same day, at one o'dock in the afternoon, the shivering returned with a sli^
degree of ooldn^d; the febrile heat, the cough, the pain, etc., were all augmented ; the
puTfte waft u jfUU and ai h^rd aa at first ; blood was consequently drawn a seecmd toe,
atid iexhitutld again an &fiammatory erust. There was now a remission of the Mrii
aymptoms, On the eveuiog of the day following) the oold fit returned ; the patn, the
h^t, the oough, etc., lucrdased considerably, in oonsaquenc^ of which the patient fMsed
a very bad night,
Next d^y there was a remisaion ; afternoon, another exacerbation, ushered in by a
cold fit, The physician conlianted himself with repeating the application of esti-
plasn%3, aud administering cockling drinks. He had no further recourse to blood-letdaz,
because the patient's streng^l^ was ^eatly exhausted, and ftom the progress of the dis-
ease and the copious sedin^ent of the urine, it was easy to discover a doable tertiaa
remittent lurking unde^ the mask of pleurisy. Lautter gave an ounce of a mixture of
bark to be taken previously to the return of the paroxysm which was very near at hand.
During the succee(|[ng night, the patient exnerienced only a ^eat l^eat, but the ooc^
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Antiperiodic Method of Treating Pneumonia. 699
and tbe pain in the sidd did Dot increase. On the fo)l«wing 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 restored. (A treatise on Malig-
nant Intermittents, by J. L. Ahbert, 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 that he had had
a paroxysm two days before. A third paroxysm occurred 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
rah crepitant well characterized, principally on the right 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
rcUe 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 fifth 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 after, 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
bark. (See Physiological Pyretology ; or a Treatise on Fevers, etc., by F. G. Boisseau,
trans, by J. R. Knox, M. D.: Philadelphia, 1832 ; pp. 443-486.)
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 various forms of malariul fever, has
been not only long, but widely held by the medical profession ; but the authors already
cited are 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
of 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 inflammation^, 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 have 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 MALARTA.
We will in the first place, institute a comparison between the mortality occasioned by
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-TOO Relations of Pneumonia to Malaria.
pneumonia in malarious and non-malarious locations. The collection of the foUowiag
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 vanoos
cities.
Upon examination of the mortuary records of various cities, it was found that the
deaths from Pneumonia, were frequently entered under the heads of Pleurisy, Inflim-
mation of the Lungs, and Congestion of the Lungs. I have grouped together the
deaths from these causes, as well as those from Hydrothorax. Hydrothorax as a general
rule r^ults from Pleuritis, a disease referable to the same general causes as poeamoDii,
and oflen associated with it. This grouping was absolutely necessitated by the varioos
modes of recording diseases adopted by diflFerent cities. Thus in Savannah, and io the
southern portion of Georgia, Pneumonia was often called Pleurisy, and was evidently
entered under this name upon the bills of mortality, or rather upon the mortuary reconb
of the various cemeteries.
MORTtlARY STATISTICS OP SAVANNAH, GEORGIA.
No more important field presented itself than Savannah, Georgia, for the inves^-
tion of the relations of Malaria to Pneumonia, and I consolidated from the mortoiry
records of this 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 years,
1804 to to 1854> inclusive.
These statistics related exclusively to the whit^, as the record of diseases of the
blacks were so imperfect, as not to permit of any general or specific classification. The
relations of the mortality to the population, were calculated from the following data.
Population of Savannah, 1800; whites, 2618 ; blacks and colored, including nejm>
slaves, 2548 ; total 5166 : 1810, whites, 2490, blacks and colored, 2725 ; total, 5215
1320, total population, 7523: 1830, total population, 7776: 1840, whites, 5778.
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 i
sandy plain, elevated forty-two feet above half tide. On the north, this plain is ter-
minated abruptly by the Savannah River, a turbid stream pursuing its slumsh oonRe
through the low grounds and rice fields of South Carolina and Georgia. Vn the eist
and west, the city is flanked by extensive tide swamps, formerly under wet (rice) cultore
at the present time, and for the past fifty 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 b
1818. The sandy plain extends for several miles beyond the city. Savannah therefbrr,
is surrounded on all sides, except the south, by malarious districts. In fact, up to ISlS,
she might justly have been regarded, cs a city situated in the midst of a vast marsh, or
rice field, reclaimed by a system of dams and canals, from its original condition of i
rich alluvial swamp.
With the establishment and perfection of the dri/'cnlture system, and with the drua-
ing and cultivation of the surrounding low lands, the health of Savannah has steadily
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 average popu-
lation of those years; in the ten years, from 1820 to 1829, inclusive, aa 1 in 17; ra
the ten years from 1830 to 1839, inclusive, as 1 in 24 ; in the eight years, from W*
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 fet^
and other diseases, and by aH diseases ; and the monthly deaths from fevers in Savannah,
during a period of 50 years, 1804 to 1853, inclusive.
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Relations of Pneumonia to Malaria.
701
TUal Annual and Monthly Deaths of the White Inhabitante of Savannah from Fever^ and Total
Deaths from other Diteaees and from all causes^ in Savannah, Oeorgia, during a period of 50
yeare, 1804-1864.
II
i«
«2
1
1
1
DEATHS
FBOIC FEVERS
IN
Years.
5
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3
1
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1804
77
112
52
80
77
63
46
87
120
64
130
126
107
150
142
120
117
125
106
150
: :
207:...' ...
238 ...' ...
169!...' ...
230L.; ...
219...' 1
183'... 1
163
212... ...
226...' 3
214... 4
300... 1
233;...l 1
272 ... ...
461 ...; 4
211... 4
510 ... —
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1
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16
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5
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6
11
11
10
19
11
13
3
10
6
14
1
8
10
4
3
38
9
585
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
5
3
10
9
10
3
11
32
38
23
19
15
28
10
13
■!
,S
20
23
41
21
1253
17
57
24
29
21
12
20
10
50
21
46
27
56
104
21
147
197
62
35
20
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
1532
2
13
9
10
11
9
2
4
5
4
14
12
10
47
40
53
27
18
9
2
2
15
5
1
6
2
4
6
3
5
1
1
30
14
27
29
6
10
22
1
6
8
2
9
10
8
5
42
9
559
1
1805^
2
1806
1807
1808
3
1809
i
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2
1810
2
4
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2
1812^
5
1813
5
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166! 134
130 103
1815
1816
146
313
76
323
649
183
133
109
42
23
62
96
23
32
126
148
135
187
168
202
158
159
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123
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1817
13
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1828
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321 ... 2
146 ...| 1
209;...' ...
159 ...i 1
3
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1830
28 139
17' 130
57; 159
36 16R
1831
147...
216 ...
202:...
1971...
228|...
249...
368 ...
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1
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7
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5
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1834
34
67
38
100
108
154
124
83
62
91
51
57
60
28
50
71
63
75
202
76
163
171
211
258
163
213
266
222
210
165
196
172
180
182
248
286
321
339
440
394
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380
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ToUl
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46
49
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139
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702
Relations of Pneumonia to Malaria,
Total monthly Deaths from all eausety Fevers excluded^ and J^rom all causes^ inehtding Fevers, in Sammm-
nahf Oa. during a period of Fifty years ^ 1804-1853) inelusive, — Whites,
Deaths from all Caoses, Fevers excluded, each
Month during Fifty years.— Whites
Deaths fm. all Causes, Fevers inclodedi
each Month during 50 years. — Whites.
TOTAL DEATHS FROH OTHER DISEASES.
Total Dsatbs fbox Fsvuh ajtd oraca I>us*b.
YEAR.
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17
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14
18
13
15
8
8
8
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7
8
10
8
18
6
13
15
20
20
17
12
21
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24
12
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11 S\ 8
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5
10
11
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4
7
5
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5
7
14
10
14
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8
5
12
12
8
10
9
8
10
18
12
10
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
17
11
10
20
24
12
10
18
17
15
10
12
11
12
11
'I
7
9
15
13
8
8
11
.1
6
15
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
14
25
25
25
13
12
17
7
23
14
29
24
30
32
44
11
11
9
17
10
7
12
11
6
15
13
10
9
21
20
11
U
27
19
13
8
8
14
15
5
13
10
7
13
8
8
21
20
22
17
20
19
19
26
17
12
17
14
12
19
14
27
28
35
47
8
9
10
6
14
15
9
6
9
6
14
10
17
17
8
17
14
22
11
12
12
15
17
10
13
14
12
(
8
6
11
9
9
12
6
10
11
16
9
8
16
12
16
11
11
23
12
12
6
5
13
12
6
19
I
12
7
11
2
9
12
9
6
6
6
14
11
5
12
11
7
8
14
12
20
8
9
17
14
15
11
18
15
7
20
13
10
52
18
34
53
21
21
24
10
13
21
28
21
16
14
18
22
20
22
15
20
18
21
12
29
17
32
40
23
19
46
17
41
117
35
31
28
18
U
20
34
14
19
12
8
38
\
)
49
39
29
19 12
1806
lOi 9
9; 6
16 12
6
11
10
5
12
11
6
8
12
8
12
72! 24 12
1806
10 2
9* 9
9 12
23' 43 19 8
1807
37! 50! 30 7
1808
10
10
34 37! 35 12
1809
7
12
10
6
12
13
10
9
16
16
11
7
24
16
13
7
6
13
15
4
12
9
7
13
6
8
20
19
21
16
19
16
19
25
17
6
14
15
9
6
8
6
11
6
7
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9
6
9
6
5
4
8
9
11
31 31
20 36
45 23
44; 56
21 17
1810
7
5
6
20
15
6
14
9
8
13
7
17
15
7
10
8
13
11
11
13
8
8
13
21
12
18
15
23
19
13
21
22
18
14
5
14
14
17
12
9
14
12
15
26
18
16
14
13
11
11
15
26
9
11
13
10
18
20
25
17
12 16
1811
22 10
l812
22 13
1813
8il3
16118
14.12
11,12
30
67
67
70
58
29
92
232
52
30
37
21
20
23
52
14
17
40
58
37
62
127
19 16
1814
IftJiO
24 9
1815
13
9
12
8
10
13
32
10
11
4
3
7
14
7
15
8
8
8
4
18
15
11
11
16
4
4
24!l0
1816 ,
14
11
2l!]0
1817
8,12
13 11
16 8
14
16
5923
1818
..Jl4
13
10
16
13
4
3
8
17
8
16
7
7
8
8
22
29
15
30
24
7
6
16
29
15
28
17
9
8
38^ 14
1819
22
17
175 62 26
1820
7
16
10
19
9
10
10
15
16
10
12
13
12
6
11
12
25
16
14
16
23
19
20
17
18
13
13
19
18
20
29
20
25
21
11
22
12
10
5
5
12
12
6
19
8
5
11
11
9
7
12
13
16
15
20
9
Ji
28
13
23
6
10
15
28
18
8
18
31
25
15
35
15
22
19
16
14
1.1
12
28
30
39
43
59
37
18
5
17
14
11
8
16
12
8
10
15
16
16
10
10
20
28
23
14
24
17
9
17
10
19
19
21
19
24
26
34
40
39
39
228 66 28
1821
79. 43 22
1822
59 33 18
1823
33 29 17
1824
20 11 11
1825
:8* 13 9
1826
15:13
39. 40 19
1827
20
14
28
19
17
12
11
47
15
23
33 15
1828
14 9
1829
29 11
1830
6
16
21 23
15 25
21; 26
30 30
34. 35
27 20
17 24
8 15
1831
7
8
13
12
12
15
8 18
1417
1832
1833
8
11
11
14
18
29
20
14
10
9
15
12
30
22
21 17
31 10
1834
2J
It
u
le
21
2(
11
If
U
\l
\i
J!
2J
21
2(
2i
23 11
1835
922
1836
14
15
19 31
1837
13*18
15 17
15 17
1421
18 18
16 16
8 8
911
10 16
14 15
16 10
17
16
26
22
24
17
28
37
36
21
22
24
26
26
23
16
33
51
28
42' 61 2S
1838
48
64
45
43
30
45
37
28
26
27
26
50
69' 39 15
1839
9|10
19 11
I01{ 42 3«
1840
55j 64 23
1841
21
11
51! 21 12
1842
9
5
13
11
8
15
15
15
22
29
26
21
5
14
17
5
19
7
11
28
23
20
30
22
33 3; IT
1843
57| 41 12
1844
12|l2
16;i7
7il3
17'27
I0|l5
19,17
18 16
32: 17 21
1845
46 20 20
1846
38: 19 24
1847
22
It
23
30
32
44
12
19
13
27
26
34
45
23. 14 20
1848
19
18
17
31
22
22
26
26
17
26
24
18
23
22
51 37 24
1849
17
16
21
31
38
37
76 40s2S
1850
3529
55: 551 47 35
1851
26
60
45
27
58
42
49 56 48 43
1852
101 119.10141
1853 „
66' 51; 46 42
Totals
...
111
2^
—
—
-
11.
—
—
'"
'"
...»
L...
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Relations qf Pneumonia to Malaria.
703
It is evident, from the preceding tables, that the various forms of fever, ioeluding
Yellow fever, Remittent, Intermittent and Congestive paroxysmal fevers, oeeasioned
more than one-third of the mortality in Savannah, Georgia, 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 tfi 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 mortuaiy record,
we observe a remarkable uniformity 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 malarial 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 suffered to a far less extent than the whites, and their bill of mor-
tality 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, Georgia, during a period of twelve years — 1840-
1851, inclusive:
Monthly Deaths amongH Blaeki and Chlored {Negro), InhabitanU of Savannah,
0/ TVretocyetfr*, 1840-1861, tnc'wtVe.
Oa.,
during a period
Y B ▲ B .
1840
16
7
11
18
21
19
13
20
20
36
18
16
1641
12
18
12
8
12
11
18
20
13
1©
22
18
1842
21
15
24
18
24
15
15
14
19
1«
13
11
1843
17
7
16
10
15
18
29
15
11
25
13
6
1844
10
8
11
12
13
19
19
20
23
16
17
15
1845
15
19
24
11
26
11
12
8
18
16
19
21
1846
7
6
10
13
19
17
11
18
14
18
20
16
1847
11
11
13
12
10
11
17
13
17
19
21
20
1848
19
20
15
15
23
20
25
13
21
31
18
19
1849
34
21
24
16
28
25
21
32
25
19
29
15
1850
28
19
24
31
23
25
16
15
21
26
29
22
1851
JaDoary ....4
20
Febraary
March
8
13
April
17
"•y
JaD9. ...',
18
2^
July
18
August, »
SeDtember '.....
16
16
October
23
November
IB
December
12
An ezaminaton 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 t^t^ni39 were relatively greater than amongst the white inhabitants of
^vannah.
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704
Relations of Pneumonia to Malaria.
Deaths Caused by Pneumonia j Pleurisy and Hydroihorax^ and by all Diseases and AcadtnU^ in iki
White Population of Savannah^ Georgia^ during a Period of Fifty Years, 1804-1853, mcIbrm,
vnth the ratio of deaths from Pneumonia, Pleurisy and Hydrothoraz, to the total deaths frxm all
causes^ and to the White Population, and the ratio of deaths from all causes to the population.
Yeak.
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
1829
11.0
1830
16.5
1831
11.2
1832
11.9
1833
14.3
1834
15.2
1835
14.2
1836
13.3
1837
14.0
1838
10.3
1839
13.-7
1840
12.1
1841
7.6
1842
16.6
1843
7.0
1844
4.5
1845
9.8
1846
13.4
1847
14.9
1848
30.1
1849
32.5
1850
18.3
1851
13.7
1852
30.8
1853
h
1
^^
9
a
as-
ta
.?B
J
h
8>
gi
§
•f
1
7
209
6
159
6
147
12
216
6
202
4
197
4
228-
9
249
9
358
5
331
3
367
5
380
5
305
9
272
12
256
11
247
7
229
7
240
8
210
13
298
10
357
12
384
13
414
24
642
18
470
26.5
24.5
18.0
33.6
49.2
57.0
27.6
39.7
66.2
123.3
76.0
51.0
30.2
21.3
22.4
32.7
34.2
26.2
22.9
35.7
32.0
31.8
26.6
26.1
783
800
408
833
1,275
1,300
588
599
1,100
1,866
1,177
1,200
699
533
600
971
1,000
887
567
800
699
684
391
549
29.5
32.6
23.1
24.7
25.9
22J
2U
15.0
16.6
15.2
15.2
19.6
22.8
25.0
26.7
29.8
29.1
34.2
24J
22.0
21.9
21.4
14.6
21.0
Totfl deaths fh>m Pneumoniii, Pleurisy and Hydrotborax, 497.
Total deaths from all causes, 14.332.
^atio of deaths ftom Pjieumonta, Pleurisy aud Hy^drothorax in total deaths from all causes, oqe death in 2SJ.
Of four hundred and ninety-seven doatlis caused by Poenmonia, Pleurisy and Hydro-
thorax, amongst the white inhabitants of Savannah, Georgia, during a period ef fiftj
years, 1804-1853, inclusive, sixty-five occurred in January; sixty-seven in Februtfy;
fifly-six in March ; twenty-five in April ; twenty^even in May ; nine in June ; thirteen
in July ; twelve in August , nineteen in September ; nineteen in October ; thirty-iiiM
in November, and forty-six in December.
Thus, during the season of Spring (March, April and May), one hundred and eight
deaths were caused by Pneumonia, Pleurisy and Hydrothorax, during a period of fifty
years ; during Summer (June, 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 Savin-
nah, Georgia, during a period embracing half a century, related to cold and vidfis-
tudes of temperature, rather than to the action of Malaria, which caused the greatest
number of deaths, at the period in which the smallest number from Pneumonia, Flea-
yisy and Hydrothrax occurred.
Out of a grand total of fourteen thousand three hundred and thirty-two deaths bm
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Relations of Pneumonia to Malaria. 705
all causes, during a period of fifty years in SavanDah, 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.
MORTUARY STATISTICS OF AUGUSTA, GEORGIA. '
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 weH 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 sea, and about thirty-two feet above low-water mark in the Savan-
nah river. Opposite Centre street, the river is three hundred and fifly 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
laige 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
liver, 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 tertiary 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.
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706 Relations of Pneumonia to Malaria.
Monthly DealJa in Augusta^ Georgia, in White and Negro Races, during 18 years, from 18iS-1865,
inclusive.
WHITES. BLACKS AND OOLOBED.
If the preceding table be compared with the correspoDding table relating to the
monthly mortality in Savannah, it will be seen that the deaths are mnch more
uniformly distributed during the whole period of the year, in Augusta, Oeorgia. This
difference appears to be due, in a great measure, to the greater exemption of the latter
city from the various forms of Mdarial or Paroxysmal fevers.
It will be seen from the following table, that the deaths from the various forms of
Malarial fever, were relatively, about ^ight fol^ more numerous in Savmnoah,
Georgia,
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Relations of Pneumonia to Malaria.
707
Deaths from Typhoid Fever ^ Yelloto Fever, and the variotu formt of Malarial Fever , in Auffutta, Ga.
durinff a period of Eighteen yeara^ 1848-1865, inelutive.
WHITES.
1
BLACKS AND COLORED.
TEAR.
SB
a
a
'«3
n
e
1
:
>
•o
2.
X
^
B
0
6
•
>
B
3
o •
o
s ,
g- i
•
1^
CO H
: n
: »
March
February
January
i i i
>
e
oo
TOTAL DEATHS
PROM FEVERS
December
November
October
September
1848 ^
1
1.
.2
.. 1
2 3
.. 2
4.
3
3
5
12
57 1
]
'*5.
6.
8.
4
8
8
71
9
11
2...
1 ...
1 1
6 3
3 1
2...
. 1
. 1
3 1
6 1
9 1
1 1
4 4
2 2
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
1
1
1
7
.. 1 .
1 ... .
2 1 .
3 2.
2....
8 3.
.. 5
1850
2
1
]
... 1...
... 1...
1
... 1...
... 1 1
9
1851 „
]
1
3
2
3
4
1
2
2
2
1
19
2
1
12
2
7
3
6
9
2.
6
2
3
5
16 1
31
6
10
3 4
4 2
1 2
3 47
1 4
. ]
6 4
5 2
3 4
1 4
3 6
2 2
2 11
7 7
S 11
10
1862
1
1
...
. 12
1853
. 0
1854
1
3
2
1
2
2
2
1
12
2
5
1
. 19
1855
1
1
1
1
1
2
1
1
1
] 2
1856
3
I
3
1 ...
2 1.
1 5
1857
3
2
. 12
1858
... 2...
... 1 ...
1... 2
1
2
1
1 2...
I .
. 3
1859
2
1
1... ]
... 2...
1 1 1
1 1 4
1 2 2
... 1...
1 2 3
I
2
2
1
6
1
2
2
3
3
1
20
...
"i
2
2
4.
56 4
84 7
1....
1... .
3 2
4 1
. 1 .
2 2..
8 18..
6 32
. 7
I860 „
11
1861
1
2
4
2
3
2 15
1862
2
3
1
1
2
1
9
2
]
6
1 19
1863
. 17
1864
8
1865
. 154
Total
28
10
1
21
33
55
816
^117
150 6
2 18
639
6 7 3
6 12 17
25
48
9 317
In 1854, Yellow fever caused amongst the whites, forty-five deaths in September ;
fifly-two in October, and twelve in November ; amongst the blacks and colored, four
in September, seven in October, 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 almost 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; 1849, whites 6, blacks 4; 1850, whites 4, blacks 1; 1851,
whites 16, blacks 6; 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; 1859, whites 15, blacks 5; I860,
whites 11, blacks 6; 1861, whites 26, blacks 12; 1862, whites 58, blacks 11 ; 1863,
whites 23, blacks 9; 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 hospitals, and to the influx of strangers, both black and
white. It appears that the deaths and diseases of the soldiers were entered upon the
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 1st of July ; but during the first five
months of this year (1866,) Small Pox destroyed 260 blacks and 37 whites. Total
deaths all causes during this period, whites 373, blacks 468.
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Relations of Pneumonia to Malaria.
^
.t-
V-^
.<=> .Q
I"?
11^
-$>§:§
■i^s I
^^ ^ Ip
^^ 0<
C -^ ^
•2 ^ §
S -* 55
IK
00 S
I
, Proportion of doatb«, all c«u»c«, in
1 total popuIaUon, Whiles and Blacks.
1 death in
s^igq:^;
s
?3 ?< rt
UP.P.
^s
'rf
rt
55
§
» ««
i
ProporUon of deathi, all causes in
Black and Colored population. 1
1 death in
^55S!?3^?322?s????t5s*^;=5J:?:'=
1)
' Proportion of deaths, all causes, in
sgiH5s§'5v5SS5S^5;sg2S2?j;2:«
■I
, Proportion of deaths IVom Pneumonia
and Pleurisy in Blacks aud Whites,
1 1 to toUl population. 1 death In
mrMnMUMMun^
! Proportion of deaths from Pneumonia
and Pleurisy, amongst Blacks, in
Black population. 1 death in
Proportion of deaths Arom Pneumonia
and PlourisT. In Whites, to White
population, 1 death in
^5%iumMUHUfMn
[ Proportion or deaths from Pneumonia
and Pleurisy, nmouKst Blacks and
M'hites, in deaths from all ciuses.
1 death in
5S5S3|3525S2Sa5S5Sv"2
s
, ToUl deathi from all causes, Blacks
1 and Whites.
O r- ?r r- « ;C C cl «!« C t- « 1-. f^ *•".«. '®. '^. *^ *^.
I- cT d (N t^ si 35 v.* ,i .? o t- »« o t- 1- 5 « ^ ec o
CSCTi-l i-iriri rl ^
"
Total deaths from Pneumonia and
1 -Pleurisy, Blacks and Whites.
i
Proportion of deaths from Pneu-
tDonia and Pleurisy in deaths
fh>m all causes.
1^
1
ToUl deaths f^m all causes
s
H
1 e
S
Q
5
CO
g
Toul deaths from Pneumonia and
Pleurisy.
ii
December
r-'Mrc :(N?i.- :-* : c^ 'N : .-. .^ ?. w. r- ^
-i
November
"r-( ir^^f^ pz :'>jf-i?<MC^M»-* : :»»•«
^ 1
-i!
October
September
:- : : :^5 : : '^ »-• :*• • • ! • I"
AtlgMSt
-
July
'^ : j ^ "^ *" "^ : '"'
^
June
:r-l^ r?« jMS^r^
2 '
1
May 1
April
r^'Nrjr: — — M5^ :•-
y u ■
1 ~
r-«C<M'NX^MM5^''^'-
o
;r-i-p — r-i— ?:•* :<Mrtrti-'e03>l»-r-f-iS'^
Jt
• J., ^ r^Mr^rtr-i^-i-rcr^i'S.- :«c«22
_!'
Proportion of deaths from Pneu-
monia and Pleurisy In deaths
ftom all causes.
•o M o «o M T. ^ ic X ci L- t- (N r-. c. p -r e: ?<»«»-.
d*ici'M'x*iM^jo?;^t-«r^©^r---2I3
ToUl deaths fh>m all causes.
1
Total deaths f^m Pneumonia and
Plearisy.
j--.«ox2»2i=''S«2^^2§5§^^4S
%
i
X
St
December
—
^ 1
NoTember
. : : : - •• l|
October
•" i
p- —>
September
p-^f
1'
August
=
July
^
f- .f
f-( ■;
5
June •.
"" i'*
r-i.
May
: i :'^^'
April
rt
r- -N-iT- *<'
- :- : -.M
March
W -fl- r^ - -9- -T - ^ ^
February
(M
r^?l,-r-(N?:C40 3i>Jrtr-.W-WOt-l^«S |CS
January
-5
1
1
1
3
h
9
7i
5
Sg
i
i
it
of
^
^
§
i
i
i
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Relations of Pneumonia to Malaria. TOO
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 21 years,
1845 to 1865, inclusive, 6240 deaths from all causas 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 mort^ility 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 mortdity, 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 occurring 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 highest 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 inde-
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 comparison of the following mor-
tuary statistics.
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710
Relations of Pneumonia to Malaria.
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Total Deaths from Pneumonia, Pleu-
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Proportion of Deaths ftpom Pueumo-
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Proportion of Deaths from Pneumo-
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Total Deaths, all causes .
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Proportion of Deaths from
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Total Deaths from all causes.
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Relations of Pneumonia to Malaria. 711
DeaUufrom Pneumonia^ Pleuritis and HydrothoraXy and from all Cautet^ in New OrUanSy La.y during
a period of 9 yean^ embracing 1849, 1850, 1853, 1867, 1869, 1870, 1871, 1872, 1873.
Population of New Orleant, U. S, C, 1850, WhiUss, 89,459; Blackaand Colored 26,916; total, 116,375
" " 1860, " 144,596; *• '« 27,074; " 168,670
" «» 1870, " 140,923; " " 50,456; " 191,418
In 1860, Pnetunonia, 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 598 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, 1 in 23.7; 1869, 1 in 20.5; 1865, 1 in 25.6; 1868, \
in 35.7 inhabitant^.
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713
Relations of Pneumonia to Malaria^
Deailis from Inflammalion and Congestion of the Lungs, {Pneumonia) j PUurisy and Hydrothontx^ m
New York, with the relations to total deaths from all causes, and the Population of the CUy,
during Fifty Years, 1804-1853, inclusive. Population of New York, 1800, 60,489; 18<^,
15,110] 1810,96,373; 1815.100,619; 1820,123,706; 1825,166,086; 1830,202,589; 1835,
270,089; 1840,312,710; 1845,371,223; 1850,515,394; 1855,629,819; 1860,805,358.
1804....
99
760
1805
102
742
1806
127
630
1807
138
605
1808.....
100
887
1809
106
909
1810
147
655
1811
137
708
1812
122
807
1813
233
421
1814
206
483
1815
80
1257
1816
222
473
1817
238
459
1818
192
596
1819
199
595
1820
161
768
1821
132
998
1822
189
742
1823
193
766
1824
225
693
1825
253
656
1826
373
461
1827
434
410
1828
306
514
H.! *
2125
2344
2225
2312
2014
2108
2167
2524
2553
2283
1974
2507
2739
2527
3265
3176
3515
3542
3231
3444
4341
5018
4973
5181
5181
11 BU
s 2 I 5* £ s; 2
- 3 - O O 3 ,
- a O •
£.^= oi
3« )• :< = *
Year.
34.3
22
32.2
23
35.3
17
3G.2
44.0
44.0
44.50
38.4
38.1
43.0
50 4
40.1
38.3
43.2
35.0
37.3
40.0
37.2
43.3
42.9
36.1
33.9
34,6
34.3
36.2
16
20
19
14
17
20
9.8
9
31
12
10
17
16
21
19
17
18
19
20
13
12
17
2f?
1829
1830
1831
1832
1833
1834
1835
1836
1837
1838
1839
1840
1841
1842
1843
1844
1845
1846
1847
1848
1849
1850
1851.,...
1852
1853
0-3*= 85
B >^ S 2
-Hi
©a* «
290
374
273
428
463
464
566
502
589
685
675
570
694
733
709
658
647
974
889
940
1205
1272
1571
1449
1514
674
841
798
560
548
577
477
557
495
438
453
548
468
458
490
543
573
410
481
489
402
405
336
372
369
f
I
Is. l"s.
5,094
5,537
6,363
10,359
5,746
9,082
7,082
8,009
8,732
8,053
7.953
8,474
9,115'
9,176!
8,693,
8,875
10,983
11,318
15,788
15,919
23,773
16,978
23,024
21,631
22,702
39.6
36.4
32.6
23.1
44.2
20.2
39.1
34.9
33.2
37.2
38.4
36.8
35.6
36.6
40.0
40.5
33.8
33.3
27.1
28.8
20.4
30.3
23.9
24.9
24.4
18
14
23
24
12
19
15
15
14
11
II
14
13
12
12
13
17
11
17
17
19
13
14
15
13
The total number of Emigrants in New York during a period of fifty years, l,fi27,174.
Total deaths during fifty years, 3G4,C9o ; of which, Pneumonia ai^d Pleurisy caused 1.23,75.'), or 1 deatlt in lo^ J
ft\l effuses.
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Relations of Pneumonia to Malaria.
(13
Toittf Deatlis from all Caiuct^ amongst Whites and Blacks^ and Deaths from Pneumonia^ Pleurisy and
HydrothoraXj in Philadelphia , Pennsylvania^ during a period o/ 10 years^ 1831-1840 inclusive.
h
n
Propor
ral Mort
tttI Popu
Deatli in
HI
Propor
among I
1 Death i
i
5*1 §
VJh
YEAR.
AC
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tionof <tene-
ality, to To-
lation. One
5-^ =
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III!
0t
§25
i 93
: - p
i! ^
N r
ill
1831
174,541
4623
37.89 3
9.6
33.6
292
.')97
15.9
1832
179,694
6425
28.21 2
8.83
22.65
325
583
19.1
1833
185,000
4128
45.36 4
7.32
35.28 .
243
761
17.2
1834
190,461
4765
40.09 4
1.46
33.27 1
247
771
19.4
X835
196,084
5358
37.39 3
8.32
31.21 ,
334
587
16.0
1836
301,976
5022
41.25 4
3.80
24.47 1
296
706
17.0
1837
207,834
4881
43.89 4
5.16
30.75 1
321
647
15.3
1838
213,970
5118
43.27 4
5.00
29.23 i
328
656
15.6
1839
220,387
4765
48.08 4
9.48
31.30 ;
322
683
14.4
1840
226,693
4593
49.57 5
2.28
38.68 j
297
760
15.3
48,678
41.15 4
3.12
31.05 1
3005
16.1
i Oat of a grand total of forty-eight thousand six hundred and Bcventy-eight deaths
occurring in Philadelphia, during a period of ten years, 1831-1840, three thousand
and five, were caused by Pneumonia, Pleurisy and Hydrothorax, which gives the pro-
portion of 1 death in 16.1 deaths from all causes.
From a careful comparison of the preceding statistics, the following 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
and fatal, than in cities situated in the interior, and in the more northern latitudes, and
in localities comparatively free from malarial influence, as Augusta Georgia, 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«
lively rare.
Third. The preceding statistics, 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 causation 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 characterised bv 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 Human
System, to the Symptoms and Progress of Pneumonia.
GENERAL RESULTS OF INVESTIGATIONS ON THE RELATIONS OF THE ACTION OF
MALARIA IN THE HUMAN SYSTEM, TO THE SYMPTOMS AND PROGRESS OF
PNEUMONIA.
First. There is no necessary connection between Pneumonia and Malarial JPever.
In healthy, elevated, non-malarious regions, pneuinonia is almost never complicate^
with malarial fever,
90
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714 Relations of Pneumonia to Malaria.
In malarious regions, on the other hand, pneumonia is frequently complicated with
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 paroxjsnud
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 effects
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 so
depressed as to be unable to resist the action of the malarial poison.
Second. 7%e Malarial Poison indnces profound alterations in the constituents oftk
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 alt^^ in
quality. The albumen is in like manner diminished. The extractive and coloriog
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 corpus-
cles and the presence of coloring matters in the blood.
Third. During the active stages of Malarial Fever, phosphorus, and the compounds
of phosphorus in the nervous structures and in the colored blood corpuscles, as teed as
sulphur and the compounds of sulphur in the muscular structures, undergo more rapid
changes than in the normal state, and phosphonc acid and the phosphates, andsulphhric
acid and the sulphates appear in increased quantities in the urine.
The waste of phosphorus and its compounds in the blood corpuscles and nervons
structures during the active stages of the fever, is far greater than the supply of the»
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 sloio action of the Malarial Poison, as well as during the
active stages of the paroxysm, important changes take place in the Liver and Spleen.
In both organs, the colored-blood corpuscles are destroyed in large nuoibers, and the
coloring matter, resulting from the disintegration of the red corpuscles, accumulates 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, cellulose i*
found in both the liver and spleen, whilst grape sugar is absent from the liver. Th«
bile is altered both in chemical constitution and physical properties.
Fifth, Thai the chemistry of the body is still farther deranged in Malarial Ferer. u
evidenced by the changes in the excretions.
During the chill, and at the very commencement of the hot stage, phosphoric add
disappears almost entirely from the urine ; as the hot stage progresses, and the febrile
action and the heat commence to decline, there is an augmentation of phosphoric add.
But what is Qtill more important in its bearings upon pneumonia, the uric add is
increased, or remains at the normal standard, during the chill; disappears aimoA
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, ami
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, in
gout and rheumatism, will often prove an excitant to inflammatory action, this tendency
in malarial fever to the generation of large quantities of uric acid during the intermis-
sions, and even during the period of convalesence, is important in its bearings, not onhr
upon pneumonia, but also upon neuralgic afiections.
I have in my own case observed changes in the urine, and especially in the uric acid,
during severe headaches of wialarial origin, similar to those observed in well defined
cases of paroxysniial fever.
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Relations of Pneumonia to Malaria. 715
Sixth. One of the most marJced and important of the phenomena of Malarial Fever,
in its connection with inftammations of internal organs, is the congestion of important
organs at stated intervals.
It would even appear that, asiJe 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 blood in the central portions of the circulatory system, the altered blood
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 dtructures,
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 also, 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*
tion, 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. As 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 des-
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
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716 Retattons of Pneumonia to Malaria.
the chemical changes which they 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
difiusion of the inflammation over a greater extent of tissue, and in a correspondiag
degree renders it more severe and dangerous.
We have in these facts an explanation of the sudden and fatal character of many cases
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 scroo?
fluid into the air cells and bronchial tubes of the lungs. In such cases the capillaries of
the blood, being in an enfeebled state, the fibrin of the blood being diminished in qwn-
tity and altered in physical and chemical properties, the colored blood corpuscles being
diminished in number and physically and chemically altered, the solid matters of tk
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 the lung resulted ; the serous portion of
the blood poured into the air cells, bronchial tubes and trachea ; the supplies of oxygen
were in a great measure cut ofi*; the chemical changes of the solids and fluids were in i
corresponding degree checked ; and the physical forces, heat, and electricity, and the
nervous force, developed by these changes, were, as a necessary consequence, correspond-
ingly diminished.
Broussais in his history of chronic phlegmasise, has recorded several analogous cises
of fatal pleuritic and pulmonic afibctions attacking those suffering with malarial fever;
and Andral, in his "Clinique Medicale," has given at length a fatal case of pneumonia,
with pulmonary <Bdema and double pleuritic effusion following and supervening upon
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 710: Irishman, age 2(3; height, 5 feet 11 inches; weight, 170 pounds; black hiir:
black eyes; full, dark brown beard and moustache. Limbs full and round, chest broad aad
well developed. Has been in America, (New York) nine years, and in Savannah three months.
During this time be has followed the occupation of a baker.
September U, 12 m., 1857. Has just entered the Savannah Hospital with Remittent fever
Pulse accelerated but feeble, and his complexion shows the effects of malarial fever. Stn
that he has been sick for one week, and has been living near the depot of the Albanj as-i
Gulf Rail Road, in a low malarious situation. Under the action of Sulphate of Qainia &a<!
stimulants, the febrile excitement disappeared in the course of four days ; the patient hov-
ever, was left in a very feeble condition ; complHined of great weakness, his pulse was feeble,
the action of the intellect sluggish, and be had a peculiarly disagreeable smell, which was not
permanently removed, either by water, or by change of clothing. Under the action of toaics
he recovered sufficiently to walk about the yard; but continued however, weak, low spirited,
and indisposed to action.
September 27th. Complained of torpor of the bowels. A mild Cathartic was administereii
September 28th. Has a cough. The wind has been from the North East for some Mmt,
and the weather has been cold and damp, and epidemic catarrh is prevailing. About two-
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. He
was up and about, when I went the rounds of the wards at 9 o'clock p. m. Shortly after tbi*
he complained of great oppression of the lungs, difficulty of breathing, and loss of moscuU'
power.
29tb, 9 o'clock a. m. During the night took a sudden and remarkable change for the vonf
Respiration spasmodic, iind sotinds as if the air cells, bronchial tubes and trachea contaiaH
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Relations of Pneumonia to Malaria. ?17
lar^e quantities of flaid, and is attended with a loud rattling sound, in the thorax. The
churning, rattling, gurgling, crackling sounds of the lungs and trachea are very lond, 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 surrounding medium. The expres-
sion of his eyes and countenance, and his efforts to converse, show that he is intelligent ; he
18 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 circula-
tion, and did not increase the animal temperature, because the supply of oxygen necessary
for the chemical changes which generated the physical, muscular 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
full 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.
Head: — Dura-mater presented the usual appearance. Arachnoid membrane transparent and
healthy; blood-vessels of pia-mater filled with blood. When the dura-mater was removed, an
. olcer 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, aud 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
accounted 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.
Chett: — Heart normal in size; the right ventricle contained a large, yellow fibrinous clot,
attached to the chordse tendinese and carnss columns, 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.
Zungt : — The lungs were greatly distended and did not collapse in the slightest perceptible de-
greej 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 cut, the air cells, 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 fluid was clear ; in others it was
reddish. The fluid resembled serum in all respects, and was not mucus. Here, then, we
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.
Liver: — 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, about 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 is
CTident, from this examination, that the structures of the liver were recovering from the effects
of the malarial 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, appeeu-ed to be recovering
from the effects of malarial fever.
Kidneys: — Healthy.
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718 Relations of Pneumonia to Malaria.
We belittve 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 alterations in the blood
and capillaries, liver and spleen, and primarily by its action, or secondarily by the
action of the altered products in the blood, affected the sympathetic and eerebro^inal
nervous systems. The patient, although weak and lethargic on account of these pttbo-
logieal 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 diese fact*.
safely assert that if no other disease had occurred, the lesion of the left hemisphere of
the brain, and the effects of the malarial poison, would not have proved fatal.
In this skate of slow convalesence, the patient was suddenly seis^ with the prevailio?
influenza. The mucous membrane of the br.onchial tubes and air cells was irritated
The irritation of the mucous membrane was followed by congestion of the blood-veasel-
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 chemi(kl propertia ;
the colored blood corpuscles were diminished in number, and physically and chemieillT
altered ; the solid matters of the blood were diminished ; and the physical and chemkal
relations between the individual constituents of the blood and capillaries were distmrbei
Healthy, limited inflammation was impossible. Diffused inflammation of all the stract-
ures of the lungs resulted ; the serous portion of the blood poured into the air-edlN
bronchial tubes and trachea ; the supply of oxygen was in a great measure cat off; tk
chemical changes of the solids and fluids in a corresponding degree checked ; the php-
ical forces, heat and electricity, and the nervous force, developed by the chemical
changes were, as a necessary consequence, correspondingly diminished. The immediitc
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 ISO poaD«ii
tftll. spare frame, light hair, blue eyes ; paU, sallow complexion. Has been running on Sa;
boats and rafts, up and down the Savannah River, between Savannah and Augusta, for t^t
last twelve months. Habits irregular; addicted to the use of ardent spirits. Says that ha
constitution has suflfered much from the exposure to the hot sun and night air on the riTcr
and also from an intemperate use of ardent spirits.
September 20th, 1857. A flat, laden with wood, which he was bringing to the city m
sunk in shoal water. He was all day in the water up to his waist, fishing oat the wood; ^i
Rt night had a chill, followed by fever. The fever went oflF before morning, and on theses',
day he was employed Hgain in the water. The chill returned at night, and was followed b^
high fever. Has been sick from that day to the present time, September 27tb, w^ithoatu;
medical attendance. Pulse 106 ; respiration accelerated, labored; skin hot and drj ; cat^
tenance distressed; has a haggard, anxious look; complains of great^ thirst, of pains in ii
back and bones, and of great exhaustion. His pulse although rapid is feeble, and bis hnti
aippear to be completely exhausted. His fever remitted slightly on the next day, but retaw-
on the 29th inst. Under the action of large doses of Sulphate of Quinia, and Sisapiis^
Stimulants, (snake root tea, milk punch, wine, whisky and brandy,) the febrile ezcitcBf*-
subsided, the urine regained its normal hue, and on the 4th inst., of the following moDihi-*
pulse was 70 and respiration 18; temperature normal and function of skin noroal, >'-
although apparently very weak, the patient was able to be up and about the ward. Dtrc;
the attack tbe saliva was acid, and the urine copious; from 20,000 to 25,000 ^raios w^
excreted daily. The specific gravity was correspondingly low, from 1012 to 1014. Tbei^si-
dant discharge of urine was due to the large quantities of water which his thirst led hio' ,
take, and also to the diuretic action of the infusion of snake root. Throughout tbe atu:>
his pulse was feeble, and his forces greatly exhausted, and he required close atieotioa.»<
the free administration of Stimulants.
October 5th. This morning, escaped clandestinely from the hospital.
8th. Has returned. Pulse 120 ; skin hot and dry; respiration accelerated, labored; cos- ■
plains of great pain in the back of his head and neck; these parts are swollen and paifi^
upon pressure. (Cold water dressing to back of head and neck).
9th. His head has been shaved, and the tissues above the occipital bone, and aboft t^
left temporal and parietal bones are swollen, and the skin looks black, and is ulc«aia^ ^
several places. The swelling extends down along the neck, and reaches the superior p«rt^
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of the left shoulder. To the finger the swollen parts feel as if there was a collection of fluid
heneath the skin. Says that he is suffering intense pain; countenance distressed and bagp:ard ;
pulse 128 : skin hot and dry; respiration thoracic, labored, accelerated. r
10th. 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 bead, he complains of intense pain in
his chest. The pain in the chest cuts short the respiration, and renders it spasmodic. His
countenance is expres8i?e of great agony and terror.
llth. Pulse 140, rapid and very feeble; respiration 24, labored, thoracic, spasmodic. Thv
pain in his chest is intense ; he groans and cries out at every breath, and the expression of
bis countenance is indicative of great agony, terror and horror. Was restless and delirious
during the night, and during his 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 afford relief, a free crucial incision was made
at the most prominent part of the swelling. Nothing but blood issued. The hsemorrhage
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. During 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 be 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 nine hours after death. Exterior. — Body 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 blood 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 flbrous 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
serum.
Head. — 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 consistence
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.
CheH. — Heart somewhat enlarged. Pericardium contained one fluidounce of golden serum.
All the cavities of the heart contained golden colored clots. The right auricle had a large
golden colored clot, which was attached to the earns columnae and chord® tendinese 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. All
those clots were firm and elastic.
Lungs. — 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 w.alls of the thorax, was covered with
soft 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
but recently effused, probably within the last seventy hours. This inflammation of the pleura
occasioned the severe pain in the chest during lifel The lungs were much congested with
blood, and when cut, they resembled liver. 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
effects of malarial fever. Cut surface of a light, bronr.e 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 upon its under surface a slate colored spot, three inches in diameter, which resembled iu
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all respects the liver of a recent case. When an incision was made across ibis spot, thecal
surface presented for one sixth of an inch, the true malarial hue ; below this, it approached
more nearly the normal hue. The structures of the liver did not appear to be softened.
Spleen, — Much enlarged, of a dark, slate color, and although much softer than a nonatl
spleen, it was much harder than a spleen of a recent case of malarial fever. Weight, 31
ounces. This organ, like the liver, appeared to be just recovering from the effects of maltml
fever. Kidneys appeared to be somewhat enlarged ; the calices infundibnla and pelvis of th«
kidney contained a small quantity of a thick yellow fluid,
The following appears to be the cause and history of the last attack ;
The patient left the hospital when he was in an exceedingly feeble conditioD, after &
severe attack of Remittent fever. It is probable that he indulged bis taste for arieoi
spirits ; for the day on which he left the hospital wag *• Election Day.'*
The wind was from the northeast, and the weather damp and cool, with occaiiofial
scuds of rain and mist. Exposure to this cool, damp wind, fresh from the oeeao, and
the low-grounds and swamps of Georgia and South Carolina, not only during the day,
but probably during the night also, in a state of intoxication, induced a severe atttd of
pleuro-pneumonia.
The swelling on the back of his head was due either to a blow, or to inflammation In
the cellular tissue and muscles, analogous to the inflammation of the lungs, and probtUj
arising from the same cause.
The large amount of serum efl'used into the bronchial tubes ; the large amoaat of
golden colored serum effused into the cellular tissue of the neck and head, and the largt
golden fibrous clots in the heart and arteries ; the settling of the blood in the most
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 rmtiooi
between this element and the other elements of the blood to each other, and to tb«
blood-vessels and capillaries.
Andral, in his "Clinique Medicale," gives the following interesting case of Pnetuno-
nia, with pulmonary oedema, and double pleuritic effusion, following Intermittent ferer;
Case 712. — A man about fifty-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 as
hour, was followed by bent, then by a profuse sweat. On the 9th, there was apyrezia. Tke
12th, the patient entered La Charit^. We saw him at the beginning of the third accessioD:
he felt icy cold in the trunk and extremities; however, the skin was bnrning hot; paltt
hard and frequent. At nine o'clock, the sensation of cold was succeeded by aseusatioaof
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 14th, the patient no longet felt any shivering, hot merelji
little heat, with spme frequency of pulse. On the 15tb, apyrezia. On the 16th, thedsjof
the fever, at 10 in the morning, the patient felt a slight shivering, then be was seized witbi
burning heat over all the right side of the thorax, from the last ribs to tbo azilU. TbepAit
which was augmented by the slightest motion, did not cease till 10 o'clock at night. latbi
night a profuse sweat took place.
In the morning there was great dyspncDa; speech short and panting; decubitus ob ti«
back. The pain of the preceding day had not reappeared, but the patient ezpectorated tkm
or four viscid, transparent sputa, of a greenish yellow color. A well marked, crepitoosr^
was heard on the right, anteriorly and laterally. Posteriorly, on both sides, the respirstios
was very loud, sufiBciently clear, mixed in some points only, and at intervals, with a crepitosi
rule; it was the same on the left anteriorly. Pulse frequent and hard ; akin hot and dit:
tongue whitish; diarrhoea. (He was bled to eight ounces). The blood presented a large cni-
samcntum, without a coat. On the 18th, a loud, crepitous rale was heard over all tbeptrti
of the chest; percussion elicited everywhere a clear sound, except low down on both oda
from the sixth or seventh rib. The pneumonic characters of the expectoration still contiflBti
Pulse, 110; forty-three respirations in a minute; the tongue was dry and pale. (Aootke/
bleeding to eight ounces ; sinapisms to the legs) A thick, greenish coat on the sorfiieeBf
the crassamentum. On the 19th his state was the same. He died the next morning.
Post-mortem. — On cutting into the tissue of the two lungs, an enormous quantity offwthj,
colorless serum was seen to gush out from every part. The pulmonary parenchyma vis
everywhere of a grayish white color, and crepitated perfectly, except near the right lug. &
this latter part there was observed in separate patches > tissue of a livid, red color, whidi^
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Relations of Pneumonia to Malaria. 721
not crepitate, aud was very easily toru. Tbcsc different inflamed portions combined, would
ecarccly have equalled the size of an orange. On the left, from the level of the seventh or
eighth rib to the 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 the 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 the quantities of the latter. It was a turbid serum, in the midst of which a
considerable number of albuminous flocculi floated. A black, coagulated blood flllcd the
four cavities of the heart, and distended the right auricle in particular.
When this patient entered LaGharit6, he was afflicted with an intermittent fever, exempt
from all serious complication. The fourth fit was prevented by Sulphate of Quinine. To-
wards the time when the fifth should have returned, the shivering and pain of side marked
tbe invasion of the plenritis on the right side ; the respiration soon became embarrassed ;
some crcpitous rAle was heard at first in some parts, then over almost all the thorax ; finally,
pneumonic sputa appeared. Tbe 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 rAle was due to serous effusion.
(c.) The liability of persons who have suifered with malarial fever in the summer
and fall, to be seized with Pneumonia in the winter and spring, and the danger of these
inflammatory attacks, following or engrafted upon paroxysmal fever, have long been
known to the public, as well as to the profession.
In many cases, these inflammations, engrafted upon malarial fever, or following its
effects, are clearly dependent for their excitation upon the vicissitudes of the weather,
and especially upon the agency ot cold.
In healthy beings exposed to cold, there in 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 chemical actions. As long as the fixed normal temperature
of health is maintained in the trunk and important organs of animal aud 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 forces be so depressed that the respiratory and circulatory actions are so impaired
that the materials are not distributed with sufficient volume and celerity to maintain the
neoessary 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
tbe 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-
tral organs.
It is a 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
nervous 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 those changes in the mutual rela-
tions and constitution of the blood, and capillaries, and organs ensue, which frequently
result in the establishment of inflammation. And it is not unreasonable to suppose
that during such disturbances, chemical products may be formed of a totally different
character from those of the healthy organism ; just as in the laboratory, with the same
organic materials, different products are formed under different degrees of heat ; ancl
01
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722 Relations of Pneumonia to Malaria.
a^.90, that the excrementitious matters necessarily resulting from the nutrition of the
organs and development of the forces may be retained in the blood and struct^ires, from
the congestion of the kidneys, and the impairment, if not total cessation of the functioii
of the skin, consequent upon the constriction of its pores and vessels and diminutioD of
its nervous supplies, following the reduction of temperature ; and still farth^, that
these altered products and excrementitious matters may irritate certain organs and
excite in them inflammation. *
As therefore, the malarial poison destroys those constituents of the blood and n^vow
system most intimately associated with, and necessary to, the generation of heat, and
of all the nervous and physical forces , and as it farther depresses the nenrons ud
muscular forces, and the action of the heart, and the tonicity of the arteries, and tend*
of itself to induce congestions of the internal organs, it is evident that it renders its
victims, when exposed to the vicissitudes of weadier, and especially to the prolonged
action of cold, exceedingly liable to inflammations.
(d.) 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 tbc
urates.
In like manner, in inflammations existing in healthy organizations, when resolution
takes place, there is an increased excretion of the urates.
If, therefore, the existence in the blood, and non-elimination of these excrementitkms
bodies in certain diseases, as gout and rheumatism, tend to excite local inflammataov.
it is but reasonable to suppose that their non-elimination from any cause, asXfrom tbf
effiects of cold, previously described, may, in like manner tendJto*excite local inflamma-
tions in those suffering from the effects of the malarial poison.
(e,) Afler the excitation of Pneumonic Inflammation^from any cau8e,|[the periodic
changes, and especially the periodic congestions of the internal organs, induced by tlw
action of the malarial poison, tend to aggravate and increase the inflammation.
During the cold stage, the blood stagnates, and accumulates in the capillaries of
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 containing
vessels, especially the capillaries, have been disturbed ; because the r^^lar normal
chemical changes necessary for the development of the forces which work the machinefj
are not generated with sufficient energy, or if generated, with even increased energr.
they are not generated in the right position and in the proper quantities, and the ecf-
relation of the physical, chemical, nervous and vital forces is Jthus deranged ; because
the action of the sympathetic nervous system which accompanies the blood-Tcssels, and
regulates the circulation, and respiration, and secretion, and nutrition, and excndoa.
and relates them to each other, and to the cerebro-spinal system, has been disturbed W
the direct and indirect action of the poison, by the direct action of the poison upon tli
sympathetic and cerebro-spinal nervous systems, or by the relations of the cbemkil
Changes induced, or the products generated in the constituents of the blood by ti*
malarial poison, to the sympathetic and cerebro-spinal nervous systems.
From these facts and considerations, we arrive at the followbg practical conduskw:
First Whilst the malarial poison cannot be said directly to produce pneonouL
still it is capable of inducing auch changes in the blood, and in the nutridre and exat
tory processes, as to predispose the system to this and other inflammations. And dwf-
fore,
Secondly. The physician should never in the treatment of pneumonia, in thc« wfco
have been exposed to the action of malaria, lose sight of its effJects in complkitifi;
inflammation of the lungs, and of the consequent necessity of arresting at cna, 'i
possible, the farther action of the malarial poison.
As no remedy can compare with quinine for the accomplishment of this result, its
use would in the present state of our knowhdge appear to be imperatiTely demsBdoi
in the treatment of jnepmonia arising in nialarious regions, and presenting well Bmkti
and recurrent paroxysms.
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Relations of Pneumonia to Malaria. 723
This 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
effects sufBcient 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«3
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
BO 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
malarial 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.
General 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 so 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
general 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 ell 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 b3cn destroyed ;
and the stimulants not only arouse the depressed nervous system, and through the sym-
pathetic and Cirebro-spinal gangila, excite the circulatory system to a full and salutary
action for the introduction and distribution of the elements of nutrition and secretion
so necessary to the favorable progress and termination of all inflammations, but they
also presei^e 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.
Fifthly. Quinine may arrest inflammations, or promote their resolution by other
modes than its anti-periodio powers, as by its sedative and excretory powers, or by its
nflaenee on the nervous system and capillary and general circulations.
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'724 Relations of Pneumonia to Malaria.
If the value of this agent in the treatment of inflammation depends upon some sneb
power other than its anti-periodic effects, 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 of the results of the treatmeot
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 hare
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 ie
fifty would prove fatal. This is surely an extraordinary result, and far different from the
results of the treatment 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 pnen-
monia, and in many cases of this disease employed quinine, stimulants, and nutritioiu
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 inclined to
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 iht
heroic and poisonous drugs so extensively employed in the treatment of pneumonia, ami
our patients were supplied with nutritious diet, and the strength was supported ; in other
words, depressing agents were withheld, the strength was supported, and nature w^
allowed to have her perfect work.
The Confederate statistics demonstrate that but little confidence c£;n be placed in the
dogmatic assertions of practitioners, apart from a careful record of cases and the preser-
vation of the actual statistics.
The careful determination of the value of ((uinine in the treatment of pneomonia,
as well as the best mode and period of its administration, as well as the relative actioD
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 wcllestablished facts are worthy of eonstaot
consideration.
(Jncom plicated pneumonia, especially in young and vigorous constitutions, almotf
always gets well, if instead of being lowered, the vital powers are supported, and the
excretion of effete products assisted.
From the accounts which have been publisihed concerning the natural progress of
pneumonia, it would appear that very slight cases of limited inflammation may be con-
valescent on the seventh day ; that the majority of cases of medium intensity reoover
between the seventh and fourteenth days, and very severe ones between the fourteenth and
twenty-first days.
In the report of the cases, the extent and character of the inflammation, together
with the symptoms, progress, complications, and termination of the disease, as well as the
exact period of its commencement and the establishment of convalescence, should be
noted with scrupulous accuracy.
Without the careful record of these points, the value of such investigations will be
greatly impaired.
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Relations of Pneumonia to Malaria. 725
Gaided by the preceding principles, the general plan which I have 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 may 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 often result from the application of a blister, over
the seat of the greatest pain. Sulphate of Quinia, Opium, Ipecac, Aconite, Veratrum
Viride and Yellow Jessamine, (Gelseminum Semper virens,) have been employed during
the active stages of the disease, from their supposed or known effects upon the progress
of inflammation.
In the treatment of adults, 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 stimulants appear to be demanded in sonic
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 equalizing the circulation. Quinine preserves the integrity of the blood, regulates
and promotes excretion, equalizes 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 Br. Grace 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
inflinamation. 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 temperature in fever ^ 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
thus to lessen the production of heat. Thus Ranke and Keener, found that the tissue
changes were diminished under the action of large doses of Quinine. Zuntz has recorded
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:i6 Relations of Pnenmonia to Malaria,
the observation that Quinine in ten grain doses, lessens the daily excretioo of urea bj
one-third or more; and Uaruh has found the same to occur when Quinine is adminis-
tered in fevers. Harley added Quinine to blood, and found that it took up less oxygen,
and gave off less Carbonic Acid, than blood which had not thus been treated. Znnti
and Schute have employed the changes in the alkalinity of the blood for the deCermi-
nation of the same fact. Thus, if fresh blood be drawn, a development of acid begiai
in it ; and as this acidification depends on oxidation, the diminished alkalinity of tbe
blood thereby produced, furnishes a test of the rapidity with which oxidation proceeds;
and it has been determined by the experiments of Zuntz, Scharsenbroich and Schate,
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 are especially important in their bearing on the questiai
of the direct action of v quinine on the chemical changes of the blood, or of its indirect
action through the nervous system, which show that when putrefying liquids are injected
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 diminbhed. Such expe-
riments, not only throw light upon the therapeutic action of such alkaloids as quinine,
but they also illustrate, as it were, the very nature of the processes of those diseases,
the effects of which they modify or counteract by the peculiar chain of chemical actions
which they induce in the blood.
I have employed Dover's Powder in the treatment of Pneumonia, for the sddative
effects of the Opium, the expectorant effects of the Ipecac, and the diuretic propertief
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 genenl
blood-letting may prove of decided benefit.
As far as my experience extends, the Tincture of Yellow Jasmine (GebenionBi
Sempervirens), diminishes the frequency and force of the heart's action, diminishes tht
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 m-
portance. The strength of the patient should be maintained, and the materials 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 reictt-
lar intervals. Milk, and concentrated beef and chicken tea, should hold the higheH
place amongst the aliments employed during the active stages of pneumonia.
In private practice, the proportion of deaths under the preceding plan of (reatme^
has not exceeded three per cent.
It is my experience, that in hospital practice, the rate of mortality in pDenmonia, 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 symp-
toms are aggravated by the exposure and fatigue incident to the transfer.
Third. In many cases, the result has been decided before it is in the power of the
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 engrafted on fatal forms of
disease, as Phthisis Pulmonalis and Bright's Disease of the Kidneys, occur in ho^tal
practice.
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Relations of Pn$umonia to Malaria. 727
Sixth. The types of pneumonia manifested in different seasons, 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 cases :
During a period of forty-five months, out of a grand 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 Bespiratory System, including Phthisis Pulmonalis,
numbered two hundred and ninety-nine, with sixty-three 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
forW-nine cases, with seventeen deaths (one death in 8.7 cases, or 11. per cent.).
inid 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 cases
were uncomplicated, all of which recovered, and two cases were complicated with
- phthbis, both of which terminated fatally) ; during six months, October, 1874, to April,
1875, total cases, four hundred 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 pleurt)-pneuraonia, 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, (cases 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
of 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 cases, or 43.9 per cent.; 1871, 109 cases, 44 deaths, one death in 2.5
eases, or 40.3 per cent.; 1872, 135 oases, 59 deaths, one death in 2.3 cases, or 43.7
per cent; 1873, 161 cases, 61 deaths, one death in 3.6 cases, or 37.9 per cent.; 1874,
130 eases, 43 deaths, one death in 3. eases or 33. per cent.
The following brief notee upon a portion of the cases treated in my wards, will
illustrate the general results :
Case 713: J. 0., age 50; native of Ireland; laborer; entered Ward la, December 15th,
1874^ Poeumonia of right lung: tubular breathing; crepitant and subcrcpitant rales; dull-
ness upon percussion ; increase of vocal fremitus ; bronchophony ; rapid pulse and respiration ;
elevated temperature; flushed cheeks; tongue coated with brown fur; rusty colored sputa.
The bowels were opened by a mercurial, and four grains of a mixture of equal parts of
Qainine and Dover's Powder were administered every three hours ; and ten drops of the
TtQCtnre of YeUow Jts^nnjin^ Qelseminum, every ^ix hours. ']["»'pe»^tinc stupes were applied
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728 Relations of Pneumonia to Malaria.
over the region of the inflamed lung. Milk Punch and Beef Tea were administered at regq-
lar intervals. In the course of nine days, the chlorides reappeared in the urine aad the
febrile excitement subsided, and convalescence was established. The patient was discharged.
capable of performing bis usual manual labors, on the 15th of January, one month after bit
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 cnstom to retaio
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, is
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 long. Eo<
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 28ib, ISU.
Pneumonia of left lung. Treatment as in case 713; recovered; discharged January 234,
1875.
Case 716: D. F., age 24; native of New Orleans ; gardener; entered Ward 25, Janaary
8d, 1875. Pneumonia supervening upon, and complicated with Malarial, fever. Entered oi
the 4th day of the Pneumonic inflammation. Quinine and Dover's Powders were freely used,
and both the Pneumonic inflammation and Malarial fever were arrested, and the patient wis
discharged January 15th, 1875.
Case 717 : W. C, age 38 ; native of Ireland; laborer; entered Ward 29, January 5th, 18T3.
Pneumonia of right lung complicated with Intermittent fever. Treatment as in preceding
case; recovered; discharged January 18th.
Case 718: B. B., native of France; age 44; baker; entered Ward 29, January 8lh, 1875.
Pneumonia of right lung; recovered ; discharged January 16th.
Case 719 : H. R., native of China ; age 23 ; laborer ; entered Ward 30, January lltb, 1875.
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 ITlh,
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 Janaary
27th, 1875.
Case 722 : J. OB., age 30; native of Ireland; brakesman; height, six feot, six inches;
entered Ward 2», January 20th, 1875, on 4th day of disease. Pneumonia of both lungs,
complicated with Plcuritis. Treatment as in case 713. Pneumonic inflammation arrested;
progress satisfactory; recovery; discharged February 5lh, 1875.
Case 723 ; J. B., age 48 ; unlive of Ireland ; laborer; entered Ward 30, January 23th, 18Tj.
Pneumonia; recovered; discharged March 12th, 1875.
Case 724: M. McM., age 40; Ireland; carpenter. Ward 29, January 2(>lh. Pneumonia
and Intermittent Fever ; recovered; discharged February 8th.
Case 725 : H. R,, age 40 ; native of Ireland , laborer. Ward 29, February 4th. Pneamo*
nia. Treatment as in case 713. Recovered; discharged March 3d, 1875.
Case 726: J. C, age 29; native of Ireland; laborer; entered Ward 29, February 23tiL
Pneumonia ; recovered; discharged March 18th, 1875.
Case 727; H. B., age 23; native of Germany; baker; Ward 30, February 27th, 18T5-
Pneumonia supervening upon and complicated with Remittent Malarial fever. Patient had
high fever, and delirium, and great prostration for five days. Treatment consisting chioiy of
Quinine and Dover's Powder, and Tincture Yellow Jessamine. Recovered ; discharged 3i«rch
1875.
Cask 728 : J. H., age 57 ; native of Ohio ; laborer; Ward 30, March 1st, 1875. Pneamonia.
Recovered ; discharged March 13th.
Case 729: J. F. C., age 48; native of France; painter; Ward 30, October I3th, ISI*.
Double Pleuro-Pncumouia. Had been sick six days, before entering the hospital. DallnesS
upon percussion over both lungs, especially over lower lobes, where there was tobala'
breathing, and absence of respiratory murmur; Pleuritic effusion upon right side. InteasC
pain upon right side. Rapid pulse and respiration ; great prostration ; cheeks mnCh coo>
^rested ; lips purple; tongue dry and coated with brown fur, and red at tip and edg€S:
delirium. Prognosis unfavorable. Died October 16th, three days after entering the hospitai.
Case 730: J. D., age 39; native of Ireland; laborer; Ward 29, December 23d. Douhle
Pneumonia with bloody expectoration. Dullness upon percussion, absence of respiralorr
murmur, and tubular breathing, over lower lobes of both lungs; s^»uta consists of almo^
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Relations of Pneumonia to Malaria. 729
pure blood. High fever, flushed face, rapid respiratioa ; congested lips and extremities;
delirium. Prognosis unfavorable. Expectoration ceased entirely on the 24tb ; patient died
December 25tb, 1873, on' third day after enterifig the hospital.
CAgB 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
purple appearance. Intense pain over inflamed portions of both lungs. Chlorides absent
from urine. Little or no expectoration. Died January 10th.
Case 732 : G. A., nge 38; native of Maryland; sailor; Ward 13, Jonuary 17th, 1875.
Had been sick four days before entering. Double Pleuro-Pneumonia. High temperature ;
rapid respiration ; great prostration ; congested purple lips and cheeks ; delirium. Under
the use of Quinine, Dover's Powder, and Tincture of Yellow Jessamine, and together with
nutritious diet and alcoholic stiumlants, this apparently hopeless case recovered, and was
discharged February 18th.
Casb 733 : J. S., age 40 ; native of England ; sailor ; Ward 20, January 24th, 1875. Patient
bad been sick six days before entrance into hospital. High fever ; great prostration ; severe pain
in right side; profuse expectoration of sero-purent matter. Auscultation and percussion,
revealed, in addition to pneumonic solidification of lungs, the existence of an abscess in right
lung, resulting from the destruction of the pulmonary tissue by the pneumonic inflammation.
Died February 13th, 1875.
PoMt-mortem Examination. — Inferior lobes and posterior portions of both lungs in a state of
grey hepatization. Left pleuritic cavity contained fluid, and coagulabie lymph with adhe-
sions. Abscess of right lung. Liver enlarged and cirrbosed. Kidneys normal. Urine con-
tained no albumen.
Case 734: R. W., age 27; native of (ierniany ; 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
Tincture of Yellow Jessamine, together with alcoholic stimulants and nutritious diet, pneu*
roonic inflammation arrested. This patient was suffering with secondary syphilis. Recovered.
Discharged February 24th.
Case 735: P. H. 6., age 45 ; native of Ireland; laborer; W. 13, February 22d. Had been
«ick six days. Dullness upon percussion with bronchial breathing over upper lobes of both
lungs. 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.; 25th, morning, temperature, 104^.5 ; evening,
106°; 26th, morning, temperature, 107°; violent delirium. Face and extremities present a dusky
purplish appearance. Died February 2Cth. 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 27lh, 1875.
Had been sick 8 days.
Dullness upon percussion, with bronchial breathing over large tracts of both lungs. High
fever, rapid pulse, rapid respiration, little or no expectoration ; chlorides absent from urine.
No 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.
Poit-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 effects
upon the progress of the disease.
Case 737 : H. K., age 23 ; native of England ; sailor. Entered ward 13, Feb. 10th, 187^
Pleurb-Pneumonia of both lungs, and Pericarditis engrafted on Phthisis Pulmonalis. Enterea
with elevated temperature, rapid pulse, rapid respiration ; oppressed respiration, blue lips
and hands. Dullness and absence of respiratory sounds, with exception of tubular breathing
over left lung, and over upper lobe of right lung ; friction sound over 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 r2th,
evening, temperature, 105; 13th, morning, 104°; evening, 105°; 14th, morning, 103°; even-
ing", 104°.8; 15th, morning, 101°.4; evening, 104°; morning, pulse, 112; respiration, 31 ;
16th, morning, pulse 122 ; respiration 35 ; temperature, 103°.3 ; evening, 104°; 17th, morn-
ing, pulse, 120; respiration, 42; temperature, 104°; evening, 105°; I8th, mornings pulse,
110; respiration, 42 ; temperature, 103.
Died February 18th, 1873.
Post-mortem examination revealed tubercular deposits in both lungs ; solidification, and
softening, and gray hepatization of entire left lung, and of upper lobe of right lung; golden
colored, coagulabie lymph over surface of pleura and pericardiuna. Bronchial to^hes ClUe«^
^itb sero-purulent matter. Cavity in right lung.
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Cask 73B : A. G., native of Cuba j age 23 ; sailor. Ward 13, Feb. 4tb, 1873. Plearo-
Pneumonia of both lungs, engrafted on Pbtbisis Pulmonalis. Entered with high feyer, rapid
pulse, rapid respiration, great prostration, delirium, dullness over both lungs, with crepitant,
sub-crepitant, mucous, sibilant and sonorous rales. Expectoration quite profus6, and also
purulent, and partially gelatinous, and rusty colored. Flatness upon percussion, most marked
in inferior clavicular region of both lungs. Died Feb. 16th, 1873.
Po9t-mortem Examination. — Miliary tubercles scattered through both lungs. Portions of both
lungs were iu a state of pneumonic inflammation and hepatization. Coagulable lymph apoo
pleura.
Large cavity in superior lobe of left lung. Pneumonic inflammation confined chiefly to left
lung.
In this case, (738), the patient had, eight months before his death, suffered with a suddea
and profuse hsemorrjiage from the lungs. At this time entered the Charity Hospital, aad
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 out: con-
plained of intense pain in both sides; distressed, haggard expression ; high fever, rapid pnlie.
rapid respiration ; cavernous respiration in superior mammary region of left lung ; friction
sounds of pleuritis ; crepitant, sub-crepitant, mucous, sibilant and sonorous rales. Right Idq 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, 30 ;* evening, 105**. €th,
morning, temperature, 101^.8 ; pulse, 88 ; respiration, 34 ; evening, temperature, 105°^.
7th, morning, temperature, 100°.6: pulse, 80; respiration, 34 ; evening, 105**.8. 8th, morn-
ing, temperature, 101^.4; pulse, 90 ; respiration, 35 ; evening, 105^.4. 9th, morning, tem-
perature, 102°; pulse, 88; respiration, 33 ; evening, temperature, 106°. 10th, morning, tem-
perature, 101° ; pulse, 88; respiration, 33 ; evening, temperature, 106.°7. 11th, morning, tem-
perature, 106°; pulse, 104; respiration, 42; evening, temperature, 106°.9 ; pulse, 140; rc»-
piration, 50. 12th, morning, temperature, 104°; pulse, 130; respiration, 44; evening, tem-
perature, 105°. 1 ; pulse, 136 ; respiration, 50. 13th, morning, temperature, 10l°.3 ; pulse, 140:
respiration, 50 ; evening, temperature, 105°.6; pulse, 160; respiration, 50. 14th, morning,
temperature, 102°; pulse, 130; respiration, 44; evening, temperature, 103°; pulse, 140; res-
piration, 50. 15th, morning, temperature, 102°; pulse, 144; respiration, 42; evening, tem-
perature, 104° ; pulse, 150 ; respiration, 44. 16th, morning, temperature, 101°.8 ; pulse, 112:
respiration, 43. Died Ju.> 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 plearitie
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 temperature which tk«
supervention of pneumonia and pleuritic inflammation is capable of inducing in patients suf*
fering with phthisis pulmonalis.
As a general rule, the temperature is elevated above the normal standard in phthisis, bat
this elevation is less than that characteristic of pneumonia.
Cask 739 : P. H., age, 88 j native of New Orleans : ward 13, November 23d, 18*12 ; pleuro-
pneumonia of both lungs, engrafted on malarial fever. Both lungs involved ; right lung entirely
solidifled ; flatness on percussion, and absence of respiratory murmur over right lung, aa4
superior portion of left lung; violent delirium ; rapid, feeble pulse ; congestion of capillanes;
lips and extremities purple ; no trace of chlorides in urine*; no albumen ; urine high-colored
and loaded with urea and uric acid ; sputa very small in amount and almost entirely absent
I was compelled to use opium with great caution in this case, on account of the great
embarrassment of respiration and the pain caused by the pleuritic inflammation. CompleU
solidification of ih^ inflamed portions of the lungs had occurred before the patient entered
the Charity Hospital.
Post'Tnortem Examination: — Pleura of both lungs inflamed and coated with fibrinous tflyuiea-
Gray hepatization of right lung and of superior portion of left lung.
Case 740 : J. P— , age 42 ; native of Ireland; ward 29, February, 1873 ; double pneo*
monia. Disease caused by exposure to cold, damp and wet on banks of the Mississippi. En-
tered with great oppression and capillary congestion ; lips blue ; dullness on percussion over
right lung ; tubular breathing, and absence of vesicular murmur in lower lobe of left lonj.
Temperature of axilla, at time of entrance, February 14th, m., 103°. 2 F. 16lh, pulse, 145:
respiration, 28; temperature, morning, 103°. 17th, pulse, 130; respiration, 22; temperature.
103°. 5. 18th, morning, pulse, 132; respiration, 22; temperature, 104° F. Died July Idth.
Cask 741: A. McC-: , age 54; Scotland; laborer; entered Charity Hospital, March 2^tli,
1873. Pleuro-pneumonia of both lungs supervening on malarial fever. Disease caused bj
exposure to wet ^^^(J damp in swamps of Mississippi river, and abuse qf alcoholic stimulanif.
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Entered my ward ia extremis : rapid, feeble pulse; labored, embarrassed respiration; un-
bealtbj malarial hae ; congestion of capillaries of face and extremities ; lips and extremities
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 everj 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
28th. 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 lung; entire absence of respiratory murmur, and presence of tubular breathing
over position of large bronchial tubes. Lower lobe of left lung flat on percussion. Great
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. 29th, morning
temperature, 104°.5 ; pulse, 112; respiration, 52 ; evening, temperature, 104°.8; pulse, 112;
respiration, 60. 30th, morning, 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 Ist, 1873.
Pott'-mortem examination — Diagnom confirm'^: — Gray hepatization of entire right lung, with
eflTasion 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.
Case 743: C. P , age 25; native of England. Entered Charity Hospital, February
10th, 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 for some time, before entering the hospital. Flat-
ness over entire left lung, with absence of respiratory murmur, and presence of tubular
breathing over region of large bronchial tubas. 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.
Case 744: S. M. C., age 21, native of Virginia; entered Charity 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 necessary to confine the patient in bed. Quinine, Dover's
Powders, Alcoholic Stimulants and blisters to side, produced no visible beneficial effects.
I9th, temperature of axilla, morning, 100°. 5. 20th morning, 102°.6 ; 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 percussion 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 extending in both lungs. 27th, morning, pulse, 128 ; respiration, 24; tempera-
ture, 103°.5; evening. 104°.5. 28th, morning, temperature 105°.; pulse, 120; respiration, 24 ;
evening, pulse 140; respiration, 38 ; temperature, 104°. 5. March Ist, pulse, 140 ; respiration,
45 ; temperature, 104°.5. Died March 1st, 1873.
Post-mortem, — 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-
tion 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 was of a deep red color, and loaded with urea, uric acid, biliary acids and the
coloring matters of the bile.
Case 745 : J. K.) age 43 ; native of Ireland ; laborer. Entered Charity Hospital, March 8th|
1873 ; high fever; delirium ; lips and hands 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. Great congestion of the capillaries of the
extremities, and the veins appear to be filled with black blood. No expectoration. Bled at
nosa. Died within twenty-four hours after entering my ward, (March 9th.)
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732 Relations of Pneumonia to Malaria.
Poit-martem Examination revealed graj hepatization of entire left lung, effusion of coagnlable
lymph on surface of pleura, 8olidi6cation of lower lobe of right lung. The solidification of
the left lung, ai^d of the lower lobe of the right lung was complete.
The absence of expectoration in this and other cases of pneumonia, which occurred darioi^
the winter and spring of 1873, appear to be referable to ihe severity of the tjpe of the diseast
and to the rapidity with which large practs of the pulmonary tissue was solidified.
CA8m746: 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 ptii
and difficulty in respiration. Diagnosis : pleuro-pneumonia 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; temperaturv
104°.4 F.; evening, pulse 144; temperature 104°. 4 ; 24th, morning, pulse 120; temperatare
103*^; evening, temperature 105°.3; 25th, morning, temperature 103°: evening, 105^.6; 26lh.
morning, pulse 119; temperature 104° ; evening, pulse 128; temperature 105°.3; 27tb, mora-
ing, pulse 126; respiration 18: temperature 104°.5; evening, pulse 126; respiration 24:
temperature 103°.5; 28th, morning, pulse 114; respiration 24 ; temperature 103°; evening,
pulse 108; respiration 30; temperature 104°.5 ; 20Lh, morning, pulse 114; respiration 6«-
temperature 102°.6 ; evening, pulse 132 ; respiration 60; temperature 101°. Died November
30th, 1872 ; sputa very scant, almost entirely absent.
Post-mortem. — Pleura of both lungs coated with yellow plastic lymph. Gray hepatizatioa
of right lung and superior portion of left lung. Liver and spleen presented evidences of the
preceding action of the malarial poison.
Cash 747 : T. S., age 20, native of Boston, Mass.; entered C. H. 13th February, with Pneu-
monia and Dysentery. Dullness upon percussion of left lung ; discharges from bowels macn'>
and blood. Under Quinine, Dover's Powder and Sub. Xit. of Bismuth, the patient recovered.
The temperature during the active stages of the Pneumonia, ranged from 102° to U>4°.8 F.
Cask 748 : Augustus J., age 34, native of Sweden. Admitted January 20th, 1873. MV
seized with pain inside and difficulty of breathing, and fever, two days before entrance iot»
hospital. Had suffered with Malarial Fever. The following observations were made npoe
the pulse and temperature: January 22d, morniug, pulse 108; temperature 104°.6; ereoiD^,
pulse 104; temperature 103°.9 ; 23d, morning, pulse 84; temperature 100°. 5; evening, palst
108; temperature 104°. 2; 24th, morning, pulse lOO; temperature 99°; evening, pulse 1^:
temperature 104°; 25th, morning, pulse 80: temperature 00°; evening, pulse 104; tempera-
ture 104°; 26th, morning, pulse 98; temperature 101 : evening, pulse 100; temperature 103^.
27th, morning, pulse 98; temperature 102°; evening, pulse 82; temperature 101**; 28th.
morning, pulse 80 ; temperature 101°. 6; evening, pulse 88; temperature 103°; 29tb, mornia^.
pulse 72 ; temperature 101°; evening, pulse 80; temperature 102°; 30th, morning, pulse 7« :
temperature 99°.3; evening, pulse 76; temperature 101°. 8. Daily records of the temperatare
were made in this case, up to the date of his discbarge, March 3d, 1872. Recovery attnbatH
chiefly to Quinine, Dover's Powder and nutritious diet.
Cask 749: J. H., age 45, native of Canada. Kutercd ward 13, January Oih, 18*3. Had
been suffering with symptoms of Phthisis Pulmonalis, vi^ : cough, expectoration and fever.
for some time before the present attack. After exposure to wet and cold on the Mississippi
River, was seized with pain in the side, oppression of breathing and high fever. Patiest
determined to come South to New Orleans, on account of his health (cough, fever and Bight
sweats). Whilst passing on steamboat, from Cairo to Memphis, was exposed to cold and wet
nnd on the 26th of December, 1872, was seized >vilh pain in right side, attended with incessast
cough, profuse, purulent and pneumonic e.\pccloralion, great oppression of breathing, rapid
pulse and elevated temperature.
January 13th, 1873. Mucous, sonorous, crepitant and sub-crepitant rales heard over both
lungs. Expectoration profuse and purulent. Morning, temperature 100°; evening, 105*.
January 14th. Dullness upon percussion over upper portion of right lung; greatest above
fifth rib, in which position the dullness is more correctly termed absolute flatness. Left Uif
more resonant, and mucous and sonorous rnles heard loudest In infra- clavicular region. Nc
albumen in urine, chlorides also absent.
Temperature, — Morning 09°, evening 103; 15th, morning 101, evening 105 ; 16th, moraiBf
99, evening 106; I7th, morning 100, evening 105.5 ; 18th, morning 99, evening 106 ; l?ib.
morning 100, evening 105.8 ; 20th, morning 99.4, evening 106.1 ; 2l8t, morning 99, evenlag
103 ; 22d, morning 99.4, evening 105 ; 23d, morning 102, evening 107.8 ; 24th, morning 105.4
evening 105; 25th, morning 100, evening 105; 26th, morning 98.8, evening lOT-3 ; 27tK
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Relations of Pneumonia to Malaria. 733
morntDg 97.5, evenins^ 107.2 ; 28tb, morning 100, evening 107.3 ; 29tb, morning 99.5 F.
Swelling of feet observed January 21st. January 26tb, bad severe cbill in tbe afternoon,
lasttog three boars, attended witb 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 27th and 28th. No beneficial effects whatever
were observed, and the temperature reached 107, in the evening of both days. Died January
'i9th, 6 p. M. Temperature fell before death.
This case, 749, furnishes another striking illustration of the marked elevation 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,
in 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 Pnenraonia.
The chills and profuse sweats which characterized the case (749), appeared to be due to the
absorption of the products of inflammation.
Sadden elevations of temperature in Phthisis may also be excited by inflammation of the
brain and its meninges, as in the following case.
Casb 750. — J. M., age 15, native of Austria. Entered ward 15, Charity Hospital, Dec. 2 J.
1872. Pale, anaemic, emaciated ; feeble, irritable pulse ; flatness in infra-clavicular region of
both lungs. Cavity with cavernous respiration in right lung. Marked daily oscillations of
temperature. Jauuary 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
suflTered with violent pain in 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
102°4. F., whilst on the 21st, during the delirium, the thermometer in the axilla indicated
106°. 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-
mum axillary temperature was 103°.2.
On the 2d of February the patient again complained of pain in the head, the pulse became
fuller and stronger, the patient became delirious, and the increaseof 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. 7th, 8th, 9th, 10th, 14th,
15th, 16th, 22d, 23d, 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 llih. Tcntp.^ralure. — Morning 102, evening 103 ; 12th, morning 101.5, evening 103.2 ;
13th, morning 102, evening 103.6; 14th, morning 101.8, evening 103; 15th, morning 101.8,
evening 103.5 ; 16ih> morning 101.5, evening 104; 17th, morning 101.5, evening 103 ; 18th,
morning 102, evening 103; 19th, morning 100.2, evening 102; 20th, morning 100.2, evening
102.5; 21st, morning 100.3, evening 106.2; 22d, morning 99, evening 104.2; 23d, morning
101, evening 104; 24th, morning 100.6, evening 103.8; 25th, morning 100.8, evening 103.1 ;
26th, morning 101. evening 103.1; 27tb, morning 101, evening 103.5; 28th, morning 102,
evening 102.6; 29th, morning 100, evening 103.6; 30th, morning 99.8, evening 103; 3lst,
morning 100.2, evening 103. February 1st, morning 105.5, evening 102; 2d, morning 100,
evening 105.4; 3d, morning 99.2, evening 103; 4th, morning 99.1, evening 104; 5th, morning
100, evening 103; 6th, morning 101.2, evening 102.5; 7th, morning 101, evening 104; 8th,
morning 101, evening 104.6 ; 9th, morning 101.5, evening 102; 10th, morning 101, evening
104.6; 11th, morning 101.2, evening 103.8; 12th, morning 100, evening 103.6 ; 14th, morning
lOOf evening 104.5; 16th, morning 102.2, evening, 105; I6th, morning 101.2, evening 104.8;
17th, morning 100, evening 103 ; 21st, morning 101.6, evening 102 ; 22d, morning 101, evening
105; 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 ; 9tb, morning 102, evening 102.8 ; lOtb, morning 101, evening 103.4
11th, 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 tbe Hypophospbites of Lime, Iron, Soda and Potassa, Cod-Liver Oil, Alcoholic
Stimulants and nutritions diet.
Cask 751. — N. W., age 34; native of Denmark; sailor, clerk. Admitted into the Charity
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734 Relations of Pneumonia to Malaria.
Hospital January 13th, 1873. Suffered with cough attended with fe^er, December, 18*71. At
this time suffered with haemoptysis, which induced great prostration. Has had no recarr«Bce
of ihe haemoptysis, but has been under the care of physicians, and has pursued his ordinary
avocations up to the time of his entrance into the Charity Hospital, February 1st. PaUeat
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 says that
he has never suffered with syphilis. Marked depression in super-clavicular, and also in infra-
clavicular regions, over apices of both lungs. Dullness not amounting to flatness, over apicei
of both lungs ; more niarked over the left ; puerile respiration over middle and lower portioas
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 Pneumonia. 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 tenacious.
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 ; 20th, momiag
102, evening 105; 2lst, 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, eveniog
105; 26th, morning 101.2, evening 103 6; 27th, morning 102, evening 103.6; 28th, moraisf
102, evening 104; 29th, morning 101.4, evening 104.4; 30th, morning 100, eyening 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 inflammatios
of circumscribed portions of the lungs.
Under the continuous use of Cod-liver Oil, Hypophosphites, Alcoholic Stimulants asd natri-
tious diet, the improvement of this patient was slow, but marked, and upon the 1st of Marck,
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 19th, 1872. Tubercular deposits and cavity in right lung; Phthisis; increased
respiration ; cavernous respiration ; bronchophony ; crepitant and mucous rales.
The temperature was recorded daily during a period of 30 days. The maximum morniag
temperature 102.6, minimum 100 ; maximum evening temperature 104.5, minimum 99. At a
general rule, the temperature in this case of Phthisis did not rise above 102.6, during the U
hours. This patient improved under the treatment with Cod-Liver Oil and hypopbospbites,
and bitter tonics, and with the increase of flesh there was also a diminution of temperatnre,
and the variations between ihe morning and evening temperatures were less marked.
Case 753 : A. K., age 32 ; native of Sweden. Entered Charity HospiUl, September 21ft,
1872. Says that his father died with Syphilis. Had suffered with cough and fever severd
months before entering the hospital. Dullness on percussion, and tubular respiration, aad
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 upon the temper-
ature, the maximum morning axillary temperature, was 101, minimum 100; maximnm eveniag
temperature 102.8, minimum 101. The mean evening temperature was 102.2, and the meai
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 Hypophospbltes, and Tincture of
Cinchona, with nutritious diet, this patient slowly improved, and was discharged at his owa
request, February 3d, 1873, a favorable opportunity having offered for his return to his natin
country.
Case 754 : J. W., age 32 ; native of Ireland. Entered Charity Hospital, September 3d,
1872. Dullness on percussion, with tubular breathing, bronchophony and mucous rales, it
infra-clavicular region of both lungs. The existence of Phthisis also manifested by the per-
sistent elevation of temperature. The morning axillary temperature ranged between 99 and
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 Iti,
1673. Has led a life of exposure, and had hiemorrhage twice from bis lungs. During th«
past three months has suffered with cough and fever, and has lost considerable flesh. S«jf
that both his parents lived to old age, and died of acute diseases. Apex beat of heart is
normal position, but the first sound is accompanied by a murmur, propagated along the coont
of the aorta. The pulsations of the arch of the aorta are distinctly visible in the supra-aterasl
region, which is much fuller than normal. When the hand is placed on the tnmor in tk«
notch of the sternum, the enlarged dilated arch of the aorta can be distinctly felt, and a ttresf
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Relations of Pneumonia to Malaria. 735
impulse is communicated to the fingers, synchronous with the contraction of the yentricles.
Patient suffers with night sweats, and expectorates purulent matter. Infra-clavicular regions
of both lungs, flat and dull upon percussion, with tubular breathing and raucous rales. Diag-
nosis ; dilatation of arch of aorta and phthisis pulmonalis.
Daring a period of 90 days 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 duo mainly to the state of almost absolute rest.
Cod-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 756 : T. C, age 37; native of Indiana. Entered ward 13, December 2d, 1873. Dis-
ease, Phthisis, complicated with Hydro-Pneumo-Thorax of left lung. The Pneumo-Thorax
appeared to have been the result of the softening and ulceration of a tuberculous mass upon
ibe surface of the lungs. As far as could be estimated, by careful auscultation, percussion
and succussion, about two quarts of liquid had been efi'used 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
sixth 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 sounds ; 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 during 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 10l°.5, and the evening temperature from 98.5 to
103° F., 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
pulse, 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 New York. From let-
ters received from this patient, I learned that he had reached home in safety, and continued
to improve.
October Tith, morning, pulse 110, respiration 26, temperature 101.®5; evening, pulse 118,
respiration 28, temperature 102°. 13th, morning, pulse 120, respiration 28, temperature
100.^5; evening, pulse 126, respiration 28, temperature 101.e7. 14th, morning, pulse 112.
respiration 30. temperature 100.°5; evening, pulse 102, respiration 30, temperature lOO.^S.
15th, morning, pulse 106, respiration 37, temperature 95.°7 ; evening, pulse 130, respiration
34, temperature 102.°6. 16th, morning, pulse 118, respiration 40, temperature 101.°6; even-
ing, pulsd 114, respiration 44, temperature 103°. 17th, morning, pulse 120, respiration 36,
temperature 101.°2 ; evening, pulse 120, respiration 40, temperature 105.'^2. 18th, pulse 120,
respiration 38, temperature I02.o2. 20tb, evening, pulse 136, respiration 38. temperature
105-^1. 22d, morning, pulse 120, respiration 44, temper (tore 100.°1 ; evening, temperature
103.°8.
Case 759: A. Q. Age 19. Entered ward 13, January, 1872. From the history, it was
evident that this patient had suffered with phthisis pulmonalis for several mouths 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 symptoms continued from the 2lst to
the 29th of January, and the maximum axillary temperature was 104o.8 F. On the 19th of
February, symptoms of circumscribed interstitial pneumonia again appcarcl, and 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 illustrate these
changes in the temperature of phthisis as influenced by the puemonic inflammation :
January 22d; morning, temperature — degree*^ 104.8, evening 105.5 ; 23d, morning 100.5, even-
ing 104.2 ; 24th, moroiug 99j evening 104 ; 25th, morning 99, evening 104 ; 2f»th, morning lOl
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736 Relations of Pneumonia to Malaiia,
evening 105 ; 27th, morning 102, evening 105; 28th, morning 101.5, e?emng 103.8; 39ik,
morning 101, evening 102 ; 30tb, morning 99.7, evening 101.8 ; 31gt, morning 100.3, evenrnf
101; February Ist, morning 100, evening 101 ; 2d, morning 99.5, evening 100; 3d, morfting
99.8, evening 102.3 ; 4tb, morning 100.2, evening 101.8; &th, morning 99, evening lOU;
6th, morning 99.9, evening 101.8 ; 7th, morning 99, evening 100.5 ; 8th, morning 99.8, eveniftf
102; 9th, morning 99.7, evening 100.5; 10th, morning 99.9, evening 100.3; I3\hj moraiaf
98.5, evening 100.3 ; 14tb, morning 99.4, evening 100.4; 15th, morning 99.2, evening 101^;
16th, morning 99.5, evening 100 ; 17th, morning 99.5, evening 101.7 ; 18th morning 99.8, eve-
ning 101.5 ; 19th, morning 100, evening 102.8 ; 20th, morning 101.2, evening 103 ; 21si, man-
ing 101.2, evening 103; 22d, morning 101, evening 103.8 ; 23d, morning 100.5, evening 102.5,
The temperature remained for a number of dayg oscillating between 99° and 102^. There
was no return of the pneumonic inflammation, and the patient improved under the nsta!
treatment with cod-liver oil and tonics, and was finally discharged at his own request.
Cask 760: J. C. K -. Age 24. Entered ward 13, February 4th, 1873, with pnenmonit,
of lower lobe of right lung. The temperature ranged from 104.8 to 105.4, until the 8tk,
when there was a decided improvement in all the symptoms. The temperature oscillated
between 98.8 and 103, until the 19th, when there was evidence of a fresh accession of pnes*
monic inflammation involving the middle lobe. The temperature reached the highest poist
on the 22d, 105.8, and then descended rapidly and continued oscillating between 100 and 102,
until couvalesence was fully established. The following observations extracted from tbc
record of thirty days, will illustrate the effects upon the temperature of the pncnmoik
inflammation :
February 4th, evening; temperature— degrees^ 104.9; 5th, morning lt)3, evening 105; »tii,
morning 102, evening 104.9; 8th, morning 101, evening 101.5; 9th, morning 101,eveoia{r
101.5 ; 10th, morning 101, evening 103.2; 11th, morning 100.8, evening 102.6; 13th, momisg
100, evening 101.2 ; 13th, morning 100, evening 102; 14th, morning 100.4, evening 101.S;
15th, evening 100.8; 16th, evening 100.4; 17th, evening 101.5; 18tb, evening 98.8 ; ISU,
morning 99.5, evening 103 ; 20th, morning 99.5, evening 104.3 ; 21st, morning 105, cveniag
104.3 ; 22d, evening 105.8; 23d, morning 102, evening 102.1 ; 24th, morning 101, evening 101^:
25th, morning 09.8, evening 102.9; 26th, morning 99, evening 101.5; 27th, morning 97>,
evening 99.1 ; 28th, morning 99.5,
The temperature maintained the normal standard after the 28th, and there was no retsra
of the pneumonic inflammation, and the patient was discharged as soon as his strength vu
sufficient for active work.
Case 761 : J. J., age 21. During convalescence from yellow fever, this patient was attacked
with pleuritis of the right lung, November 4th, 1873. The highest point of temperatare was
reached on the 6th and 7th, when the thermometer stood at 103.5. After the subsidence of
the active inflammation, and after some effusion had taken place, the temperature for a period
of seven days oscillated between 98.5 and 101.5.
Case 762: A. W., age 21. Entered Charity Hospital, November 1st, 1873. Pleuro-Paeii-
roonia of left lung. The highest point reached by the temperature in this casc was 104, aid
for a period of sixteen days, the temperature oscillated between 99.8 and 104 : the pulse ranged
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-appeared
in the urine. Recovery in this case was complete, and without any accumulation of liquid it
the diseased pleuritic cavity.
Case 763 : J. W., age 35 ; native of Ireland. Entered Charily Hospital, December lit.
1872. Has been exposed to cold and wet ; was seized with cough, chill, pain in left side, aid
high fever. December 1st, left lung dull upon percussion; crepitant and sub-orepitant rakf
heard over left lung. Respiratory murmur diminished, and tubular breathing iocreasc^
Expectorates rusty colored sputa ; chlorides entirely absent from the urine. The bowels w»t
opened with 10 grains of Calomel, combined with 5 grains of Quinine. The action of tliii
purgative, was followed by the mixture of Quinine and Dover's Powders, Turpentine Stapes
were applied over left lung. The strength of the patient was sustained with nntritloas <Hc«.
Under this treatment recovery was speedy and complete. The following observations will
illustrate the changes of temperature.
December 1st, morning, pulse 92. respiration 30, temperature 100.5; evening, pulse lli,
respiration 30, temperature 105.2. 2d, morning, pulse 108, respiration 24, temperatare Idi;
evening, pulse 150, respiration 30 temperature 105.3. 3d, morning, pulse 120, respiration 24,
temperature 104; evening, pulse 120, respiration 24, temperature 104.5. 4th, morning, pnlft
110, respiration 24, temperature 103.2; evening, pulse 112, respiration 24, temperatare 104.
5th, morning, pulse 104, respiration 18, temperature 101 ; evening, pulse 116, respiratioa 24.
temperature 102.8. 6th, morning, pulse 89, respiration 18, temperatare 99.8; evening, palse
92, respiration 18, temperature 100.2. 7th, morning, pulse 86, respiration 18, temperatuf
97 ; evening, pulse 84, respiration 18, temperature 97.5. 8th, morning, pulse 88, respiratiea
12, temperature 97.5; evening, pulse 78, respiration 18^ temperature 9"^.^. 9ibj momiaf.
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Relations of Pneumonia to Malaria. 737
palse 80, respiration 18, temperature 97.5; eyening, poise 70, respiration IB, temperature
97.5.
Case 764 : C. P., age 25 ; native of England. Entered February 10th, died February 15th,
1873. Disease, Pleuro-Pneuroonia, engrafted on malarial ferer, 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 hospitai. Flatness over entire left long, with absence of respi-
ratory murmur, with tubular breathing over region of large bronchial tubes. No expectora-
tion. Bowels ** running off; " discbarges 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 106.2 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-
i°Sr* pulse 110, respiration 44, temperature 105.6; evening, pulse 120, respiration 46, tempera-
tare 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 (he Pneumonia.
Bowels moved continuously throughout the disease. Pulse rapid; cheeks greatly con-
gested. As the disease progressed, the lips became blue.
Autopsy l6kour8 after death. — Heart normal. Lower lobe of left 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 tabular 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 ; lobull distinct. Spleen enlarged to about four times the normal size, and soft-
ened. Ileum, colon and rectum, (mucoyis membrane) congested, Some ulcers of mucous
membrane in colon. Peyers glands distinct, but without any special deposit.
Case 765: T. McD., age 28 ; native of Ireland. Entered Charity Hospital, November 12th,
1872. Plenro-Pneumonia of right lung Intense pain in right side; rusty colored sputa.
Has been sick for several days before catering the hospital. November 13tb, morning, pulse
110, respiration 45, temperature 103; evening, pulse 130, respiration 36, temperatue 104.6.
14th, morning, pulse 106, respiration 30, temperature 103 ; evening, pulse 120, respiration 27,
temperature 105. 15th, morning, pulse 106, respiration 30, temperature 101.8 ; evening, pulse
100, respiration 23, temperature 100. 16th, morning, pulse 90, respiration 21, temperature
98.4 ; evening, pulse 83, respiration 22, temperature 99.
This patient continued to improve, and was discharged. At my first visit, I placed this
patient upon 6^ grains of the mixture of equal parts of Quinine and Dover's Powders, every
four hours, and also gave Tincture of Cinchona and alcoholic stimulants. Under this treat-
ment the temperature rapidly fell, and the respiration became slower.
Case 766 : H. O'R., age 40 ; native of Ireland. Admitted into Charily Hospital, February
4th, 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 sides 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 ; vesicular murmur over
upper lobes of both lungs. The patient is of great size, being 6} feet in height, and with
broad chest, and large limbs. Utter prostration of strength ; rusty colored sputa.
February 5th, morning, pulse 124, respiration 40, temperature 104.6; evening, pulse 128,
respiration 48, temperature 105.4. Olh, morning, pulse 122, respiration 44, temperature 103.4.
7th, morning, pulse 124, respiration 46, temperature 103.6. 8th, morning, pulse 120, respira-
tion 44, temperature 102.2; evening, pulse 110, respiration 36, temperature 102, 9th, pulse
100, respiration 36, temperature 98.5. 10th, morning, pulse 96, respiration 30, temperature
99 ; evening, pulse 88, respiration 38, temperature 100. 11th, 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 82, respiration 28, temperature 98.5.
This patient was treated with Quinine, Dover's Powder and Tincture tf Yellow Jessamine.
The pneumonic inflammation was arrested in both lungs. The temperature descended, and
the patient was discharged at his own request, at the end of two weeks.
The preceding observations not only illustrate the method of treatment and the gen-
eral characters of the cases of Pneumonia in my wards in the Charity Hospital, but
they also show that the elevated temperature (fever) characteristic of the active sta^e
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740 Relations of Pnenmonia to Malaria.
of Pneumonia, is coincident with and accompanies the progress of the local inflamiiit-
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 effused fibrinous effusion in and around the air cells is absorbed and
developed into dense tissue, the fall of temperature is rapid and comparatively penm-
nent. In those cases, however, in which the inflamed tissues undergo d^eneration 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 n^id
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 caMB.
When the pneumonic inflammation subsides, the temperature assumes the course chw-
acteristic of Phthisis.
I have drawn up the preceding table, with the design of determining, as fdi as possi-
ble, the relative value of the different modes which have been employed in the treat-
ment of Pneumonia.
The important fact illustrated by this table is, that the mortality from Pneumonia, 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 different 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 the
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, 1849-1853, inclusive, with only two deaths,
or a mortality of 2.7 per cent, or one death in thirty-four cases.
It remains that wo should examine the method of treatment employed by this acca-
rate and learned physician, which yielded such favorable results, in a highly mahuioos
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 defects 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 aggregate 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 certain
complications and a new set of symptoms, which seemed very materially to influence
the progress and result of the attack ; and second, that these complications had a certain
relation to the treatment. The complications were an ileo-colitis, with its attendant
symptoms ; a dry and red tongue, tympanitic abdomen, and diarrhoeic or dysenteric
stools ; sometimes succeeded shortly after its advent, sometimes accompanied from the
b^inning 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 bj
several circumstances. It was observed that those cases in which the treatment w»
begun early resulted less favorably, as a general rule, other things being nearly eqnal,
than those in which the treatment was begun later, and consequently was less protracted ;
that in the former the complications were more common, and when not fatal, the attack
was more obstinate, and followed by a slower convalescence ; and lastly, it was observed
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Relation of Pneumonia to Malaria. 741
that serious affections of the gastro-intestinal mucous membrane never occurred in the
b^inning 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 unfrequently
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 we have treated with tjirtar emetic principally, we do not hesitate
to say, that half as many deaths have occurred in consequence of gastro-enteritis —
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 "*
With reference to blood-letting, the objections which Dr. Ames noticed in the course
of his 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
say, 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
bleeding 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 yeys, 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.
La^nnec 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, after as many vcne
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 visiting, for the first time, a person of adult age having Pneumonia in the first
♦ New Orleans Medical and Surgical Journal, vol. v. 1848, p. 291.
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742 Relations of Pneumonia to Malaria.
or second stage, pleuropneumonia or pneumo-bronchitis, the following prescriptions ire
made :
R. Tincture Aconitum Napellus (saturated,) gtt, xii; Quinias Sulph. Vel. Feno-
Cjan., grains, xxxvi ; Morphia Sulph., grain, i ; m. ft. pil. xii.
R. Solution of Phosphorus, gtt, xvi; water, 4 fluidounces.
Of the first, two pills are directed to be taken every third or fourth hour, usual] j
every fourth, each dose being preceded one or two hours, by a teaspoonfal of the phos-
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 firet
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 perooU-
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. Ames its em-
ployment as a substitute for bleeding and antimony.
The dose advised, two drops, may be considered a medium dose, when made op 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 often enough to induce some nausea, or slight vomiting,
particularly in the first stages of pneumonia. It is not n*eedful to go fdrther, as a gen-
eral rule, in order to get the best effects of the remedy, without, at the 8am3 tiai3, htr-
rassing the patient with its sickening influence.
On some occasions, however, when the attack wears an unusually threatening aspect,
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 circamstaoces,
the development of the toxicological action of the remedy, to any great extent, is not
desirable ; for if the dose be too large or be too often repeated, its effects may become
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 ol
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 drynees,
or rather a feeling of dryness, and constriction of the throat; burning, tingling and
numbness in the mouth, and numbness in the skin of the hands and feet, and frequently
over other parts of the%urface.
Children bear somewhat larger doses, in proportion to age, than adults. A child six
or eight months old, can generally take one-fourth of a drop without inconvenience, and
one twelve or eighteen months will frequently bear a third or a half a drop. The dose
for adults and children, should be repeated, except in case3 of unusual violence, at in-
tervals of not less than three hours ; in no circumstances ought the intervals be leas
than two hours.
The best effect of this remedy in pneumonia, like bleeding, is exerted in the first
stage, or that of capillary repletion. After the second stage is completed, throughout
the greater part of the inflamed structure, though not at all doubtful as a remedy, nor,
indeed, any the less eificient or certain in its curative action than before, the latter »
usually less promptly exhibited as regards both the rational and the physical signs. *Vs
a substitute for bleeding, it seems to possess several other advantages. While it redu-
ces the force and frequency of the pulse with greater certainty, though somewhat less
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 is no
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Relations of Pneumonia to Malaria. 743
tendency to any violent reaction 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, so 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 stiage 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.
Dr. 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
oapillaries. 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 : fii-st, Aconite ;
secondly, Antimony ; thirdly. Phosphorus ; fourthly, Quinine. Dr. Ames puts Pha*^-
phorusjn 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
given in a dose large enough to 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
medicinal 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
is 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. Ames, 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
indispensable. When a malarious taint is an obvious complication, or when the pul-
monic 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 great difficulty. The excess of fibrin in the blood, the
yioWnce of the local inflan^n^ation, and the exalted state of the innervation, may overcome
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744 Relations of Pneumonia to M
the tendency of the cause of periodical fever to manifest
it becomes a safe rule to begin the treatment of pneuB
called,) by making quinine a component part of it.
The custom of Dr. Ames was to give it in the mai
effects on the head became very well marked, and if tl
then satisfactory, or such as may be properly attributed
and give the x\conite in water.
Dr. Ames regarded blisters as important adjuncts i
He found them to be most beneficial when applied in tl
applied, they never seemed to produce any general irrit
pain, and appeared to assist in resolving the local inflan
Morphine, (or Opium), besides its occasional use as
duced into the plan of treatment, in order to effect tv
was to prevent any irritation of the bowels, or to rem(
of the disease is to take on this kind of complication,
aggravates the danger of an attack, as well by its unfa
affection, as by the presence of disease in the two vital (
disposition to an enteric complication is sometimes so
active disease from very slight causes ; even Quinine
produce this effect. Hence the advantage of combini
timing the doses of the opiate as that its quieting effect
uous. The rule with Dr. Ames was to keep the bowe
cut medicines forming no part of the treatment.
The other object was to prevent inflammation o
endeavored to accomplish by the judicious use of opiate
blisters.
In his opinion, the fears so often expressed by sys
use of opiates before the acute febrile excitement is su
their aggravating the inflammation by checking expector
In noting the cases. Dr. Ames followed the rule of
the lungs in which the diagnosis of Pneumonia could
as those in which the pulmonic inflammation was not tl
case. Of the 68 cases recorded upon the Uiblc of Dr.
blacks. Both of the deaths occurred amongst the blac
were affected, and in forfy cases the inflammation wi
lunjr.
We have thus endeavored to give a thorough and iui
Dr. Ames, as it appears to be the most important coi
Pneumonia which lias ever emanated from Southern ph
In 18G6, I submitted the tabular statement of results
in various Confederate and European hospitals, togethei
gations on the relations of malaria to Pneumonia, to io
ability and judgment I had confidence, and these prac
nicnt of Pneumonia, will be ccncludcd with extracts frc
ClIARLOTTESV
Pr. Joseph Jones :
Aft/ Dear Doctor:
I do not remember to have seen anywhere else, as just t
subject, or as clear a statement of the way in which the pr
predispose to inflammation of llie lungs.
Your table of the mortality of Pneumonia, under differ
nished me food for much reflection. The death rate at
occurred in the Confederate service, except at Atlanta, A
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Relations of Pneumonia to Malaria. 745
far as I controlled it,) in carefullj supporting the patient by nutritious food — gentle revulsion
by turpentine stupes or light blisters, the use of saline diaphoretics, and the timelj 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,)
farnish 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-
tality at Charlottesville. * * *
Believe me, my dear Doctor, very sincerely and kindly, votir friend,
J. S. DAVIS.
Philadklphia, December 8th, 1860.
Db. Joseph Jones :
Mi/ 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 1 requested my publishers to send 3*ou in my name ,
aod 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,
aod the importance of the use of quinia in the complicated affection. My own experience
long since abundantly convinced me that quinine is not only capable of curing this form of
Pneamonia, 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. * *
You 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, 1866.
Prof. Joseph JoneSy M. D. :
Mt' Dear Dr. Jones— Your favor of the 12th inst., has reached me, and demands my
acknowledgment and thanks. 1 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
No. 1), 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
No. 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 ytt take up, we find
Pneumonia occupying a prominent place, perhaps, generally the second, Consumption being
first. In Ramsey's table, for thirteen years, of New York mortality. Consumption yields
37,038 ; Convulsions 23,063 ; Marasmus 18,696; Cholera Infantum 16,331 ; Pneumonia 15,138 -f-
Inflammation of Chest 168 -{- Congestion of Lungs 3,230 r^^ 18,536. But Convulsions, 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) 3781.
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, I am amazed and humiliated. If
all cases "tend to recovery/' how \\9S^ so many thou8«vn.d9 been hindered fcpin iKis ^atutAl
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746 Relations of Pneumonia to Malaria.
terniinution, and " done to death ? '' If by the interference of our Profession, the sooner we
disband the better.
I have seen very few cases die of Pneumonia, complicated or uncomplicated ; but I have bc<o
unfortunate enoirprh to lose one occasionally in my large and long practice. Yet I never ii-
tend one without flattering myself that I had been of some use to him — either palliating his suf-
lerings, or, if I could not save, prolonging his life.
Hospital cases, my dear Doctor, do not offer fair tests, as thus : if a wretched pauper be
lirought from a miserable and lillhy hovel into a comfortable ward, cleansed, warmed, clothed,
IVd — he undergoes a change of condition far more impressive than all the appliances of the
Materia Mcdica could eflect— a change for the better, hygienic, curative, in every waj
restorative.
Hut select cases, in good houses, in a city, and change nothing of their sunoundings; let
one hundred be poulticed and dieted, or left to quiet rest in bed, and treat another hundred
with Quinin, a few with the lancet pro re-nata, above all with Opium or with Calomel—til 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 instructive
records, and when extensive and varied enough, would be conclusive. At present, we mast
continue doubtful and anxious— such is the destiny of the reflective physician, certainly
seems unattainable, but "Probability is the Rule of Life," and I think it probable that we
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,
8.VMX HENRY DICKSON.
PuiLA DELPHI A, Dcccmbcr nth, 18G6.
DocTOB Joseph jonks :
Ml/ Most Esteemed Frienrl, * * ♦ » »
I have read with much interest your paper on Pneumonia and Malaria. 1 endorse even-
word of it except protiene, (there is no such organic body— albumen or albuminoid expresses
the truth.) I go further, healthy inflammation not merely limits disease, it cures and ciiin-
guishes it, and it disappears. When perfect hepatization-^the second stage of Pueumonit
has taken place, the primary affection which preceded and induced inflammation it sirtnp-
lated by the coagulation of healthy flbrin ; all vital action, circulation, inervation, notritite
action, all are terminated, the tissue is reduced in structure and vitality, to cartilaginoai
tissue or even below it.
December 8th, I had proceeded thus far, when 1 was interrupted, and soon after was seiipl
with a most furious attack of Neuralgia, which continued all yesterday ; and to day my betd
has been a *• muddle," from the opiates with which 1 was compelled to stupefy my neurons
sensibility.
Now to resume our subject, John Hunter was the first who recognized that inflammatioa
was a salutary process, a therapeutic agent of nature. Inflammation of that type or natarf,
he called healthy inflammation ; but there was another type or kind of.inflammatioo, which
not only failed to arrest or to influence a diseased state favorably, but actually to aggrariie
it; that he named unhealthy inflammation. He could not account for the difference. The
capital fact of inflammation had not then been ascertained-; we are indebted for it to Andrti
and Gavarret. It is that inflammation develops fibrin in the blood. It is the blood ih»t
determines the type of inflammation. When the crasis of the blood is normal, the fibria
possesses its plastic properties in a perfect state; it coagulates firmly, glues tissues together,
and consolidates loose spongy tissues, and reduces them to the lowest type of structure— iH
vital action, normal or pathological, is arrested. This is healthy inflammation. Butifibe
rrasis of the blood be deteriorated, or contaminated, inflammation does not convert albumen
into fibrin, or produces an imperfect uncoagulablc fibrin, and this is unhealtliy inflammiition.
It fails to arrest the disease. In Pneumonia there is no second stage — rales in the lungs and
bloody sputa coQtinuc to the epd — always fatal.
For a per\Q(^ of forty years Pn^umo^ia presented its noimil typa, running thrjugh its first
second, and t^ird stages. Except ip double pneumonia, the death rate wa.<« small. Aboot
1857 or 18^^, {\ change took plape i many cases remained in the first stage — the second stAge
aborted j po perfect hepatization p.ccurred i and all such were fatal. A number of oar res-
pectable citr^^fls were victiipsLJ fts Dr. IJaro, Dr. 4. K. Mitchell, Judge Kane, and other?.
Cases are no,^ less frequent;, i^i^4 ^ a™ ^^^ Wormed as to its present type. Cases of Poea-
monia hav^- b?ep diminishing for the last five years, and I have not bc^p ablQ to n^ccrtaiQ
whether ith^sTOSQUKd its normal type of three successive stages^
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Relations of Pneumonia to Malaria. 747
What you say of Malaria is perfectly correct. There can be no doubt that it frequently
exists in a dormant state, and is excited into activity coincidentally with the development of
another disease. I have not met with it in Pneumonia ; but in a period from 1820 to 26, when
we had all forms of malarial diseases in the summer, cases occurring in the winter frequently
assumed the intermittent type.
My dear Doctor, I have made an effort to write though with difficulty, I fear you will find it
difficult to read what I have written — my fingers are so stiff, and my hand unsteady, (hat
writing in long letters is almost illegible.
* » » * * . «
Adieu my last, best friend, but most esteemed,
SAMUEL JACKSON,
224 South-Eighth Street.
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OBSEIlViS.TIOISrB
ON DISEASES OF THE
Osseous System,
MOLLITIES OS8IUM
(MALAKOSTEON, OSTEO-MALACIA, OSTEO SARCOSIS, KNOCHENERWEICHrXG,
RACHITISMUS ADULTORUM. RICKETS, OR SOFTENIXG OF
BONES IN THE ADULT.)
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OBSERVATICNS ON DISEASES OF THE OSSEOUS SYSTEM— MOLLI-
TIES OSSIUM.
CHAPTER XIX.
HISTORICAL NOTES ON MOLLITIES OSSU'M.
No mention of this disease in the works of Hippocrates, Paulus .'Eginctn, Aretaeus and other
ancient writers. Observations of Sachsius, Petra k Castro, Avicenna, Morgagni, Fernelius^
Raellius, Hildanus, Gabrielli, Courtialis, Bauda, Saviard, Valsalva, Petit, Boerhaave and
others. Reference to the literature of Mollities Ossium.
The peculiar coDdition of the bones, kuowii as Mollities Oisium, is so rarely met with
in the United States, that many experienced and a^ed practitioners have never seen a
case ; but one case was recorded in the largest American medical journal, during a
period of thirty years from its commencement, and a careful examination of several of
the largest American medical journals has added nothing to the libt of cases ; and even
in the annals of European medicine, we can scarcely find twenty-five well marked exam-
ples.
It is doubtiiil whether the ancients were acquainted with this disease ; we have been
unable to discover in the works of Hippocrates, Paulus ^Egineta, Aretaaus, and other
ancient writers, any observations which could be referred to Mollities Ossium.
If the statements of Sachsius and Petra k Castro are to be received as applying to
this disease, it was known to the Arabs, under the name of Alachad and Alzeniena,
and was cured by Avicenna ; some of the interpreters of Avicenna, however, regard the
disease which he is said to have cured, as a paralysis of the limbs, rather than a soft-
ness of the bones.
Abbon, the monk, who lived in the ninth century, relates an extraordinary instance
where a very large man was reduced by it to the diminutive size of a child. Abulsedda
asserts that the body of the prophet Gatteb was without bones, so that his limbs could be
f »lded 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 soft and flexible, and without solid bones. (I)e Morbis
Internis. Kara Quaedam, No. 7, 4to. Paris, 16U9).
John Baptist Morgagni, in his " Seats and Causes of Disease," mentions several
authors, as Fernelius (1500-1558), Kuellius Jacobus Hollerius, Gulielmus Fabricius
UUdanus (1560-1634), Peter Borellus (1620-1678), Thomas Bartholin (1616-1680),
and Daniel Protenius, who had recorded observations apparently referring to this dis-
ease, but it is difficult to decide the nature of the softening, whether the result of
syphilis, cancer or rickets.
The first i^ncqui vocal observation which Morgagni quotes, is that of Gabriel! , who,
in 1688, in dissecting the bones of a matron, found them universally softened and flexi-
ble, the Jong bones being converted into a soft, reddish flesh, apparently without
tenacious fibres. Morgagni also quotes a similar qbservation of Courtialis, on another
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752 Mollities Ossium,
woman, whose bones could be bent, and resembled fungous and soft flesh, impregnated
with a bloody serum.
One of the earliest and most distinct accounts of the disease was given by Baudi, in
1665, who, in 1650, observed for ten years the progress of the disease in the case of t
citizen of Sedan.
Saviard, in 1691, and Lambert, in 1700, published cases.
Morgagni describes briefly a case observed and related to him by Valsalva, about tlie
latter part of the seventeenth century, although it was not published until 1760. This
case of Valsalva, was that of a woman who had completed her fiftieth year, and wm
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 aetnil
cautery, if it had not ceased spontaneously. In a little time after, the woman begaa to
be troubled with pain in her bones ; with which, having long been afflicted, she begiB,
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 time.
To this symptom another was afterwards added, that the bones of the lower limbs begin
to be bent, as if they were made of wax, and to be in pain, even on the slightest motion.
At length, in examining her body after death, the ossa innominata, the ossa femoris tod
tibia, and those bones that make up the arch of the cranium, were found to be flexibie.
just as if they were made up of pretty thick paper ; on their surface they were spon^,
and at the meditullium, in some places, carious. Morgagni afterwards saw these bones,
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 interesting observation that all of them were of a vm
b.id color and small, because they could not be cleaned internally, giving an unotuosity
t) the fingers in handling them.
This observation, indicating that the bones had undergone fatty degeneratioD. hts
been confirmed, as we shall see hereafter, by more recent and extensive observadoos.
This change was similar to that described by John Hunter, in the case of Moliitia
Oisium reported by Mr. Goodwin. (" The component parts of the bone were totalljr
altered, the structure being very different from other bones, and wholly composed of a
new substance, resembling a species of fatty tumor, and giving the appearance of a
spongy bone deprived of its earth, and soaked in fats." )
Petit, Manchart, Platner, Haller and others, have recorded observations which might
be referred to this disease ; and Boerhaave mentions an instance in which a mao who
lived with his bones in a state of softness, and not without the most severe pains, had
his bones after death similar to a pultaceous substance, like that which is prepared froiB
bones in Papin's digester.
The disease appeans to be sometimes confined to a single bone. Thus, in a c»e
reported to Mr, Solly by Mr. Hodgson, of Birmingham, the patient was aboat thirtj
years of age. the leg much bent, the integuments much thickened and ulcerated, caosiDg
so much annoyance and injury to the general health, that it was thought right to ampa-
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 cancellated
structure was filled with a soft, red material, resembling that which is found in fotil
bones. ^Ir. Solly refers to another case, in which it was supposed that the same dis-
oas3 existed in the femur, and not in any other bone, of a man about fifty years of age.
It had been in this state for many years, and after it became so, it had once been ^ii^
tured with very little violence. The bone was very much thickened and bent ; it did
not appear to be a case of necrosis ; an instrument was constructed for this patient, by
which the weight of that side was transferred to the leg ftx)m the pelvis, so as to pro-
te3t the femur from pressure, and with this contrivance, the man was able to walk aad
follow his employment. Med. Chir. Trans., vol. ix, p. 453.
Mollities Cssium is not confined to the human species.. I have aeea a well maiked
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Mollities Ossium, 753
case iu a monkey iu New Orleans ; all the extremities were arfected, the bones being
soiYened, fractured and distorted in various directions. Mr. Spooner, Professor of
Anatomy in the Vetinary College, informed Mr. Solly that he had observed the dis-
ease iu some hounds l^longing to Lord Middleton. 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 morbid
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 Bcvan, in the " Transactions of the Royal Philo-
.sophieal 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.*
*The SSeats aud Causes of Diseases Investigated by Anatomy ; in five Books, &c., by John
Baptist Morgagni, Chief Professor and President of the University of Padua. Translated by
BeDJamin Alexander, M. D., vol. iii, pp. 344-347.
Traits deg Mala^dies des Os. Par M. Du Vernez. Paris, 1751. Tome 1. Preface V., p.
136.
Sachsius, In Schol. and Obs. 37. A. 1, Dec. 1 Eph., N. C.
Avicenna, Vid. c. 2 ; Fen. 2, 1,3. Can. Avicen.
Fernelius, De Addit. rer. Caus., 1, 2, c. 0.
Jacobus HoUerius, In adjectis, 1, 1, de Morb. Int. Raris quibusd, n. 7.
Hildanus, Cent. 1, Obs. Chir. 45, and Cent, 6, Obs. 74.
Borellus In fine Rpilog. additi, ad. Cent. 4, Hist, and Obs. Med. Phys.
Bartholin, Cent. 6, Hist. Anat., 40.
Prottenius, 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.
Gourtialis, Hist, de TAcad. R. des Sc. Ann. 1700, Obs. 2.
Saviard, Nouveau Recueil, &c. Obs. 62, p. 274, 1702.
Valsalva — Morgagni. Epist., Iviii, 4.
S. Bevan, Phil. Tr., vol. xlii, p. 488.
Petit, Mem. de la m^me Acad., A. 1722.
Mauchart, Eph. N. C, Cent. 9. Obs. 30.
Nebelius, Act. N. C, Tom. 1, Obs. 15, and Tom. 5, Ob.*?. 111.
Camerarius, Tom. Cod. 1, Obs. 53.
Boerbaare, Prielect. ad. Inst., J 401.
Bromfield, Histoire de la Maladie Singulia', par M. MurunU. Fills, 17r)2.
Mem. de I'Acad., 1753. Ambrose Hosty.
Phil. Trans., 1753, vol. xlviii, p. 26.
John Pringle. Phil. Trans., 1853, vol. xlviii, p. 2U7.
Percival Pott, Phil. Trans., 1740, vol. xli. No. 459, p. UIU.
Bromfield, Chirurgical Observations and Cases, vol. ii.
Ludwig Haller, Diss. Med. Pract., Tom. vi, p. 327. Lips. 1757.
H. Thompson, Med. Obs. and Inquiries, vol. v. p. 259.
Acrel, Dissertatio, &c. Upsalse, 1785.
Renard, RamolUssement Remarkable, &c. Mayence, 1804.
Howship, Med. Chirurg. Trans. Edinb., vol. ii, p. 136.
Fries, Dissert, de Emollttioni, Ossium. Argento, 1775.
Boyear, Trait6 des Maladies Chir., t. 3, p. 607, kc. Paris, 1814.
Richerand« Nosoge. Chir., t. 3, p. 142.
Gooch's Chirurgical Works, vol. ii, pp. 393-399. Ed., 1792.
James Wilson, Lectures on the Structure and Physiology of the Parts comprising the Ske-
leton^ and on the Diseases of the Bones and Joints, p. 252, kc. London, 1820.
M. Robertz, Archives Gen^rales de M^decine, 1834, p. 435.
Medico-Chirurgical Review, 183G, p. 254.
Gentleman's Magazine, August, 1748.
M. Saillant, Histoire de la Socicl6 Royal de Medecine. Annee 178U, p. 98.
Thomas Blizard Curling, Medico-Chirurgical Transactions, vol. xx, 1836, pp. 336-373.
Samuel Solly, Medico-Chirurgical Transactions, vol. ix, 2d Series, 1844, pp. 435-461.
J. W. Tenney, American Journal of the Medical Sciences, vol. x\\% 1839, \i\}. .'l06-509^
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764 Mollities Ossium,
Thomas K. Cliambers, London I^ancet, March 25, 1854. Rauking's Abstract, 185-1, vol. i, p
114.
Charles Bell, London Lancet, March 15, 1834, p. 918.
Henry Bence Jones, Philosophical Trans., 1848, p. 55. •
William Macint.vre, Med. Chir. Trans., vol. xxiiii.
Dalrymple, Dublin Quarterly Journal, 1846, p. 85 ; Path. Soc. Trans., 184G-T.
Simon's Animal Chemistry, Am. Ed., p. 511 ; p. COl.
.Marchnnd, Simon's Animal Chemistry, p. 511.
Bostock, Pitisch, Bogner, Lehmann, Von Bibra, Marchaud, Reese, Solly, Bamiibutltani, Bar-
) uel, Buisson, on the Chemical Composition of the Bones in Mollities Ossium. Simon's AoioMil
Chemistry, p. GOl ; Becquerel and Rodier's Pathological Chemistry, p. 507 ; RokiUDskj's
Pathological Anntomy, vol. iii. p. 144; Lchmann's Physiological Chemistry; Medico-Chiror-
gical Trans., vol. 21 ; Gay's Hospital Reports, No. viii ; April, 1839, No. 9 ; Medico-Chimrgical
Rfview. July 1, 1839, pp. 246-247, Am. Ed.; Medico-Chirurgical Trans., vol. zxvii, p. 43:>:
The New York Medical Record, March 15, 1869, vol. iv, No. 74, p. 25.
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CHAPTER XX.
CASES ILLUSTRATING THE NATURE, PROGRESS. TERMINATION, AND ANATOMICAL LESIONS OF
MOLLITIES OSSIUM.
Case of Miss Bozel, observed by the author. The origin of the disease referred to constitu-
tional derangements rather than to a strictlj local disease of the bones. Gases reported
by Sylvanus Bevan, Ambrose Ilosty, John Pringle, J. W. Tenney, Thomas R. Chambers,
Samuel Solly, and others.
My attention was directed to this singular disease by the following case : Miss Ranej
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 yet been done, the main features of the disease. Such
an inductive investigation of thb 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 parentage, 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 afflict^ 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 Shelbyville,
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 Illinois, 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. Tlie island was overflowed the year after 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 grounds, continued damp
during a considerable portion of the spring and summer ; the freshet occurred in the
month of May. Shortly after her removal to this low, malarious situation. Miss Dru-
cilla, who up to this time was an active, healthy child, was seized with the ague, and
sufferred with it for eighteen months.
The softening of the bones commenced just afler 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 arm began to lose its bone, and has apparently lost all
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the eaithj matter of the humerus for the «pace of some five inches. The raoiher
states that this loss of the substauee 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. Ttie
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 foare-
arm and hand of the left side present a natural appearance. The right humerus of
right arm feels rough and enlarged, and is painful to the touch. Ulna of right am
apparently of natural length, but anterior portion projecting outwards, and th« hand
thrown inwards. Radius apparently destroyed, or converted into soft flexible maierbl
throughout a considerable portion of its extent.
Right thigh and leg much less aifected than the left. Knee-joint of right \e^ muich
swollen, with distinct veins ; ankle-joint much deformed the fibula projecting bejood
the ankle, and the lower portion of the tibia converted into soil, flexible materia],
shortened and diminished in size. The marks of several ulcers are visible upon th<-
right 1^. .
Left leg — tibia and fibula divided or absorbed in the region of the upper third, a»i
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 moUicr
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, tW
fracture was occasioned by the action of the muscles of the thigh, after the weakening
and absorption of a large portion of the shaft of the bone. The correctness of the ptat«-
ment is sustained by the existence of callus around the extremities of the bones.
i. eft foot and ankle in place and of good shape.
Patient suffers with continued pain in left side of the head ; sight in left eye mndi
impaired, and eyeballs very prominent, as if the orbits had been thickened and the soft
parts pushed forward. At times the pain in the head i.** said to be quite intense.
Complexion sallow, with leaden, jaundiced hue, and anaemic, the complexion of this
patient resembles in all respects that of one who has been long subjected to the actko
of the malarial poi.son, and whose blood, liver, and spleen havel>een thoroughly affiert^
by its action.
The effect of the mollities ossium has been to arrest the growth of the patient, f<ir
although eighteen years of age, she is only three feet nine inches in length, and weighs
not more than a child of four years of age. In exhibiting the case before the medKa^
class, I took Miss Drucilla out of the carriage and carried her up stains 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 cheerfullT
and although confined entirely to the bed, and unable to do anything for herself, ia t
great comfort to her mother, and a general favorite with all ; and her mother told mt
that in their groat poverty and distress, and in the numerous straits which hefeil then,
she was her main stay for advice.
The softening of the bones does not appear to have had any connection with sjpiiiEi^
as the patient was perfectly healthy up to the time of the appearance of the malana]
fever, at the age of five, and her younger sister, born after the family left the unheal-
thy island on the Ohio river, is a fine healthy girl of ten years of age, with full wdl
formed limbs, and rosy, healthy countenance.
The ill-health of the father appears to be due to bad diet and the irregular habits anti
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 wkicfa
would more especially supply the elements for the bones.
2d. The improvement of the general condition by nutritious diet and the action «4
alteratives.
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3d. The regulation of the bowels, which had been habitually constipated oi^
costive.
4th. The restoration, or rather the esUblishment 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 liuidounce; iodide of potassium,
two drachms; syrup or gmger, eight fluidounces — mix. Teaspoonful in wineglass-
ful of water three times a day) ; and by the regulation of the bowels and uterus by the
pills 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 woman"), the general health improved, and the head symptoms
were alleviated.
In 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 after a brief
illness, on the 1st of February, 1869. 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 destroys the blood corpus-
cles more rapidly than any other febrile poison, but nho diminishes the phosphates of the
blood. ( Observations on some of tJie Physical^ Physiologisal^ and Fatliological Phe-
notnena of Malarial Fever , Transactions of the American Medical Association ^ 1859).
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 ( transactions American Medical Asso-
ciation, 1859): 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 syphilis.
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 either increased or remains 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 di£fcrent 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 alkalies, soda and potassa, or lime ; after the continuance of those
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758 Mollities Ossium.
changes, which result ia the increased formation of phosphoric acid in the nerrons tod
muscular structures, the insoluble phosphates of the structures appear to be diasolfed,
and hence the accumulation of the salts of lime in the urine. On the other hand, the
chloride of sodium, a highly soluble salt, increases in the earlier stages, and diminishfii
in the urine during the intermission or remission.
The pale, sallow, aaBmic hue of this patient, together with the rapid, feeble pnbe, and
periodic febrile excitement, indicated profound alterations in the composition of Ae
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 derange-
ment of the blood and nutritiTe acts bj the presence and continued action of a specife
poison, especially as this disease is known to originate most frequently amongst the ill-
conditioned and ill-fed inhabitants of large mi^nu&cturing towns, and in females whee
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 coosdtn-
tional derano^ements. 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 de^ang^
ment, fever, wasting, and abnormal condition of the urinary secretion preceding aod
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 phosphate
and carbonates of lime and magnesia, which might be regarded as comparatively deyoiil
of vitality, bone presents a complicated structure into which the most highly vitaliied
and most complex tissues, as vessels and nerves, enter. The numerous cavities wd
canals which penetrate the fresh bones are not empty, but contain a true natritiTe
plasma, complex in its constitution, derived primarily from the blood circulating thro;^l»
the osseous tissue, and obtaining its physical and chemical elements directly from thai
fluid, and in common with all the other fluids of the body, subject to physical Uws of
endosmosis and absorption, and to chemical changes. The investigations of Virdiow
Donders, and Hope, have even rendered it probable that the bone-corpuscles and 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 oeHalar
spaces are derived. While an excess of earthy salts in the blood, conjoined withaa
increased alkalinity, may tond to the deposition of phosphates, on the other haodafl
increase of acid in the blood, whether received from the alimentary canal by absorpiioD.
or from the mal-assimilation of the elements of the nutritive fluids, or from some arrest
or perversion in the process of secretion, would tend to the solution of the mina*
constituents of the osseous system.
In the following case, reported by Sylvanus Bevan,* thesoflening of the bonM w?
preceded and accompanied with a frequent and copious discharge of urine, gradual wast
ing of the body, hectic fever, quick, feeble pulse, thirst, pains in the shoulders anl
limbs, and loss of appetite. After the continuance of these symptoms during the period
of two years, accompanied with great emaciation, the patient was attacked with in inter
mittent, which appeared to alter the character and quantity of the urinary dischaip
and, after the relief of the intermittent fever, the appetite returned, the breathia?
became freer, and the hectic fever was much lessened ; but the pains in the limbs con-
tinued, and, aft«r being confined to her bed for several months on account of the weak
ness and pains in her limbs, the bones of the legs became soft and pliable.
Case 768: The wife of one B. S., in ihe year 1738, was taken with a diabetes, "^'^^^^^
usual symptoms, viz : a frequent copious discUarge of urine, a gradual wasting of the bodj,
• An extraordinary *ca8o of tlie Bones of a womt'tt IwcnmlnR Boft and flexible. By Mr. Syltanu* Beraa, T. B. ^
PUilos. Trans., vol. xlii, 1743. No. 470, p. 48**.
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a hectic fever, with a quick, low pulse, thirst, great pains ia ber shoulders, back and limbs,
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, but the pains in her limbs still continued. She recovered her appetite, breathed
freely, and her hectic much lessened, though she had some appearance of it at times.
About eighteen months since, she bad such a weakness and pains in her limbs, that it con-
fined ber 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 bones.
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 inch. 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 size. 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
UmiDse of the bones soft, and become membranous, about the thickness of the peritoneum,
containing, instead of a bony substance, a fluid of the consistence of honey, when it is thick,
uf 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
9pongy 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 Qaeriot, of Paris, reported by Ambrose
Hosty, the disease occurred 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
touched her skin. The attendant physician supposed that the phosphate of lime was
discharged both by the skin and kidneys, and in the sputa.
Caib 769:* Anne Elixabeth 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, arter 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
CpODths after, she fell on ber left side, which gave her great pain in her leg, thigh, and hip of
that side, and made them swell ; but there was neither fracture nor dislocation. Her pains,
after sometime, 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
eve? ber 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 were so weak that she
could not stand upon her feet.
\n about six months after her last lying-in her pains returned worse than before ; and about
\be aap;\e time an abundance of white chalky sediment appeared in her urine, and the fore-
f nger oi her right h^nd was observed to be distorted towards the little finger, which was
t^e first appearance of t\je dissolution that ensued. Soon after, the lower extremities began
* The Case of Anne EllzftbetU Qucrlot, of Paris, whose Bones dUtorted and softened. By Ambrose Ilosty, M. D« ,
;kf Parts. PW'osophlcal Transacttoni*, 1753, vol. xlvlil, p. 2tt ; AbridRmcnt of Phil. Tmns., vol. x, pp :n3-;4H;.
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to taru upwards gradually, audaltuost in a parallel line with the body, and conUnaing till, in
nine months, her lower limbs were turned upwards. All the bones were affected, efpeclally
the thorax, which had lost its natural form and capacity, and she was altogether migermblj
distorted.
This miserable state was attended with exquisite pains, and according to the seat of then
the patient used to say, " Now, such a part works." Sometimes they abated, and then she
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 dui;ing her BaSeringt. li
WAS quite cretaceous, and, reduced into a fine powder, fermented gently with acids. Sht
could bear no covering but a few napkins, both from inward heat, and to avoid loading her
breast. Notwithstanding her preternatural posture, the evacuations by stool and urioe wer«
regularly and easily performed. Her flesh seemed dead and cedematous, the skin rough and
scaly, so that a modification was often apprehended. She had a cough, a laborious respira-
tion, and sometimes a spitting of blood, from the coarctation of her breast, all its bones ply*
ing inwardly. She was capable of no other motion than turning her head on both sides,
stirring her left arm in the shoulder-joint 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 rery 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 coDStast
dropping: violent pains in her head — in short, a great weakness in all the org^ans, which
showed how much the head was affected.
The distortion of her limbs went so fast in August and September, that almost every day
something new was observed ; especially the left foot, during that time, came down gradn-
ally near eighteen inches from under her ear, where it lay before. It was also obserfied, io
August, that her neck grew visibly smaller, the thora.x much narrower. And then the nap-
kins in which she spit grew black in washing, and stained as from the mercurial ointment:
though this cause was not suspected, as it could not be learned that she had ever used any
mercury. lu a month after he observed the same thing on all the linen that touched b^
skiu. 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 lineo
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 belieTe 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 linen.
Dr. Hosty was also led to think that this sediment was the earthy matter that gives the bones
their solidity and hardness, which had been dissolved by the "same vitiated quality of the
fluids, and evacuated by the emunctories already mentioned.
After great sufferintrs she died the 9th of November. Her body was opened in the presents
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 basis. 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 peroni
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 bead of the
humerus was much diminished and flattened, its middle part very small, pliable, softened ia
all points, yet in some friable.
The cubit and radius suffered the same alterations with the humerus. By stretching all
her limbs, they laid them straight ; but they soon after returned to their former cqnre. The
phalanges of the fingers were not so much softened, but w^re easily cut and bent like whale-
bone. The femur was rather a fleshy body than a bone ;. its cavity was filled with a reddiah
suet, instead of marrow, which accumulated in different points, and bulged on\ the fleshy
stiles. The capacity of the pelvis was much diminished; the bones that composed it wen
softened, thickened, and contracted. The spine kept its natural form ; the vertebrsB soft and
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, were
doubled over each other. The clavicles seemed almost cartilaginous. The shoulder-blades
were much thicker than natural, less broad, and entirely disfigured. The two protnberantes
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 tnet
at all of a diploe. Their substance abounded with an extremely diluted serum, easily sqneesed
out by a gentle pressure of the fingers. The sutures almost obUteriited ; the bones of tto
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MoUities Ossium. 761
basil and the face shared 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
?he had fVom her infancy, beginning in some part of it. When young, 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 viscera : but their si'.e diminished by the compres-
sion, and a universal cachexy.
There could be no cause aBsfigned of this woman's disorder, as she gave no sign**
plain enough to prove cither a scurvy, pox, or klng'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 dis-
orders common to their age ; one four years old, died of the measles.
In the following case of Mary Hays, reported by John Pringle, the patient suffered
first with chlorosis (green sickness) and suppression of the menst*s, and was seized with
pain universally attended with feverish symptoms.
Case 7Y0: Mary Hays,* of Sloke-Holy-Cross, near Norwich, gave the following account,
June 2l8t, 1752 : That she was born Januarj- llth, 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 greensickness,
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 chiefly confined to her thighs and legs, but not
increased by external pressure.
In September, 1749, she broke her leg 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 ankle in a few months, as did tliose 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 scurvy, 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 last eighteen months may be attributed to a chalybeate
medicine, though medicines 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 she had found little alteration in her complaints in general,
though her appetite and digestion were rather better, but that the difficulty of breathing,
which she had long labored under, gradually increased, and the thorax appeared so much
straitened as necessarily impeded the expansion of the lungs.
Her spine became much distorted, any motion of the vertebrae of her loins gave extreme
pain, and her thighs and legs were become entirely useless, which wholly confined her to bed
in a sitting posture; and the bones she rested on, having lost their solidity,' were much
spread. Also the ends of her finger and thumbs, by frequent endeavors to lif^t herself up for
ease^ became very broad and flat. Then she measured but 4 feet, though before' tfi is disease
came on her she was about 5i feet high, and well shaped. . .,
This is 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 to the
examination of her body, etc., after death.
From that time to her death, which happened July 0th, 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 four months, a tendency in her
legs to mortify, which had lonr/ been anasarcotUj and excoriated almost nil over : she retaining
her senses perfectly to the last moment of her life, and dying without showing the least signs
of the agonies of death.
♦ A Bemarkable Cabe of Fragillfy, Flexibility, and Di««olution of the Bones. By Jtba Priugle, Jf. J.I , V. R. 84
Fhiloe. Trans., 175.3, vol, xlviil, p. 297; Abridgment of Philos. Tran? , vol. j^^ pp. 400-408,
9H
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MoUities Ossium,
Two davs after death, Uer limbs being first well stretched out, she was exactlj measared,
and found wanting of her natural stature more than 2 feet and 2 inches. Then the thorax
rtnd abdomen were opened, the sternum being entirely removed, with part of the ribs, in order
10 gain at once a full view of these cavities, and discover how the viscera there cooUioed had
obstructed each other in their respective functions. The heart and lungs were sonnd boi
flaccid, and much confined in their motion, to which the enormous size of the liver con-
tributed in some measure, extending quite across the abdomen, and bearing hard agaiost ibf
diaphragm. The lungs did not adhere to the pleura, nor was the liver scirrhous, but faaltr
only in bulk. The mesentery was sound, except only one large scirrhous gland on ii. Tb«
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 lime, the
minister waiting at the church for interment, and the relatives becoming iropatieDt^ bat th«
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
the head, thorax, spine, and pelvis nearly to the same degree of softness. Those of the lowtr
extremities much more dissolved than those of the upper, or of any other part. They wert
cut quite through their whole length without turning the edge of the knife, and much le»
resistance was found than firm muscular flesh would have made, being changed into a kind cf
parenchymatous substance, like the soft, dark colored liver, only meeting here and there with
bony lamina?, thin as an egg-shell.
Those bones were most dissolved which in their natural state were moat 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, iui4
looks as if the wonderful change they had undergone might bo caused by the marrov
having acquired a dissolving quality, for it was evident that the dissolution began withu
side, from the bony laminae remaining here and there on the outside, and nowheie d*.
and the pain not being increased at first by external pressure.
The periosteum was thicker than ordinary — the cartilages rather thinner — feui
nowhere in a state of dissolution like the bones. The day after this examination sow
of the whole substance of the leg and thigh bones, that was entirely dissolved into i
kind of pulp, was sent to an ingenious chemist, and by the experiments which he madt
he said he could discover neither acid nor alkali prevailing in it.
The disease in the following case, reported by Dr. J. W. Tenney; was preceded »d
accompanied by general weakness, emaciation, and copious discharges of urine, depoatis:
an abundant light colored sediment, and by suppression of the menses. The patkst
referred the origin of the disorder to exposure to a cold atmosphere and standing ii
snow in thin shoes after fatigue and proftise perspiration,
Case T71 : Mrs. D. W., »t. 43, was the mother of five children. Her health had been bui
indifferent for the last fifteen months. She complained of general weakness, and especullj
in her lower limbs, emaciation, very copious discharges of urine depositing an abondaot l^i
colored sediment. She had experienced some colic pains, and in walking her gait was rollicc
bringing the centre of the gravity at each step directly over the limb on which the wcigbt of
the body was thrown.
Her menstrual periods had ceased for about eighteen months. The origin of her disorder
she had always supposed to have been exposure to a cold atmosphere and standing in txtovia
thin shoes after fatigiie and profuse perspiration. After that period hitting the foot, in walk-
log, against the slightest itopediment, was sufficient to throw her down.
In November last, being troubled with neuralgic pains about the face and jaw, aadisp-
pos^ng they might proceed from a decayed tooth in the under jaw, she requested that it nigfci
be extracted, but on attempting to raisa the tooth with the forceps it was found necetsaiyts
desist and use rollers, as the bone seemed to bend though hut slight force was used. A f*^
days after it was found so difficult to extract the last tooth on the right side from the waalof
firmness in the bone and tension in the muscles that it was left in the socket. From this tine
the muscular strength of the patient fa^ed fast, though her appetite remained tolerably goe^
and her stomach generally retained apd digested her food, though it occasionally rejected til
nourishment for a day or two. She became at length unable to support her weight or raiK
herself from the bed to which she was soon confined.
In the latter part of March her thigh-^bone was found flexed at about a right angle near t:^
centre. The patient was not sensible of it till it was accidentally discovered and suppoe^^
to be broken ; but? ppon bringing it ^pto \tg i?.Qtu,ral poJllUQR; 1Q. crepitation ^^ pen^Tti
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MolUties Ossium. 763
and the extreme emaciation of the limb enabled as to satisfy ourselves that instead of being
broken the limb was bent.
The outer limbs on examination, also, were found in the same condition, especially the long
bones, which bai so far lost their firmness as to be perfectly flexed from their position, which
they would receive 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
nnasually rapid flow of ideas; voice strong, pain not severe.
Aut4>p9y 26 hourt after 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, prodncing 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 bone 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 open 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 as 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 being
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
same condition. The right humerus and femur seemed equally flexible, and had not retained
their shape ; the boues 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 vertebrae could be
cut into or their processes cut off with more facility than if they had 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 muscles
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 tsily cut with the finger nails, especially
the right side. The uterus was in the same state, though not to the same degree.
The nerves retained their natural form, haraness 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.*
Ifc is worthy of note, that in the preceding case the muscles were altered as well as
the bones ; and in this soften in^j, and perhaps fatty degeneration of the muscles, We
find additional and conclusive proof that the origin of the disease cannot be referred
alone to the local changes in the bones.
If the disease was dependent upon an inflammation and alteration of the periosteum,
we would not find this membrane so uniformly healthy and unaltered.
That the blood and blood-vessels are 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. Ohambera, M. D.,
is interesting, as affording a portrait, at an early stage of the disease, when it has rarely
* Case of Mollitiefl Oulum. By .7. W. Tcnney, M. T>., of Wobater, Mats. American Joaraal of the Madlcal 9d-
I. Yol. XX vi, 1S39, pp. im-^fO^.
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764 Moltities Omum.
been a subject for observation, and as indicating that the defeneration of the bones wu
preceded by that of the muscles^ and that the degeneration of the two tissaes was
dependent upon the same crasis.
It is also worthy of note, that the degeneration wa^ least advanced in the external
circumference of the bone, and perfect fat- vesicles were found in both bone and musde.
Case 772 : * The case was that of a youDg woman, twenty-six years of age, admitted into
St. Mary's Hospital, in March, 1853. She had never been able to follow any calling, on
account of tveak health. The principal features of the case, in the early stage, coniistedii
defective muscular power, the flesh of the body feeling exceedingly soft and flabby, the calf
hanging down flaccid and baggy. DuriDg her residence at St. Mary's Hospital the bones of
the back and limbs were examined several times, without any deviation from the natural siaie
being discovered.
Spontaneous fracture, first of one femur and afterwards of the other, occurred at St. Georgt*
Hospital, and subsequently very marked changes in the osseous structures took place. Thai,
in April, 1853, the right arm became painful to the touch, and paralytic ; in May, the same
misfortune happened to the left upper extremity ; in June, the pelvic arch gave way ; in Jalr
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 distonioi
of the lower parts of the trunk was so }?reat that the faeces could not be expelled. She ditd
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 the color of
muscle, and presented to the knife scarcely more resistance than brain, its shape beia:
retained by the aid of the tough periosteum.
The microscope exhibited the bone as consisting of large, fat vesicles, some containiai^a
white, others a reddish oil. The parts next the periosteum, which felt gritty, preseoUl
when examined under a quarter-inch glass, some islands of opaque bone, the bone corpnidt-
being indistinct, and the %analiculi not to be discovered.
The addition of hydrochloric acid caused a slight disengagement of gas.
The muscular fibre i)resentcd everywhere the characteristic degeneration.
In the preceding case, the muncular .system, as well as the i»shcous, had underjrone
fatty degeneration.
Mr. Samuel Solly has described two interesting cases of Mollitjes 0*<ium. wbifb
agree in their general symptoms with those previously record ^d.f
Case 773 : The first case described by Mr. Solly, was that of a young woman, aged tweau-
nine, who, having enjoyed good health in early life, began to decline at nineteen, aftfran
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 caas?
never united again. The spine began to yield about the age of twenty-four or twenty-five
the patient began to stoop; and could not support herself in the upright position for aaj
length of time. At this time she had paralysis of the ri^lil hand, which took place saddea-'*^
and lasted about fourteen days.
A visit to Gravesend was proposed by her friends, but in crossing King William Street, ibe
fell down and struck her knee against the curbstone. For this accident she was admitted as
an out patient at the Western Dispensary, and continued so about six months. She derivei
benefit froiu bathing the knee with salt water, and the limb was restored suflScientiy to eaabif
her to walk. After this she kept a day school, but became nervous and desponding. Her
friends remarked great difference in her manner, her disposition seemed changed from a=
open and amiable temper, to one of restlessness and suspicion. They became fe^ul that fbc
was going out of her mind. She still, however, continued to conduct her school with kf
usual attention and care.
- In May, 1839, being exposed to damp, she had an attack of acute rheumatism, when ^^
was placed under the care of Mr. Dutton, of York Street, Bryanstone Square.
She was confined to her bed for six weeks, but during the course of her disease she com-
plained very much of pain over the head, but particularly at the posterior part Sheva*
occasionally violently delirious. At the approach of convalescence, mania set in, and diriw
its existence she attempted to commit suicide.
* Lancet, March 2.% 18o4. Ranking^ Abetract, 1864, vol. 1, p. IH.
t Medico-Chirurgical Transactions, vol. xxvii ; 2d8eiaes, vol. ix, 1344, pp. 441-455. Medira*
Chirurgical Review, .\pril, 1845, Am. ed., pp» 448r450.
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MoUities Ossium, 765
to August, 1839, she was removed to St. Lake's Hospital. At this period ber general
health was better than it bad 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
sboolders, 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
ibe 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 hauuches, and, though she frequently screamed violently as in pain, she bad no
tit, 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, but 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 Infirmary, from whence she was sent to Hanwell on the
lUh 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 ber 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
suffe'r from spasm of the muscles, as many of these cases do, and the urine, during the whole
time she was at IJanwell, was clear and natural. Her appetite was good, and all the function*
duly performed, with the exception of the catamenia. 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.
Po9t-mortem examination of the boihf^ Hanwell, October 29tb. Height, measured after death,
four feet two inches, great emaciation. Head large in proportion to the size of the body ;
chest very much deformed, pinched up, aud 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 humerus swollen, sbatt 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 darkgrumous matter,
varying 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 diploe 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 2Ibs. 5} ozs.; arachnoid membrane milky and
slightly thickened. The brain as well as the viscera ot the chest and abdomen were perfectly
healthy.
Chemical analysis of the bone by Dr. Leeson: —
Medulla.
Animal matter ..» 24.Tfi
Phosphate and carbonate of lime 1.83
Water 73.30
lOO.ou
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766 Mollities Ossiim.
Bone.
Animal matter 18.T5
Phosphate and carbonate of lime 29.17
Water 5108
100.00
In the preceding case the parents were healthy, hoth 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 soms
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 an attack
of scarlet fever (soon after the age of 19), and that whilst in the earliest and most
active stages, the urine contained a whitish sediment, in thelattsr stages, this excretion
was clear.
In the second case reported by Mr. Solly, the urine was found on examination lo
contain a large quantity of phosphate of lime, between three and four times the qnantitj
of healthy urine. The examination of the bones after death showed an exce^ of fkttr
matter, deficiency of the phosphates, and disproportion of the medullary cells to the
substance of the bone. The left 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 fonnd 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, at the time of her marriage, was about five
feet five inches and a half; her general figure slight. She was born in Dorsetshire, bat wu
in service for fourteen years in London, as a housemaid, previous to her marriage. She wt?
always able to do her work with ease. Her general health has been good, though, the stj^
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 marriage
from the white discharge. She considers that her health has been failing her for about 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
any other circumstance relating to her general health, until June, 1841, when she had rheu-
matic pains in her limbs, but never any true rheumatic fever, nor any swelling of the joiaU.
From this time she constantly suffered l^rom what she considered rheumatic pains, and wassv
feeble on her feet that in February, 1842, she had a fall — which, in fact, she says she had bees
expecting every day — when her left thigh was much bruised ; but she did not feel anythiBg
give way ; but in consequence of the bruises she was confined to her room. After this, ihe
occasionally suffered a great deal of pain in her limbs, which, she says, seemed to be in her
bones; and she was not able to walk unless on her left leg, and with assistance, dragging 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 suddenlj felt
the most excruciating pain, just as if her thigh were being brokeu in a thousand pieces; and
her husband told me that he felt her thighs give away, and that they were suddenly drtvn
np ; and from this time she has been entirely confined to her bed. She says that the muscles
of her arms were now painful and swollen, but by rubbing them with oils she relieved then.
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 lateral
curvature of the spine; in the dorsal region the convexity is to the right, the concavity totbe
left. In the centre of the lumbar region the spine curves forwards : the inferior vertebrt«.
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 rib?
project backwards to their anatomical angles ; from that point they are bent direcUy forwards,
forming an acute angle, which projects posteriorly, looking at first sight like the spinous pro-
cesses of the vertebrae in a very thin person ; the side of the thorax from the angles being
flattened or slightly concave, and the lateral diameter of the chest much diminished In eonfe-
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Mollities Ossium. 767
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 clavicles 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 ie 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 come 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
I'ith 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 maxillae 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 puffy, and its natural
appearance changed.
The thorax is much narrower. On the left side there is a depression about the circum-
ference 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
distinctly 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 the right thigh-bone has become more flexible,
HS previous to her removal to the hospital the foot was drawn completely over the head — the
same 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,
na has occurred in similar cases, but I learn that she- does not.
April 15th. 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 stay in the hospital that X 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
tinaes 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
unnatural. Dr. Bees kindly analyzed a portion of it, but be informs me he detected nothing
abnormal. The immediate cause of her death appears to have been asphyxia. Mr. B. Travers
saw her in her last moments, and he says the laboring condition of the respiratory organs
was very painful to witness. She took a little wine about twenty minutes past six, when her
sister noticed some difificuliy of breathing, and the patient stated she thought she was sinking :
$he then became purple, and struggled some little time before she expired.
21 St. Poit^mortem examination fifteen hours after death. — Thermometer 60° Fahr. 10 a. m.
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 beeq
reported during life, it was found that the radius and ulna on the right side had given wav
above the middle, and that the metacarpal bones ar.d phalanges of the same hand were all
flexible. On the left side a]l the bones of the upper extremity appeared in their natural con*
dition inasmuch as their form was not altered ; but in testing ihoir strength they yielded to a
very slight force, and they might be bent in almost any direction, the laminated shell break-
ing off short. In the lower extremities the tibia and fibula of (he left side yielded about two
inches from the knee-joint; below this point they were firm. Those on the right side resisted
pressure, and though they were not so heavy or hard as in a henlihy subject, the disease had
evidently made very little if any progress in them.
Head. — Culvarinm very soft ; dura mater excessively adherent, and, when torn off, innumer^
able vessels poured forth their blood in large quantity. The under surface of the calvarium
was more vascular than I 8cai;cely ^yer remen^ber ^o hoiy^ jje^^ it, ^n^ all the vessels vei[^ fi^U
qC ^Kfk blq<id.
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768 Mollities Ossium,
Some serous effusion within tlie cavity of tlie arachnoid.
The brain was healthy throughout; the hemispherical ganglion was natural in appearance,
neither pale nor dark-colored.
Thorax: — This cavity was so much diminished in its transverse lateral diameter that s
skewer passed from one side to the other, through the intercostal space between the fifth aad
' 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-
ately over the heart. It was in this hollow that the heart could be seen puliating dorieg
life. The serous membranes of the heart and lungs were all healthy.
The right lung was compressed to about one-fourth of its natural size, presenting tbeap-
pearance which it does when hydrothorax is present, for it was excessively congested, and
almost impervious to air ; very much consolidated, but not from inflammatory effosioo. The
left lung was also diminished in size, but to not more than half the extent of the right: it tu
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 ordinary granular appearance
of this fluid.
The thoracic duct was almost empty ; the fluid which it contained consisted of grannki
matter similar to that of the lacteald, and also some chyle-globules, which were of the oiotl
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 found
to consist solely of phosphate of lime.
Female organs healthy.
Section of the bones: — The bones of the skull were not thickened ; they were very vascuUr
and soft, though by no means so much so as in the first case ; they contained, in small qoaa-
tity, the same kind of red substance which was observed in the former case. Their sections
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 formiB^
it were not very red. The head of the bone was more injected than the lower end of it; »i
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 beei«
removed, that the bone retained nearly all its natural firmness.
Sections : The Sternum. — Kxternally this bone did not seem much altered in firmness ; it wM noi
at all altered in form. But internally the disease had advanced rapidly, absorbtion of the
earthy matter h&ving taken place in patches, and the red substance occupied its place. The
appearance it exhibited has been very beaniifuUy represented by Mr. Kearny.
Ribs. — It was evident, from the external form of these bones, that they were extensively
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 tones as in the rest.
Thigh-bones. — The right one alone was divided, and in this the disease had made soch pro-
gress, in the centre of it, that the whole of the osseous matter had been lemoved, andnothinj
but periosteum and membranous matter left; while at the upper part of the lower tbirdoJ
the bone, ihe red matter was abundant, exhibiting various hues, from a deep Modenared,io
a bright scarlet crimson, the osseous Inininated shell remaining, but almost as thin as i
wafer ; then towards the condyles a portion of the bono was nearly of its natural color, onh
yellower and softer, from an abundance of fatty deposit. The extremity of the bone, to ih«
extent of about one-third of an inch, was of a bright red color, contrasting beauUfnlly with
the clear, healthy color of the cariilnge. This redness was evidently the effect of inflammatory
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 Stephens. There was; however,
:i difference of considerable interest, in a pathological point of view, in illustration of the
course of the disease.
The cells which conlair.cd the red matter were distinct throughout the section, bat in son*
of them this matter had become entirely absorbed; a transparent serum occupied its place-
The head of the bone was completely hollow, and filled with serum ; there were two other
smaller cavities at the lower portion of this part of the bone, filled in the same manner.
The red matter I examined carefully under the microscope, with my friend, Mr. Birkettt, of
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 conW be
removed. It mingled readily with water, rendering the fluid turbid. In it I could see cells
with nnclei of two kind?. The first round, and clearly exhibiting a nucleus and nuclwlts;
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Mollities Ossium. 769
thejr were, bowever, few in number, and certainly could not be eaid to compose 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, rarely two, never more. There was a tendency to elongate into the cau-
date cells, but this appearance was very rare. Many other cells of irregular figure and shape,
some with, others without central nuclei, existed.
•' Large cavities existed in the body of the vertebrte, 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
malignant disease, was difficult to determine; in the femur I saw nothing but fat cells and
blood-disks."
*'Tbe red colored matter in the bones,'* says Mr. G. Rainey, of St. Thomas' Hospital, who
alio examined it, *' consists of a multitude ot roundish bodies, almost the size 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 King'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."
Ailer a careful consideration of all the facta, and especially by comparing the appear-
ances after death with the symptoms duriDg life, of this awful disease, Mr. Solly
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
iDvariably attendant on this disease, but more especially in its commencement, and
exhibits itself afler death, by an arterial redness of the parts. The absorbent vessels
are at the same time ud naturally 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,
as 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, grumous matter, which has been so universally found in this disease, and which
was so 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 concluded that the enormous hypertrophy of the bones of the skull, in his
first case, as 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
suddenly, but 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 effect 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 Blizard 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 ihe London Hospital, from the
workhouse at Poplar, February 18th, 1833, in consequence of a fracture of the right femur.
_ • Obwrrations on Some of the Forms of Atrophy of Bone^ By Thcwms BUyard Curling ; lledico-Clilr«rgica\
Traniac- tlons, 1836, vol. xx.pp, 356-37a.
97
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770 MolUties Ossium.
She lind been an inmale there since the I8th of September, 1827, and bad been bed-ridden
for nearly four years, on account of paralysis of the lower extremities. The hip and koM-
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 the knees and thighs. She had been sobjeci
to hysteric fits, also to a slight cough, and ever since her last confinement had been troabM
with incontinence of urine, in which secretion, nothing peculiar hid at any time bees
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 fractarcd.
About a fortnight after her admission, whilst being moved in bed, her right homerns vis
also broken. The arm was placed in splints, butfrom this time she gradually sank, and diedoi
the 19th 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 calct-
reous deposit in the lumbar and iliac glands, and a fistulous communication between tbe
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. AH the articulations were in a healthy ittte.
The periosteum was everywhere normal, except over the trochanters, where it was eotirel;
detached, owing, most probably, to inflammation induced by the pressure to which they had
been so long subjected. The bones of the skull and pelvis might be cut with a strong knife,
but the ribs and vertebrte were only slightly affected, being scarcely less firm than nnil
The femur consisted of a thin shell of bone filled with medulla, its cellular structure bcto^
entirely obliterated, except in the head of the bone and at the trochanters, where there wu t
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 alio con-
sisted of a mere shell of bone, elastic, and yielding under the finger like a thin piece of irort,
the cancelli being removed, and the interior likewise filled with medulla. Although onlji
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 bonei'
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 thigh bone; it did not
yield to pressure, and in order to make a section of it, the use of a saw was necesstrj
whereas, all the bones of the lower extremities could be readily cut with a knife. The walli-
however, of the bones of the superior extremities were preternaturally thin, and their medoi-
lary cavities evidenty enlarged. Upon making section of the different bones, patches of a
light red color were remarked at different parts, and these, upon inspection with a magoifief.
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 thi
medulla of an old subject, and several of the bones having been placed for some months in
water to masoerate, it was converted into adipocire, 9, beautiful specimen of which vM
afforded by a section of the humerus
It is to be regretted that it wag impossible to obtain a fuller account of her state of
health, and of the different secretions at an earlier period of the disease.
From a review of all the circumstances connected with this and other forms of itro-
phy of bone, Mr. Curling oonoludea that the wasting of the osseous tissue is here tlM
result of defective nutrition, and not of increased activity in absorption, and resembla
the decay which occurs in advancing years; in both, the lesion is more remarkable in
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 tiat
the wasting process would go on most rapidly in the cancellous and vascular parts of
bone, whereas wo find that the denser parts, and those of inferior vascularity are nw*
i^apidly removed.
Again, the disease appears first iq the bones of the lower extremities, for the same
reason, prohaWy, that all moybid changes consequent upon defective nutrition, or a feeble
circulation, commenoe oftener in the depending parts,
Aooording to Mr, Curling, the various apearances presented by the medulla, whiA
is sometimes describecl as vitiated, or as being of a reddish color, and resembling Mi,
liver or tallow, is owing to slight modifications in the secretion, together with acnt
d^ree of increased yascularity in the medullary membrane, or to the medulla being
mixed up with bl(^4. ^^^^^^^^^^^^7 effused, as would readily happen if thei^ was nmck
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MoUities Ossium. 771
distortion. Mr. Curliog was satisfied, from his examination of the hones in this dis-
ease, that the matter with which the hones are filled is nothing else than an increase of
the true medalla, somewhat altered in appearance, but very slightly in its essential
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. Kilian 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 membranes: within the bone ; and
most probably the progressive absorption of the bone itself was merely one of the con-
sequences of the long continuance of the malady."*
If the view expressed by Mr. Solly be true, that Mollities Ossium is of an inflamm i-
tory character, it ia evident, however, that the altered state of the osseous tissue is essen-
tially different from that which commonly occurs in infiamed bones. Thus, in inflam-
nnition of the bones, the periosteum is always more or Ipss involved, and the appearance
of extravasation of blood in MoUities 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
as the scorbutic state continues. And in some cases of scurvy the callus of old fractures
is destroyed after it had been formed. Boyer, in his Lectures on the Diseases of the
Bones, 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 abo well established that in this peculiar state of the system induced by same-
ness 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
in 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. Grooch and Dr. Pringle, to the Royal
Society in 1753, had symptoms of scurvy, and bled much at the gums. Madame
Supiot, 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, but 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 soi^ning, the urine deposited
a white, chalky sediment, which came away after her pains, and ceased towards the
termination of this protracted case, when scarcely a bonQ xeiD^Aned for the disease to
* Edinburg Medico-Cbirurgical Transactions, vol. ii^
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772 Mollities Ostium.
prey upon. Both the arioe and saliva stained the linen black. In the case of Jaoies
Stephenson, recorded by H. Thompson in his Medical Observations and Inquiries (vol
y), for the first two years of the disease, the urine deposited a whitish sediment, whidi.
upon evaporation, became like mortar, and the patient, a shoemaker, at Wapping, Tended
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 wis
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 wiUi somethii^
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 bone, 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 eroeti'
tions, vomiting and sweats.
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CHAPTER XXI.
KELATIONS OF MOLLITIES OSSIUM TO FRAGILITAS OSSIUM.
•
Case of Marshal Lewis, observed by the author — Illustration of the hereditary brittleness or
bones, recorded by 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 is true that the bones become fragile in certain stages of moUities 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 — 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
in 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 Raney Drucilla Bozel.
Cabb 776 : Marshall Lewis ; dark mulatto ; age 24 ; Nashville, Tennessee, 1868. His father
und mother stated that, when about two years of age, Marshall was attacked with typhoid
fever in the fall of the year, during an epidemic of this disease which prevailed in the neigh*
borbood. 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
short oflf 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 bad numerous fractures, num-
bering in all near fifty. 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
at that time was more active in his habits (followed bis trade of boot-making) than at the
present 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
supplied with powerful pectoral muscles, and long, muscular, strong arms. Length of body
from crest of ileum to top of bead, 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
fractures and bending of the legs and thighs. Arms powerful and long ; length of arm from
shoulder 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
use of cratches 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, thickj shining, horn-like skin, although they do uot strike the ground
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774 Mollities Ossium.
in walking. The length of the right thigh is only 15 inches, and that of the right leg abont
16 inches. Feet quite small ; the patient wears No. 2 shoes. Length of foot, 8 incb«i;
breadth across sole of foot, 3^ inches. Thighs, although misshapen and bent like a bow,
with large masses of callus thrown out along the femur, are still large and mnscolar, vbiltt
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 appeaniDce
of the fragilitas ossium ; and in addition to this, in reply to various inquiries relating tocoi-
stitutional and family diseases and tendencies, I was informed that the niece of UanbaHi
father has had numerous fractures, being afflicted in a similar manner with Marshall, altboogh
she has borne children and is apparently stout and healthy.
Mother of Marshall, a powerful, hardy, black negro woman, age 52, has had twelve childrtB,
all of whom were vigorous and strong. Those of her grown children whom I have seen an
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 fVom moMa
ossium, were :
1st. The fractures were attended with little or no pain, and healed rapidly by tbe
formation of callus.
2d. The general health of Marshall Lewis 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 iather't
indicated a constitutional origin of the disease, or rather that the brittlcnen of tk
bones was hereditary.
Dr. Paull, of London, has recorded a striking illuatration of the hereditary biittle-
ness of bones and their repeated fracture in members of the same family. All t^
members of a family residing in the commune of Offenbach have had fractures j thra
of them have each had two fractures ; another three ; one has even had as many as firt
fractures of one or the other extremity ; and to produce these injuries no considenUc
violence was in general requisite. The father and grandfather before them had ftx-
tures of the limbs. Dr. PauU, moreover, described this family as a very healthy one.
without any scrofulous or other perceptible taint. It is remarkable that not one of
them suffered a fracture before the age of eight, so that one might suppose that thi^
peculiar fragility of the osseous matter was developed only towards the age of puberty.
Dr. Paull conceived that the condition of this fragility consisted in some change of tbe
chemical constituents of the bones in their relations to each other.
It has been frequently observed that men addicted to the use of brandy oflen erpe-
rience fractures (in consequence of a degree of brittleness induced in the bones,) 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 bin*
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 drunkards are cored
only very slowly, precisely the contrary was the case in the family above mentioned ; i«
in every instance that occurred in it the fracture was very speedily consolidated, so U»t
generally the callus was perfectly firm at the end of three weeks. When tbe same boM
has been broken a second time, it has never occurred at the seat of the oallus.
We are justified by these cases in assuming the position that there is a state of the
asseous system correctly indicated by the term fragilitas ossium, which cannot be referred
to the syphilitic, scrofulous, or cancerous cachexia, and which exists with perfect health,
and the repeated fractures are rapidly united by callus.
Cass 777 : A remarkable case of fragility of the bones, accompanied by caries and nlcen-
tion, with profuse suppuration, came under my notice in the female wards of the Charity Bos*
pital, during the summer of 1869. The disease, which occurred in a virgin adult feaulf,
twenty-eight years of age, was referred to the action of inherited and constitntioiial sypUlii
This case was so remarkable, that, I obtained the body, after death, which apparent!/ v>t
caused by the profuse suppuration from the numerous open ulcers, commtinicAting witiitbe
fractured extremities of the carious bones, and prepared the skeleton, which is preserved la
tbe pathological collection of my Practical Laboratory of Pathological Gheinistry and Toxi*
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Mollitiei Ossium. 775
4
cology. The intellect was clear, and the appetite and digestion good up to the time of death.
The following is an outline of this singular case:
I obserTed this unfortunate woman in the Charitj Hospital, onlj a day or two before her
oeath. At the time of mj observation, she appeared to be exceedingly feeble, and was a mass
of offensife, running sores. I obtained the body after death, and had the skeleton carefully
prepared. The hymen was perfect, and the disease appeared to have been derived from in-
heritance, and to have manifested itself in early childhood. The feet are very small — not
mnch 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 vertebras were all carious. The upper jaw contained
one small tooth, and the lower jaw three teeth. The alveol» was completely absorbed. The
outer and inner tables of the skull were perforated in several different places. The lower
JAW, on the rig^it 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 scapulsB and sternum, the lower jaw and the cranium
were all eroded through in various places.
The booes are dimiaished la speoifio gravity, and present a light, spongj appearance,
as 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.
Cask 778 : The following is an outline of this case :
Charles R. Barker, C. S. vols. 7th 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, 21st 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 thigh 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
w^as confined to his bed for more than four months, during which time, there was but little
progress in the healing of the wound, the discharge continuing, although there was partial
union of the fiaps. At the end of this period, the patient attempted to walk on crutches, and
on the 20th 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 offensive pus were discharged. The patient was
so mnch 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 poctiona
of the flaps united. In December, the patient was able to travel to Georgia, and enter the
general hospital at Augusta, January 10th, 1863, fl^nd at this time came under my treatment*
After careful examination, the bone was found to be extensively diseased ; and the discharge
(rQn^ several fistulous openings was profuse a.nd foetid. At ^be time that thia patient entered
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776 MolUties Ossium.
the general hospital, be was In a most weak and feeble condition, and saflTered firom hecUe
fever consequent upon tbe condition of the stnmp. The poise was rapid and feeble, andth«
complexion duskj and nnhealthy. Tbe slonghing went on rapidly, until the bone of the
thigh was exposed and denuded. The patient was placed upon the Tartrate of Iron tad
Potassa, Sulphate of Quinia. generous diet, and stimulants and opiates. Under this treatment,
the patient gathered sufficient strength to resume the use of his crutches. After some im-
prudence, the patient was again prostrated. Tbe bone, which was examined daily, fiosllj
protruded a little and gave unmistakable evidence that it was detached. On the 24tb of Maj,
I placed the patient under tbe influence of chloroform, and abstracted the bone, seven and a
half inches in length, and extending to the trochanter. I lost sight of this patient, anttl I
found him in the Charitj Hospital this winter, just after I had exhibited the diseased bone to
the medical class. The limb healed up entirely, and the patient wears a stump. Tbe perioi-
teum of the bone threw out another bone, and the thigh feels as if it had a large bone.
The bones affected with syphilis, were in striking contrast to the dense, strong bones
of a man who had suffered with rickets and caries of the vertebrae, and who was god*
denlj killed.
Specimens illustrating these various points, are preserved in my Practioal Labratoiy.
The following case illustrated the ravages caused by Scroftila, and the wondofiil
resources of nature in the endurance of disease. I observed this case in NashviBe,
Tennessee, and at my request, Dr. John W. Morton, Jr., drew up a careful r^rt, ind
also caused the execution of photographs.
Cask 7t9 ; lUuiirating extensive Caries of the Vertebra and Bibsj and Perforation of the Lungs,
Berry Subbs (colored); age 20 years. From birth up to 1861, was stout and healthy, sad
worked as a blacksmith. At this time suffered with swelling and inflammation of tbe Ljuh
phatic Glauds of tbe neck. In 1863, Joined the Federal Army, but returned to bis home is
Alexandria, Tennessee, in 1864, in feeble health, with extensive ulcerations on the neck tad
chest. Came to Nashville, 1866. I saw him for the first time, July 15th, 186t. The folloT*
ing was his condition : Black skin, woolly head, with thick projecting lips ; large, swoUcb
abdomen ; heads of long bones enlarged ; knee and ankle-joints swollen ; hands and feet
very large ; ill-formed. Appetite irregular, sometimes deficient, at other times raveaosi.
Craves fruit and vegetables, Speaks with great difficulty ; voice feeble and irregular ; air
issues from an ulcer which penetrates through the 3d and 4th ribs of the left side, and com-
municates with the lung. The patient breathes through this opening as well as through th»
mouth. He is able to practice respiration through the opening when the mouth is olofed.
The opening into the lung is about one inch in diameter, and is surrounded by exteniiTt
marks of ulceration. Tbe last cervical, 1st, 2d, llth and 12th dorsal vertebrae are carious,
and discharge pus. The spine has both a lateral and anterior curvature. The bead is forced
down upon the chest. It is necessary for the patient to carry a pad upon the chin in order
to facilitate respiration. Lateral and anterior and posterior motions of the head almost
QDtirely lost. Ulcers exist over the neck and breast and sternum, which discharge pas ts4
fragments of bone. Pus, with fragments of bone, issue from the ear. A large ulcer is sIm
I
a
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EEMABKS.
Berry Subbs
1st. IJealthy subject
2d. '* ''
3d. ** "
4th. " »
5th. «* "
92
131
136
180
136
140
ins.
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70
703
69
70
61
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30)
341
36
36
32}
33
Berry Tubbi, w'ght
at IS years, IW
pounds.
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MoUities Ossium. 777
found ill the left aiilla, wliicli penetrates tlirougb the ribs into the lungs, ami respiration i>
performed through this as well as through the one previously described. Several of the
bones of the feet and hands are in like manner carious. Pulse, in sitting posture, 102, stand-
ings, 120; respiration, sitting, 32, standing, 48; temperature of hand, 98. °5, under tongue,
i»H.°5. Very feeble, walks with great difficulty. 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 20th. The preceding measurements will illustrate
the effects of the cnries of the vertebni' and ribs in altering the proportions of the form in
this cftse.
^7
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Mollities Ossium, 779
while lu mollities ossium it is sudden and rapid in its progress, and accompaDied often
with great pain.
The progress of this aflfection 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
eases, 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 bi/ the Hunterian Preparations, quot^
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, w^ith 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, affcer 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 instancei, that such persons, on recovery from the disease,
acquire a surprising degree of strength. Sir Charles Bell* mentions an individual by
the 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 afflicted 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, and rickety subject, called
the " Little Hercules."
The general health in Mollities Ossium is hopelessly impaired, the flesh and strength
diminish daily, and in some cases the muscle^s undergo fatty degeneration. The observa-
tions thus far recorded, have not been sufficiently numerous or accurate to decide the
question 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
nnscmic condition of the system, rather than to fatty degeneration of the muscles ; and
We have just seen that after recovery from this disease, the muscular strength, so far
from being impaired, is oflen wonderfully increased.
In Mollities Ossium, the loss of earthy matter in the osseous system is rapid, and is
frequently attended with a copious phosphatic deposit in the urine, and the bones do
not simply lose their earthy constituents and become reduced 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 cases, the bones consist finally of an external
nhell filled with oily or lardaceous matter held in membranous tissue.
According to Mr. Curling, the atrophy is eccentric, commencing invariably from the
interior of the bones ; in the long bones, affecting first the internal part of the shaft,
* London Lancet, March 15, 1834, p. 918.
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Mollities Ossium, 781
ture of a brown or reddish hue predominates, and Ls at tirst filled with a 83rous liquid,
which may be squeezed out, as if from wet leather ; after some time the serous or albu-
minoid liquid occupying the tube and cancelli is transformed into a gelatinous substance,
which is gradually organized into a cartilaginous state. The j^ower to separate and
deposit bony or earthy matter appears to be entirely wanting in the organic cells of the
osseous S3'stem in mollities ossium, whilst in rachitis this power is only temporarily
suspended or arrested, and is resumed with increiv^ed energy after the removal of the
diseased state.
Mr. Edward Stanley, as early as 181(3, 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 bones, 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. Leveillc^^ had given an account of the structure of a
soft, rickety bone, with a representation of its curved figure. It is described as having
been tixceedingly light, yielding with facility to the scalpel, and presenting throughout
a cellular and spongy texture. Memoires cle Physiologic et de 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 is also thickened. ' (Anatomic G^nerale, Tom. iii.)
The several bones examined by Mr. Stanley, exhibited nearly the same structure as that
here described by L6veille and Bichat, excepting that the periosteum was not thickened
as 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 its 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 undergone
diflferent degrees of curvature, and where the process of restoration had been completed <
Mr. Stanley discovered that there invariably obtains an exact relation to the circum-
stances of each case, with respect to the situation, extent and direction in which the
earthy matter is deposited ; thus it is obvious that in the curved bone, the part where
there is the greatest need of strength, to prevent its further yielding, is in the middle
of its 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 impai-ted 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
superincumbent 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 db^-
position to bend is greater. It is obvious what will be the application of this principle
to the strengthening of a curved, rickety bone, as may be readily exemplified by
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C H A P T i: R XXIII.
RELATIONS OF MOLHTIKS Ot«lVM TO C'ANCEB.
The briitleness of th« bones in cancer has long been obserTed— Casei recorded of softening and
alterations of the bones, by Lovisius, Percival Pott, and Prof. R. W. Smith.
MoLLlTiKS Ossium, in that, as far as is known, it is not amenable to remedies, but
pui-sues its career steadily, unaffected for good by medical treatment ; and in that there
is in this disease an increased cell-generation in the aifected structures ; and, still further,
in that, in recorded cases of cancer, some of the bones have been found in a state
ilosely resembling, if not identical with mollitios — bears a stronger resemblance to cancer
than to any other disease.
The brittlenegs of the bones in cancer has long been observed. Thus, the celebrated
liovisius, more than a century ago, in dissecting the body of a woman sixty years of
aire, who had labored fur some time under a cancer of the breast, and who had broken
th2 08 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, drj', friable, and rjuite
loose from the parieties of the bony cavities.
In a case which recently cime under my 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. Cancerous deposits were found also in the
liver and spleen.
In the following case, recorded by the celebrated 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 November, 1737, a gentleman, aged 27, complained of a Sl^'elling in the inside
of bis right thigh. On examination, it appeared to be an encysted tumor of the steatomatous
kind, lying loose between the sartorius and vastus internus muscles. Mr. Pott took it out,
and the patient got well in six weeks. After this he continued well for near a year, except
that he complained at times of a slight pain in the joint of that hip, which went off and
returned 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 ill the evening, if he sat down. This continued on him for three or four weeks, and
then the pain in bis hip became worse. The cold bath, flesh-brush, horseback exercise, a
course of aethiops mineral, cinnabar, of antimony, gum guaiac, calomel, purgatives and
mineral waters, as well as travellincr and chantrc of climate, afforded no relief. Periodicnl
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Mollities Ossium. 785
for two years aud a half, when a scab formed upon its surface, upon the separation of which,
a Tcry 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 could not endure that any one should touch her ; and her efforts to move herself in the
bed were, upon several occasions, followed by fracture.
She died exhausted by pain and suffering aud 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
system ; for, with the exception of a tubercle about the size 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, trom 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
presented a most unhealthy appearance ; the ribs contained numerous deposits of scirrhus in
their interior, and several of them were fractured ; the disease occupied the spinal columi)
from the lower part of the cervical region to the sacrum, the cancellated tissue of the bones
had disappeared, and its place was occupied by a firm, elastic, scirrhous structure of uniform
consistence and of a roseate hue; and the bones of the pelvis were entirely converted into a
iicirrhous structure.
The characters of this heterogeneous deposit were precisely the same in all the affected
bones ; it was white, firm, tough, and dense in its texture, highly elastic, and cut like carti-
lage ; it in no respect differed from true scirrhus as it is seen in the human breast The
osseous tissue in contact with it had suffered no alteration but such as resulted from
absorption.
It ig evident that such a case as the preoeding was involved in obscurity during the
life of the patient, and simulated closely mollities ossium in many of its symptoms.
In a ease of secondary cancer in the spine and other parts after removal of scirrhus
of the breast, reported by Mr. Ca3sar Hawkins, the centre of the neck appeared a little
^pnk forwards, ap if the upper vertebrje had been depressed iji that position. Upon
dis£(ection, the body of the fifth cervical vertebra was very irregular on its surface, and
was softened throughout, with much enlargement of the ct'lls of the canoelli, which
was filled with a sanguineous pulpy fluid ; the two adjoining vertebrao showed a lesser
degree of the same morbid structure. 3ir. F. Holmes has recorded a ca$e of. cancer
of the bones after scirrhus of the breast, in which some of the ribs were perfectly
flexible ; and in a case of well-marked cancer 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
osseons texture, it is sometimes difficult to determine in which tissue the disease had
its origin ; it appears to be true, however, that whether the bone be primarily or
secondarily affected, its density is altered and it is rendered more fragile and spongy in
its texture.
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Moltittes Ossium. 7ST
under axilla, lOO^. 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 involving the bone. Exploration with trochar
gave no evidence of piis. 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 Incbes; 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 10I®.2
'* 16; " " 100®.5
" 16; " <' 990.6
« 16; *• <» 1010.2
** 16; " *' 1000.5
'* 16; '« " 1000.6
" 15; " *' 990.5
" 15; " '< 1000.0
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 :
Exterior : — 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.
Cheat: — No adhesions. Luugs emphysematous. Pericardium contained considerable fluid.
Abdomen: — Peritoneum very thin; sigmoid flexure greatly distended with gas; small intes-
tines greatly contracted and aneemic.
Liver friable, and on its convex surface a small circumscribed abscess. Kidneys lobulated,
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 mnscnlar
structures of the thigh and surrounded the bone, and numerous osseous spicule 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 V. M.
((
96;
August 26, 9 A. M.
u
88;
" 6 p. M.
ti
86;
August 27, 9 A. M.
u
88;
»» 6 p. M.
i(
85;
August 28, 9 A. M.
(t
88;
" 6 P. M.
«
86;
Died August 12th.
Thel
force!
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Mollities Ossium, 789
made out regarding the abdominal and thoracic organs, except tliat tbe cardiac impulse was
too strong, and the prsecordial dullness too great, without cardiac murmur.
The patient attributed his illness to a strain, but it appears that for some time previously
he had been subject to wandering pains about the breast and shoulders. The urine of thii^
patient was submitted to the examination of Dr. Beuce Jones, with the following result. The
free acid was increased, the phosphates were in much larger amount than in health, and the
urioe was loaded with a peculiar form of animal matter resembling albumen in its chemical
composition coagulable by heat, but not by nitric acid.
The following table presents the general characters of the urint , as determined by Dr. Bence
Jone» :
•(iMH.iii<< K»rthT pho**-
nme. ri:v/ilr !»»»"»«*« *" KfactJon. Frecl|»»»tfl», *«.
«™^"y 1000 pun!..
Xov. 1, 1845. 1034.2 Slightly acid. ^Ncdiment of phosphate of lime
oxalate of lime, and urinary
casts.
" 3, " 104H.2 5.H8 Acid. Trate of ammonia, phosphate
of lime, and urinary casts.
<* 7, '' 1039.G 5.65 »^lightly alkaline. Phosphates of lime and casts.
** 8, '• '' Heavy deposit of phosphates.
*» 9, " 10.37.2 " Loaded with urates.
** 18, *' 1039.6 ».... Acid. Trate of ammonia, phosphate
of lime, and oxalate of lime.
" 27, " 1031..3 8.05
*» 29, *' 1037.9 8.24
"30, " 1042.7 11.85 Slightly acid. No 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
Uric acid 0.96
Earthy phosphates 1.20
Chloride of sodium 3.83
Sulphate of potash 2.10
Alkaline phosphates * 4.45
The following are the conclusions arrived at by Dr. Bence Jones, afler a careful
examination of the peculiar albuminoid substance in the urine :
Ist. This substance is an oxide of albumen, and from the ultimate analysis, 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 eonoemed, each
ounce of urine passed was equivalent to an ounce of blood lost.
3d. The peculiar characteristic 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 seminalesi
4th. This substance must again be looked for in acute eases of mollities ossiunl.
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
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^^^
CHAPTER XXV.
(i»MI»ARISUX OF THE CUKMICAL COMPOSITION OF THE B02<K8 IN MOLLITIIW 08SIIM WITH THAT
OF HEALTH AND VARIOUS DISEASED STATES— GENERAL (X)NCLUSIONS.
Aimlysis of healthy bones by varioui chemists, and of the bones in Mollities Ossium hiuI
vnrious diseased states, by Bostock, Proscb, Bogne, Ragsby, Lebmann, Von Bibra, Marchand,
Reese, Tuson, Barruel, Buisson, Valentin, and others — General conclusions as to the nature
of Mullities Ossium.
NoTWiTHSTANDiNa the comparative simplicity of the analysis of bone, much remains
to be accomplished before the true nature of its alterations in various diseases are deter-
mined with accuracy. Unfortunately, many analyses of morbid bones are unaccompanityd
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
b«jiie earth, the strongly basic phosphate of lime is replaced by a less basic salt.
The nej^lect to ascertain the quantity of the carbonate of lime in the fresh bone, or
in the earthy constituents, by the direct determination of the carbonic acid, as well as
the employment, in most analyses of bones, of the older method of Berzelius for the
determination of the phosphate of lime, has left it doubtful whether it exists in bone as
8CaO, 3POs or 3CaO, PO^.
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
mollities ossium.
Becquerel and Rodier give the mean composition of human bone, as deduced from
fifty-four analyses, made by different enperimenters, as follows :
Phosphate of lime,. , 54.07
Phosphate of magnesia , , , 1.20
Carboaate of lime , , 7.40
Fat 1.35
Soda and salts of soda 0.93
Cartilage 35.05
Lehmann represents the oonstituUon of compact osseous tissue, as deduced from th«
best analysis, as :
Phosphate of lioat , 57
Carbonate. of lime.. , 8
Pluoride of caleium.... ^., , 1
Pko5phal« of magnasia , 1
Mineral constituents , ,..^,, 67
Cartilage ,,,.,,„^.^^^^^....v,.,..^...,,.^.. 33
100
The comparison of the composition of the l^ones in mollities. ©9siiiiii with that of
health, reveals the following marked chances :
V, Increase of fat^
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Mollities Ossinw,
793
tABlU.-^Cowpogition 0/ Jlcalthij Bones {Human) aecordinff to Von liihrn^ litrzeliiis^ Thmmon
Marchamly Valentin^ and Lehmann.
ti
: 5 ;
i
9
?
I »
.1 O
AlTIIUE
5»S
3
iH;
'1
1
9
1 2,1
i IS
If
or
?*IBJK(T8.
Bo.XKS.
-S'' o
: (i '
ii
ANAIY6IB.
mi
1 : o
i s
fT
'
Uf f
, ;«? ;
B
1 :
: JS*
: "^
YoQ BIbm
Male fatiirt, Oto
7 niontliR
' Fomur
t
; 53.40 3.<m;
1
1
' 2.10
1
1.00
40,38
tract's
1
Tibia
:^\Ai\ : 3.10
2.00 '
1.07
1 40.37
1 traces
1
HuiutM-iis
.>3.i.j 'A.i)r,
1.9<;
l.()2
40.82
tnic(«
Ft'iiiale fu>(urt
Vina
57.«M ' :,.K(;
1.10 0.(4)
84.78
i 0.63
7 months
1
Itatiiiis
:.7.G7 oM
j O.lMJ ' (».G7
.14.08
O..'i0
Clavicles
.''»(i.*»6 .'"».7.'>
1 l.<«7 1 0.73
34.54
0.96
Scapula
; r.7.13 1 .-).1»9
1 1.12 0.G2
:m.33
0.82
Infant, 2 months
Tibia
:»7.54 fi.Oii
' l.ltt (».73
3.3.8C
(►.82
1
...
Ulna
r^KiWt ♦;.07
J 1.0<» 1.H5
34.92
1.01
... U monthst
Feniui-
, -18.11 li.VA
0.97 1.23
47.71
1.80
Tibia
48.r»3 5.79
l.OO 1.24
41.,50
1.92
Hu morns
1 :a).i:, \ U.13
1.00 ! 1
MO
39..-|4
1.89
...
Ulna
I 48.0(; 1 fi.20
l.Ol ]
.24
41.79
1.79
IladitiB
; 4.-».38 .'V.ll
l».95 1.07
45.05
1.8.3
"
...
Rilw
1 42.3-.i
5.G0
0.89 1 1.09
48..%
1.15
Scapula
42M
5.08
1.92 1.10
48.:Ui
!.(«
Female child,
Fonnir
.•.9.o«;
5.91
1.24 ' 0.69
31.28
O.J»2
3 months.
!
\
Tibia
.".0.75 ' COO
1.34 oa\:\
31 ..34
aa-.
Girl, 19 years
Femur
54.78 ' lO.W
l.:J4 0.83
.31.15
1.00
HumeruH
54.84 10.82
1.26 0.79
31.37
0.92
••r
Woman, 2o yn».
Femur
57.12
8.90
1.70 1 0.60
29.54
1.82
...
Tibia
57.18
8.9:j
1.70 ! 0.61
29.58
2.00
Humerus
58.0:^
9.0^1
1.59 0.59
29.66
1.09
Ulna
57.5'2
8.97
1.71 0.67
29.14
1.99
RadiuM
57-J8 8.95
1.72 1 0.63
29.43
1.89
Ribs
52.91
8.66
1.40 , 0.60 1
3:j.06
2,.37
Clavicles
5«).35
8.88
1.69 0.59
30.66
1.83
1
Vertebne
44.28
8.00
1.44 a
.53
43.44
2.31
.-.
Fibula
57.39
8.92
1.63 0
.60
29.49
1.97
Scapula
54.76
8.5S
1.53 0
.51
32.90
1.73
3Ietacarpus
57.77
8.92
1..58 0
.61
29.23
1.89
Cranium
57.66
8.75
1.69 0
.63
29.87
1.40
.••
Man, U5 yeara
Femur
59.63
7.33
1.32 0
.69
29.70
J.53
1.55
Tibia
58.95
7.08
1.30 ' 1
.70 1
30.42
I
Humerus
59.95 7.76
1.09 0
.72 1
29.28
1.28
,,,
Ulna
59.30 7.3*
1.35 0
.73 1
29.98
1.29
Ribs
56.66 1 6.64
1.07 0
.62 ;
:i3.97
2.04
...
Cranium
38.4;i
8.00
1.40 U
.90 '
•29.93
1.35
... c»8 yeai-»
Comp't sub.
of femur
58.23
8.35
1.03 0
.92 ,
31.47
1.35
,,.
Spongy bone
42.82 19.37
1.00 0
.90
35.83
1.35
of femur
Woman, 62 yrs.
Femur
61.17
4.46
lJ» 0
.90
28.03
2.16
... 76 yre.
Femur
57.36
7.48
1.10 . 0
.97
33.16
0.93
B^rzelius,
Human bone
Bonefl
53.04
11.30
1.16
37.17
1.S0 .
Thomson.
Human
Femur
48.67
14.00
0.49
^
39.72
2.50 1
Femur
51.12
9.77
0.63
^,
35.93
0.69 '
Xarnhaod,
Man, 30 yeaiii
Femur
53.26
10.21
1.05
32.25
Li-
VklenUa,
... 38 yeare
Tibia
52.93 i 7.66
0.25
38.02
^,
no
Lehman, .
... 40 yeara
Humerus
56.61 I 9.20
1.08 ,
1.72
61.52
Radius
52.25 9.76
1.06 '
1.72
83-76
Ulna
53.98 9.51
1.07 j
1.38
33.23
...
Femur
58.93 9.28
1.09
1.44
28.61
Fibula
.52.99 9A3
1.06 1
asc3=:
1.44
34.13
Composition of^ Bones in Mollities Ossium ( Osteomalacia),
Vertebra. Vcr eLra. Co!iU.
(Boftock.) (Prosch.) (Pro«ch.)
PhoBphate of lime , 13.60 13.25 33.66
Phosphate of magnesia , 0.82
Carbonate of lime 1.13 5.95 4.60
Sulphate of lime and sulphate of soda 4.70 o.90 0.40
Cartilage Id.lh 74.64 49.77
Fats 5.2C U.Ga
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ties Ossium,
795
M0LLITIE8. HRALTH.
Kaitha AOimal P.rfh. AllilllKl
KarUit. „.„g^ KarUw. ^^^^^
32.^0 07.50 G0.02 39.98
30.00 70.00 57.49 42.51
26.13 73.87 57.42 42.58
8 table it will be observed that in the diseased, an
ins more earthy matter than either the ribs or ver-
ibra; thus we have the same order preserved in
md ribs in health approach very nearly in their
:er ; while in moUities a considerable difference
his indicates that though the bones are all acted
t that the absorption does not go on equally in
m others. There, is however, an approach to an
g that the diseased bones have lost about half
same order as regards proportional constitution
)ula containing more earthy matter than the ribs,
•eriment, that the earthy matter obtained from
ains, as nearly as possible, 86 per cent, of pho8-
rthy matter from the trunk bones contained, on
led on mixing together the earths obtained from
vith mollities, and subjecting them to analysis,
id to contain only 78 per cent, of phosphate of
ibsorptiou of earthy matter by disease is accom-
)f phosphate of lime to carbonate. This would
away earthy matter containing a very large per-
j it otherwise, we should never find bone earth
)f that earth ; the smallest in health being 81.2
ime. That the carbonate is absorbed together
though small proportion in these processes, is
e most changed by the absorption of their earthy
rom healthy bone earth in the general average
a of lim3. {Gn^s Hospital Reports^ No. 8,
il Review, July Ist, 1839, pp. 246-247, Am.
analyzed by Dr. G. 0. Reese may have been
lie acid, as the lactic, during the preparation of
the clear demonstration of the existence of the
previous to incineration, we cannot lay much
jase when compared with t^e phosphate of lime.
;is of the medullary membrane and osseous sub-
st^omalacia. The analysis of the affected bone
Moilullarv uiatter. (ifAcoud iustt«r.
24.78 18.75
1.8.T 29.17
73.39 52.08
(detailed by Dr. Rarasbotham, in the reports of
3d, yielded :
jbtained from seven specimens ; the extremes werf
xxvii, p. 435.
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Mollities Ostium.
797
Table.:^ Chemical Compontton of Diseaeed Bonea in BackitiSj CariH^ Necrom^ (hteopoMy Sclero$it
Ezottotit, Osteoid 7\imor, Arthritis, and Callvt. By Lehmannj Rggtiry, Von Bibre^ Pelome
Valentiriy Lassaigne, Marchand and Simon.
AVTHOR
or
AXALTSIS.
DlSBASE.
Boxes.
786 I Lehmann
787
788
789 Ragiibj
790 Yon Bibm
791 I Pelonxe and
792 Fleming
7W Mjtrchand
7$H Valentin
79r. Von Blbra
Rucblts
Z child
790
797
798
800 ' Bagsbj
801 ,
H(I2
Laaeaigno
81)3
Simou
801
MaKliand
tw
Lehmann
^06 LaMMigne
CarieM, nian
girl
wuuian
man
... »irl
MTonian
man
Necroai« ...
Ostooposis
6cl«ro8fB, man
syphilitic i
Exostosis j
Osteoid tumor I
Arthritis, topha-
ceous deposit
Arthritis, chron-
icgont
Callosities
TibU
Scapula A humerus
Ulna
I>or8al Yertebra
&ibs
Cranium
Radius
Femur
Patella
Vertebrw
Radius
F^mur
Tibia
Vertebrw
Femur
TibU
Metacarpi
Metacarpal bonos
Fcninr
Patella
Tarsus
Vertebra?
Tibia
Phalanges
Bone
Fracture
Cranium
Femur
Thickened bone
Exostosis
Knee-bone
Femur
Radius and ulna
57.20.
6.60
36;) ;
6.5
30.0 .
14.0
38.86 1
2.70
8.00,
0.62
9.20
0.64
42.12
8.24
43.18
8.60
36.16
8.41
36 J3!
9.82
37.02
8.99
33.3 ,
5.7
32.5 1
6^
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Mollities Ossium, 799
C. Schmidt proved clearly that free lactic acid was present iu the fluid of the cylin-
drical bones in 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 investigated the composition of the phosphate of lime contained in
these bones, found in addition to carbonate of lime i basic phosphate of lime, and
believes that phosphate of normal bone (SCaOjPOs) is converted by means of the free
acid into this less basic salt.
The singular and painful disease of the jaw-bones, produced by the fumes of phos-
phorus and phosphoric acid,* renders it probable that in mollities ossium, 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.
*For an interesting account of the Diseases of Workmen engaged in making Lucifer Matches,
sec American Journal of the Medical Sciences, Oct. 184G, N. S., vol. xii., p. 525.
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INDEX TO VOL. I., MEDICAL AND SURGICAL MEMOIRS.
A
FUM.
ABSORPTION. Experiments illastratiiiK the process of. 668-578
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 Action of Serum and Solutions of the Sulphate
of Magnesia through dead animal membranes 57l
Derangements of the process of Absorption in the Human System 577
ABORTIVE SYSTEM OF TREATING PNEUMONIA 695
ACONITE. Value of as a remedy in Traumalic Tetanus 406
Value of ns a remedy in Pneumonia 742
-EGINETA, 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 470-649
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 Hi-althy Blood 684
Of Blood in Malarial Fever 685
Of Blood in Marsh Cachexia 587
Of Blood in Cardiac Dropsy 608
Of Blood in Chronic Brigbt's Disease 637
Of Urine in Pneumonia 670
Of Composition of Bone in Man 793
Of Composition of Bone in MoUities 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, Kdlliker and others, on Minute Ana-
tomy of Nervous System 48, 49, 60
Investigations of J. Lockhart 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 TeUnns 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 497-601
Pathological, of Dropsy arising from Alterations of Blood 589-603
Pathological, of Cardiac Dropsy 609-619
Pathological, of Hepatic Dropsy 621-633
Pathological, of Renal Dropsy and of Bright's Disease of Kidneys 636-645
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INDEX. 803
PageB4
BLOOD. Composition of in Malarial Fever 585
Composition of in Marsh Cachexia 587
Composition of in Cardiac Dropsy 608
BLOOD-LETTING. In Tetanus, 344-401 ; in Cerebro-Spinal Meningitis, 482-545 ;
In Pneumonia 684
BOERHAAVE, on the Structure and Functions of Nerves 6
BONES. Diseases and Composition of 751
BRAIN. Views of Aristotle, Pythagoras, Plato, Herophilus, Erasistratus, and Galen
on structure and functions 1-5
Observations on by Rondeletius, in 1550 4
Observations of VaroUius on its connection with Spinal Cord 5
Views of Willis, as to its structure and functions, 5 ; of Boerhaave, 6 ; of
Albinns, 7 ; Malpighi, 7 ; Unzer 8 ; Prochaska 12 ; Bicbat 14 ; Cuvier 17 ;
Le Gallois 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, observations on by Valentin 48 ; Remak 48 ; Stilling
49; Volkmann49; Kolliker49; Clarke 50 ; Van der Kolk 52
Comparative Anatomy and Physiology of, according to Professor Owen 62
Triedmann on Anatomy of Fcetal Brain 64
Experiments on, by Flourens 66 ; Dcsmoulins 67 ; Rolando 67 ; Magendie 68 ;
Bouillaud .*. 69
Literature of. Diseases of 70
Doctrine of Gall ,.... 70
Minute structure of, according to J. Lnys 72
Observations of Poufour du Petit and Marc Dax, on relations of loss of speech
to lesions of Brain 73
Experiments on various portions of the Brain, by Fritsch and Hitzig, 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
CALABAR BEAN. Extract of, in treatment of Traumatic Tetanus 404
CAMPBELL, HENRY F. On Excito-Secretory System of Nerves 96
(-AMKUEK. On Nervous System .* 99
CARPENTER, WILLIAM B. On Structure of Nervous System in Invertebrate
Animals 44
CASES. Traurajitic Tetanus. 142, 156. 157, 158, 161, 163, 166, 168, 170, 182, 199,
201, 209, 210, 213, 214, 216, 217, 218, 219, :M2, 355, 356-383.
Traumiitic Tetanus. Table showing the age, sex, nature of injury, results
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INDEX. 805
Pagw
OLEGHORN, GEORGE on Remittent Pneumonia 697
COTTER, on Nervous System 5
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 Pathology of Tetanus 215-216
CONFEDERATE ARMY. Cases and Deaths in, from Diseases of the Nervous Sys-
tem 424-425, 426-436
Statistics of Pneumonia and Typhoid Fever in 650-668
CORONBLLA GETULA. Action of Hydrocyanic Acid on 290
COURTEEN, on Nervous System 79
CRAIGIE, on Pathology of' Tetanus 215
CROCODILE, Brain of 63
CRUIKSHANK, WILLIAM. Experiments on Parvagum and Intercostal Nerve 82
On Nervoug System 79, 99, 107
CULLEN, WILLIAM, on Nature of Tetanus 159
Treatment of Tetanus 339
CURLING, THOMAS BLIZARD, on Ab-^ence of Inflammation in Tetanus 163
Patholosry of Tetanus 209-216
Treatment of Tetanus 343
On Mollities Ossium 778
CURRIR, 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
D
DALTON, JOHN C. M. D., PROF. Experiments with Sulpho-Cyanide of Potassium
and Strychnine, illustrating the relations of the Muscular and Nervous Forces 124
DALRYMPIiE, Observations on Mollities Ossium 754
DAVIS, JOHN S. M. D., PROF., University of Virginia. Letter on Treatment of
Pneumonia in the Confederate Army ♦ 744
DAVY, JOHN on Aniraal Electricity 117
DAVY, HUMPHREY, SIR: Experiments wiih Nitrous Oxide Gas 234
DAZILLE. on Tetanus 364
DE la RIVE, Hypothesis of the Nature of the Nervous Forces y 125-129
DEMME, on Pathologicl Anatomy of Tetanus 222
DESCARTES, on the Nature of the Nervous force 116
DESMOULINS, 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. D., PROF. Letter on Treatment of Pneumonia 745
DIETETIC SYSTEM of Treating Pneumonia 670-680
DIBTL, 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, Experiments 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 557-646
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 Alterations of the Blood 584-604
Arising from the Action of Malaria 584-604
Arising from Derangements of the circulatory apparatus — Cardiac Dropsy 605-620
Hepatic, arising from some obstruction to the circulation of the blood through
the Liver 621-634
Arising from Lesions of the Kidney — Renal Dropsy 635-646
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F
Pages.
FARADAY. On Animal Electricity 117
FERNELIUS. On Nervous System 115
FERRIBR DAVID, PROF. Experiments on Brain 74-75
FERGUSON, A. On Treatment of Tetanus 377
FEVER. Malarial 477
Malarial; Tabular View of the Changes of the Blood, Urine, Circulation, Tem-
perature, and Respiration 485-496
Malarial. Pathological Anatomy of. 497-501
Malarial, Relations of, to Cerebro-Spinal Meningitis 483-506
Differences between the Symptoms and Pathological Lesions of Cerebro-Spinal
Meningitis and Malignant Malarial Fever 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 Tetanus 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 v ^^"^i 531-534
Typhus 477
Yellow 477
Yellow, Pathological Anatomy of. 497-501
FISH. Prof. Owen, on Functions of Cerebellum of. 62
Brain of 71
FLOURENS. Experiments of, on Functions of Cerebrum and Cerebellum 66, 69, 73, 169
On Circulation 286
FODERA. On Functions of Spinal Cord 37
FONTANA. On Nervous System 79, 81, 285
FOURNIE AND BAUNIS. Experiments on Brain 77, 78, 169
FOVILLE. On Functions of Cerebellum 77-78
FRASER. On Treatment of Tetanus 405
FOSTER, M. On Treatment of Tetanus 377
FOULKE. 0. On Treatment of Tetanus 369
FRANQUE. On Amount of Urea excreted by Healthy Men 190
FREE ACID. In Urine of Tetanus 192
FRAGILIT.\S OSSIUM 773
FRANCOIS. On Tetanus 255
FUGATE, F. H. On Treatment of Tetanus 374
FRERICHS. Observation on Pathology of Liver and Pigment deposits 595-599, 600, 627
G
GALEN. On Nervous System 4, 5, 79, 115
On Tetanus 159
GALL. On Functions of Brain 67, 70, 71
GALL BLADDER, in Malarial Fever 500
in Yellow Fever 500
GALLOIS, JULIAN JOHN C^SAR LE. Analysis of Works and Experiments of, on
Nervous Svstem 16, 17, 18, 19, 65, 79, 83, 285, 312
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INDEX. 815
IVigef.
PNEUMONIA. Cases of, entered in Field Reports of the Donfederato Army, Janu-
ary, 1862 to July. 1863 660
Cases of, entered on Hospital Reports of the Confederate Army, January, 1862,
^ July, 1863 G51
Cases and Deaths in the Confederate Forces, serving in South Carolina, Georgia
and Florida G5J
Cases and Deaths in Confederate States Army, serving in and around Mobile,
Alabama, on Gulf of Mexico 6r.2
Cases and Deaths, in Army of the West - 653
Cases and Deaths, in Army of the Valley of Viaglnia, General T. J. Jackson... 653
Cases and Deaths in General Hospitals, in the Army of the Potomac 656
Cases and Deaths in General Hospitals, in and around Richmond, Virginia 658-660
Cases and Deaths in General Hospital at Charlottesville, Virginia 662-667
Cases and Deaths in various Confederate Hospitals 664-667
Examination of the Different Modes of Treatment 6(?i)
Dietetic System of Treatment f;7o-680
Rational Treatment ^ 680-684
Antiphlogistic System of Treatment ^.- 6h4-6J>4
Aniiperiodic or Abortive System of Treating Pneumonia 6J»:i-747
Table Illustrating the rate of Mortality in Pneumouia under Differeni MoiUs
of Treatment 738
Cases Illustrating Symptoms and Results of Treatment of. ii7o. 677. 716, 720. 727. 739
Mortuary Statistics of, in Savannah, Georgia 701-704
Mortuary Statistics of, in Augusta, Georgia 7u5-70»
Mortuary Statistics of, In Charleston, South Carolina 710
Mortuary Statistics of, in New Orleans, Louisiana 710-711
Mortuary Statistics 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-
masini, 688; by Laennec, 688; John Hunter, 691; by Jean Senac, 695;
George Cleghorn, 697 ; Lautter, 697 ; Broussais, 699 ; Dr. S. Ames, of Mont-
gomery Alabama, 740 ; Dr. J. S. Davis. 744 ; Dr, George B. Wood, 745 ;
by Dr. Samuel Henry Dickson, 745; by Dr. Samuel Jackson "'46
POTTER, H.G. On Treatment of Tetanus..... 368
PLUTARCH. On the Plague 414
POLLOCK, D. On Treatment of Tetanus 369
PROCHASKA, GEORGE. Analysis of Work of, on Nervous System »--^?
On Reflex Nervous Actions ^j*
On distinction between Voluntary and Involuntary Actions ^^
T^»>r,r,,9° ^»fl«e°<^e of Nerves over Circulation and Secretion ^^'^^
ooSS2^^» ^- S- O'* Treatment of Tetanus fj"
PREVOST. On Treatment of Tetanus 1«!
POTASSIUM, SULPHO, CYANIDE. Effects of, on Nerves and Muscles )24
r>DTToo»?.*°*^^- **P®"°"^'*^^ *^° effects of, on Plants and Animals •• ^i^'o-m
^ttFIp '^^^^' Experiments Illustrating effects of, on Plants and Animals "^ %c,
rULSE. Changes of, in TeUnus, 178 ; in Cerebro- Spinal Meningitis .^^
Changes of, in Malarial Fever
^riv'rJi?^ ^" '^' Treatment of Pneumonia.^ rV-^i^ '^'''''
QUINCKE AND NAUNYN. Experiments of. Illustrating the Relaiious of ihe Nor- ^^^
rfcTTtnir T^«8 System to the D. velopment of Heat 377
WtriOK, L. J. Treatment of Tetanus - •-
UASORI AND TOMMASINL On the Treatment of Pneumonia witbTurtttr Emetic. ^^
wii^rSovy* ^- ^° Treatment of Tetanus 524-5^
wpiT. r? "^^^^ Action of Poison on Livin|r Animals ^..^.^ ...••a-- '"^ 1
SpplrVS^;;^^™- Experiments of, on Section of Nerves ,. nHc^rvA-
liEFLEX ACTION of Nervous System, Cerebro-Spinal Nervous System. 0*^.^^^^ I
Uous on, by Unzer, 9-12; Prqchaska, 13-14; C^yie^ 16; Le Gullai^ i
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INDEX.. 817
T
I*HgeH.
TAIUiES. 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 25f>
Deaths from h>pasmi and Convulsions during 50 years in Savannah, Ga. 2G0
Deaths from Traumatic Tetanus in Charleston, S. C, during 14 years 261
Deaths from Trismus Nascentium in Charleston, S. C, during 14 years 261
Deaths from Convulsions in Charleston, S. C 262
Deaths from Tetanus, Trismus Nascentium 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 Trine, and Circulation, Respi-
ration and Temperature in Malarial Fever ^ 485-41>6
Tabular view of the Pathological Anatomy of Yellow Fever and Malarial Fever 497
Illustrating the Duration of Cerebro-Spinal Meningitis 643
Of Mortality, in ('erebro-Spinal Meningitis 544
Osmosis and the Absorption and Action of Purgatives •">75
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 Confederate Army 650-667
Monthly Deaths from Pneumonia, in Savannah, Ga., 1804-1853 701-702-704
Monthly Deaths of Colored Inhabitants of Savannah, Ga "04
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 Chemistrv of ihe Osseous System in Health and Disease 793-797
TRAUMATIC TRTANrS. 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 Tetanus 142, 158, 161, 163, 166, 168
The Essential Phenomena of Fever and Inflammation absent in Tetanus J*;^
Temperature in Traumatic Tetanus ;;•• 154-Ibt»
Observations of Hippocrates, Aretiens Galen, Horatianus Rhases, Cclsus
Brown, Cullen, 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 tne ^_j^^
temperature of Traumatic Tetanus "l^jtj
Portion of the Nervous System involved in Traumatic Tetanus. ...... •.•;•••••.•••••
Case of Tetanic Spasms, caused by fracture and depression of the Oraniuro, ^^^
reported bv Professor E. Geddings, of Charleston, S. C • •••"•
Case of Tetanus recorded by Baron Larrev, supervening on Lance wouna ^^^
right side of head '. r^'V^VB ^^^
Relations of the (Cerebrum and Cerebellnm to the phenomena of letanus ^^^
Case of wound of the Cerebellum, followed by Tetanus.. ••'•;• Vi^nl'ional
The phenomena of Traumatic Tetanus, dependent upon the exalted }«^^^»^"* 171
activity of the gray matter of the Medulla Oblongata and Spinal Lora • ^^^
Partial or localized tetanus ['"^ 'rt'aiacov-
The Phenomena of Tetanus, elucidated by the aid of the more recent <1^«*^^ ni^\18
eries of Physiological Science '^"'\""f\ VJ«'\ntchcn.
Observations of Valentin, Kolliker, Kiihne, Forraann Beale, ^^i^^^^^^^.^^^^^^ of
Schmidt and others, on the Minute Structure and mode of distribution ^..4.11^
Nerves
Itw
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' INDEX. 819
Pages.
TRAUMATIC TETUNU8. Experiments Illustrating the direct Action of Prussic
Acid, Cyanide of Potas-sium and Strychnine on the Heart 290-296
Experiments on the Effects of Chlorine on the Circulation 296, 297
Experiments with Bin-oxide of Nitrogen, Per-oxide of Nitrogen amLStrychnia 29H
Experiments Illustrating the direct Action of Prussic Acid on the Medulla 29a
Experiments Illustrating the Action of Prussic Acid, Cyanide of Potassium,
Strychnine, Chlorine and other Poisons, on Warm-Blooded Animals 303-327
Relations of the Aciion of the Heart in Warm-Blooded Animals to the Cerebro-
spinal and Sympathetic Systems 309-316
General Conclusions, as to the Nature of the Effects of certain Poisons 327-334
Tabular View of the Symptoms of Tetanus and Hydrophobia, and ot the
Poisonous Effects of Strychnine, Woorara and Hydrocyanic Acid 332
Treatment of Traumatic Tetanus * 334-407
Historical Notes on the Treatment of Tetanus, Practice of Hippocrates,
Aretaeus, Pelops, Aurelianus, Paulus ^gineta, Celsus, Cullen, Brown, Hun-
ter, Larrey, Hennen, MacGregor, Dickson, Blane, Currie, Trarers, Cnrling,
O'Brien, Hall, Matteucci, Poland, Bretton, Todd, MacLeod and others 336-3r»4
Table showing the Age, Sex, Nature of Injury, Results, Methods of Treatment
in Four Hundred and Twenty Cases of TeUuus, consolidated by the Author 355-383
Analysis of the Results of Treatment in Four Hundred and Twenty Cases of
Tetanus .* 384-407
u
TRIXE, Composition of. in Traumatic Tetanus 142, 151, 188, 198
UREA. Amount Excreted in Health 189
Amount Excreted in Traumatic Tetanus 188-192
Amount Excreted in Malarial Fever.. 487-489
Amount Excreud in Typhoid Fevtr ^^^
Amount Excreted in Pneumonia ... 191,670
VH\Q ACID. Amount Excreted m Health 19;
Amount Excreied in Traumatic Tetanus ^^'-^
Amount Excreted in Malarial Fever 488
Amount Excreted in Pneumonia ^"^^
TRINE. Composition of, in Malarial Fever 487, 489 679
Composition of, in Pueumonia ^"^^
Composition of, in Mollities Ossium '^^^
UXZER, JOHN AUGUSTUS. Analysis of Work on Structure and Functions of the
Nervous System 8-14
On Relation of the Spinal Cord to Voluntary aud Involuntary .Motions 11-12
OnReaex Actions ^^'^'^
V
VALK, W. W. On Pathology of Tetanus -\^
On Treatmelii of Tetanus ^^^
VALSALVA. On Nervous System °
\ ALLl. On Relations of Nervou? and Muscular Force and Electrical Force ,., iuL
VALENTIN. On Nervoas Sysiem 1.7-28J
J.-^^^^L^^'S. On the Relations ot the Spinal Cord to the Brain „-.
VANDERPOOL. On the Treatment of Tetanus : l
^.^^L®^^^TTEN. On Nervous System <,. U5
VASO .MOTOR SYSTEM OF NERVES '' ^ 80
^ vrw\?^®**^^* ^° Relations of the Sympathetic to Circulation 49
VULKMANN. On Structure of Spinal Cord 07-289
^^^ Experiments of, on Vaso Motor System of Nerves 500
V OGEL, JULIUS. On Osmosis \V8
V-HrT"^' ^'^ Muscular Contractility, and on Animal Electricity 366
V^^^i^»51'^- ^" Treatmenr of Tetanus 1^<^
\ IRCHOW. On Mollities Ossium
W 1^
WAGNER, on Diseases of Brain ^'^^
^^TSON, THO.MAS, on Dropsy ;:, ^^^
^ALKER, ALEXANDER, on Sensitive and Motor Nerves • — ^^^ 36^
wixraTril^]^* °° Treatment of Tetanus • \ ..; ^*lt
wl^fT^^^'«'n*'"^*"«^^*<^fSy'"P»'^^^^^ /^^^ ^^^
W|it,LS, SPENCER, o« Treatment of Tetapus. ...-.• .•••^•••^—^•••^•*^^'^^
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